STI management in Tanzanian private drugstores: practices and roles of drug sellers

OBJECTIVES

To describe the role and possible contribution of private drugstores in sexually transmitted infection (STI) management in rural Tanzania.

METHODS

A cross-sectional study that included drug sellers in private drugstores in eight districts of Tanzania. Data collected through interviews with drug sellers and the simulated client method presenting a male and female STI case. "QATI" scores (Questions, Advice, Treatment and drug Information) were developed to describe overall STI management.

RESULTS

Although 74% of drug sellers stated that there were no STI-related drugs in the store, medications were dispensed in 78% of male and 63% of female simulated client visits. The clients were dispensed drugs recommended in the Tanzanian guidelines for syndromic management of urethral or vaginal discharge in 80% of male and 90% of female cases. Drug sellers dispensed antibiotics during 76% of male and 35% of female simulated client visits. Dosage regimens were often incorrect and complete syndromic management rarely provided. Most drug sellers agreed that it is within their professional role to give information on STI treatment (89%) and prevention (95%). Drug-use information was almost always provided. Advice was however seldom given and questions occasionally asked. Overall STI management was better for men than for women.

CONCLUSIONS

The drug sellers, although aware of the prescription-only status of antibiotics, saw themselves as having a role in STI management and were ready to provide drugs. In this resource-limited setting, drug sellers could provide effective and safe STI management especially to male patients if given appropriate tools to improve practice. The consequences of this for official policy need to be discussed.

May-Thurner syndrome in a pediatric renal transplant recipient--case report and literature review

Vascular complications post-renal transplantation are not very common and can be associated with increased risk of graft loss. We report an unusual case of a young, female teenager with asymmetrical leg swelling. After one month of transplantation, the patient developed a rise in serum creatinine with right leg swelling (ipsilateral to transplant) from compression of the iliac vein by a right renal transplant lymphocele, which resolved after lymphocele drainage. Subsequently, left leg swelling (contralateral to transplant) was noticed and the diagnosis of May-Thurner syndrome was made by MRV. The patient was successfully managed with oral Plavix, stockings and leg elevation. The allograft function remained stable at 18 months post-transplant.

Primary tumour resection and survival in the palliative management of metastatic colorectal cancer

AIM

To examine whether surgical resection of the primary tumour confers a survival benefit and to identify the predictive factors of outcome in patients presenting with asymptomatic metastatic colorectal cancer (CRC).

MATERIALS AND METHODS

A review of a hospital database in a tertiary institution over a 6-year period (1999-2005) revealed 70 patients with asymptomatic primary CRC and unresectable liver metastases treated initially by systemic chemotherapy. A multivariate regression analysis model was used to determine the relative influence of multiple tumours, single/multiple liver metastases, tumour site, differentiation, response of liver and primary tumour to chemotherapy, biochemical response to chemotherapy, age at presentation, performance status and surgical intervention for the CRC primary.

RESULTS

In 67 cases (3 lost to follow-up), 63 had multiple and 4 single surgically irresectable liver metastases. A total of 41 deaths were recorded. All patients received systemic chemotherapy and surgery was performed for bowel obstruction, bleeding or stable disease (n=32). Surgery (OR 0.26; p=0.00013) and clinical response of the primary tumour (OR 0.53; p=0.012) were independently associated with prolonged survival. Proximal tumours (OR 2.61; p=0.0075) and multiple primaries (OR 3.37; p=0.02) were associated with poor outcome.

CONCLUSIONS

Surgical resection and response of the primary tumour to chemotherapy may be associated with improved survival, but proximal or multiple cancers predict poor outcome in patients with asymptomatic CRC and unresectable metastatic disease.

Neutropenic enterocolitis

We report a case of neutropenic enterocolitis diagnosed on computerized tomography abdomen in a 56-year-old man having high-grade non-Hodgkin's lymphoma. After appropriate management, the patient recovered completely.

Investigating mosquito-net coverage in Nigeria. How useful are consumer marketing surveys?

A marketing company conducting a consumer omnibus survey (COS) in April 2000 was paid to include questions about household ownership of mosquito nets. At the time of the survey, which involved 5018 respondents, most and perhaps all of the nets owned by the respondents would have been untreated, as a product for net treatment was then virtually unavailable. Sampling was conducted in all 36 states and the Federal Capital Territory, Abuja. Core questions were asked about socio-demographic and socio-economic characteristics, and commissioned questions were asked about household net ownership, the source of the household's newest net, if any, and the price paid for that net. The data were analysed using bivariate and multivariate methods. Socio-economic status was measured using an asset index. The estimated number of nets was adjusted using information on asset ownership from the national Demographic and Health Survey of 1999. After this adjustment for sampling bias, net coverage and the total number of nets in Nigerian households were estimated to be approximately 9% and 3 million, respectively. The single most important association with net ownership was access to a flit-gun. It appears that COS are a potentially useful source of information for assessing mosquito-net coverage at household level and monitoring changes over time. They have the advantage of being administered frequently, and they are relatively low cost. The present results were comparable with those from other studies conducted at a similar time. The main disadvantage of COS is sampling bias but, as shown here, it is often possible to adjust for this.

