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.

Managing cirrhosis with limited resources: perspectives from sub-Saharan Africa.

Cirrhosis represents the end stage of chronic liver disease. Sub-Saharan Africa, a resource-constrained region, has a high burden of chronic liver disease, with causes including chronic viral hepatitis, excessive alcohol use, and metabolic dysfunction-associated steatotic liver disease (MASLD), the risk of which is burgeoning. The development of liver cirrhosis predicts for morbidity and mortality, driven by both liver dysfunction and the consequences of portal hypertension. Compensated cirrhosis portends a better prognosis than decompensated cirrhosis, highlighting the need for the early diagnosis of cirrhosis and its causes. With resource challenges, the diagnosis and management of cirrhosis is demanding, but less costly and less invasive interventions with substantial benefits, ranging from simple blood tests to transient elastography, are feasible in such settings. Simple interventions are also available to manage the complex manifestations of decompensation, such as ß blockers in variceal bleeding prophylaxis, salt restriction and appropriate diuretic use in ascites, and lactulose and generic rifaximin in hepatic encephalopathy. Ultimately, managing the underlying causative factors of liver disease is key in improving prognosis. Management demands expanded policy interventions to increase screening and treatment for hepatitis B and C and reduce alcohol use and the metabolic factors driving MASLD. Furthermore, the skills needed for more specialised interventions, such as transjugular intrahepatic portosystemic shunt procedures and even liver transplantation, warrant planning, increased capacity, and support for regional centres of excellence. Such centres are already being developed in sub-Saharan Africa, demonstrating what can be achieved with dedicated initiatives and individuals.

Diabetes mellitus type 2 in urban Ghana: characteristics and associated factors.

BACKGROUND: Sub-Saharan Africa faces a rapid spread of diabetes mellitus type 2 (DM2) but its potentially specific characteristics are inadequately defined. In this hospital-based study in Kumasi, Ghana, we aimed at characterizing clinical, anthropometric, socio-economic, nutritional and behavioural parameters of DM2 patients and at identifying associated factors. METHODS: Between August 2007 and June 2008, 1466 individuals were recruited from diabetes and hypertension clinics, outpatients, community, and hospital staff. Fasting plasma glucose (FPG), serum lipids and urinary albumin were measured. Physical examination, anthropometry, and interviews on medical history, socio-economic status (SES), physical activity and nutritional behaviour were performed. RESULTS: The majority of the 675 DM2 patients (mean FPG, 8.31 mmol/L) was female (75%) and aged 40-60 years (mean, 55 years). DM2 was known in 97% of patients, almost all were on medication. Many had hypertension (63%) and microalbuminuria (43%); diabetic complications occurred in 20%. Overweight (body mass index > 25 kg/m2), increased body fat (> 20% (male), > 33% (female)), and central adiposity (waist-to-hip ratio > 0.90 (male), > 0.85 (female)) were frequent occurring in 53%, 56%, and 75%, respectively. Triglycerides were increased (≥ 1.695 mmol/L) in 31% and cholesterol (≥ 5.17 mmol/L) in 65%. Illiteracy (46%) was high and SES indicators generally low. Factors independently associated with DM2 included a diabetes family history (adjusted odds ratio (aOR), 3.8; 95% confidence interval (95%CI), 2.6-5.5), abdominal adiposity (aOR, 2.6; 95%CI, 1.8-3.9), increased triglycerides (aOR, 1.8; 95%CI, 1.1-3.0), and also several indicators of low SES. CONCLUSIONS: In this study from urban Ghana, DM2 affects predominantly obese patients of rather low socio-economic status and frequently is accompanied by hypertension and hyperlipidaemia. Prevention and management need to account for a specific risk profile in this population.

Feasibility of focused cardiac ultrasound training for non-cardiologists in a resource-limited setting using a handheld ultrasound machine.

BACKGROUND: Heart disease remains a leading cause of morbidity and mortality, particularly in low- and middle-income countries. Access to diagnostic modalities is limited in these settings. Limited echocardiographic studies performed by non-cardiologists can increase access, improve diagnosis and allow for earlier medical therapy. METHODS: Two internal medicine residents at a tertiary-level hospital in Ghana were trained to perform limited echocardiographic studies. Each trainee performed 50 echocardiograms and interpreted 20 studies across three predetermined timepoints. Interpretation was compared to expert interpretation. RESULTS: Agreement improved over time. At the final evaluation, there was high agreement across all aspects: left ventricular structure (70%, kappa 0.52, p = 0.01), left ventricular function (80%, kappa 0.65, p = 0.004), right ventricular structure (90%, kappa 0.71, p = 0.002), right ventricular function (100%, kappa 1.00, p < 0.001), and presence of effusion (100%, kappa 1.00, p < 0.001). CONCLUSIONS: Non-cardiologists can be trained in focused echocardiography using handheld machines. Such training can increase access to diagnostic capabilities in resource-limited settings.

