Re: Breast cancer screening in a resource poor country: ultrasound versus mammography by Omidiji O.A.T, Campbell P.C, Irurhe N. K, Atalabi O.M and Toyobo O.O Ghana Med J 2017;51(21):6-12 DOI: http://dx.doi.org/10.4314/gmj.v51i1.2

Re: Breast cancer screening in a resource poor country: ultrasound versus mammography by Omidiji O.A.T, Campbell P.C, Irurhe N. K, Atalabi O.M and ToyoboO.O Ghana Med J 2017;51(21):6-12 DOI: http://dx.doi.org/10.4314/gmj.v51i1.

Clustering populations by health and social care with multiple long-term conditions: a cohort study - the English Longitudinal Study of Ageing (ELSA)

Background The integration of health and social care services is a potential solution for improving care, despite monetary constraints and increasing demand. How two or more multiple long-term conditions (MLTC) cluster, interact and associate with socioeconomic factors, and affect access to unscheduled primary healthcare services is understudied. Aim To cluster an MLTC population by health and social care, examine clusters, and quantify associations with health outcomes. Method A retrospective cohort study was conducted using the ELSA database (2002 to 2019) on 19802 participants aged ≥50 years. Ten major health conditions, and social care need, including difficulty in activities of daily living (ADL) and mobility, for example, were used to cluster MLTC by latent class modelling. Multivariate logistic regression models were used to establish further association. Results The mean age of the participants at baseline (wave 2) was about 66 years and 55% of participants were female, with more than 60% developing MLTC in their lifetime (waves 2 to 9). Of the five distinct latent clusters, cluster 5 was the most significant cluster composed of lung diseases, stroke, dementia, and high ADL and mobility difficulty scores. The majority of the participants were aged 70–79 years, female, and married. The odds of having a longer nursing home stay were 8.97 (95% confidence interval = 4.36 to 18.45), and death was 10% higher in this cluster compared to the highest probability cluster 4 in the maximally adjusted regression model. Conclusion This study identified MLTC clusters by social care need with the highest primary care demand. Targeting clinical practice to prevent MLTC progression for these groups may lessen future pressures on primary care demand

Wooden toothpick partially embedded in the gastric antrum: a case report of an unusual finding in open access gastrointestinal endoscopy

Ingested toothpick is an unusual occurrence in clinical practice. This is a medical emergency and all effort should be made to localize the toothpick and appropriate intervention instituted. We report a case of accidentally ingested toothpick with successful endoscopic removal in a case of a 24year old male who presented for open access endoscopy with complaint of abdominal pain. During endoscopy a foreign body (sharp object) was seen partially embedded at the gastric antrum which was later identified as a wooden toothpick. Endoscopic removal was done using a Caesar grasping forceps (CGF-1-240). No complication was reported during and after the procedure. Ingested toothpickshould be managed as an emergency in all cases and should be considered an important differential diagnosis in clients with complaint of abdominal pain especially in open access endoscopy.Funding: NoneKeywords: Ingested Toothpick, Open access endoscopy, abdominal pai

Recommendations for cervical cancer prevention and control in Ghana: public education and human papillomavirus vaccination

Globally, cervical cancer is a major public health issue causing increasing morbidity and mortality especially in low and middle-income countries where preventive and control measures are lacking. In Ghana, it is the most common cancer among women. Approaches to reduce the incidence and mortality of the disease in Ghana have had little success due to lack of accurate data on the disease among other factors, to inform policies on prevention, early detection, diagnosis and treatment. Additionally, the lack of clear commitment, policy direction and resources has hinderedthe scale-up of some of the initiatives implemented to curb the cervical cancer situation in Ghana. In this paper, we make recommendations on cervical cancer education and human papillomavirus vaccination. A collaborative approach is needed involving both private and government organizations, health professionals and the general public. Public education on cervical cancer and HPV vaccination needs to be delivered through a mixture of systems including both healthcare facilities and outreach programs, involving teachers, youth groups, community members and professional bodies. The vaccination of adolescents aged 10-14 years using the nonavalent HPV vaccine will beimportant in reducing the incidence and mortality of cervical cancer in Ghana. The integration of public education on cervical cancer prevention, HPV vaccination and screening programs into both medical and public health services is critical in achieving high coverage of these programs.Funding: NoneKeywords: Cervical cancer, Education, HPV vaccination, Prevention, Ghan

Are people with mesothelioma who respond to the English Cancer Patient Experience Survey representative of the national mesothelioma population? A data comparison with cancer registry patients from the National Lung Cancer Audit

