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TREATMENT AND OUTCOMES OF PEDIATRIC SUPRACONDYLAR HUMERAL FRACTURES IN KORLE-BU TEACHING HOSPITAL.
(BAIDOO PAA KWESI, 2015-12-01) BAIDOO, PAA KWESI
BACKGROUND Supracondylar humeral fractures are the most common elbow fractures in the pediatric population. These normally result from either a fall on the outstretched hand or the flexed elbow resulting in either the extension or flexion types respectively. They are usually associated with complications such as neurovascular injuries, compartment syndrome, pin tract infections and malunion which in the end after the cosmetic and functional outcomes according to the Flynn’s criteria. The objective of this study was to determine the treatment and outcomes of pediatric supracondylar fractures of the distal humerus at Korle Bu Teaching hospital. METHODOLOGY This was a prospective study carried out at the trauma and orthopedic unit of Korle Bu Teaching Hospital, Accra. Patients for this study were recruited over a year period from January 2014 to January 2015. An evaluation form was filled by the principal investigator and attached to patient’s folders. One hundred and one patients were entered into the study. Treatment of supracondylar humeral fractures in children were guided by the department’s protocol. Patients were followed up over a six (6) month period . Data collected during this period were entered into the REDCap data base, which is a secured web based data collection tool hosted by the University of California, San Francisco (UCSF). The results were then analysed using SPSS version 23. RESULTS The mean age was 5.2 years with a peak of 4-5 years. There were seventy three (73) males and twenty eight (28) females with a ratio of 2.6:1. Most of the injuries occurred at home (64.3%) followed by at school (27.7%). The left arm (non-dominant) was the most injured (62%) compared to the right (38%), though most of the patients seen were right hand dominant (92%). Gartland type III (43.6%) was the commonest fracture followed by type I (31.7%) and type II (24.7%) respectively. Outcomes of management of these fractures were satisfactory based on Flynn’s criteria in over 95 % of the patients. The pediatric quality of life outcome was significantly affected at three weeks after the injury. However, they returned to the population normal at six month. Pin tract infections (5 patients), nerve injury (3 patient), vascular (1 patient), cubitus varus (1 patient), elbow stiffness (1 patient) and myositis ossificans (1 patient) were the complications observed in the study and were mostly associated with high energy injuries (type III fractures). CONCLUSIONS Pediatric supracondylar humeral fractures are very common injuries and their diagnosis and treatment presents a major difficulty to us as orthopedic surgeons. However, through this study, it is concluded that the outcomes of treatment of these fractures at our institution is satisfactory and comparable to other places where they manage such fractures.
EPIDEMIOLOGY AND TREATMENT OUTCOME IN PATIENTS PRESENTING WITH PLANTAR FASCIITIS AT THE KORLE BU TEACHING HOSPITAL
(NGISSAH, REUBEN KWESI SAKYI, 2015-12-01) NGISSAH, REUBEN KWESI SAKYI
Background Plantar fasciitis (PF) is a common cause of heel pad pain. The pain associated with this clinical condition can result in impairment of activities of daily living. Although the diagnosis of this condition is easy to clinch, the aetiology remains unclear with numerous treatment options, because no single treatment has strong scientific evidence to support its use to improve outcome. For most patients presenting with this condition at the Orthopaedic unit of Korle-Bu Teaching Hospital (KBTH), the main treatments offered are plantar fascia stretching exercises and corticosteroid injection if the former fails. The rationale of this study was to describe the epidemiology of this clinical condition, identify some of the risk factors common in patients presenting to the Orthopaedic unit of the Korle Bu Teaching Hospital and to determine baseline outcome of KBTH treatment protocol for PF and compare it to those reported in the literature. Methods This was a longitudinal study on patients presenting with plantar fasciitis to the unit between September, 2014 and August, 2015. Those who met the inclusion criteria were recruited in this study. All newly diagnosed patients were offered plantar fascia stretching exercises; those who failed to respond to treatment based on the Visual Analogue Scale for pain and a modification of foot function index after a month or two were offered corticosteroid injection in addition to plantar fascia stretching exercise. Results Forty four patients met the inclusion criteria for this study with an incidence of 2.75% of all new cases reporting at the Orthopaedic OPD of the KBTH over the study period. At the end of the 12th week, thirty seven patients were available for follow up. Majority of the patients seen were females (thirty eight), leading to a female to male preponderance of 6.3:1. Twenty three patients representing 52.5% belonged to the age group of 41-50%. The mean age was 47.9 years with a standard deviation of 9.7 years. All the patients seen responded ‘yes’ to morning pain marked after a few couple of steps and to pain after prolonged periods of inactivity. Twenty six patients (59.1%), admitted to be involved in occupations that involved prolonged weight bearing. No significant structural risk factors in terms of pes planus, pes cavus, and leg length discrepancy were detected. Ninety percent of the patients seen were either overweight, obese or morbidly obese. Thirty five patients (79.4%) had a heel spur on X-ray. At four weeks, out of the 42 patients available for follow up, only 5(11.9%) required steroid injection in addition to physiotherapy. At eight weeks, only one (2.56%) of the 39 patients available for follow up had steroid injection in addition to the physiotherapy. By the end of the 12 weeks, 37 patients were available for follow up. All the 37 patients had significant improvement in their VAS scores as well as their modified foot function index scores. The means and (standard deviations) for VAS scores at baseline, 4th week, 8th week and 12th week were, 7.05 (2.2); 5.05 (2.5); 3.15 (1.6); 1.9 (1.2) respectively. The means for the modified FFI at baseline, 4th week, 8th week and 12th week were, 16.0, 11.4, 6.8, 3.7 respectively, with corresponding standard deviations of 4.0, 5.6, 4.6, and 3.0 respectively. These results shows a trend in improvement of symptoms with time. Conclusions Plantar Fasciitis was found to be common in females. Majority of the patients were middle aged 41 to 50 years with a mean age of 47.9 years and a standard deviation of 9.7 years. Early morning pain at the heel which is marked with few couple of steps is characteristic of plantar fasciitis. Not all patients with plantar fasciitis have a heel spur on X-ray. Structural risk factors in terms of pes cavus, pes planus, and leg length discrepancy were uncommon in this study. Elevated BMI, happened to be a major risk factor in this study; ninety percent of the patient were either overweight, obese or morbidly obese. Stretching exercises should be employed as the first line of treatment for patients presenting with plantar fasciitis
FACTORS CONTRIBUTING TO LATE PRESENTATION OF PATIENTS WITH STRABISMUS TO THE KOMFO ANOKYE TEACHING HOSPITAL, GHANA
(AMANKWAA-FREMPONG DOREEN, 2020-11-26) AMANKWAA-FREMPONG, DOREEN
Introduction Strabismus is an ophthalmic condition that refers to the misalignment of the eyes. It is a common eye problem in both children and adults resulting in reduced visual acuity, abnormal binocular vision and low self-esteem. Anecdotally, most patients with strabismus present late to the Eye Clinic at the Komfo Anokye Teaching Hospital (KATH). Factors contributing to this late presentation have not been studied. This study sought to determine the factors contributing to late presentation of patients with strabismus at KATH. Methods This was a hospital-based cross-sectional study of factors contributing to late presentation of patients with strabismus at KATH. Patients with strabismus who met the inclusion criteria were examined after informed consent and assent. Socio-demographic characteristics of the patients such as age, sex, place of residence, education, etc., were recorded using a structured questionnaire. Clinical findings (age at onset of strabismus, age at presentation, deviating eye, type of deviation, etc.) were documented on the questionnaire. Data collected was analysed using SPSS Version 20 and presented using descriptive and inferential statistics. Chi-square test, odds ratios and 95 % confidence intervals were computed. P-values less than 0.05 were considered statistically significant. Results A total of 330 (males-180, 54.5 % and females-150 (45.5 %) patients were recruited into this study. The mean age at onset and presentation of strabismus were 4.0±1.2 years and 10.1±9.4 years. Age of patient, education of patient, having no relative with strabismus, monthly income level of family and having no knowledge about strabismus were associated with late presentation of patients with strabismus (p-values = 0.002, 0.001, 0.025, 0.001 and 0.001 vi respectively). There was no association between type of strabismus, type of deviation, presenting visual acuity, angle of deviation and late presentation of patients with strabismus (p-values = 0.423, 0.196, 0.446 and 0.624). Children were 0.1 times less likely to present late compared to adults [OR = 0.1; CI = (0.01-0.8); p-value = 0.032]. Participants with lower education were 1.6 times more likely to present late with strabismus compared to those having higher education [OR = 1.6; CI = (1.1-2.3); p-value = 0.006]. Beneficiaries of National Health Insurance Scheme (NHIS) were 0.4 times less likely to present late compared with non-beneficiaries of NHIS [OR= 0.4; CI = (0.2 -0.9); p-value = 0.037]. Patients with no knowledge about strabismus were 2.9 times more likely to present late compared with those who have knowledge about strabismus [OR= 2.9; CI = (1.5 -5.8); p-value = 0.002]. Patients who have no relatives with strabismus 2 times more likely to present late compared with those having relatives with strabismus [OR= 2.0; CI = (1.0 -4.3); p-value = 0.042]. Conclusions Age, education of patient, having no relative with strabismus, monthly income level of family and having no knowledge about strabismus were associated with late presentation of strabismus. Being an adult, having a lower level of education, not having NHIS and knowledge about strabismus, not having relatives with strabismus could predict late presentation of patients with strabismus.
