Standardised Competency-Based Training of Medical Doctors and Associate Clinicians in Inguinal Repair with Mesh in Sierra Leone.

INTRODUCTION: In low-income settings, there is a high unmet need for hernia surgery, and most procedures are performed with tissue repair techniques. In preparation for a randomized clinical trial, medical doctors and associate clinicians received a short-course competency-based training on inguinal hernia repair with mesh under local anaesthesia. The aim of this study was to evaluate feasibility, safety and effectiveness of the training. METHODS: All trainees received a one-day theoretical module on mesh hernia repair under local anaesthesia followed by hands-on training. Performance was assessed using the American College of Surgeon's Groin Hernia Operative Performance Rating System. Patients were followed up two weeks and one year after surgery. Outcomes of the patients operated on during the training trial were compared to the 229 trial patients operated on after the training. RESULTS: During three surgical camps, seven medical doctors and six associate clinicians were trained. In total, 129 patients were operated on as part of the training. Of the 13 trainees, 11 reached proficiency. Patients in the training group had more wound infections after two weeks (8.5% versus 3.1%; p = 0.041). There was no difference in recurrence and mortality after one year, and none of the deaths were attributed to the surgery. DISCUSSION AND CONCLUSION: Mesh repair is the international standard for inguinal hernia repair worldwide. Nevertheless, this is not widely accessible in low-income settings. This study has demonstrated that short-course intensive hands-on training of MDs and ACs in mesh hernia repair is effective and safe. TRIAL REGISTRATION: International Clinical Trial Registry ISRCTN63478884.

Perforated peptic ulcer.

Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.

Prevalence of Inguinal Hernia in Adult Men in the Ashanti Region of Ghana.

BACKGROUND: Inguinal hernia is thought to be common in rural Ghana, though no recent data exist on hernia prevalence in the country. This information is needed to guide policy and increase access to safe hernia repair in Ghana and other low-resource settings. METHODS: Adult men randomly selected from the Barekese sub-district of Ashanti Region, Ghana were examined by surgeons for the presence of inguinal hernia. Men with hernia completed a survey on demographics, knowledge of the disease, and barriers to surgical treatment. RESULTS: A total of 803 participants were examined, while 105 participants completed the survey. The prevalence of inguinal hernia was 10.8 % (95 % CI 8.0, 13.6 %), and 2.2 % (95 % CI 0, 5.4 %) of participants had scars indicative of previous repair, making the overall prevalence of treated and untreated inguinal hernia 13.0 % (95 % CI 10.2, 15.7 %). Prevalence of inguinal hernia increased with age; 35.4 % (95 % CI 23.6, 47.2 %) of men aged 65 and older had inguinal hernia. Untreated inguinal hernia was associated with lower socio-economic status. Of those with inguinal hernia, 52.4 % did not know the cause of hernia. The most common reason cited for failing to seek medical care was cost (48.2 %). CONCLUSION: Although inguinal hernia is common among adult men living in rural Ghana, surgical repair rates are low. We propose a multi-faceted public health campaign aimed at increasing access to safe hernia repair in Ghana. This approach includes a training program of non-surgeons in inguinal hernia repair headed by the Ghana Hernia Society and could be adapted for use in other low-resource settings.

Characterizing Breast Cancer in a Population with Increased Prevalence of Triple-Negative Breast Cancer: Androgen Receptor and ALDH1 Expression in Ghanaian Women.

BACKGROUND: The androgen receptor (AR) is a commonly-expressed hormone receptor in breast cancer and may be a marker of response to targeted anti-androgen therapy, a particularly attractive option for triple-negative breast cancer (TNBC). Gene expression studies suggest that ARs may distinguish a luminal/AR TNBC subtype from stem cell-like subtypes. TNBC frequency is two to three times higher in African American and African breast cancers compared with White American and European breast cancers, yet little is known regarding TNBC subtypes in high-frequency African-ancestry populations. We evaluated ARs and the mammary stem cell marker aldehyde dehydrogenase 1 (ALDH1) among breast cancers from Ghana, Africa. METHODS: Overall, 147 formalin-fixed, paraffin-embedded invasive breast cancers from the Komfo Anoyke Teaching Hospital in Ghana were studied at the University of Michigan, and analyzed immunohistochemically for estrogen receptor (ER), progesterone receptor (PR), HER2/neu, ALDH1, and AR expression. RESULTS: The median age of patients was 45 years. Only 31 cases (21 %) were ER-positive, and 14 (10 %) were HER2-positive; 89 (61 %) were TNBCs. For the entire group, 44 % were AR-positive and 45 % were ALDH1-positive. ER/PR-positive tumors were more likely to be AR-positive compared with ER/PR-negative tumors (87 vs. 26 %; p < 0.0001), but there was no association between ALDH1 and AR expression. Among the TNBC cases, 45 % were ALDH1-positive and 24 % were AR-positive. ALDH1 positivity was associated with AR positivity within the subset of TNBC (36 vs. 14 %; p = 0.019). CONCLUSION: We confirmed other studies showing a high frequency of TNBC in Africa. Surprisingly, ALDH1 was found to correlate with AR expression among TNBC, suggesting that novel TNBC subtypes may exist among populations with African ancestry.

