Surgical output in Kibaale district, Uganda

BACKGROUND

The output of major surgeries in eastern Africa is low and varies considerably between hospitals and regions. This study in rural Uganda relates surgical output to number of hospital beds, number of in-patient admissions, number of new out-patient visits, estimated catchment area population and number of doctors and nurses. This was to facilitate comparison between institutions and areas and to determine surgical resource needs.

OBJECTIVES

To describe the quantitative output of surgery in a Ugandan district and to demonstrate the use of standardised indicators for the purpose of comparison, monitoring, resource needs assessment and planning.

DATA SOURCES

Retrospective review and analysis of inpatient and outpatient records at Kagadi district hospital, Kibaale district, Western Uganda, the only hospital providing major surgery in the district.

STUDY SELECTION

Data on all recorded major and minor surgical operations in the hospital during two complete calendar years, 1996 and 1997.

DATA SYNTHESIS

In 1996 and 1997 there were 331 and 309 major operations performed respectively in Kagadi hospital, Kibaale district. This output corresponded to 3.3 and 3.1 per 100 beds; 270 and 270 per 1,000 in-patient admissions; 328 and 267 per year per 10,000 new out-patient visits; 166 and 155 per 100,000 catchment area population; 83 and 77 per doctor; 27.6 and 25.8 per nurse. Minor surgery output at the same hospital in 1996 and 1997 were 185 and 190 respectively. This corresponded to 183 and 164 per 10,000 new outpatient visits and 93 and 95 operations per 100,000 catchment area population.

CONCLUSIONS

The output of surgery in the district was very low in comparison with Europe and North America but within the range common in Eastern Africa. For planning and performance review purposes the most useful indicators are surgical output per 100 beds per year; per 1000 inpatient admissions; per doctor and per nurse per year because they measure workload against available resources. Output per 100,000 estimated catchment area population is useful in relating output to need. These indicators are recommended to be incorporated in district and hospital performance reviews and in annual reports.

Bounds on the CP asymmetry in b --> sgamma decays

We have measured the CP asymmetry A(CP) identical with[gamma(b-->sgamma)-gammab-->sgamma)]/[gamma(b-->sgamma)+gamma(b-->sgamma)] to be A(CP) = (-0.079+/-0.108+/-0.022) (1.0+/-0.030), implying that, at 90% confidence level, A(CP) lies between -0.27 and +0.10. These limits rule out some extreme non-standard-model predictions, but are consistent with most, as well as with the standard model.

Bounds on the CP asymmetry in like-sign dileptons from B(0)B*(0) meson decays

We have measured the charge asymmetry in like-sign dilepton yields from B(0)B*(0) meson decays using the CLEO detector at the Cornell Electron Storage Ring. We find a(0)(ll) identical with[N(l(+)l(+))-N(l(-)l(-))]/[N(l(+)l(+))+N(l(-)l(-))] = +0.013+/-0.050+/-0.005. We combine this result with a previous, independent measurement and obtain Re(epsilon(B))/(1+ the absolute value of epsilon(B)(2)) = +0.0035+/-0.0103+/-0.0015 (uncertainties are statistical and systematic, respectively) for the CP impurity parameter, epsilon(B).

Study of tau decays to six pions and a neutrino

The tau decays to six-pion final states have been studied with the CLEO detector at the Cornell Electron Storage Ring. The measured branching fractions are B(tau(-)-->2pi(-)pi(+)3pi(0)nu(tau)) = (2.2+/-0.3+/-0.4)x10(-4) and B(tau(-)-->3pi(-)2pi(+)pi(0)nu(tau)) = (1.7+/-0.2+/-0.2)x10(-4). A search for substructure in these decays shows that they are saturated by intermediate states with eta or omega mesons. We present the first observation of the decay tau(-)-->2pi(-)pi(+)omega(nu)tau and the branching fraction is measured to be (1.2+/-0.2+/-0.1)x10(-4). The measured branching fractions are in good agreement with the isospin expectations but somewhat below the conserved-vector-current predictions.