CHARACTERISTICS AND OUTCOMES OF PAEDIATRIC TRAUMATIC BRAIN INJURIES PRESENTING TO KOMFO ANOKYE TEACHING HOSPITAL.
(EKREMET, KWAME, 2021-03-08) EKREMET, KWAME
Introduction: Traumatic Brain Injury (TBI) in children is a major cause of morbidity and mortality in many countries. Despite the magnitude of this problem in children, there are limited studies to characterise paediatric TBI in Ghana. The primary objective of this study was to determine the characteristics and outcomes of children less than 15 years presenting to a tertiary academic teaching hospital with acute traumatic brain injury at discharge and three months post-injury. The secondary objective was to identify the factors which accounted for the variation in the outcomes of children presenting with TBI. Methods: This was a hybrid study consisting of a prospective cross-sectional study of consecutive children, less than 15 years of age, who presented with TBI to the Komfo Anokye Teaching Hospital Emergency Department (KATH ED): in addition, an embedded cohort study was performed which followed up for three months those patients discharged from the hospital. Socio-demographic and injury characteristics were collected. Participants were followed until hospital discharge. Mortality as an outcome at hospital disposition was determined. Another outcome, the Paediatric Glasgow Outcome Scale- Extended (GOSE), was assessed within 24 hours of discharge and repeated at three months post-TBI. Research Electronic Data Capture (REDCap) was used to enter the data into a secured database electronically. Data was exported to Microsoft Excel ® for data cleaning, after which STATA 13.1 was used for the analysis. Results: A total of 369 patients presented with paediatric trauma to the KATH ED during the study. 136 of these children were managed for traumatic brain injury (TBI) giving a prevalence of 36.86%. Males predominated (63.24%) with the 5- to 9-year age group mostly (41.91%) affected. Road traffic crashes (69.12%) with pedestrian-vehicle collision (67.02%, 63/94) were the most frequent mechanisms of paediatric TBI. The majority (94.12%) of the children with TBI were managed conservatively with a neurosurgical operative rate of 1%. Paediatric TBI mortality rate was 10.29%. Most (61.98%, 75/121) were discharged with a moderate-to-severe disability according to the paediatric GOSE. At three months post-TBI, the majority (91.18%, 93/102) of the discharged patients had a good recovery from the TBI. Severe TBI (adjusted OR [AOR] 136.02, 95% CI 2.76 to 6,706.22) and the development of complication on the ward (AOR 29.03, 95% CI 2.44 to 344.91) were independent positive predictors of mortality for children with TBI, whereas anti- seizure requirement was less likely to predict a good recovery at 3 months post- TBI (AOR, 0.15; 95% CI, 0.03 to 0.72). Interpretation: A significant number of children with TBI were discharged with an acquired disability; however, by three months post-TBI, most of the children had made a good recovery. For many children with TBI, conservative management may be sufficient as the definitive management plan. Conclusions: Paediatric TBI was common affecting 1 in 3 children presenting with paediatric trauma to KATH ED. It mainly affected males, those aged between 5 and 9 years, with RTCs being the principal mechanism of injury. Although most children with TBI were discharged with moderate-to-severe disability from the TBI, three months following the injury, most of them had recovered adequately. Successful long-term follow-up of paediatric trauma, and specifically paediatric TBI, is feasible in LMICs such as Ghana. The paediatric TBI care in Ghana could inform such care in High-Income Countries.
FACTORS INFLUENCING ADOLESCENTS’ USE OF SERVICES AT ADOLESCENT HEALTH CORNERS IN THE BRONG AHAFO REGION
(AFREH KUFFOUR OSEI, 2021-03-12) AFREH, KUFFOUR OSEI
Introduction: Adolescents are generally a healthy population. Nonetheless, they face significant health challenges. Low contraceptive use, unplanned pregnancies and Sexually Transmitted Infections (STIs) including HIV/AIDS among adolescents in sub-Saharan Africa are unacceptably high and of public health concern. Complications from pregnancy and childbirth have been identified as the leading cause of death in girls aged 15-19 yrs in low and middle income countries, where almost all the estimated 3 million unsafe abortions occur. Adolescent Health Corners (AHCs) were established at selected public health facilities in the early 2000s to create conducive environments for service delivery and utilisation by adolescents. Consequently, scale up of the AHCs was embarked upon by Ghana Health Service and her partners where UKAID through the Palladium Group’s Ghana Adolescent Reproductive Health (GHARH) Project, refurbished and equipped 54 Adolescent Health Corners in the Brong Ahafo Region. This study sought to examine factors that influence adolescents in using the services provided at the AHCs. Methods A cross-sectional study was used by adopting a mixed method of data collection. Quantitative data was collected randomly from 509 study participants selected from 11 districts sampled randomly from the 27 administrative districts across the Brong Ahafo Region. Two focus group discussions were also conducted for adolescents within two of the selected districts. Eleven in-depth interviews were conducted for health care providers at the AHCs in the selected Districts. Results Majority (73.1%) of the adolescents were aware of the presence of AHCs in their catchment area. Majority (82.5%) of the respondents who were aware of AHCs had used services at the AHCs. Females had a significantly higher odds of awareness of the existence of AHCs compared to males (AOR=2.34, CI=1051-3.62, p=0.003). Adolescents whose mothers and fathers attained a primary education had higher odds [4.25 (1.93, 9.35), 3.94 (1.21, 12.79) respectively] of being aware of AHCs in their area of residence (p<0.05). Only 48.5% of schools had School Health Clubs (SHC). Adolescents who were members of SHC were 5.86 times more likely to use the services at the AHC (p<0.002). 35.2% of respondent said that providing recreational activities in the corners would attract more adolescents and 33.8% stated that services should be provided in a friendly manner. They also called for intensification of awareness creation campaign about the existence of AHCs and services provided (18.6%), provision of regular health screening (10.1%) and abortion services at the corner (2.3%). Conclusion: AHCs are crucial in reaching out to adolescents through the provision of adequate information and services during the period of adolescence. Majority of adolescents interviewed were aware of AHCs and had used the services provided. However, efforts should be made to create more demand for the services. Establishment of SHC in schools with school children being members of the clubs was found to create additional opportunity to reach out to adolescents and improve use of services at AHCs. Services provided at AHCs should be appealing to adolescents with assured privacy and confidentiality. Trained staff should create a friendly environment to address the concerns of adolescents.
