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The GCPS Repository is a digital service and an open-access electronic archive that preserves and disseminates digital copies of scholarly publications of faculty, administrators and residents of Ghana College of Physicians and Surgeons:

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COMPARATIVE STUDY OF RE-DISPLACEMENT OF DISTAL FOREARM FRACTURES IN CHILDREN IMMOBILIZED IN ABOVE-ELBOW CAST VS BELOW-ELBOW CAST AT KORLE-BU TEACHING HOSPITAL.

(GHANA COLLEGE OF PHYSICIANS & SURGEONS, 2024-03-26) LARVIE, PRINCE GEORGE

INTRODUCTION Distal forearm fractures are among the commonest fractures seen in children. They typically are the result of fall on the outstretched hand during play. The mismatch between the rapid bone growth and mineral accrual, especially in the distal radius, makes the distal forearm susceptible to fractures from simple falls. These fractures are usually manipulated and stabilized in cast. The choice of cast for immobilizing distal forearm fractures-above elbow versus below elbow still remains controversial. There have been two systematic reviews with meta-analysis till date on the subject. They both recommended further studies on it. There is also paucity of published studies on the subject in West Africa. The literature suggests other factors may be more important in re-displacement of these fractures. AIM This study was to ascertain whether re-displacement in a below elbow cast is worse than in an above elbow cast in children with distal forearm fractures, managed at Korle-Bu Teaching Hospital. METHODS AND MATERIALS This was a non-blinded, randomized control trial, where 58 children between 4 and 13 years, attended to at Department of Orthopaedics, Korle-Bu Teaching Hospital, with closed displaced distal forearm fracture were assigned to one of 2 treatment groups, one receiving below-elbow cast and the other, above-elbow cast. Each child underwent manipulation of the fracture under conscious sedation in the Plaster Room. A below-elbow or an above-elbow POP backslab was applied. The pre- and post-manipulation angulation and apposition in the sagittal and frontal planes were assessed and recorded. A week later, the children came for a completion of the cast, before and after which the angulation and apposition, and the cast and three-point indices were recorded. The children were reviewed each week with new radiographs for 3 weeks. The radiographic parameters we measured again and complications noted and managed. Those who met the criteria for re-manipulation were manipulated. The data was analyzed using Statistical Package for the Social Sciences (SPSS) software, version 20. The categorical data was presented with graphs and tables, and differences assessed with Chi-square analysis. Continuous variables were analyzed with student t-test, using difference of means and multiple regression analysis to ascertain association. RESULTS There were no differences between the means for the two-groups with respect to sagittal angulation change (0.76±0.84 vs 0.82±2.02, p=0.88), frontal angulation change (0.49±0.75 vs 0.40±0.69, p=0.64), sagittal apposition change (0.99±1.11 vs 0.83±0.90, p=0.56), and frontal apposition change (0.87±0.82 vs 1.01±1.21, p=0.60). Multiple regression analysis showed a significant positive association between sagittal angulation change [β (95% Confidence Interval): 6.83(0.45-13.21), p=0.036], and cast index. Stepwise regression modelling also showed a positive association between the cast index and frontal apposition change [β (95% Confidence Interval): 4.69 (0.30-9.08), p= 0.036]. CONCLUSIONS The study found no difference in re-displacement between the below-elbow and above-elbow cast groups, for the management of distal forearm fractures in children. It did however find the cast index as a predictor of re-displacement, when the cut-off was set at 0.80.

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FAMILY FUNCTIONING, COPING STRATEGIES AND SEXUAL DYSFUNCTION AMONG CERVICAL CANCER PATIENTS IN THE KUMASI METROPOLIS, GHANA

