bluuebunny/crossref_metadata_2025 huggingface dataset:
Riders on the storm: loggerhead sea turtles detect and respond to a major hurricane in the Northwest Atlantic Ocean
Authors: Crowe Leah M. , Hatch Joshua M. , Patel Samir H. , Smolowitz Ronald J. , Haas Heather L.
Published: July 2020

Background

Extreme weather events, including hurricanes, have considerable biological, ecological, and anthropogenic impacts. Hurricane Irene caused substantial economic damage when it hit the Mid-Atlantic Bight (MAB) off of the eastern United States in August of 2011. The MAB is highly stratified during the summer when a strong thermocline separates warm, surface water from deep, cold water, and this oceanographic phenomenon makes modeling hurricane strength difficult. Loggerhead sea turtles (Caretta caretta) forage in the MAB primarily during the stratified season and their dive behavior to the bottom allows them to experience the oceanographic conditions of the entire water column.

Methods

In this study, we analyzed the movements and dive behavior of juvenile and adult-sized loggerhead sea turtles (n = 18) that were foraging in the MAB as Hurricane Irene moved through the region. The satellite tags deployed on these turtles transmitted location data and dive behavior as well as sea surface temperature (SST) and temperature-depth profiles during this time.

Results

Behavioral and environmental shifts were observed during and after the hurricane compared to conditions before the storm. During the hurricane, most of the turtles (n = 15) moved north of their pre-storm foraging grounds. Following the storm, some turtles left their established foraging sites (n = 8) moving south by 7.3–135.0 km, and for the others that remained (n = 10), 12% of the observed dives were longer (0.54–1.11 h) than dives observed before the storm. The in situ data collected by the turtle-borne tags captured the cooling of the SST (Mean difference = 4.47°C) and the deepening of the thermocline relative to the pre-storm conditions.

Conclusions

Some of the loggerhead behavior observed relative to a passing hurricane differed from the regular pattern of seasonal movement expected for turtles that forage in the MAB. These data documented the shifts in sea turtle behavior and distribution during an ecosystem-level perturbation and the recorded in situ data demonstrated that loggerheads observe environmental changes to the entire water column, including during extreme weather events.
Radiographic bone level around particular laser-treated dental implants: 1 to 6 years multicenter retrospective study
Authors: Mongardini C. , Zeza B. , Pelagalli P. , Blasone R. , Scilla M. , Berardini M.
Published: July 2020

Purpose

The aim of the present retrospective study was to evaluate clinical and radiological outcomes, in terms of implant survival rate, marginal bone loss, and peri-implantitis incidence, of a titanium implants with an innovative laser-treated surface.

Materials and methods

A total of 502 dental implants were inserted in four dental practices (Udine, Arezzo, Frascati, Roma) between 2008 and 2013. All inserted implants had laser-modified surface characterized by a series of 20-μm-diameter holes (7–10 μm deep) every 10 μm (Synthegra®, Geass srl, Italy). The minimum follow-up period was set at 1 year after the final restoration. Radiographs were taken after implant insertion (T0), at time of loading (T1), and during the follow-up period (last recall, T2). Marginal bone loss and peri-implant disease incidence were recorded.

Results

A total of 502 implants with a maximum follow-up period of 6 years were monitored. The mean differential between T0 and T2 was 0.05 ± 1.08 mm at the mesial aspect and 0.08 ± 1.11 mm at the distal with a mean follow-up period of 35.76 ± 18.05 months. After being in function for 1 to 6 years, implants reported varying behavior: 8.8% of sites did not show any radiographic changes and 38.5% of sites showed bone resorption. The bone appeared to have been growing coronally in 50.7% of the sites measured.

Conclusion

Implants showed a maintenance of marginal bone levels over time, and in many cases, it seems that laser-modified implant surface could promote a bone growth. The low peri-implant disease incidence recorded could be attributed to the laser titanium surface features that seem to prevent bacterial colonization. Future randomized and controlled studies are needed to confirm the results of the present multi-centrical retrospective analysis.
Effect of intimate partner violence of women on minimum acceptable diet of children aged 6–23 months in Ethiopia: evidence from 2016 Ethiopian demographic and health survey
Authors: Tsedal Desta Melaku , Yitayal Mezgebu , Abebe Zegeye , Tsegaye Adino Tesfahun
Published: July 2020

Background

The absence of proper infant and young child feeding practice results in malnutrition. Intimate Partner Violence (IPV) is potentially a major factor affecting child feeding practices. However, there is limited evidence about the effect of intimate partner violence (IPV) on a minimum acceptable diet. Therefore, in this study, we hypothesized that IPV will be associated with a lack of a minimum acceptable diet among children aged 6–23 months.

Methods

We conducted a cross-sectional analysis using the Ethiopian Demographic and Health Survey (EDHS) 2016. All child-mother pairs that participated in EDHS 2016 from all regions of Ethiopia were included. The analysis included mother-child pairs where 6–23 months aged children with mothers who were ever in a committed partnership and interviewed for domestic violence were involved. The data were weighted considering enumeration areas as a cluster and place of residence as a stratum. A binary logistic regression analysis was done to identify factors independently associated with a minimum acceptable diet.

