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Introduction: We aimed to describe the burden of fires in displaced persons settlements and identify interventions/innovations that might address gaps in current humanitarian guidelines., Methods: We performed a systematic review of: (i) academic and non-academic literature databases; and (ii) guidelines from leading humanitarian agencies/initiatives regarding fire prevention/control., Results: Of the 1521 records retrieved, 131 reports described settlement fires in 31 hosting countries since 1990. These incidents resulted in 487 deaths, 790 burn injuries, displacement of 382,486 individuals and destruction of 50,509 shelters. There was a 25-fold increase in the rate of settlement fires from 1990 to 2015 (0.002-0.051 per 100,000 refugees, respectively). Only 4 of the 15 leading humanitarian agencies provided recommendations about fire prevention/control strategies. Potentially useful interventions/innovations included safer stoves (e.g. solar cookers) and fire retardant shelter materials., Conclusion: The large and increasing number of fires in displaced persons settlements highlights the need to redress gaps in humanitarian fire prevention/control guidelines. The way forward includes: (i) developing consensus among aid agencies regarding fire prevention/control strategies; (ii) evaluating the impact of interventions/innovations on the burden of fires; and (iii) engaging agencies in a broader discussion about protecting camp residents from armed groups., (Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.)

Importance: Peripheral arterial disease (PAD) causes significant morbidity and is an important risk factor for cardiovascular disease-related mortality. However, the burden of PAD in sub-Saharan Africa is poorly understood., Objective: To assess epidemiological and clinical reports regarding PAD from sub-Saharan Africa such that the regional epidemiology and management of PAD could be described and recommendations offered., Evidence Review: A systematic search in PubMed, Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, and Google Scholar for reports pertaining to the epidemiology and/or management of PAD in sub-Saharan Africa was performed. Reports that met inclusion criteria were sorted into 3 categories: population epidemiology, clinical epidemiology, and surgical case series. Findings were extracted and described., Findings: The search returned 724 records; of these, 16 reports met inclusion criteria. Peripheral arterial disease epidemiology and/or management was reported from 10 of the 48 sub-Saharan African countries. Peripheral arterial disease prevalence ranged from 3.1% to 24% of adults aged 50 years and older and 39% to 52% of individuals with known risk factors (eg, diabetes). Medical management was only described by 2 reports; both documented significant undertreatment of PAD as a cardiovascular disease risk factor. Five surgical case series reported that trauma and diabetes-related complications were the most common indications for vascular surgery., Conclusions and Relevance: The prevalence of PAD in sub-Saharan Africa may be equal to or higher than that in high-income countries, exceeding 50% in some high-risk populations. In addition to population-based studies that better define the PAD burden in sub-Saharan Africa, health systems should consider studies and action regarding risk factor mitigation, targeted screening, medical management of PAD, and defining essential vascular care.

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.

Objective: Childhood burns are a leading cause of injury in low- and middle-income countries; most of which are preventable. We aimed to describe the prevalence of household risk factors for childhood burn injury (CBI) in semi-urban Ghana to inform prevention strategies for this growing population., Methods: We conducted a population-based survey of 200 households in a semi-urban community in Ghana. Households were randomly selected from a list of 6520 households with children aged <18 years. Caregivers were interviewed about CBI within the past 6 months and potentially modifiable household risk factors., Results: Of 6520 households, 3856 used charcoal for cooking (59%) and 3267 cooked indoors (50%). In 4544 households (70%), the stove/cooking surface was within reach of children under-five (i.e., <1m). Higher household wealth quintiles (OR 0.95; 95%CI 0.61-1.49) and increasing age (OR 0.82; 95%CI 0.68-0.99) were associated with lower odds of CBI. Living in uncompleted accommodation (OR 11.29; 95%CI 1.48-86.18 vs rented room) and cooking outside the house (OR 1.13; 95%CI 0.60-2.14 vs cooking indoors) were also predictive of CBI., Conclusions: This study identified a high prevalence of CBI risk factors in semi-urban households that may benefit from targeted community-based prevention initiatives., (Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.)

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.

