Postgraduate Medical Journal of Ghana
Volume 4 Number 2
Articles in Volume 4 number 2
THE CHANGING FACE OF MEDICAL PRACTICE
J T Anim
The practice of medicine has been with man since antiquity. Man has always endeavoured to overcome adversity and the bid to overcome the devastating effects of disease has always been a prime concern of mankind since creation. From humble beginnings, employing herbs and other materials available in the environment and relying on minimal personal skills, medical practice has evolved to the highly scientific pursuit now familiar to us. Thus, it is possible to recognise distinct phases or eras through which medical practice has evolved. The earliest era has been described as the era of Ancient Medicine which may be said to have started in pre-historic times to about 500AD. More commonly it is dated from about 3000BC when records first began in Mesopotamia concerning such practices, to 500AD, enclosing the times of such illustrious names as Hippocrates (460-379BC), Erasistratus (about 300BC) and Galen (130-201AD). During this period, causation of disease was ascribed to the supernatural and later to changes in the “humours”. Some of our local Ghanaian practices of the art of healing may be said to belong to this earliest era in the worldwide evolution of medical practice.
The next era in the evolution of medical practice is the era of Medieval Medicine also described as the era of “Monastic or Library Medicine” which was dominated by religious dogma and intolerance. Practice of medicine during this period was largely in the hands of clerics and became more theoretical than practical. In many ways, large areas of medical practice in Ghana and many developing countries may be said to belong to this era. Renaissance Medicine (16th to 18th century) started in earnest with the development of ‘bedside medicine’ and saw the shift from the theory of ‘spontaneous generation’ of disease to the theory of ‘contagion’ which spurred the search for organic causes of disease, culminating in the discovery of microorganisms as a cause of disease. Towards the end of this era, large treatment centres or hospitals have become established and the concept of the cell as the unit of the body set the stage for further scientific study of the origin, as well as mechanisms in the causation of disease.
The current era of medical practice (19th century to date) is described as the era of Modern Medicine and has been aptly described by some as the era of scientific medicine, with emphasis on diagnosis of diseases. The scientific backbone of medical practice has been provided by the concurrent development and expansion of ‘Laboratory Medical practice or Pathology’. The technical requirements of this aspect of medical practice have spawned rapid and monumental technological advances in medical practice in general. The quest to understand the
‘science behind the cure’ has resulted in rapid expansion in the contribution of laboratory medicine, and more recently, imaging studies to diagnosis of disease and further patient management. It has also helped in the development of specialties and subspecialties of medicine, all in the quest to improve patient management. With changing practices in medicine and increasing respect for ‘patient autonomy’, the practice of medicine is undergoing further changes. With current increasing availability and usage of information on the internet, patients are able to access data on various medical conditions, as well as their treatment options. Thus, patients often come to see their doctor already armed with information gleaned from the internet. Some patients may have even tried treatment options recommended by online doctors before coming to see their doctor. This state of affairs is seen increasingly in the developed countries, requiring doctors to be aware of such possibilities. The negative aspect of this increasing self-medication is that some patients may present to the doctor with a disease which they have self-managed wrongly or inadequately. Alternatively, they may even present to a health centre as an emergency, with complications of selfadministered treatment. This has necessitated a paradigm shift in modern clinical practice, leading to the emergence of the new specialty of Emergency Medicine.
This specialty has arisen out of the recognition that patient emergency conditions require collaborative activities of virtually all diagnostic and intervention specialties or subspecialties to act in concert under the same umbrella in order to optimally manage patients with these conditions. Doctors trained in emergency medicine are therefore, equipped with the skills to either handle emergency patients themselves, or summon other specialists to assist in the emergency situation. As a pre-requisite, hospitals in developed countries now operate comprehensive ‘one-stop’ emergency centres which are equipped to deal with virtually all emergencies. This practice is only now becoming available in developing countries.
In Ghana, the first comprehensive emergency centre has recently been opened in Komfo Anokye Teaching Hospital in Kumasi and similar centres are being constructed or planned for other teaching and regional hospitals. The Ghana College of Physicians and Surgeons also, in recognition of this need, has commenced training of residents in emergency medicine. One might argue that literacy rate in Ghana being low, Ghanaians are unlikely to explore the internet for… “Please Download full article”
MALIGNANT SKIN TUMOURS IN KUMASI: A FIVE YEAR REVIEW
Adu EJK, Koranteng A
Key words: Squamous cell carcinoma, basal cell carcinoma, malignant melanoma, xeroderma pigmentosum, Dermatofibrosarcoma
Background: Ultraviolet radiation is the primary aetiological agent in malignant melanoma (MM), squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). Its effect on carcinogenesis can be influenced by endogenous and exogenous factors.