NONALCOHOLIC FATTY LIVER DISEASE IN TYPE 2 DIABETES MELLITUS PATIENTS ATTENDING THE DIABETES CLINIC AT THE GREATER ACCRA REGIONAL HOSPITAL
(BAMPOH SALLY AFUA, 2021-08-26) BAMPOH, SALLY AFUA
Background: Nonalcoholic fatty liver disease is currently the leading cause of chronic liver disease and the second leading indication for liver transplantation in developed countries. It may be complicated by cirrhosis and hepatocellular carcinoma. The pathogenesis of primary nonalcoholic fatty liver disease involves insulin resistance, which also occurs in type 2 diabetes mellitus. The prevalence of nonalcoholic fatty liver disease is increasing worldwide. However, published data on this condition in Ghana is scarce. General Objective: To determine the prevalence of, and factors associated with nonalcoholic fatty liver disease in type 2 diabetes mellitus patients attending the diabetes clinic at the Greater Accra Regional Hospital in Accra, Ghana. Methodology: This study was a cross-sectional, hospital-based study conducted at the Greater Accra Regional Hospital from May to October 2018. Two hundred and thirty-five type 2 diabetes mellitus patients with insignificant alcohol history and negative screens for hepatitis B and C infection were recruited using systematic random sampling, after giving informed consent. Socio- demographic and clinical data were obtained using a semi-structured questionnaire. Anthropometric measurements, general and abdominal examinations were performed for each participant. Laboratory investigations included full blood count, fasting blood sugar, glycated haemoglobin, lipids and liver biochemistry. Abdominal ultrasonography was performed to assess for liver size and echogenicity and to measure the abdominal subcutaneous fat thickness. Non- invasive scoring systems were used to predict the presence of nonalcoholic steatohepatitis and fibrosis. Captured data was imputed and analysed using SPSS 23.0. Results: The prevalence of nonalcoholic fatty liver disease among this cohort was 38.7% (91/235). Grade 3 disease was the most prevalent (46.1%). Prevalence of nonalcoholic steatohepatitis and fibrosis using non-invasive methods was estimated to be 23.1% and 26.4% respectively, in the population diagnosed with nonalcoholic fatty liver disease. Factors associated with presence of nonalcoholic fatty liver disease included age (p-value = 0.008), shorter duration of diabetes (p- value = 0.004), body mass index (p-value <0.0001), waist circumference (p-value = 0.006), waist/hip ratio (p-value = 0.001), abdominal subcutaneous fat thickness (p-value <0.0001), hepatomegaly (p-value <0.0001), glycated haemoglobin (p-value = 0.003) and hypertriglyceridaemia (p-value = 0.021). Increasing age (OR = 0.949; 95% CI: 0.918 - 0.980), body mass index (OR = 1.108; 95% CI: 1.048- 1.171), hepatomegaly (OR = 4.230; 95% CI: 1.957 - 9.144) and elevated gamma-glutamyltransferase (OR = 3.591; 95% CI: 1.631 - 7.906) were found to be independent predictors of nonalcoholic fatty liver disease among this cohort. Conclusions: Roughly one-third of type 2 diabetes mellitus patients seen in clinics may have nonalcoholic fatty liver disease. Predictors of nonalcoholic fatty liver disease in this study include established non-modifiable risk factors such as age, as well as modifiable risk factors such as increased body mass index. Recommendations: Clinicians should utilize non-invasive markers to aid in the diagnosis of nonalcoholic fatty liver disease, especially in at-risk patients. Aggressive management of type 2 diabetes mellitus is needed to improve the outcome of the disease in Ghana. Further studies on the performance of non-invasive markers compared to liver biopsy are warranted in order to find alternate forms of diagnosis in low resource settings.
COMPARISON OF EFFECTIVENESS OF COUNSELLING ONLY, SUPPOSITORY DICLOFENAC AND LIDOCAINE SPRAY AT INTRAUTERINE DEVICE INSERTION
(YANNEY HENRY EKOW, 2021-09-30) YANNEY, HENRY EKOW
Background In Ghana, only 0.8% of married and 0.4% of unmarried women are on IUD. The perception of pain at IUD insertion is one of the main barriers of its uptake. Several pharmacological and non-pharmacological interventions have been studied. Despite these attempts, there is currently no consensus on the best form of pain management at IUD insertion. The aim of this study was therefore to compare the effectiveness of counselling only (standard of care), 10% lidocaine spray of the cervix and 100mg suppository diclofenac sodium in reducing pain at IUD insertion. Methodology A prospective study involving women of reproductive age who presented at the Family Planning Unit, Korle Bu Teaching Hospital and had accepted IUD method of contraception was conducted. Clients who met the inclusion criteria were randomized into 3 arms; suppository diclofenac, lidocaine spray and counselling only arms in a ratio of 1:1:1. A calculated sample size of 99 participants, 33 in each arm was used. All participants had a baseline counselling on the procedure and then those on diclofenac arm were given 100mg diclofenac sodium suppository 30 minutes whilst the 10% lidocaine spray arm were given 4 pumps on the cervix before the insertion. Using a 10cm- Visual Analog Scale (VAS), the pain experienced at various stages of IUD insertion, the overall pain experienced after IUD insertion, 5 minutes and 4 hours post procedure were assessed. Mean pain scores were compared using a one way ANOVA and a Post-Hoc test used to compare which two groups were significantly different from each other. Categorical variables between groups were compared using a chi-square test. The statistical significance was set at p < 0.05 and confidence interval at 95%. Results Ninety nine participants were recruited for the study. The average age of the participants was 33.6+ 6.2 years whilst the average BMI was 29.5+ 5.7kg/m2. There were 11/99 (11.11%) of respondents who were single, 3/99 (3.03%) who did not have formal education, 39/99 (39.39%) of them who had tertiary education; and 34/99 (34.34%) who were professionals. Traders and artisans represented 31/99 (31.31%) each and majority 93/99 (93.94%) were Christians. Suppository diclofenac was superior to counselling only at pain control during speculum insertion, tenaculum insertion, uterine sound insertion, IUD placement, immediately after procedure and 5 minutes after procedure. Lidocaine spray of the cervix on the other hand, was superior to counselling only throughout the procedure and up to 4 hours post procedure. Again, Lidocaine spray of the cervix was found to be superior to suppository diclofenac at pain control 5 minutes after procedure (mean pain score 0.6 versus 1.5) and 4 hours after procedure (0.7 versus 0.9) Conclusion Lidocaine spray (10%) of cervix is more effective compared to 100mg Diclofenac Sodium in reducing pain at IUD insertion. The use of 10% lidocaine spray of cervix at insertion of IUD will therefore greatly enhance clients’ satisfaction at IUD insertion and in the long run help to increase the uptake of the IUD, a highly effective long acting reversible contraceptive.
EFFECTS OF HYPERHAEMOLYSIS ON FETOMATERNAL OUTCOMES IN PREGNANT WOMEN WITH SICKLE CELL DISEASE
(ASARE EUGENIA VICKY NAA KWARLEY, 2021-09-30) ASARE, EUGENIA VICKY NAA KWARLEY
Background: Sickle cell disease (SCD) is a public health problem in sub-Saharan Africa. Recent improvement in healthcare has ensured significant increase in survival and increased chance of getting pregnant. Chronic haemolysis is a feature of SCD; haemolysis has been linked to chronic uncompensated anaemia, pulmonary hypertension, chronic leg ulcers, priapism, renal impairment, acute vaso-occlusion, venous thromboembolism and death in SCD. Hyperhaemolysis occurs in stressful conditions, and pregnancy can be stressful. Pregnancy in SCD, can be life-threatening and may be associated with poor fetomaternal outcome. Few studies, have looked at hyperhaemolysis during pregnancy and its association with fetomaternal outcome. Methodology: A prospective cohort study with 25 pregnant women with SCD, and their 2 sets of matched controls (23 pregnant women without SCD; 25 non-pregnant women with SCD) was conducted at the Obstetrics department, Korle-Bu Teaching Hospital, and the adult sickle cell clinic, Ghana Institute of Clinical Genetics, Korle-Bu. The pregnant women with and without SCD were matched for gestational age (±2weeks) and enrolled during the second trimester. Most pregnant women presenting to the clinic for their booking visit are unsure of the date of their last menstrual period. As such, the gestational age is determined by an obstetrics scan. During the second trimester an obstetrics scan gives an error margin of 10 to 14 days; hence there will be no difference in the gestational age match using ±2weeks. The SCD group (pregnant/non-pregnant) were matched for age (±2years) and phenotype. The age match was based on convenience. All pregnant women with and without SCD were followed up prospectively till six weeks postpartum. The non-pregnant women with SCD had only baseline samples drawn. The primary outcome of the study was to determine the association between hyperhaemolysis and fetomaternal outcome in pregnant women with SCD using selected markers of haemolysis- haemoglobin, absolute reticulocyte count, lactate dehydrogenase (LDH), aspartate aminotransferase (AST), serum bilirubin and urobilinogen. The maternal outcomes were acute pain, ACS and anaemia. The fetal outcomes were spontaneous abortion, intrauterine fetal death (IUFD), preterm birth and low birthweight. Data was extracted using Excel and analysed by the use of means, standard deviation, analysis of variance and logistic regression using STATA corps version 14. Results: The mean age of the study participants was 30.3 ± 5.3 years. The mean gestational age at enrollment for the pregnant women with and without SCD was 19.4 ± 3.7 weeks. There were 13 acute pain episodes in nine pregnant women with SCD with a pain incidence rate of 1.23 events per patient- years. There was no admission for ACS during the study period. Using the criteria for defining hyperhaemolysis, only one patient each had a drop in Hb ≥20% from baseline at 28 and 36 weeks’ gestation and six weeks postpartum; with no corresponding 25% increase in reticulocyte count and an increase in LDH, indirect bilirubin and AST. There were no significant differences in the concentrations of the haemolytic markers during study follow-up. Compared to the pregnant women without SCD, the pregnant women with SCD had more caesarean deliveries [4(19.0%) vrs 18(72.0%);p=0.01]; preterm births [5(27.8%) vrs 10(41.7%);p=0.35], low birthweight babies [3(16.7%) vrs 7(29.2%); p=0.74] and IUFD [0 (0.0%) vrs 2 (8.0%)] respectively. Conclusion: This study did not demonstrate hyperhaemolysis in pregnant women with SCD; hence no association between hyperhaemolysis and fetomaternal outcome could be determined. There was no difference in steady state laboratory parameters of the selected markers of haemolysis between the SCD cohorts (both pregnant and non-pregnant).