Result

Totally, 1307 observations were included in the final analysis. The mean age of mothers was 29 years (standard deviation ±6.54 years), the mean age of children was 14. ± 5.02 months, and 32% of women had intimate partner violence (IPV). Of the children, 8% had a minimum acceptable diet (minimum acceptable diet), 15% had a minimum dietary diversity, and 43% had a minimum meal frequency. Having intimate partner violence decreases children minimum acceptable diet by 65% (AOR:0.35; 95% CI:0.16, 0.77). The other factors associated with the minimum acceptable diet were caregivers attaining a secondary level of education (AOR: 4.01; 95% CI: 1.04, 15.45), currently working (AOR: 2.26; 95% CI: 1.01, 5.11), and undecided fertility desire (AOR: 4.72; 95% CI: 1.37, 16.28).

Conclusion

Intimate partner violence against women had a negative association with the minimum acceptable diet children have received. Decreasing violence against women, educating, and increasing work opportunities for them would help in improving child feeding practice and reducing malnutrition and its consequences. Further studies that focus on possible community-based interventions aiming to decrease IPV are recommended.
Modulatory effect of dry orange (citrus sinensis) peel powder on bisphenol A-induced hepatic and splenic toxicity in rats
Authors: AbdEl-Gwaad Hager Mosaad Saad , El-Wahab Hanan M. F. Abd , Mohamed Enas Ali Kamel , Sharaf Eman Hassan Abdel Aziz , Osman Amany Abdel Hameid Mahmoud
Published: July 2020

Background

Bisphenol A (BPA) is used as monomer in polycarbonate synthesis, and it acts as plasticizer in baby and water bottles and the production of epoxy resins which are used as inner coatings of many food and beverage cans. This study was carried out to evaluate the possible modulatory effect of dry orange peels powder (OPP) to attenuate the toxic effects of BPA on liver and spleen in rats.

Method

Sixty male Spargue–Dawley rats weighing 130 ± 10 g were randomly divided into six groups (n = 10 for each group). Group 1: negative control, fed on balanced diet and received corn oil. Group 2: positive control, fed on balanced diet, received BPA (350 mg/kg b.w. per orally; p.o twice weekly) suspended in corn oil. Groups from 3 to 6 fed on balanced diet supplemented with OPP in the tested doses of 12.5, 25, 50, and 100 g/Kg diet respectively, and received BPA (350 mg/kg b.w. twice weekly).

Results

There was a significant increase in liver sterol regulatory element-binding transcription factor 1 gene expression (SREBF1), serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activities, nitric oxide (NO), total cholesterol (TC), triacylglycerols (TAGs), low-density lipoprotein cholesterol (LDL-c), very low-density lipoprotein cholesterol (VLDL-c), interluken-4 (IL-4), immunoglobulin-E (IgE)levels, and total leukocytes count (TLC) in BPA group as compared to negative control group (P < 0.05).On the other hand, BPA caused a significant decrease in liver catalase activity, serum high-density lipoprotein cholesterol (HDL-c), serum immunoglobulin-M (IgM) levels, blood hemoglobin% (Hb), and red blood cell (RBCs) counts compared to the negative control group (P < 0.05). Also, the histopathological examination of liver and spleen sections supported biochemical parameters showed a significant destruction in the BPA group as compared to the negative control group.

Conclusion

It is observed that OPP dietary supplementation in the tested doses ameliorates deleterious effects induced by BPA. The improvement in these altered parameters in OPP supplemented groups was in a dose-dependent manner.
Role of ultrasound in predicting the molecular subtypes of invasive breast ductal carcinoma
Authors: Khalaf Lamiaa M. R. , Herdan Rania A.
Published: July 2020

Background

Breast cancer is a heterogeneous disease that was explained recently by the presence of multiple molecular subtypes. These subtypes are the luminal A (LA), luminal B (LB), human epidermal growth factor receptor 2 (HER2), and triple-negative (TN). In this study, we aim to investigate whether ultrasound imaging features can play a role in predicting the molecular subtypes of invasive ductal breast cancer (IDC) and to assess whether the nodal metastasis is an independent predictor for each subtype.

Results

The predictive sonographic signs for each subtype are as follows: echogenic halo, posterior shadowing, angular or spiculated margin, and unifocal mass for LA subtype; irregular shape for LB subtype; unifocal mass, abrupt interface of the tumor boundary, and posterior enhancement or no posterior change for HER2 subtype; and circumscribed or lobulated margin, oval or rounded shape, posterior enhancement or no posterior change, abrupt interface of the tumor boundary, and parallel orientation of the mass for TN. By multivariate logistic regression, presence of nodal metastasis is the strongest independent predictor for HER2 subtype, and its absence is the strongest independent predictor for LA subtype.

Conclusions

Certain sonographic signs are predictors for each molecular subtype of IDC. Nodal metastasis is an independent predictor for HER2 subtype when present and for LA subtype when absent.
Computed tomography examination of the screaming mummy “Unknown-Woman-A”
Authors: Hawass Zahi , Saleem Sahar N.
Published: July 2020

Background

The Royal Cache at Deir el Bahari in Luxor, Egypt, contained the mummy of a princess named Meritamun of uncertain identity, who was consequently designated “Unknown-Woman-A.” The mummy has a widely opened mouth as if screaming, with the unusual posture of her head tilted to the right and partially flexed legs cross at the ankles. We postulated that computed tomography (CT) would help to provide insights on life and death of “Unknown-Woman-A.”

