A retrospective review of gastroschisis epidemiology and referral patterns in northern Ghana.

PURPOSE: To describe the epidemiology and referral patterns of gastroschisis patients in northern Ghana. METHODS: A hospital-based retrospective review was undertaken at Tamale Teaching Hospital (TTH) Neonatal Intensive Care Unit (NICU) between 2014 and 2019. Data from gastroschisis patients were compared to patients with other surgical diagnoses. Descriptive and inferential statistics were performed with SAS. Referral flow maps were made with ArcGIS. RESULTS: From a total of 360 neonates admitted with surgical conditions, 12 (3%) were diagnosed with gastroschisis. Around 91% (n = 10) of gastroschisis patients were referred from other hospitals, traveling 4 h, on average. Referral patterns showed gastroschisis patients were admitted from three regions, whereas patients with other surgical diagnoses were admitted from eight regions. Only 6% (12/201) of expected gastroschisis cases were reported during the 6-year period in all regions. All gastroschisis deaths occurred within the first week of life. CONCLUSIONS: Improving access to surgical care and reducing neonatal mortality related to gastroschisis in northern Ghana is critical. This study provides a baseline to inform future gastroschisis interventions at TTH. Priority areas may include special management of low birth weight newborns, better referral systems, empowerment of community health workers, and increasing access to timely, affordable, and safe neonatal transport.

A Nationwide Enumeration of Operations Performed for Pediatric Patients in Ghana.

INTRODUCTION: Currently, there are no existing benchmarks for evaluating a nation's pediatric surgical capacity in terms of met and unmet needs. MATERIALS AND METHODS: Data on pediatric operations performed from 2014 to 2015 were obtained from a representative sample of hospitals in Ghana, then scaled up for national estimates. Operations were categorized as "essential" (most cost-effective, highest population impact) as designated by the World Bank's Disease Control Priorities versus "other." Estimates were then compared with pediatric operation rates in New Zealand to determine unmet pediatric surgery need in Ghana. RESULTS: A total of 29,884 operations were performed for children <15 years, representing an annual operation rate of 284/100,000 (95% uncertainty interval: 205-364). Essential procedures constituted 66% of all pediatric operations; 12,397 (63%) were performed at district hospitals. General surgery (8,808; 29%) and trauma (6,302; 21%) operations were most common. Operations for congenital conditions were few (826; 2.8%). Tertiary hospitals performed majority (55%) of operations outside of the essential category. Compared with the New Zealand benchmark (3,806 operations/100,000 children <15 years), Ghana is meeting only 7% of its pediatric surgical needs. CONCLUSION: Ghana has a large unmet need for pediatric surgical care. Pediatric-specific benchmarking is needed to guide surgical capacity efforts in low- and middle-income country healthcare systems.

Patient Experience and Outcomes of the Locally Organized ApriDec Medical Outreach Group.

BACKGROUND: Access to safe and effective surgery is limited in low and middle-income countries. Short-term surgical missions are a common platform to provide care, but the few published outcomes suggest unacceptable morbidity and mortality. We sought to study the safety and effectiveness of the ApriDec Medical Outreach Group (AMOG). METHODS: Data from the December 2017 and April 2018 outreaches were prospectively collected. Patient demographics, characteristics of surgery, complications of surgery, and patient quality of life were collected preoperatively and on postoperative days 15 and 30. Data were analyzed to determine complication rates and trends in quality of life. RESULTS: 260/278 (93.5%) of patients completed a 30-day follow-up. Of these, surgical site infection was the most common complication (8.0%), followed by hematoma (4.1%). Rates of urinary tract infection were 1.2% while all other complications occurred in less than 1% of patients. There were no mortalities. With increasing time after surgery (0 to 15 days to 30 days), there was a significant improvement across each of the dimensions of quality of life (p < 0.001). All patients reported satisfaction with their procedure. CONCLUSION: This study demonstrated that the care provided by AMOG group to the underserved populations of northern Ghana, yielded complication rates similar to others in low-resourced communities, leading to improved quality of life.

Burden of Neonatal Surgical Conditions in Northern Ghana.

