PMJG VOL 6 NO 1

Postgraduate Medical Journal of Ghana
Volume 6 Number 1

Articles in Volume 6 number 1

New Approach to Mental Health and the Implementation of Mental Health Law in Ghana
Seffah JD

View Editorial
New Approach to Mental Health and the Implementation of Mental Health Law in Ghana

Mental illnesses result from a complex interplay of brain circuitry, neurotransmitters, genetics, psychosocial and environmental factors. Stigma based on ignorance continues to be a significant barrier to care in Ghana, as noted by T.A Ulzen in Vol 5 No.2. He further states that the high cost of mental illnesses resulting from prolonged disability, lost productivity and direct and indirect treatment costs should inform strategic plans for the prevention and treatment of psychiatric illnesses. With a psychiatrist to patient ratio of 1:2 million people, it is imperative that all physicians and other healthcare providers be psychiatrically informed, if we are to adequately care for our mentally disabled citizens.

Psychiatric illnesses are significant in at least 50% of primary care visits but these illnesses may not be
diagnosed. Untreated, they contribute to poor medical outcomes and suicide. Major psychiatric and substance
use disorders are chronic medical illnesses of the brain, and are essentially no different from other chronic illnesses such as diabetes and hypertension.

In this issue, the journal introduces two articles on psychiatry. JJ Lamptey et al write about attention deficit
which is a very important disorder. J Clegg-Lamptey et al also write about anxiety and depression as very important associations to be studied in depth in managing our women who are afflicted with breast cancer.

T.P Ulzen’s advice on the implementation of the Mental Health Law is that it should be guided by scientific evidence and proven multi-modal treatments, including psychopharmacology and culturally informed sychotherapeutic and community-based inventions. The law should form the basis for inter-disciplinary training in public mental health education and stigma reduction among teachers, nurses, physicians, social workers, judiciary, law enforcement agencies, pastors and others. Modern communications technology which is currently underutilized must be employed in supporting sustainable solutions that offer protection of human rights and the promotion of resiliency and recovery.

Download Full Editorial


Visual Impairment in Ghanaian Patients with Brain Tumours, Factors Affecting This and Their Prognostic Significance
Tagoe NN, Essuman VA, Fordjuor G, Akpalu J, Bankah P, Ndanu TA

View Abstract
Visual Impairment in Ghanaian Patients with Brain Tumours, Factors Affecting This and Their Prognostic Significance

Key words: brain tumour, visual impairment, blindness, optic atrophy, Ghana

ABSTRACT
Background: Anecdotally, Ghanaians with brain tumours present late with visual impairment. Contributory factors are unclear.

Purpose:To determine the degree of visual impairment in Ghanaians with brain tumours, factors affecting this and their prognostic significance.

Methods: A prospective study of 70 consecutive patients newly diagnosed with brain tumours seen from November 2010 to July 2013, at Korle-Bu Teaching Hospital(KBTH), Accra, Ghana. Patients had clinical diagnosis of brain tumour with confirmation by Computerized tomography(CT) or Magnetic Resonance
Imaging(MRI). Outcome measures: presenting visual acuity, prepresentation symptom interval (PPSI), tumour size and location at presentation.

Results: Data on 70 patients was analyzed. Ages ranged from 8 days to 70 years, mean(SD) 41.8±1.8. Fortyseven (67.1%) were females. Histology was confirmed in 22(75.9%) of 29 who had surgery, comprising: pituitary adenoma, 17(77.3%) meningioma, 2(9.1%) craniopharyngioma, 2(9.1%) and combined pituitary adenoma and meningioma,1(4.5%). Common presenting symptoms were blurred vision, 65(92.9%), headache, 51(72.9%) and ocular pain, 22(31.4%). Common signs were impaired colour vision in 97(79.5%) of 122 eyes and optic atrophy in 49(35%) of 140 eyes. Fourteen (20%) patients were visually impaired and 18(25.7%) blind. Visual impairment
20(14.3%) and blindness, 61(43.6%) were present in 140 eyes. Pre-presentation symptom interval(PPSI) was longer in the blind than the visually impaired. However, no significant association was found between PPSI and visual impairment or blindness (p=0.660). No association was found between diagnosis and visual status at presentation (p=0.629)

Conclusion:Early detection of brain tumours to avoid blindness and visual impairment is needed in this population since majority (57.9%) of eyes were blind or visually impaired at presentation.

