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.

Pattern of esophageal injuries and surgical management: A retrospective review.

BACKGROUND: The consequence of significant injury to the esophagus is devastating. The initial management when timely and appropriate is rewarding and often prevents lethal complications. The objective of this study is to describe the etiology of esophageal injury in our institution, the management procedures and the mid-term results. METHOD: Consecutive patients diagnosed and managed for esophageal injury from January 2005 to March 2015 were retrospectively reviewed. RESULTS: One hundred and eleven patients were seen and treated during this period; 85 (76.6%) predominantly children were corrosive esophageal injuries who accidentally ingested caustic soda and 26 (24.4%) were traumatic esophageal injuries. Patients with corrosive esophageal injuries were predominantly male (2:1), mean age 12.8 ± 14.2 years (2-58 years) and predominantly children (53% ≤5 years; 18.8% ≥ 18 years). Patients with non-corrosive esophageal injury were also predominantly male (4:1) with a mean age of 34.4 ± 20.1 years (1-73 years). The treatment procedures for corrosive esophageal injuries included esophagocoloplasty 64 (75.3%), colopharyngoplasty 10 (11.8%), colon-flap augmentation pharyngo-esophagoplasty 4 (4.7%), colopharyngoplasty with tracheostomy 4 (4.7%) and esophagoscopy and dilatation 3 (3.5%). Mortality was 5.9% and 5 patients were lost to follow-up. In patients with noncorrosive esophageal injury, esophageal perforation from instrumentation accounted for 14 (53.9%), foreign body impaction 11 (42.3%) and spontaneous perforation 1 (3.8%) making up the rest. Management of these patients included esophagotomy and removal of foreign body 7 (26.9%), esophagectomy, cervical esophagostomy and feeding gastrostomy 10 (38.6%), primary repair 7 (26.9%), Ivor Lewis procedure 1 (3.8%) and emergency esophagectomy with colon replacement 1 (3.8%). Mortality in this group of patients was 7.7% and 4 patients were lost to follow-up. CONCLUSION: Corrosive esophageal injuries were the most frequent form of esophageal injury at our center due to unrestricted access to corrosive substances. Generally, appropriate surgical intervention in patients with esophageal injury based on individualization of care yields excellent early and mid-term results.

Seasonal gaps in measles vaccination coverage in Madagascar.

INTRODUCTION: Measles elimination depends on the successful deployment of measles containing vaccine. Vaccination programs often depend on a combination of routine and non-routine services, including supplementary immunization activities (SIAs) and vaccination weeks (VWs), that both aim to vaccinate all eligible children regardless of vaccination history or natural infection. Madagascar has used a combination of these activities to improve measles coverage. However, ongoing massive measles outbreak suggests that the country was in a "honeymoon" period and that coverage achieved needs to be re-evaluated. Although healthcare access is expected to vary seasonally in low resources settings, little evidence exists to quantify temporal fluctuations in routine vaccination, and interactions with other immunization activities. METHODS: We used three data sources: national administrative data on measles vaccine delivery from 2013 to 2016, digitized vaccination cards from 49 health centers in 6 health districts, and a survey of health workers. Data were analyzed using linear regressions, analysis of variance, and t-tests. FINDINGS: From 2013 to 2016, the footprint of SIAs and VWs is apparent, with more doses distributed during the relevant timeframes. Routine vaccination decreases in subsequent months, suggesting that additional activities may be interfering with routine services. The majority of missed vaccination opportunities occur during the rainy season. Health facility organization and shortage of vaccine contributed to vaccination gaps. Children born in June were the least likely to be vaccinated on time. DISCUSSION: Evidence that routine vaccination coverage varies over the year and is diminished by other activities suggests that maintaining routine vaccination during SIAs and VWs is a key direction for strengthening immunization programs, ensuring population immunity and avoiding future outbreaks. FUNDING: Wellcome Trust Fund, Burroughs Wellcome Fund, Gates Foundation, National Institutes of Health.

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.

[Impact of the 2009 Afssaps guidelines on the management of venous thromboembolic disease in emergency department: Before/after study]. / Impact des recommandations Afssaps 2009 sur la prise en charge de la maladie thromboembolique veineuse aux urgences : étude avant/après.