Characterizing the global burden of surgical disease: a method to estimate inguinal hernia epidemiology in Ghana.

BACKGROUND: Surgical conditions represent an immense yet underrecognized source of disease burden globally. Characterizing the burden of surgical disease has been defined as a priority research agenda in global surgery. Little is known about the epidemiology of inguinal hernia, a common easily treatable surgical condition, in resource-poor settings. METHODS: Using data from the National Health and Nutrition Examination Survey prospective cohort study of inguinal hernia, we created a method to estimate hernia epidemiology in Ghana. We calculated inguinal hernia incidence and prevalence using Ghanaian demographic data and projected hernia prevalence under three surgical rate and hernia incidence scenarios. Disability adjusted life-years (DALYs) associated with inguinal hernia along with costs for surgical repair were estimated. RESULTS: According to this approach, the prevalence of inguinal hernia in the Ghanaian general population is 3.15% (range 2.79-3.50%). Symptomatic hernias number 530,082 (range 469,501-588,980). The annual incidence of symptomatic hernias is 210 (range 186-233) per 100,000 population. At the estimated Ghanaian hernia repair rate of 30 per 100,000, a backlog of 1 million hernias in need of repair develop over 10 years. The cost of repairing all symptomatic hernias in Ghana is estimated at US $53 million, and US $106 million would be required to eliminate hernias over a 10-year period. Nearly 5 million DALYs would be averted with the repair of prevalent cases of symptomatic hernia in Ghana. CONCLUSIONS: Data generated by our method indicate the extent to which Ghana lacks the surgical capacity to address its significant inguinal hernia disease burden. This approach provides a simple framework for calculating inguinal hernia epidemiology in resource-poor settings that may be used for advocacy and program planning in multiple country contexts.

Economic evaluation of expanding inguinal hernia repair among adult males in Ghana.

An unmet need for inguinal hernia repair is significant in Ghana where the number of specialist general surgeons is extremely limited. While surgical task sharing with medical doctors without formal specialist training in surgery has been adopted for inguinal hernia repair in Ghana, no prior research has been conducted on the long-term costs and health outcomes associated with expanding operations to repair all inguinal hernias among adult males in Ghana. The study aimed to estimate cost-effectiveness of elective open mesh repair performed by medical doctors and surgeons for adult males with primary inguinal hernia compared to no treatment in Ghana and to project costs and health gains associated with expanding operation services through task sharing between medical doctors and surgeons. The study analysis adopted a healthcare system perspective. A Markov model was constructed to assess 10-year differences in costs and outcomes between operations conducted by medical doctors or surgeons and no treatment. A 10-year budget impact analysis on service expansion for groin hernia repair through increasing task sharing between the providers was conducted. Incremental cost-effectiveness ratios for medical doctors and surgeons were USD 120 and USD 129 respectively per disability-adjusted life year (DALY) averted compared to no treatment, which are below the estimated threshold value for cost-effectiveness in Ghana of USD 371-491. Repairing all inguinal hernias (1.4 million) through task sharing between the providers in the same timeframe is estimated to cost USD 194 million. Total health gains of 1.5 million DALYs averted are expected. Inguinal hernia repair is cost-effective regardless of the type of surgical provider. Scaling up of inguinal hernia repair is worthwhile, with the potential to substantially reduce the disease burden in the country.

Cost-Effectiveness Analysis of Inguinal Hernia Repair With Mesh Performed by Surgeons and Medical Doctors in Ghana.