Introduction: More than 2,700 people are diagnosed with mesothelioma each year in the UK. Survival from mesothelioma is poor and to ensure service users’ perspectives are incorporated in designing the most effective strategies to improve healthcare in England, the English Cancer Patient Experience Survey (CPES) is carried out annually in people diagnosed with cancer. We assessed whether the mesothelioma population responding to the English CPES is representative of the national mesothelioma population. Method: Data from all people in England from the National Cancer Registry defined as having an incident mesothelioma diagnosis (2009–2015) were included. Data were linked across multiple sources including CPES. Using multivariable logistic regression, clinical and sociodemographic characteristics were compared between CPES respondents with mesothelioma and all people with mesothelioma in England. Results: We identified 15,587 people diagnosed with mesothelioma, of which 1,597 (10.3%) were included in CPES. Adjusted odds ratios showed that representation in CPES decreased with older age, later stage, worse performance status, multiple comorbidities or emergency presentation at diagnosis. Gender was reasonably represented, although people with non-white ethnicity and from more deprived socioeconomic groups were underrepresented. lung cancer nurse specialist assessment was not associated with inclusion in CPES, however, having a lung cancer nurse specialist present at diagnosis was. Representation in CPES was highest for people who had chemo-radiotherapy (fully adjusted odds ratio 6.52 (95% confidence interval 5.34–7.96). Conclusion: Responses were included across all sociodemographic and clinical groups, but there was unbalanced representation when compared with the national mesothelioma population. Patients who do not receive anti-cancer treatment are particularly under-represented. It is important to consider the impact of person characteristics on CPES representation when using cancer experiences to plan service management

A systematic review and meta-analysis of the prevalence of hepatitis B virus infection among pregnant women in Nigeria

Background: Nigeria has a high burden of hepatitis B virus (HBV) infection, commonly acquired through vertical transmission. However, there is a lack of an efficient surveillance system for monitoring and understanding the epidemiology of HBV among pregnant women. Building on a previous review on the prevalence of HBV in Nigeria (2000–2013), we conducted a systematic review and meta-analysis of HBV prevalence among pregnant women in Nigeria. Methods: Four electronic databases PubMed, Embase, Global Health, and Scopus were systematically searched from January 2014 to February 2021. We also searched the African Journal Online and manually scanned the reference lists of the identified studies for potentially eligible articles. Observational studies that reported the prevalence of HBsAg and/or HBeAg among pregnant women in peer-reviewed journals were included in the study. We performed a meta-analysis using a random-effects model. We defined HBV infection as a positive test to HBsAg. Results: From the 158 studies identified, 20 studies with a total sample size of 26, 548 were included in the meta-analysis. The pooled prevalence of HBV infection among pregnant women across the studies was 6.49% (95% confidence interval [CI] = 4.75–8.46%; I2 = 96.7%, p = 0.001; n = 20). The prevalence of HBV was significantly lower among pregnant women with at least secondary education compared with those with no education or primary education (prevalence ratio = 0.7, 95% CI = 0.58–0.87; n = 10). However, the prevalence of HBV was not significantly different by age, religion, marital status, or tribe. The prevalence of HBV was not significantly different among pregnant women with previous surgery, blood transfusion, multiple lifetime sex partners, tribal marks, tattoos, scarification, or sexually transmitted infections, compared with those without these risk factors. From a total sample size of 128 (n = 7), the pooled prevalence of HBeAg among HBV-infected pregnant women was 14.59% (95% CI = 4.58–27.99%; I2 = 65.5%, p = 0.01). Subgroup analyses of HBV infection by study region and screening method, and meta-regression analysis of the study year, sample size, and quality rating were not statistically significant. Conclusions: There is an intermediate endemicity of HBV infection among pregnant women in Nigeria. Interventions, such as routine antenatal HBV screening, antiviral prophylaxis for eligible pregnant women, and infant HBV vaccination should be scaled up for the prevention of perinatal transmission of HBV infection in Nigeria

Elevated rates of horizontal gene transfer in the industrialized human microbiome

Industrialization has impacted the human gut ecosystem, resulting in altered microbiome composition and diversity. Whether bacterial genomes may also adapt to the industrialization of their host populations remains largely unexplored. Here, we investigate the extent to which the rates and targets of horizontal gene transfer (HGT) vary across thousands of bacterial strains from 15 human populations spanning a range of industrialization. We show that HGTs have accumulated in the microbiome over recent host generations and that HGT occurs at high frequency within individuals. Comparison across human populations reveals that industrialized lifestyles are associated with higher HGT rates and that the functions of HGTs are related to the level of host industrialization. Our results suggest that gut bacteria continuously acquire new functionality based on host lifestyle and that high rates of HGT may be a recent development in human history linked to industrialization.Peer reviewe