BACKGROUND: Congenital anomalies have risen to become the fifth leading cause of under-five mortality globally. The majority of deaths and disability occur in low- and middle-income countries including Ghana. This 3-year retrospective review aimed to define, for the first time, the characteristics and outcomes of neonatal surgical conditions in northern Ghana. METHODS: A retrospective study was conducted to include all admissions to the Tamale Teaching Hospital (TTH) neonatal intensive care unit (NICU) with surgical conditions between January 2014 and January 2017. Data were collected on demographics, diagnosis and outcomes. Descriptive analysis was performed on all data, and logistic regression was used to predict determinants of neonatal mortality. p < 0.05 was deemed significant. RESULTS: Three hundred and forty-seven neonates were included. Two hundred and sixty-one (75.2%) were aged 7 days or less at presentation, with males (n = 177, 52%) slightly higher than females (n = 165, 48%). The majority were delivered by spontaneous vaginal delivery (n = 247, 88%); 191 (58%) were born in hospital. Congenital anomalies accounted for 302 (87%) of the neonatal surgical cases and 45 (96%) deaths. The most common anomalies were omphalocele (n = 48, 13.8%), imperforate anus (n = 34, 9.8%), intestinal obstruction (n = 29, 8.4%), spina bifida (n = 26, 7.5%) and hydrocephalus (n = 19, 5.5%). The overall mortality rate was 13.5%. Two-thirds of the deaths (n = 30) from congenital anomalies were conditions involving the digestive system with gastroschisis having the highest mortality of 88%. Omphalocele (n = 11, 23.4%), gastroschisis (n = 7, 14.9%) and imperforate anus (n = 6, 12.8%) contributed to the most deaths. On multivariate analysis, low birthweight was significantly associated with mortality (OR 3.59, CI 1.4-9.5, p = 0.009). CONCLUSION: Congenital anomalies are a major global health problem associated with high neonatal mortality in Ghana. The highest burden in terms of both caseload and mortality is attributed to congenital anomalies involving the digestive system, which should be targeted to improve outcomes.

Trainees' preferences regarding choice of place of work after completing medical training in traditional or problem-based learning/community-based education and service curricula: a study in Ghanaian medical schools.

INTRODUCTION: Career choices, recruitment and subsequent retention of healthcare professionals in the rural areas are a major worldwide concern and challenge to the health sector, leading to human resource shortages, resulting in poor quality health care for rural communities. Medical education has integrated community-oriented medical education strategies in undergraduate medical training to help address the challenges of health care in rural communities. These strategies are likely to impact the strategies of delivering the content of undergraduate medical curricula. This study explored medical trainees' preferences regarding place of work and choice of specialty after completing training using either the traditional or mixed problem-based learning/community-based education and service (PBL/COBES) curriculum in Ghanaian medical schools. METHOD: This study was a cross-sectional descriptive design using a questionnaire consisting of 25 open- and close-ended questions. The questionnaire was administered to first-, third- and sixth-year students of two medical schools in Ghana: University of Ghana School of Medicine and Dentistry (UG-SMD) and University for Development Studies, School of Medicine and Health Sciences (UDS-SMHS). UG-SMD uses the traditional method of teaching and learning, whilst UDS-SMHS uses PBL/COBES curriculum in the training of their students. Associations between gender, type of curriculum, choice of specialty and practice location were assessed using the χ2 test. Logistic regression analysis was performed to determine the association between medical school and curriculum type and students' preparation for rural practice while controlling all other factors. Qualitative data analysis of answers to open-ended questions was performed, applying the principles of thematic analysis. RESULTS: Of the students from PBL/COBES track, 64.2% were male, and from the traditional track 52.0%. The majority (74.1%) of students from PBL/COBES track indicated that their medical school curriculum adequately prepared them for rural practice as compared to those from the traditional track (35.1%). The willingness of third-year students at UDS-SMHS to choose to practise in rural areas after graduation decreases as compared to their colleagues in first and sixth years. Students from the traditional track were 80% less likely to state that their medical school curriculum adequately prepared them for rural practice compared to students from the PBL/COBES track (odds ratio=0.19, confidence interval=0.13-0.28, p=0.001). Students following the PBL/COBES curriculum stated that the program was very useful and could influence their choice of future practice location. Students following the traditional curriculum called for the introduction of innovative teaching methodology incorporating rural outreach programs as part of the medical curriculum. CONCLUSION: Students using the PBL/COBES curriculum indicated that their curriculum adequately prepared them for future rural practice. Students following the traditional curriculum called for the introduction of an innovative teaching methodology incorporating rural outreach programs. This, they believed, would help them cultivate an interest for rural practice and also increase their willingness to choose rural practice after graduation from medical school.