Observation of new states decaying into Lambda+(c)pi(-)pi(+)

Using 13.7 fb(-1) of data recorded by the CLEO detector at the Cornell Electron Storage Ring, we investigate the spectrum of charmed baryons which decay into Lambda+(c)pi(-)pi(+) and are more massive than the Lambda+(c)(2625) baryon. We find evidence for two new states: one is broad and has an invariant mass roughly 480 MeV above that of the Lambda+(c) baryon; the other is narrow with an invariant mass of 596+/-1+/-2 MeV above the Lambda+(c) mass.

Evidence of New States Decaying into Xi(*)(c)pi

Using 13.7 fb(-1) of data recorded by the CLEO detector at Cornell Electron Storage Ring, we report evidence of two new charmed baryons: one decaying into Xi(0')(c)pi(+) with the subsequent decay Xi(0')(c)-->Xi(0)(c)gamma, and its isospin partner decaying into Xi(+')(c)pi(-) followed by Xi(+')(c)-->Xi(+)(c)gamma. We measure the following mass differences for the two states: M(Xi(0)(c)gammapi(+))-M(Xi(0)(c)) = 318.2+/-1.3+/-2.9 MeV and M(Xi(+)(c)gammapi(-))-M(Xi(+)(c)) = 324.0+/-1.3+/-3.0 MeV. We interpret these new states as the J(P) = 1 / 2(-) Xi(c1) particles, the charmed-strange analogs of the Lambda(+)(c1)(2593).

Observation of B --> phiK and B --> phiK*

We have studied two-body charmless hadronic decays of B mesons into the final states straight phiK and phiK(*). Using 9.7 million B&Bmacr; pairs collected with the CLEO II detector, we observe the decays B- --> phiK- and B0--> phiK(*0) with the following branching fractions: B(B--->phiK-) = (5.5(+2.1)(-1.8)+/-0.6)x10(-6) and B(B0--> phiK(*0)) = (11.5(+4.5+1.8)(-3.7-1.7))x10(-6). We also see evidence for the decays B0-->phiK0 and B---> phiK(*-). However, since the statistical significance is not overwhelming for these modes, we determine upper limits of <12.3x10(-6) and <22.5x10(-6) ( 90% confidence level), respectively.

Observation of the Omega(0)(c) Charmed Baryon at CLEO

The CLEO experiment at the CESR collider has used 13.7 fb(-1) of data to search for the production of the Omega(0)(c) (css ground state) in e(+)e(-) collisions at square root of (s) approximately 10.6 GeV. The modes used to study the Omega(0)(c) are Omega(-)pi(+), Omega(-)pi(+)pi(0), Xi-K-pi(+)pi(+), Xi0K-pi(+), and Omega(-)pi(+)pi(+)pi(-). We observe a signal of 40.4+/-9.0(stat) events at a mass of 2694.6+/-2.6(stat)+/-1.9(syst) MeV/c(2), for all modes combined.

Search for B --> tau(nu) and B --> K(nu)nu

We report results of a search for B-->tau(nu) in a sample of 9.7 x 10(6) charged B meson decays. We exclusively reconstruct the companion B decay to suppress background. We set an upper limit on the branching fraction B(B-->tau(nu))<8.4 x 10(-4) at 90% confidence level. We also establish B(B+/--->K+/-nu(nu))<2.4 x 10(-4) at 90% confidence level.

Measurement of the relative branching fraction of upsilon(4S) to charged and neutral B-meson pairs

We analyze 9.7x10(6) B_B pairs recorded with the CLEO detector to determine the production ratio of charged to neutral B-meson pairs produced at the Upsilon(4S) resonance. We measure the rates for B0-->J/psiK((*)0) and B+-->J/psiK((*)+) decays and use the world-average B-meson lifetime ratio to extract the relative widths f(+-) / f(00) = gamma(Upsilon(4S)-->B+B-) / gamma(Upsilon(4S)-->B0 B-0)) = 1.04+/-0.07(stat)+/-0.04(syst). With the assumption that f(+-)+f(00) = 1, we obtain f(00) = 0.49+/-0.02(stat)+/-0.01(syst) and f(+-) = 0.51+/-0.02(stat)+/-0.01(syst). This production ratio and its uncertainty apply to all exclusive B-meson branching fractions measured at the Upsilon(4S) resonance.