OBJECTIVES: Task-sharing is the pragmatic sharing of tasks between providers with different levels of training. To our knowledge, no study has examined the cost-effectiveness of surgical task-sharing of hernia repair in a low-resource setting. This study has aimed to evaluate and compare the cost-effectiveness of mesh repair performed by Ghanaian surgeons and medical doctors (MDs) following a standardized training program. METHODS: This cost-effectiveness analysis included data for 223 operations on adult men with primary reducible inguinal hernia. Cost per surgery was calculated from the healthcare system perspective. Disability weights were calculated using pre- and postoperative pain scores and benchmarks from the Global Burden of Disease Study 2017. RESULTS: The mean cost/disability-adjusted life-year (DALY) averted in the surgeon group was 444.9 United States dollars (USD) (95% confidence interval [CI] 221.2-668.5) and 278.9 USD (95% CI 199.3-358.5) in the MD group (P = .168), indicating that the operation is very cost-effective when performed by both providers. The incremental cost/DALY averted showed that task-sharing with MDs is also very cost-effective (95% bootstrap CI -436.7 to 454.9). The analysis found that increasing provider salaries is cost-effective if productivity remains high. When only symptomatic cases were analyzed, the mean cost/DALY averted reduced to 232.0 USD (95% CI 17.1-446.8) for the surgeon group and 129.7 USD (95% CI 79.6-179.8) for the MD group (P = .348), and the incremental cost/DALY averted increased by 45% but remained robust. CONCLUSIONS: Elective inguinal hernia repair with mesh performed by Ghanaian surgeons and MDs is a low-cost procedure and very cost-effective in the context of the study. To maximize cost-effectiveness, symptomatic patients should be prioritized over asymptomatic patients and a high level of productivity should be maintained.

Outcomes After Elective Inguinal Hernia Repair Performed by Associate Clinicians vs Medical Doctors in Sierra Leone: A Randomized Clinical Trial.

Importance: Task sharing of surgical duties with medical doctors (MDs) without formal surgical training and associate clinicians (ACs; health care workers corresponding to an educational level between that of a nurse and an MD) is practiced to provide surgical services to people in low-resource settings. The safety and effectiveness of this has not been fully evaluated through a randomized clinical trial. Objective: To determine whether task sharing with MDs and ACs is safe and effective in mesh hernia repair in Sierra Leone. Design, Setting, and Participants: This single-blind, noninferiority randomized clinical trial included adult, healthy men with primary inguinal hernia randomized to receiving surgical treatment from an MD or an AC. In Sierra Leone, ACs practicing surgery have received 2 years of surgical training and completed a 1-year internship. The study was conducted between October 2017 and February 2019. Patients were followed up at 2 weeks and 1 year after operations. Observers were blinded to the study arm of the patients. The study was carried out in a first-level hospital in rural Sierra Leone. Data were analyzed from March to June 2019. Interventions: All patients received an open mesh inguinal hernia repair under local anesthesia. The control group underwent operations performed by MDs, and the intervention group underwent operations performed by ACs. Main Outcomes and Measures: The primary end point was hernia recurrence at 1 year. Outcomes were assessed by blinded observers at 2 weeks and 1 year after operations. Results: A total of 230 patients were recruited (mean [SD] age, 43.0 [13.5] years), and all but 1 patient underwent inguinal hernia repair between October 23, 2017, and February 2, 2018, performed by 5 MDs and 6 ACs. A total of 114 patients were operated on by MDs, and 115 patients were operated on by ACs. There were no crossovers between the study arms. The follow-up rate was 100% at 2 weeks and 94.1% at 1 year. At 1 year, hernia recurrence occurred in 7 patients (6.9%) operated on by MDs and 1 patient (0.9%) operated on by ACs (absolute difference, -6.0 [95% CI, -11.2 to 0.7] percentage points; P < .001). Conclusions and Relevance: These findings demonstrate that task sharing of elective mesh inguinal hernia repair with ACs was safe and effective. The task sharing debate should progress to focus on optimizing surgical training programs for nonsurgeons and building capacity for elective surgical care in low- and middle-income countries. Trial Registration: isrctn.org Identifier: ISRCTN63478884.

Increasing the use of continuing professional development courses to strengthen trauma care in Ghana.