INTRODUCTION: The French Agency for Health Safety of Products published recommendations of good practices (RGP) for the treatment of venous thromboembolic disease in 2009. Four of these recommendations apply to the initial management of the disease, with the objective of this study is to determine whether the development and diffusion of the four RGP has had an impact on the practice. METHODS: A retrospective before/after study comparing 132 patients treated in emergency department of the Civil Hospices of Lyon for pulmonary embolism (PE) and/or deep venous thrombosis (DVT) in 2008-2009 ("before") and 153 patients in 2010-2011 ("after"). RESULTS: In the "before" period, 70 patients were treated for DVT and 62 patients for PE. In the "after" period, 50 patients were treated for DVT and 103 patients for PE. The compliance rate was not significantly different for the two periods for each RGP except for the indication of low molecular weight Heparin (LMWH) or fondaparinux in the absence of severe renal failure (21% "before" vs. 45% "after"; P=0.02) for patients with PE. Management for the four recommendations was conform for 5.6% of eligible patients in the "before" period and for 3.7% for the "after" period. CONCLUSION: Our study shows that globally there is no impact of RGP. The reasons appear multiple with first, the mere dissemination and the absence of implementation of these guidelines.

Establishing the Cardiothoracic Ratio Using Chest Radiographs in an Indigenous Ghanaian Population: A Simple Tool for Cardiomegaly Screening.

BACKGROUND: Cardiothoracic ratio is a simple and cheap tool in the estimation of heart size. It is a useful index of cardiac size evaluation, and a value of 50% is generally considered to indicate the upper limit of normal. STUDY OBJECTIVE: This study is to ascertain the normal mean value in cardiothoracic ratio of Ghanaians using chest radiography to serve as baseline for screening for cardiomegaly. METHODOLOGY: Standard postero-anterior radiographs of the -clients/patients were used in the study. The cardiothoracic ratio (CTR) was obtained by dividing the transverse cardiac diameter [sum of the horizontal distances from the right and left lateral-most margins of the heart to the midline (spinous processes of the vertebral bodies)] by the maximum internal thoracic diameter. Systematic sampling with appropriate inclusion and exclusion criteria were used to obtain a sample size of 1989. RESULTS: The mean transverse cardiac diameter and cardiothoracic ratio increased with age. The transverse thoracic diameter increased with age until the sixth decade when it reduced with age. The mean CTR increased gradually with age with females having greater values than males. The mean CTR of the study population were 0.459, 0.467 and 0.452 for the general population, females and males respectively. CONCLUSION: This study has been able to establish 0.459 as the mean CTR values for Ghanaians. It has also shown the relationship between age and clients/patient's cardiothoracic ratio which compares favourably with findings of a similar study in Nigeria, a neighbouring country in the West African sub region with similar ethnic and social structure.

The Ghanaian woman's experience and perception of ultrasound use in antenatal care.

OBJECTIVE: To evaluate how Ghanaian women perceive the use, and their assessment of the experience, of antenatal ultrasound scanning. DESIGN: Cross-sectional study, using interviewer-administered questionnaire, from 25th February to 16th April, 2011. SETTING: Obstetrics Units of Korle Bu Teaching Hospital, Accra, University of Ghana Hospital, Legon and Ga South District Hospital, Weija. METHODS: A total of 337 clients were randomly selected after delivery and interviewed. Issues addressed included why women went for antenatal ultrasound, their knowledge of the uses of ultrasound in pregnancy, information provided by health care providers, clients' eagerness to know the sex of their fetuses, and their overall assessment of the ultrasound scanning experience. RESULTS: The mean number of scans was 2.2(1.1). Most were performed on the request of a doctor or midwife; 154(45.7%) were not told the reasons for the request and 185(54.9%) did not have the results explained to them. For 239(70.9%) women the sonographer did not explain the procedure before the examination; 89(26.4%) were allowed to ask questions and 61(18.1%) were allowed to see their fetuses on the monitor. One hundred and sixty respondents (47.5%) asked for and were told the sex of their fetuses, with accuracy at delivery of 86.5%. CONCLUSION: Most respondents perceived antenatal ultrasound as a useful tool. There is lack of information flow from health care providers to clients concerning the indications for the ultrasound, the processes involved and the results of the procedure. Improvements in these areas are needed to enhance the experience of antenatal ultrasound among Ghanaian women.

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.

A review of the anticancer potential of the antimalarial herbal cryptolepis sanguinolenta and its major alkaloid cryptolepine.