Introduction: Prospective clinical audit of trauma care improves outcomes for the injured in high-income countries (HICs). However, equivalent, context-appropriate audit filters for use in low- and middle-income country (LMIC) district-level hospitals have not been well established. We aimed to develop context-appropriate trauma care audit filters for district-level hospitals in Ghana, was well as other LMICs more broadly., Methods: Consensus on trauma care audit filters was built between twenty panellists using a Delphi technique with four anonymous, iterative surveys designed to elicit: (i) trauma care processes to be measured; (ii) important features of audit filters for the district-level hospital setting; and (iii) potentially useful filters. Filters were ranked on a scale from 0 to 10 (10 being very useful). Consensus was measured with average percent majority opinion (APMO) cut-off rate. Target consensus was defined a priori as: a median rank of ≥9 for each filter and an APMO cut-off rate of ≥0.8., Results: Panellists agreed on trauma care processes to target (e.g. triage, phases of trauma assessment, early referral if needed) and specific features of filters for district-level hospital use (e.g. simplicity, unassuming of resource capacity). APMO cut-off rate increased successively: Round 1--0.58; Round 2--0.66; Round 3--0.76; and Round 4--0.82. After Round 4, target consensus on 22 trauma care and referral-specific filters was reached. Example filters include: triage--vital signs are recorded within 15 min of arrival (must include breathing assessment, heart rate, blood pressure, oxygen saturation if available); circulation--a large bore IV was placed within 15 min of patient arrival; referral--if referral is activated, the referring clinician and receiving facility communicate by phone or radio prior to transfer., Conclusion: This study proposes trauma care audit filters appropriate for LMIC district-level hospitals. Given the successes of similar filters in HICs and obstetric care filters in LMICs, the collection and reporting of prospective trauma care audit filters may be an important step towards improving care for the injured at district-level hospitals in LMICs., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: This study aimed to describe national peripheral vascular disease (PVD) risk and health burden, and vascular care capacity in Ghana. The gap between PVD burden and vascular care capacity in low- and middle-income countries was defined, and capacity improvement priorities were identified., Methods: Data to estimate PVD risk factor burden were obtained from the World Health Organization Study on Global Ageing and Adult Health (SAGE), Ghana, and the Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) database. In addition, a novel nationwide assessment of vascular care capacity was performed, with 20 vascular care items assessed at 40 hospitals in Ghana. Factors contributing to specific item deficiency were described., Results: From the SAGE database, there were 4305 respondents aged at least 50 years with data to estimate PVD risk. Of these, 57·4 per cent were at moderate to risk high of PVD with at least three risk factors; extrapolating nationally, the estimate was 1 654 557 people. Based on IHME GBD data, the estimated disability-adjusted life-years incurred from PVD increased fivefold from 1990 to 2010 (from 6·3 to 31·7 per 100 000 persons respectively). Vascular care capacity assessment demonstrated marked deficiencies in items for diagnosis, and in perioperative and vascular surgical care. Deficiencies were most often due to absence of equipment, lack of training and technology breakage., Conclusion: Risk factor reduction and management as well as optimization of current resources are paramount to avoid the large burden of PVD falling on healthcare systems in low- and middle-income countries. These countries are not well equipped to handle vascular surgical care, and rapid development of such capacity would be difficult and expensive., (© 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.)

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., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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.

Background: This study aimed to assess availability of trauma care technology in Ghana. In addition, factors contributing to deficiencies were evaluated. By doing so, potential solutions to inefficient aspects of health systems management and maladapted technology for trauma care in low- and middle-income countries (LMICs) could be identified., Methods: Thirty-two 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 the challenges and successes of item availability at 40 purposively sampled district, regional, and tertiary hospitals., Results: Hospital assessments demonstrated marked deficiencies. Some of these were low cost, such as basic airway supplies, chest tubes, and cervical collars. Item non-availability resulted from several contributing factors, namely equipment absence, lack of training, frequent stock-outs, and technology breakage. A number of root causes for these factors were identified, including ineffective healthcare financing by way of untimely national insurance reimbursements, procurement and stock-management practices, and critical gaps in local biomedical engineering and trauma care training. Nonetheless, local examples of successfully overcoming deficiencies were identified (e.g., public-private partnering, ensuring company engineers trained technicians on-the-job during technology installation or servicing)., Conclusion: While availability of several low-cost items could be better supplied by improvements in stock-management and procurement policies, there is a critical need for redress of the national insurance reimbursement system and trauma care training of district hospital staff. Further, developing local service and technical support capabilities is more and more pressing as technology plays an increasingly important role in LMIC healthcare systems.

