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Kothari K, Damoi JO, Zeizafoun N, Asiimwe P, Glerum K, Bakaleke M, Giibwa A, Umphlett M, Marin M, Zhang LP. Increasing access to pathology services in low- and middle-income countries through innovative use of telepathology. Surg Endosc 2023; 37:7206-7211. [PMID: 37365395 DOI: 10.1007/s00464-023-10220-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION In low- and middle-income countries (LMICs), surgical care can be limited by access to pathology services. In Uganda, the pathologist-to-population ratio is less than 1 to 1 million people. The Kyabirwa Surgical Center in Jinja, Uganda, created a telepathology service in collaboration with an academic institution in New York City. This study demonstrated the feasibility and considerations of implementing a telepathology model to supplement the critical pathology needs of a low-income country. METHODS This was a retrospective, single-center study of an ambulatory surgery center with pathology capability using virtual microscopy. The remote pathologist (also known as a telepathologist) controlled the microscope and reviewed histology images transmitted across the network in real time. In addition, this study collected demographics, clinical histories, the surgeon's preliminary diagnoses, and the pathology reports from the center's electronic medical record. RESULTS Nikon's NIS Element Software was used as a dynamic, robotic microscopy model with a video conferencing platform for communication. An underground fiber optic cable established Internet connectivity. After a two-hour tutorial session, the lab technician and pathologist were able to proficiently use the software. The remote pathologist read (1) pathology slides with inconclusive reports from external pathology labs, and (2) tissues labeled by the surgeon as suspicious for malignancy, which belonged to patients who lacked financial means for pathology services. Between April 2021 and July 2022, tissue samples of 110 patients were examined by a telepathologist. The most common malignancies on histology were squamous cell carcinoma of the esophagus, ductal carcinoma of the breast, and colorectal adenocarcinoma. CONCLUSION With the increasing availability of video conference platforms and network connections, telepathology is an emerging field that can be used by surgeons in LMICs to improve access to pathology services, confirming histological diagnosis of malignancies to ensure appropriate treatment.
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Affiliation(s)
- Krsna Kothari
- Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
| | | | - Nebras Zeizafoun
- Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | | | - Katie Glerum
- Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | | | | | - Melissa Umphlett
- Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Michael Marin
- Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Linda P Zhang
- Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
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Omali D, Buzibye A, Kwizera R, Byakika-Kibwika P, Namakula R, Matovu J, Mbabazi O, Mande E, Sekaggya-Wiltshire C, Nakanjako D, Gutteck U, McAdam K, Easterbrook P, Kambugu A, Fehr J, Castelnuovo B, Manabe YC, Lamorde M, Mueller D, Merry C. Building clinical pharmacology laboratory capacity in low- and middle-income countries: Experience from Uganda. Afr J Lab Med 2023; 12:1956. [PMID: 36873289 PMCID: PMC9982508 DOI: 10.4102/ajlm.v12i1.1956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 11/30/2022] [Indexed: 02/05/2023] Open
Abstract
Background Research and clinical use of clinical pharmacology laboratories are limited in low- and middle-income countries. We describe our experience in building and sustaining laboratory capacity for clinical pharmacology at the Infectious Diseases Institute, Kampala, Uganda. Intervention Existing laboratory infrastructure was repurposed, and new equipment was acquired. Laboratory personnel were hired and trained to optimise, validate, and develop in-house methods for testing antiretroviral, anti-tuberculosis and other drugs, including 10 high-performance liquid chromatography methods and four mass spectrometry methods. We reviewed all research collaborations and projects for which samples were assayed in the laboratory from January 2006 to November 2020. We assessed laboratory staff mentorship from collaborative relationships and the contribution of research projects towards human resource development, assay development, and equipment and maintenance costs. We further assessed the quality of testing and use of the laboratory for research and clinical care. Lessons learnt Fourteen years post inception, the clinical pharmacology laboratory had contributed significantly to the overall research output at the institute by supporting 26 pharmacokinetic studies. The laboratory has actively participated in an international external quality assurance programme for the last four years. For clinical care, a therapeutic drug monitoring service is accessible to patients living with HIV at the Adult Infectious Diseases clinic in Kampala, Uganda. Recommendations Driven primarily by research projects, clinical pharmacology laboratory capacity was successfully established in Uganda, resulting in sustained research output and clinical support. Strategies implemented in building capacity for this laboratory may guide similar processes in other low- and middle-income countries.