Injury is a major cause of death and disability in Ghana. Strengthening care of the injured is essential to reduce this burden. Trauma continuing professional development (CPD) courses are an important component of strengthening trauma care. In many countries, including Ghana, their use needs to be more uniformly promoted. We propose lowcost strategies to increase the utilization of trauma CPD in Ghana, especially in district hospitals and higher need areas. These strategies include developing plans by regional health directorates and teaching hospitals for the regions for which they are responsible. Lists could be kept and monitored of which hospitals have doctors with which type of training. Those hospitals that need to have at least one doctor trained could be flagged for notice of upcoming courses in the area and especially encouraged to have the needed doctors attend. The targets should include at least one surgeon or one emergency physician at all regional or large district hospitals who have taken the Advanced Trauma Life Support (ATLS) (or locally-developed alternative) in the past 4 years, and each district hospital should have at least one doctor who has taken the Primary Trauma Care (PTC) or Trauma Evaluation and Management (TEAM) (or locally-developed alternatives) in the past 4 years. Parallel measures would increase enrollment in the courses during training, such as promoting TEAM for all medical students and ATLS for all surgery residents. It is important to develop and utilize more "home grown" alternatives to increase the long-term sustainability of these efforts. FUNDING: None.

Aggressive angiomyxoma in African women: a report of two cases.

BACKGROUND: Aggressive angiomyxoma (AAM) is a rare soft tissue tumour usually of the perineum. There is no report in the surgical literature of a description of AAM in black Africans. OBJECTIVE: To report the first description of AAM in black Africa women in the surgical literature and to highlight the value of special immunostains in the complete characterization these rare tumours. METHODS: Case one was a 38-year-old pre-menopausal woman who presented with a five-year history of a painless mass in the left buttock extending to the left side of the perineum with recent ulceration. Clinical examination revealed a pale and febrile woman with an ulcerated 60 x 40 cm mass distorting the left gluteal region and the left side of the perineum. In case two, a 28-year old woman reported for the assessment of pedunculated mass arising from the right labium major that has been present for four years. Clinical examination revealed a 19 x 15.5 cm well-circumscribed mass in the perineum. The mass was completely covered by thickened hairy skin and attached to the right labium majored by a short thick stalk that measured 5 cm x 7 cm in size. Both tumours were excised via incisions in the perineum. RESULTS: In both cases the histopathology of the surgical specimens was reported as bland hypocellular tumours with spindle and stellate cells that lacked mitotic activity consistent with a diagnosis of an aggressive angiomyxoma. CONCLUSION: The clinical and histopathological features of the tumours described in this report are consistent with a diagnosis of aggressive angiomyxoma. To the best of our knowledge this is the first ever report of AAM in black African women.

Outcomes After Inguinal Hernia Repair With Mesh Performed by Medical Doctors and Surgeons in Ghana.

Importance: Inguinal hernia is the most common general surgical condition in the world. Although task sharing of surgical care with nonsurgeons represents one method to increase access to essential surgery, the safety and outcomes of this strategy are not well described for hernia repair. Objective: To compare outcomes after inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana. Design, Setting, and Participants: This prospective cohort study was conducted from February 15, 2017, to September 17, 2018, at the Volta Regional Hospital in Ho, Ghana. Following successful completion of a training course, 3 medical doctors and 2 surgeons performed inguinal hernia repair with mesh according to the Lichtenstein technique on 242 men with primary, reducible inguinal hernia. Main Outcomes and Measures: The primary end point was hernia recurrence at 1 year. The noninferiority limit was set at 5 percentage points. Secondary end points included postoperative complications at 2 weeks and patient satisfaction, pain, and self-assessed health status at 1 year. Results: Two-hundred forty-two patients were included; 119 men underwent operations performed by medical doctors and 123 men underwent operations performed by surgeons. Preoperative patient characteristics were similar in both groups. Two-hundred thirty-seven patients (97.9%) were seen at follow-up at 2 weeks, and 223 patients (92.1%) were seen at follow-up at 1 year. The absolute difference in recurrence rate between the medical doctor group (1 [0.9%]) and the surgeon group (3 [2.8%]) was -1.9 (1-tailed 95% CI, -4.8; P < .001), demonstrating noninferiority of the medical doctors. There were no statistically significant differences in postoperative complications (34 [29.1%] vs 29 [24.2%]), patient satisfaction (112 [98.2%] vs 108 [99.1%]), severe chronic pain (1 [0.9%] vs 4 [3.7%]), or self-assessed health (85.9 vs 83.7 of 100) for medical doctors and surgeons. Conclusions and Relevance: This study shows that medical doctors can be trained to perform elective inguinal hernia repair with mesh in men with good results and high patient satisfaction in a low-resource setting. This finding supports surgical task sharing to combat the global burden of hernia disease.