Mortality burden due to liver cirrhosis and hepatocellular carcinoma in Ghana; prevalence of risk factors and predictors of poor in-hospital survival.

Liver-related diseases, including liver cirrhosis and hepatocellular carcinoma (HCC), are significant causes of mortality globally. Specific causes and predictors of liver-related mortality in low resource settings require assessment to help inform clinical decision making and develop strategies for improved survival. The objectives of this study were to determine the proportion of liver-related deaths associated with liver cirrhosis, HCC, and their known risk factors, and secondly to determine predictors of in-hospital mortality among cirrhosis and HCC patients in Ghana. We first performed a cross-sectional review of death register entries from 11 referral hospitals in Ghana to determine the proportion of liver-related deaths and the proportion of risk factors associated with these deaths. Secondly, we conducted a retrospective cohort review of 172 in-patient liver cirrhosis and HCC cases admitted to a tertiary referral centre and determined predictors of in-hospital mortality using binary logistic regression and Kaplan-Meier survival analysis. In total, 8.8% of deaths in Ghanaian adults were due to liver-related causes. The proportion of liver-related deaths attributed to HBV infection was 48.8% (95% CI: 45.95-51.76), HCV infection was 7.0% (95% CI: 5.58-8.45), HBV-HCV co-infection 0.5% (95% CI: 0.1-0.9) and alcohol was 10.0% (95% CI: 8.30-11.67). Of 172 cases of HCC and liver cirrhosis, the in-patient mortality rate was 54.1%. Predictors of in-patient mortality in cirrhotic patients were increasing WBC (OR = 1.14 95% CI: 1.00-1.30) and the revised model for end-stage liver disease with 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, HBV is linked to a high proportion of HCC-related deaths in Ghana, with high in-hospital mortality rates that require targeted policies to improve survival.

Serum Uric acid is a better indicator of kidney impairment than serum uric acid to creatine ratio ; a cross sectional study of type 2 diabetes mellitus patients.

BACKGROUND: Type 2 diabetes mellitus (T2DM) patients are likely to develop kidney disease. The need to identify more accessible and cheaper diagnostic biomarkers cannot be overemphasized. This study investigated the ability of serum uric and uric acid to creatinine ratio in assessing the kidney function of T2DM patients and determined the relationship between serum uric acid to creatinine ratio and estimated glomerular filtration rate (eGFR). METHODS: One hundred and fifty-five (155) consented T2DM patients were recruited from the diabetes clinic of the Cape Coast Teaching hospital. Anthropometric variables and blood pressure were measured. Serum uric acid (SUA), serum creatinine and urine protein were estimated using standard protocols. Uric acid to creatinine ratio (UA:CR), eGFR were then calculated. RESULTS: From the receiver operator characteristic (ROC) curve obtained, serum uric acid was found to be a better predictor of impaired renal function than UA:CR at p = 0.0001. The uric acid levels of participants in the fourth quartile of each category was found to be significant at p = 0.010 and can be used as indicators of kidney function in these participants. According to the odds ratio, the UA:CR will not be suitable to be used as an indicator of kidney function in any of the participants because their odds ratios were all less than 1. A total of 29(18.7 %) participants were found to have CKD with their eGFR falling below 60 ml/mins per 1.73 m2. A significant positive relationship was found between serum uric acid and the staging of CKD according to eGFR whiles a negative relationship was found with UA:CR and CKD (p < 0.0001). CONCLUSIONS: Serum uric acid is a better indicator of renal impairment (eGFR < 60 ml/mins per 1.73 m2) than UA:CR in patients with type 2 diabetes mellitus.

Health-care provision and policy for non-alcoholic fatty liver disease in sub-Saharan Africa.