Cryptolepis sanguinolenta (Lindl.) Schltr (Periplocaceae), has a longstanding traditional use in the treatment of malaria in the West African region. Recent evidence suggests that the aqueous extract from the roots and the major alkaloid from the plant, cryptolepine, have prospects as cancer chemotherapeutic agents on account of their potent cytotoxicity to mammalian cells. Several mechanisms have been proposed to explain the cytotoxic activities of the agents. However, emerging evidence from their anti-inflammatory actions suggest that the mechanism of the cytotoxicity may be closely related to its anti-inflammatory activity. This review looks at the mechanisms of cryptolepis-induced cytotoxicity, its link with inflammation and its potential as anticancer agent. The elucidation of these interwoven mechanisms may be useful in the development of cryptolepine or other analogues as new anticancer agents.

Management of intrathoracic oesophageal perforation: analysis of 16 cases.

Intrathoracic oesophageal perforation remains a life-threatening lesion that requires early diagnosis and the appropriate intervention in order to reduce morbidity and mortality. Management depends largely on the cause of the perforation, the integrity of the oesophagus and the time lapse between the perforation and the commencement of treatment. Our aim was to evaluate the management options that were employed in the treatment of patients with oesophageal perforation and the outcome. The records of 16 patients (11 males and 5 females) who had been operated on from 1994-2009 were retrospectively reviewed. Their ages ranged between 2-66 years (mean 36.4). Malignant oesophageal perforations were excluded from the study. The aetiology was iatrogenic in 10 (62.5%), foreign bodies five (31.2%) and spontaneous one (6.2%). Six patients (37.5%) presented within 24 h of their injury and 10 (62.5%) presented after 24 h. Thoracotomy and intrathoracic primary repair was possible in five (31.2%) cases. Oesophagectomy, cervical oesophagostomy and feeding gastrostomy were carried out in 11 (68.8%). Oesophageal substitution was by colon, routed retrosternally. One patient (6.2%) died after oesophagectomy from overwhelming sepsis. Oesophageal perforation is a life-threatening condition. Early diagnosis and the institution of prompt and appropriate treatment ensure good outcome.

Fostering repeat donations in Ghana.

INTRODUCTION: Most African countries are challenged in recruiting and retaining voluntary blood donors by cost and other complexities and in establishing and implementing national blood policies. The availability of replacement donors who are a cheaper source of blood has not enhanced repeat voluntary donor initiatives. METHODS: An overview of activities for recruiting and retaining voluntary blood donors was carried out. Donor records from mobile sessions were reviewed from 2002 to 2008. RESULTS AND DISCUSSION: A total of 71,701 blood donations; 45,515 (63.5%) being voluntary donations with 11,680 (25%) repeat donations were collected during the study period. Donations from schools and colleges contributed a steady 60% of total voluntary whilst radio station blood drives increased contribution from 10 to 27%. Though Muslim population is less than 20%, blood collection was above the 30-donation cost-effectiveness threshold with a repeat donation trend reaching 60%. In contrast Christian worshippers provided <25 unit/session and 30% repeat donations. Repeat donation trends amongst school donors and radio blood drives were 20% and 70% respectively. CONCLUSION: Repeat donations rates have been variable amongst different blood donor groups in Kumasi, Ghana. The impact of community leaders in propagating altruism cannot be overemphasized. Programs aiming at motivating replacement donors to be repeat donors should be developed and assessed.

Permanent complete heart block following surgical correction of congenital heart disease.

BACKGROUND: The risk of complete heart block (CHB) from congenital heart repairs in Ghana is unknown. This information is important for referring physicians and in pre-operative counselling of patients and facilitates the process of obtaining informed consent for such repairs. OBJECTIVES: This study was undertaken to determine the incidence of permanent post-operative CHB requiring pacemaker implantation; and the post-operative problems related to the pacemaker. DESIGN: Retrospective study design. SETTING: The National Cardiothoracic Centre (NCTC), Korle-Bu Teaching Hospital, Accra, Ghana. METHOD: Review of all patients who had intra-cardiac repair of congenital heart disease known to predispose to post-operative complete heart block from January 1993 to December 2008 was carried out with computation of the frequency of complete heart block according to the intra-operative diagnoses. RESULTS: Six out of 242 patients (2.5%) developed permanent post-operative CHB. All underwent closure of a large perimembranous ventricular septal defect (VSD) either as an isolated defect (2 of 151 or 1.3%) or in the setting of conotruncal anomalies (4 of 73 or 5.5%). The dominant parental concern relating to the implanted device was the financial implications of future multiple surgeries to replace a depleted pulse generator. CONCLUSION: Permanent post-operative complete heart block occurred in 1.3% of patients undergoing VSD repair and 5.5% of those undergoing repair of conotruncal anomalies (Fallot's tetralogy). The dominant anatomic risk factor was a large perimembranous VSD as an isolated defect or as part of a conotruncal anomaly. Permanent pacemaker implantation in this setting is attended by a low morbidity.

