A multi-centre investigation of macrovascular and non-ocular microvascular complications in children and adolescents with diabetes mellitus in southern Ghana

Objectives

To investigate the prevalence of macrovascular and non-ocular microvascular complications and the associated factors among children and adolescents with diabetes mellitus in selected hospitals in southern Ghana.

Design

A cross-sectional study.

Setting

The out-patient clinics of the Departments of Child Health, Medicine and Therapeutics, Family Medicine, Ophthalmology, and the National Diabetes Management and Research Centre, all at the Korle Bu Teaching Hospital, Accra, as well as from Cape-Coast Teaching Hospital in the Central Region of Ghana.

Participants

Fifty-eight children and adolescents aged 4-19 years who had been diagnosed with diabetes mellitus.

Main outcome measures

Macrovascular (peripheral artery disease and coronary heart disease) and non-ocular microvascular complications (neuropathy and nephropathy).

Results

Data from 58 children and adolescents with diabetes were analysed. The mean age of participants was 14.6±2.6 years, and a female preponderance was observed (45, 77.6%). The prevalence of macrovascular and non-ocular microvascular complications was 27.6% and 8.6%, respectively. Long duration of diabetes diagnosis (p=0.044) and low triglycerides (p=0.009) were associated with microvascular complications, while high triglycerides (p=0.032), lower HDL cholesterol (p=0.046), and abnormal body mass index (p=0.020) were associated with macrovascular complications.

Conclusions

Macrovascular and non-ocular microvascular complications are common among children and adolescents with diabetes in southern Ghana and are associated with a long duration of diabetes diagnosis, abnormal body mass index, low HDL cholesterol, and triglyceride levels. Therefore, the early institution of regular screening for diabetes-related complications to allow early detection and appropriate management is recommended.

Funding

University of Ghana Research Fund.

A Cross-Sectional Study of Ocular Changes in Children and Adolescents with Diabetes Mellitus in Selected Health Facilities in Ghana

BACKGROUND

The main objective of the study was to determine the prevalence of diabetic retinopathy (DR), other diabetes-related ocular changes (e.g., cataracts, corneal ulceration), and non-diabetic ocular disease in Ghanaian children and adolescents. The second objective was to evaluate the relationship between these conditions and age at diagnosis, current age, diabetes mellitus (DM) duration, and participant's sex.

METHODS

A cross-sectional study, undertaken by a multidisciplinary team, included a cohort of children and adolescents (4-19 years) with DM recruited from selected health facilities in Ghana, from March 2016 to September 2019, after written informed consent or assent. The cohort will be followed up for 3 years to determine the natural course of the ocular changes, reported later. Participants were examined for all microvascular and macrovascular complications, non-diabetic ocular disease, anthropometric measurements, laboratory characteristics and quality of life issues. Full ocular examination was also undertaken. Statistical Package for Social Sciences (SPSS Version 25.0) was used for the data analysis. Continuous and categorical variables were presented as mean and standard deviation (SD), median (interquartile range) and as percentages (%), respectively. T-test and Mann-Whitney U test were used in establishing associations.

RESULTS

A total of 58 participants were recruited. DR was detected in only 1 out of 58 (1.7%) participants at baseline. Cataracts were the most common ocular finding, detected in 42 (72%) at baseline. Other anterior segment changes observed included blepharitis 46 (79.3%) and tear film instability 38 (65.5%). There was a significant positive association between duration of the DM and the risk of cataract (p = 0.027). Participants' age at diagnosis was significantly associated with the presence of prominent corneal nerves (p = 0.004).

CONCLUSIONS

DR was uncommon in this cohort of young persons with DM in Ghana. Cataracts, blepharitis and refractive errors were ocular changes commonly observed. All young persons with diabetes should undergo regular eye examination in all clinics where follow-up care is provided.

Residency training in Ghana: the residents' perspective

Background

Prior to 1973, West African citizens completed postgraduate medical and surgical training abroad, particularly in the United Kingdom. In 2003, the Ghana College of Physicians and Surgeons were established respectively and began to offer specialized training locally. The aim of this study was to obtain and evaluate the views of Medical and Surgical Residents of the GCPS on their training in Ghana.

Method

A descriptive cross-sectional study was undertaken whereby a 25 item, self-administered questionnaire, was distributed to 170 residents of Korle Bu and Komfo Anokye Teaching Hospitals in Ghana. Information regarding the residents' sociodemographic characteristics, level of residency, and satisfaction with the programs in terms of clinical supervision, didactic teaching, program duration and research training was collected.