Nuclear spin relaxation of sodium cations in bacteriophage Pf1 solutions

The nuclear magnetic resonance (NMR) spectra for the I=3/2 23Na cation dissolved into filamentous bacteriophage Pf1 solutions display line splittings and relaxation times consistent with an interaction between the 23Na nuclear quadrupole moment and the electric field gradient produced by the negatively charged Pf1 particles. The 23Na NMR line splittings and relaxation rates corresponding to magnetization recovery and single, double, and triple quantum coherence decays are measured in Pf1 solutions and compared to theoretical values. The deviation of the observed dc spectral density J0 from the equal first harmonic J(omega0) and second harmonic J(2omega0) values as J(omega0)=J(2omega0) not equal to J0 in these solutions suggests that ion migration in the electric field gradient of the Pf1 particles produces an anisotropic relaxation mechanism. Correlation functions and thus spectral densities for this process are calculated from solutions to the Fokker-Planck equation for radial motion in an electric potential and used to estimate measured relaxation rates. Appropriate electric potentials are generated from the solutions to the Poisson-Boltzmann equation for a charged Pf1 particle in aqueous phase, functions that lead to theoretical estimates of NMR line splittings consistent with experimental observations.

Low sale of antibiotics without prescription: a cross-sectional study in Zimbabwean private pharmacies

OBJECTIVES

To assess the quality of private pharmacy practice with a focus on the extent of antibiotic sales without prescription in private pharmacies in four Zimbabwean cities in relation to two tracer infectious conditions-sexually transmitted infections (STIs) among females and males, and diarrhoea in a child.

METHODS

A cross-sectional study including pharmacies in Harare and three other towns. Information about each pharmacy was collected through structured interviews. Staff were interviewed using a different structured interview guide and simulated clients were used to assess staff performance. Data were analysed statistically, and step models to evaluate pharmacist performance were developed.

RESULTS

A majority (69%) stated that they would never sell an antibiotic without a prescription and very few actually did in spite of a high patient demand. Few respondents however performed acceptably regarding provision of information and advice in relation to guidelines: 8% for the STI male, 33% for the STI female and 22% for the diarrhoea scenario.

CONCLUSIONS

The study revealed low sales of antibiotics without prescription, showing good adherence to the letter of the law. However, few respondents performed acceptably in relation to guidelines when considering information and advice for the tracer conditions.

Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial)

OBJECTIVE

To ascertain whether a clinically important difference exists in the incidence of gynaecological infection between surgical management and expectant or medical management of miscarriage.

DESIGN

Randomised controlled trial comparing medical and expectant management with surgical management of first trimester miscarriage.

SETTING

Early pregnancy assessment units of seven hospitals in the United Kingdom.

PARTICIPANTS

Women of less than 13 weeks' gestation, with a diagnosis of early fetal demise or incomplete miscarriage.

INTERVENTIONS

Expectant management (no specific intervention); medical management (vaginal dose of misoprostol preceded, for women with early fetal demise, by oral mifepristone 24-48 hours earlier); surgical management (surgical evacuation).

MAIN OUTCOME MEASURES

Confirmed gynaecological infection at 14 days and eight weeks; need for unplanned admission or surgical intervention.

RESULTS

1200 women were recruited: 399 to expectant management, 398 to medical management, and 403 to surgical management. No differences were found in the incidence of confirmed infection within 14 days between the expectant group (3%) and the surgical group (3%) (risk difference 0.2%, 95% confidence interval - 2.2% to 2.7%) or between the medical group (2%) and the surgical group (0.7%, - 1.6% to 3.1%). Compared with the surgical group, the number of unplanned hospital admissions was significantly higher in both the expectant group (risk difference - 41%, - 47% to - 36%) and the medical group (- 10%, - 15% to - 6%). Similarly, when compared with the surgical group, the number of women who had an unplanned surgical curettage was significantly higher in the expectant group (risk difference - 39%, - 44% to - 34%) and the medical group (- 30%, - 35% to - 25%).

CONCLUSIONS

The incidence of gynaecological infection after surgical, expectant, and medical management of first trimester miscarriage is low (2-3%), and no evidence exists of a difference by the method of management. However, significantly more unplanned admissions and unplanned surgical curettage occurred after expectant management and medical management than after surgical management. TRIAL REGISTRATION NATIONAL RESEARCH REGISTER: N0467011677/N0467073587.

