Antimalarials dispensing pattern by patent medicine dealers in rural settlements in Nigeria

The pattern of antimalarial dispensing by Patent Medicine Dealers (PMD) was studied in 17 villages of Gokana (Ogoni Land) in Rivers State of Nigeria. Of the 40 PMDs studied only eight (20%) had had formal health training and only eight could understand doctor's prescriptions. In total, 19 different types of antimalarials could be obtained from the individual ranges of antimalarials displayed by the 40 PMDs in the study. Chloroquine phosphate was the most frequently available. Twenty-three (57.5%) of PMDs administered Chloroquine at below the recommended dose of this drug. Twelve (30%) PMDs, eight with formal training and four others, administered the correct dose whilst five (12.5%) gave too much. All 40 of the PMDs studied knew how to dispense Daraprim and Fansidar correctly. We conclude that malaria control through prevention and treatment would be more effective if PMDs were to receive training on antimalarial dispensing alongside Community Health Workers.

Children's weights: guess or measure by tape?

Children's doses of drugs are prescribed according to bodyweight but in resource-poor countries weighing scales may be unavailable, inaccurate, or broken. We designed a length/weight tape for use in our community and found it reasonably accurate for weights of 4-16 kg and better than a clinician's guess.

Pentoxifylline as an ancillary treatment for severe falciparum malaria in Thailand

Pentoxifylline, an inhibitor of tumor necrosis factor, has been evaluated as an antimalarial agent in combination with artesunate in 45 patients with severe falciparum malaria. Patients were admitted to the intensive care unit at the Hospital for Tropical Diseases in Bangkok, Thailand, and randomly assigned to treatment for 72 hr with a combination of intravenously administered artesunate and 1) placebo, 2) low-dose pentoxifylline (0.83 mg/kg/hr), or 3) high-dose pentoxifylline (1.67 mg/kg/hr). All 45 patients had one or more manifestations of severe malaria such as cerebral malaria (n = 18), renal failure requiring hemodialysis (n = 9), azotemia (n = 8), jaundice (n = 25), or hyperparasitemia (n = 30). The overall severity was comparable in the three groups. Clinical outcome was assessed with respect to the parasite clearance time and the fever clearance time in all patients. In addition, a number of subsidiary outcome variables were examined in specific subgroups, including the recovery time from coma for patients with cerebral malaria, the duration of intubation in patients with respiratory distress, the number of hemodialysis treatments needed for patients with acute renal failure, and the number of units of blood administered to patients requiring transfusion. Concentrations of tumor necrosis factor were reduced in all three groups at 48 hr after treatment. No significant differences among the three treatment groups were found for any of the outcome variables examined. We conclude that the addition of pentoxifylline to artesunate therapy for severe malaria produced no evident clinical benefit.

Efficacy and safety of liposomal amphotericin B (AmBisome) for visceral leishmaniasis in endemic developing countries

Reported are the results of a study to determine the efficacy and safety of liposomal amphotericin B (AmBisome) for treating visceral leishmaniasis (kala-azar) in several developing countries where the disease is endemic (Brazil, India, and Kenya). At each study site, sequential cohorts of 10 patients each were treated with AmBisome at a dose of 2 mg.kg-1.day-1 (2 MKD). The first cohort received regimen 1:2 MKD on days 1-6 and day 10 (total dose: 14 mg/kg). If the efficacy with this regimen was satisfactory, a second cohort received regimen 2:2 MKD on days 1-4 and 10 (total dose: 10 mg/kg); and a third cohort received regimen 3:2 MKD on days 1, 5, and 10 (total dose: 6 mg/kg). In India, regimens 1, 2, and 3 (which were studied concurrently) each cured 100% of 10 patients. In Kenya, regimen 1 cured all 10 patients, regimen 2 cured 90% of 10 patients, but regimen 3 cured only 20% of 5 patients. In Brazil, regimen 1 was only partially curative: 5 of 13 patients (62%). Therefore, 15 patients were administered regimen 4 (2 MKD for 10 consecutive days; total dose, 20 mg/kg) and 13 patients were cured (83%). These results suggest that for the treatment of kala-azar the following doses of AmBisome should be administered: in India and Kenya, 2 mg/kg on days 1-4 and day 10; and in Brazil, 2 mg/kg on days 1-10.

School-based deworming program yields small improvement in growth of Zanzibari school children after one year

Efficacy trials of antihelminthic therapies conducted in Africa have reported improvements in children's growth, but nutritional evaluations of large-scale deworming programs are lacking. We evaluated the first-year effect on growth of a school-based deworming program in Zanzibar, where growth retardation occurs in school children. Children in four primary schools were given thrice-yearly mebendazole (500 mg) and compared with children in four schools that received twice-yearly mebendazole and children in four non-program schools. Evaluation schools were randomly selected and allocated to control, twice-yearly or thrice-yearly deworming. Approximately 1000 children in each program group completed the 1-y follow-up. Children <10 y old gained 0.27 kg more weight (P < 0.05) and 0.13 cm more height (P = 0.20) in the twice-yearly group, and 0. 20 kg more weight (P = 0.07) and 0.30 cm more height (P < 0.01) in the thrice-yearly group, compared with the control group. Children <10 y old with higher heights-for-age at baseline had higher weight and height gains in response to deworming. In children >/=10 y old, overall program effects on height or weight gains were not significant. But in this age range, younger boys had significant improvements in height gain with thrice-yearly deworming, and children with higher heights-for-age had greater improvements in weight gain with deworming. We conclude that the deworming program improved the growth of school children, especially children who were younger and less stunted, but the improvements were small. More effective antihelminthic regimens or additional dietary or disease control interventions may be needed to substantially improve the growth of school children in areas such as Zanzibar.