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

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

Developing and implementing an interventional bundle to reduce mortality from gastroschisis in low-resource settings.

Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, service delivery and implementation outcomes for 2-years at each site. The primary clinical outcome will be all-cause, in-hospital mortality. Secondary outcomes include the occurrence of a major complication, length of hospital stay and time to full enteral feeds. Service delivery outcomes include time to hospital and primary intervention, and adherence to the pre-hospital and in-hospital protocols.  Implementation outcomes are acceptability, adoption, appropriateness, feasibility, fidelity, coverage, cost and sustainability. Pre- and post-intervention clinical outcomes will be compared using Chi-squared analysis, unpaired t-test and/or Mann-Whitney U test. Time-series analysis will be undertaken using Statistical Process Control to identify significant trends and shifts in outcome overtime. Multivariate logistic regression analysis will be used to identify clinical and implementation factors affecting outcome with adjustment for confounders. Outcome: This will be the first multi-centre interventional study to our knowledge aimed at reducing mortality from gastroschisis in low-resource settings. If successful, detailed evaluation of both the clinical and implementation components of the study will allow sustainability in the study sites and further scale-up. Registration: ClinicalTrials.gov Identifier NCT03724214.

Barriers to Timely Presentation of Patients with Surgical Conditions at Tamale Teaching Hospital in Northern Ghana.

BACKGROUND: Improving access to surgical services and understanding the barriers to receiving timely care are necessary to save lives. The aim of this study was to assess barriers to timely presentation to an appropriate medical facility using the Three-Delay model, for patients presenting to Tamale Teaching Hospital, in northern Ghana. METHODS: In 2013, patients with delays in seeking surgical care were prospectively identified. Pairwise correlation coefficients between delay in presentation and factors associated with delay were conducted and served as a foundation for a multivariate log-linear regression model. RESULTS: A total of 718 patients presented with an average delay of 22.1 months. Delays in receiving care were most common (56.4%), while delays in seeking care were seen in 52.3% of patients. "Initially seeking treatment at the nearest facility, but appropriate care was unavailable" was reported by 56.4% and predicted longer delays (p < 0.001). 42.9% of patients had delays secondary to treatment from a traditional or religious healer, which also predicted longer delays (p < 0.001). On multivariate regression, emergent presentation was the strongest predictor of shorter delays (OR 0.058, p = 0.002), while treatment from a traditional or religious healer and initially seeking treatment at another hospital predicted longer delays (OR 7.6, p = 0.008, and OR 4.3, p  = 0.006, respectively). CONCLUSIONS: Barriers to care leading to long delays in presentation are common in northern Ghana. Interventions should focus on educating traditional and religious healers in addition to building surgical capacity at district hospitals.

Working among the rural communities in Ghana - why doctors choose to engage in rural practice.