Purpose:To document the clinical and epidemiological features of patients presenting with malignant skin tumours at Komfo Anokye Teaching Hospital (KATH), from January 2009 to December 2013.
Methods:Records of patients treated for malignant skin tumours at KATH were retrieved from the surgical out-patient department and theatre records and analysed.
Results: 38 patients comprising 16 males and 22 females were treated for malignant skin disease from January 2009 to December 2013. Their ages ranged from 12 to 84 years (mean 48.4, SD=20.2). Predominant lesions were SCC (17 cases), MM (12 cases), and dermatofibrosarcoma protuberans (DFSP), (four cases). SCC were located on the scalp (eight cases), lower limbs (six cases), upper limb (two cases) and trunk (one). All MM lesions were located on the foot. DFSP lesions were found on the leg (one case), trunk (one case), and shoulders (two cases). Basosquamous carcinoma (BSC) was found on the trunk of an albino. All patients were treated surgically (48 procedures); three SCC patients had radiotherapy; one MM patient had chemotherapy.
Conclusion:SCC, MM and DFSP were the main malignant skin tumours managed. Chronic wounds, scars and skin bleaching were the exogenous factors; whilst albinism and xeroderma pigmentosum were the endogenous factors identified. For prevention, early case detection, adequate treatment of wounds and sun avoidance are advocated.
PROSTATE CANCER DIAGNOSTIC METHODS IN KORLE BU TEACHING
HOSPITAL, ACCRA, GHANA
A.D. Abrahams, J.E. Mensah, Y. Tettey
HOSPITAL, ACCRA, GHANA
Key words: DRE, SePSA, TRUS-biopsy, prostate cancer
Background: The diagnosis of prostate cancer is based on a combination of digital rectal examination (DRE), serum prostate specific antigen (SePSA) estimation and trans-rectal ultrasound guided biopsy (TRUS-B) of the prostate, the latter being the gold standard for prostate cancer diagnosis. This study compared the diagnostic rate of prostate cancer in patients attending the urology clinic at Korle-bu Teaching Hospital, Accra, Ghana, using these methods.
Methods: One hundred and fifty male patients 45 years and older with abnormal DRE and raised or rising SePSA had TRUS biopsy done. The biopsies were processed routinely and all cancer positive slides were graded using the Gleason scoring system. DRE findings were comparatively analysed statistically against SePSA and histological findings.
Results: Of the 150 subjects, 71(47.3%) were diagnosed as benign and 79(52.7%) had cancer on TRUS-B. Cancer diagnosis rate using a combination of DRE and SePSA was slightly higher (66.4%) than using DRE (64.5%) or SePSA (53.7%) in isolation.
Conclusion: DRE was found to have a high positive predictive value, probably due to the late presentation of majority of the patients in this study. SePSA alone is not very reliable, and results must be interpreted with caution due to significant false positive rates. Combining DRE and SePSA improves cancer diagnosis rates.
SEX AND RURAL-URBAN DISPARITIES IN SELF-REPORTED CHRONIC NONCOMMUNICABLE DISEASES AND HEALTH RISKS AMONG OLDER ADULTS IN GHANA: IMPLICATIONS FOR THE NATIONAL AGING POLICY
Yawson AE, Dako-Gyeke P, Hewlett S, Calys-Tagoe BNL, Malm KL, Hagan-Seneadza NA, AgyeiBaffour P, Baddoo NA, Martey P, Mensah G, Minicuci N, Naidoo N, Chatterji S, Kowal P, Biritwum RB
Key words: older adults, chronic diseases, sex differences, rural-urban differences, national ageing policy
Objective: Differences exist in the composition and morbidity/mortality patterns of older persons. This analysis determined sex differences and rural-urban disparities in common chronic diseases and health risks among older persons in Ghana.
Methods: This work was based on World Health Organization’s (WHO) multi-country Study on global AGEing and adult health (SAGE), conducted in six countries including Ghana. Nationally representative sample of 4725 persons ≥50 years was involved in this analysis. Data were obtained on eight self-reported chronic diseases and analysed by sex and location.
