Management of psychiatric problems in a Kenyan mission hospital

Many psychiatric conditions are found in the rural general hospital in Kenya and are recognisable and manageable along standard Western lines. An essential element in management is the training of the nursing staff. The psychiatric patient should be actively managed and can benefit from the unsophisticated treatment possible at the mission hospital.     

Bacterial meningitis in southwestern Alaska

Between July 1, 1971, and June 30, 1974, thirty-nine cases of bacterial meningitis were diagnosed at the Alaska Native Health Service Hospital at Bethel, Alaska. Thirty-two (82%) occurred in infants less than one year of age. Haemophilus influenzae (H. influenzae) was the predominant causative agent, and was isolated from 23 (72%) of the 32 patients under one year of age. The annual incidence of H. influenzae meningitis in the Bethel area was 63/100,000, and the annual incidence of H. influenzae meningitis in children less than five years of age was 474/100,000 cases.     

Removal of deciduous canine tooth buds in Kenyan rural Maasai

The removal of deciduous canine tooth buds in early childhood is a practice that has been documented in Kenya and in neighboring countries. This paper describes the occurrence, rationale and method of this practice amongst rural Kenyan Maasai. In a group of 95 children aged between six months and two years, who were examined in 1991/92, 87% were found to have undergone the removal of one or more deciduous canine tooth buds. In an older age group (3-7 years of age), 72% of the 111 children examined exhibited missing mandibular or maxillary deciduous canines. It was found that the actual removal of a deciduous tooth bud is often performed by middle-aged Maasai women who enucleate the developing tooth using a pointed pen-knife. There exists a strong belief among the Maasai that diarrhoea, vomiting and other febrile illnesses of early childhood are caused by the gingival swelling over the canine region, and which is thought to contain 'worms' or 'nylon' teeth. The immediate and long-term hazards of this practice include profuse bleeding, infection and damage to the developing permanent canines. A multi-disciplinary approach involving social anthropologists in addition to dental and medical personnel, is recommend in order to discourage this harmful operation that appears to be on the increase.     

Tuberculosis meningitis in Hong Kong: experience in a regional hospital

Tuberculous meningitis (TBM) remains common in Hong Kong. From January 1996 to June 1997, 11 adult patients with TBM presented to Queen Mary Hospital, a regional hospital in Hong Kong. The annual incidence of TBM was estimated at 1.8 per 100,000 population. Nine patients were local Chinese, and only one patient had the acquired immune-deficiency syndrome (AIDS). In contrast to the classical presentation as a chronic indolent disease, our patients presented acutely: the mean duration from onset of symptoms to presentation was 4.8 days (range 0-10). The most common presenting symptoms were headache (64%), fever (46%), or both (36%), with focal deficits occurring in 64% of patients. Cerebrospinal fluid (CSF) culture and polymerase chain reaction (PCR) were positive in 30% and 29% of cases. Mean CSF cell count, protein and glucose levels were 340 x 10(6)/L, 267 mg/dL, and 2.3 mmol/L, respectively. Extra-neural tuberculosis occurred in 46% of cases. All patients survived and responded to treatment. Drug-induced hepatotoxicity was common; 64% of patients developed biochemical hepatitis.     

Tuberculous meningitis in an urban general hospital

We analyzed the clinical and laboratory findings of 19 patients with tuberculous meningitis seen between 1966 and 1974 at the Henry Ford Hospital. Eighteen patients were adults at the time of diagnosis. In eight patients, the history suggested that the infection with the tubercle bacillus had occurred in the remote past. Cerebrospinal fluid analysis was often typical for tuberculous meningitis; stains for Mycobacterium tuberculosis were usually negative. Of 16 patients who were treated, five died and five suffered permanent neurological sequelae. The addition to rifampin to isoniazid therapy did not improve either survival or permanent sequelae. We were not able to analyze the effect of steroids on the disease.     

Neurologic consultation practice in a general hospital of a rural area

The purpose of this ongoing study is to evaluate the safety and efficacy of new minimally invasive pervaginam cystourethropexy and sling procedures for the treatment of female genuine stress urinary incontinence. A total of 75 women (mean age, 52.8 years) underwent either a cystourethropexy or a sling procedure. A miniature bone anchor and a staple-like bone anchor driver were used for the fixation of periurethral tissue or a xenogenic sling to the pubic bone. With a mean follow-up of eight months, 61 patients (82%) were completely cured of stress incontinence, 10 (14%) reported a more than 50% decrease in pad usage, and 4 patients showed failure early following surgery. The exclusively pervaginam cystourethropexy and sling procedures are minimally invasive, safe, and effective. Further experience and longer follow-up are necessary to establish their role in the treatment of women with stress urinary incontinence.     