Outcome of thrombolysis for massive pulmonary embolism.

BACKGROUND: Deep vein thrombosis is increasingly being diagnosed in Ghana. The commonest complication that leads to death is pulmonary embolism. The mortality rate from massive pulmonary embolism is high even with intervention. Thrombolysis is recommended in massive embolism. OBJECTIVE: To determine the outcome of thrombolysis in the management of massive pulmonary embolism in patients admitted to the Cardiothoracic Intensive Care unit. METHOD: A retrospective audit of the patients who were admitted to the Intensive care unit of the National Cardiothoracic centre with a diagnosis of massive pulmonary embolism between 1st January 2003 and 31st September 2007. RESULTS: Seventeen patients were admitted with the diagnosis of massive pulmonary embolism of which 14 were thrombolysed. Commonest clinical presentations were dyspnoea in 17(100.0%) and hypotension in 12(70.3%) of the patients. Streptokinase was used in 13(92.9%) and urokinase in 1(7.1%) of the patients. The main complications of thrombolysis were bleeding in 12(85.7%), hypotension in 10(71.4%) and nausea and vomiting in 7(50.0%) of the patients. Postthrombolysis, the respiratory function deteriorated in 12 (85.7%) of the patients which required mechanical ventilation. The overall mortality rate was 35.3%. Three patients died before thrombolysis. Of the 14 (82.4%) who were thrombolysed 3(21.4%) died within 8 hours. CONCLUSION: The mortality rate of patients with massive pulmonary embolism is high even after thrombolysis. The commonest complication of thrombolysis was bleeding.

Synchronised cardioversion for chronic atrail fibrillation.

SUMMARY OBJECTIVE: To determine whether elective cardioversion was successful in establishing sinus rhythm in patients with chronic atrial fibrillation and the energy used for the cardioversion using a monophasic defibrillator. DESIGN: This is a retrospective descriptive study. SETTING: Intensive care unit of the National Cardiothoracic Centre, Korle-bu Teaching Hospital. SUBJECTS: Twelve consecutive patients referred by physicians with chronic atrial fibrillation which had not responded appropriately to pharmacological agents. METHOD: Using the intensive care admissions and discharge register and report book, the patients case notes were retrieved. The pre-cardioversion echocardiography diagnosis and drugs were noted. The results of cardioversion, and the current rhythm status were also reviewed. RESULTS: There were twelve elective cardioversions for chronic atrial fibrillation during the period under investigation. All the patients were on warfarin with INR-2.2-2.8. Eight of the patients had initial echocardiographic evidence of thrombi in the left atrium. Sinus rhythm was established in 9(75%) of the patients. The mean energy used for the cardioversion was 384.4+/-167.7J. Of the 3 with failed cardioversion, one was later successfully cardioverted to sinus rhythm. On review, 9(75%) of the patients are still in sinus rhythm 6 months to 15 months after cardioversion. Six of these patients continue with oral amiodarone however. CONCLUSION: Synchronized cardioversion for chronic atrial fibrillation is safe and may be successful after failure of pharmacologic cardioversion in patients where sinus rhythm is desirable.

Surgical management of constrictive pericarditis.