Results

CT findings indicate that “Unknown-Woman-A” died in her fifties (sixth decade of life) and suffered from advanced diffuse atherosclerosis. “Unknown-Woman-A” was well mummified and eviscerated, and her body cavity was filled with resin. The desiccated brain had shifted to the right inside her skull. We presume that “Unknown-Woman-A” died of a sudden and massive myocardial infarction. Death spasm induced her unusual posture, and the contracted body was apparently mummified before relaxing her postmortem position.

Conclusions

This CT study has provided useful information about the mummy designated “Unknown-Woman-A” including her mummification style, underlying advanced cardiovascular atherosclerosis disease, and her possible death circumstances.
Are summer schools a way to improve recruitment in psychiatry?
Authors: O'Brien Aileen
Published: July 2020

Summer schools are traditionally used to encourage sixth form students to consider a career in medicine. Is it worth attracting students earlier in their school career, concentrating on psychiatry? Wyke et al describe an innovative project attempting to do just that.
Clozapine treatment and risk of COVID-19 infection: retrospective cohort study
Authors: Govind Risha , Fonseca de Freitas Daniela , Pritchard Megan , Hayes Richard D. , MacCabe James H.
Published: July 2020

Background

Clozapine, an antipsychotic with unique efficacy in treatment-resistant psychosis, is associated with increased susceptibility to infection, including pneumonia.

Aims

To investigate associations between clozapine treatment and increased risk of COVID-19 infection in patients with schizophrenia-spectrum disorders who are receiving antipsychotic medications in a geographically defined population in London, UK.

Method

Using information from South London and Maudsley NHS Foundation Trust (SLAM) clinical records, via the Clinical Record Interactive Search system, we identified 6309 individuals who had an ICD-10 diagnosis of schizophrenia-spectrum disorders and were taking antipsychotics at the time of the COVID-19 pandemic onset in the UK. People who were on clozapine treatment were compared with those on any other antipsychotic treatment for risk of contracting COVID-19 between 1 March and 18 May 2020. We tested associations between clozapine treatment and COVID-19 infection, adjusting for gender, age, ethnicity, body mass index (BMI), smoking status and SLAM service use.

Results

Of 6309 participants, 102 tested positive for COVID-19. Individuals who were on clozapine had increased risk of COVID-19 infection compared with those who were on other antipsychotic medication (unadjusted hazard ratio HR =2.62, 95% CI 1.73–3.96), which was attenuated after adjusting for potential confounders, including clinical contact (adjusted HR = 1.76, 95% CI 1.14–2.72).

Conclusions

These findings provide support for the hypothesis that clozapine treatment is associated with an increased risk of COVID-19 infection. Further research will be needed in other samples to confirm this association. Potential clinical implications are discussed.
Quest for Universal Health Coverage for Pediatric Acute Lymphoblastic Leukemia in Mexico
Authors: Muñoz-Aguirre Paloma , Huerta Rodrigo , Lajous Martin
Published: July 2020

PURPOSE

Until 2005, most Mexican children did not have coverage for cancer treatment. In that year, Seguro Popular began funding the treatment of children with acute lymphoblastic leukemia (ALL). We aimed to estimate 5-year survival in children with ALL. We also sought to evaluate the relationship of hospital volume, out-of-state treatment, and treatment administered by an adult hematologist to 5-year survival.

METHODS

We categorized patients according to risk (National Cancer Institute age criteria), hospital volume, out-of-state treatment, and treatment administered by an adult hematologist. We obtained overall 5-year survival using the Kaplan-Meier method and compared survival among groups. We used Cox proportional hazards regression analysis to conduct multivariable analysis and obtained hazard ratios (HRs) and 95% CI.

RESULTS

Between 2005 and 2015, 9,555 children were treated for ALL under Seguro Popular. Mean age (± standard deviation) was 7.4 (4.7) years. Five-year overall survival was 61% (95% CI, 60% to 62%); survival for high-risk patients was 51% (95% CI, 49% to 52%) and 66% (95% CI, 65% to 67%) for those with standard risk. We observed state heterogeneity (Sinaloa: 75% [95% CI, 69% to 80%] v Campeche: 45% [95% CI, 54% to 62%]). Patients who were treated in low-volume hospitals had lower survival rates compared with those treated in medium- and high-volume hospitals (HR v low, 1.17 [95% CI, 1.08 to 1.26]). Patients treated outside of their residence state had 10% lower mortality compared with those treated in their home state (HR, 0.89 [95% CI, 0.82 to 0.99]). The hazard of death among children who were treated by an adult hematologist was 1.93 times (95% CI, 1.44 times to 2.57 times) higher than the hazard of death among those treated by a pediatric oncologist/hematologist (26% [95% CI, 16% to 37%] v 61% [95% CI, 60% to 62%]).

CONCLUSION

Our results highlight the disparities in survival for ALL in Mexico. Health reform must consider increasing the patient volume required for hospital accreditation and mandating treatment by pediatric oncologists/hematologists.
Exposure to Particulate Matter Air Pollution and the Incidence and Mortality of GI Cancers: A Systematic Review
Authors: Spangler Emily , Jones Rena , Livinski Alicia , Dawsey Sanford , Haley Natalie
Published: July 2020

PURPOSE

High levels of particulate matter (PM) air pollution increase the risk of developing cardiovascular diseases, asthma, and cancer. Outdoor air pollution, especially PM, is classified as a human carcinogen on the basis of associations with lung cancer, but research investigating other cancer sites is limited. This systematic review investigates the scope and quality of existing literature on PM and the incidence and mortality of GI cancers.