A comparative clinical trial of sequential treatments of severe malaria with artesunate suppository followed by mefloquine in Thailand

Sixty-three patients with severe falciparum malaria were randomly administered one of the two regimens of a sequential combination of artesunate suppository followed by an oral mefloquine tablet. Thirty-two patients received artesunate suppositories (200 mg/capsule) given rectally at 0, 4, 8, 12, 24, 36, 48, and 60 hr (total = 1,600 mg: Group I). Thirty-one patients received the same artesunate suppositories given rectally at 0, 12, 24, 36, 48, and 60 hr (total = 1,200 mg: Group II). Both regimens were followed by two doses of oral mefloquine, 750 mg given at 72 hr and 500 mg at 84 hr. Patient baseline characteristics were comparable in the two groups. All patients were admitted for 28 days to the Bangkok Hospital for Tropical Diseases to assess efficacy, tolerability, and delayed neuropsychiatric effects. The mean [SD] parasite clearance time was significantly shorter in Group I than Group II (47.3 [12.4] hr versus 55.3 [17.4] hr; P = 0.05) and the rate of parasite reduction was significantly faster in Group I (P = 0.05, by log-rank test). Mean [SD] fever clearance times were similar in the two Groups (71.1 [41.2] hr and 76.9 [47.9] hr, respectively). Twenty-two patients with unrousable coma on admission (median Glasgow Coma Score = 9) regained consciousness after 1-4 days. No deaths occurred. Sixty of sixty-three patients were parasitologically and clinically cured within 3-4 days of treatment. Three patients (5%) with deteriorating conditions required rescue treatment (one patient in Group I was administered intravenous artesunate, and two patients in Group II required two extra doses of suppository). No patients had major adverse drug effects. The cure rates at 28 days of follow-up in Group I were 96% (26 of 27 patients) and 89% (24 of 27 patients) in Group II. Artesunate suppository followed by mefloquine was well tolerated and effective. In severe malaria, the sequential treatment is a suitable alternative treatment to parenteral drugs. Further studies in a larger number of patients under field conditions are required.

Home medication injection among Latina women in Los Angeles: implications for health education and prevention

Reuse of needles and syringes after home injection of medications and vitamins may be a risk for transmission of HIV. An exploratory study was done to determine (1) how commonly injectable medications were used in the home; (2) whether needles and syringes were reused; and (3) common practices for cleaning needles and syringes. A survey was conducted of low income Latina women (n = 216) who were attending a Public Health Foundation nutrition programme for women, infants and children (WIC) in Los Angeles. To clarify and expand on the survey findings, focus group interviews were done with an additional 55 women attending WIC. Quantitative data were analysed using descriptive and comparative statistics. Qualitative data were subjected to content analysis. The use of injectable medications purchased in Mexico was fairly common (43.5%); reuse of disposable needles and syringes (48%) and sharing (36%) among injectors were also common. Methods of cleaning needles and syringes were inadequate to CDC recommended guidelines. Injectors and non-injectors differed significantly in ethnicity, religion, and marital status. The only significant predictor of medication injection was educational level. Analysis of qualitative data revealed the reasons that Latina subjects were injecting medication; how they were transporting medicines from Mexico; and how they were cleaning their equipment. The practical implications for health education and prevention programmes should include an awareness that home use and reuse of needles for injection of medications may be common in some social groups and that knowledge of the potential dangers in reuse and sharing of needles may not extend to home medication injection.

Impact of the change from an injectable to a fully oral regimen on patient adherence to ambulatory tuberculosis treatment in Dar es Salaam, Tanzania

OBJECTIVE

To measure the impact on patient adherence to directly observed ambulatory tuberculosis treatment substituting an all-oral treatment regimen for a regimen containing streptomycin.

METHODS

The expected and observed attendance of patients during the intensive phase of anti-tuberculosis treatment was measured daily at two out-patient clinics in Dar es Salaam. During the observation period, treatment was changed from a regimen containing streptomycin to an all-oral regimen, and attendance proportions were compared for the three periods during which patients always, sometimes or never received streptomycin during the intensive phase of treatment.

RESULTS

In Kinondoni, an average of 98 patients was expected every day, in Ilala 127. No significant difference was observed in attendance in Kinondoni between periods when patients always (median attendance 95.9%) and never (median 95.7%) received streptomycin injections as part of their intensive phase treatment for tuberculosis. In Ilala, no difference was noted in attendance between the period in which patients received streptomycin for at least part of their treatment (median 91.3%) and the period when ethambutol had fully replaced streptomycin (median 91.8%).

CONCLUSIONS

In these two districts of Dar es Salaam, patient adherence to a completely oral treatment regimen was indistinguishable from that to a streptomycin-containing regimen. Given the potential of iatrogenic transmission of HIV and the advantages in reduced staff time and drug costs, the results clearly justify the replacement of streptomycin with ethambutol in Tanzania for new patients receiving an ambulatory rifampicin-containing regimen.

Comparative study of fluconazole and clotrimazole for the treatment of vulvovaginal candidiasis

BACKGROUND

The introduction of the triazole antifungal agent fluconazole, which can be used via an oral route and single dose, has had a significant impact on patient compliance.

GOAL OF THIS STUDY

To compare the efficacy and safety of a single oral dose of 150 mg fluconazole with that of a 100-mg clotrimazole vaginal suppository twice a day in the morning and at bedtime for 3 days in the treatment of vulvovaginal candidiasis.

STUDY DESIGN

A single-blind, randomized controlled trial was conducted at Ramathibodi Hospital between June 1 and September 30, 1993.

RESULTS

There were 53 women in the group treated with fluconazole and 50 in the group treated with clotrimazole. There was no significant difference between the two groups regarding clinical characteristics (age and length of follow-up period). Mycological cure rates approximately 1 week after treatment were 79.2% in the fluconazole group and 80.0% in the clotrimazole group. Approximately 4 weeks after treatment, these rates were 60.4% and 66.0%, respectively. The side effects were minimal and did not warrant any treatment. The differences in the results were not statistically significant.

CONCLUSION

We recommend that a single oral dose of 150 mg of fluconazole be given as an alternative method of treating vulvovaginal candidiasis, but the cost is higher than for clotrimazole.