Results

117 residents completed the survey, yielding a response rate of 68.8%. 59.8% were males and 40.2% females. The age of the residents ranged from 25 to 40 years with a mean age of 32.7+1.4 years. Majority of residents (92.3%) were satisfied with the duration of the programs . Slightly more than half of the residents (50.4%) were satisfied with the clinical supervision, however only a third of the respondents (33.3%) were satisfied with the didactic teaching and an even smaller percentage (17.1%) with research training.

Conclusion

Whilst majority of residents were satisfied with the duration of the residency program, the perspective of the respondents was that trainees would benefit from additional didactic teaching and increased research exposure.

Funding

None

Hepatitis B virus surface antigen and antibody markers in children at a major paediatric hospital after the pentavalent DTP-HBV-Hib vaccination

OBJECTIVES

The knowledge about outcomes of infant vaccination against HBV infections using the DPT-HepB-Hib vaccine in Ghana is limited. This study therefore investigated the levels of immunity to HBV among children who received the DPT-HepB-Hib vaccine and HBsAg carriage in non-responders. Correlates for non-response or poor response were also investigated.

METHODS

Cross-sectional study. A major paediatric hospital in Accra. Four hundred and twenty four children between the ages of 5 to 32 months who had completed the full vaccination schedule for the DPT-HepB-Hib vaccine.

RESULTS

Of the 424 children, 358 (84.4%) developed anti-HBs while 340 (80.2%) developed ≥10 mIU/ml anti-HBs (sero-protection) and 3 had HBsAg. A binary logistic regression analysis showed that younger children were associated with sero-conversion (p=.022) and sero-protection (p=.021). For anti-HBs titres ≥100 mIU/ml age was a weaker but significant contributor (p=.041), as compared to the number of vaccines from different manufacturers the child used (p=.028). The mean age of those who used a single type of vaccine was higher (14.75 ± 6.056 months; n=268) than those who used vaccines from two or more manufacturers (11.96 ± 4.645 months; n=156), p= <.001 (CI: -3.897 - 1.688), an indication that efforts to procure vaccine from same source when it was initially introduced are waning.

CONCLUSIONS

There is still a residual possibility of infection with HBV in spite of infant vaccination. In the light of possible loss of anamnestic response over time, there is the need to consider a birth dose for HBV vaccination for all neonates or booster dose for infants who may not have received the vaccine at birth. Using vaccines from a single manufacturer is recommended.

FUNDING

None declared.

Presentation of children with advanced retinoblastoma for treatment in Ghana: the caretakers' perspectives

BACKGROUND

Retinoblastoma, the commonest childhood malignant intraocular tumour, is diagnosed late, with less than 50% survival in developing countries, including Ghana.

OBJECTIVES

To determine, from caretakers' perspective, contributing factors to late presentation of children with retinoblastoma.

METHODS

A cross-sectional study involving questionnaire administration to consenting caretakers of consecutive children diagnosed with advanced retinoblastoma at the Eye Unit, Korle-Bu Teaching Hospital, Accra, Ghana, from September 2008-June 2011. Clinical diagnosis was confirmed by CT scan or ultrasonography. Ethical approval was granted by University of Ghana Medical School.

RESULTS

Forty caretakers aged 22-58 years (mean = 32.8 ± 7.8yrs) were interviewed. Twenty-four (60%) were females, 36(90%) were parents. Thirty-two (80%) had at least primary level of education. Initial symptoms noticed by caretakers were: white spot 35(87.5%), redness 3(7.5%), proptosis 1(2.5%) and squint 1(2.5%). Thirty-five caretakers (87.5%) sought prior treatment between 1-24 months (median=1month) and 7(37%) beyond 3months, mainly from health/eye centres 34(85%). Six caretakers (15.4%) knew their children had cancer, 11(27.5%) had heard about retinoblastoma, but only 2(5.0%) knew treatment existed. Thirty-two caretakers (80%) would accept enucleation with prosthesis and 17(42.5%) without it. Cost: 8(20% respondents) and lack of awareness of prognosis of retinoblastoma 12(30% respondents) were stated as important factors though they did not prove significant. Caretakers' level of education, occupation and gender had no significant association with knowledge about retinoblastoma, awareness of treatment or cure, acceptance of enucleation with or without prosthesis, nor awareness of prognosis without treatment, p>0.05.