Results: Women ≥50 years in rural-urban locations self-reported more ill-health than men of comparable age. Educational levels, household incomes and possession of health insurance were lower among rural
residents. Alcohol and tobacco use were significantly higher in rural locations (61% vs. 55.3%) and (29.6% vs. 20.9%) respectively, while obesity was significantly higher among urban residents (17.5% vs. 4.5%). Sex differences in prevalence of chronic conditions were statistically significant for-Angina (F:M 1.8), Arthritis (F:M 1.7), Depression (F:M 2.9), Diabetes (F:M 1.3), Hypertension (F:M 1.8) and Stroke (F:M 1.2). Urbanrural disparities were significant for chronic lung disease (1% vs. 0.4%), diabetes (6.4% vs. 2.2%), hypertension (22.8% vs. 7.3%) and stroke (4% vs1.7%).
Conclusion:Preventive health programmes and provision and targeting of social protection (improved access to health care and pensions) should consider sex and location of vulnerable older persons as the country implements the national aging policy.
TWENTY-TWO YEARS OF REPAIR OF ATRIAL SEPTAL DEFECTS IN GHANA
Tamatey MN, Sereboe LA, Tettey MM, Edwin F, Entsua-Mensah K, Gyan B, Aniteye EA, Ofosu-Appiah EA, Okyere I, Mohammed I, Adzamli IK, Offei-Larbi G
Key words: Atrial septal defect, surgical repair, outcome
Background: Atrial septal defects (ASDs) are one of the most common types of congenital heart disease. Repair is often necessary to forestall the various complications associated with the natural history. Surgical repair under cardiopulmonary bypass has been one of the standard modes of treatment. Much of the data available is from the rest of the world. There is not much data from the West African sub region. The purpose of this study is therefore to provide data from this sub region, guide both referring and operating clinicians in their decisions, and also to serve as comparative data for future studies. We analysed our institutional data to determine the age and sex distribution, the types of ASD and the outcome of surgical repair.
Methods: A retrospective study was done for all patients who had surgical repair of ASD from January 1992 to December 2013 in the National Cardiothoracic Centre. The data was analysed using Microsoft excel 2010 software.
Results: There were 129 patients, 2 in the first year and 9 in the last year of the study. There were 53 (41.0%) males and 76 (59.0%) females. The mean age was 17.6 ± 14.9 years (1 – 70), The commonest age group was 1 – 10 years; 53 (41.0%), followed by 11 – 20 years; 36 (27.9%). Secundum ASDs were the commonest, 104 (80.6%), followed by primum ASDs 14 (10.9%), and sinus venosus ASDs 6 (4.7%). Large defects described as common atrium were 5 (3.9%). Autologous pericardium was used in repairing 125 (96.9%) and GORETEX® patch was used in the remaining 4 (3.1%). Thirty-three (25.7%) cases had associated cardiac anomalies that needed concomitant surgical intervention. The commonest was cleft in the anterior mitral leaflet causing severe mitral regurgitation 12 (9.3%), followed by pulmonary stenosis (PS) 11 (8.5%). There was an early mortality of 2 (1.6%). No other significant complication was encountered.
Conclusion: Surgical repair of ASDs in this sub region has been going on for over two decades now, with excellent outcomes. Patients with ASDs must be offered repair as soon as possible to forestall the serious complications that may follow unrepaired ASDs.
PREDICTORS OF PRE-ECLAMPSIA: A HOSPITAL BASED STUDY IN ACCRA, GHANA
Otu-Nyarko S, Quansah Asare G, Sackey S, Tagoe E.A
STUDY IN ACCRA, GHANA
Key words: Pre-eclampsia, Eclampsia, Ghana, maternal death, Pre-cursor
Background: Pre-eclampsia is a medical condition which develops after 20 weeks of pregnancy, where blood pressure is elevated to 140/90mm/Hg or more, with significant amounts of protein in the urine. It is a pre-cursor of eclampsia and leads to increased morbidity and mortality in the affected mother and fetus or baby. The only cure for pre-eclampsia involves delivery of the placenta. Pre-eclampsia is asymptomatic and difficult to predict in the first trimester of pregnancy.
Methods: This was a case control study done at the Police Hospital in Accra, using secondary data which were antenatal clinic records from 1st January 2008 to 31st December 2010. We sought to determine the number of deliveries complicated with pre-eclampsia, the proportion of deliveries complicated by preeclampsia, and risk factors of pre-eclampsia.
Results: The proportion of deliveries complicated by pre-eclampsia was 2.5%. We found no association between pre-eclampsia and season of delivery, maternal blood group, history of previous abortions, maternal infections of syphilis, HIV and Hepatitis B. We found maternal age of 25 years and above, parity of one and systolic blood pressure of 130mm/Hg or more at booking were statistically significant predictors of pre-eclampsia.