Falciparum malaria in eastern Thailand: a randomized trial of the efficacy of a single dose of mefloquine

Reported are the results of a randomized trial of a single dose of mefloquine (15 mg/kg or 25 mg/kg body weight) for the treatment of uncomplicated multidrug-resistant falciparum malaria. Of the 110 adult patients enrolled in the study 57 were randomly assigned to the 15 mg/kg group and 53 to the 25 mg/kg group. The baseline characteristics of the patients did not differ significantly in the two groups, except that those in the 15 mg/kg group had lower haemoglobin levels. Adverse effects following treatment were commoner in the 25 mg/kg group, but not significantly so. Seven patients (6%) did not complete the 42-day follow-up. The parasitological failure rates in the 15 and 25 mg/kg groups were, respectively, 50% (28/56) and 43% (25/53) on day 28, and 62% (33/53) and 56% (28/50) on day 42. Treatment failures were not correlated with the serum mefloquine concentrations on day 2, and 13 out of 19 patients with serum mefloquine concentrations > 2000 micrograms/l on day 2 showed an R response during the follow-up. The mean ratio between the concentrations of the (SR)-(-) and (RS)-(+) enantiomers of mefloquine on day 2 was 3.37, indicating that there are differences in their pharmacokinetics. Re-treatment of patients who showed an R response with seven days of quinine (30 mg.kg-1.day-1)+tetracycline (25 mg.kg-1.day-1) was successful in 93% of the cases.

Schistosomiasis prevalence after administration of praziquantel to school children in Melela village, Morogoro region, Tanzania

A study of the prevalence of schistosomiasis was carried out in 253 school children in Melela, Tanzania, one year after a single dose of praziquantel, 40 mg/kg body weight. The cure rate was 90.4%. However the new incidence estimate was 21.2% in children who were initially negative. The use of reagent strips in urine tests for the detection of urinary schistosomiasis was also evaluated. The presence of blood in the urine was highly sensitive (> 96%) and specific (87%). The sensitivity of proteinuria was less, but it was highly specific (94%). This study shows that chemotherapy will have to be combined with other measures to achieve lasting benefits and raises the question as to how often the population should be treated. It also confirms the value of urine test strips as an indirect diagnostic test for urinary schistosomiasis in an endemic area. Further follow-up is necessary to make useful predictions concerning incidence and reinfection rates in the community. This will also help in deciding how often chemotherapy should be given to the population.

Knowledge and management of malaria in Dar es Salaam, Tanzania

A study of knowledge and management of malaria was undertaken prospectively in 20 dispensaries, 20 drug stores, 120 patients attending dispensaries and 120 customers at drug stores in Dar es Salaam, Tanzania. This was a descriptive study where two different questionnaires were developed and administered to the target groups in oral interview. All the respondents were aged 14 years and above. The results of the interview showed that the knowledge of rural medical aides (RMA's) on signs and symptoms of malaria and which drugs cure malaria was satisfactory. However, only 65% of the RMA's could remember the correct dose of chloroquine for an adult. Although the knowledge of drug sellers on signs and symptoms of malaria was adequate, 45% of them did not know the correct dose of chloroquine. In view of the fact that only 30% of patients and 20% of shoppers knew the correct dose of chloroquine for adults, it appears that their management of malaria is inadequate. To improve the management of malaria at dispensary and drug store level, there is a need to introduce treatment charts and/or guidelines and the Ministry of Health should promote health education to the public.

The effect of dose of mifepristone and gestation on the efficacy of medical abortion with mifepristone and misoprostol

Although it has been demonstrated that a combination of mifepristone and a prostaglandin is an effective method of inducing abortion in early pregnancy, the optimum dose of the antigestogen is unknown. Women (n = 220) requesting abortion in early pregnancy (< or = 63 days amenorrhoea) were randomized to receive a single dose of either 600 or 200 mg mifepristone followed 48 h later by a single dose of 600 micrograms misoprostol by mouth. The percentage of women who had a complete abortion (93.6% confidence interval 90.4-95.5%) was identical in the two groups. There was no significant difference in the number of women who passed the fetus within 4 h of receiving the prostaglandin (64 versus 74%), the days of bleeding (14.6 +/- 1.1 versus 15.3 +/- 0.9) nor in the onset of the next period (39.7 +/- 1.3 versus 36.7 +/- 1.3) respectively between the groups receiving 200 or 600 mg mifepristone. However, the complete abortion rate was significantly higher in women < or = 49 days compared to women 50-63 days amenorrhoea (97.5 versus 89.1% respectively; P < 0.02). There was no difference in any of the other parameters at different weeks of gestation. We conclude: (i) that the recommended dose of mifepristone could be reduced from 600 to 200 mg without loss of clinical efficacy, (ii) that the combination of mifepristone and 600 micrograms misoprostol is a highly effective alternative to vacuum aspiration for inducing abortion in women < 50 days amenorrhoea and (iii) at gestation > 56 days, this combination may result in too many incomplete abortions to be clinically acceptable.

Vivax malaria resistant to treatment and prophylaxis with chloroquine

Chloroquine has been the treatment of choice for vivax malaria for more than 40 years. Lately, several case-reports have suggested the emergence of resistance to chloroquine in Plasmodium vivax in Papua New Guinea and Indonesia. We undertook prospective treatment and prophylaxis trials of chloroquine in children and adults with vivax malaria living in Irian Jaya (Indonesia New Guinea). 46 villagers with P vivax parasitaemia were treated with chloroquine by mouth (25 mg base/kg body weight divided over 3 days) and followed up for 14 days. Parasitaemia cleared initially but recurred within 14 days in 10 (22%) subjects. All recurrences were in children younger than 11 years, 7 of whom were younger than 4 years; the failure rate among children under 4 was 70%. 7 of the patients with recurrences were given a second course of chloroquine. In all, the infections initially cleared but recurrent parasitaemia developed in 5 (71%) within 14 days. Whole-blood chloroquine concentrations were consistently above those previously shown to cure P vivax blood infections (90 micrograms/L whole blood). Subjects whose initial infections cleared and who had no parasitaemia on day 14 received weekly prophylaxis with chloroquine. Despite the presence of expected blood chloroquine concentrations, P vivax parasitaemia developed in 9 of 17 subjects receiving prophylaxis during 8 weeks of follow-up (median time to parasitaemia 5.3 weeks). Chloroquine can no longer be relied upon for effective treatment or chemoprophylaxis of P vivax blood infections acquired in this part of New Guinea.