BACKGROUND: An unequal distribution of health personnel, leading to unfavourable differences in health status between urban and rural populations, is a serious cause for concern globally. Part of the solution to this problem lies in attracting medical doctors to rural, remote communities, which presents a real challenge. The present study therefore explored the factors that influence medical doctors' decision to practise in rural Ghana. METHODS: We conducted a cross-sectional descriptive study based on questionnaires. Participants were doctors working in health facilities in the districts and rural areas of the Northern Region, Ghana. The qualitative data analysis consisted of an iterative process of open, axial and selective coding. RESULTS: We administered the questionnaires to 40 doctors, 27 of whom completed and returned the form, signalling a response rate of 67.5%. The majority of the doctors were male (88.9%) and had been trained at the University for Development Studies, School of Medicine and Health Sciences (UDS-SMHS) (63%). Although they had chosen to work in the remote areas, they identified a number of factors that could prevent future doctors from accepting rural postings, such as: a lack of social amenities, financial and material resources; limited career progression opportunities; and too little emphasis on rural practice in medical school curricula. Moreover, respondents flagged specific stakeholders who, in their opinion, had a major role to play in the attraction of doctors and in convincing them to work in remote areas. CONCLUSIONS: The medical doctors we surveyed had gravitated to the rural areas themselves for the opportunity to acquire clinical skills and gain experience and professional independence. Nevertheless, they felt that in order to attract such cadre of health professionals to rural areas and retain them there, specific challenges needed addressing. For instance, they called for an enforceable, national policy on rural postings, demanding strong political commitment and leadership. Another recommendation flowing from the study findings is to extend the introduction of Community-Based Education and Service (COBES) or similar curriculum components to other medical schools in order to prepare students for rural practice, increasing the likelihood of them accepting rural postings.

Our Experience with the Use of Low Cost Mesh in Tension-Free Inguinal Hernioplasty in Northern Ghana.

OBJECTIVES: To describe our experience and success in the use of low cost mesh for the repair of inguinal hernias in consenting adult patients. METHODS: A prospective study was carried out from August 2010 to December 2013 in ten district hospitals across Northern Ghana. The patients were divided into four groups according to Kingsnorth's classification of hernias. Low cost mesh was used to repair uncomplicated groin hernia. Those hernias associated with complications were excluded. We assessed the patients for wound infection, long term incisional pain and recurrence of hernia. The data collected was entered, cleaned, validated and analyzed. RESULTS: One hundred and eighty-four patients had tension-free repair of their inguinal hernias using non-insecticide impregnated mosquito net mesh. The median age of the patients was 51 years. The male to female ratio was 7:1. Using Kingsnorth's classification, H3 hernias were (62, 33.7%), followed by the H1 group (56, 30.4%). Local anaesthesia was used in 70% and less than 5% had general anaesthesia. The cost of low cost mesh to each patient was calculated to be $ 1.8(GH¢7.2) vs $ 45(GH¢ 180) for commercial mesh of same size. The benefit to the patient and the facility was enormous. Wound hematoma was noticed in 7% while superficial surgical site infection was 3%. No patient reported of long term wound pain. There was no recurrence of hernia. CONCLUSION: Low cost mesh such as sterilized mosquito net mesh for use in hernioplasty in resource-limited settings is reasonable, acceptable and cost-effective, it should be widely propagated. FUNDING: None declared.

Cost-Effectiveness of a Locally Organized Surgical Outreach Mission: Making a Case for Strengthening Local Non-Governmental Organizations.

INTRODUCTION: Many low- and middle-income countries (LMICs) have a high prevalence of unmet surgical need. Provision of operations through surgical outreach missions, mostly led by foreign organizations, offers a way to address the problem. We sought to assess the cost-effectiveness of surgical outreach missions provided by a wholly local organization in Ghana to highlight the role local groups might play in reducing the unmet surgical need of their communities. METHODS: We calculated the disability-adjusted life years (DALY) averted by surgical outreach mission activities of ApriDec Medical Outreach Group (AMOG), a Ghanaian non-governmental organization. The total cost of their activities was also calculated. Conclusions about cost-effectiveness were made according to World Health Organization (WHO)-suggested parameters. RESULTS: We analyzed 2008 patients who had been operated upon by AMOG since December 2011. Operations performed included hernia repairs (824 patients, 41%) and excision biopsy of soft tissue masses (364 patients, 18%). More specialized operations included thyroidectomy (103 patients, 5.1%), urological procedures (including prostatectomy) (71 patients, 3.5%), and plastic surgery (26 patients, 1.3%). Total cost of the outreach trips was $283,762, and 2079 DALY were averted; cost per DALY averted was 136.49 USD. The mission trips were "very cost-effective" per WHO parameters. There was a trend toward a lower cost per DALY averted with subsequent outreach trips organized by AMOG. CONCLUSION: Our findings suggest that providing surgical services through wholly local surgical mission trips to underserved LMIC communities might represent a cost-effective and viable option for countries seeking to reduce the growing unmet surgical needs of their populations.