METHODS

This review was conducted in accordance with the PRISMA protocol guidelines and submitted under PROSPERO ID: 139597. Initial searches of 5 databases yielded 2,041 articles, of which 762 duplicates were removed. Eligible studies evaluated an association between PM and at least one GI cancer. The titles and abstracts of 1,279 articles were screened independently and 102 articles were selected for additional screening. Ten studies were included in the final analysis. We evaluated the overall quality of included studies using GRADE criteria.

RESULTS

All articles meeting the criteria for inclusion were of cohort study design and published in 2015 or later. Methods for assessing PM exposure varied. More than one half (n = 6) of the studies investigated liver cancer. Most met the GRADE criteria for moderate certainty or greater. Six studies found a statistically significant positive association, and none found evidence of a negative association.

CONCLUSION

Evidence of a positive association between the incidence and mortality of GI cancers exists; however, few studies have evaluated this association. Methods of assessing exposure are highly variable. Future researchers should strive to conduct more studies in the most affected geographic areas to evaluate the impact of different PM exposure assessment approaches on observed associations, and include the evaluation of cancer subtypes and specific chemical components of PM.
Analysis of the National Cancer Institute’s Investment in Site-Specific Cancer Research Funding Involving Collaborators in Latin America and Its Correspondence to Regional Cancer Burden
Authors: Vargas Jasmin Serena , Abudu Rachel , Duncan Kalina
Published: July 2020

PURPOSE

Economic and social-behavioral changes over the last two decades in Latin America and the Caribbean (LAC) are associated with increases in the regional cancer burden. We aim to describe the National Cancer Institute–funded extramural research portfolio with collaborators in the LAC between fiscal years 2014 and 2018 and compare project numbers by site with subregional cancer burden.

METHODS

This analysis included National Cancer Institute–funded extramural projects with LAC collaborators from fiscal years 2014 to 2018 from the National Institutes of Health IMPAC II database. Projects were stratified by Pan American Health Organization’s Latin American subregions, tumor sites, and regional site-specific rates of cancer incidence and mortality using Globocan 2018 estimates. To better understand subregional variations in cancer incidence and mortality, this analysis focused on the top 5 sites of incidence and mortality in LAC after breast and prostate cancer.

RESULTS

Between fiscal years 2014 and 2018, 108 projects with LAC collaborators were funded. Project collaborators came from 22 countries in the region, and projects covered 20 tumor sites. The Southern Cone had the most projects funded, followed by the Central American Isthmus and Mexico, Andes, Latin Caribbean, and non-Latin Caribbean—this was roughly proportional to subregional populations. Variation exists at the subregional level for the top 5 cancers when comparing incidence and mortality with subregional project counts. Disparities between projects and incidence by tumor site were the largest for colorectal, lung, and uterine cancers. Disparities between projects and mortality by tumor site were the largest for lung and uterine cancers. Disparities between projects and both components of cancer burden by subregion were the largest for the Latin Caribbean and non-Latin Caribbean. The number of funded projects for Kaposi sarcoma and non-Hodgkin lymphoma largely outpaced both incidence and mortality in every subregion.

CONCLUSION

This analysis suggests that projects’ alignment with cancer burden is variable by subregion, provides an understanding of cancer research funding by site, and highlights areas of interest for additional investigation, training, and collaboration in LAC.
Evaluating the Impact of Nicotine Regulatory Policies in a Rapidly Changing Market: Findings From the ITC Project in the United States, Canada, United Kingdom, and Australia
Authors: Cummings K. Michael , Fong Geoffrey T. , Borland Ron , McNeill Ann , O’Connor Richard J. , Goniewicz Maciej , Hammond David , Bickel Warren , Levy David , Thompson Mary , Hyland Andrew
Published: July 2020

PURPOSE

Tobacco smoking is the leading preventable cause of death, projected to claim up to one billion deaths in the 21st century. Smoking is the leading cause of cancer, accounting for approximately 30% of cancer cases globally. The recent surge in nicotine vaping products (NVPs), such as e-cigarettes, has led to astounding global changes in the tobacco/nicotine landscape, prompting vigorous debate about whether these products represent a positive or negative public health impact.

METHODS

In 2016, the International Tobacco Control (ITC) Project created a multimethod program of 5 linked projects to examine NVP design/content, the interplay between NVPs and cigarettes in adults and youth, the impact of NVP regulations, and implications of NVPs on public health in 4 countries that vary in regulatory approach to NVPs: the United States, United Kingdom, Canada, and Australia—the first ever multicountry longitudinal study of e-cigarettes and other NVPs.

RESULTS

This presentation will describe the overall research program and then review key findings from these 5 linked international projects: the ITC Four-Country Adult Smoking and Vaping Survey, the ITC International Youth Smoking and Vaping Survey, the ITC product testing project, the experimental marketplace project, and the simulation study estimating the impact of different parameters, including the prevalence of NVP use and restrictiveness of policies on NVPs. The overall objective of these ITC projects was to evaluate and understand the impact of different policies on the uptake, use, reasons for use, and impact of use among youth and among adults over time and across countries.