Background: Burns are common in low- and middle-income countries (LMICs) and complicated by unhygienic conditions, malnutrition, use of high-risk homemade dressings and delayed presentation. Resultantly, use of routine systemic antibiotic prophylaxis (SAP) to prevent wound infection is common practice despite this intervention being abandoned in high-income countries due to increased antimicrobial resistance and non-bacterial suprainfection., Methods: A best evidence topic (BET) was constructed using a structured protocol. The question addressed was: In LMICs, does routine use of SAP reduce burn wound infection, morbidity or mortality?, Results: From 704 retrieved records, 48 reports met criteria to be examined. Of those, 3 studies represented the best available evidence. Together, two randomized clinical trials (RCTs) and a retrospective cohort study reported no difference in the proportion of wound infection, any infection or length of hospital stay between SAP groups and controls. One RCT described a greater proportion of wounds infected with P. aeruginosa among SAP arms compared to controls. The studies had few participants and significant methodological weaknesses., Conclusion: On the basis of limited, currently available evidence, the use of SAP cannot be recommended for patients in LMICs that present soon after burn injury., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Introduction: Children in low- and middle-income countries (LMIC) often receive care outside the formal medical sector. Improving pre-hospital first aid has proven to be highly cost-effective in lowering trauma mortality. Few studies in LMIC have examined home first aid practices for injured children., Methods: We conducted a representative population-based survey of 200 caregivers of children under 18 years of age, representing 6520 households. Caregivers were interviewed about their first aid practices and care-seeking behaviors when a child sustained an injury at home. Injuries of interest included burns, lacerations, fractures and choking. Reported practices were characterized as recommended, low-risk, and potentially harmful., Results: For common injuries, 75-96% of caregivers reported employing a recommended practice (e.g., running cool water over a burn injury). However, for these same injuries, 13-61% of caregivers also identified potentially harmful management strategies (e.g., applying sand to a laceration). Choking had the highest proportion (96%) of recommended first aid practice: (e.g., hitting the child's back) and the lowest percent (13%) of potentially harmful practices (e.g., attempting manual removal). Fractures had the lowest percent (75%) of recommended practices (e.g., immediately bringing the child to a health facility). Burns had the highest percent (61%) of potentially harmful practices (e.g., applying kerosene)., Conclusions: While most caregivers were aware of helpful first aid practices to administer for a child injury, many parents also described potentially harmful practices or delays in seeking medical attention. As parents are the de facto first responders to childhood injury, there are opportunities to strengthen pre-hospital care for children in LMICs.

Introduction: Laparoscopy has become the gold standard for many surgical cases in the developed world. It however, remains a rarity in developing countries for several reasons, a major one being cost. This study aimed to determine the knowledge and attitude of patients attending Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana toward laparoscopic surgery and their willingness to pay for it., Methods: A cross-sectional survey was conducted among patients attending specialist clinics at KATH., Results: 1070 patients participated. Mean age was 40±15 years. 54% were city-dwellers. 14% had salary-paying jobs. None had undergone prior laparoscopic surgery. 3% had knowledge of laparoscopy. 95% preferred laparoscopy to open surgery mainly because of faster recovery and less post-op pain. Age >45 years (AOR = 0.53, p = 0.03) and higher education (AOR = 2.00, p = 0.04) were significant predictors of patient choice. Among those preferring laparoscopy, 78% were willing to pay more than the baseline cost of open surgery for laparoscopy. A history of previous abdominal surgery (AOR = 0.67, p = 0.02), having a salaried job compared with being unemployed (AOR = 2.36, p < 0.01) and living in the city compared with the village (AOR = 1.78, p = 0.04) were significant predictors of patients' willingness to pay more for laparoscopy., Conclusion: Knowledge about laparoscopy and its benefits are severely lacking among patients at KATH. Once educated about its benefits, most people prefer laparoscopy even if they needed to pay more for it even in resource-limited countries like Ghana.