CONCLUSION

Low awareness of the cause, treatment and prognosis of retinoblastoma exists among caretakers of children with advanced retinoblastoma. This may contribute to the late stage of the disease presentation.

Five Years Of Family Medicine Undergraduate Education In Ghana: A Wake-Up Call!

OBJECTIVES

Given the introduction in 2008 of undergraduate family medicine in the University of Ghana, the study aimed to identify the perceptions of medical students in Ghana about family medicine with regard to knowledge and relevance as well as specialty preferences.

DESIGN

A cross-sectional survey.

METHOD

Investigators conducted yearly surveys of first clinical year students at the University of Ghana School of Medicine and Dentistry over a 5-year period (2008-2012) using a semi-structured questionnaire. Data was analysed using the first class group as baseline for comparison.

MAIN OUTCOME MEASURES

Trends in respondents' awareness of different aspects of family medicine, their attitudes towards the specialty and their expressed preference or lack of preference for family medicine as a potential specialty for themselves.

RESULTS

Over the five-year period, 748 of 893 eligible first year students participated which comprised 84% of students. Awareness of family medicine as a medical specialty remained high but insignificantly declined over the period of study (88% to 80%, p=0.058). Preference for family medicine as career choice remained low at 4%, but an increase from 2% baseline though insignificant (p=0.397). The primary reason for not listing family medicine as career choice was unfamiliarity with the specialty (80%).

CONCLUSION

Although awareness of family medicine among medical students in Ghana remains relatively high, their knowledge is insufficient to influence their career decisions for family medicine. This is a wake-up call!

FUNDING

None declared.

Epidemiology and recurrence rate of pterygium post excision in Ghanaians

OBJECTIVES

To determine the epidemiology and recurrence rate of pterygium after excision using bare sclera technique.

DESIGN

Prospective non-comparative study.

SETTING

Ophthalmology unit, Korle-Bu Teaching Hospital, Accra, Ghana.

METHODS

The study involved 60 consecutive patients with primary apterygial from July 1998 to December 2000 who had bare sclera excision after informed consent. They were post-operatively followed up for 30-months.

RESULTS

Thirty-five patients (58%) were females. The patients' ages ranged from 17-75 years, mean (±12.6). Overall recurrence was 22(37%). The main complications encountered include were granuloma 20 %(n=12), restriction in medial rectus muscle motility 2(3%), persistent vascularisation at excision site 2(3%) and adherence leucoma with uveitis 1(2%). No significant association was found between recurrence and pterygium morphology, calcification, allergy and occupation (indoor or outdoor).

CONCLUSION

The recurrence rate after pterygium excision using bare sclera technique in Ghanaians is high (37%).

Dermis-fat grafts and enucleation in Ghanaian children: 5 years' experience

BACKGROUND

Enucleation in young children often results in retarded orbital growth ipsilaterally. The need for an implant that will naturally grow with the child, like Dermis-fat Graft (DFG), for managing the anophthalmia has been of interest over the years.

OBJECTIVE

To evaluate the use of DFG as an implant for volume replacement post-enucleation.

STUDY DESIGN

A prospective non-comparative case series involving 18 consecutive children who had DFG either primarily or secondarily in conjunction with enucleation for intraocular pathologies, from December 2007 to September 2012, at the ophthalmology unit, Korle-Bu. Data from patients who had a minimum of three months follow up(FUP) were analysed.

OUTCOME MEASURES

Complete covering of DFG with healthy conjunctiva, increase in volume of DFG, and presence or absence of complications.

RESULTS

Fifteen patients were analysed, aged nine months to ten years (mean (SD), 3.7±2.7years). Eight (53.3%) were females. Thirteen (86.7%) DFGs were secondary and 2(13.3%) primary. Indications for enucleation were intraocular retinoblastoma (n=10, 66.7%), unexplained retinal detachment mimicking retinoblastoma (n=3,20.0%), anterior staphyloma (n=1,6.7%) and medulloepithelioma (n=1,6.7%). Fourteen (93.3%) patients showed increase in volume of DFG. Time for Conjunctival reepithelialisation of the dermal surface was four to fourteen weeks (mean/median=5.5/4.0). Complications encountered were infection (n=1,6.7%), infection with necrosis (n=1,6.7%), melanosis /keratinization (n=2, 13.3%) and cysts(n=2,13.3%). The patients were followed up for 3 to 54 months (mean/median 20.13 /16.00).

CONCLUSION

DFG for management of post-enucleation anophthalmia in Ghanaian children showed 93.3% success.