Conclusion:These three variables could be used to select pregnant women in the first 20 weeks of pregnancy for focused surveillance, and as a tool for selecting women for early referral for specialist care. We however recommend larger studies with the addition of lifestyle variables in further studies.
THE ASSOCIATION BETWEEN CHRONIC KIDNEY DISEASE, HYPERURICAEMIA AND PROTEINURIA IN ADULT PATIENTS ATTENDING OUTPATIENT CLINICS IN BANJUL, THE GAMBIA
Nkum BC, Micah FB, Eghan BA, Ankrah TC, Nyan O
Key words: Systemic Hypertension, Chronic Kidney Disease, Renal Failure, Hyperuricaemia, Proteinuria
Background: Chronic kidney disease (CKD) is manifested by irreversible worsening renal function and is associated with proteinuria and hyperuricaemia.
Objective: To determine the prevalence of CKD, hyperuricaemia and proteinuria and explore the relationship between CKD, hyperuricaemia and proteinuria among outpatients in Banjul, The Gambia.
Design: Prospective cross-sectional study
Setting: Outpatient clinics of Edward Francis Small Teaching Hospital and Medical Research Council Laboratories in Banjul
Methods:Two hundred and eight consecutive patients with hypertension on treatment and 108 nonhypertensive patients aged over 25years were enrolled. A questionnaire was filled and anthropometric measurements were taken. An oral glucose tolerance test was done. Serum uric acid and creatinine were determined from venous blood samples and proteinuria was determined by urine dipsticks. The estimated glomerular filtration rate (GFR) was calculated using the Cockcroft and Gault equation. CKD was defined and classified by The National Kidney Foundation’s Kidney Diseases Outcomes Quality Initiative guidelines.
Results: The results of 300 participants were included in this analysis. The prevalence of hyperuricaemia was 36%, proteinuria 25% and CKD 41% (10.7% of participants had Stage 1, 6.7% Stage 2, 21.7% Stage 3, 1.3% Stage 4 and 0.3% Stage 5). The mean uric acid was 0.33 (0.13) mmol/L, mean creatinine 88.1 (54.1) μmol/L and mean GFR was 103.2 (80.2) ml/min/1.73 m2 .There was a strong and significant association between hyperuricaemia, proteinuria and CKD among these participants before and even after controlling for age, sex, hypertension and diabetes mellitus.
Conclusion:The prevalence of CKD, hyperuricaemia and proteinuria in patients attending clinics in Banjul was high. There was a strong and significant association between CKD, hyperuricaemia and proteinuria
IMPACT OF FREE MATERNAL CARE POLICY ON MATERNAL AND CHILD HEALTH INDICATORS IN GHANA
Sefogah PE, Gurol I
Key words: Free maternal care, Policy, Impact
Background: Maternal and child mortality remain major global public health challenges. Majority of the world’s maternal mortality occur in low–income countries including Ghana, where financial barriers make maternal healthcare inaccessible to many women during obstetric emergencies, resulting in avoidable maternal deaths. Ghana implemented a free maternal care policy nation-wide in 2008 to provide pregnant women antenatal, delivery and postnatal care in public, and accredited private healthcare facilities. This work assesses the impact of the policy on selected Maternal and Child Health (MCH) indicators in Ghana.
Methods: Literature on financial barriers to maternal healthcare in Low Income Countries (LICs) was reviewed. WHO databases were searched for MCH indicators for Ghana from 2000-2011, aggregated and trends analysed. Additional data was obtained from Maamobi Polyclinic, Koforidua Regional Hospital (KRH), and the Korle Bu Teaching Hospitals (KBTH). These were statistically analysed for trends to assess the policy’s impact on these indicators.
Results: Over four years of implementation, average antenatal coverage increased by 2%, skilled birth attendance 11%; contraceptive prevalence unchanged and unmet need for contraception rose marginally. Under-5 mortality declined by 22%. KBTH recorded increased antenatal (ANC) attendance and decreased annual deliveries that were non-significant. Maternal Mortality Rate (MMR) increased by 89/100,000LB; Caesarean section (C/S) rate rose by 5.5%, fresh still birth (FSB) rate increased and Neonatal intensive care unit (NICU) admissions surged 21%. KRH recorded significant increases in deliveries by 2114; C/S rate by 3% while MMR reduced by 0.56% (562/100,000LB). However, the FSB proportion increased by 13%, ANC attendance reduced by 567, annual deliveries rose by 300, C/S rate and FSB increased by 3% and 11% respectively per year at the Maamobi Polyclinic.
Conclusion:Encouraging trends were observed in the MCH indicators attributable to the policy. Increasing FSB rates indicate inadequate care quality especially intra-partum monitoring possibly due to over-stretched staff and facilities from rising patient loads.