ASSOCIATION BETWEEN FAMILY RESOURCES AND DRUG ADHERENCE IN HYPERTENSIVE MANAGEMENT AT THE CHRONIC CARE CLINIC OF KOMFO ANOKYE TEACHING HOSPITAL
(OPOKU CONSTANCE AFRA, 2021-10-25) OPOKU, CONSTANCE AFRA
Introduction Hypertension is the commonest risk factor for cardiovascular diseases which is currently the leading cause of death globally. Of the almost 1.4 billion people with hypertension worldwide, 71.4% (one billion) are found in low and middle-income countries (LMIC) with the WHO Africa region having the highest current prevalence of hypertension. One of the strongest pillars in the multifactorial approach to the management of hypertension is improving medication adherence to antihypertensives. It is imperative that innovative ways be sought to achieve this goal among health practitioners and especially Family Physicians who aim to provide comprehensive care for any pathology including hypertension. Even though there is information on social determinants of health and their influence on medication adherence and hypertension, little is known about the effect of family resources on medication adherence in hypertension and consequently blood pressure control. Aim To determine the relationship between Family Resources and Medication Adherence in patients with essential hypertension Materials and Methods This was a cross-sectional study carried out at the Chronic Care Clinic of the Family Medicine Directorate at the Komfo Anokye Teaching Hospital. Systematic sampling was used to select 110 patients with essential hypertension attending the clinic. Patients were administered a questionnaire which incorporated the Morisky 8 adherence Scale, the SCREEM questionnaire for measuring family resources and general demographic data. Medical records of the patients were also assessed to obtain current and previous blood pressure control records. The information obtained was entered into epi-info, cleaned and transferred into STATA statistical software (Version 15). Basic demographic data and frequencies were extracted following which Chi square analysis and Fisher exact tests were conducted and multivariate regression performed on specific variables to assess relevant relationships. The results of the analysed data were then presented as frequencies in tables and charts. Results A total of 110 patients with essential hypertension were enrolled in this study majority of whom were female (94, 85.5%), Christian (102, 92.7%), married (54, 49.1%) had basic education (84, 76.4%) and had uncontrolled blood pressure (65, 59.1%). Adequate family resources were reported by most respondents (85, 77.3%) with religious resources most reported as being available (89.1%) while the least available resource was economic (30.9%). The results also showed that married participants were more likely to have adequate family resources (p = 0.04) and Christians were more likely to report adequate social resources (p = 0.04). Majority of participants self-reported medium or high adherence to their antihypertensive medication (68.2%), however participant demographics had no influence on medication adherence or blood pressure control. Conclusion The most available family resource was the religious resource with the least available resource being economic. Self- reported medication adherence was found to be adequate in majority of respondents, with 68.2% of respondents reporting either medium or adequate medication adherence. No association was found between family resources and medication adherence among respondents. It is imperative that further research be conducted to establish how to harness religious resources in the improvement of medication adherence. It is also recommended that other objective adherence measuring tools be used to assess for possible relationships between family resources and medication adherence in the control of essential hypertension.
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.
ENDOMETRIAL CANCER – A 10-YEAR REVIEW OF CLINICOPATHOLOGICAL FEATURES AND TREATMENT OUTCOME
(DADZIE, MARY – ANN, 2022-03-01) DADZIE, MARY – ANN
Although recently there have been significant advances in the understanding of endometrial cancer biology, the role of lymphadenectomy, adjuvant radiation, and chemotherapy is still not well defined. As a result, variability in the management of endometrial cancer across oncology centres is common and may have an impact on outcomes. There is limited literature on the current incidence of endometrial cancer, its detailed clinicopathological pattern, prognosis and practices in the management of endometrial cancer from Ghana. Lack of such information hampers the development of strategies to improve the outcome. Aim: To assess the treatment outcomes and factors affecting recurrence and survival in endometrial cancer patients treated with curative intent at the Korle Bu Teaching Hospital from January 2009 to December 2018. Methodology: In this retrospective study, data on patients with histological diagnosis of endometrial carcinoma seen at the National Radiotherapy, Oncology and Nuclear Medicine Centre treated between 1st January 2009 and 31st December 2018 were retrieved from the database. All patients had total abdominal hysterectomy with or without pelvic +/- para-aortic lymphadenectomy/sampling. Adjuvant therapy included external beam radiotherapy (EBRT) on cobalt- 60 machine +/-vaginal brachytherapy either with low or high dose rate +/- chemotherapy depending on risk stratification. Information regarding the demographic, clinical and pathological status of patients, type and sequence of treatment and follow-up of the patient after treatment was retrieved from the patients’ medical records. Patients that met the inclusion criteria were assessed. They were then categorized into risks groups based on the PORTEC definition and analyzed for the following endpoints: loco-regional and distant recurrence rates, the overall and disease–free survival rates, and factors affecting recurrence, disease-free and overall survival. Results: A total of 146 out of 269 patients were eligible for the study. The mean age was 61.3 years with majority being postmenopausal (77%) and a high prevalence of hypertension (42%) and diabetes (20%). The commonest presentation was abnormal vaginal bleeding (79%) and major histological type was endometrioid adenocarcinoma (78%). All patients had total abdominal hysterectomy with bilateral salpingo-oophrectomy with a lymph node dissection rate of 11% and a lymph node positivity rate of 62.5%. Less than half (47%) were FIGO stage 1. The 5year overall survival was 87.5%, 69%. 57% and 30% respectively for low, intermediate, high Intermediate and high risk patients (P-value: 0.001) whiles that for disease-free survival was 67%, 59%, 64.5% and 54% (P- value: 0.74). Adjuvant radiotherapy resulted in significantly improved 2year disease-free survival compared to those who had no radiotherapy in intermediate (100% vs 54% p-value: 0.006), high intermediate (87.5% vs 63%, p-value:0.041) and high risk (70.5% vs 45.5% p-value :0.041) but not overall survival. There was no difference in disease free and overall survival between patients who had pelvic lymphadenectomy and those who did not. After a median follow up of 34.5 months, there were 51 (35%) recurrences, majority of which were pelvic. Lymphovascular space invasion was the only factor associated with recurrence(p-value:0.01) whiles FIGO stage (P-value: 0.05), grade(p-value:0.03) and histology(p-calue:0.02) were associated with survival. Marital status was the only sociodemographic factor associated with survival Conclusion: Overall survival outcome for patients with endometrial cancer is comparable to developed countries but not disease-free survival which was poorer due to high recurrence rate. Adjuvant radiotherapy significantly improved the disease-free survival notably in intermediate risk population. Novel molecular testing is needed to better risk stratify and select patients who will benefit from adjuvant therapy to mitigate the high pelvic recurrences observed in the study.