Background: There are few population-based studies on household child injury in African countries., Objectives: To determine the incidence, characteristics and risk factors of household and neighbourhood injury among children in semiurban communities in Kumasi, Ghana., Methods: We conducted a cross-sectional population-weighted survey of 200 randomly selected caregivers of children under 18, representing 6801 households. Caregivers were interviewed about moderate to severe childhood injuries occurring within the past 6 months, for which the child staying home from school or activity, and/or required medical care. Multivariable logistic regression was used to identify factors associated with injury risk., Results: Annual injury incidence was 593.5 injuries per 1000 children. Common causes of injury were falls (315.7 injuries per 1000 children), followed by cuts/lacerations and burns. Most injuries (93.8%) were of moderate severity. Children whose caregivers were hourly workers (AOR=1.97; 95% CI 1.06 to 3.68) had increased odds of sustaining an injury compared to those of unemployed caregivers. Girls had decreased odds of injury (AOR=0.59; 95% CI 0.39 to 0.91). Cooking outdoors (AOR=0.45; 95% CI 0.27 to 0.76) and presence of cabinet/cupboards (AOR=0.41; 95% CI 0.24 to 0.70) in the house were protective. Among children under 5 years of age, living in uncompleted accommodation was associated with higher odds of injury compared with living in a rented single room (AOR=3.67; 95% CI 1.17 to 11.48)., Conclusions: The incidence of household and neighbourhood child injury is high in semiurban Kumasi. We identified several novel injury risk factors (hourly work, younger children) and protective factors (cooking outdoors, presence of cabinet/cupboards). These data may identify priorities for household injury prevention., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: A disproportionate number of surgeries in low- and middle-income countries (LMICs) are performed in tertiary facilities. The referral process may be an under-recognized barrier to timely and cost-effective surgical care. This study aimed to assess the quality of referrals for surgery to a tertiary hospital in Ghana and identify ways to improve access to timely care., Methods: All elective surgical referrals to Komfo Anokye Teaching Hospital for two consecutive months were assessed. Seven essential items in a referral were recorded as present or absent. The proportion of missing information was described and evaluated between facility, referring clinician type and whether or not a structured form was used., Results: Of the 643 referrals assessed, none recorded all essential items. The median number of missing items was 4 (range 1-7). Clinicians that did not use a form missed 5 or more essential items 50% of the time, compared with 8% when a structured form was used (p = 0.001). However, even with the use of a structured form, 1 or 2 items were not recorded for 10% of referrals and up to 3 items for 45% of referrals., Conclusion: Structured forms reduce missing essential information on referrals for surgery. However, proposing that a structured form be used is not enough to ensure consistent communication of essential items. Referred patients may benefit from referrer feedback mechanisms or electronic referral systems. Though often not considered among interventions to improve surgical capacity in LMICs, referral process improvements may improve access to timely surgical care., (Copyright © 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: The prevalence of gallstones among Ghanaians is unknown. We aimed to determine the prevalence of gallstones among persons undergoing abdominal ultrasound at the Komfo Anokye Teaching Hospital (KATH)., Methods: We performed a cross-sectional study of patients aged ≥14years presenting to KATH for abdominal ultrasound between 2009 and 2012. Patient demographics were recorded. The gallbladder was assessed by ultrasonography. Cholelithiasis was defined as presence of gallstones or absence of gallbladder. Data was expressed as descriptive and inferential statistics., Results: There were 2824 participants. 55% were females. Mean age was 47±18 years. Mean body mass index (BMI) was 24.0±5.5. Mean parity among females was 3±3. Prevalence of cholelithiasis was 5.9 (95%C.I:5.0,6.8). Females had a high prevalence compared to males (6.8 vs 4.7). Prevalence increased steadily by age. Prevalence was 6.6, 5.1 and 8.8 for patients with BMI <18.5, 18.5-24.9 and ≥30 respectively. Prevalence among women with parity of 0,1-5 and >5 was 3.1, 6.7 and 6.4 respectively.On multivariate regression analysis, female sex (AOR=1.55;p<0.05), age≥40 years (AOR=2.05;p<0.01), BMI<18.5 (AOR=1.25;p>0.05) or BMI≥30 (AOR=1.39;p>0.05) and family history of gallstones (AOR=11.9;p<0.01) increased the odds of cholelithiasis., Conclusions: Prevalence of cholelithiasis among patients undergoing ultrasonography at KATH was 5.9. Patient age, sex and family history significantly influenced the prevalence.

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., (© 2015 S. Karger AG, Basel.)