Breast cancer presenting as a mass in the axilla: a report of two cases.

BACKGROUND: Breast cancer presenting initially as enlarged axillary lymph node is very unusual. OBJECTIVE: To highlight the less frequent clinical presentation of breast cancer as persistent isolated, unilateral axillary lymphadenopathy. METHODS: A report of two patients who presented with persistent axillary lymphadenopathy. Case one was a 65-year old woman who presented with an eight-month history of a painless mass in the right axilla. Clinical breast examination was normal. A mammogram was performed. The sub-clinical mass was excised using wire-guided localization providing a specimen for histology. A complete dissection of the right axilla was done and the specimen sent for histological examination. In a second case a 73-year old otherwise healthy woman reported for the assessment of two painful masses in the right axilla. Two hard ovoid masses 2.5 cm x 3.5 cm and 3.0 cm x 3.5 cm were palpated in the right axilla. No other masses were palpable. Both breasts were normal on examination. Mammograms and chest X-rays were done. Fine needle aspiration cytology was done on both masses. A right sided complete axillary lymph node dissection was performed. RESULTS: In case one, mammogram revealed a 5-mm sub mass in the right breast that was shown to be carcinoma. In case two the mammograms and chest X-rays were normal. Histologic examination of the surgical specimen from the axilla showed that four of the seven lymph nodes removed contained metastases. CONCLUSION: Axillary nodal metastasis as the initial presentation of breast cancer in our women is no different from the presentation in women from other populations.

Acute surgical admissions for abdominal pain in adults in Kumasi, Ghana.

BACKGROUND: Abdominal pain of less than a weeks' duration is the presenting complaint in one of every five patients admitted to the surgical Accidents and Emergency Ward of the Komfo Anokye Teaching Hospital in Kumasi. This study is a prospective one, to determine the cause of abdominal pain in a large number of patients. METHODS: A monthly audit of discharge summaries for all patients admitted with acute abdominal pain was prepared and transferred to a special study pro forma to provide data over the 84-month period from January 1998 to December 2004. RESULTS: There were 3114 patients, 2070 men and 1044 women. The ages ranged from 15 to 95 years. The seven most common causes of the admissions were acute appendicitis 698 (22.4%), typhoid ileal perforation (506) 16.2%, acute intestinal obstruction 391 (12.6%), gastroduodenal perforations 342 (11.0%), non-specific abdominal pain 306 (9.8%), abdominal injures 260 (8.3%) and acute cholecystitis 102 (3.2%). There were 1976 (63.4%) emergency operations. Appendicectomy was a common operation that was carried out (638 cases or 32.3%). Two hundred and thirty patients (7.4%) died. Thirty-five patients died before and 195 after operation. Of these 230 deaths, 110 (47.8%) reported to the hospital after three or more days of illness. Twenty-six per cent and 23.7% of postoperative deaths occurred after emergency colonic resections and closure of gastroduodenal perforations, respectively. CONCLUSION: Acute appendicitis, typhoid ileal perforation, acute intestinal obstruction and gastroduodenal perforations were the leading causes of acute admissions for abdominal pain to our hospital. Late presentation was associated with increased mortality.

Case series of acute presentation of abdominal TB in Ghana.