The Epidemiology of Cervical Cancer in Ghana

INTRODUCTION: Cervical cancer is a significant health issue worldwide. It is the fourth most common cancer among women with more than 85% of new cases of the disease occurring in low- and middle-income countries. Cervical cancer is the most common cancer among women in Ghana. Incidence and mortality rates are unknown due to an absence of a national-based population cancer registry. HPV positivity has been shown to be a necessary initiator of cervical cancer but the infection progresses to cancer only in a small number of women. Cofactors associated with the disease progression are not well understood. The study was designed to assess the epidemiology of cervical cancer in Ghana. AIMS: • Estimate the regional cervical cancer incidence and mortality using data from two large referral hospitals in Ghana. • Use results from the above study to estimate national incidence and mortality rates of the disease. • Estimate the 1, 3 and 5 year disease-specific survival rates of Ghanaian women diagnosed with invasive cervical cancer. • Determine the HPV DNA prevalence and prevailing HPV types present in Ghanaian women with and without cervical cancer. • Determine the associations between cofactors and a woman’s risk of developing cervical cancer in Ghana. METHODS: Medical records and other hospital data of women diagnosed with cervical cancer from January 2010 to December 2013 were reviewed at Korle-Bu Teaching Hospital, Accra, and Komfo Anokye Teaching Hospital, Kumasi, in Ghana. Telephone interviews were also conducted for patients and relatives to gather further information. To assess the risk factors for cervical cancer in Ghana, a hospital-based case-control study was undertaken. Women aged 18-95 years with a new diagnosis of invasive cervical cancer that had been histologically confirmed were considered for inclusion as cases. Controls were a random selection from the same hospitals as the cases. A structured questionnaire was administered to the women after which a request for a cervical smear was made for the reporting of cytological abnormalities and laboratory detection of HPV DNA to establish the HPV types present. RESULTS: Using the data from review of medical records and telephone interviews, the incidence, mortality and survival rates of women diagnosed with invasive cervical cancer in Ghana were estimated. An increased risk of cervical cancer with age was found. The incidence rate of cervical cancer was highest for women aged 75-79 years and decreased at older ages. Incidence and mortality rates were higher in the Greater Accra and Ashanti regions of Ghana than for other regions. At three years from diagnosis, overall disease-specific survival was 39%. Unsurprisingly, stage at presentation and histological type were strong predictors of cervical cancer survival. Some forms of treatment were also associated with better survival than others. A total of 206 women with incident cervical cancer and 230 controls were recruited for the case-control study to identify possible risk factors and cofactors for cervical cancer in Ghana. The results of the case-control study confirmed many known established risk factors associated with cervical cancer. These included age, an increased number of pregnancies, higher parity and oral contraceptive use. In addition, use of firewood for cooking, use of homemade sanitary towels and having a polygamous husband was associated with an increased risk of cervical cancer in this study after adjustment for the presence of highest oncogenic HPV types. High prevalence of HPV was detected among women with cervical cancer (80.1%). HPV types 45, 16, 18, 35 and 52 were the most common types detected among cases. Knowledge of HPV and cervical cancer was very low overall among women with and without cervical cancer. CONCLUSIONS: In addition to the presence of high-risk oncogenic HPV DNA, parity and oral contraceptive use was associated with an increase risk of cervical cancer in Ghana. The results of the research suggest that the identification of factors associated with the progression of HPV positivity to invasive cervical cancer may help reduce the burden of cervical cancer in Ghana. In addition, the development of a cancer control programme that takes into consideration the social and cultural factors for the prevention, early detection and diagnosis, treatment and palliative aspects of cervical cancer is needed to combat the disease.