Ivermectin dose assessment without weighing scales

Described are two alternatives to the weighing of patients for assessing the dose of ivermectin for use in mass chemotherapy campaigns against onchocerciasis. The first method uses height to separate patients into four dosing categories (1/2, 1, 11/2 and 2 tablets), while the second involves estimating one of these dosing categories according to an individual's physical appearance, without making any measurements. Data for the height-based method were obtained from 6373 people who were taking part in a placebo-controlled trial of ivermectin in northern Nigeria. Use of an arbitrary trade-off of approximately 100 people "overdosed" for every person "underdosed" would lead to 0.5% of the population being underdosed by 1/2 tablet, 46.5% being dosed correctly, 51.7% being overdosed by 1/2 tablet, and 1.2% being overdosed by 1 tablet. The physical appearance approach involved three observers and 779 subjects. A total of 82% of the observers' estimates were "correct", with all the incorrect dosing deviating by only 1/2 tablet from the dose that the subjects should have received.

Possible interaction between oxcarbazepine and an oral contraceptive

The effect of oxcarbazepine (OCBZ) on the kinetics of an oral contraceptive containing ethinyloestradiol (EE) and levonorgestrel (LNG) was investigated in 13 healthy female volunteers who had previously received the contraceptive for at least 3 months. After 15 days of the first study cycle, each subject received, in addition to the oral contraceptive, 300 mg OCBZ on day 16, 300 mg twice daily on day 17, and 300 mg three times daily from day 18 of the first cycle to day 18 of the next menstrual cycle. The area under the curve values for both EE and LNG decreased when OCBZ was given with the oral contraceptive (p = 0.006, analysis of variance). The results indicate that OCBZ, like most antiepileptic drugs (AEDs), decreases the bioavailability of EE and LNG, perhaps by affecting metabolism or protein binding.

Response of Ethiopian human immunodeficiency virus type 1 isolates to antiviral compounds

Human immunodeficiency virus type 1 (HIV-1) isolates of 8 Ethiopian and 8 Swedish untreated AIDS-patients were examined for their sensitivity to 3'-azido-3'-deoxythymidine (AZT), 2',3'-dideoxyinosine (ddI) and leukocyte-derived interferon-alpha (IFN-alpha). No significant difference in drug sensitivity was found between Ethiopian and Swedish isolates, which all were sensitive to AZT, ddI and IFN-alpha except for one Swedish isolate. This isolate exhibited a mutation at amino acid position 215. These results suggest that it should be possible to perform clinical trials in Ethiopia using the same dose regimens as in Sweden.

Determining drug dosages by height: applying a model made for coastal children in Papua New Guinea to children from the highlands

A height scale for the determination of drug dosages in children of the Madang area was applied to children from the Nipa area of the Papua New Guinea highlands. In only 13 out of 1314 children (1.0%) did the use of the height scale result in drug doses below the recommended minimum dose per kilogram of bodyweight. The scale can therefore be used safely for highlands children in areas where facilities for accurate weighing are not available.

Cryptococcal meningitis in a young Ethiopian woman with AIDS

The case of a 20 year old Ethiopian woman with cryptococcal meningitis and acquired immunodeficiency syndrome (AIDS) is presented. Though cryptococcal infections have been reported from many countries throughout the world, this is the first case reported from Ethiopia in a patient with the acquired immunodeficiency syndrome (AIDS). The clinical manifestations, diagnosis, and treatment are discussed, with a review of recent literature.

Pulmonary tuberculosis in Kigali, Rwanda. Impact of human immunodeficiency virus infection on clinical and radiographic presentation

The aim of the present study was to compare the clinical and radiographic presentation as well as the therapeutic outcome of pulmonary tuberculosis (PT) in adult patients with and without human immunodeficiency virus type 1 (HIV-1) infection in Kigali, Rwanda. Over a 17-month period 59 consecutive patients with bacteriologically and/or histopathologically documented PT were enrolled. Of these, 48 (81%) patients were HIV seropositive. Among these, 35 fit the WHO clinical criteria for AIDS (WHOCCA) at the time of admission. Significant differences were found between the HIV-seropositive and HIV-seronegative groups of patients: fever (85 versus 36%; p less than 0.001), tuberculin skin test anergy (69 versus 0%; p less than 0.01), mediastinal and/or hilar adenopathies (31 versus 0%; p = 0.05), and pleural effusion (43 versus 9%; p less than 0.05) were more frequently encountered in the HIV-seropositive group, and upper lobe infiltrates (55 versus 16%; p less than 0.02) and cavitation (91 versus 39%; p less than 0.003) were more often seen in the HIV-seronegative group. However, HIV-seropositive patients not meeting WHOCCA were less frequently anergic (0 versus 100%; p less than 0.001) and feverish (53 versus 97%; p less than 0.01) and more often had cavitation (69 versus 28%; p less than 0.02) and less often mediastinal and/or hilar adenopathies (7 versus 40%; p less than 0.04) compared with HIV-seropositive patients meeting WHOCCA. Under antituberculosis treatment, clearance of fever was slower in HIV-seropositive compared with HIV-seronegative patients, and among the HIV-seropositive group it was slower in those fitting WHOCCA.(ABSTRACT TRUNCATED AT 250 WORDS)

Tuberculous meningitis in patients infected with the human immunodeficiency virus

BACKGROUND AND METHODS

Tuberculosis is a frequent complication of human immunodeficiency virus (HIV) infection. We describe the clinical manifestations and outcomes of tuberculous meningitis in patients with HIV infection, and compare them with those in non-HIV-infected patients. We reviewed the records from 1985 through 1990 at two large referral hospitals in Madrid for patients who had Mycobacterium tuberculosis isolated from cerebrospinal fluid.