(Ghana Consllege of Physicians and Surgeons, 2023-03-15) ACQUAH-HAGAN, GERTRUDE

Introduction: Cervical cancer is arguably the most common cancer among women in Ghana, and it is associated with 16% of mortality due to cancer. In the Kumasi metropolis, it is the second most diagnosed gynecological cancer after breast cancer. This study assessed the extent of sexual dysfunction in women diagnosed with cervical cancer in the Kumasi metropolis; and explored the role of family functioning and coping strategies in dealing with the diagnosis of cervical cancer. Methods: The study was conducted from June to December 2020 among women who had a confirmed diagnosis of cervical cancer at the Komfo Anokye Teaching Hospital, Kumasi, by employing a concurrent triangulation design where both qualitative and quantitative data was collected at the same time. In all, 181 and 15 women were included in the quantitative and qualitative aspects, respectively. Data was collected using a structured questionnaire and in-depth interview guides. Sexual dysfunction, coping strategies and family functioning were measured using the Female Sexual Functional Index (FSFI), the brief-COPE and the Family APGAR scale respectively. Data was analyzed using STATA (version 16.0) statistical software package. Bivariate associations were tested using the chi-square test and fisher exact tests. The relationship between family functioning, sexual dysfunction and coping strategies was assessed using logistic and linear regression models where appropriate. Inferences were made with 95% confidence interval with 5% error margin and a p-value of <0.05. Data from the in-depth interviews were analyzed thematically using variable matrix, flow charts, and relevant quotes to highlight result. Results: The mean age of the women was 58 years (±12.85). More than two-thirds (124; 68.5%) had between 2 – 3 sexual partners and about two-thirds (119; 65.7%) had their first sexual intercourse at age 18. Participants frequently engaged in adaptive coping strategies with religious coping being the most adopted (mean =7.81, SD =0.60). Almost all (96.1%) the respondents had sexual dysfunction. Nearly two-thirds (65.7%) had highly dysfunctional families and nearly one-third (31.5%) had moderately dysfunctional families. Women with parity of 4 – 7 [OR=2.14, 95% CI: 1.12 – 4.07] and 8-13 children [OR=5.52, 95% CI: 1.50 – 20.4] had higher odds of having a functional family compared to those with 0 – 3 children. Having dysfunctional family was associated with a higher mean active coping [β=5.99; 95% CI: 4.54 – 7.46] and lower mean avoidant coping [β= -1.49; 95% CI: -2.60 – -0.38], compared with women who had functional families. There was no significant association between sexual functioning and family functioning. In the qualitative study, the women recounted difficulties with sexual intercourse due to bleeding, pain, fear and advice from doctors. Most of the women coped with their conditions by praying about it. Social support was mainly received from the husbands and children of women with cervical cancer. Almost all the women however disclosed having financial challenges because of the high cost of treatment. Conclusions: This research provides evidence of the prevalence and lived realities of sexual-related challenges and coping strategies among women diagnosed with cervical cancer. Majority of the respondents frequently engaged in adaptive coping strategies, with religious coping being the most engaged coping strategy among the women. There was high prevalence of sexual dysfunction and dysfunctional families among the women studied. Family function was positively associated with adaptive coping and negative associated with maladaptive coping strategies. Health campaigns on cervical cancer should be intensified to demystify the disease and its effects on patients, and also to harness support for women with cervical cancer.

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ULTRASONOGRAPHIC FINDINGS OF THE ACHILLES TENDON IN ASYMPTOMATIC VOLUNTEERS AT THE KORLE BU TEACHING HOSPITAL, ACCRA.