CONCLUSION

The ITC project’s multimethod, multicountry research program illustrates the unique value of cross-country research to examine the public health impact of the evolving nicotine marketplace and of regulations on the broadening array of nicotine products throughout the world.
Long-Term Follow Up of an Occupational Cohort in Yunnan, People’s Republic of China: 20-Year Postscreening Follow Up and 8-Year Lung Cancer Screening
Authors: Su Zheng , Wei Meng-Na , Fan Ya-Guang , Hu Zhi-Wei , Wang Jian-Ning , Qiao You-Lin
Published: July 2020

PURPOSE

There is no long-term, population-based cohort screening evidence for lung cancer in China. This study aimed to evaluate whether increased screening rounds could reduce mortality as a result of lung cancer.

METHODS

We conducted a one-armed, prospective lung cancer screening cohort study with chest radiography and sputum cytology in Yunnan, People’s Republic of China, from 1992 to 1999. A total of 9,295 tin miners age 40 years or older were enrolled in this study and follow up ended on December 31, 2018. We stratified patients into 4 subgroups on the basis of screening rounds—1-2, 3-4, 5-6, or 7-8 rounds within 8 years—and selected 1-2 screening rounds within 8 years as the control group. Hazard ratios (HRs) and 95% CIs for the effect of screening rounds on mortality were estimated using Cox proportional hazards regression models.

RESULTS

Of participants, 831 (8.9%) were lost to follow up, and 4,517 patients died, 1,600 from cancer (1,135 from lung cancer), 1,519 from circulatory system diseases, and 619 from respiratory diseases. Participants who received 7-8 screening rounds within 8 years had reduced lung cancer mortality by 46% (HR, 0.54; 95% CI, 0.46 to 0.63 in all age groups. For those who received 5-6 screening rounds within 8 years, the benefit of reduction was mostly observed in patients older than age 52 years (HR, 0.63; 95% CI, 0.52 to 0.77), and there was no effect among those age 52 years or younger (HR, 0.72; 95% CI, 0.48 to 1.07). In contrast, only for those patients age 52 years or younger did 3-4 screening rounds within 8 years decrease mortality from lung cancer (HR, 0.56; 95% CI, 0.36 to 0.87).

CONCLUSION

We showed that increased screening rounds could reduce lung cancer mortality in a high-risk population, but the effect is influenced by age group. The optimal screening strategy for different age groups needs additional investigation.
Germline Mutations in Latin American Women With Breast Cancer
Authors: Ren Megan , Orozco Anali , Flores-Ramos Liliana Gómez , Albanez Anaseidy , Garland Lisa , Jones Kristine , Wang Mingyi , Ralon Sergio , Gharzouzi Eduardo , Orozco Roberto , Torres-Mejía Gabriela , Dean Michael
Published: July 2020

PURPOSE

Breast cancer is the most common form of cancer among women in Latin America. Limited health care access, late-stage diagnosis, and lack of knowledge on the mutation profile of cancer susceptibility genes in low- and middle-income country populations lead to higher mortality rates. To address this health disparity, this study analyzes the breast cancer mutation profile of women from Mexico and Guatemala. Results from this study can be used to improve breast cancer screenings in these countries and for Latin American women living in the United States.

METHODS

Genomic and clinical data of women with breast tumors were obtained at the Instituto Nacional de Salud Publica in Mexico and Instituto Nacional de Cancerologia in Guatemala. Mutations in known breast cancer susceptibility genes were identified using targeted sequencing and were validated by manual review in the Integrative Genomics Viewer and pathogenicity determined using online databases (ClinVar and Varsome). Finally, variants were compared with corresponding clinical data for population-wide trends.

RESULTS

The Mexico study identified 14% of cases with pathogenic mutations in a sample of 201 patients and the Guatemala study contained 11% pathogenic mutations in 673 patients. The most frequently mutated genes for both populations were BRCA1, BRCA2, PALB2, and TP53, with BRCA1/2 mutations accounting for 7% to 10% of all variants. Patients with pathogenic mutations were found to have a significantly younger age of onset than patients without mutations, and a family history of breast cancer was pronounced in patients with pathogenic mutations.

CONCLUSION

The results of this study increase our understanding of the molecular and pathologic characteristics of breast cancer in Latin American women. This list of pathogenic variants and their clinical characteristics should be used to inform cancer screening, diagnosis, and treatment in the United States and abroad.
Implementing Technology That Disrupts Health Systems but not Quality of Care: The Pocket Colposcope in Lima, Peru
Authors: Krieger Marlee , Ramanujam Nimmi , Dotson Libby Mary Elizabeth
Published: July 2020

PURPOSE

Innovative devices are often targeted at increasing access, improving quality, or reducing costs—the three axes of the infamous Iron Triangle of Health Care, which are notoriously difficult to simultaneously optimize. The main aim of this study was to demonstrate that disruptive technologies, if high quality and appropriately implemented, can result in improved access, cost, and quality of care, overcoming the conventional constraints of the Iron Triangle framework.

METHODS

Our team conducted a global value chain analysis of the Pocket Colposcope in Lima, Peru, and developed surveys and conducted in-depth interviews to evaluate Pocket Colposcope stakeholders. All surveys were developed with consultations from the Duke Evidence Lab and had institutional review board approval.