RESULTS

Of 2205 patients with tuberculosis, 455 (21 percent) also had HIV infection, of whom 45 had M. tuberculosis isolated from the cerebrospinal fluid. Of the 37 HIV-infected patients with tuberculous meningitis for whom records were available, 24 (65 percent) had clinical or radiologic evidence of extrameningeal tuberculosis at the time of admission. In 18 of 26 patients (69 percent), a CT scan of the head was abnormal. In most patients, analysis of cerebrospinal fluid showed pleocytosis (median white-cell count, 0.234 x 10(9) per liter) and hypoglycorrhachia (median glucose level, 1.3 mmol per liter), but in 43 percent (15 of 35), the level of protein in cerebrospinal fluid was normal. In four patients with HIV infection, tuberculosis was only discovered after their deaths. Of the 33 patients who received antituberculous treatment, 7 died (in-hospital mortality, 21 percent). Illness lasting more than 14 days before admission and a CD4+ cell count of less than 0.2 x 10(9) per liter (200 per cubic millimeter) were associated with a poor prognosis. Comparison with tuberculous meningitis in patients without HIV infection showed that the presentation, clinical manifestations, cerebrospinal fluid findings, and mortality were generally similar in the two groups. However, of the 1750 patients without HIV infection, only 2 percent (38 patients) had tuberculous meningitis, as compared with 10 percent of the HIV-infected patients (P less than 0.001).

CONCLUSIONS

HIV-infected patients with tuberculosis are at increased risk for meningitis, but infection with HIV does not appear to change the clinical manifestations or the outcome of tuberculous meningitis.

Comparison of artemether and chloroquine for severe malaria in Gambian children

Artemether is an oil-soluble methyl ether of artemesinin (qinghaosu). It has been studied extensively in China, where it has been shown to be rapidly effective in severe falciparum malaria. Nearly all the patients studied previously were adults. We have investigated the efficacy of artemether in children with moderate or severe falciparum malaria. In the preliminary study of moderately severe malaria, 30 Gambian children were randomised in pairs to receive either intramuscular artemether (4 mg/kg loading dose followed by 2 mg/kg daily) or intramuscular chloroquine ('Nivaquine') 3.5 mg base/kg every 6 h. Both drugs were well tolerated and rapidly effective. The times to parasite clearance were significantly shorter in the artemether recipients (mean 36.7 [SD 11.3] vs 48.4 [16.8] h, p less than 0.05). 43 children with severe malaria were then randomised to receive intramuscular treatment with the same regimens of artemether (n = 21) or chloroquine (n = 22) as used in the preliminary study. 8 children (19%) died. There were no significant differences between the two groups in the clinical, haematological, biochemical, or parasitological measures of therapeutic response in survivors and there was no evidence of local or systemic toxicity. Despite similar parasite counts on admission, clearance times overall were longer in severe malaria than in moderate malaria. Artemether is a well tolerated and rapidly effective parenteral treatment for severe malaria in children, and would be especially valuable in areas with chloroquine-resistant P falciparum.

Hirsutism: metabolic effects of two commonly used oral contraceptives and spironolactone

Fifty-one hirsute women were randomly treated for nine months with ethinyl estradiol 35 ug plus norethindrone 0.4 mg or 30 ug ethinyl estradiol plus 1.5 mg norethindrone acetate if they needed contraception or spironolactone 200 mg daily if they did not. Metabolic evaluations in response to therapy demonstrated triglyceride elevations with the two oral contraceptives but not with spironolactone. While systolic blood pressure was lower with spironolactone, fasting insulin levels were higher as opposed to either low-dose oral contraceptive preparation. Ethinyl estradiol 30 ug plus 1.5 mg norethindrone acetate lowered 3-alpha-diol glucuronide levels, yet ethinyl estradiol 35 ug plus norethindrone 0.4 mg and spironolactone were more effective in lowering Ferriman-Gallwey Scores. Treatment strategies for hirsute women need to consider metabolic consequences as well as efficacy.

Anticonvulsants in pregnancy

OBJECTIVE

To review the potential problems and their management associated with the use of anticonvulsant drugs during pregnancy.

DATA SOURCES

Studies published between 1968 and 1990 assessing the effect of pregnancy on the pharmacokinetics of anticonvulsant drugs, the teratogenicity of anticonvulsants, breast feeding and anticonvulsants and use of the oral contraceptive pill in patients taking anticonvulsant medication, were reviewed.

RESULTS OF DATA SYNTHESIS

In general, plasma levels fall during pregnancy and rise during the puerperium. A number of factors including possible reduced absorption, increased volume of distribution, reduced protein binding, increased clearance and noncompliance, contribute to this fall in plasma concentration. All anticonvulsants are potentially teratogenic. The incidence of fetal malformations is higher in patients treated with multiple anticonvulsant drugs and on higher dosages with higher plasma levels. Anticonvulsants are excreted in low concentrations in breast milk. All anticonvulsants except valproic acid have been associated with failure of the oral contraceptive pill. This is due to liver enzyme induction of these drugs.

CONCLUSION

As plasma levels of anticonvulsants fall during pregnancy, concentrations should be monitored regularly. Due to the fall in protein binding, marginally low total plasma levels of highly protein bound drugs may not reflect reduced unbound levels, and hence an increase in dosage may not be required. In order to reduce teratogenicity, one should aim to use a single anticonvulsant drug and the lowest dosage able to achieve seizure control. In general, breast feeding is not contraindicated.