Assessment of Barriers to Essential Surgical Care in Two Communities in the Upper West Region, Ghana.

Systematic assessments of individual-and community-level barriers to surgical care (BSC) in low-and middle-income countries that might inform potential interventions are lacking. We used a novel tool to assess BSC systematically during a surgical outreach in two communities in Upper West region, Ghana. Results were scored in three dimensions of barriers to care (acceptability, affordability, and accessibility); higher dimension scores signified less salient barriers. A total index out of 10 was derived. In total, 169 individuals participated in Nadowli (68, 40%) and in Nandom (101, 60%). Nadowli had fewer BSC than Nandom (median index 7.8 vs 7.2; p < .001). Dimension scores ranged from 10.8 to 14.5 out of 18 points. Fear or mistrust of surgical care and stigma were reported more frequently in Nandom (p < .001). Reported barriers were not always the same in each community. Systematically defining barriers to essential surgical care provides an opportunity for planning targeted interventions at the community-level.

Barriers to essential surgical care experienced by women in the two northernmost regions of Ghana: a cross-sectional survey.

BACKGROUND: Women in developing countries might experience certain barriers to care more frequently than men. We aimed to describe barriers to essential surgical care that women face in five communities in Ghana. METHODS: Questions regarding potential barriers were asked during surgical outreaches to five communities in the northernmost regions of Ghana. Responses were scored in three dimensions from 0 to 18 (i.e., 'acceptability,' 'affordability,' and 'accessibility'; 18 implied no barriers). A barrier to care index out of 10 was derived (10 implied no barriers). An open-ended question to elicit gender-specific barriers was also asked. RESULTS: Of the 320 participants approached, 315 responded (response rate 98 %); 149 were women (47 %). Women had a slightly lower barriers to surgical care index (median index 7.4; IQR 3.9-9.1) than men (7.9; IQR 3.9-9.4; p = 0.002). Compared with men, women had lower accessibility and acceptability dimension scores (14.4/18 vs 14.4/18; p = 0.001 and 13.5/18 vs 14/18; p = 0.05, respectively), but similar affordability scores (13.5/18 vs 13.5/18; p = 0.13). Factors contributing to low dimension scores among women included fear of anesthesia, lack of social support, and difficulty navigating healthcare, as well as lack of hospital privacy and confidentiality. CONCLUSION: Women had a slightly lower barriers to surgical care index than men, which may indicate greater barriers to surgical care. However, the actual significance of this difference is not yet known. Community-level education regarding the safety and benefits of essential surgical care is needed. Additionally, healthcare facilities must ensure a private and confidential care environment. These interventions might ameliorate some barriers to essential surgical care for women in Ghana, as well as other LMICs more broadly.

Serial Assessment of Trauma Care Capacity in Ghana in 2004 and 2014.

IMPORTANCE: Trauma care capacity assessments in developing countries have generated evidence to support advocacy, detailed baseline capabilities, and informed targeted interventions. However, serial assessments to determine the effect of capacity improvements or changes over time have rarely been performed. OBJECTIVE: To compare the availability of trauma care resources in Ghana between 2004 and 2014 to assess the effects of a decade of change in the trauma care landscape and derive recommendations for improvements. DESIGN, SETTING, AND PARTICIPANTS: Capacity assessments were performed using direct inspection and structured interviews derived from the World Health Organization's Guidelines for Essential Trauma Care. In Ghana, 10 hospitals in 2004 and 32 hospitals in 2014 were purposively sampled to represent those most likely to care for injuries. Clinical staff, administrators, logistic/procurement officers, and technicians/biomedical engineers who interacted, directly or indirectly, with trauma care resources were interviewed at each hospital. MAIN OUTCOMES AND MEASURES: Availability of items for trauma care was rated from 0 (complete absence) to 3 (fully available). Factors contributing to deficiency in 2014 were determined for items rated lower than 3. Each item rated lower than 3 at a specific hospital was defined as a hospital-item deficiency. Scores for total number of hospital-item deficiencies were derived for each contributing factor. RESULTS: There were significant improvements in mean ratings for trauma care resources: district-level (smaller) hospitals had a mean rating of 0.8 for all items in 2004 vs 1.3 in 2014 (P = .002); regional (larger) hospitals had a mean rating of 1.1 in 2004 vs 1.4 in 2014 (P = .01). However, a number of critical deficiencies remain (eg, chest tubes, diagnostics, and orthopedic and neurosurgical care; mean ratings ≤ 2). Leading contributing factors were item absence (503 hospital-item deficiencies), lack of training (335 hospital-item deficiencies), and stockout of consumables (137 hospital-item deficiencies). CONCLUSIONS AND RELEVANCE: There has been significant improvement in trauma care capacity during the past decade in Ghana; however, critical deficiencies remain and require urgent redress to avert preventable death and disability. Serial capacity assessment is a valuable tool for monitoring efforts to strengthen trauma care systems, identifying what has been successful, and highlighting needs.