First observation of the decays B(0) --> D(*-)p_p pi+ and B(0) --> D(*-)p_n

We report the first observation of exclusive decays of the type B-->D(*)N_NX, where N is a nucleon. Using a sample of 9.7x10(6)B_B pairs collected with the CLEO detector operating at the Cornell Electron Storage Ring, we measure the branching fractions B(B0-->D(*-)p_p pi(+)) = (6.5(+1.3)(-1.2)+/-1.0)x10(-4) and B(B0-->D(*-)p_n) = (14.5(+3.4)(-3.0)+/-2.7)x10(-4). Antineutrons are identified by their annihilation in the CsI electromagnetic calorimeter.

Measurement of the lambda(+)(c) lifetime

The Lambda+c lifetime is measured using 9.0 fb(-1) of e+e- annihilation data collected on or just below the Upsilon(4S) resonance with the CLEO II.V detector at CESR. Using an unbinned maximum likelihood fit, the Lambda+c lifetime is measured to be 179.6+/-6.9(stat)+/-4.4(syst) fs. The precision of this colliding beam measurement is comparable to other measurements, which are based on fixed-target experiments, with different systematic uncertainties.

First observation of the sigma(*+)(c) baryon and a new measurement of the sigma(*+)(c) mass

Using data recorded with the CLEO II and CLEO II.V detector configurations at the Cornell Electron Storage Rings, we report the first observation and mass measurement of the Sigma(*+)(c) charmed baryon, and an updated measurement of the mass of the Sigma(+)(c) baryon. We find M(Sigma(*+)(c))-M(Lambda(+)(c)) = (231.0+/-1.1+/-2.0) MeV, and M(Sigma(+)(c))-M(Lambda(+)(c)) = (166.4+/-0.2+/-0.3) MeV, where the errors are statistical and systematic, respectively.

Minor surgery at hospitals and clinics in a Kenyan district

BACKGROUND

Minor surgical operations are performed at almost all hospitals, health centres and dispensaries in Africa. A large proportion of the operations are urgent, prompted by injuries and acute infections. They are rarely recorded and reported systematically, and rates and patterns are poorly known.

OBJECTIVE

To describe of all minor surgery performed on a rural African population during one year.

DESIGN

Prospective recording and analysis of minor surgical procedures and of the patients undergoing the same procedures.

SETTING

Hospitals, health centres, dispensaries and mission clinics in Meru district, Kenya.

RESULTS

Out of 26,858 minor operations performed (2,066/100,000 people/year) 22,838 were done at the five hospitals in the district while 2,510 were done at 49 mission clinics (4.3/clinic/month), 764 at ten health centres (6.4/health centre/month) and 620 at 29 dispensaries (1.8/dispensary/month). The most common operations were episiotomy, tooth extraction, wound suture and incision and drainage of abscess. More minor surgery is done on women than on men, and the difference is related to obstetrical procedures.

CONCLUSIONS

Relatively few operations were performed at health centres, dispensaries and mission clinics. Possible explanations include perceived quality of care, staff motivation, poor service access outside office hours and service charges.

Study of B Decays to Charmonium States: B-->eta(c)K and B --> chi(c0)K

In a sample of 9.66x10(6)B&Bmacr; pairs collected with the CLEO detector we make the first observation of B decays to an eta(c) and a kaon. We measure branching fractions B(B+-->eta(c)K+) = (0.69(+0.26)(-0.21)+/-0.08+/-0.20)x10(-3) and B(B degrees -->eta(c)K degrees ) = (1.09(+0.55)(-0.42)+/-0.12+/-0.31)x10(-3), where the first error is statistical, the second is systematic, and the third is from the eta(c) branching fraction uncertainty. From these we extract the eta(c) decay constant in the factorization approximation, f(eta(c)) = 335+/-75 MeV. We also search for B decays to a chi(c0) and a kaon. No evidence for a signal is found and we set 90% C.L. upper limits: B(B+-->chi(c0)K+)<4.8x10(-4) and B(B degrees -->chi(c0)K degrees )<5.0x10(-4).