Drug use and the role of patients and prescribers

In order to move towards rational drug use in any national or local setting the methods of inquiry have to be expanded. Both the public and private sector have to be addressed. In the latter the pharmacists might be studied using a tracer, fictitious client. One important factor influencing prescribing, drug information, has rarely been assessed scientifically. Experimental studies using group randomization are, however feasible even in developing countries. The individual human being must be in the focus of drug studies and health care and health in the foreground. The combination of qualitative and quantitative methods will assist us to achieve rational drug use that is culturally acceptable, economically feasible and pharmacologically sound.

Control of Schistosoma mansoni in the Blue Nile Valley of western Ethiopia by mass chemotherapy and focal snail control: a primary health care experience

A simplified combination of human mass treatment with oxamniquine and focal snail control has been applied in a local Schistosoma mansoni control programme in a primary health care setting in the Dalati and Agallu Metti areas of the Ethiopian Blue Nile Valley. Teams of local health personnel and farmers did the daily work under intermittent supervision. Monthly snail surveys near the major villages disclosed a seasonal pattern with many infected snails during the dry season in upper stagnant sections of tributary rivers (1000-1200 m altitude) with favourable temperatures, and few snails in the rainy season. The highest prevalences and intensities of human infection were found in the 15-19 year age group living in the lower altitudes around 700 m. 5067 individuals (50-80% of the local population) were treated with 20-40 mg oxamniquine per kg body weight during the rainy seasons of 1985 (Dalati) and 1986 (Agallu Metti). In the Dalati area cross sectional surveys in 1985 and 1986, before and after the mass treatment, showed a reduction in prevalence from 42.4% to 11.4%, while in the Agallu Metti area a stratified random sample showed a prevalence reduction from 65.4% in 1986 to 7.8% in 1987 and a reduction in the prevalence of moderate to heavy infection (greater than 100 eggs per gram of stool) from 36.9% to 1.4%. Beginning in 1986 niclosamide was applied focally wherever infected snails were found and the monthly snail surveillance continued until 1989. As a result of this combined approach overall snail infection rates were reduced from 11.2% (Dalati) and 32% (Agallu Metti) to zero and 2% respectively. In 1989 the human prevalence was still only 8.6% in Agallu Metti. This programme has shown that it is feasible to control S. mansoni in these very remote localities through the primary health care system.

Sustained protection against mortality and morbidity from malaria in rural Gambian children by chemoprophylaxis given by village health workers

Mortality and morbidity from malaria were measured in children for a one-year period in a rural area of The Gambia 3-4 years after the introduction of a primary health care programme into some villages in the study area. Among children resident in primary health care villages who received treatment for febrile illnesses from a village health worker resident in their village there was no reduction in overall mortality or in morbidity from malaria compared with levels found in villages without a primary health care worker. However, among children aged 3-59 months who received malaria chemoprophylaxis from a village health worker in addition to treatment there was a 49% reduction in mortality and a 73% reduction in attacks of clinical malaria. The level of protection against malaria achieved by chemoprophylaxis given by village health workers 3-4 years after the chemoprophylaxis programme was started was as high as that obtained shortly after the introduction of the primary health care programme.

Effect of menstrual cycle phase and oral contraceptive use on serum lithium levels after a loading dose of lithium in normal women

Serum lithium levels were analyzed in six healthy, normal women during the midfollicular, midluteal, and premenstrual phases of their menstrual cycles after they had received 300 mg of lithium carbonate orally. An identical protocol was followed for seven women with artificial cycles induced by oral contraceptive steroids. Analysis of variance for repeated measures over time showed no significant differences between groups or between cycle phases. Therefore, hormonal effects of ovarian or contraceptive steroids per se do not appear to alter serum lithium concentrations. Other factors may account for changing lithium requirements during the menstrual cycle in some patients with affective illness.

Use of spironolactone in treatment of hirsutism

Spironolactone (Aldactone), 100 mg to 200 mg daily, has antiandrogenic effects that may enhance treatment of androgen-excess syndromes, particularly severe hirsutism. Combination therapy with an oral contraceptive or with dexamethasone appears to have a beneficial effect. Side effects are transient. The drug should be avoided during pregnancy and in women who have a family history of breast cancer, although there is no proven association between spironolactone and breast malignancy.

Oral ciprofloxacin versus ceftriaxone for the treatment of urethritis from resistant Neisseria gonorrhoeae in Zambia

Neisseria gonorrhoeae strains resistant to treatment with penicillin, tetracycline, and/or spectinomycin are increasing in prevalence in many parts of the world. In Zambia, 52% of N. gonorrhoeae isolates produced beta-lactamase in 1986. Few oral regimens have proven effective for treatment of resistant N. gonorrhoeae. We conducted a prospective, double-blind, randomized clinical trial of 250 mg of ciprofloxacin given orally versus 250 mg of ceftriaxone given intramuscularly for treatment of uncomplicated gonococcal urethritis in adult males. Two hundred men were enrolled and treated. The two groups were comparable in age (27.5 years), prevalence of latent syphilis (14 and 10%), and human immunodeficiency virus infection (32 and 38%). Of 165 patients with cultures positive for N. gonorrhoeae who returned for follow-up, ciprofloxacin cured 83 of 83 (100%), including 26 with penicillinase-producing N. gonorrhoeae (PPNG) and 21 with N. gonorrhoeae with chromosomally mediated resistance to multiple antibiotics (CMRNG), and ceftriaxone cured 81 of 82 (98.7%), including 30 with PPNG and 19 with CMRNG. Both treatment regimens were well tolerated. Chlamydia trachomatis in urethral exudate was found by direct fluorescent-antibody microscopic examination or by culture in 10 (5%) participants. All N. gonorrhoeae isolates were inhibited by ceftriaxone at 0.06 micrograms/ml, except one which was inhibited at 0.125 micrograms/ml, while ciprofloxacin inhibited all isolates at 0.03 micrograms/ml. Ciprofloxacin is a safe and effective therapy for uncomplicated gonococcal urethritis, including that caused by PPNG and CMRNG in human immunodeficiency virus-infected men.

