COMPARISON OF INTRAMUSCULAR ARTEMETHER AND INTRAVENOUS QUININE IN THE TREATMENT OF SUDANESE CHILDREN WITH SEVERE FALCIPARUM MALARIA

I. Adam, H.M Idris, A.A. Mohamed-Ali, New Halfa Hospital, New Halfa, Sudan, I.A. A/elbasit, MSc, PhD Student and M.I Elbashir MD, PhD, Associate

Professor, Department of Biochemistry, MD, PhD, Associate Professor, Faculty of Medicine, University of Khartoum, P.O. Box 102, 11111, Khartoum, Sudan

Request for reprints to:  Dr. M.I. Elbashir, Department of Biochemistry, Faculty of Medicine, University of Khartoum, P.O. Box 102, 11111 Khartoum, Sudan

ABSTRACT

Objectives: To compare the efficacy of intramuscular artemether and intravenous quinine in the treatment of severe falciparum malaria.

Design: An open randomized controlled clinical trial.

Setting: New Halfa Teaching Hospital, Eastern Sudan, in the period November 2001-January 2002.

Subjects: Forty one male and female children; 21 on artemether and 20 on quinine.

Main outcome measures: Fever clearance time, parasite clearance time, coma resolution time and side effects of the two drugs.

Results:  The two groups (artemether and quinine) were well matched in the admission variable. The mean ± (SD) fever clearance time was 30.5 ± (20.9) hours in the artemether group, while it was 18.0± (8.1) hours in the quinine group; the difference was highly significant (P=0.02). The mean parasite clearance time was shorter in the artemether group than in the quinine group, but it was not statistically significant, (16.0 vs. 22.4 hours; p>0.05). In comatose patients (three in the artemether group, three in the quinine group) the time of recovery from coma was significantly shorter in artemether group than in quinine group (12.5 vs. 20.16 hours; P<0.05). Recrudescence of P. falciparum (confirmed by polymerase chain reaction) occurred in one out of fifteen patients (6.6%) in the quinine group seen on day 28, which was successfully treated by sulphadoxinepyrimethamine. In the quinine group, one patient died and one patient developed hypoglycaemia.

Conclusion: Artemether caused faster parasite clearance than quinine, but quinine lowered the temperature in shorter time than artemether. The results obtained show that artemether can be used as safe and effective alternative drug for the treatment of severe falciparum malaria in the wake of the growing resistance to quinine in Sudan.

 

 

 

FACTORS INFLUENCING ACCEPTABILITY OF VOLUNTARY COUNSELLING AND TESTING FOR HIV IN BUSHENYI DISTRICT OF UGANDA

F. Nuwaha, MD, PhD, Directorate of Health Services, Bushenyi District, P.O. Box 1, Bushenyi-Uganda

D. Kabatesi, MD, MPH, Sexually Transmitted Diseases Clinic, Mulago Hospital, P.O. Box 7051, Kampala, Uganda

M. Muganwa, MD, MPH, Senior Lecturer, Institute of Public Health, Makerere University,

P.O. Box 7052, Kampala, Uganda

C.C. Whalen, MD, MS, Associate Professor, Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio, USA

Request for reprints to:  Dr. F. Nuwaha, P.O. Box 6924, Kampala, Uganda 

ABSTRACT

Objective:  To understand the factors influencing choice of voluntary counselling and testing (VCT) for HIV with a view of suggesting measures for increased uptake.

Design:  Focus group discussions were used to elicit reasons for carrying out VCT and a cross sectional survey to estimate the proportion of people who undertake VCT.

Setting: Bushenyi district, Uganda.

Participants: A cluster random sample of 219 people and four purposively selected focus group discussions with 32 participants.

Main outcome measures:  Elicited attitudinal beliefs, self-efficacy expectations, and social influences that are probably associated with VCT for HIV based on the Attitude Social influence self-Efficacy (ASE) Model. The proportion of people who had ever undertaken VCT for HIV was also determined.

Results: Thirty-eight(17%) of the 219 people interviewed had ever undergone HIV. The factors influencing VCT for HIV were consequences of a test result, influences from a sexual partner, cost of VCT, physical accessibility of VCT, awareness, risk of HIV infection, need for linking VCT with care (especially availability of anti-retrovirals) and perceived quality of care of VCT services.

Conclusions: Increased mobilisation and access for VCT, reducing costs of VCT, linking of VCT with care, and emphasising the positive consequences of VCT as well as providing high quality VCT services may increase the number of people seeking VCT.