Superovulatory response and embryo recovery after treatment with different gonadotrophins during induced luteal phase in Camelus dromedarius

Superovulation, embryo recovery and transfer were attempted in 19 dromedary camels of about 6-10 years of age, and having calved at least once. Superovulation was done using two commercially available porcine FSH preparations, FSH-I (II donors) and FSH-2 (8 donors) during a luteal phase created by inducing ovulation with hCG. The superovulatory response was assessed by ultrasonography. The embryo recovery was attempted non-surgically in sitting position on day 8 and day 7 after first mating in one FSH-1 and one FSH-2 group, respectively. Considerable individual variation in response to the superovulatory stimulus was observed. No significant difference was observed between the two groups in terms of superovulatory response and embryo recovery (p > 0.05). In total 30 embryos were recovered from 17 donors (1.51 embryos/donor). Recipients were synchronized with donors using hCG. Eight embryos were transferred, resulting in two pregnancies and live births.

Further observations on LKB1/STK11 status and cancer risk in Peutz-Jeghers syndrome

Germline mutations in the LKB1/STK11 tumour suppressor gene cause Peutz-Jeghers syndrome (PJS), a rare dominant disorder. In addition to typical hamartomatous gastrointestinal polyps and pigmented perioral lesions, PJS is associated with an increased risk of tumours at multiple sites. Follow-up information on carriers is limited and genetic heterogeneity makes counselling and management in PJS difficult. Here we report the analysis of the LKB1/STK11 locus in a series of 33 PJS families, and estimation of cancer risks in carriers and noncarriers. Germline mutations of LKB1/STK11 were identified in 52% of cases. This observation reinforces the hypothesis of a second PJS locus. In carriers of LKB1/STK11 mutations, the risk of cancer was markedly elevated. The risk of developing any cancer in carriers by age 65 years was 47% (95% CI: 27-73%) with elevated risks of both gastrointestinal and breast cancer. PJS with germline mutations in LKB1/STK11 are at a very high relative and absolute risk of multiple gastrointestinal and nongastrointestinal cancers. To obtain precise estimates of risk associated with PJS requires further studies of genotype-phenotype especially with respect to LKB1/STK11 negative cases, as this group is likely to be heterogeneous.

Coexisting chondroblastoma and osteochondroma: a case report

The coexistence of two different types of benign cartilaginous tumours of bone in the same patient has not been reported in literature. We report a case in which a sixteen-year-old male had a benign chondroblastoma of the proximal left humerus and an osteochondroma of the distal left femur. Both originated at the same time and had a progressive increase in size with growth.

Factors limiting the rate of living-related kidney donation to children in an inner city setting

A recent review of our center experience revealed that only 38% of our pediatric renal transplants come from living-related donors (LRD), which is 11% lower than the national average. The present study was designed to identify factors that limit the availability of LRD in our population pool. Retrospective chart reviews and subsequent telephone interviews were conducted with parents of all children who received renal replacement therapy (RRT) at our institution from 1990 to 1999. The availability of parents and their willingness to donate a kidney were noted. Self-reported willingness was defined as the verbal expression of a desire to donate. Firm willingness was defined as the completion of the steps necessary for donation, unless excluded by the medical team. Factors that may impact the ability to donate, such as donor age, ethnicity, religion, educational attainment, employment, and presence of other siblings younger than 18 yr of age, were evaluated. Statistical analyses were performed using the Student's t-test and chi-square analysis. Significant results were entered into a single-step multiple regression analysis. Sixty children were identified with RRT, of whom 60% were Blacks, 30% Hispanics, 7% Caucasians, and 3% Asian. Fifty-five mothers were available for interview. Forty-four mothers reported a desire to donate, nine were unwilling to donate, and two were undecided. However, only 35 attended for screening. Only 30 fathers were available and, of these, 27 reported willingness to donate, yet only 20 attended for screening. Seventy-four per cent (26 out of 35) of mothers screened and 55% (11 out of 20) of fathers screened were medically unsuitable for kidney donation. Nineteen potential donors had hypertension, diabetes and/or obesity, seven had renal disease, four had anemia, two had hepatitis C, and five had other conditions. Expressed unwillingness to donate was associated with a greater number of children (3.1 compared to 1.5 children in addition to the child with end-stage renal disease [ESRD]) (odds ratio 2.91, p < 0.05) and employment (26.3% vs. 4.0%, p < 0.05) (odds ratio 31.2, p = 0.05). Comparing mothers who were firmly willing to donate with mothers who did not complete screening and evaluation, unwilling mothers had, likewise, a greater number of children (2.9 vs. 1.2 in addition to the child with ESRD) (odds ratio 3.23, p < 0.01) and a greater number of years of education (12.4 vs. 10.4) (odds ratio 2.14, p < 0.05). Hence, the availability of living kidney donors for our inner city children is severely limited by a high rate of single parenthood and a high rate of comorbid conditions in the parental donor pool. Furthermore, there is a diminished capacity of the available parent, particularly the mother, to donate as she tends to have numerous other dependents.