Financial Toxicity: Unveiling the Burden of Cancer Care on Patients in Rwanda.

INTRODUCTION: Cancer is a major public health problem in Rwanda and other low- and middle-income countries (LMICs). While there have been some improvements in access to cancer treatment, the cost of care has increased, leading to financial toxicity and treatment barriers for many patients. This study explores the financial toxicity of cancer care in Rwanda. METHODS: This prospective cross-sectional study was conducted at 3 referral hospitals in Rwanda, which deliver most of the country's cancer care. Data were collected over 6 months from June 1 to December 1, 2022 by trained research assistants (RAs) using a modified validated data collection tool. RAs interviewed consecutive eligible patients with breast cancer, cervical cancer, colorectal cancer, Hodgkin's and non-Hodgkin's lymphoma who were on active systemic therapy. The study aimed to identify sources of financial burden. Data were analyzed using descriptive statistics. RESULTS: 239 patients were included; 75% (n = 180/239) were female and mean age was 51 years. Breast, cervix, and colorectal cancers were the most common diagnoses (42%, 100/239; 24%, 58/239; and 24%, 57/239, respectively) and 54% (n = 129/239) were diagnosed with advanced stage (stages III-IV). Financial burden was high; 44% (n = 106/239) of respondents sold property, 29% (n = 70/239) asked for charity from public, family, or friends, and 16% (n = 37/239) took loans with interest to fund cancer treatment. CONCLUSION: Despite health insurance which covers many elements of cancer care, a substantial proportion of patients on anti-cancer treatment in Rwanda experience major financial toxicity. Novel health financing solutions are needed to ensure accessible and affordable cancer care.

Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference.

Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.

New insights into hexavalent chromium exposure in electron donor limited denitrification: bio-electron behavior.

The bio-electron behavior (electron production, transmission, and consumption) response to a typical heavy metal, hexavalent chromium, was unraveled in the electron donor limited system (EDLS) and electron donor sufficient system (EDSS). Nicotinamide adenine dinucleotide and adenosine triphosphate production were reduced by 44% and 47%, respectively, due to glucose metabolism inhibition, leading to NO3--N declining to 31% in EDLS. The decreased electron carrier contents and denitrifying enzymes activity inhibited electron transmission and consumption in both EDLS and EDSS. Additionally, electron transfer and antioxidant stress abilities were reduced, further hindering the survival of denitrifiers in EDLS. The lack of dominant genera (Comamonas, Thermomonas, and Microbacterium) in EDLS was the primary reason for poor biofilm formation and chromium adaptability. The decreased expression of enzymes related to glucose metabolism caused the imbalance of electron supply, transport, and consumption in EDLS, adversely impacting nitrogen metabolism and inhibiting denitrification performance.

A Variable Radius Side Window Direct SLAM Method Based on Semantic Information.

Simultaneous Localization and Mapping (SLAM) is a challenging and key issue in the mobile robotic fields. In terms of the visual SLAM problem, the direct methods are more suitable for more expansive scenes with many repetitive features or less texture in contrast with the feature-based methods. However, the robustness of the direct methods is weaker than that of the feature-based methods. To deal with this problem, an improved direct sparse odometry with loop closure (LDSO) is proposed, where the performance of the SLAM system under the influence of different imaging disturbances of the camera is focused on. In the proposed method, a method based on the side window strategy is proposed for preprocessing the input images with a multilayer stacked pixel blender. Then, a variable radius side window strategy based on semantic information is proposed to reduce the weight of selected points on semistatic objects, which can reduce the computation and improve the accuracy of the SLAM system based on the direct method. Various experiments are conducted on the KITTI dataset and TUM RGB-D dataset to test the performance of the proposed method under different camera imaging disturbances. The quantitative and qualitative evaluations show that the proposed method has better robustness than the state-of-the-art direct methods in the literature. Finally, a real-world experiment is conducted, and the results prove the effectiveness of the proposed method.