SUMMARY BACKGROUND: Constrictive pericarditis is a disease characterized by marked thickening and dense scarring of the pericardium with pericardial sac obliteration, or calcification of the pericardium. Without treatment this disease is characterized by high morbidity and mortality. OBJECTIVE: To review the surgical management of constructive pericarditis and the post operative challenges. METHODS: Eleven patients who had pericardiectomy for constructive pericarditis between 2000 and 2005 were studied. Data was obtained from the operating theatre register, histopathological reports and patient's case notes. RESULTS: The mean age was 33 years with a range of 14 to 53 years. There were seven males (63.6%) and four females (36.4%). Seven (63.6%) out of the eleven patients operated were treated for pulmonary tuberculosis. The cause of pericardial constriction in four patients (36.4%) was undetermined. Follow up period was between 4-59 months. The mean follow up was 17.5 months. Seven patients (63.6%) were off diuretics and had no exercise intolerance. Patients were classified using the New York Heart Association (NYHA) n (NYHA) functional and therapeutic classification in class I-V. Two patients preoperatively in class III are now in class I after surgery on low dose diuretics. One patient who had calcific constrictive pericarditis and came in class III was now in class II with diuretics after 3 years of follow up. There was no postoperative mortality. One patient was lost to follow up. CONCLUSION: Pericardiectomy is a useful procedure for constrictive pericarditis and was beneficial to all the patients in this study with an improvement in their functional capacity. Intensive peri-operative monitoring and management reduced morbidity and mortality.

Surgical Management of Constrictive Pericarditis

Background: Constrictive pericarditis is a disease characterized by marked thickening and dense scarring of the pericardium with pericardial sac obliteration; or calcifica- tion of the pericardium. Without treatment this disease is characterized by high morbidity and mortality. Objective: To review the surgical management of constructive pericarditis and the post operative challenges. Methods: Eleven patients who had pericardiectomy for constructive pericarditis between 2000 and 2005 were studied. Data was obtained from the operating theatre register; histopathological reports and patient's case notes. Results: The mean age was 33 years with a range of 14 to 53 years. There were seven males (63.6) and four females (36.4). Seven (63.6) out of the eleven patients operated were treated for pulmonary tuberculosis. The cause of pericardial constriction in four patients (36.4) was undetermined. Follow up period was between 4-59 months. The mean follow up was 17.5 months. Seven patients (63.6) were off diuretics and had no exercise intolerance. Patients were classified using the New York Heart Association (NYHA) n (NYHA) functional and therapeutic classification in class I-V. Two patients preoperatively in class III are now in class I after surgery on low dose diuretics. One patient who had calcific constrictive pericarditis and came in class III was now in class II with diuretics after 3 years of follow up. There was no postoperative mortality. One patient was lost to follow up. Conclusion: Pericardiectomy is a useful procedure for constrictive pericarditis and was beneficial to all the patients in this study with an improvement in their functional capacity. Intensive peri-operative monitoring and management reduced morbidity and mortality

Knowledge, attitude and practice universal basic precautions by medical personnel in a teaching hospital.

SUMMARY BACKGROUND: Universal Basic Precautions (UBP) are not well understood nor implemented by health professionals, though crucial in HIV/AIDS prevention. As defined by Garner, UBP refers to "the prevention of transmission of blood borne pathogens like HIV through strict respect by health workers of rules concerning care and nursing" OBJECTIVES: To find out knowledge and attitudes of medical personnel doctors in the Department of Surgery of the Korle Bu Teaching Hospital to HIV transmission and to find out their current practices of UBP in surgery. METHODS: The study was carried out using a structured questionnaire which was self administered to fifty medical personnel after preliminary introduction at a plenary session. RESULTS: Results showed that alleged knowledge did not match actual tested knowledge (92% verses 71%). Knowledge of all the forms of HIV transmission was rather limited among medical personnel. Practice of UBP was also not universal as 44% preferred to rely on pre-op HIV testing of patients and knowledge of their status whilst 36% of respondents admitted reluctance to perform an invasive procedure on an HIV positive patient. CONCLUSION: This study shows the need for the Ministry of Health, the Ghana Health Service and its institutions to develop and implement specific policies on the practice of UBP, training of health care providers and ensuring the consistent supply of protective materials.

An approach to investigating the importance of high potency polycyclic aromatic hydrocarbons (PAHs) in the induction of lung cancer by air pollution.

Evidence suggests that people living in urban areas have an increased risk of lung cancer due to higher levels of air pollution in these areas. Benzo[a]pyrene (B[a]P) is currently used as the main indicator of carcinogenic polycyclic aromatic hydrocarbons (PAHs) in air pollution, but there is concern that B[a]P may not be the ideal surrogate of choice for PAH mixtures since higher potency PAHs have recently been identified which could potentially contribute more and variably to the overall carcinogenicity. Dibenzo[a,h]anthracene (DBA) and dibenzo[a,l]pyrene (DB[a,l]P) are estimated to have carcinogenic potencies 10 or more times greater than B[a]P but data on their presence and formation in the environment are limited. Several occupational and environmental PAH biomonitoring studies are reviewed here, with particular focus on the specific exposure groups, study design, sample tissue, in particular the use of nasal tissues, and biomarkers used in each study. Consideration of these data is then used to propose a novel biomonitoring approach to evaluate exposure, uptake and the role of high potency PAHs in air pollution-related lung cancer. This is based upon an occupational study examining specific DNA adducts for DBA and DB[a,l]P in nasal cells to evaluate the extent to which these high potency PAHs might contribute to the increased risk of developing lung cancer from air pollution.