Download Full Article


The Prevalence of Attention Deficit Hyperactivity Disorders in A Cluster of Primary Schools in The Ayawaso Submetro, Accra, Ghana
LAMPTEY JJ, THOMAS J

View Abstract
The Prevalence of Attention Deficit Hyperactivity Disorders in A Cluster of Primary Schools in The Ayawaso Submetro, Accra, Ghana

Key words: Prevalence rates, ADHD, selected primary schools, Ayawaso Sub Metro, Accra

ABSTRACT
Background: Attention deficit hyperactivity disorder (ADHD) is a heterogeneous group of disorders characterized by a high level of inattentive, hyperactive and impulsive behaviour that begins in childhood. It is developmentally inappropriate and impairs the functional life of the affected child at home and at school. Although ADHD is a very common childhood developmental disorder, it is not given the attention it deserves in childhood disorders in Ghana. Children affected by ADHD present with numerous psychosocial problems in the communities they live, wherever they find themselves, and in later life. These psychosocial problems include substance, child and sexual abuses. They also present a range of psychiatric and behavioural disorders e.g. suicides and homicides. They are prone to becoming school dropouts, armed robbers and prostitutes. The present study looked at the prevalence of ADHD in a cluster of primary schools in Accra, Ghana. This study is expected to give evidence for early secondary prevention.

Methods: Using random sampling, 18 primary schools were selected from 58 primary schools in the Ayawaso sub metropolitan area in Accra, Ghana. Six out of the eighteen primary schools refused to take part in the study for various reasons. The final cohort of pupils, were from 12 schools with a total population of four hundred and four (404). Their ages ranged from 5 to 9 years. Parents, guardians and teachers were asked to complete the rating scores of symptoms of ADHD by Corners which is based on DSM-IV. The study also assessed the educational status of guardians and parents from the questionnaires.

Results: The total number of ADHD males and females was forty (40) and thirty seven (37) espectively. The prevalence of ADHD in the males and female cohorts were ten percent (10%) and nine-point one percent (9.1%) respectively, making a total prevalence of nineteen-point one percent (19.1%).

Conclusion:The prevalence of ADHD in the selected primary schools was nineteen-point one percent (19.1%). The study also showed that lower socioeducational status may be a positive risk factor for ADHD.

Download Full Article


Comparing Vaginal and Oral Administration of Misoprostol for Cervical Ripening and Induction of Labour in Prolonged Pregnancies
Frempong R

View Abstract
Comparing Vaginal and Oral Administration of Misoprostol for Cervical Ripening and Induction of Labour in Prolonged Pregnancies

Key words: Induction of labour, vaginal misoprostol, oral misoprostol, induction delivery interval

ABSTRACT
Background: Dinoprostone (prostaglandin E2), is presently used as the approved standard protocol for cervical ripening and labour induction. In search for a cheaper alternative, misoprostol (prostaglandin E1) has been found to be a good substitute. The ideal dose, route and frequency of administration of misoprostol are, however, still under investigation. Although, vaginal application of misoprostol has been validated as a reasonable means of induction, there is patient resistance to digital vaginal examination and there is a risk of ascending infection. For these reasons, oral administration of misoprostol for cervical ripening and labour induction has been tried.

Objective: The efficacy and safety of oral and vaginal misoprostol for the elective induction of labour with prolonged pregnancy and unfavourable cervix was compared through a prospective study over a period of one year at the Military Hospital, Accra.

Methods: A prospective, non-blinded randomised study of 148 women with prolonged pregnancy. Data was collected using a prepared structured case record form (data profoma). The study population was randomized into two groups and given 50 µg misoprostol orally in one group and 50 µg vaginally in the other. The main outcomes were measured as induction to delivery time, vaginal delivery achieved within 24 hours and the incidence of uterine hyperstimulation with fetal heart rate (FHR) changes.