Background: This study aimed to describe the characteristics of patients diagnosed with hepatocellular carcinoma (HCC) at the Komfo Anokye Teaching Hospital (KATH) in Ghana and to determine their treatment options per the Barcelona Clinic Liver Cancer (BCLC) algorithm., Methods: We reviewed the medical records of patients diagnosed with HCC at KATH in the period 2007-2013. Patient demographics, medical history, investigations, management, and outcome were extracted. BCLC staging was applied to determine their treatment options. Results were expressed as descriptive statistics., Results: The charts for 206/465 patients were available for review. The male:female ratio was 2:1 and mean age was 44.0 ± 14.5 years. Common presenting complaints were abdominal distension, abdominal pain, and jaundice. hepatitis B virus (HBV) positivity was 52 %. Almost all patients received only supportive treatment. None underwent surgery, ablation, or transarterial chemoembolization. BCLC staging could be completed for 118 patients. Using predicted INR values in cases without the result, < 8 % of patients were eligible for resection, transplantation, or ablation; 25-53 % were eligible for embolization or sorafenib therapy. Up to 72 % were eligible only for supportive care. Seventy-six percent of patients reviewed were discharged alive; 71 % of patients whose charts were not available died during an admission. Thus, of the 465-patient cohort, 50 % died in the hospital., Conclusions: The majority of HCC in our population is caused by HBV. Up to 61 % of patients may be eligible for curative treatment, transarterial chemoembolization, or sorafenib treatment. This percentage may be increased with a robust surveillance program for patients at increased risk for HCC. Hepatitis B vaccination must also be a public health priority.

Introduction: Characteristics of patients undergoing Upper GI endoscopy (UGIE) in Kumasi, Ghana are largely unknown. This paper reviews the work of three endoscopy units in Kumasi., Methods: A review of the records of patients undergoing diagnostic UGIE in the three centers from October 2006 to December 2011 was undertaken., Results: 3110 completed UGIE were performed over the period. In 80% of the patients the primary indication for UGIE was dyspepsia occurring without any other symptom. In 50% of patients UGIE findings were normal. Peptic ulcer disease, the most common positive finding, was diagnosed in 27.4% of patients. The odds ratio (O.R) of yielding a positive endoscopic finding for patients presenting with recurrent vomiting, dyspepsia associated with weight loss and UGI bleeding were 3.87 (95% C.I: 2.23-6.69), 1.72 (95% C.I: 1.03-2.87) and 1.81 (95% C.I: 1.03-3.16) respectively. Dyspepsia without any other symptom, on the other hand, yielded a positive endoscopic finding with O.R of 0.67 (95% CI: 0.57-0.80). Alarm symptoms (UGI bleeding, recurrent vomiting, dysphagia or weight loss associated with dyspepsia) yielded a positive endoscopic finding with an O.R of 2.34 (95% C.I: 1.74-3.13)., Conclusion: Most patients in Kumasi underwent UGIE because of dyspepsia in the absence of any other symptom. These patients were more likely to have normal endoscopic findings. The opposite was true for those presenting with alarm symptoms. Our results suggest that initial UGIE may be preferentially offered to patients presenting with alarm symptoms especially in resource-poor settings such as ours.

Background: Komfo Anokye Teaching Hospital (KATH) is the second largest hospital in Ghana. Two years have elapsed after performance of the first laparoscopic cholecystectomy., Objectives: To examine our experience and lessons learned., Design: Retrospective review., Setting: Komfo Anokye Teaching Hospital (KATH)., Subjects: We reviewed leadership support, the role of a surgeon champion, training of physician and OR staff, influence of surgeons from outside Ghana and equipment status. The results of laparoscopic cholecystectomies performed from 2010-2012 were compared with information available from open cholecystectomies over the same period., Results: Evidence of leadership support included equipment purchase and invitation of outside experts yearly from 2008. A KATH surgeon champion was identified in 2010. A dedicated OR team received training and exhibited excellent ownership of equipment preparation. Since 2010, 25 laparoscopic cholecystectomies have been performed, 17 independently by a single surgeon. Average operative time was 1.41 hours and length of stay (LOS) 1.5 days. Conversion rate was 4.0% (1/25). Complication rate was 20.0% (5/25), none involving haemorrhage or injuries to bile ducts or bowel. Median patient satisfaction score was 5 on a scale of 1-5 where 5 is most satisfied. Complication rates and hospital stay were lower than for open cholecystectomy (20.0% vs 34.5%, p > 0.05 and 1.5 days vs 6.6 days, p < 0.001 respectively). Operative times were on average 27 min onger for laparoscopic cholecystectomy (p < 0.01)., Conclusion: Laparoscopic cholecystectomy at KATH has become a reality with less complications rates, shorter LOS, and trends towards improved patient satisfaction. Expanding laparoscopic surgery in Ghana requires its inclusion into residency training programmes and public education about its benefits for both patients and physicians.