Sub-Saharan Africa, which has a population of more than 1 billion people, carries 24% of the global burden of disease and spends the least on health care of any region, relying heavily on international development assistance to deliver health care for HIV, tuberculosis, and malaria. The demographic and epidemiological transitions occurring in sub-Saharan Africa, with rising prevalences of obesity and diabetes, enhance the risk of non-alcoholic fatty liver disease (NAFLD), yet this remains an unrecognised complication of metabolic syndrome. There are no guidance documents on NAFLD from sub-Saharan Africa, and non-communicable disease (NCD) guidance documents do not include the associated burden of fatty liver disease. Combating the health and socioeconomic burden of NAFLD requires an integrated liver health approach, with task-shifting to primary health care. Using clear guidance documents to link education and management of HIV, viral hepatitis, NAFLD, and associated NCDs is also crucial to an integrated approach to infectious diseases and NCDs, which requires targeted funding from both governments and international development agencies.

Is malaria immunity a possible protection against severe symptoms and outcomes of COVID-19?

Malaria-endemic areas of the world are noted for high morbidity and mortality from malaria. Also noted in these areas is the majority of persons in the population having acquired malaria immunity. Though this acquired malaria immunity does not prevent infection, it resists the multiplication of Plasmodium parasites, restricting disease to merely uncomplicated cases or asymptomatic infections. Does this acquired malaria immunity in endemic areas protect against other diseases, especially outbreak diseases like COVID-19? Does malaria activation of innate immunity resulting in trained or tolerance immunity contribute to protection against COVID-19? In an attempt to answer these questions, this review highlights the components of malaria and viral immunity and explores possible links with immunity against COVID-19. With malaria-endemic areas of the world having a fair share of cases of COVID-19, it is important to direct research in this area to evaluate and harness any benefits of acquired malaria immunity to help mitigate the effects of COVID-19 and any possible future outbreaks. FUNDING: None declared.

Acute kidney injury among medical and surgical in-patients in the Cape Coast Teaching Hospital, Cape Coast, Ghana: a prospective cross-sectional study.

BACKGROUND: Acute kidney injury (AKI) is a syndrome associated with high morbidity, mortality and high hospital costs. Despite its adverse clinical and economic effects, only a few studies have reported reliable estimates on the incidence of AKI in sub-Sahara Africa. We assessed the incidence and associated factors of AKI among medical and surgical patients admitted to a tertiary hospital in Ghana. METHODS: A prospective cross-sectional study was conducted among one hundred and forty-five (145) consecutive patients admitted to the medical and the surgical wards at the Cape Coast Teaching Hospital (CCTH), Cape Coast, Ghana from April 2017 to April 2018. Socio-demographic and clinical information were collected using structured questionnaires. AKI was diagnosed and staged with the KDIGO guideline, using admission serum creatinine as baseline kidney function. RESULTS: The mean age of the study participants was 46.6±17.7 years, whilst the male:female ratio was 68:77. The overall incidence of AKI among the participants was 15.9% (95% CI: 10.33 - 22.84%). Stage 1 AKI occurred in 56.5% of the participants, whilst stages 2 and 3 AKI respectively occurred among 4.1% and 2.8% of respondents. About 20% of the participants in the medical ward developed AKI (n= 15) whilst 12% of those in surgical ward developed AKI (n= 8). Among the participants admitted to the medical ward, 60.0%, 26.7% and 13.3% had stages 1, 2 and 3 AKI respectively. Whilst 50.0%, 25.0% and 25.0% respectively developed stages 1, 2 and 3 AKI in the surgical ward. Medical patients with AKI had hypertension (40%), followed by liver disease (33.3%); 37.5% of surgical inpatients had gastrointestinal (GI) disorders. CONCLUSION: The incidence of AKI is high among medical and surgical patients in-patients in the CCTH, Ghana, with hypertension and liver disease as major comorbidities.

Low iron stores in preconception nulliparous women; a two-center cross-sectional study in peri-urban Ghana.