(Ghana College of Physicians and Surgeons, 2022-02-01) NIXON, HAROLD RICKETTS

Introduction: The Achilles tendon (AT) is the thickest and strongest tendon in the human body. It is the conjoint tendon of the gastrocnemius and soleus muscles in the posterior compartment of the leg. It is one of the most commonly injured tendons and is frequently affected by a wide range of inflammatory and degenerative processes. However, AT pathology is often oligosymptomatic and under-evaluated; because symptoms and signs of tendon pathology are open to variable interpretation. Traditional methods of investigating the AT have been magnetic resonance imaging (MRI) and computed tomography (CT) and most of the existing data was obtained from non-African individuals. Noting that genetic differences between the races can result in phenotypic variability, it is likely that the existing data does not fully represent the asymptomatic African AT. Ultrasonography (USG) is a reliable, safe and inexpensive imaging modality for evaluating the AT. In our local setting; USG is the least expensive and most readily available of the available imaging modalities for evaluating the AT. However, there is no definitive work outlining the normal USG features of the AT in our region. This knowledge gap in the USG imaging findings of the AT causes delays in the diagnosis and cost-efficient management of AT pathology. This study sought to determine the USG characteristics of the AT in the asymptomatic population of an African country; thence defining the ‘normal’ USG characteristics of the AT. Objective: To determine the ultrasonographic imaging findings of the Achilles tendon in asymptomatic volunteers at the Korle Bu Teaching Hospital, Accra. Materials and Methods: This was a hospital-based, cross-sectional study at the Radiology department of the Korle Bu Teaching Hospital. The participants (all asymptomatic volunteers above the age of 10 years) were selected with use of standardized questionnaires before inclusion into this study. USG examinations were carried out using a Toshiba Aplio 300 ultrasound machine (Toshiba medical systems corporation, Japan); equipped with a Linear Array 4.8-11 MHz transducer. In all patients, both ATs were scanned. Analysis: Captured data was analyzed in Statistical Package for Social Science (SPSS Inc., Chicago, IL, USA) version 25.0. The main outcome parameters being the echogenicity and thickness of the AT. Ankle dominance and other variables such as age, sex, height and BMI were expressed as percentages and/or graphs. Results: 342 subjects (including 162 males and 180 females) were recruited into the study and underwent bilateral ultrasound examination of their AT. 100% of the ATs reviewed were homogeneously hyperechoic - with mean thickness of 4.84 ± 0.92 mm. Males had thicker AT than females in all groups. 87.7% of dominant AT were thicker than non-dominant AT. Body height had a significant positive correlation with AT thickness. Conclusions: The asymptomatic AT is homogeneously hyperechoic and has mean thickness of 4.84 ± 0.92 mm on USG examination. Departures from these measurements should alert a radiologist to possible pathology when scanning a patient. The results of this study differ from other studies done on non-African populations; suggesting the need for further study on our indigenous population.

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DIABETIC KETOACIDOSIS IN PREGNANCY AND MATERNAL AND FETAL OUTCOMES IN KORLE BU TEACHING HOSPITAL

(Ghana College of Physicians and Surgeons, 2023-03-31) AGYAPONG, JEFF OSEI

Introduction Diabetic ketoacidosis (DKA) is a state of relative or absolute insulin deficiency that results in major metabolic changes including increased glucose production accompanied by decreased peripheral uptake and enhanced protein catabolism and lipolysis. It affects 1 to 3% of diabetic pregnancies. It most commonly complicates type 1 diabetes mellitus (DM) but also affects type 2 DM and more occasionally gestational DM. The incidence is higher in the second and third trimesters of pregnancy when insulin resistance peaks. Diagnosis is based on a triad of hyperglycaemia, ketonaemia or ketonuria, and metabolic acidosis. In pregnancy, DKA tends to occur at lower blood glucose levels. Euglycaemic DKA is a rare condition in which ketoacidosis occurs at normal blood glucose levels. This occurs more commonly in pregnancy. DKA in pregnancy significantly increases the risk of maternal and fetal morbidity and mortality. Management can be very challenging and must involve a multidisciplinary team in a high-dependency or intensive care unit. Maternal complications include acute kidney injury, adult respiratory distress syndrome, cerebral oedema, coma, and death. Fetal complications include fetal heart rate abnormalities, fetal demise, prematurity, and long-term neurodevelopmental delay. The objective of this study was to determine the incidence of DKA in pregnancy in KBTH and maternal and fetal outcomes. Methods This was a prospective cohort study. The study population was pregnant women with diabetes admitted at KBTH. Pregnant women who met the eligibility criteria were screened for ketonuria every time they were seen at the obstetrics emergency room or admitted to the maternity ward or labour ward. Women with urine ketones ≥2+ were tested for bicarbonate and/or pH. Women with pH<7.3 or bicarbonate <15mmol/l became the DKA cases. All the women were followed up for maternal and fetal outcomes including maternal mortality, fetal demise, preterm birth, etc. The association between DKA and maternal and fetal outcomes was determined with logistic regression using a confidence interval (CI) of 95%. Odds ratios were obtained and measurements with p-value <0.05 were deemed statistically significant. Multivariate analysis was done to control for confounders and adjusted odds ratios were determined. viii Results We screened 234 women, representing 91% of pregnant women with diabetes who were admitted at KBTH from 1 st September 2021 to 28th February 2022. Forty-four of them had significant ketonuria and six had DKA, giving an incidence of 2.6%. Two-thirds of the cases occurred in the second and third trimesters. Half occurred in women with GDM. A third had euglycaemic DKA. All the cases were managed according to the KBTH management protocol for DKA in pregnancy. They all recovered. There was no maternal mortality among the DKA cases. We found no significant effect of DKA on maternal and fetal outcomes. Conclusions The incidence of DKA in pregnancy in KBTH is similar to what has been reported in other parts of the world. Universal screening of all pregnant women with diabetes for DKA led to early diagnosis and prompt treatment. The pregnancy outcomes in pregnant women with DKA were comparable to those without DKA.