Neurofibromas are benign tumours arising from neurons andperineural cells. Although they are common inneurofibromatosis, occasionally solitary neurofibromas may occur. A rare case of solitary neurofibroma presenting as a giant gluteal mass in a male patient without a personal or family history of neurofibromatosis is presented. Pre-operative imaging gave useful information about the extent of the mass which was then totally excised with histology revealing a non-plexiform neurofibroma. Distinguishing between isolated neurofibromas and those associated with neurofibromatosis is important because the treatment and prognosis differ greatly with the former having a good prognosis after total excision.

Introduction: Our aim was to report our experience with 23 patients presenting with 32 peripheral aneurysms secondary to Behcet's disease (BD) and their outcome after vascular surgery., Methods: The study was retrospective in nature. Except for those presenting with aneurysm rupture, patients underwent surgery after treatment of acute inflammatory lesions. All aneurysms appeared to be pseudo-aneurysms. Graft interposition with polytetrafluoroethylene or saphenous vein was most commonly employed. Postoperatively, all patients were put on immunosuppressive and antiplatelet therapy. Follow-up was done every 6-12 months, complications recorded and managed appropriately., Results: All the patients were males. The mean age at diagnosis of a peripheral aneurysm was 41.0 ± 9 years. There were 17 (53%) femoral, 8 (25%) popliteal, two carotid, two external iliac, two brachial and one internal iliac aneurysms. Fourteen (61%) patients had a single peripheral aneurysm while nine had two. Surgery was performed for all initially presenting 23 aneurysms. Six patients with multiple peripheral aneurysms had surgery for their second asymptomatic aneurysm. The mean follow-up period was 84 ± 62 months. Of 29 aneurysms operated on, 7 (24%) anastomotic pseudo-aneurysms and 11 (38%) graft occlusions developed. Five (22%) patients underwent major lower extremity amputations. Six (26%) mortalities were recorded., Conclusion: Surgery for peripheral aneurysms in BD is warranted in many instances. Results of operation can be improved by prolonged monitoring. However, despite all efforts, peripheral aneurysm involvement in BD worsens the prognosis., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Introduction: Gastrointestinal stromal tumours (GISTs) are uncommon tumours of the gastrointestinal (GI) tract. We report a case of a gastric GIST that presented acutely as a gastroduodenal intussusception., Case Presentation: A 59-year-old woman presented with a week's history of vomiting anything she swallowed. Physical examination revealed a mildly tender abdomen without guarding or rebound tenderness. An epigastric mass was, however, palpated. Abdominal ultrasonography suggested an intussusception. At laparotomy, a tumour on the anterior wall of the stomach causing intussusception of the stomach into the duodenum was found. After reducing the intussusception, a wedge resection of the tumour was performed, which proved to be a GIST., Discussion: GISTs represent a rare group of neoplasms of the GI tract. Gastric intussusception is a rarely documented condition. Symptoms range from intermittent epigastric pain to sudden onsets of severe pain with vomiting and shock. Pre-operative diagnosis can be difficult and diagnosis cannot be confirmed until surgery. The treatment of choice for localised gastric GIST is surgical resection., Conclusion: Although gastroduodenal intussusception, particularly secondary to a GIST, is uncommon, clinicians need to have a high index of suspicion in acutely vomiting patients, especially if they have experienced similar symptoms intermittently in the immediate past.

A 39-year-old woman presented with ischemia of the left hand. Angiography revealed thrombosis of forearm arteries. Surgical intervention was unsuccessful. CT angiography revealed an exostosis on the distal humerus close to the brachial artery which we believe was the cause of repetitive minor trauma to the brachial artery leading to embolic occlusion of the radial and ulnar arteries. Early diagnosis of the underlying cause is the key to successful treatment of hand ischemia. For patients without risk factors for arterial occlusive disease, imaging of bony structures must be performed in order not to miss the likely cause of an insidious repetitive vascular trauma.