OBJECTIVES: The nutritional status of women affects pregnancy outcomes. Preconception care adequately prepares women for the demands of pregnancy. The aim of this study was to evaluate the prepregnancy iron status of nulliparous women in Ghana to provide empirical data to inform policy formulation. METHODS: We recruited 336 nulliparous women of reproductive age from Denkyembour District and Ejura Municipal assemblies, respectively, in the Eastern and Ashanti regions of Ghana. Serum ferritin was estimated to assess the women's iron stores. Hemoglobin (Hb) variants and fecal occult blood were determined for participants using cellulose acetate electrophoresis and lateral flow chromatographic immunoassay, respectively. Logistic regression analysis was used to determine factors associated with depleted iron stores (ferritin < 15 ng/dL). RESULTS: Whereas 41.5% of the women were anemic (Hb <11.5 g/dL), 34.5% were iron depleted (serum ferritin <15 g/mL; C-reactive protein <5 ng/dL). Also, 17.1% suffered from iron deficiency anemia (concomitant Hb <11.5 g/dL and serum ferritin <15 ng/dL). Serum ferritin significantly differed among the participants with anemia (P < 0.001). Multivariate regression analysis showed that age (<20 y: adjusted odds ratio [AOR], 13.916, P = 0.002; 20-30 y: AOR, 4.304, P = 0.023), moderate anemia (AOR, 3.045, P = 0.004), Ashanti region (AOR, 3.984, P = 0.002), and mean cell volume <80 fL (AOR, 2.546, P = 0.003) were significantly associated with increased odds of having depleted iron stores. However, body mass index, waist-to-hip ratio >0.85, educational status, or inherited Hb type were not significantly associated with depleted iron stores. CONCLUSION: The high prevalence of depleted iron stores in nulliparous women is a severe public health problem that requires attention.

Gastroenterology practice in the COVID-19 era: Ghana Association for the Study of Liver and Digestive Diseases (GASLIDD) position statement.

The COVID-19 pandemic has impacted healthcare negatively across the globe. The practice of gastroenterology has been affected especially gastrointestinal (GI) endoscopy which is considered high risk for transmission of the virus. As a community of practitioners there is the need to share information and make evidence-based statements to guide GI practice in Ghana. This GASLIDD position statement based on the growing and rapidly evolving body of knowledge is to provide up to date information on the COVID-19 disease and guidance for the practice of gastroenterology in Ghana and beyond. It is to help the GI community of practice to maintain the highest level of health delivery and safety for our patients, staff, community and GI practitioners. FUNDING: Self-funded.

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 toothpick should 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: None.

Review of errors in the issue of medical certificates of cause of death in a tertiary hospital in Ghana.

OBJECTIVE: Reliable mortality statistics are useful in determining national policies on preventive and interventional medicine. This study reviews, completed medical certificates of cause of death at the Cape Coast Teaching Hospital, in order to determine their accuracy and reliability. METHODS: A one-year review of Medical Certificates of Cause of Death (MCCD) signed between 01-01-2013 and 31-12-2013 in the medical, pediatric, surgical and obstetrics/gynecology departments of Cape Coast Teaching Hospital were done, analyzing for errors using the WHO/ICD-10 guidelines as the standard. The errors were grouped into minor and major errors. RESULTS: In all, 337 medical certificates of cause of death were audited. Majority, 212(62.9%) were issued in the internal medicine and therapeutics department. 30.86% (104) MCCDs were completed by specialists while 69.14% (233) were completed by non-specialist medical officers. Over half (56.68%) of the MCCDs had major errors while all (100%) had at least one minor error. CONCLUSION: Our study showed significant errors in MCCD records, with the errors more likely in certificates issued by non-specialist medical officers. All the certificates audited had at least one minor error. Training of doctors on proper completion of MCCDs is strongly advocated. FUNDING: None of the authors received any financial support for this study.

High risk of coagulopathy among Type-2 Diabetes Mellitus clients at a municipal hospital in Ghana.

BACKGROUND: Persistent hyperglycaemia in diabetes mellitus causes coagulopathies due to glycation of haemoglobin, prothrombin, fibrinogen and other proteins involved in the clotting mechanism. Shortened activated partial thromboplastin time (APTT) and prothrombin time (PT) reflect hypercoagulable state, which is associated with an increased thrombotic risk and adverse cardiovascular effects. This study assessed the coagulation profile of type 2 diabetes mellitus (T2DM) clients at a municipal hospital in Ghana. METHODS: A hospital-based case-control study was conducted from January to April 2015 at the Agona Swedru Municipal Hospital. Sixty (60) persons with T2DM and 40 without were recruited and screened using appropriate protocols. Blood samples were collected for coagulation and biochemical tests. Demographic and clinical information were collected using pre-tested questionnaire. Data was analyzed with GraphPad Prism version 5. RESULTS: APTT and PT were significantly shorter among patients with T2DM compared to those without (20.88 ± 5.19 v 31.23 ± 5.41, P=0.0001; and 11.03 ± 2.06sec v 14.46 ± 1.86, P=0.0001 respectively). INR was decreased among patients with T2DM compared to those without (0.83 ± 0.18 v 1.13 ± 0.17, P=0.0001). No significant difference was found in platelet count between T2DM and non-diabetics (179.85 ± 66.15×103 /mm3 v 168.55 ± 35.77×103 /mm3, P=0.326). Serum magnesium was lower among the T2DM patients compared to the non-diabetics, while serum ionized calcium was significantly higher among the T2DM patients (P<0.05). CONCLUSION: Clients with T2DM may have a high coagulation risk evidenced by shortened APTT, PT and a high ionized calcium compared with controls. FUNDING: Study was funded by Lord Ampomah and Solomon Panford.