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

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

Barriers to Essential Surgical Care in Low- and Middle-Income Countries: A Pilot Study of a Comprehensive Assessment Tool in Ghana.

BACKGROUND: Beyond resource deficiencies, other barriers to care prevent patients from receiving surgery in low- and middle-income countries (LMICs). This study aimed to develop and pilot a comprehensive, generalizable tool for assessing the barriers to surgical care. METHODS: Sociodemographic, clinical and 38 questions regarding potential barriers to surgical care were asked during a surgical outreach to two district and one regional hospital in Upper East Region, Ghana. Sites were selected to capture individuals with prolonged unmet surgical needs and represent geographic, socioeconomic, and healthcare development differences. Results were indexed into three dimensions of barriers to care (i.e., 'acceptability,' 'affordability,' and 'accessibility') so that communities could be compared and targeted interventions developed. RESULTS: The tool was administered to 148 participants (98 % response rate): Bolgatanga 54 (37 %); Amiah 16 (11 %); and Sandema 78 (52 %). Amiah had the fewest barriers to surgical care (median index 8.3; IQR 7.6-9.3), followed by Sandema (8.2; IQR 5.3-9.2) and Bolgatanga (6.7; IQR 3.9-9.5). Individual dimension scores (i.e., acceptability, affordability, accessibility) ranged from 10.8 to 18 out of 18 possible points. Main factors contributing to low dimension scores were different between communities: Bolgatanga-cost and healthcare navigation; Amiah-social marginalization and poor medical understanding; Sandema-distance to surgically capable facility. CONCLUSION: This study identified a number of significant barriers, as well as successes for patients' ability and willingness to access surgical care that differed between communities. The tool itself was well accepted, easy to administer and provided valuable data from which targeted interventions can be developed.

Changing Epidemiology of Intestinal Obstruction in Ghana: Signs of Increasing Surgical Capacity and an Aging Population.

INTRODUCTION: This study aimed to describe the epidemiology and outcomes of intestinal obstruction at a tertiary hospital in Ghana over time. METHODS: Records of all patients admitted to a tertiary hospital from 2007 to 2011 with intestinal obstruction were identified using ICD-9 codes. Sociodemographic and clinical data were compared to a previously published series of intestinal obstructions from 1998 to 2003. Factors contributing to longer than expected hospital stays and death were further examined. RESULTS: Of the 230 records reviewed, 108 patients (47%) had obstructions due to adhesions, 50 (21%) had volvulus, 22 (7%) had an ileus from perforation and 14 (6%) had intussusception. Hernia fell from the 1st to the 8th most common cause of obstruction. Patients with intestinal obstruction were older in 2007-2011 compared to those presenting between 1998 and 2003 (p < 0.001); conditions associated with older age (e.g., volvulus and neoplasia) were more frequently encountered (p < 0.001). Age over 50 years was strong factor of in-hospital death (adjusted OR 14.2, 95% CI 1.41-142.95). CONCLUSION: Efforts to reduce hernia backlog and expand the surgical workforce may have had an effect on intestinal obstruction epidemiology in Ghana. Increasing aging-related pathology and a higher risk of death in elderly patients suggest that improvement in geriatric surgical care is urgently needed.