Results: The mean induction to delivery interval was shorter in vaginal group than oral group but the differences did not reach statistical significance (12.9hrs vs 14.3hrs; mean difference -1.42, P value = 0.24). The shorter duration of vaginal misoprostol, however, was significant for nulliparous women (13.4hrs vs 17.9hrs; mean difference 4.53, p less than 0.05). There was less failure to achieve vaginal delivery within 24 hours of induction in the vaginal route group, but the differences did not reach statistical significance (6.1% vs. 6.8%; p = 0.81). Fewer women needed oxytocin augmentation in the vaginal group (24.2% vs.17.4%, p = 0.11). There was a higher incidence of uterine hyperstimulation in the vaginal group but not significant (14.7% vs 6.1%, p = 0.10).
APGAR scores at 5 minutes showed no difference between the two groups (1.49% vs. 2.99%, p = 0.42).

Conclusion:Early detection of brain tumours to avoid blindness and visual impairment is needed in this population since majority (57.9%) of eyes were blind or visually impaired at presentation.

Download Full Article


Experience with Palliative Procedures for Congenital Cyanotic Heart Diseases in Ghana: A 20-Year ReviewMen In The Niger-Delta Region Of Nigeria
Tamatey MN, Sereboe LA, Tettey MM, Edwin F, Entsua-Mensah K, Gyan B, Aniteye EA, Adzamli IK, OffeiLarbi G, Ibrahim UE

View Abstract
Experience with Palliative Procedures for Congenital Cyanotic Heart Diseases in Ghana: A 20-Year Review

Key words: Congenital cyanotic heart diseases, Palliative procedures, Good outcome, Ghana

ABSTRACT
Background: Currently, in the management of congenital cyanotic heart diseases with favourable anatomy, primary correction is the preferred choice. But palliative procedures have still maintained an important role in resource-poor regions of the world. We sought to analyze our institutional results for such palliation over a 20-year period. The purpose of the study was to provide information that would guide both practitioners and referring doctors on the future management of congenital cyanotic heart diseases, and also to provide data for comparative studies in the sub region in the future.

Methods: A retrospective study was carried out in the National Cardiothoracic Centre involving all patients who had palliative procedures for congenital cyanotic heart diseases from January 1992 to December 2011.

Results: There were 264 patients, 59% males and 41% females. The case load increased from 2 cases per year in the first year to 34 in the last year of the study. The age range was 4 months – 42 years, with a mean of 7.1 ± 6.9 years. Tetralogy of Fallot comprised 257 (97.4%) of the cases, tricuspid atresia 4 (1.5%), and double outlet right ventricle 3 (1.1%). The modified BlalockTaussig shunt (MBTS) was performed in 262 (92.2%), and the Waterston shunt in 2 (0.8%) of the cases. The overall complication rate was 11.8%, comprising shunt occlusion 7.6%, bleeding requiring re-exploration 0.8% and early mortality of 3.4%.

Conclusion:The modified Blalock-Taussig shunt provided good palliation for congenital cyanotic heart diseases in this environment. We consider it a suitable management alternative when financial and logistic
constraints delay primary repair in resource-poor settings.

Download Full Article


External Structural Congenital Anomalies Diagnosed at Birth in Tamale Teaching Hospital
Nuertey BD, Gumanga SK, Kolbila D, Malechi H, Asilfi A, Konsosa M, Dawuni VA, Duodu E, Osei-Posu G, Mahama IB

View Abstract
External Structural Congenital Anomalies Diagnosed at Birth in Tamale Teaching Hospital

Key words: Induction of labour, vaginal misoprostol, oral misoprostol, induction delivery interval

ABSTRACT
Background: In the year 2013, about 276,000 of the 2.71 million neonatal deaths were directly attributable to congenital anomalies of which an estimated 95%, occurred in low and middle-income countries.

Methods: This study was part of surveillance on external structural congenital anomalies conducted in the Tamale teaching hospital from 1st January 2011 to 31st December 2015. Aggregate data on maternal characteristics and outcome of delivery were collected from the records in the antenatal clinics, labour and delivery room, and midwifery monthly returns.