RESULTS

The global value chain identified 5 leverage points: regulatory approval, task shifting, collaboration, telemedicine, and patient acceptance. We also identified stakeholders and processes that affect the degree to which the Pocket Colposcope is successfully implemented. Of women surveyed, 39.4% answered that they had previously wanted a cervical cancer screening test, but had been unable to receive one as a result of some barrier. The most common responses were distance to clinics (31.0%), participants could not leave work (27.6%), and patients were afraid of receiving a cancer diagnosis (20.7%). All 4 midwives who participated in the focus group identified the portability of the Pocket Colposcope as the device’s most appealing feature. Providers identified the quality of the image, cost to patient, and ease of use as the 3 most important aspects of the Pocket Colposcope.

CONCLUSION

The Pocket Colposcope provides an opportunity to make high-quality diagnostic technology more accessible at a cheaper price for more people. Often, disruptive technology in low-income settings is expected to increase access at the cost of reducing quality. In the case of the Pocket Colposcope, the disruptive technology is significantly cheaper than existing technology, but quality is still high enough to succeed.
Development of Tanzania’s First National Cancer Treatment Guidelines
Authors: Ndumbalo Jerry , Mvungi Nanzoke , Meena Stephen , Ngoma Mamsau , Mseti Mark , Buckle Geoffrey , Van Loon Katherine , DeBoer Rebecca J. , Mwaiselage Julius
Published: July 2020

PURPOSE

Tanzania and other low-income countries face a growing burden of cancer and a pressing need to strengthen cancer care delivery systems. The overall case fatality from cancer is disproportionately higher in low-income countries, and adherence to standard treatment guidelines is a critical component of addressing disparities in outcomes. In 2017, Tanzania’s Ministry of Health, Community Development, Gender, Elderly, and Children (MOHCDGEC) commissioned leaders at Ocean Road Cancer Institute to develop Tanzania’s first National Cancer Treatment Guidelines.

METHODS

In 2017, we convened 90 stakeholders from 15 institutions in Tanzania to form 10 different technical working groups (TWGs). TWGs were organized according to disease-specific categories and were composed of representatives from relevant disciplines, including surgeons, gynecologists, pediatricians, radiologists, pathologists, oncologists, social workers, dieticians, and nurses. Each TWG conducted a review of the current literature and prepared a summary of the epidemiology, diagnostic, and staging procedures; options for management; and essential medicines currently available in Tanzania. In 2018, after multiple revisions and meetings of each TWG, the guidelines underwent an external review with 2 oncologists from Tanzania participating in consultations with approximately 30 disease-specific experts at the University of California, San Francisco.

RESULTS

Guidelines were developed for a total of 70 diseases. The guidelines are intended to be facilitative, enabling, and providing the basis for the attainment of high standards in the management of cancers in a resource-constrained setting. Guidelines were formatted for dissemination in both hard copy and soft copy using the AgileMD platform.

CONCLUSION

In February 2020, Tanzania’s MOHCDGEC disseminated its first-ever National Cancer Treatment Guidelines. After dissemination, MOHCDGEC will implement a monitoring and evaluation strategy that ensures and promotes the use of the guidelines. We have developed a theory-informed implementation strategy that focuses on education, workflow modifications, and behavior change that will be piloted at Ocean Road Cancer Institute.
Traditional and Commercial Alcohols as Risk Factors for Esophageal Cancer in Tanzania
Authors: Keir Alexandra , Buckle Geoffrey , Akoko Larry , Mgisha William , Mwaiselage Julius , Deardorff Katrina , Paciorek Alan , Zhang Li , Van Loon Katherine , Mmbaga Elia , Mushi Beatrice
Published: July 2020

PURPOSE

Esophageal cancer (EC) is one of the most common cancers in East Africa; however, risk factors that underly the high incidence in this region are not well understood. We aimed to investigate the association between exposure to specific alcohol subtypes and EC in Tanzania.

METHODS

We performed a secondary analysis of data from a hospital-based, case-control study conducted at Muhimbili National Hospital and Ocean Road Cancer Institute in Dar es Salaam, Tanzania. Cases of EC were identified between 2014 and 2016. Hospital controls were identified from patients with nonmalignant conditions and matched 1:1 for gender and age (± 10 years). Interviews were conducted using a survey with culturally relevant and context-specific questions on alcohol and smoking exposure. Conditional logistic regression analyses were applied to evaluate specific associations of potential exposures and EC.

RESULTS

A total of 473 EC cases and 473 controls were enrolled. Alcohol consumption was reported in 61% and 64% of cases and controls, respectively. Neither ‘current use of alcohol (any type)’, nor ‘ever use’ were associated with EC; however, local brew consumption was associated with increased EC risk (odds ratio [OR], 2.01; 95% CI, 1.53 to 2.66; P < .01). Increased risk was observed with consumption of gongo (OR, 2.91), komoni (OR, 2.41), wanzuki (OR, 2.40), kindi (OR, 3.13), and kangara (OR, 2.86). Smoking increased EC risk; however, it did not significantly modify the association between EC and alcohol subtypes.

