Twenty Years of Repair of Ventricular Septal Defects in Ghana.

BACKGROUND: Ventricular Septal Defect (VSD) is the commonest congenital heart disease. Without appropriate treatment, it is associated with significant morbidity and mortality. Surgical repair under cardiopulmonary bypass has been the standard treatment. Results of such treatment is not readily available from the West African sub region. We analysed the outcome of surgical repair of VSDs carried out in this Centre over a 20-year period. PATIENTS AND METHODS: A retrospective study was done for all patients who had surgical repair of VSD from January 1993 to December 2012. RESULTS: There were a total of 207 patients, with 6 and 23 of them operated on in the first and last years of the study respectively. There were 121 (58.5%) males and 86 (41.5%) females. The mean age was 10.0 ± 10.5 (11 months - 55 years), with a median of 7 years. The modal class interval was 0 - 5 years (46.4%). Most of the VSDs were perimembranous 168 (81.1%), followed by outlet VSDs 19 (9.2%), muscular VSDs 11 (5.3%) and inlet VSDs 9 (4.4%). Fifty-four cases (26%) had associated congenital cardiac anomalies that needed concomitant surgical intervention, with the commonest being Pulmonary Stenosis (PS) 21 (10.1%), followed by Patent Ductus Ateriosus (PDA) 10 (4.8%). The complication rate was 6.4% (13 cases), comprising a morbidity of 4.4 % (9 cases) and early mortality of 2.0% (4 cases). The morbidity was due to bleeding requiring re-exploration 2 (1.0%), residual VSD requiring re-do 3 (1.4%), complete heart block requiring permanent pacemaker implantation 2 (1.0%), acute renal failure requiring dialysis 1 (0.5%), sternal wound infection requiring debridement 1 (0.5%). The mortality was due to pulmonary hypertension. CONCLUSION: With a morbidity of 4.4% and early mortality of 2.0%, the outcome of surgical repair of VSDs from this study is good. Children with VSDs must be offered repair as soon as possible to avoid the numerous complications that usually follow untreated VSDs.

Characterization of anti-EBA175RIII-V in asymptomatic adults and children living in communities in the Greater Accra Region of Ghana with varying malaria transmission intensities.

BACKGROUND: Antibodies against Region III-V of the erythrocyte binding antigen (EBA) 175 (EBA175RIII-V) have been suggested to provide protection from malaria in a natural infection. However, the quality and quantity of naturally induced antibodies to EBA175RIII-V has not been fully characterized in different cohorts of Ghanaians. This study sought to determine the characteristics of antibodies against EBA175RIII-V in asymptomatic adults and children living in two communities of varying P. falciparum parasite prevalence in southern Ghana. METHODS: Microscopic evaluation of thick and thin blood smears was used to identify asymptomatic Plasmodium falciparum carriage and indirect enzyme linked immunosorbent (ELISA) used to assess antibody concentrations and avidity. RESULTS: Parasite carriage estimated by microscopy in Obom was 35.6% as opposed to 3.5% in Asutsuare. Levels of IgG, IgG1, IgG2, IgG3 and IgG4 against EBA175RIII-V in the participants from Obom were significantly higher (P < 0.05, Dunn's Multiple Comparison test) than those in Asutsuare. However the relative avidity of IgG antibodies against EBA175RIII-V was significantly higher (P < 0.0001, Mann Whitney test) in Asutsuare than in Obom. CONCLUSIONS: People living in communities with limited exposure to P. falciparum parasites have low quantities of high avidity antibodies against EBA175RIII-V whilst people living in communities with high exposure to the parasites have high quantities of age-dependent but low avidity antibodies against EBA175RIII-V.

Sickle Cell Disease: Reappraisal of the Role of Foetal Haemoglobin Levels in the Frequency of Vaso-Occlusive Crisis.