Group B Streptococcal septicaemia/meningitis in neonates in a Singapore teaching hospital

Several studies have indicated that frequent allelic losses in some specific chromosomal regions occur during colorectal cancer (CRC) progression. To clarify the correlation between such allelic losses and metastatic potential, the allelotype of lymph node-positive early CRCs, which are small but extremely malignant cancers consisting of metastatically competent cells, were investigated. Nineteen paraffin-embedded specimens of early CRC (pT1 tumors according to TNM classification) with positive lymph nodes were collected. The tumor tissues were examined for loss of heterozygosity (LOH), using microsatellite markers on chromosomes 1p34-36, 8p21-22, 14q32, 18q21 and 22q12-13. The relationship between p53 protein expression and the metastatic status was also investigated by immunohistochemical staining. A group of 20 early CRCs with negative lymph nodes having a similar distribution of macroscopic appearance were used as controls. Among the 19 node-positive tumors, LOH at 8p21-22 and 18q21 was detected in 11 cases (57.9%) and 17 cases (89.4%), respectively. Allelic losses within these 2 regions in node-positive tumors were significantly more frequent than that in node-negative ones (p < 0.01). No significant correlation was found between LOH at 1p34-36, 14q32 or 22q12-13 and lymph node metastasis. p53 protein expression was not significantly associated with lymph node metastasis. Our results suggest that putative tumor suppressor genes, which may be involved in the metastatic process of CRC, are located on chromosomes 8p21-22 and 18q21. Allelic losses in these regions are possible risk factors for lymph node metastasis of early CRC.     

Bacterial endocarditis: results of a survey in a children''s hospital in France

Recent studies have shown the insulin-like effect of vanadyl sulphate or sodium ortho (or meta-)vanadate administered orally to rats. Toxicity of these drugs and reluctance by the animals to drink the solutions and take food, concerning the amelioration of some diabetes syndrome discussed in 1994 by Domingo et al. (1), McNeill et al. (2) and Wiliams and Malabu (3), prompted us to investigate a new vanadate complex: disodium bis(oxalato)oxovanadate (IV), Na2[VO(OX)2]H2O. The main object of the experiment was to study whether this complex administered as 3 mmol/l solution in 0.5% NaCl during 7 days could act on the subcellular level and influence the activity of liver Golgi membrane galactosyltransferase activity. Free blood sugar level was lowered (but was still higher than in the control group) in diabetic rats after seven days of vanadate action and was accompanied by lowered, however not statistically significant, serum triglyceride levels. The yields of isolated Golgi-rich membrane fractions were about half of the level in diabetic groups (untreated and treated with vanadium) compared with the control groups. Purity of these membrane fractions, expressed as nmol Gal transferred per mg of proteins and per h, was the same in four groups investigated and showed the possibility to compare them. Activity of galactosyltransferase calculated in nmol Gal transferred per 1 g of liver and per 1 h or per whole liver in the same time (as a possibility of glycosylation of the secretory and membrane glycoproteins) was lower in both diabetic groups. However, after vanadium treatment (D+V group), the activity was higher than in untreated diabetic rats (D group) in three of five investigated animals. Vanadyl-oxalate complex did not normalize in a statistically significant manner the enzyme activity which was significantly lower in diabetes than in control. This is similar to insulin influence on the galactosyltransferase activity reported previously by Kaczmarski et al. in 1981 (4) and Kordowiak et al. in 1981 (5).     

Bacteriological analysis of various environmental sources in a rural hospital

The prognosis of patients with end-stage cardiac disease has dramatically changed with transplantation. The incidence of complications remains relatively high and needs a very careful follow-up to have good long term results.     

Implementation of a professional practice model for nursing in a rural hospital

Growing concern about rural hospitals and the health of rural citizens highlight the need for high quality, progressive nursing care. To address this concern, several program changes to improve patient and organizational outcomes were made in one rural hospital; implementation success varied. Hospital culture and changes occurring within the health care environment affected the change process.     