RADIOLOGICAL ANATOMY OF THE ARTERIAL SUPPLY OF THE PROSTATE GLAND
(BABATUNDE BASHIRU JIMAH, 2022-03-01) BABATUNDE, BASHIRU JIMAH
Background: In West Africa and Ghana, prostate arterial embolization (PAE) is a novel procedure. To ensure effective prostatic arterial embolization and selective intervention, a thorough understanding of prostate artery anatomy and its relationship to prostate size is required. Aim: The purpose of this study is to describe the anatomy of adult male prostate arterial supply and correlate them with prostate gland size and artery diameter on Computed Tomography of patients presenting to Euracare Advanced Diagnostic and Heart Centre. Methodology: A prospective cross-sectional study was conducted, at Euracare Advanced Diagnostics and Heart Centre. Patients who presented for Computed Tomography Angiography of the pelvis were included in the study. A total of 104 pelvic halves (52 males) were studied, and pertinent conclusions were reached. The diameter of the prostate artery and the volume of the prostate gland were measured. The Pearson Correlation coefficient was used to calculate the correlation between prostate artery diameter and prostate gland volume. The branching pattern of the prostate artery was classified using the de Assis et al (2015) classification, which serves as the foundation for most classifications. Result: According to the data, 37 (71.15 %) of the patients had enlarged prostate gland with a volume greater than 30ml. All of the patients aged 60 and above had an enlarged prostate gland and were mostly married. A higher proportion of patients with enlarged prostate (18, 94.74 %) had a history of prostate disease. In each pelvic half, one prostate artery was discovered. There were three types of prostate arterial branching. The majority of the pelvic halves (61, 58.7 %) had type 1, followed by type III and type II. In 50% of the pelvic halves, the origin was symmetrical type I. The mean prostate artery diameter was 1.28mm + 0.16 on the right and 1.26mm + 0.18 on the left, which was higher among those over 60. The average prostate gland volume was 42.58+14.17ml. The mean volume was higher in those over 60 (54.22+2.52 ml) compared to those under 60 (32.60+5.11ml), p =0.0000. The prostate gland volume and the diameter of the right (r=0.4771, p=0.0003) and left (r=0.5131, p=0.0001) arteries showed a significant positive correlation. Similar findings were made with those who had enlarged prostate glands with the right (r-0.3559, p=0.0306) and left (r = 0.4176, p=0.0101) prostate arteries.. Conclusion: The prostate arteries in the study population had type I, III, and II origins. The mean prostate artery diameter increases with increasing age and increasing prostate volume.
OUTCOMES AND DETERMINANTS OF PSA BASED HIGH RISK PROSTATE CANCER PATIENTS TREATED WITH CURATIVE RADIATION AT KORLE BU TEACHING HOSPITAL ACCRA, GHANA
(ARYEETEY NAA ADORKOR, 2022-03-01) ARYEETEY, NAA ADORKOR
BACKGROUND: Prostate cancer (CAP) is one of the commonest male cancers worldwide. Usually described as a slow growing malignancy, treatment outcomes are often favourable with five-year overall survival quoted at 80% even in the metastatic setting of disease. Risk categorisation prior to treatment using several parameters including but not limited to prostate specific antigen (PSA), Gleason score, clinical stage and recently molecular features allows for tailored treatment predicated on life expectancy and the risk of recurrence. Local treatment is with radical prostatectomy, external beam radiotherapy and brachytherapy. The management of high risk localised prostate cancer patients with high PSA remains a challenge as there is paucity of data on treatment outcomes. External beam radiotherapy (EBRT) to doses above 70Gy with peri-radiotherapy androgen deprivation therapy (ADT) in the neoadjuvant, concurrent and adjuvant setting for 2-3 years is the recommended standard treatment for high risk disease. Partial implant brachytherapy, low dose rate permanent implant of radioactive isotopes (I125, Cs-131 and Pd 103), augmented with EBRT (45Gy-50Gy) is an alternative for local treatment of high risk disease. High dose rate brachytherapy (Ir-192 and Co-60) currently in use delivers doses upwards of 12Gy per fraction to the prostate gland. This can be used in the stead of low dose rate brachytherapy. Both options allow for dose escalation with reduced side effects to organs at risk. Treatment outcomes for patients with increasing PSA maybe inferior compared to those with low pre-treatment PSA levels represented by short time to biochemical failure and high biochemical failure rates, assuming the suspicion that patients with high pre-treatment PSA harbour early micro metastatic disease holds true. With evidence suggesting improved outcomes for localised treatment even in the presence of clinically evident metastasis, treatment outcomes are expected to be improved irrespective of pre-treatment PSA. The question though is whether outcomes will differ with increasing PSA levels. Aim: To compare the treatment outcomes of localised high risk prostate cancer patients treated with curative intent using radiation therapy based on their pre-treatment PSA levels and the effect of a Gleason grade of 5 as primary grade on treatment outcomes METHODOLOGY: In this retrospective chart review that combined descriptive and inferential study design, a cohort of patients treated from January 2010 to December 2014 were described for their demographic, tumour and treatment characteristics. A core group with localised high risk prostate cancer based on their PSA levels between 20-200ng/ml treated with curative intent with external beam radiotherapy alone (EBRT) or brachytherapy augmented by external beam radiotherapy(BRACHY+EBRT) with or without androgen deprivation therapy (ADT) were grouped based on their pre-treatment PSA levels. Group A had PSA 20-49.9 ng/ml Group B 50-99.9ng/ml and C 100-200ng/ml and followed up from date of diagnosis to 31st December 2020. The patients were analysed using inferential statistic for treatment outcomes; biochemical and overall survival using Kaplan Meier curves and compared using log rank test. Patients were also compared for biochemical and overall survival outcomes based on their primary Gleason grade and combined Gleason score. Kruskal Wallis test of means was used for univariate analysis of non-parametric data and Cox regression analysis for multivariate analysis. RESULTS: Eighty three percent of patients seen were evaluable for descriptive statistics (486 of 584). The median age at presentation was 67 years (range of 44-85 years). Adenocarcinoma was the commonest histology forming more than 99.6% of histologically diagnosed patients. The median PSA at presentation was 31.9ng/ml (interquartile range 20ng/ml-95ng/ml). Clinical stage T2N0 was the modal stage at diagnosis. Combined Gleason score was available for all but one patient with localised disease but only 88% of the patients had primary and secondary Gleason grades recorded. Majority of the patients seen had high risk disease (53%), 7% low risk, 21% intermediate risk and 18% patients with metastatic disease. Data was inadequate to risk categorise 1% of the patients. Approximately half of patients with localised disease did not receive their intended curative treatment. High risk patients had the highest default rate of 58%. External beam radiotherapy was the most used treatment modality. The mean dose for EBRT only was 72.42Gy, mean D90 was168.68Gy for brachytherapy only and for combination therapy the mean D90 of 109.60Gy and 45.35Gy for brachytherapy and EBRT respectively. Mean duration of treatment was for EBRT only was 8.9 weeks for the intended 7.5 weeks. Medical castration was the most used form of ADT. ADT was used for a mean of 14.6 months mainly in the high risk group. Four patients had bilateral total orchiectomy as lifelong ADT while 2 patients had radiotherapy concurrent with diethylstilbesterol (DES) and then for a total of 36 months. The core group was followed up for a median of 7.25 years (range 4-10.5 years). There was a statistically significant difference in biochemical failure free survival when patients were stratified on pre- treatment PSA with p-value of 0.033. Based on combined Gleason score, biochemical failure free survival approached statistical significance with a p-value of 0.083. There was no difference in biochemical failure free survival when compared based on primary Gleason grade The 5 and 10-year biochemical free survival ranged from 46-68% and 36%-62% respectively, highest for Group B. Group C did not reach the 10 year mark for follow-up. Stratified for primary Gleason grade, biochemical failure free survival was about 55% at 10 years for primary Gleason grade 2-3. Primary Gleason 5 had biochemical failure free survival of 52% at 10years. Gleason 4 did not reach the 10-year follow-up mark but it was below that for Gleason 5 at 6 years, 38%. The curves were not statistically significantly different from each other with a pvalue of 0.311. Nadir PSA value was found to be statistically significant for predicting biochemical failure free survival on both univariate and multivariate analysis. A Receiver operator characteristic (ROC) curve drawn to predict 4 year biochemical failure free survival based on the nadir PSA found 0.07ng/ml as the threshold PSA (p-value 0.047). Estimated overall survival rates were above 70% at 10 years irrespective of patient stratification; pre-treatment PSA, primary Gleason grade or combined Gleason score. Overall survival showed a trend towards statistical significance when patients were assessed based on their combined Gleason score (p-value 0.06). This was not the case for pre-treatment PSA or primary Gleason grade. The biochemical failure free survival for group A, did not translate into overall survival benefit. A planned systematic analysis to predict PSA cut off for curative treatment for localised high risk prostate cancer was abandoned due to the lack of difference in overall survival outcomes when patients were grouped based initial PSA. CONCLUSION: Demography (age) and histological types of prostate cancer patients seen at the hospital compares to the rest of the world. Survival outcomes for localised high risk prostate cancer patients treated with radiotherapy and ADT at the National Radiotherapy Oncology and Nuclear Medicine Centre (NRONMC) of the Korle Bu Teaching Hospital (KBTH) is also comparable to existing published datasets. In our analysis a high initial presenting PSA up to 200ng/ml influenced biochemical outcomes in favour of low initial PSA. There was no difference in overall survival outcomes. This suggests all patients should receive curative treatment irrespective of pre-treatment PSA (up to 200ng/ml) provided there is no clinical or radiologic evidence of metastasis. There were no predictors of overall survival but nadir PSA