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Affiliation(s)
- Denis Omali
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Allan Buzibye
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Richard Kwizera
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rhoda Namakula
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joshua Matovu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Olive Mbabazi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Emmanuel Mande
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Damalie Nakanjako
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ursula Gutteck
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Keith McAdam
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Philippa Easterbrook
- Department of Human Immunodeficiency Virus, World Health Organization, Geneva, Switzerland
| | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jan Fehr
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Barbara Castelnuovo
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Yukari C Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Mueller
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Concepta Merry
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland
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Bebell LM, Ngonzi J, Meier FA, Carreon CK, Birungi A, Kerry VB, Atwine R, Roberts DJ. Building Perinatal Pathology Research Capacity in Sub-Saharan Africa. Front Med (Lausanne) 2022; 9:958840. [PMID: 35872791 PMCID: PMC9304650 DOI: 10.3389/fmed.2022.958840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/24/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Over two million stillbirths and neonatal deaths occur in sub-Saharan Africa (sSA) annually. Despite multilateral efforts, reducing perinatal mortality has been slow. Although targeted pathologic investigation can often determine the cause of perinatal death, in resource-limited settings, stillbirths, early neonatal deaths, and placentas are rarely examined pathologically. However, the placenta is a key source of diagnostic information and is the main determinant of fetal growth and development in utero, influencing child health outcomes. Methods In 2016, our collaborative intercontinental group began investigating infectious perinatal death and adverse child health outcomes in Uganda. We developed and initiated a 4-day combined didactic/practical curriculum to train health workers in placental collection, gross placental examination, and tissue sampling for histology. We also trained a local technician to perform immunohistochemistry staining. Results Overall, we trained 12 health workers who performed gross placental assessment for > 1,000 placentas, obtaining > 5,000 formalin-fixed tissue samples for research diagnostic use. Median placental weights ranged from 425 to 456 g, and 33.3% of placentas were < 10th percentile in weight, corrected for gestational age. Acute chorioamnionitis (32.3%) and maternal vascular malperfusion (25.4%) were common diagnoses. Discussion Through a targeted training program, we built capacity at a university-affiliated hospital in sSA to independently perform placental collection, gross pathologic examination, and placental tissue processing for histology and special stains. Our training model can be applied to other collaborative research endeavors in diverse resource-limited settings to improve research and clinical capacity and competency for diagnostics and management of stillbirth, neonatal death, and child health outcomes.
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Affiliation(s)
- Lisa M. Bebell
- Division of Infectious Diseases, Department of Medicine, Medical Practice Evaluation Center and Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- *Correspondence: Lisa M. Bebell,
| | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Frederick A. Meier
- Department of Pathology, Wayne State University School of Medicine, Detroit, MI, United States
| | - Chrystalle Katte Carreon
- Division of Women’s and Perinatal Pathology, Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
- Department of Pathology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Abraham Birungi
- Department of Pathology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Vanessa B. Kerry
- Division of Pulmonary and Critical Care Medicine and Center for Global Health, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Seed Global Health, Boston, MA, United States
| | - Raymond Atwine
- Department of Pathology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Drucilla J. Roberts
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Chipidza FE, Kayembe MKA, Nkele I, Efstathiou JA, Chabner BA, Abramson J, Dryden-Peterson SL, Sohani AR. Accuracy of Pathologic Diagnosis in Patients With Lymphoma and Survival: A Prospective Analysis From Botswana. JCO Glob Oncol 2021; 7:1620-1632. [PMID: 34860565 PMCID: PMC8654434 DOI: 10.1200/go.21.00209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE With intense HIV epidemics, southern African countries have a high burden of classic Hodgkin lymphoma (CHL) and non-Hodgkin lymphoma (NHL). However, suboptimal access to pathology resources limits subtype classification. We sought to assess the diagnostic accuracy of specimens classified as lymphoma and to determine association between discordant pathologic diagnosis and overall survival. METHODS Seventy patients with CHL or NHL and treated at three Botswana hospitals from 2010 to 2016 were analyzed. Local pathologic assessment relied primarily on morphology. All cases underwent secondary US hematopathology review, which is considered gold standard. RESULTS The median follow-up was 58 months. The overall reclassification rate was 20 of 70 cases (29%). All 20 CHL cases were correctly classified in Botswana, and mixed cellularity was the most common subtype, diagnosed in 11 (55%) cases. Of 47 confirmed NHL cases, diffuse large B-cell lymphoma was the final US diagnosis in 28 cases (60%), another aggressive B-cell NHL in nine (19%), an indolent B-cell NHL in six (13%), and T-cell NHL in four (9%). Common types of diagnostic discordance included NHL subtype reclassification (11 of 20, 55%) and CHL reclassified as NHL (7 of 20, 35%). Concordant versus discordant diagnosis after secondary review was associated with improved 5-year overall survival (60.1% v 26.3%, P = .0066). Discordant diagnosis was independently associated with increased risk of death (adjusted hazard ratio 2.733; 95% CI, 1.102 to 6.775; P = .0300) even after stratifying results by CHL versus NHL. CONCLUSION In this single prospective cohort, discordant pathologic diagnosis was associated with a nearly three-fold increased risk of death. Limited access to relatively basic diagnostic techniques impairs treatment decisions and leads to poor patient outcomes in low-resource countries.