Strategic assessment of the availability of pediatric trauma care equipment, technology and supplies in Ghana.

BACKGROUND: This study aimed to assess the availability of pediatric trauma care items (i.e. equipment, supplies, technology) and factors contributing to deficiencies in Ghana. METHODS: Ten universal and 9 pediatric-sized items were selected from the World Health Organization's Guidelines for Essential Trauma Care. Direct inspection and structured interviews with administrative, clinical and biomedical engineering staff were used to assess item availability at 40 purposively sampled district, regional and tertiary hospitals in Ghana. RESULTS: Hospital assessments demonstrated marked deficiencies for a number of essential items (e.g. basic airway supplies, chest tubes, blood pressure cuffs, electrolyte determination, portable X-ray). Lack of pediatric-sized items resulting from equipment absence, lack of training, frequent stock-outs and technology breakage were common. Pediatric items were consistently less available than adult-sized items at each hospital level. CONCLUSION: This study identified several successes and problems with pediatric trauma care item availability in Ghana. Item availability could be improved, both affordably and reliably, by better organization and planning (e.g. regular assessment of demand and inventory, reliable financing for essential trauma care items). In addition, technology items were often broken. Developing local service and biomedical engineering capability was highlighted as a priority to avoid long periods of equipment breakage.

Treatment of cancer in sub-Saharan Africa.

Cancer is rapidly becoming a public health crisis in low-income and middle-income countries. In sub-Saharan Africa, patients often present with advanced disease. Little health-care infrastructure exists, and few personnel are available for the care of patients. Surgeons are often central to cancer care in the region, since they can be the only physician a patient sees for diagnosis, treatment (including chemotherapy), and palliative care. Poor access to surgical care is a major impediment to cancer care in sub-Saharan Africa. Additional obstacles include the cost of oncological care, poor infrastructure, and the scarcity of medical oncologists, pathologists, radiation oncologists, and other health-care workers who are needed for cancer care. We describe treatment options for patients with cancer in sub-Saharan Africa, with a focus on the role of surgery in relation to medical and radiation oncology, and argue that surgery must be included in public health efforts to improve cancer care in the region.

Expression of aldehyde dehydrogenase 1 as a marker of mammary stem cells in benign and malignant breast lesions of Ghanaian women.

BACKGROUND: Breast cancers that are negative for the estrogen receptor (ER), the progesterone receptor (PR), and the HER2 (human epidermal growth factor receptor 2) marker are more prevalent among African women, and the biologically aggressive nature of these triple-negative breast cancers (TNBCs) may be attributed to their mammary stem cell features. Little is known about expression of the mammary stem cell marker aldehyde dehydrogenase 1 (ALDH1) in African women. Novel data are reported regarding ALDH1 expression in benign and cancerous breast tissue of Ghanaian women. METHODS: Formalin-fixed, paraffin-embedded specimens were transported from the Komfo Anoyke Teaching Hospital in Kumasi, Ghana to the University of Michigan for centralized histopathology study. Expression of ER, PR, HER2, and ALDH1 was assessed by immunohistochemistry. ALDH1 staining was further characterized by its presence in stromal versus epithelial and/or tumor components of tissue. RESULTS: A total of 173 women contributed to this study: 69 with benign breast conditions, mean age 24 years, and 104 with breast cancer, mean age 49 years. The proportion of benign breast conditions expressing stromal ALDH1 (n = 40, 58%) was significantly higher than those with cancer (n = 44, 42.3%) (P = .043). Among the cancers, TNBC had the highest prevalence of ALDH1 expression, either in stroma or in epithelial cells. More than 2-fold higher likelihood of ALDH1 expression was observed in TNBC cases compared with other breast cancer subtypes (odds ratio = 2.38, 95% confidence interval 1.03-5.52, P = .042). CONCLUSIONS: ALDH1 expression was higher in stromal components of benign compared with cancerous lesions. Of the ER-, PR-, and HER2-defined subtypes of breast cancer, expression of ALDH1 was highest in TNBC.