CONCLUSION

This is the first case-control study to report a detailed analysis of alcohol exposures as a potential risk factor for EC in Tanzania. Although combined measures of alcohol use were not found to be associated with EC, several types of locally brewed alcohols emerged as risk factors. Additional research is needed to investigate these findings and examine the carcinogenic role of ingredients and/or contaminants, as well as any interactions with other putative risk factors in this region.
Novel Approaches for Monitoring and Controlling Major Cancer Risk Factors in China
Authors: Zhang Yawei , Zhou Baosen , Zeng Hongmei , Xiang Yongbing , Wang Jinfeng , Zhu Cairong , Bai Yana , Jiang Min , Li Xuelian , Ran Xianhui , Li Honglan , Tan Yuting , Liao Yilan , Li Ni , Li Xin , Dai Min
Published: July 2020

PURPOSE

Globally, approximately one fourth of newly diagnosed cancer cases (24%) and one third of cancer deaths (30%) in 2018 occurred in China. Despite advanced scientific knowledge about risk factors, the incidence of many cancers continuous to increase, which indicates an urgent need for an effective preventive strategy.

METHODS

For better monitoring and control of major cancer risk factors in China, a research program was launched at the end of 2016. The program aims to develop novel algorithms for cancer risk prediction and prevention, build tools for both real-time risk factor collection and for transmission of intervention-related messages, and to create a cancer prevention platform. It is funded by the Chinese Ministry of Science and Technology. The China National Cancer Center plays a leading role.

RESULTS

This research program includes 5 projects. The first project will develop a means of collecting data on major cancer risk factors and personalized prevention message-sending apps. The second project will establish 20 population-based, high-quality tumor registries with extensive information on cancer treatment and prognosis. The third project will validate the apps and models developed through the first project in 6 large prospective cohort studies involving diverse populations. The fourth project will apply temporal and spatial high-dimensional data-mining approaches and use historical data, including national cancer incidence and mortality data, air pollution monitoring data, national surveys on smoking and nutrition, etc, to develop a cancer incidence and mortality mapping system. The fifth project will build risk prediction models and establish a cancer prevention Web site to showcase results from other projects.

CONCLUSION

This study has the potential to revolutionize the path of current cancer prevention by leading it toward personalized cancer prevention.
Development of Nutrition Educational Materials for Pediatric Oncology Patients in Tanzania
Authors: Gillespie Anna , Raveendran Yadurshini , Monko Dafrosa , Gisiri Robert , Schroeder Kristin
Published: July 2020

PURPOSE

More than 30% of children in sub-Saharan Africa are malnourished at baseline. Patients with cancer become further malnourished by metabolically active tumors and starvation during extended hospital stays when parents cannot afford food. If cancer outcomes could be improved by optimizing nutrition, then this would provide a cost-effective intervention for future implementation and research. The current study targeted caregiver nutrition knowledge, attitudes, and practices to develop educational materials for children who are diagnosed with cancer at Bugando Medical Centre in Mwanza, Tanzania.

METHODS

A quantitative survey developed using UN Food and Agriculture guidelines was used to assess the knowledge, attitudes, and practices of nutrition among caregivers of children with cancer presenting from June to August 2019. On the basis of responses, targeted education materials—A2 posters, A4 posters, and 50 pamphlets—were developed in collaboration with a local nutritionist to address gaps in caregiver nutrition knowledge.

RESULTS

A total of 36 caregivers and 21 stakeholders completed surveys. The majority of caregivers reported food insecurity (94%) and limited knowledge on nutrition (92%). Identified key knowledge gaps included appropriate food selection, understanding of macronutrients, and food safety. Specific media—posters and pamphlets—were designed to be simple and targeted for specific symptoms, as well as to encourage positive eating habits among patients and families.

CONCLUSION

This study developed a targeted intervention to improve nutrition knowledge for caregivers of children with cancer. The multiple media sources created can be used alongside verbal education sessions by nutritionists to increase exposure and the likelihood of retention and application. Although this was developed at a single institution, the media created targeted consensus nutrition information for children with cancer and is mostly pictorial, so it can be used regardless of literacy or language. Implementation evaluation is ongoing, with plans to share these materials with pediatric cancer centers throughout Tanzania and sub-Saharan Africa.
Mixed-Methods Evaluation of Multiple Perspectives on Breast Cancer Control to Guide Stakeholder Selection of Implementation Strategies: The Time to A.C.T. Study in Mwanza, Tanzania
Authors: Rositch Anne F. , Chao Christina , Passaniti Anna , Mwakatobe Kisa , Visvanathan Kala , Masalu Nestory
Published: July 2020

PURPOSE

Tanzania recently developed national guidelines for early diagnosis of breast cancer to combat increasing incidence and mortality. The aim of this multiphase, adaptive implementation science study was therefore to assess the local context, couple implementation strategies with identified barriers, and test these strategies to improve breast cancer control, creating an adaptive A.C.T. framework with broad applicability to other low- and middle-income country settings.

METHODS

The assessment phase was made up of a broad medical chart review of women seeking care for breast concerns (n = 664); a knowledge, attitudes, and practices survey of community women (n = 1,129); and a knowledge, attitudes, and practices survey of health care providers (n = 114), followed by in-depth interviews (n = 15).

RESULTS

Women presented to the Zonal Hospital with swelling (45%) or a palpable lump (31%), with an average symptom duration of 6 months. Most diagnoses were based on clinical exam only (54%) and included 16% breast cancer. Of these, 43% had no treatment recorded, 50% had surgery at a median of 2.5 months, and 7% had chemotherapy only. Knowledge surveys indicated that 59% of women had heard of breast cancer, but only 14% felt they knew any signs or symptoms. Encouragingly, 56% were fairly to very confident that they would notice breast changes, and 74% said they would be somewhat to very likely to seek care, with 96% noting the severity of symptoms as a motivator. Providers indicated that barriers to care included low community knowledge and repeated misdiagnosis at the primary level. The majority of providers (95%) believe clinical breast examination is feasible to implement for symptomatic patients, yet only 65% feel they have sufficient training.