A clinical epidemiological study on end-stage liver disease in Ghana

End-stage liver disease (ESLD), including advanced liver cirrhosis and hepatocellular carcinoma (HCC), is the final stage of long-standing injury to the liver due to risk factors such as chronic viral hepatitis and alcoholic liver disease. There is a high disease burden and mortality globally, especially in sub-Saharan African (SSA) countries such as Ghana, where the primary cause of HCC and cirrhosis is infection with hepatitis B virus (HBV). To overcome the problem of ESLD in Ghana and SSA, epidemiological data on patient characteristics, challenges with diagnosis and management and mortality estimates are necessary so that well-directed and appropriate policies can be developed. This thesis, therefore, aimed to determine the clinical epidemiological profile of liver cirrhosis and HCC patients in Ghana and to explore diagnostic and management practices associated with the care of patients. In Study I, we described the clinical characteristics of ESLD from liver cirrhosis and HCC in Ghana and evaluated the performance of the aspartate aminotransferase (AST) - platelet ratio index (APRI) score and alpha fetoprotein (AFP) in a cross-sectional study involving 141 HCC, 216 cirrhosis and 218 chronic HBV patients. We found a median age at diagnosis of 44 years, with most patients presenting at an advanced stage of disease. APRI cut-off of 2 had sensitivity of 45.4% and specificity of 95% in the diagnosis of cirrhosis, whilst a cut-off of 1 had sensitivity of 75.9% and specificity of 89%. The AUC of AFP of 0.88 indicated the utility of this test in the surveillance of HCC in Ghana. Study II evaluated the in-hospital testing of HBV infection and burden of disease in Ghana by reviewing hospital-based data from 136,068 laboratory register entries, 165,213 blood bank register entries, and 83,920 delivery register entries in 22 healthcare institutions. We found that HBsAg RDT testing was widely available in government hospitals, however, HBV serological profile and DNA testing were mostly limited to teaching hospitals. The crude national seroprevalence was 8.40% ((95% CI 8.25-8.57%), whilst the pooled estimate was 11.39% (95% CI 10.43-12.35). Seroprevalence in children <5 years was 1.87% (95% CI 1.07-3.27). Our study indicated that Ghana remains a country with high endemicity and limitations in the full complement of testing for HBV infection. In Study III, we explored the opinions and practices of cirrhosis patients and health workers on the nutritional management of cirrhosis through a qualitative study. We found that patients and health workers felt dietary recommendations for patients were frequently addressed but could be significantly improved. Additionally, we found that local guidelines were not available for nutritional assessment and management in the opinion of study participants. Participants believed these to be important and necessary in managing cirrhosis patients in Ghana. Study IV assessed the proportion of liver-related deaths from liver cirrhosis and HCC, and their known risk factors in Ghana, and determined clinical factors associated with mortality. We found that 8.8% of deaths between 2018 -2020 in adults aged 18 years and above were due to liver-related causes. The proportion of liver-related deaths associated with HBV infection was 48.76%, HCV infection was 10.0%, and alcohol was 7.01%. Predictors of in-patient mortality in cirrhotic patients were elevated WBC (OR = 1.14 95% CI: 1.00 -1.30) and the revised model for end-stage liver disease with incorporation of sodium (MELD-Na) score (OR = 1.24 95% CI: 1.01-1.54). For HCC patients, female sex (OR=3.74 95% CI: 1.09-12.81) and hepatic encephalopathy (grade 1) were associated with higher mortality (OR = 5.66 95% CI: 1.10-29.2). In conclusion, this thesis presented the current landscape of end-stage liver disease, clinical epidemiology, diagnosis, and management in Ghana. It enhanced knowledge of the burden of viral hepatitis-related to liver cirrhosis and liver cancer. Finally, it shed light on factors associated with in-hospital mortality in Ghana

Clinical Profile and Limitations in the Management of HBV Patients Attending Clinic at a District Hospital in Ghana

Background. Chronic hepatitis B (CHB) is estimated to cause between 500,000 and 1.2 million deaths worldwide every year through cirrhosis and hepatocellular carcinoma (HCC). Liver cirrhosis and HCC are the commonest liver diseases causing death in Ghana. The most critical problem in the management of CHB in sub-Saharan Africa is the high cost of investigations and antiviral drugs. There is scanty information concerning newly diagnosed CHB patients and their management challenges in Ghana. This study sought to determine the clinical characteristics and management challenges of CHB patients in Ghana. Methodology. A prospective cohort study was conducted involving newly diagnosed CHB patients being managed at St. Dominic Hospital. Patient demographic and clinical features were abstracted using a standardized questionnaire. The proportion of patients able to undertake investigations and treatment were determined, and the limitations to standard management were recorded. The performance of APRI score in the diagnosis of cirrhosis was also investigated. Results. Of the 334 patients with newly diagnosed CHB, the median age at diagnosis was 35 (IQR 28–44) years. Less than a quarter (22.2%) were able to undertake viral load testing and 23.4% were eligible for treatment. Of those who were eligible for treatment, only 42.3% were able to initiate treatment. Almost a third of cases (32.1%) reported late with liver-related complications. The sensitivity of APRI score with cut-off value of 2 in the diagnosis of liver cirrhosis was 70.2% and specificity was 97.9%. Conclusion. A high proportion of newly diagnosed CHB patients presented late and with liver-related complications. Majority were not able to afford viral load testing and antiviral medication. Screening of hepatitis B among the general population and inclusion of CHB management in the National Health Insurance Scheme should be encouraged