We report on a six-year prospective study to determine the presentation and outcome of acute abdominal TB at Komfo Anokye Teaching Hospital. Between January 1998 and December 2003, material for biopsy including resected bowel was taken from all cases of acute abdomen, which at laparotomy were suspected as one or other form of abdominal TB. TB-positive cases were then retrospectively analysed for clinical presentation and outcome of surgical treatment. There were 96 histologically proven cases of abdominal TB, 60 in women and 36 in men. Seventy patients (72.9%) were admitted as acute intestinal obstruction with acute abdominal pain, vomiting, constipation, distension and fluid levels on abdominal X-ray. Twenty-two (22.9%) patients were admitted as acute diffused peritonitis - with generalized abdominal tenderness, guarding and rebound - and four (4.2%) as acute appendicitis. There were 74 emergency bowel resections (77% resection rate) for 34 ileocaecal masses, 16 strictures, 10 perforations and 14 adhesions, with a mortality of 4.2%. Previous series from our subregion have reported similar emergency resection mortality rates for other abdominal conditions. All the patients received postoperative anti-TB therapy. This paper notes that acute intestinal obstruction is the most common acute presentation of abdominal TB in our environment. The results of emergency resection compare favourably with resection for other acute abdominal conditions.

An audit of appendicitis and appendicectomy in Kumasi, Ghana.

BACKGROUND: Acute appendicitis is a leading cause of emergency admission into our hospital. A report on 638 surgical abdominal explorations following emergency admissions for suspected acute appendicitis is presented. The study was conducted at the Komfo Anokye Teaching Hospital between January 1998 and December 2004. METHOD: During the 7-year period, all consecutive adult patients admitted to our hospital emergency department with suspected appendicitis and who subsequently had an operation done provided the material for the study. Patients whose symptoms settled without operation were excluded. A special proforma was designed to record patient demographic details, clinical features, laboratory data, operative findings and outcome of treatment. RESULTS: Six hundred and thirty-eight patients were studied. These were 408 men and 230 women; a male to female ratio of 1.7:1. The mean age was 32.4 +/- 15.0 S.D years. All patients were admitted with abdominal pains that were initially located at the umbilicus in 38.0% and diffused in 31.8%. Vomiting 85.7%, fever 73.0% and anorexia 49.0% were the most frequent associated symptoms. The mean duration of illness was 74 hours. Right iliac fossa pain and tenderness were present in 612 patients (89.22 %). The total white cell count was significantly raised (p = 0.05). Six hundred and thirty-eight appendicectomies were performed. Thirty-nine percent (249/638) of the appendices were perforated at operation and 25.9% (56/216) of the removed appendices had no histological evidence of inflammation. The complication rate was 43.1% and wound infection (41.5%) was the most common. The average stay in hospital was 7 days. There were 12 deaths--a mortality rate of 1.9%--mostly elderly patients. CONCLUSION: The diagnosis of appendicitis in our environment is clinical and based mainly on the combination of abdominal pains, signs of peritoneal irritation, and a raised total white cell count with neutrophilia. This mode of presentation is similar to that seen in other communities. The treatment of appendicitis in our hospital is appendicectomy. The negative appendicectomy rate of 25.9% falls within the range reported in other studies. More than a third of the appendices were perforated. The considerable morbidity and appreciable mortality from acute appendicitis in our community are due mainly to the late presentation of our patients.

Perforated gastric and duodenal ulcers in an urban African population.

BACKGROUND: Perforations of the stomach and duodenum are frequent causes of acute generalized peritonitis in our environment. This is a prospective study of 331 cases of gastric and duodenal perforations. STUDY DESIGN: A consecutive series of adult patients admitted and treated for acute generalized peritonitis due to peptic ulcer perforations was studied prospectively from January 1998 to June 2004. A specially designed proforma was used to record patient characteristics, clinical and operative findings and outcome. Additional information on self-medication and other relevant social habits was obtained and recorded. The data was analysed and the ratio of gastric to duodenal perforations as well as factors associated with perforations determined. RESULTS: More males were affected by a ratio of 3.3:1. For all the patients the median age was 55.0 and the mean age was 52.2 +/- 17.5 years. The mean age of the perforated gastric ulcer patients was 47.7 +/- 17.1 years but higher for perforated duodenal ulcer patients at 64.8 +/- 11.4 years. There were 244 gastric and 87 duodenal perforations giving a ratio of 2.8:1. Most of these perforations were associated with the intake of Non Steroidal Anti Inflammatory Drugs (NSAIDS) 158 (47.7%), habitual ingestion of herbal medicines or concoctions 81 (24.5%) and prolonged fasting for religious reasons, 18 (5.4%). Acute renal failure 32 patients (31.1%), continuing or persistent peritonitis 12 patients (11.6%), wound infection 25 patients (24.3%), and chest infection 12 patients (11.6%), were some of the 103 post-operative complications seen. The overall mortality was 73( 22.1%). The death rate from perforated duodenal ulcer was 27 (32.2%) and that from perforated gastric ulcer was 46 (20.1%). CONCLUSION: In our community perforated gastric ulcer is seen more often than perforated duodenal ulcer. These gastric perforations are related to the widespread use of NSAIDS and herbal medicines.