BACKGROUND: Foetal haemoglobin has been implicated in the modulation of sickle cell crisis. Its level is generally inversely proportional to the severity of sickle cell disease (SCD) for a given sickle cell phenotypes. The main aim of therapy for vaso-occlusive crisis (VOC), which is the hallmark of SCD, is to reduce the chances of sickling through the prevention of polymerization of HbS. One way of preventing this polymerization is by increasing foetal haemoglobin levels. OBJECTIVES: To determine the relationship between HbF levels and the frequency of crisis in SCD patients in Ghana. METHOD: A longitudinal retrospective survey covering a period of 30 months was carried out on adult SCD patients at the Sickle Cell Clinic of the Korle-Bu Teaching Hospital. RESULTS: Eighty-three adults aged 15 to 65 years made up of 40 males and 43 femalea were studied. Analysis of variance (ANOVA) gave significant results in Hb and HbF levels. Higher HbF levels were positively related to less frequent crisis and were significantly high in SCD patients than in controls. HbF effects on the clinical manifestations on SCD were variable. CONCLUSION: Threshold values of HbF play a role in reducing the frequency of vaso-occlusive crisis in SCD patients and this finding contributes to the body of available literature on SCD severity. However our work does not give the apparent threshold level of helpful HBF Level in SCD.

ASSESSMENT OF OXIDATIVE STRESS IN EARLY AND LATE ONSET PRE-ECLAMPSIA AMONG GHANAIAN WOMEN.

BACKGROUND: Pre-eclampsia is a multisystem pregnancy-related disorder with multiple theories regarding its aetiology resulting in lack of reliable screening tests and well-established measures for primary prevention. However, oxidative stress is increasingly being implicated in the pathogenesi of pre-eclampsia although conflicting findings have been reported. AIM: To determine and compare the levels of oxidative stress in early and late onset pre-eclampsia by measuring urinary excretion of isoprostane and total antioxidant power (TAP) in a cohort of pre-eclamptic women at Korle Bu Teaching Hospital. METHODOLOGY: This was a cross-sectional study conducted at Korle-Bu Teaching Hospital, Accra, Ghana involving pre-eclamptic women between the ages 18 and 45 years who gave written informed consent. Urinary isoprostane levels were determined using an enzyme-linked immunosorbent assay (ELISA) kit whereas the Total Anti-oxidant Power in urine samples was determined using Total Antioxidant Power Colorimetric Microplate Assay kit. The data obtained were analyzed using MEGASTAT statistical software package. RESULTS: We included 102 pre-eclamptic women comprising 68 (66.7%) and 34 (33.3%) with early-onset and late-onset pre-eclampsia respectively. There were no statistically significant differences between the mean maternal age, haematological indices, serum ALT, AST, ALT, albumin, urea, creatinine uric acid and total protein at the time of diagnosis. The mean gestational age at diagnosis of early and late onset pre-eclampsia were 31.65 ± 0.41 and 38.03 ± 0.21 respectively (p ˂ 0.001). Also, there were statistically significant differences between the diastolic blood pressure (BP), systolic BP and mean arterial pressure (MAP) at diagnosis of pre-eclampsia in the two categories. The mean urinary Isoprostane excretion was significantly higher in the early onset pre-eclamptic group (3.04 ± 0.34 ng/mg Cr) compared to that of the late onset pre-eclamptic group (2.36 ± 0.45 ng/mg Cr), (p=0.019). Urinary total antioxidant power (TAP) in early onset PE (1.64 ± 0.06) was lower but not significantly different from that of late onset PE (1.74 ± 0.09) with p = 0.369. CONCLUSION: Significantly increased urinary isoprostane excretion was detected in early onset pre-eclampsia compared to late onset pre-eclampsia, suggestive of increased oxidative stress in the former. However, there was no significant difference in total anti-oxidant power between the two categories of pre-eclampsia women although there was a tendency of reduced total antioxidant power in the women with early onset pre-ecalmpsia.

Boerhaave's syndrome: diagnosis and successful primary repair one month after the oesophageal perforation.

Boerhaave's syndrome (Spontaneous oesophageal perforation following forceful vomiting) is uncommon. However, when it occurs and the appropriate treatment is not given on time, it is fraught with early complications, leading to a very high mortality rate. This is a characteristic feature of this syndrome. Patient survival is in days. We present the case of an uncommon scenario of this syndrome in which the actual diagnosis was made one month after the oesophageal perforation, which was followed by primary repair, with a very good outcome.

In vitro anti-plasmodial activity of three herbal remedies for malaria in Ghana: Adenia cissampeloides (Planch.) Harms., Termina liaivorensis A. Chev, and Elaeis guineensis Jacq.