Results: A total of 35,383 live births were recorded in the study. Overall, 161 external congenital anomalies were recorded over the period. The overall incidence of external congenital anomalies over the five-year period was 455 per 100,000 live births. The gastrointestinal (GIT) system accounted for (77) 47.8%, Central nervous system (65) 40.4%, Major musculoskeletal (9) 5.6%, Genitourinary system about (2) 1.2%, Multisystemic and syndromes accounted for (8) 5.0% of all external structural congenital anomalies. The incidence of specific congenital anomalies found during the study period were as follows; Spina bifida 104.6 per 100,000 live births, Exomphalus/ omphalocele 84.8 per 100,000 live births and Anencephaly 5.7 per 100,000 live births. The incidence of Oro-facial cleft, Hydrocephalus and Imperforate anus were 73.5, 48.0 and 39.6 per 100,000 live births respectively.

Conclusion:External structural congenital anomalies rate in the northern sector of Ghana is unacceptably high. Trend analysis has demonstrated the steady decline in neural tube defects.

Download Full Article


Stab Suprapubic Catheter Insertion: Indications and Peri-Operative Complications, A Four and Half Year Review at The Korle Bu Teaching Hospital, Accra
Asante EKA, Mensah JE, Klufio GO, Kyei MY, Ampadu K N

View Abstract
Stab Suprapubic Catheter Insertion: Indications and Peri-Operative Complications, A Four and Half Year Review at The Korle Bu Teaching Hospital, Accra

Key words: Urinary retention, Stab suprapubic catheter insertion, Complications, Reusable trocar and sheath,
Surgeon grade

ABSTRACT
Background: Suprapubic catheter insertion is a common urological procedure, which is often considered to be simple and safe even in inexperienced hands. The objective of our study was to determine the peri-operative morbidity associated with Stab Suprapubic Catheter Insertion (SSPCI) (i.e. stab suprapubic cystostomy).

Methods: A total of 429 patients who had suprapubic catheter insertion using the stab method (with trocar and sheath) at the Korle-Bu Teaching Hospital, Accra, between January 2010 and June 2014 were identified and their case notes reviewed to determine the peri-operative complication rate in relation to the categories of doctors who undertook the procedure.

Results: The commonest indication for a stab suprapubic catheter insertion was acute/chronic retention of urine secondary to benign prostatic hyperplasia (BPH). The overall complication rate was 3.5% with bowel perforation constituting 0.7% of the complications.

Conclusion:Stab suprapubic catheter insertion is a safe and effective bedside procedure for bladder drainage when urethral catheterization fails or is undesirable, and can be performed by all grades of
surgeons/medical doctors, in selected patients. Complications associated with the procedure can be reduced to a minimum by strict attention to some technical details.

Download Full Article


Indirect Obstetrics Causes of Maternal Death: A-20 Year Retrospective Autopsy Study at The Korle-Bu Teaching Hospital
Der EM, Adu-Bonsaffoh K, Kwame-Aryee RA, Akosa BA

View Abstract
Indirect Obstetrics Causes of Maternal Death: A-20 Year Retrospective Autopsy Study at The Korle-Bu Teaching Hospital

Key words: Indirect obstetric causes, Autopsy, Maternal death
Surgeon grade

ABSTRACT
Background: The pattern and contributions of indirect causes of maternal deaths in Ghana from autopsy data have not been studied. The aim of this study was to estimate the proportions, the spectrum and demographic characteristics of maternal deaths that resulted from indirect obstetrics causes, and to offer recommendations.

Methods: This was a retrospective study of the above stated parameters from autopsy records in the department of pathology of Korle-Bu Teaching Hospital (KBTH).