Legal termination of pregnancy among teenagers and older women in Soweto, 1999-2001.

BACKGROUND: Legal termination of pregnancy (TOP) was introduced in South Africa in 1996. No data are available to relate the numbers of TOPs to the total number of pregnancies in specific health regions. The level of use of TOPs by women of different age groups is not known. OBJECTIVE: To determine the proportion of pregnancies that end in TOP, with special reference to maternal age, and to measure trends in use from 1999 to 2001. SETTING: Greater Soweto, Orange Farm and Lenasia, a densely populated urban health region served by Chris Hani Baragwanath Hospital and comprehensive primary care reproductive health services. METHODS: Two cross-sectional studies performed in 1999 and 2001, counting all pregnancies managed in state-run health services, including legal terminations, spontaneous miscarriages, ectopic pregnancies and deliveries. RESULTS: There were 5,412 pregnancies in the study period (9 weeks) in 1999, and 5,316 in the study period (8 weeks) in 2001. The TOP rates decreased from 16.1% to 13.6% (P = 0.20). The TOP rates for teenagers decreased from 22.3% to 16.3% (P = 0.006), but were higher than those for older women (15.2% in 1999 and 13.2% in 2001, P = 0.006 and 0.028 respectively). TOP rates for teenagers 13-16 years decreased from 28.0% to 23.0% (P = 0.44), and rates for older teenagers declined from 21.0% to 14.9% (P = 0.008). In 2001, 16.2% of women aged 35 and above underwent TOP, compared with 12.7% of women aged 20-34 years (P = 0.014). CONCLUSION: Use of TOP services was highest in women at the extremes of reproductive age. There was a significant decline in TOP rates among older teenagers between 1999 and 2001. These data, from a comprehensive urban reproductive health service, provide a benchmark for comparison elsewhere and in the future.

Musculoskeletal conditions in children attending two Togolese hospitals.

OBJECTIVE: A retrospective study was conducted in order to point out the different kinds of musculoskeletal conditions observed in children attending two Togolese hospitals. RESULTS: A total of 434 (242 females, 192 males) of the 29 620 children examined (1.5%) were suffering from these conditions. Probable joint and bone infections (187 patients, 43%), limb deformities (106 patients, 24%), osteochondrosis (60 patients, 14%) and vaso-occlusive crisis due to haemoglobinopathies (29 patients, 7%) were the main conditions observed. Osteomyelitis observed in 128 patients affected the humerus (25 patients), radius (10 patients), femur (68 patients), tibia (15 patients), fibula (five patients), and both tibia and fibula (five patients). Probably, infectious arthritis seen in 30 patients affected mainly the hip (11 patients) and the knee (13 patients). In the spine, infection affected the midthoracic and upper lumbar areas. Underdevelopment, sickle cell anaemia and sickle cell haemoglobin C disease were the main risk factors in determining susceptibility to infections. Vaso-occlusive crises were due to sickle cell anaemia (11 patients) and sickle cell haemoglobin C disease (18 patients). Osteochondrosis seen in 60 patients free from haemoglobinopathy involved the spine (Scheuermann's disease, 38 patients) and the hip (Legg-Calvé-Perthes disease, 22 patients). Limb deformities were observed in the knee (varus and valgus deformities in 64 patients) and the foot (talipes varus equin in 40 patients). CONCLUSION: This study's findings, which require further confirmation, suggest some conclusions. Scheuermann's disease can explain in part the degenerative disc conditions observed in African adults. Valgus and varus deformities play an important role in the development of knee osteoarthritis in Black Africa. An African child with joint or bone pain should be investigated for sickle cell anaemia. In the future, improved lifestyle and better health care will be essential to reduce bone and joint infections, and allow refined diagnosis of connective tissue diseases now probably underestimated in African children.