 

 

 

NON-TYPHI SALMONELLA IN CHILDREN WITH SEVERE MALARIA

J.O. Oundo, MSc, Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya, Department of Biochemistry, Kenyatta University, P.O. Box 43844, Nairobi, Kenya

F. Muli, PhD, Department of Biochemistry, Kenyatta University, P.O. Box 43844, Nairobi, Kenya

S. Kariuki, PhD

P.G. Waiyaki, PhD, Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya

Y. Iijima, PhD, Kobe Institute of Health, 4-6, Minatojima-Nakamachi, Chuo-ku, Kobe 650-0046, Japan

J. Berkley, Centre for Geographic Medicine Research Coast/Wellcome Research Laboratories, Kilifi, Kenya and Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK

G.O. Kokwaro, PhD, Wellcome Trust Research Laboratories, Nairobi, Kenya

C.J. Ngetsa, OND

S. Mwarumba, HND, Centre for Geographic Medicine Research Coast/Wellcome Research

Laboratories, Kilifi, Kenya

R. Torto, PhD, Department of Biochemisry, Kenyatta University, P.O. Box 43844, Nairobi, Kenya

B. Lowe, MPhil, Centre for Geographic Medicine Research Coast/Wellcome Research Laboratories, Kilifi, Kenya, Nufffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK.

Request for reprints to:  Mr. J.O. Oundo, Centre for Microbiology Research, Kenya Medical Research Institute, P.O. Box 19464, Nairobi, 00202, Kenya

ABSTRACT

Objective:  To determine the association between Plasmodium falciparum malaria andnon-typhi Salmonella in children.

Design: Cross-sectional hospital based study.

Setting: Kilifi District Hospital (KDH) between January 1997 and June 2001.

Subjects: Children aged between three months to 123 months (mean age 28.28 months) and who had been admitted to the paediatric or High Dependency Research Ward (HDRW) of the KDH.

Methods: A total of 19, 118 blood cultures routinely obtained for all admissions and 1,820 clinically indicated stools samples were obtained from 9,147 children admitted with malaria. The specimens were cultured and antibiotic sensitivity done using standard laboratory procedures with stringent internal and external quality control in place.

Results: The total bacterial pathogens isolated from blood and stool were 1,395/19,118 (7.3%) and 342/1,820 (19%) respectively. Non-typhi salmonella consisted of 260/1,395 (18.6%) of the positive blood cultures and 92/324 (28.4%) of the stool cultures out of which a total of 101 NTS occurred in children with severe malaria. Out of the 9,147 malaria cases admitted, 101/9,147 (1.10%) had concomitant NTS infection. NTS with severe malaria as a proportion of all malaria admissions for the period varied between 0.8% and 1.5%. There was a significant association (p-value=0.032) between clinical outcome of death and female sex of the patient. The NTS isolates which occurred with severe malaria showed various levels of antibiotic resistance. They were resistant to ampicillin (35%), chloramphenicol (18%), gentamicin (22%), cefuroxime (29%), sulphamethoxazole-trimethoprim (39%), ciprofloxacin (3%), cefotaxime (14%), amoxycillin-clavulanic acid (26%) and tobramycin (18.0%). Multidrug resistance (MDR) was seen in 34 (33.6%) of the isolates.

Conclusions: NTS and severe malaria occurring together are a problem in this area and that a large number of the isolates are MDR. An elaborate case-controlled study is required to elucidate the chain of events of both NTS and malaria parasite co-existence.

 

 

 

AEROBIC PATHOGENIC BACTERIA IN POST-OPERATIVE WOUNDS AT MOI TEACHING AND REFERRAL HOSPITAL

J. Andhoga, A.G. Macharia, I.R. Maikuma, Z.S. Wanyonyi, Medical students, Moi University, Faculty of Health Sciences

B.R. Ayumba, MBChB, MMed, Lecturer, Department of Surgery

R. Kakai, BEd(Sc), MSc, PhD, Lecturer, Department of Medical Microbiology and Parasitology, Moi University, Faculty of Health Sciences, Moi University, P.O. Box 4606, Eldoret, Kenya

Request for reprints to:  Dr. R. Kakai, Department of Medical Microbiology and Parasitology, Faculty of Health Sciences, Moi University, P.O Box 4606, Eldoret,

Kenya

ABSTRACT

Background: The emergence of bacterial antimicrobial resistance associated with acquired infections has made the choice of empirical therapy more difficult and expensive, hence the need for continuous research to determine their sensitivity patterns.

Objectives: To identify the common aerobic pathogenic bacteria in post-operative wounds at Moi Teaching and Referral Hospital (MTRH) and determine their sensitivity patterns to routine antibiotics used.

Design: Cross-sectional study.

Setting: Moi Teaching and Referral Hospital (MTRH) Surgical, Obstetrics and Gynaecology wards.

Patients: Sixty three patients chosen by convenient sampling between May and June 2001 were included in the study. A total of eighty four isolates were obtained from these patients.

Materials and Methods: Isolation of pathogens and their antibiotic sensitivity determination was conducted in the Department of Medical Microbiology Laboratory, Faculty of Health Sciences, Moi University. The bacteria were cultured on blood agar, MacConkey and Nutrient agar followed by identification using biochemical tests (catalase urease, coagulase, triple sugar iron). Disc diffusion method on Muller-Hinton agar was used for sensitivity testing.

Results:  Staphylococcus aureus species were the most common pathogenic bacteria isolated from the post-operative wounds. Other organisms included Proteus, Pseudomonas and Escherichia coli. There was a multi-drug resistance pattern observed, with minocyline being the most effective drug against S. aureus.

Conclusion: There is need for review of policies on prescription practice on the use of existing therapeutics choice to limit the spread of resistance. This will ensure reduced patient stay and cost incurred.