CONCLUSION

In all, 8 larger barriers were synthesized and linked to evidence-based interventions as potential solutions. All barriers and solutions were ranked by key stakeholders on the basis of feasibility, importance, and sustainability. These were incorporated into a 3-component intervention to improve breast cancer care at the Zonal Hospital and rollout is underway.
Geographic Variation in Access to Pathology and Laboratory Services in Tanzania: A Cross-Sectional Geospatial Analysis
Authors: Iyer Hari S. , Wolf Nicholas G. , Vuhahula Edda , Massambu Charles , Shah Devanshi , Schroeder Lee F. , Castro Marcia C. , Fleming Kenneth , Flanigan John S.
Published: July 2020

PURPOSE

Increasing noncommunicable disease burden in sub-Saharan Africa requires the urgent scale-up of pathology and laboratory medicine (PALM) services. To identify service gaps at the district level, we studied geographic variation in the correlation between travel time to health facilities and population density.

METHODS

We linked geospatial data for Tanzania from multiple sources. Facility locations were extracted from a comprehensive facility list in Africa. Data on geographic factors, demographics, and roads were collected from government and nonprofit databases. We classified facilities assuming increasing PALM service readiness by level: dispensaries, health centers, district hospitals, and regional/referral hospitals. We input these data into the AccessMod 5 algorithm to estimate travel time across Tanzania with 1-km resolution for each PALM classification. We then calculated district-level averages of population and travel time for each PALM category. Associations between these variables were estimated using a bivariable local indicator of spatial autocorrelation, specifying immediate contiguity neighborhood definition. Spatial analysis was restricted to 172 contiguous districts (islands not included). Significance tests were two sided, with an α of .05.

RESULTS

Analysis included 5,342 dispensaries, 667 health centers, 185 district hospitals, and 34 regional/referral hospitals. Maps revealed clusters of estimated travel time in excess of 6 hours in less populated western and southern districts. More districts reported an average travel time of less than 1 hour to the nearest dispensary (69%) than to regional/referral hospitals (16%). Bivariable local indicators of spatial autocorrelation revealed few significant clusters of spatial correlations; however, significant correlations between low population density and longer travel times in neighboring districts were obtained for 13%, 16%, 15%, and 13% of districts for dispensaries, health centers, district hospitals, and regional/referral hospitals, respectively.

CONCLUSION

Limited variability of district-level spatial correlations suggests somewhat equitable geographic allocation of PALM services in Tanzania, with small areas of low population density and long travel times that demand additional intervention. Limitations include a lack of ascertainment of specific PALM services.
Facilitating Adoption of Evidence-Based Cervical Cancer Screening Strategies in the Peruvian Amazon Using a Novel Methodology: The Integrative Systems Praxis for Implementation Research (INSPIRE)
Authors: Paz-Soldan Valerie A. , Meza Graciela , Carillo Lita , Jurczuk Magdalena , Rositch Anne , Soto Sandra , Kosek Margaret , Zevallos Karine , Jeronimo Jose , Ladron de Guevara Gabi , Brown Joanna , Kohler-Smith Anna , Vasquez Javier , Lopez Renso , Rios Reyles , Gravitt Patti E.
Published: July 2020

PURPOSE

The aim to this work was to develop an operational research methodology for context-appropriate selection, adaptation, and evaluation of the implementation of novel cervical cancer screening and treatment methods.

METHODS

We developed the Integrative Systems Practice for Implementation Research (INSPIRE) methodology, a multifaceted strategy that blends existing theoretical implementation research frameworks and defines specific research methods for use at each phase. INSPIRE is a participatory, iterative process involving 4 phases: system understanding, finding leverage, acting, and learning/adapting. Mixed methods were used to meet the objectives of each INSPIRE phase. Qualitative methods were grounded in soft systems methodology and CFIR, and quantitative methods in RE-AIM. Pathway and scenario analyses supplemented standard research methods.

RESULTS

We engaged more than 90 multilevel stakeholders in the design of a new and improved screen-and-treat system. Elaboration of system process maps through triangulation of the mixed-methods data served to create a shared reference of the current system in participatory discussions. Significant leverage opportunities were identified, including reducing fragmentation, inefficiency, and a lack of standardization to increase women’s acceptability of screening and adherence to the continuum of care. A variety of interventions were evaluated using a multiple scenario analysis tool and, ultimately, stakeholders recommended adoption of human papillomavirus testing/self-sampling to increase coverage and ablative treatment of all human papillomavirus–positive women to reduce loss to follow up. Implementation was launched in July 2019, and iterative application of INSPIRE to early implementation challenges is being used to ensure real-time adaptation to emerging system behaviors and the acceptability and sustainability of the program.

CONCLUSION

Continued success in the engagement of stakeholders in shared decision making suggests that using the INSPIRE methodology in designing implementation strategies increases a sense of ownership in the process, which may lead to more sustainable screening programs in low- and middle-income countries compared with top-down approaches.