BACKGROUND: Herbal remedies of Adenia cissampeloides, Terminalia ivorensis, and Elaeis guineensis among others have been used in Ghana for the treatment of various ailments including malaria. However, most of these remedies have not been scientifically investigated. OBJECTIVE: This study, therefore, seeks to investigate the anti-plasmodial activity of these plants. MATERIALS AND METHODS: The ethanolic extracts of A. cissampeloides stem, T. ivorensis stem bark, and E. guineensis leaves were tested for in vitro anti-plasmodial activity against chloroquine-resistant strains of Plasmodium falciparum. Thin blood films were used to assess the level of parasitemia and growth inhibition of the extracts. RESULTS: The IC (50) of A. cissampeloides, T. ivorensis, and E. guineensis were 8.521, 6.949, and 1.195 µg/ml, respectively, compared to artesunate with IC(50) of 0.031 µg/ml. CONCLUSION: The result of this study appears to confirm the folkloric anti-malarial use these plants.

Genotoxicity, cytotoxicity and toxicological evaluation of whole plant extracts of the medicinal plant Phyllanthus niruri (Phyllanthaceae).

Phyllanthus niruri is a medicinal plant (commonly known as stone breaker) found in the tropics and other parts of the world. It is known for its capacity to block the formation of calcium oxalate crystals and kidney stone formation in urolithiasis. This plant has been used to treat hyperglycemia, hypertension, pain, and mild cases of malaria. We examined the geno-, cyto- and overall toxicity of P. niruri whole plant ethanolic extract. The extract was administered as a single dose of 30 or 300 mg/kg to laboratory rats by gavage, accompanied by negative (0.9% saline) and positive (10 mg/mL N-ethyl-N-nitrosourea) controls that were injected intramuscularly 48 h after extract administration. The ratio of polychromatic (PCE)/normochromatic erythrocytes (NCE) from femur bone marrow was scored for genotoxicity. Cytotoxicity was determined using descending concentrations (0.2-0.0125 g/mL) of the extract incubated with peripheral blood mononuclear cells. Lactate dehydrogenase release from damaged cells was determined and the CC(50) calculated. Subchronic administration of the extract at 30 or 300 mg/kg was done for 90 days to determine general toxicity. PCE:NCE (%) for the extract and negative control was 63, compared to 168 (positive control). The CC(50) was 26.3 mg/mL and hepato-renal toxicity after subchronic extract administration was nil. We conclude that ethanol extract of P. niruri is not cytotoxic or genotoxic, and is generally non-toxic on subchronic administration.

Circulating epstein-barr virus in children living in malaria-endemic areas.

Children living in malaria-endemic regions have high incidence of Burkitt's lymphoma (BL), the aetiology of which involves Plasmodium falciparum malaria and Epstein-Barr virus (EBV) infections. Acute malarial infection impairs the EBV-specific immune responses with the consequent increase in the number of EBV-carrying B cells in the circulation. To further understand the potential influence of malarial infection on the EBV persistence in children living in malaria-endemic areas, we studied the occurrence and quantified cell-free EBV-DNA in plasma from 73 Ghanaian children with and without acute malarial infection. Viral DNA was detected in 40% of the samples (47% in the malaria-infected and 34% in the nonmalaria group) but was absent in plasma from Ghanaian adults and healthy Italian children. These findings provide evidence that viral reactivation is common among children living in malaria-endemic areas, and may contribute to the increased risk for endemic BL. The data also suggest that the epidemiology of EBV infection and persistence varies in different areas of the world.

Allelic polymorphisms in the repeat and promoter regions of the interleukin-4 gene and malaria severity in Ghanaian children.

Immunoglobulin E has been associated with severe malaria suggesting a regulatory role for interleukin (IL)-4 and/or IgE in the pathogenesis of severe malaria. We have investigated possible associations between polymorphisms in the IL-4 repeat region (intron 3) and promoter regions (IL-4 +33CT and - 590CT) in Ghanaian children with severe malaria. There was a significantly higher frequency of IL-4 intron-3 B1B1 genotype in the cerebral malaria group [P < 0.0001, odds ratio (OR) = 8.7]. The genotype and allele frequencies of the IL-4 -590 and +33 polymorphisms did not differ between the four study groups. Carriers of IL-4 +33T/-590T with cerebral malaria had elevated total IgE compared to non-carriers (P = 0.03). Our data suggest that IL-4 and/or IgE play a regulatory role in the pathogenesis of severe or complicated malaria.