POSTOPERATIVE PAIN MANAGEMENT IN EMERGENCY ABDOMINAL SURGERY: BIMODAL VERSUS UNIMODAL ANALGESIA
(GYAMFI, FRANK ENOCH, 2022-03-01) GYAMFI, FRANK ENOCH
Introduction Emergency abdominal surgery may be the right intervention for patients who have traumatic abdominal injuries or surgically correctible abdominal disease processes. The pain after surgery can be distressful to patients if not optimally managed. Postoperative pain management in developing countries like Ghana is considered to be suboptimal. In Ghana, there is a paucity of data comparing the efficacy of parenteral opioids as unimodal analgesia with a combination of paracetamol and opioids in postoperative pain management. Aim This study compared the efficacy of intramuscular (i.m.) morphine as unimodal analgesic with bimodal administration of i.v paracetamol and i.m. morphine in managing postoperative pain in emergency abdominal surgery. Methods/Design This study was conducted at the Surgery Directorate of Komfo Anokye Teaching Hospital, Kumasi, Ghana. It was a single-blinded randomised controlled trial (RCT). Participants were randomised into two arms: those receiving i.m. morphine only and those receiving a combination of i.v. paracetamol and i.m. morphine. Inclusion criteria were patients between 18 and 80 years undergoing emergency abdominal surgery. Elective surgery, contraindications to morphine or paracetamol were exclusion criteria. Pain intensity was measured at intervals of one, three, six, twelve and twenty-four hours after a patient received the first dose of analgesia at the recovery ward, using the Numeric Rating Scale for pain. Data were collected with a structured questionnaire, using an electronic data capturing system and extracted onto STATA 13 for analysis. Chi-Square test and multivariate logistic regression analysis were carried out, putting into consideration odd ratios where statistical significance was derived with p<0.05. Results A total of 110 participants were recruited and data from 108 were analysed of which 75% were males and 25% were females. Mean pain scores were lower at six hours, twelve hours and twenty-four hours after the administration of the first dose of analgesia with statistical significance (P-value 0.02, 0.002 and 0.001 respectively) for those who received only Morphine as opposed to morphine with paracetamol. There was no statistically significant difference between the length of stay and whether a participant received morphine or morphine with paracetamol (P-value 0.33). Those who received only morphine had their first bowel movement earlier than those who received a combination of morphine and paracetamol (P-value 0.03). Nausea and/or vomiting was likely to occur if a participant received only morphine as opposed to receiving morphine with paracetamol ( P-value 0.02). Conclusion Receiving morphine alone or morphine with paracetamol provided adequate pain relief after emergency abdominal surgery even though those who received morphine alone had a lower mean pain score. Whether a patient received morphine alone or morphine with paracetamol did not have any statistical difference in the length of stay. Nausea and vomiting were common in those who received morphine only.
EFFECT OF PERINEURAL DEXAMETHASONE ON ULTRASOUND GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCK FOR POST CAESAREAN ANALGESIA AT KORLE-BU TEACHING HOSPITAL
(SOTTIE AKWANFO YAW DANIEL, 2022-04-01) SOTTIE, AKWANFO YAW DANIEL
INTRODUCTION Caesarean delivery (CD) is a common surgical procedure with associated significant post-operative pain. Adequate post caesarean analgesia enables the new mother to take care of the new born while preventing the debilitating effects of uncontrolled post-operative pain. The most frequent negative response to caesarean delivery in Ghanaian women is pain. Analgesic options following CD in Korle-Bu Teaching Hospital include the use of intrathecal opioids (fentanyl), parenteral opioids (intramuscular pethidine), intravenous paracetamol and rectal diclofenac. The addition of the bilateral transversus abdominis plane (TAP) block with dexamethasone as an adjunct to the existing pain management modalities will provide adequate post caesarean delivery analgesia and improve patient satisfaction. AIM The aim of this study was to assess the effectiveness and safety of perineural dexamethasone in ultrasound guided bilateral TAP block in providing post-operative analgesia in parturients who underwent caesarean delivery under spinal anaesthesia at Korle-Bu Teaching Hospital. METHODS This was a prospective, randomized, double blind study of 99 electively booked patients for caesarean delivery under spinal anaesthesia. These were divided into three groups of 33 each after meeting inclusion/exclusion criteria and giving informed consent. Ultrasound guided bilateral TAP block was administered immediately after caesarean delivery under spinal anaesthesia (using either bupivacaine + dexamethasone (group A), only bupivacaine (group B) or only saline (group C)). Time to request for first analgesia, systemic opioid consumption, numerical rating scale (NRS) pain scores, incidence of pruritus, nausea and vomiting and participants’ satisfaction were recorded. This was entered into Microsoft Excel spread sheet and Statistical Package for the Social Scientists (SPSS) software version 25 used for data analysis. RESULTS The time to first analgesic request was significantly prolonged in the bupivacaine group (327.5 ± 98.69 minutes) compared to the saline group (256.5 ± 72.33 minutes) (p-value = 0.023); with addition of dexamethasone resulting in further prolongation (485.2 ± 143.03 minutes) (p-value < 0.0001) of the time to first rescue analgesic. There was a significantly lower consumption of systemic opioids in the bupivacaine group (269.1 ± 64.44mg) compared to the saline group (380.6 ± 39.21mg) (p-value < 0.0001); with further significant lowering of opioid analgesic requirements (113.6 ± 81.58mg) on addition of dexamethasone (p-value < 0.0001). NRS pain scores at rest and on coughing were lower in the intervention groups compared to the control group. Lower NRS pain scores were recorded with addition of dexamethasone although they were not always significant. The incidence of adverse events of pruritus, nausea and vomiting and sedation was not significantly different amongst the three groups. Participants who had dexamethasone + bupivacaine had higher satisfaction scores than participants who had bupivacaine; who in turn had higher satisfaction scores than participants who had saline. CONCLUSION Addition of dexamethasone to bupivacaine for a TAP block is safe, has opioid sparing effect and provided better postoperative analgesia after Caesarean delivery compared to control and bupivacaine alone TAP at Korle-Bu Teaching Hospital.
PERIOPERATIVE ANALGESIC EFFECT OF SERRATUS ANTERIOR PLANE BLOCK ON BREAST SURGERY. A PROSPECTIVE, RANDOMIZED, CONTROLLED DOUBLE BLIND STUDY CONDUCTED AT THE KORLE BU TEACHING HOSPITAL, ACCRA, GHANA.
(MENSAH KOFI DAVID, 2022-04-01) MENSAH, KOFI DAVID
INTRODUCTION Breast cancer is the most common cancer in women both in the developed and less developed world, according to World Health Organisation. The mainstay of treatment for breast cancer is breast surgery. Pain after breast surgery has been described as moderate to severe. Inadequately treated post-operative pain after breast surgery invariably leads to greater postoperative morbidity, higher hospital cost and persistent post-operative pain. Opioids have been the drugs of choice for management of postoperative pain after breast surgery, however, they are associated with many undesirable side effects. Serratus anterior plane (SAP) block is a new interfascial injection technique for analgesia of the chest wall. There is paucity of data with regards to its use for pain relief and possible opioid-sparing in the West Africa subregion. AIM The aim of this study was to determine whether serratus anterior plane block administered for breast surgery has analgesic effect during the perioperative period in patients undergoing elective breast surgery at the Korle-Bu Teaching Hospital. METHODOLOGY This was a prospective, randomized, double-blinded study. Following Ethical Committee approval, patients who fulfilled the inclusion criteria and gave informed consent were consecutively enrolled into the study. A total of fifty-two (52) patients were enrolled into the study and were randomly assigned into one of two groups. The intervention group (n=26) and the placebo group(n=26). Patients demographic characteristics were recorded. Their pre-induction blood pressure, heart rate, respiratory rate and oxygen saturation were also noted. All patients underwent standard general anaesthesia and their airways secured with laryngeal mask airways. After induction of anaesthesia a blinded anaesthetist performed ultrasound guided serratus anterior plane block with 0.25% plain bupivacaine or 0.9% normal saline. Intraoperatively, heart rate and mean arterial blood pressure were maintained within 20% of the preoperative baseline values by giving intravenous bolus doses of morphine. Intraoperatively, patients’ blood pressure, heart rate and respiratory rate were recorded every five minutes. After surgery, a blinded investigator assessed and noted the numerical rating scale (NRS) score of pain at the recovery ward when patients were conscious and alert, at 1, 4, 8 and 24 hours postoperatively. The incidence of PONV was recorded immediate postoperative period and at 1, 4, 8 and 24 hours postoperatively. Patient satisfaction was also assessed using a simple questionnaire. RESULTS Patients receiving SAP block had lower NRS scores at all measured time points but this was only statistically significant at 4 hours postoperative time(p-value=0.002). The mean intraoperative opioid consumed (morphine equivalent) was slightly higher in the control group (11.9±1.5mg) than it was in the intervention group(11.3±1.5mg), however the difference was not statistically significant (p value = 0.131) There was statistically significant difference in the postoperative opioid consumption in the intervention group and the control group (4.6±5.7mg versus 10.5 ± 6mg) respectively (p value=0.001). Most participants in this study did not experience PONV. Those who had PONV, the highest incidence occurred 4 hours postoperatively but this was not statistically significant between the two groups (p-value = 0.098). No participant experienced severe PONV. No adverse effects were noticed in those who had the SAP block. Generally, patients in both groups were very satisfied with their postoperative pain management. CONCLUSION Serratus anterior plane block reduces NRS pain scores postoperatively. It also significantly reduces postoperative opioid consumption but does not significantly reduce intraoperative opioid consumption.