Perceptions of medical students about family medicine in Ghana

OBJECTIVES

To determine the perceptions of medical students in Ghana about family medicine with regard to knowledge and relevance as well as specialty preferences.

DESIGN

A descriptive study.

METHOD

The study was conducted on first clinical year students of the University of Ghana Medical School (first group of students introduced to the specialty of family medicine) in July 2008, using structured questionnaire. Data was analyzed by descriptive statistics.

MAIN OUTCOME MEASURES

The respondents' awareness of family medicine, their views on the relevance of family medicine and their specialty preferences.

RESULTS

Level of awareness of the specialty was high among the students (88.0%, [95% CI 80.2-93.6]). Information from friends and relations was the major source of awareness (29.5%, CI 20.2-40.3). Majority of the students perceived that family physicians are capable of providing total health care for 85-95% of their clients (54.4%, CI 44.1-64.5) and also reduce overall cost of health care (79.8%, CI 70.5-87.2). However, only 2.4% (CI 0.4-7.6) were considering postgraduate training in family medicine. The major factor for specialty choice was personal interest (75.6%, CI 65.9-83.6) and the main reason for not choosing family medicine was inadequate understanding of the specialty (79.3%, CI 69.5-87.0).

CONCLUSION

There is high level of awareness of family medicine among medical students in Ghana however very few students want to choose it as a specialty because of inadequate understanding of the specialty.

Combined trabeculotomy and trabeculectomy: outcome for primary congenital glaucoma in a West African population

PURPOSE

To evaluate the surgical outcome of combined trabeculotomy-trabeculectomy in Ghanaian children with primary congenital glaucoma.

MATERIALS AND METHODS

A retrospective case series involving 19 eyes of 12 consecutive children with primary congenital glaucoma who had primary trabeculotomy-trabeculectomy from 12 August 2004 to 30 June 2008, at the Korle-Bu Teaching Hospital, Ghana. Main outcome measures were preoperative and postoperative intraocular pressures, corneal diameter, corneal clarity, bleb characteristics, duration of follow-up, surgical success, and complications.

RESULTS

A total of 19 eyes of 12 patients met the inclusion criteria. Six of the patients were males. Mean age at diagnosis was 4.4 (range 2-8) months. Mean age at surgery was 5.9 months (range 3-16). Eight (67%) infants had bilateral disease. Mean duration of follow-up was 13.1 (range 5-38) months. The preoperative mean horizontal corneal diameter was 13.4 ± 1.1(range 12-16) mm. Complete success (intraocular pressure <21 mm Hg) was obtained in 15 (79%) eyes. The probability of success was 94.4, 83.3, 66.7, 44.4, 38.9, 33.3, and 13.3% at 3, 6, 9, 12, 15, 18, and 21 months, respectively (Kaplan-Meier analysis). All eyes had corneal oedema preoperatively. Seventeen eyes (90%) had clear cornea at their last follow-up. Mean preoperative and postoperative intraocular pressures were 30.3 ± 8.8 and 18.1 ± 6.8 mm Hg respectively (P<0.001, t-test). Twelve (63%) eyes had well-functioning blebs at the last follow-up. One eye (5%) developed seclusio pupillae and cataract postoperatively.

CONCLUSION

The overall success for combined trabeculotomy-trabeculectomy in Ghanaian children with primary congenital glaucoma was 79%. The probability of success reduced from more than 66% in the first 9 months postoperatively to below 45% after that.

Retinopathy in severe malaria in Ghanaian children--overlap between fundus changes in cerebral and non-cerebral malaria

BACKGROUND

In malaria-endemic areas, reliably establishing parasitaemia for diagnosis of malaria can be difficult. A retinopathy with some features unique to severe malaria with a predictive value on prognosis, has been described. Detection of this retinopathy could be a useful diagnostic tool. This study was designed to determine the diagnostic usefulness of retinopathy on ophthalmoscopy in severe malaria syndromes: Cerebral malaria (CM) and non-cerebral severe malaria (non-CM), i.e. malaria with respiratory distress (RD) and malaria with severe anaemia (SA), in Ghanaian children. Secondly, to determine any association between retinopathy and the occurrence of convulsions in patients with CM.

METHODS AND SUBJECTS

A cross-sectional study of consecutive patients on admission with severe malaria who were assessed for retinal signs, at the Department of Child Health, Korle-Bu Teaching Hospital, Accra, from July to August 2002 was done. All children had dilated-fundus examination by direct and indirect ophthalmoscopy.