Polymorphisms in interleukin-1beta and interleukin-1 receptor antagonist genes and malaria in Ghanaian children.

We have investigated the possible associations between polymorphisms in two interleukin-1 (IL-1) genes and severity of Plasmodium falciparum malaria in Ghanaian children with cerebral malaria, severe anaemia or uncomplicated malaria and controls. There was no significant difference in genotype and allele frequencies in IL-1beta exon 5 or interleukin-1 receptor antagonist (IL-1ra) polymorphisms between the studied groups, suggesting that the two polymorphisms may not be involved in the pathogenesis of severe malaria. When parasitaemias in uncomplicated malaria patients were evaluated, a significantly higher level of parasitaemia was observed among carriers of IL-1beta A2 allele as compared with noncarriers of this allele (P = 0.01). The mean parasitaemia in an age-matched asymptomatic group did not reveal such associations. These data suggest that IL-1beta exon 5 allele 2 may play a possible role in the clinical outcome of uncomplicated malaria.

Complement binding to erythrocytes is associated with macrophage activation and reduced haemoglobin in Plasmodium falciparum malaria.

We have examined IgG and complement factor C3d deposition on erythrocytes by means of the direct Coombs' test (DAT) and looked for an association with the anaemia seen in falciparum malaria in children living in an area of hyperendemic malaria transmission (in Ghana). In one study (in 1997), 53 out of 199 patients had a positive DAT. Of these, 45 samples reacted with anti-C3d antibodies, 2 with anti-IgG and 6 with both reagents. There were significantly lower haemoglobin (Hb)-levels and higher prevalence of spleen enlargement in DAT-positive than in DAT-negative patients. Hb-levels were independently associated with DAT and age. This initial study was designed to investigate the role of intravascular haemolysis (IVH), but we found no association between IVH and either DAT result or anaemia. Because of the risk of selection bias we repeated the study using consecutive enrollment of malaria patients and were able to confirm the results in a total of 49 DAT-positive and 183 DAT-negative patients. This second study (in 1998) was designed to look at the importance of erythrophagocytosis through measurement of plasma neopterin levels and total nitrite and nitrate as markers of NO-release. Both parameters were significantly higher in DAT-positive than in DAT-negative patients (P < 0.001), indicating that complement binding to erythrocytes was associated with macrophage activation. Plasma levels of haptoglobin, interleukin-10 and tumour necrosis factor-alpha did not vary between the groups. The studies support the role of complement activation and erythrophagocytosis in the pathogenesis of anaemia in falciparum malaria in African children.

Haptoglobin phenotypes in HIV-1-seropositive patients in Ghana: decreased risk for Hp0 individuals.

Plasma haptoglobin phenotypes were determined by polyacrylamide gel electrophoresis, followed by benzidine staining for 58 HIV-1 seropositive Ghanaians and 79 randomly selected age-matched controls. Hp0 was present in only 14% of HIV-1 seropositive individuals compared with more than 40% of the controls. The Hp0 individuals showed a highly significant reduced risk for HIV-1 infection (OR = 0. 21, 95% CI = 0.09-0.51, p = 0.0002). Hp0 may have a protective effect in HIV-1 infection.

Haptoglobin 1-1 is associated with susceptibility to severe Plasmodium falciparum malaria.

The haptoglobin (Hp) phenotypes were determined by polyacrylamide-gel electrophoresis in plasma samples obtained in 1997 from 113 Plasmodium falciparum malaria patients (aged 1-12 years) with strictly defined cerebral malaria, severe malarial anaemia, or uncomplicated malaria and 42 age-matched healthy controls from the same area (coastal Ghana). Hp1-1 was significantly more prevalent among the patients (43%) than among healthy controls (7.1%), whereas Hp2-1 and Hp2-2 were underrepresented among the patients (11% and 2%, respectively) compared to the control donors (33% and 14%, respectively). No significant difference in frequency of Hp0 was observed between patients and controls. Among the malaria patients, the Hp1-1 phenotype was significantly more prevalent among patients with the complications of cerebral malaria and severe anaemia compared to patients with uncomplicated disease, whereas the reverse was seen with respect to Hp2-1 and Hp2-2. Our data suggest that the Hp1-1 phenotype is associated with susceptibility to P. falciparum malaria in general, and to the development of severe disease in particular.