Introduction: Congenital transmesenteric hernias represent a very small group of internal hernias which are uncommon and are a rare cause of intestinal obstruction. Diagnosis is frequently made at surgery. Reports of congenital transmesenteric hernia in the English literature usually involve the pediatric population; adult cases are rarer., Case Report: A 22-year-old man who presented with a day's history of severe abdominal pain but without classic physical examination signs of abdominal obstruction was operated upon on account of increasing abdominal pain and distention associated with shock. Laparotomy revealed a congenital transmesenteric defect through which loops of bowel had herniated and become gangrenous, resulting in resection and end-to-end anastomosis., Discussion: Congenital transmesenteric defects causing internal hernias in adults are rare. Preoperative diagnosis of the condition is difficult, in part, because there are no radiographic or laboratory findings to confirm the suspicion. Misdiagnosis resulting in delayed exploration may lead to small bowel necrosis and subsequent mortality., Conclusion: A congenital internal hernia should be considered in a patient with bowel obstruction without previous abdominal surgery, inflammatory abdominal condition, or trauma. We wish to emphasize that, rather than trying to establish a correct diagnosis, the patient's clinical features should lead to early surgery in order to reduce morbidity and possible mortality.

Study Design: This is a case report., Objective: The purpose was to report a patient whose migrated L4-S1 femur graft led to perforation of the cecum., Summary of Background Data: Autograft bone use during spinal surgery is quite commonplace nowadays. With time due to infection, technical mishaps, or disease recurrence, these autografts may break off their points of attachments and with their subsequent migration lead to serious complications., Methods: The patient who had the history of a stabilization operation performed for his L5-S1 spondylolisthesis grade III by way of a L4-L5, S1 transpedicular rod screw presented with high fever and abdominal tenderness. The patient underwent a laparatomy and a perforation on the medial aspect of the cecum, and a femur graft extending into the cecum through the perforation was found., Results: The graft was removed and the cecum was primarily repaired. The patient was discharged on the 15th postoperative day after an uneventful postoperative course., Conclusion: We have presented a case whose migrated L4-S1 femur graft led to perforation of the cecum. We recommend that frequent radiologic follow-up should be done in patients at risk to show complications early enough to avert severe consequences.

Buerger's disease is an inflammatory occlusive disease which commonly involves medium-sized or smaller vessels of extremities. Mesenteric involvement in Buerger's disease is very rare. It can occur at any time during the course of the disease and presents with acute mesenteric ischaemia. In this study, a case of Buerger's disease with mesenteric involvement diagnosed before the onset of acute mesenteric ischaemia and managed endovascularly is reported.

Introduction: Axillary node status is the most important prognostic factor for patients with primary breast carcinoma, making axillary lymph node dissection (ALND) a standard surgical treatment of breast cancer. Postoperative sequelae to ALND is frequently reported. In this study we aimed to find out objectively, how much damage is caused to these nerves during ALND., Patients and Methods: A total of 50 breast cancer patients who underwent surgical treatment in our Breast and Endocrine Surgery Unit between March 1998 and July 2004 were included in the study. Surgical treatment of these patients consisted of breast conserving surgery or total mastectomy combined with ALND. To compare operated patients with non-operated patients as a control, only patients who had undergone unilateral surgery were included in the study so that the non-operated side served as the normal control for each patient. All patients had a postoperative review with an anatomical and functional examination at least 6 months after the operation. Computed tomography was then performed and the M. latissimus dorsi (MLD), M. pectoralis major (MPM) and M. serratus anterior (MSA) thicknesses were measured., Results: On physical examination, the aforementioned muscles in all the patients were found to be intact and functional. Sixty-four percent of the operated patients group were found to have various degrees of hypoesthesia. MLD, MPM and MSA amongst the non-operated patients group were found to be significantly thicker than the corresponding muscles amongst operated patients group., Conclusion: We conclude that a significant amount of reduction in the thickness of the MLD, MPM and MSA occurs after ALND. Also, sensory deficit occurs, especially on the upper medial portion of the arm, showing damage to the intercostobrachial nerves.

A case of a giant renal artery aneurysm and multiple small branch aneurysms in a 48-year old man is presented. The largest aneurysm was repaired successfully with kidney preservation. Small branch aneurysms were left alone. Subsequent CT scans 6, 12 and 20 months after the operation revealed the same aneurysms without any increase in size and shape.

A case of aortoiliac occlusive disease in the presence of a horseshoe kidney anomaly is presented. The importance of careful preoperative planning by way of specialized investigations is stressed and the merits of both the anterior transperitoneal and retroperitoneal approaches to aortoiliac reconstruction in the presence of a horseshoe kidney are outlined.