Results: Approximately 15.2%, of all maternal deaths during the period of study were indirect obstetric causes with a mean age of 28.0 years. About 32.5% of the deaths were recorded in women within 25 – 29 year age group. A little more than a third (35.9%) of the deaths occurred in a health facility. The common underlying indirect causes of death were: infections 99 (39.4%), SCD 73 (29.1%), anaemia in pregnancy 32 (12.7%), chronic liver disease (CLD) 15 (6.0%), cardiovascular disorders (CVS) 10 (4.0%), pulmonary thromboembolism (PE) 8 (3.2%) and neoplastic lesions 5 (2.0%). The common infections were: HIV/AIDS 24 (24.2%), pneumonia 19 (19.1%), purulent bacterial meningitis 17 (17.2%), malaria 9 (9.1%) and tuberculosis 8 (8.1%). The common complications of SCD leading to death were: anaemia 40 (54.8%), haemolytic crisis 10 (13.7%) and acute chest syndrome 9 (12.3%). The major complications of anaemia and CLD in pregnancy leading to death were congestive cardiac failure 28 (87.7%) and septicaemia 7 (46.7%). Deaths due to CLD 3 (37.5%) CVS 6(40.0%) and
neoplastic lesions 3 (60.0%) were commoner within the age group of 30 – 34 years. Deaths due to CVS disorders 6 (60.0%) and neoplastic lesions 3 (60.0%) occurred commonly in health facilities.

Conclusion:The study found that 15.2% of all maternal deaths were due to indirect causes. These commonly occurred in the community and in the 25 -29 year age group. Infections were the commonest cause of death. The authors conclude that indirect causes of maternal deaths cannot be ignored and that efforts should be focused on their reduction. Research is needed in this area of maternal death including the mechanisms by which these cause death and what programme could reduce it.

Download Full Article


Pattern of Breast Cancer Referral to Palliative Care and The Complimentary Role of a Palliative Care Unit in A Resource-Limited Country
Agodirin SO, Rahman GA, Olatoke SA, Durojaiye AO

View Abstract
Pattern of Breast Cancer Referral to Palliative Care and The Complimentary Role of a Palliative Care Unit in A Resource-Limited Country

Key words: palliative care, challenges, breast cancer

ABSTRACT
Background: Poor quality of end of life care is an information problem. Information about palliative and end of life care is sparse from developing countries. Only 10 percent of the information in this field of care emanates from developing countries where about 85% of annual deaths due to cancerous diseases occur. We present review of breast cancer patients referred to Palliative unit of our hospital between May 2009 and June 2013. This article demonstrates challenges to palliative care and the complementary role of the palliative unit to palliative care in developing countries.

Methods: The records of the Palliative unit University of Ilorin Teaching Hospital were reviewed for information about the stage of the disease at referral, performance status of the patients, the support given by the palliative unit and outcome of care.

Results: One hundred and one patients were reviewed for breast cancer by the Palliative unit during the study period. Most of the referrals were from one of a general surgery units in the hospital. The number of referrals per year showed no sustained commitment to referral for palliation. The palliative unit provided counselling, home visitation and source of psychosocial and financial support. The median survival duration was 3 months. 59 percent of the recorded deaths were at home.

Conclusion:This report demonstrated that even though the palliative unit filled a void in the management of breast cancer patients, palliative care is still not widely accepted.

Download Full Article


Treatment Outcome of Open Tibial Shaft Fractures in A Teaching Hospital in Ghana
Tolgou Y, Ofori A, Holdbrook-smith H, Wegdam H

View Abstract
Treatment Outcome of Open Tibial Shaft Fractures in A Teaching Hospital in Ghana

Key words: Treatment outcomes, Tibia, Open fracture

ABSTRACT
Background: Objective of this prospective study is to report results of treatment of open tibia fractures in Korle-Bu Teaching Hospital Accra Ghana.

Methods: In this prospective study 47 patients were considered over a 6-month period from February 2012 to July 2012, and each patient was however followed up for at least 3 months. Treatment of these fractures was guided by the unit protocol.

Results: Out of the 47 patients, 35 (74%) had a good outcome and 12 (26%) had complications.

Conclusion:The results of treatment of open fracture of tibia in this study are encouraging (with 74% of patients having a good outcome). Considering that three decades ago an open fracture of the tibia in Ghana had the common fate of surgical Amputation, Sepsis and Death. Further improvements in treatment of these fractures with early antibiotics, Debridement and irrigation and modern stabilization methods are recommended.