Pyrimethamine: an approach to the development of a male contraceptive

With the human population of the world currently more than 5.2 billion and growing at an explosive rate, the need for additional forms of readily available contraception appears paramount. To date, contraception techniques in the male have been very limited. The present study demonstrates the ability of pyrimethamine (PYR) to cause spermatogenic arrest and male infertility in mice in a dose-dependent manner. Furthermore, upon cessation of drug administration all animals returned to normal fertility status. It is also suggested that the action of PYR is due to its antifolate action. Thus, PYR represents another approach toward development of a male contraceptive.

Sex-difference and the effects of smoking and oral contraceptive steroids on the kinetics of diflunisal

The single dose pharmacokinetics of diflunisal were studied in 4 groups of 6 young volunteers: control men, control women, women taking low estrogen oral contraceptive steroids (OCS), and women smokers (10-20 cigarettes day). The plasma clearance of diflunisal was significantly higher in men (0.169 ml.min-1.kg-1) and in women on OCS (0.165 ml.min-1.kg-1) as compared to control women (0.108 ml.min-1.kg-1). Partial metabolic clearances of diflunisal by the three conjugative pathways (phenolic and acyl glucuronide formation, sulphate conjugation) were all increased in men and women OCS users as compared to control women. Statistically significant increases, however, were only observed for the partial metabolic clearance of diflunisal by phenolic glucuronidation between men and women (2.91 vs. 1.85 ml.min-1 respectively), and for the partial clearance by acyl glucuronidation between OCS users and control women (4.81 vs. 3.01 ml.min-1 respectively). Smoking resulted in a moderate increase (35%) in plasma diflunisal clearance. However, a significant reduction in total urinary recovery of diflunisal and its glucuronide and sulphate conjugates was found in smokers (70.5% in smokers as compared to 84.2-87.2% in the 3 other study groups). Consequently, smoking may have induced hydroxylation, a minor oxidative metabolic pathway of diflunisal recently discovered in man.

Breastfeeding and medical disease

Breastfeeding is an important opportunity for both mother and infant. There are nutritional, immunologic, infection protection, and psychological reasons to preserve lactation when illness intervenes. The internist will have patients with acute self-limited disease who are breastfeeding and patients with chronic long-term illness who wish to breastfeed their infants. The internist will need to consider the breastfeeding and the infant when planning treatment. The risk of treatment to the infant versus the great benefits of breastfeeding in most cases will support continuing breastfeeding. This article discusses the key considerations in managing the lactating woman with an illness.

Transdermal delivery of steroids

The advantages of delivering drugs through the skin for systemic therapy have been widely recognized and represent a growing sector in drug development. Transdermal delivery of steroids is also a rapidly expanding field and in various clinical situations where hormonal replacement therapy is needed this route of administration is a real breakthrough, considering the relative toxicity of some steroids when given orally. Various transdermal systems have been designed, all of them aimed at achieving a constant release rate of the molecules contained in their reservoir through the intact skin. The skin itself, and especially the outermost layer, the stratum corneum, can play the roles of a reservoir and a rate-controlling membrane. So far, estradiol, progesterone and testosterone have been demonstrated to be good candidates for transdermal delivery. The effectiveness and the acceptability of transdermal delivery of estradiol in postmenopausal women have been demonstrated. The efficacy of topical administration of progesterone in patients with benign breast disease has also been proved. More recently, the high rate of acceptability and efficacy of transdermal testosterone in male hypogonadism has been demonstrated. The transdermal delivery of steroids is therefore expected to make a significant impact on the quality of patient care both in men and in women.

Effect of continuous intravenous infusion of zidovudine (AZT) in children with symptomatic HIV infection

To produce concentrations of zidovudine (AZT) in plasma and cerebrospinal fluid that would provide constant inhibition of the replication of human immunodeficiency virus (HIV), we gave AZT by continuous intravenous infusion to 21 children ranging in age from 14 months to 12 years who had acquired HIV infection through transfusions or perinatally. All patients were symptomatic before AZT treatment (Class P2 of the Centers for Disease Control); 13 (62 percent) had evidence of neurodevelopmental abnormalities. The mean CD4/CD8 ratio was 0.18; 11 patients had CD4 counts below 0.2 x 10(9) per liter. We administered AZT at four dose levels: 0.5, 0.9, 1.4, and 1.8 mg per kilogram of body weight per hour. The plasma drug concentrations achieved at the respective dose levels were 1.9 +/- 0.3, 2.8 +/- 1.4, 3.1 +/- 1.1, and 4.5 +/- 1.0 microM. The steady-state cerebrospinal fluid:plasma ratio was 0.24 +/- 0.07. The only evidence of toxicity was bone marrow suppression. Transfusion was required in 14 patients because of low levels of hemoglobin (5 mmol per liter [less than 8 g per deciliter]). Dose-limiting neutropenia (less than 0.5 x 10(9) polymorphonuclear leukocytes per cubic millimeter) occurred in most patients who received doses of 1.4 mg per kilogram per hour or more. Improvement in neurodevelopmental abnormalities occurred in all 13 children who had presented with encephalopathy before treatment. Serial measurements of IQ before therapy and after three and six months of continuous therapy with AZT showed that IQ scores, including those for verbal and performance IQ, rose in these 13 patients and in 5 other children who had no detectable evidence of encephalopathy before treatment. Most patients also had increased appetite and weight, decreased lymphadenopathy and hepatosplenomegaly, decreased immunoglobulin levels, and increased numbers of CD4 cells. In some patients the improvement in the features of encephalopathy occurred despite the absence of immunologic improvement. We conclude that AZT is beneficial in children with symptomatic HIV infection, especially those with encephalopathy (which may be subclinical), and that the optimal continuous intravenous dose of AZT in children is between 0.9 and 1.4 mg per kilogram per hour.