Characteristics, management, and outcomes of patients with hepatocellular carcinoma in Africa: a multicountry observational study from the Africa Liver Cancer Consortium.

BACKGROUND: Hepatocellular carcinoma is a leading cause of cancer-related death in Africa, but there is still no comprehensive description of the current status of its epidemiology in Africa. We therefore initiated an African hepatocellular carcinoma consortium aiming to describe the clinical presentation, management, and outcomes of patients with hepatocellular carcinoma in Africa. METHODS: We did a multicentre, multicountry, retrospective observational cohort study, inviting investigators from the African Network for Gastrointestinal and Liver Diseases to participate in the consortium to develop hepatocellular carcinoma research databases and biospecimen repositories. Participating institutions were from Cameroon, Egypt, Ethiopia, Ghana, Ivory Coast, Nigeria, Sudan, Tanzania, and Uganda. Clinical information-demographic characteristics, cause of disease, liver-related blood tests, tumour characteristics, treatments, last follow-up date, and survival status-for patients diagnosed with hepatocellular carcinoma between Aug 1, 2006, and April 1, 2016, were extracted from medical records by participating investigators. Because patients from Egypt showed differences in characteristics compared with patients from the other countries, we divided patients into two groups for analysis; Egypt versus other African countries. We undertook a multifactorial analysis using the Cox proportional hazards model to identify factors affecting survival (assessed from the time of diagnosis to last known follow-up or death). FINDINGS: We obtained information for 2566 patients at 21 tertiary referral centres (two in Egypt, nine in Nigeria, four in Ghana, and one each in the Ivory Coast, Cameroon, Sudan, Ethiopia, Tanzania, and Uganda). 1251 patients were from Egypt and 1315 were from the other African countries (491 from Ghana, 363 from Nigeria, 277 from Ivory Coast, 59 from Cameroon, 51 from Sudan, 33 from Ethiopia, 21 from Tanzania, and 20 from Uganda). The median age at which hepatocellular carcinoma was diagnosed significantly later in Egypt than the other African countries (58 years [IQR 53-63] vs 46 years [36-58]; p<0·0001). Hepatitis C virus was the leading cause of hepatocellular carcinoma in Egypt (1054 [84%] of 1251 patients), and hepatitis B virus was the leading cause in the other African countries (597 [55%] of 1082 patients). Substantially fewer patients received treatment specifically for hepatocellular carcinoma in the other African countries than in Egypt (43 [3%] of 1315 vs 956 [76%] of 1251; p<0·0001). Among patients with survival information (605 [48%] of 1251 in Egypt and 583 [44%] of 1315 in other African countries), median survival was shorter in the other African countries than in Egypt (2·5 months [95% CI 2·0-3·1] vs 10·9 months [9·6-12·0]; p<0·0001). Factors independently associated with poor survival were: being from an African countries other than Egypt (hazard ratio [HR] 1·59 [95% CI 1·13-2·20]; p=0·01), hepatic encephalopathy (2·81 [1·72-4·42]; p=0·0004), diameter of the largest tumour (1·07 per cm increase [1·04-1·11]; p<0·0001), log α-fetoprotein (1·10 per unit increase [1·02-1·20]; p=0·0188), Eastern Cooperative Oncology Group performance status 3-4 (2·92 [2·13-3·93]; p<0·0001) and no treatment (1·79 [1·44-2·22]; p<0·0001). INTERPRETATION: Characteristics of hepatocellular carcinoma differ between Egypt and other African countries. The proportion of patients receiving specific treatment in other African countries was low and their outcomes were extremely poor. Urgent efforts are needed to develop health policy strategies to decrease the burden of hepatocellular carcinoma in Africa. FUNDING: None.