CONSENT TO MEDICAL TREATMENT: WHAT ABOUT THE ADULT PATIENT WHO IS INCAPABLE OF PROVIDING A VALID CONSENT?
Introduction: Consent to medical treatment is a principle that is increasingly gaining attention in health care systems across the world. For consent to be valid, five essential elements must exist. The patient must have the mental ‘capacity’ to provide consent, he or she must receive adequate and accurate information, understand the information disclosed, make a decision voluntarily and without coercion, and then authorize the treatment1. In an article on ‘consent to medical treatment’ in a previous edition of this journal, I outlined how the Ghanaian courts may resolve consent related information disclosure disputes. That article dealt with the provision of information to the adult patient who has the mental capacity to provide lawful consent to medical treatment. A likely question that an interested reader of that article may ask is; ‘what are the legal provisions in Ghana for treating patients who lack the capacity to provide lawful consent to medical treatment as a result of factors such as a young age, disease, severe brain or mental illness or incapacity such as occurs in severe dementia, severe learning disabilities, and being unconscious?’. The purpose of this article is to attempt to answer such a question. The scope of the article is limited to the management of the adult patient without the mental capacity to consent to medical treatment, which for the purpose of this article, in Ghana, refers to any individual aged 18 years or older who lacks the mental capacity. The legal provisions and considerations for obtaining consent for treating the ‘minor’ will be dealt with in a separate article.
NICOLAU SYNDROME: A CASE REPORT OF A RARE DEBILITATING COMPLICATION FOLLOWING INTRAMUSCULAR INJECTION OF PENICILLIN
Dedey F, Affram N K, Amoah Y, Nsaful J, Adu – Aryee NA
Key words: Nicolau Syndrome, Intramuscular injections, prevention
Objective: Nicolau Syndrome is a rare, debilitating and sometimes fatal complication resulting from the administration of parenteral medication. It is associated with administration of a variety of medications. It causes a local aseptic ischaemic necrosis of the muscles, subcutaneous tissues and skin. It may be associated with neurological deficits and organ failure. The administration of parenteral medication is common in our health institutions, but this complication seems to be unknown. We would like to increase awareness about its existence and the preventive measures to take in order to minimize its occurrence as it can be associated with significant morbidity and even mortality.
Case report and interventions: Case report and interventions: A young man presented with sudden onset of severe pain in the right buttock and the whole right lower limb with associated paralysis after an intramuscular injection of penicillin. He developed a darkened patch of skin at the site of the injection on the right buttock and also on the right leg anteriorly. This progressed to necrosis of the skin, subcutaneous tissue and muscles and osteomyelitis of the right tibia. He also presented with acute renal failure. After serial debridement, wound dressing and antibiotic treatment the wound healed with extensive scarring, the osteomyelitis resolved and the neurological deficit improved leaving a foot drop. His renal function normalized after several sessions of haemodialysis.
Conclusion:Administration of parenteral medication can be complicated by debilitating conditions such as Nicolau Syndrome. No specific treatment exists, so it is best prevented by taking the necessary precautions during administration of parenteral medication when indicated.
GASTRIC DIVERTICULUM: A RARE CAUSE OF DYSPEPSIA
Wu Lily P, Asare OK, Clegg-Lamptey JNA
Key words: Gastric diverticulum, Epigastric pain, Dyspepsia, Proton pump inhibitors, Endoscopy.
Objective: Diverticular disease of the stomach is uncommon and rarely suspected in all cases of upper gastro-intestinal pathology. The aim of this report is to demonstrate gastric diverticulum as an uncommon cause of upper gastrointestinal symptoms. The literature in Ghana shows no documented record; and we therefore seek to highlight gastric diverticulum as a possible differential diagnosis when evaluating patients with dyspepsia.
Case Report and Intervention: We present a case of a 26 year old man who presented to the outpatient clinic with a 2-year history of recurrent epigastric pain and dyspepsia. This patient had previous upper gastrointestinal endoscopies which were normal. The recurrence of his symptoms necessitated a referral to Korle-Bu Teaching Hospital, a tertiary hospital, where the diagnosis of gastric diverticulum was confirmed at endoscopy. He was managed with proton pump inhibitors. Treatment is largely conservative, except in complicated cases such as bleeding and perforation where surgery is indicated.
Conclusion:Gastric diverticulum is rare in Ghana. A high index of suspicion is required to make a diagnosis especially in symptomatic patients with apparently normal gastric mucosa at endoscopy.