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FACTORS ASSOCIATED WITH ABNORMAL CERVICAL CYTOLOGY AMONG 6 POSTPARTUM WOMEN IN THE ACCRA METROPOLIS

(Ghana College of Physicians and Surgeons, 2023-05-22) AMOH, MICHAEL YAW

Background Cervical cancer is a growing global health issue that significantly increases morbidity and mortality among women, particularly those in sub-Saharan Africa. The extended pre-invasive stage of the disease characterized by cervical cytological abnormalities can be detected early and prevented from developing into invasive tumors with the aid of robust screening procedures such as Pap (Papanicolaou) smear. Ghana does not have a national programme on screening for cervical cancer. The postpartum period presents a golden opportunity for a Pap smear to be done as most women will go through this stage at least once in their lifetime and also, a large cohort of women can be evaluated at that time. Aim To determine the prevalence and the types of abnormal cervical cytology as well as the associated factors among 6 weeks postpartum women in selected hospitals in the Accra Metropolis. Methodology In this cross-sectional study, 370 women who were 6 weeks postpartum and attended postnatal clinics at Korle Bu Teaching Hospital and the Greater Accra Regional Hospital were assessed for the prevalence and the types of abnormal cervical cytology as well as the associated factors. Participants were recruited via consecutive sampling after ethical approval and informed consent had been obtained. Pretested researcher administered questionnaire was used to collect the socio-demographic, obstetric and gynaecologic characteristics of the participants. Conventional Pap smears were taken and analyzed for all the study participants. Those with abnormal results underwent colposcopy. Data collected were summarized and analyzed using Statistical Package for the Social Sciences version (SPSS) 20. Descriptive statistics such as frequencies, mean and standard deviation were used. Bivariate analysis and multivariate analysis with logistic regression were used to model associations between the dependent and independent variables. A p-value of <0.05 was considered statistically significant at a confidence interval of 95%. Results In all data on 370 participants were included in the analysis. The prevalence of abnormal cervical cytology among the participants was 39/370 (10.5%) at a confidence interval of 95% (7.6%-14.1%). ASCUS (Atypical Squamous Cell of Undetermined Significance) was the most common abnormal cervical cytology representing 31/370 (8.4%). A multiple logistic regression analysis showed that a history of Sexually Transmitted Infection (aOR = 34.88; 95% CI = 13.75 – 88.48; p < 0.001) and a history of irregular condom use (aOR = 4.95; 95% CI = 2.03 – 12.05; p < 0.001) were significantly associated with abnormal cervical cytology. Colposcopy was performed on all participants with abnormal cervical cytology, excluding ASCUS, and the results were adequate and normal. Conclusion The prevalence of abnormal cervical cytology in the post-partum period is 10.5%. The factors associated with abnormal cervical cytology are a history of Sexually Transmitted Infection and a history of irregular condom use. Colposcopy was adequate and normal for all the participants who had abnormal cervical cytology. Efforts must be made to include routine cervical precancer screening in the care given to women during their six-week postpartum visit.