Haptoglobin polymorphism in human immunodeficiency virus infection: Hp0 phenotype limits depletion of CD4 cell counts in HIV-1-seropositive individuals.

Patients seropositive for human immunodeficiency virus (HIV) type 1 and seronegative control subjects were categorized by their haptoglobin phenotypes, which were determined by electrophoresis of hemoglobin-supplemented plasma samples followed by benzidine staining. The CD4 cell counts, determined by flow cytometry from peripheral blood mononuclear cells according to subject categories, were severely diminished in seropositive patients with the Hp2-2 phenotype (P<.025). In contrast, the CD4 cell counts for patients with the Hp0 phenotype remained relatively high (P<.025), compared with those of the controls. In seronegative patients, CD4 cell counts were generally high (P<.005), but they were more elevated in subjects with Hp2-2 and Hp1-1, although the differences were not significant. Thus, the Hp2-2 phenotype is associated with poor outcome in HIV-1 infection, whereas the Hp0 phenotype is associated with a better prognosis once the patient is infected with HIV-1. Haptoglobin polymorphism plays a significant role in HIV-1 infection and transmission.

Seroreactivity to Pf 155/RESA in two malaria endemic ecological zones in Southern Ghana.

Seroepidemiological data are becoming important tools in determining transmission patterns of malaria. We have undertaken a study in 2 different ecological zones in southern Ghana during both the dry and wet seasons. Virtually all the subjects studied were positive to the crude parasite antigen (92%), with majority showing high titres in both areas. Whilst there was a statistical difference in Geometrical Mean Titre (GMT) between the two areas, seasonal variation was not seen. Antibody levels to the Pfl55/RESA and its repeat pepetide (EENV)6 increased progres notsively with age in endemic areas. These findings have relevance in determining malaria transmission in endemic areas.

Seroreactivity to Pf 155/RESA in Two Malaria Endemic Ecological Zones in Southern Ghana

Seroepidemiological data are becoming important tools in determining transmission patterns of malaria. We have undertaken a study in 2 different ecological zones in southern Ghana during both the dry and wet seasons. Virtually all the subjects studied were positive to the crude parasite antigen (92); with majority showing high titres in both areas. Whilst there was a statistical difference in Geometrical Mean Titre (GMT) between the two areas; seasonal variation was not seen. Antibody levels to the Pfl55/RESA and its repeat pepetide (EENV)6 increased progres notsively with age in endemic areas. These findings have relevance in determining malaria transmission in endemic areas

Human monocytes cultured with and without interferon-gamma inhibit Plasmodium falciparum parasite growth in vitro via secretion of reactive nitrogen intermediates.

Adherent cells from human peripheral blood were studied for their interaction with asexual blood forms of Plasmodium falciparum in vitro. Freshly isolated monocytes only showed weak anti-parasitic effects. However, an enhancement of this anti-parasitic activity was apparent when monocytes were allowed to mature in vitro. Monocytes activated with IFN-gamma for two or three days had an enhanced anti-parasitic effect. In contrast, the inhibition mediated by cells incubated for five days was the same with or without IFN-gamma treatment. There was no evidence of toxicity when IFN-gamma at high concentrations was added directly to P. falciparum cultures. The anti-parasitic activity of the activated cells seemed to be due to nitric oxide since incubation of macrophages with L-NMMA reduced the level of inhibition. However, inhibition was only partial suggesting that other factors also were involved in inhibition of parasite growth.

Assessment of anthropometric measurements, blood analytes and liver enzymes in Ghanaian alcoholics.

Anthropometric measurements of alcoholics and non alcoholics of similar economic background were compared and the results reveal that there are no marked differences between the two. However, the biochemical analyses indicates that alcohol predisposes to fat storage, may contribute to iron deficiency and plays a direct etiologic role in liver disease.

Biochemical and haematological markers of alcohol intake in Ghanaians.

The serum gamma-glutamyltransferase (GGT), aspartate aminotransferase (AST), urate and triglyceride and mean cell volume (MCV) were determined in 60 total abstainers, 56 social drinkers and 100 alcoholics. Both enzymes and urate showed progressive rise with increasing alcohol intake. The mean cell volume was only moderately elevated. Gamma-glutamyltransferase (GGT), aspartate aminotransferase (AST), and urate are sensitive enough to detect people who take in alcohol regularly and yet may be regarded as normal and not alcohol dependent.