Download Full Article


Anxiety and Depression Among Breast Cancer Patients in A Tertiary Hospital in Ghana
Calys-Tagoe BNL, Senaedza NAH, Arthur CA, Clegg-Lamptey JN

View Abstract
Anxiety and Depression Among Breast Cancer Patients in A Tertiary Hospital in Ghana

Key words: Breast cancer, anxiety, depression, oncology unit, Ghana

ABSTRACT
Background: Breast cancer is the second most common cancer globally and the most frequent cancer among women. It is associated with significant psychological morbidity including anxiety and depression. The extent of this burden has however not been documented in the Ghanaian setting. This study aimed at determining the prevalence of anxiety and depression amongst patients with breast cancer at the Korle Bu Teaching Hospital (KBTH).

Methods: A cross-sectional study was carried out among 120 breast cancer patients using a structured questionnaire to obtain socio-demographic characteristics of patients. The hospital anxiety and depression scale (HADS) was used to assess for depression and anxiety in these patients.

Results: The overall prevalence of depression was 84.2%, while that for anxiety was 92.5%. Forty-four percent of the study participants had both anxiety and depression. There was no significant difference in depression (p=0.796) and anxiety (p=0.999) prevalence between post-menopausal (82.9% and 92.1%
respectively) and pre-menopausal (86.4% and 93.2% respectively) patients. A significant difference in prevalence of depression alone (p=0.033) and depression in combination with anxiety (0.025) was found between those living with their partners and those living without their partners. Average monthly income was found to be significantly associated with anxiety alone (p=0.014) as well as anxiety and depression combination (p=0.032) but not with depression alone (p=0.101).

Conclusion:The prevalence of anxiety and depression are quite high among breast cancer patients at the Korle Bu Teaching Hospital. Anxiety was significantly associated with the average monthly income while depression was associated with the marital status of patients. The high prevalence of both anxiety and depression among breast cancer patients makes it imperative for psychotherapy to be incorporated as an integral part of the management of breast cancer patients for the entire duration of the illness but more especially during the period immediately following diagnosis.

Download Full Article


Ectopic Pregnancy After Bilateral Tubal Ligation – A Case Report
Sefogah PE, Onuzo CK, Gordon AS

View Abstract
Ectopic Pregnancy After Bilateral Tubal Ligation – A Case Report

Key words: Ectopic, Pregnancy, Tubal, Ligation, Permanent, Contraception, Complication, Ghana

ABSTRACT
Summary: Tubal ligation is a permanent voluntary form of contraception in which a woman’s fallopian tubes are surgically cut or blocked off to prevent pregnancy. The procedure is a common method for achieving permanent sterilization and can be done at a Caesarean section or at a mini-laparotomy either immediately postpartum or as an interval procedure.

ReportTo report the case of a 35year old woman (G3P2) who was successfully managed for ectopic pregnancy after a bilateral tubal ligation, and review the literature on this rare complication and its
management.

Conclusion:This case has demonstrated that even though ectopic pregnancy after bilateral tubal ligation is uncommon, sterilization does not invariably confer permanent infertility in all cases.

Download Full Article


Exercise Induced Paralysis in Two Young Ghanaian Men
Abubakari BB, Adjei P, Osei-Poku F, Nkromah K, Akpalu A

View Abstract
Exercise Induced Paralysis in Two Young Ghanaian Men

Key words: Ectopic, Pregnancy, Tubal, Ligation, Permanent, Contraception, Complication, Ghana

ABSTRACT
Summary: We present two cases of young Ghanaian males who presented to the Korle Bu Teaching Hospital between August and September 2013 with a history of exercise induced quadriparesis and diagnosed to have hypokalaemic periodic paralysis. Both patients had had recurrent paralysis for years without a diagnosis. The condition is part of a heterogeneous group of chanellopathies that affect sodium, potassium, and calcium channels in membrane cells. It has autosomal dominant inheritance with male preponderance, common in Caucasians and Asians and rare in blacks.

Download Full Article