Extra gonadal sclerosing stromal tumour in the transverse mesocolon.

Sclerosing stromal tumour (SST) is a rare benign sex cord stromal tumour of the ovary. We report a case of sclerosing stromal tumour of the mesentery in a 32-year-old Para one who presented with intra abdominal mass, menstrual irregularity and secondary infertility. Histopathology and immunohistochemistry of the completely excised tumour was consistent with sclerosing stromal tumour, immunoreactive only to vimentin. No ovarian tissue was found in the sectioned tumour. Her menses became regular and she conceived 3 months after complete excision and delivered after 9 months. Hormonal assay was not done because SST was least suspected. From literature this is the first case of SST in the transverse mesocolon reported in the West African subregion, and may probably be one of the rare cases of hormonally active SST.

Breast Cancer and African Ancestry: Lessons Learned at the 10-Year Anniversary of the Ghana-Michigan Research Partnership and International Breast Registry.

Women with African ancestry in western, sub-Saharan Africa and in the United States represent a population subset facing an increased risk of being diagnosed with biologically aggressive phenotypes of breast cancer that are negative for the estrogen receptor, the progesterone receptor, and the HER2/neu marker. These tumors are commonly referred to as triple-negative breast cancer. Disparities in breast cancer incidence and outcome related to racial or ethnic identity motivated the establishment of the International Breast Registry, on the basis of partnerships between the Komfo Anokye Teaching Hospital in Kumasi, Ghana, the University of Michigan Comprehensive Cancer Center in Ann Arbor, Michigan, and the Henry Ford Health System in Detroit, Michigan. This research collaborative has featured educational training programs as well as scientific investigations related to the comparative biology of breast cancer in Ghanaian African, African American, and white/European American patients. Currently, the International Breast Registry has expanded to include African American patients throughout the United States by partnering with the Sisters Network (a national African American breast cancer survivors' organization) and additional sites in Ghana (representing West Africa) as well as Ethiopia (representing East Africa). Its activities are now coordinated through the Henry Ford Health System International Center for the Study of Breast Cancer Subtypes. Herein, we review the history and results of this international program at its 10-year anniversary.

Causes of acute peritonitis in 1188 consecutive adult patients in Ghana.

In a five-year prospective study, 1188 consecutive adult patients were admitted and treated for acute generalized peritonitis at the Surgical Emergency Unit of the Komfo Anokye Teaching Hospital, Kumasi, Ghana. Appendicitis and typhoid ileal perforation were the commonest causes, occurring in 43.1% and 35.1% of patients, respectively. Other conditions (gastroduodenal perforations, ruptured abscesses, traumatic bowel perforations and amoebic colonic perforations) accounted for fewer than 25% of cases.

An audit of excised breast lumps in Ghanaian women.

BACKGROUND: In our environment, all patients presenting with breast masses insist on complete surgical removal as the preferred treatment option acceptable to them. We report on a 6-year prospective study of the clinical and pathological features of these breasts masses excised for histopathological examination. STUDY DESIGN: Details of all consecutive women referred to the surgical out-patients' clinic of the Komfo Anokye Teaching Hospital from January 1998 to December 2003 inclusive, for clinical assessment and excision of breast masses were prospectively recorded. Open surgical biopsies were performed on these masses and the pathological features recorded. RESULT: A total of 443 patients were reported. Approximately 80% of the women were 40 years old or younger There were 355 (80.9%) benign breast lesions and 88 (19.1%) carcinomas. The principal histopathological types were fibroadenoma, fibrocystic breast changes and carcinoma occurring in 47.7%, 23.9% and 19.1% of the patients respectively. The cumulative frequency at >30 years for fibroadenoma and carcinoma was 0.81 and 0.11 respectively. No carcinomas were found below 26 years. There was a significant association between the ages of the patients and the type of breast disease (X2 = 20.9 P <0.05). CONCLUSION: Discrete breast masses in Ghanaian women are mostly due to benign breast disease. The risk of cancer increases with the age of the patient especially after 30 years.