Injuries as a public health problem in sub-Saharan Africa: epidemiology and prospects for control

Injuries are common and on increase in most developing countries, including sub-Saharan Africa. A large proportion of the injuries are caused by road traffic accidents, falls, burns, assaults, bites, stings and other animal-related injuries, poisonings, drownings/near-drownings and suicide. Globally, injuries are responsible for about five per cent of the total mortality, and the overall global annual costs were estimated in the late 1980s at around 500 billion US dollars. The burden and pattern of injuries in Africa and other developing areas are poorly known and not well studied. The incidence is on the increase, partly due to rapid growth of motorised transport and to expansion of industrial production without adequate safety precautions. This is a review of data on various kinds of injuries in developing countries with a focus on sub-Saharan Africa. A computerised search of the relevant literature published between 1985 and 1998 was conducted and a manual search of journals publishing texts on health in low-income countries and in tropical environments was also done. A few studies on injury prevention policy and on research related to injury epidemiology and prevention have also been identified and included. It is concluded that in a relatively typical East African area with a total mortality rate of 1,300/100,000/year, injuries are likely to cause around 100 of these deaths. The corresponding total rate of significant injuries is estimated at 40,000/100,000/year with a breakdown as tabulated below. [table: see text] Although a few surveys and other investigations of injuries have been conducted over the years, injury epidemiology and control remain under-researched and relatively neglected subject areas. Much needs to be done. Collection and analysis of injury data need to be standardised, for example regarding age groups, gender disaggregation and severity. Injuries and accidents should be subdivided in at least road traffic injury, fall, burn, assault, poisoning, drowning, suicide, homicide and others, and details regarding time and place, victim and main cause should be noted. Morbidity survey field staff should be informed that injuries are part of the illness concept and that questions should be asked accordingly. Details regarding the circumstances surrounding different injuries must be known to those who develop preventive programmes. Injury is a public health problem affecting some people more than others. Our ordinary environment--the home, the work-site, the street or road--represents various kinds of risk, and some of these are difficult to eliminate. Not only do we have to accept much of our environment with its existing houses, equipment, vehicles, transport systems, energy supply, toxic substances etcetera, many also suffer from various inherited or acquired conditions that increase the risk. We therefore need to develop safer and more "forgiving" living environments where ordinary people can live and move around safely. Injury control activities may focus on different categories of injury. Road safety measures often include information and education campaigns, improved driver training, road design and maintenance, regular vehicle safety checks, separation of pedestrians from vehicle traffic, speed limits, safety belt, air-bag and helmet use, special training and control of public service vehicle drivers, bicycle lane separation, road lighting, reflectorised materials on clothing, review of the road traffic related legislation and law enforcement, and emergency medical services improvement. Domestic injuries can be prevented for example with window guards, child barriers at stairs, smoke detectors, clothes and furniture in less flammable materials, replacement of open stoves, stabilising of open lamps, fire-fighting equipment and practice, child-proof poison packaging and storage, safe disposal of toxic waste, home safety education of parents, and strict building code enforcement. Occupational injuries can largely be prevented if well adapted to the work environment. Research is required in several areas. An improved facility-based injury recording and reporting system needs to be developed and tested. There is need to combine data collection methods, such as interview surveys, hospital records, police records, focus group discussions and key informant interviews. The outcome of emergency medical care and of different forms of transport and referral needs to be determined. Different combinations of preventive interventions needs to be evaluated. This review is intended as guidance for those who need a broad overview of the subject of injury occurrence and prevention in Africa, for example in preparation for the development of injury control programmes or to help identify issues requiring further research in this field.