RESULTS

Fifty-eight children aged between six months and nine years were recruited. Twenty six(45%) had CM, 22 with convulsion; 26(45%) had SA and six(10%) had RD.Any retinopathy was seen in: CM 19(73%), SA 14(54%), RD 3(50.0%), CM with convulsion 15(68%) and CM without convulsion 4(100%). Comparison between CM versus non-CM groups showed a significant risk relationship between retinal whitening and CM(OR = 11.0, CI = 2.2- 56.1, p = 0.001). There was no significant association with papilloedema(OR = 0.9, CI = 0.3 - 3.0, p = 0.9), macular whitening(OR = 1.6, CI = 0.5 - 4.8, p = 0.4), macular haemorrhage(OR = 0.28, CI = 0.03 - 2.7 p = 0.2), retinal haemorrhage(OR = 1.9, CI = 0.6 - 5.6, p = 0.3), vessel abnormality(OR = 1.9, CI = 0.6 - 6.1, p = 0.3) and cotton wool spots(OR not calculated, p = 0.08).Tortuous and engorged retinal veins, not previously described as a feature of CM, was the most common vascular abnormality(15/58 = 26%) and was detected even in the absence of papilloedema.

CONCLUSION

Retinal whitening, a sign suggestive of retinal ischaemia, was significantly more common in CM than in non-CM syndromes. However, the high prevalence of any retinopathy in the latter suggests that the brain and the retina may be suffering from ischaemia in both CM and non-CM.

Feasibility of thyroid ultrasonography in field studies in a developing country, Ghana

This study was carried out to determine the feasibility of using ultrasonography for goitre estimation in the field situation. It is a cross sectional study that was conducted using community based cluster sample. Thyroid sonography was performed on 112 randomly selected school children aged 10 -15 years from two districts in the Greater Accra area of Ghana, using normative values for thyroid volume recommended by WHO/ICCIDD. The mean age of all subjects was 13.5 years+/-0.13 SEM. The male to female ratio was 1:1. The mean height and weight of the children were 1.5 metres+/-0.9 SEM and 38.1 Kg+/-0.7 SEM, respectively. The mean body surface area was 1.27 m2+/-0.2. There were no significant gender differences in their ages (13.6yrs+/-0.2 SEM, 13.4yrs+/-0.1 SEM, respectively) and height (1.50m+/-1.6 SEM, 1.46m+/-1.7 SEM, respectively). The girls (40.0kg+/-1.2 SEM) weighed more than the boys (35.6kg+/-1.1). The mean and median urinary iodine concentration were 82.4+/-8.5 SEM and 67.9 ug/l, respectively. All the children examined had normal thyroid sonogram. The thyroid volumes ranged from 3.6 ml to 15.3ml. The mean thyroid volume was 7.0ml+/-0.2 SEM and the thyroid volume was higher in the girls (7.5ml+/-0.3 SEM) than the boys (6.5ml+/-0.2 SEM). The criteria of thyroid volume per age and sex yielded a goitre prevalence of 1.8 %. In contrast, the criteria of thyroid volume by surface area yielded a goitre prevalence of 8 %. Our study has shown that it is feasible to employ ultrasonography for field studies to determine goitre prevalence in school children in a developing country such as Ghana. However, the best criteria for goitre in children in Ghana, requires to be confirmed in future studies.

Epidemiological aspects of oral tori in a Ghanaian community

AIM

To determine the prevalence of oral tori, commonly found among Ghanaians, and compare with that in other regions.

METHOD

Dental examination records of all 926 patients seen from January 1998 to April 2000 in a dental outpatient clinic in Accra, Ghana, were studied. The existence of a torus had systematically and routinely been ascertained by visual inspection and palpation.

RESULTS

Frequency distribution and cross-tabulation analysis showed an overall prevalence of 14.6% with a female: male ratio of 1.1: 1. The most prevalent variety was the bilateral mandibular torus (12.1%) and the midpalatal torus of the maxillary tori (4.3 %). Females had 2.2 times the probability of having midpalatal torus compared to men (Odds Ratio (OR) = 2.2; Confidence Interval: 1.05, 4.70). There was a very strong concurrent relationship between mandibular and maxillary tori (OR = 16; CI = 7.8, 32.5).

CONCLUSION

Comparisons indicated a strong similarity between torus prevalence in Ghana and the Caribbean regions. This should help in further discussions on the epidemiology of this bony anomaly.