The effect of RU486 administered during the proliferative and secretory phase of the cycle on the bleeding pattern, hormonal parameters and the endometrium

Seventeen healthy women aged 24-45 years with regular menstrual periods, proven fertility and not using steroidal contraceptives or IUD were recruited for the study. The volunteers were followed during one control, one treatment and one follow-up cycle. Daily morning urine samples were obtained during the control and the treatment cycle. The samples were analysed with regard to pregnanediol glucuronide (P2-G), oestrone glucuronide (E1-G), oestradiol (E2), progesterone (P4), LH and creatinine. During the entire 3-month study the subjects kept a record of uterine bleeding and side effects. The subjects received 50 mg RU486 daily either on cycle days 7-10 (n = 7) or on cycle days 20-23 (n = 10). An endometrial biopsy was taken on cycle day 10 in the first group and on cycle days 21-28 in the second group of patients. Treatment during the proliferative phase caused significant prolongation of the cycle length due to a delay of the oestrogen and LH surge. However, once the oestrogen concentration started to increase, the remaining part of the cycle was normal. The length of the follow-up cycle was similar to that of the control cycle. The morphology of the endometrium did not differ from control samples taken from untreated women at the same time of the cycle. All ovulating women (n = 9) treated in the mid-luteal phase started to bleed on the 3rd to 4th day of the treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Trial of ibuprofen to prevent post-vasectomy complications

Sperm granuloma and epididymitis remain 2 of the most common and incapacitating complications of vasectomy. A study was designed to evaluate the possibility of reducing these inflammatory complications with a prophylactic course of a nonsteroidal anti-inflammatory drug. Patients undergoing outpatient vasectomy were randomized into 2 groups. Group 1 received a prophylactic course of ibuprofen and group 2 received no medication. The ibuprofen was tolerated well and no adverse reactions were noted. There was no increase in postoperative bleeding or hematoma formation. There was no clinical benefit or decrease in complication rate in the ibuprofen-treated group.

Early pregnancy termination: a comparison between vacuum aspiration and medical abortion using prostaglandin (16,16 dimethyl-trans-delta 2-PGE1 methyl ester) or the antiprogestogen RU 486

Three different regimens for termination of early pregnancy by medical means were compared to vacuum aspiration. Women seeking therapeutic abortion of pregnancy (less than or equal to 56 days amenorrhoea) were allocated to one of four treatment groups: (1) vacuum aspiration (n = 28); (2) 1 mg vaginal pessary of a prostaglandin analogue (gemeprost) every 3 h for up to 5 pessaries (n = 30); (3) the antigestogen (RU 486--mefipristone) 150 mg per day for 4 days by mouth (n = 20); (4) RU 486 in the same dose as group 3 together with 1 mg gemeprost on day 3 (n = 19). Complete abortion occurred more often in women treated with vacuum aspiration (96%), gemeprost alone (97%) and RU 486 plus gemeprost (95%) than in those treated with RU 486 alone (60%). In women receiving up to five gemeprost pessaries alone vomiting occurred in 7 (23%) and diarrhoea in 10 (33%); 16 (53%) required parenteral opiates for relief of pain. Side-effects and analgesic requirements were much reduced in the women who received RU 486 alone or in combination with a single gemeprost pessary. There was no difference in the number of days of vaginal bleeding after abortion between the four groups although there was wide individual variation (mean 10 days, range 1-34). These results confirm that medical induction of abortion in early pregnancy with prostaglandin vaginal pessaries is as effective as vacuum aspiration and that the dose can be reduced five-fold without loss of efficacy when used in combination with RU 486.

The effect of the antiprogestin RU 486 on uterine contractility and sensitivity to prostaglandin and oxytocin

The effect of RU 486, a steroid acting as an antiprogestin at the receptor level, on uterine contractility and sensitivity to the prostaglandin analogue, 16-phenoxy-PGE2 methyl sulfonylamide (16-phenoxy-PGE2) and to oxytocin was studied in 29 women in early pregnancy. Seven untreated women at the same stage of pregnancy served as controls. In the untreated women no spontaneous uterine contractility was recorded and the response to 0.25 mg 16-phenoxy-PGE2 was characterized by an increase in uterine tonus with superimposed irregular contractions of low amplitude. Treatment with 25 mg RU 486 twice daily resulted in the appearance of regular uterine contractions at 24 h in two out of five patients and in all patients at 36, 48 and 72 h after the start of RU 486 treatment. The withdrawal of progesterone influence changed the inactive early pregnant uterus into an active organ. Administration of 16-phenoxy-PGE2 caused an obvious stimulation of both frequency and amplitude of the contractions. In addition, the significantly increased sensitivity to the prostaglandin analogue, but not to oxytocin, was already apparent 24 h after the start of RU 486 treatment. We have previously shown that the addition of one intramuscular injection of 16-phenoxy-PGE2 on the fourth day of treatment with RU 486 (25 mg twice daily) significantly increased the abortifacient effect of the antiprogestin during early pregnancy. The present study suggests that a shorter treatment may be possible.

Induction of therapeutic abortion in early pregnancy with mifepristone in combination with prostaglandin pessary

Therapeutic abortion was induced in 100 women in early pregnancy (less than 56 days' amenorrhoea) with a combination of the antigestagen mifepristone (RU 486) and a synthetic prostaglandin analogue, gemeprost. Mifepristone in oral doses of 400-600 mg was followed 48 h later by a gemeprost vaginal pessary (0.5-1.0 mg). Bleeding was induced in all women 22-70 h after the mifepristone dose and although bleeding continued for 4-43 days (median 12) the total measured blood-loss was only a median of 72.5 ml (range 15-398). Complete abortion occurred in 95 women. Surgical evacuation of the uterus for minimum debris was required in the remaining 5. Only 10 women had diarrhoea or pain that required opioid analgesia. The combination of mifepristone and gemeprost provides a safe and effective alternative to surgical evacuation of the uterus for therapeutic abortion in early pregnancy.