Measurements of the mass, total width, and two-photon partial width of the eta(c) meson

Using 13.4 fb(-1) of data collected with the CLEO detector at the Cornell Electron Storage Ring, we have observed 300 events for the two-photon production of ground-state pseudoscalar charmonium in the decay eta(c)-->K(0)(S)K-/+pi(+/-). We have measured the eta(c) mass to be [2980.4+/-2.3 (stat)+/-0.6 (syst)] MeV and its full width as [27.0+/-5.8 (stat)+/-1.4 (syst)] MeV. We have determined the two-photon partial width of the eta(c) meson to be [7.6+/-0.8 (stat)+/-0.4 (syst)+/-2.3 (br)] keV, with the last uncertainty associated with the decay branching fraction.

Study of charmless hadronic B meson decays to pseudoscalar-vector final states

We report results of searches for charmless hadronic B meson decays to pseudoscalar( pi(+/-), K+/-, pi(0), or K(0)(S))-vector( rho, K(*), or omega) final states. By using 9.7x10(6) BB pairs collected with the CLEO detector, we report the first observation of B(-)--->pi(-)rho(0), B(0)-->pi(+/-)rho(-/+), and B(-)-->pi(-)omega, which are expected to be dominated by hadronic b-->u transitions. The measured branching fractions are (10.4(+3.3)(-3.4)+/-2.1)x10(-6), (27.6(+8.4)(-7.4)+/-4.2)x10(-6), and (11.3(+3.3)(-2.9)+/-1. 4)x10(-6), respectively. Branching fraction upper limits are set for all of the other decay modes investigated.

Household survey of injuries in a Kenyan district

OBJECTIVE

To determine the pattern and burden of injuries, their causes and action taken in a rural and urban community in Kenya.

DESIGN

Household interview survey and focus group discussions.

SETTING

Four rural villages and five urban clusters in Kiambu District, Kenya.

SUBJECTS

A total of 1,980 members of 200 rural and 230 urban households.

RESULTS

The number of reported injuries was 495, corresponding to 300,000 injuries per 100,000 people per year. Most common were cut or piercing (38.4%), followed by fall (16.2%), burn or scald (14.3%), animal bite or kick (10.1%), hit by moving object (5.9%) and road traffic accident (3.6%). Poisoning, sub-mersion/drowning and explosion were uncommon, each below three per cent. Of all reported injuries, 149 (30.1%) sought care from traditional healers, 91 (18.4%) were subject to self-care, 76 (15.4%) obtained service from drug shops, 22 (4.4%) were brought to a health facility for attention and 17 (3.4%) took no action at all. Additional information was obtained through focus group discussions with students, teachers and members of women groups. These generated detailed information about cases of sexual assault within and outside households which had not been captured during the previous household interviews.

CONCLUSION

Injuries are very common but most of them are mild, prompting only home care or no action at all. Only one out of 25 injuries were brought to a health facility for attention. Some types of injury, such as domestic violence and sexual assault, are more likely to be captured through focus group discussions than during household interviews. A combination of methods is likely to best reflect the pattern of injury at community level.

Airborne surgical outreach services in eastern Africa

BACKGROUND

African Medical and Research Foundation (AMREF) has for forty years offered airborne specialist surgeons or surgical teams to supplement the major surgery conducted by local hospital staff, particularly in Kenya and Tanzania.

OBJECTIVE

To quantify and qualitatively describe the contribution of airborne surgical outreach services in relation to the total surgical output of remote rural hospitals in Kenya and Tanzania.

DATA SOURCES

Surgical theatre registration books of one government and two church/mission owned hospitals in Kenya and Tanzania from 1994 to 1995; and service records kept by the surgeons during outreach trips in the same period.

RESULTS

AMREF contributed 15.1% of all major operations, and operations performed by AMREF were relatively complex. The average number of AMREF's major operations performed per visit was 17 and per visit day 4.3. Numerous minor operations and examinations, ward rounds and an average of 10 patient consultations per day were done during the visits.

CONCLUSIONS

Total population-based operation rates, and rates by sex and age, are useful indicators for monitoring and comparison. Every hospital should report, annually, major operations performed by type and by age and sex of patients, with special mention of operations and consultations performed by visiting teams, if any. Each hospital should also state the estimated population of its current catchment area.