TYPES, PRESENTATION AND CHALLENGES WITH THE MANAGEMENT OF ANORECTAL MALFORMATIONS AT KOMFO ANOKYE TEACHING HOSPITAL, KUMASI, GHANA.
(AGYEI FAREEDA, 2022-06-08) AGYEI FAREEDA
Introduction: Anorectal malformations remain a significant challenge to the child and the paediatric surgeon. Clinical outcomes depend on the surgeon's skill, the type of anorectal malformation, associated anomalies and the availability of perioperative and rehabilitation facilities. Anorectal malformation is rare, occurring in about 2-6 per 10000 live births. ⁠ However, its rarity becomes relative in Sub-Saharan Africa, where few surgeons are paediatric surgeons, and only a handful of these few surgeons handle these cases. The burden of treating these patients falls on the few paediatric surgeons available in the region. The paediatric surgeon is faced with challenging clinical scenarios; some children present with complications, either as a result of late presentation or from the initial surgery, done mainly by a local surgeon as a lifesaving procedure. Understanding the challenges the patient, the parents and caregivers, and the paediatric surgeon face in this resource-limited setting is essential. Aim: The aim of the study was to assess the types, modes of presentation, the challenges carers of patients with anorectal malformation encounter during management and the cost implication in a resource-challenged tertiary teaching hospital, Komfo Anokye Teaching (KATH), in Kumasi, Ghana. Methods: The study was a cross-sectional descriptive study carried out on Anorectal malformations at the Paediatric Surgery Unit of Komfo Anokye Teaching Hospital (KATH) over a period of eight months. It employed both qualitative and quantitative study design which was taken at the same time period; a concurrent mixed methodology. Data on all children with anorectal malformation being managed by the Paediatric Surgery Unit of the Department of Surgery, KATH, were obtained. The ARM types, presentation, associated anomalies, surgical interventions, peri operative challenges; challenges with managing and taking care of a child with anorectal condition, and the cost of managing the condition were captured using a structured questionnaire (quantitative study). In-depth interviews of guardians of the children with anorectal malformations who were being managed were also conducted (qualitative study). Results: A total of 61 patients (male: female ratio 1:0.96) were included in the study. A majority, 35 (57.38%), of the patients with anorectal malformations were observed between days 2 and 5. The average birth weight was 3.12kg (SD =0.51). Most of the patients, 88.52% reported late (> 24hrs). Majority of the patients 55.74% presented in a stable state at the emergency department. Acute intestinal obstruction accounted for 32.79% of presentations. All the 61 patients with anorectal malformation underwent a staged procedure. The majority, 60 (98.63%) out of the 61 patients, underwent a three-staged procedure; an initial colostomy, definitive repair, and colostomy closure. Only 1 patient underwent a two-stage procedure in which colostomy + PSARP was done on day 1 of presentation. Closure of colostomy was done 14 months later. The definitive repair for all the children who underwent the three-staged procedure was PSARP. For this study, 45 (75%) had had PSARP, and 29 (48.33%) had closure of colostomy done at the end of the study. Overall complication after all surgeries was 39.3%. There was no significant association between, birth weight (p-value = 0.596), the presence of a fistula (p-value = 0.061), when the malformation was detected (p-value = 0.349) and time of presentation to KATH, (p-value = 0.306). Overall Complications at the initial colostomy, PSARP and colostomy closure were 21.6%, 26.7%, and 27.59%, respectively. The mean duration between a colostomy and PSARP was 7.02 +/- 2.05 months, while between PSARP and colostomy closure was eight months. The mortality rate at the end of the study was 3.3%. The length of stay in the hospital was 11.89 +/- 8.93 days, 29.95 +/- 9.26 days, and 17.51+/- 7.0 days for the initial colostomy, PSARP and the closure of colostomy respectively. The mean cost for the complete three-staged procedure was GHC11604.93 ($2053.90) (1$ = GHC5.65), with out-of-pocket payments accounting for 61.91% of the total cost. 44.3% of the caregivers rated the cost as moderate. Findings from the qualitative study indicated that most caregivers lacked adequate knowledge regarding anorectal malformations. Most respondents highlighted the stigma associated with having a child with ARM and having a colostomy. Rescheduling surgeries, financial constraints, increased out-of-pocket payments, and lack of psychological support were some challenges caregivers had with managing anorectal malformations. Conclusion: Anorectal malformation is challenging to the paediatric surgeon, the patient and the carer. There is a general lack of awareness about the condition among health professionals and carers. The stigma attached to having a child with colostomy is rife and it is associated with a lot of psychological trauma to the carers and family members. The cost of managing anorectal malformation is high and steps must be taken to help carers pay for the cost. Improving public awareness of the condition and our referral system, providing psychological support, training more stoma therapists, increasing the partial amount the NHIS pays for this condition will all go a long way to improve the management and the lives of children born with this congenital abnormality.
TYPES, PRESENTATION AND CHALLENGES WITH THE MANAGEMENT OF ANORECTAL MALFORMATIONS AT KOMFO ANOKYE TEACHING HOSPITAL, KUMASI, GHANA.
(AGYEI, FAREEDA, 2022-06-08) AGYEI, FAREEDA
Introduction: Anorectal malformations remain a significant challenge to the child and the paediatric surgeon. Clinical outcomes depend on the surgeon's skill, the type of anorectal malformation, associated anomalies and the availability of perioperative and rehabilitation facilities. Anorectal malformation is rare, occurring in about 2-6 per 10000 live births. ⁠ However, its rarity becomes relative in Sub-Saharan Africa, where few surgeons are paediatric surgeons, and only a handful of these few surgeons handle these cases. The burden of treating these patients falls on the few paediatric surgeons available in the region. The paediatric surgeon is faced with challenging clinical scenarios; some children present with complications, either as a result of late presentation or from the initial surgery, done mainly by a local surgeon as a lifesaving procedure. Understanding the challenges the patient, the parents and caregivers, and the paediatric surgeon face in this resource-limited setting is essential. Aim: The aim of the study was to assess the types, modes of presentation, the challenges carers of patients with anorectal malformation encounter during management and the cost implication in a resource-challenged tertiary teaching hospital, Komfo Anokye Teaching (KATH), in Kumasi, Ghana. Methods: The study was a cross-sectional descriptive study carried out on Anorectal malformations at the Paediatric Surgery Unit of Komfo Anokye Teaching Hospital (KATH) over a period of eight months. It employed both qualitative and quantitative study design which was taken at the same time period; a concurrent mixed methodology. Data on all children with anorectal malformation being managed by the Paediatric Surgery Unit of the Department of Surgery, KATH, were obtained. The ARM types, presentation, associated anomalies, surgical interventions, peri operative challenges; challenges with managing and taking care of a child with anorectal condition, and the cost of managing the condition were captured using a structured questionnaire (quantitative study). In-depth interviews of guardians of the children with anorectal malformations who were being managed were also conducted (qualitative study). Results: A total of 61 patients (male: female ratio 1:0.96) were included in the study. A majority, 35 (57.38%), of the patients with anorectal malformations were observed between days 2 and 5. The average birth weight was 3.12kg (SD =0.51). Most of the patients, 88.52% reported late (> 24hrs). Majority of the patients 55.74% presented in a stable state at the emergency department. Acute intestinal obstruction accounted for 32.79% of presentations. All the 61 patients with anorectal malformation underwent a staged procedure. The majority, 60 (98.63%) out of the 61 patients, underwent a three-staged procedure; an initial colostomy, definitive repair, and colostomy closure. Only 1 patient underwent a two-stage procedure in which colostomy + PSARP was done on day 1 of presentation. Closure of colostomy was done 14 months later. The definitive repair for all the children who underwent the three-staged procedure was PSARP. For this study, 45 (75%) had had PSARP, and 29 (48.33%) had closure of colostomy done at the end of the study. Overall complication after all surgeries was 39.3%. There was no significant association between, birth weight (p-value = 0.596), the presence of a fistula (p-value = 0.061), when the malformation was detected (p-value = 0.349) and time of presentation to KATH, (p-value = 0.306). Overall Complications at the initial colostomy, PSARP and colostomy closure were 21.6%, 26.7%, and 27.59%, respectively. The mean duration between a colostomy and PSARP was 7.02 +/- 2.05 months, while between PSARP and colostomy closure was eight months. The mortality rate at the end of the study was 3.3%. The length of stay in the hospital was 11.89 +/- 8.93 days, 29.95 +/- 9.26 days, and 17.51+/- 7.0 days for the initial colostomy, PSARP and the closure of colostomy respectively. The mean cost for the complete three-staged procedure was GHC11604.93 ($2053.90) (1$ = GHC5.65), with out-of-pocket payments accounting for 61.91% of the total cost. 44.3% of the caregivers rated the cost as moderate. Findings from the qualitative study indicated that most caregivers lacked adequate knowledge regarding anorectal malformations. Most respondents highlighted the stigma associated with having a child with ARM and having a colostomy. Rescheduling surgeries, financial constraints, increased out-of-pocket payments, and lack of psychological support were some challenges caregivers had with managing anorectal malformations. Conclusion: Anorectal malformation is challenging to the paediatric surgeon, the patient and the carer. There is a general lack of awareness about the condition among health professionals and carers. The stigma attached to having a child with colostomy is rife and it is associated with a lot of psychological trauma to the carers and family members. The cost of managing anorectal malformation is high and steps must be taken to help carers pay for the cost. Improving public awareness of the condition and our referral system, providing psychological support, training more stoma therapists, increasing the partial amount the NHIS pays for this condition will all go a long way to improve the management and the lives of children born with this congenital abnormality.