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Affiliation(s)
- Fallon E Chipidza
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA.,Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Mukendi K A Kayembe
- University of Botswana, Gaborone, Botswana.,Ministry of Health, Gaborone, Botswana
| | - Isaac Nkele
- Botswana Harvard AIDS Institute, Gaborone, Botswana
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | | | | | - Scott L Dryden-Peterson
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Aliyah R Sohani
- Department of Pathology, Massachusetts General Hospital, Boston, MA
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Osinde G, Niyonzima N, Mulema V, Kyambadde D, Mulumba Y, Obayo S, Anecho E, Watera S, Constance M, Kadhumbula S, Orem J. Increasing access to quality anticancer medicines in low- and middle-income countries: the experience of Uganda. Future Oncol 2021; 17:2735-2745. [PMID: 33855863 DOI: 10.2217/fon-2021-0117] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Cancer is one of the leading causes of death with 9.6 million deaths registered in 2018, of which 70% occur in Africa, Asia and Central and South America, the low-and middle-income countries (LMICs). The global annual expenditure on anticancer medicines increased from $96 billion in 2013 to $133 billion in 2017. This growth rate is several folds that of newly diagnosed cancer cases and therefore estimated to reach up to $200 billion by 2022. The Uganda Cancer Institute, Uganda's national referral cancer center, has increased access to cancer medicines through an efficient and cost-saving procurement system. The system has achieved cost savings of more than USD 2,000,000 on a total of 37 of 42 essential cancer medicines. This has resulted in 85.8% availability superseding the WHO's 80% target. All selected products were procured from manufacturers with stringent regulatory authority approval or a proven track record of quality products.
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Affiliation(s)
- Godfrey Osinde
- Uganda Cancer Institute, Kampala, Upper Mulago Hill Road, P.O Box 3935, Kampala, Uganda
| | - Nixon Niyonzima
- Uganda Cancer Institute, Kampala, Upper Mulago Hill Road, P.O Box 3935, Kampala, Uganda.,Makerere University, University Road, P.O Box 7062, Kampala, Uganda.,Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., Seattle, WA 98109-1024, USA
| | - Vivienne Mulema
- Clinton Health Access Initiative Uganda, Plot 8, Moyo Close, Kololo, Kampala
| | - Deo Kyambadde
- Uganda Cancer Institute, Kampala, Upper Mulago Hill Road, P.O Box 3935, Kampala, Uganda
| | - Yusuf Mulumba
- Uganda Cancer Institute, Kampala, Upper Mulago Hill Road, P.O Box 3935, Kampala, Uganda
| | - Siraj Obayo
- Uganda Cancer Institute, Kampala, Upper Mulago Hill Road, P.O Box 3935, Kampala, Uganda
| | - Ezra Anecho
- Uganda Cancer Institute, Kampala, Upper Mulago Hill Road, P.O Box 3935, Kampala, Uganda
| | - Susan Watera
- Uganda Cancer Institute, Kampala, Upper Mulago Hill Road, P.O Box 3935, Kampala, Uganda
| | - Mughuma Constance
- Uganda Cancer Institute, Kampala, Upper Mulago Hill Road, P.O Box 3935, Kampala, Uganda
| | - Sylivestor Kadhumbula
- Uganda Cancer Institute, Kampala, Upper Mulago Hill Road, P.O Box 3935, Kampala, Uganda
| | - Jackson Orem
- Uganda Cancer Institute, Kampala, Upper Mulago Hill Road, P.O Box 3935, Kampala, Uganda.,Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., Seattle, WA 98109-1024, USA
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