Socio-cultural information in support of local health planning: conclusions from a survey in rural Kenya

Existing health information systems in developing countries are managed and used mainly by biomedically trained personnel and by general healthcare administrators. They focus on epidemiology, service utilization and finance; they generate little of the socio-cultural data needed for developing and adjusting health services and disease control programmes to local health-related perceptions, values and resources. This paper reviews some of the published literature on socio-cultural factors related to health and summarizes the findings of a health household interview study in rural Kenya. It concludes that local views on specific disease categories and their causes are crucial for the planning of local disease control and that health information systems need to be expanded to incorporate such data. It discusses methods of generating community-based socio-cultural health information likely to be useful, particularly at district level. Options include observation, household interviews, focus group discussions and key informant interviews. Four improvements are suggested: (1) health information systems should be reoriented to focus less on individual patients and clients and more on population-based information including socio-cultural data; (2) post-basic health manpower training is needed in applied health-related social sciences; (3) staff positions for social scientists at central, provincial and district levels of the health sector; and (4) expansion of research on national and local socio-cultural issues of relevance to health and care-seeking behaviour.

[Geriatric psychiatry--a specialty gaining recognition]

Services for elderly, mentally ill people have developed in response to changing needs in society. In 1990 most of the 650 beds allocated to elderly patients in psychiatric hospitals were occupied by long-term care patients. Outpatient programmes hardly existed. In 1995 about 400 beds were allocated to geriatric psychiatry. They were served by 40 physicians and 20 psychologists. Out-patients' clinics were established. Most of the in-patients were short-term admissions. Nowadays, departments of geriatric psychiatry define themselves as diagnostic and short-term units. About a third of the in-patients suffer from dementia, a third from depression, and a third from various other psychiatric disorders. The authors recommend that a special unit for geriatric psychiatry should be established in every county in Norway. Funds should be allocated for professorships at all universities.

Health and the elderly in developing countries with special reference to sub-Saharan Africa

The numbers of elderly people in sub-Saharan Africa are growing rapidly with increasing life expectancy while at the same time the proportions of children in the populations are declining. The number of people 80 years and above increased tenfold in large parts of Africa since the 1950's, and the number of widows is growing fast. All this has several implications, including erosion of the social support by extended families and a dramatic change in the disease pattern. There will be increasing rates of cancer, liver cirrhosis, kidney failure, eye disease, osteoarthrosis, diabetes, mental illness and chronic degenerative illnesses such as cardiovascular disease. Multiple illness and permanent disability will become more common. African health care systems are ill-prepared for this transition, and social security for the elderly need to be improved in the coming years. Local and regional research into morbidity and well-being is important for policy formulation. The situation of different categories of chronically sick needs to be investigated. Improved health in childhood and middle age will probably be followed by improved health in old age, and this may offset the burden on the health care system of the growing number of elderly.

North-South health research collaboration: challenges in institutional interaction

North-South health development cooperation often includes research financed largely by external donors. The cooperation varies between projects and programmes with regard to subject area, mix of disciplines involved, research methods, training components and project management arrangements. A variety of problems is encountered, but they are rarely described and discussed in published project reports. We authors conducted a study of a small number of European health researchers collaborating with researchers from the Third World. We focused upon projects involving both biomedical and social science researchers, and apart from a literature review three methods were applied: self-administered questionnaires to European researchers, semistructured interviews with five IHCAR researchers, and written summaries by the three authors, each on one recent or ongoing collaborative project of their choice. Most collaborative projects were initiated from the North and are monodisciplinary or partly interdisciplinary in the sense that researchers did independent data collection preceded by joint planning and followed by joint analysis and write-up. There may be disagreements concerning remuneration such as allowances in relation to fieldwork and training. Socio-cultural misunderstanding and conflict was reportedly rare, and no serious problems were reported regarding authorship and publishing. It is concluded that collaborative research is a complex and poorly understood process with considerable potential and worth pursuing despite the problems. Difficulties related to logistics and finance are easily and freely discussed, while there is little evidence that transdisciplinary research is conducted or even discussed. We recommend that published and unpublished reports on collaborative research projects include more detailed accounts of the North-South collaborative arrangements and their management, ethical and financial aspects.