EFFECTS OF STEROID EYE DROPS ON INTRAOCULAR PRESSURE IN PATIENTS POST CATARACT SURGERY AND ASSOCIATED RISK FACTORS AT A TERTIARY FACILITY AND ITS OUTREACH CENTRE
(MENSA-BONSU, AKOSUA BADU, 2022-06-14) MENSA-BONSU, AKOSUA BADU
Introduction Topical corticosteroids are routinely used after cataract surgery to decrease inflammation, relieve pain, and improve visual outcomes. However, they are known to have significant side effects, whether topically or systemically administered. Not much is known about the incidence of Steroid-Induced Ocular Hypertension (SiOH) in adult Ghanaians undergoing cataract surgery. Considering the immense negative impact visual impairment has on the quality of life of those affected, it is imperative to know the incidence of SiOH in the Ghanaian population. This would help in outlining preventive measures for potential ocular complications among patients undergoing cataract surgery. General Aim To determine the effect of steroid eye drops on intraocular pressure in patients post-cataract surgery and its associated risk factors. Methods This is a prospective cohort study of the effect of steroid eyedrops in patients post-cataract surgery at Korle Bu Teaching Hospital and Emmanuel Eye Centre. Patients undergoing cataract surgery were recruited into the study after informed consent. Demographic information, history and findings from ocular examinations were documented using a structured questionnaire. Baseline intraocular pressures were recorded. Post-operative intraocular pressures were measured on day one, weeks one, five and thirteen after surgery. Continuous numerical data were summarized as mean and Standard deviation (SD) and categorical data as percentages (%). Mean change in intraocular pressure from baseline was computed. Risk factors for SiOH were analysed using a Binary Logistic Regression Model and presented as Odds ratios and 95% Confidence Intervals. Kaplan-Meier survival function was used in calculating the average time (days) to develop SiOH among study participants. P-values less than 0.05 were considered statistically significant. Results A total of 124 patients participated in this study with a mean age of 66.1±13.6 years. Majority 75 (60.0 %) of the study participants were females. The overall mean pre-operative intra ocular pressure (IOP)in the study eyes was 17.8±4.4 mmHg with a 5.3% increase in IOP from baseline which was not statistically significant (p = 0.061). The incidence of SiOH in the study was 29% on post-operative day one and reduced to 1.6% at 13 weeks. In a univariate and multivariate analysis, there were no risk factors associated with the development of SiOH . A sub analysis of the ocular responses however picked up age as a risk factor for responding to the use of topical steroids. Participants aged 70 years and above were more likely to respond to the use of topical steroids after cataract surgery though this did not translate to a significant likelihood of developing SiOH in this cohort of patients undergoing cataract surgery. From Kaplan-Meier analysis, the overall mean time (days) to develop SiOH among the study participants was 55.3 days (95% CI= 47.3 – 63.3 days). Conclusion SiOH post-cataract surgery is a common complication in this study cohort with an incidence of 36.3 %; most of which (29%) occurred within the first month post-operation. There were no risk factors associated with the development of SiOH in this study. Patients undergoing cataract surgery should have their IOP monitored closely during their early postoperative visits to prevent ocular complications associated with prolonged raised IOP.
DETERMINATION OF NORMATIVE VALUES FOR CENTRAL CORNEAL THICKNESS IN GHANAIAN CHILDREN IN THE ABLEKUMA SOUTH SUB-METROPOLITAN AREA
(BEYUO, VERA MAWUSIME, 2022-06-14) BEYUO, VERA MAWUSIME
Background The thickness of the cornea has importance in ocular health. Several studies including the work done by the Ocular Hypertension Treatment Study (OHTS) have demonstrated the significance of Central Corneal Thickness (CCT) measurements in the accurate assessment of intraocular pressure (IOP), accurate diagnosis and prognosis of glaucoma. The variation of CCT with age, gender and race have also been confirmed in studies. CCT has been shown to increase gradually with age in children stabilizing after the age of 10 years and has been shown to be thinner in African/Americans compared to whites. In the adult population, CCT values have been shown to affect the accurate diagnosis and management of glaucoma resulting in the need for assessment of the normal CCT values for any given population. The racial and ethnic variation in CCT values does not support extrapolation of normal population values from one geographic location to the other. In Ghana, data on normal CCT values in children is lacking, resulting in assessment of intraocular pressure based on reference values from populations with potentially different CCT values. It is therefore imperative that CCT values be assessed in healthy Ghanaian children to determine normal values for our population. This will provide baseline data for assessment of deviations from the mean values in the Ghanaian population in future studies to better correlate CCT with IOP values in Ghana. Aim The overall aim of this study was to measure the CCT in healthy Ghanaian children and determine the normal values of defined age-groups. Materials and methods A prospective cross-sectional study was conducted to measure the CCT of 420 children (840 eyes) aged 6 to 15 years. Informed written consent was obtained from parents/ guardians and assent obtained from children aged 8 years and above. An interviewer-administered questionnaire was used to obtain demographic data followed by an anterior and posterior ocular exam. One drop of 0.5% amethocaine was instilled in the eye 1 minute prior to measurement after which a hand-held pachymeter was used to take 3 measurements from the central 3mm of the cornea of the eye. Data handling and statistical analysis plan Statistically significant differences were assessed with the independent t-test for differences in continuous variables such as CCT, analysis of variance (ANOVA) for differences between groups such as age and gender and linear regression for differences in trends. Statistical significance was set at a p value of less than 0.05. Results: The overall mean CCT was 538.8 ± 27 µm (420 children, 840 eyes) and among children aged 6-8 years was 541.4±24.9 µm., for children aged 8-10 years 534.9±25.8 µm and those 10-15 years 538.3±28.6 µm. ANOVA (Analysis of variance with the F statistics) with the Post Hoc tests showed no significant difference in mean CCT among the age groups for both eyes. There was found to be a weak negative correlation between CCT and age. Thus, CCT decreased with age. Though CCT was higher in males, the difference was not statistically significant. Our study also demonstrated that there was a weak positive correlation between CCT and IOP. CCT was higher in hyperopes compared to emmetropes and thinnest in myopes and the difference was statistically significant. Conclusion: CCT in healthy Ghanaian children was found to be 538.8 ± 27 µm and did not vary significantly among age groups or sex. Results of this study provide baseline data for larger national studies that could ultimately lead to the development of national reference ranges for CCT values in the Ghanaian paediatric population. Secondary benefits of this study include improvement in the diagnosis, prognostic prediction, and management of glaucoma in children.

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