Treatment of oesophageal carcinoma at a small rural hospital

OBJECTIVE: For the primary treatment of pseudophakic retinal detachment, vitrectomy could be preferred to episcleral buckle because it does not induce myopia, it clears opacities of the posterior capsule and/or of the vitreous and allows a good visualization of the fundus. This study was determined to compare the anatomic and functional results of vitrectomy and episcleral buckle. METHODS: from 1990 to 1995, 93 pseudophakic eyes were operated on for retinal detachment. 75 eyes were treated with episcleral buckle (group I) and 18 eyes were treated with vitrectomy (group II). In the latter group, 4 eyes had a giant tear, and 4 other eyes had a macular hole associated with high myopia. The anatomic and functional results were analyzed retrospectively. RESULTS: The retina was reattached with one operation in 67 eyes of group I (89%) and 16 of group II (89%). More than one month after the first operation, the retina redetached in 6 eyes of Group I (8%) and one eye of group II (6%). The causes of failure were a) new or missed retinal tears [Group I: 10 eyes (13%), group II: 3 eyes (17%)] and b) vitreoretinal proliferation (group I: 4 eyes, group II: 0). The number of subsequent reoperations for failures or recurrences was higher in group I than in group II. At the final examination, the retina was attached in 73 eyes of group I (97%) and in 18 eyes of group II (100%). The Kruskal-Wallis test did not detect any difference between the two groups concerning the pre- or postoperative visual acuities. CONCLUSION: Vitrectomy seems as effective as episcleral buckle for the treatment of pseudophakic retinal detachment and offers additional advantages.     

Major and minor surgery at a rural African hospital

Surgical operations performed at Ombo Hospital in Western Kenya from January to December 1989 were studied and annual surgical rates were calculated based on the estimated catchment area population. The total annual rate of major surgery at this church-supported hospital was 207 operations per 100,000 people. This rate is similar to those at other East African hospitals while rates in industrialized countries are 20-35 times higher. The most common major procedures were Caesarean section, laparotomy, hernia repair and salpingectomy. The 1989 rate of minor operations at the hospital was 1286 per 100,000 people with tooth extraction, wound suture, incision and drainage, evacuation of the uterine cavity and closed reduction of fracture as the most frequent procedures. Major operations were performed exclusively by doctors while minor surgery was carried out mainly by clinical officers, nurses and other auxiliary staff.     

Cost of comprehensive pharmaceutical services in a 45-bed rural hospital

The financial impact of a comprehensive pharmacy program on patient charges and hospital operating costs in a 45-bed community hospital was studied. Data were collected retrospectively for the fiscal year prior to initiating pharmacy services (FY73), the fiscal year during program development (FY74) and the fiscal year following full operations (FY75). The total cost of pharmacy services increased 75% from FY73 to FY75, with the largest dollar increase being in pharmacy salaries. Large increases among other cost items also were noted. The average total cost for pharmacy services increased from $3.28 per patient day in FY73 to $6.04 in FY75 (84%). Total hospital cost per patient day increased by approximately $35 from FY73 to FY75 (5%). The pharmaceutical services fee per dose of medication administered did not change from FY73 to FY75. Patient charges per day for medications and pharmaceutical services increased $0.55 (9.8%) from FY73 to FY75. There was a 55% reduction in the number of items carried in pharmacy inventory from FY73 to FY74 following the initiation of a formulary and a unit dose drug distribution system.     

Bacterial meningitis in the United States in 1995. Active Surveillance Team

BACKGROUND: Before the introduction of the conjugate vaccines, Haemophilus influenzae type b was the major cause of bacterial meningitis in the United States, and meningitis was primarily a disease of infants and young children. We describe the epidemiologic features of bacterial meningitis five years after the H. influenzae type b conjugate vaccines were licensed for routine immunization of infants. METHODS: Data were collected from active, population-based surveillance for culture-confirmed meningitis and other invasive bacterial disease during 1995 in laboratories serving all the acute care hospitals in 22 counties of four states (total population, more than 10 million). The rates were compared with those for 1986 obtained by similar surveillance. RESULTS: On the basis of 248 cases of bacterial meningitis in the surveillance areas, the rates of meningitis (per 100,000) for the major pathogens in 1995 were Streptococcus pneumoniae, 1.1; Neisseria meningitidis, 0.6; group B streptococcus, 0.3; Listeria monocytogenes, 0.2; and H. influenzae, 0.2. Group B streptococcus was the predominant pathogen among newborns, N. meningitidis among children 2 to 18 years old, and S. pneumoniae among adults. Pneumococcal meningitis had the highest case fatality rate (21 percent) and in 36 percent of cases was caused by organisms that were not susceptible to penicillin. From these data, we estimate that 5755 cases of bacterial meningitis were caused by these five pathogens in the United States in 1995, as compared with 12,920 cases in 1986, a reduction of 55 percent. The median age of persons with bacterial meningitis increased greatly, from 15 months in 1986 to 25 years in 1995, largely as a result of a 94 percent reduction in the number of cases of H. influenzae meningitis. CONCLUSIONS: Because of the vaccine-related decline in meningitis due to H. influenzae type b, bacterial meningitis in the United States is now a disease predominantly of adults rather than of infants and young children.