 

 

 

PATTERN OF USE OF SKIN CARE PRODUCTS IN CHILDREN WITH AND WITHOUT ECZEMATOUS SKIN LESIONS

D.C. Wamalwa, MBChB, MMed, Lecturer

E.M. Wafula, MBChB, MMed, Associate Professor, Department of Paediatrics and Child Health

T.M. Munyao, MBChB, MMed, Senior Lecturer, Department of Medicine

F. V. Murila, MBChB, MMed, Lecturer. Department of Paediatrics and Child Health, College of

Health Sciences, University of Nairobi, P.O. Box 19676, Nairobi, Kenya

Request for reprints to:  Dr. D.C. Wamalwa, Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, P.O Box 19676,

Nairobi, Kenya

ABSTRACT

Objective: To compare the pattern of use of skin care products between children with eczematous skin lesions and those without.

Design: Case control study.

Setting: Two well baby clinics at the Kenyatta National Hospital and the Mbagathi District Hospital in Nairobi.

Subjects: Eighty nine infants with eczematous skin lesions and 89 age and sex matched controls without skin lesions.

Main outcome measures: Presence and severity of skin lesions related to the type of skin care products used by the child.

Results: Exposure to various products was not significantly different between infants with skin lesions and those without. However, more mothers whose children had a skin rash had made a change in the type of soap and or skin cream used for their child (p<0.0001). The principal reason for changing products was skin rash in the baby and most mothers made changes away from scented baby soap products.

Conclusion: The study found no significant difference between the cases and controls regarding the type of skin care products used.

 

 

 

INFLUENCE OF AGE AND PROGNOSIS OF BREAST CANCER IN NIGERIA

O.F.R Ikpat, MD, PhD, Lecturer, Department of Pathology

R. Ndoma-Egba, FRCS, Lecturer, Department of Surgery, University of Calabar Teaching Hospital, Nigeria,

Y. Collan, FRCPath, Professor, Department of Pathology, University of Turku, Finland

Request for reprints to:  Dr. O.F.R. Ikpatt, Department of Pathology, University of Calabar Teaching Hospital, Calabar, Nigeria

ABSTRACT

Objective: To determine the relationship between the age at diagnosis and established prognostic factors of breast cancers in Calabar, Nigeria. Attempts made to assess the prognostic value of age at presentation.

Design: Retrospective study of invasive breast cancer seen in Calabar over a seventeen year period. Pearson’s correlation, univariate and multivariate Cox’s regression were used.

Setting: University of Calabar Teaching Hospital, Calabar, Nigeria, a referral and teaching hospital.

Subjects: Three hundred cases of invasive breast cancer diagnosed between 1983 and 1999 in Calabar, Nigeria. The necessary follow-up data was available for 129 patients.

Results: The mean age at diagnosis of breast cancer in Nigeria was 42.7 years (SD 12.2, range 18-85 years). Patients less than 40 years accounted for 39.8% of the total number of patients with infiltrating breast carcinoma. In the whole material (n=300), there was a positive association between age and tumour size (r=0.44, p=<0.0001), stage (r=0.47, p=<0.0001), the degree of necrosis (r=0.21, p=0.0002), histological grade (r=0.11, p=0.0476), MAI (mitotic activity index, r=0.12, p=0.0338), and MNA (mean nuclear area, r=0.17, p=0.0033). The correlation between age and SMI (standardized mitotic index), AI (apoptotic index), SMI/AI ratio, and FTD (fraction of fields showing tubular differentiation) were not statistically significant. The optimal decisive prognostic cut point for age was 33 years (p=0.0064). Age was also a significant prognosticator when used as a continuous variable (p=0.0240). Survival was better in the younger patients. However, in the Cox’s multivariate analysis involving SMI, tumour size and age (both as a continuous variable and using the determined cut point of 33 years), the age at diagnosis lacked an independent prognostic value.

Conclusion: The more advanced nature of breast cancers and the possible more aggressive tumours (reflected by the higher MNA values) in the older patients may explain the poorer survival seen in patients diagnosed at 40 years or above. It is also probable that the lifestyle differences between the two studied age groups may influence the early detection and prompt commencement of therapy. Screening and treatment approaches between the two age groups may differ in view of the differences.

 

 

 

BIOMEDICAL CHALLENGES OF HUMAN SENESCENCE:  A REVIEW

A.G.Tumbo-Oeri, BSc (Hons), PhD., OGW, Associate Professor, Immunology Unit, Department of Biochemistry, College of Health Sciences, University of Nairobi, P.O Box 30197, Nairobi, Kenya

ABSTRACT

Objective: To summarise and discuss the progress made in the study of human senescence over the past one hundred years and assess the achievements to date.

Data sources: Published original research and reviews during the past one hundred years.

Study selection: The summary focused on those contributions that tested the various hypotheses that attempt to identify and explain the factors that are involved in the ageing process.

Data extraction and synthesis: Online and manual library searches provided a body of data on which the summaries and discussions were based. Specific questions were addressed:  Why does ageing occur? What are the key mechanisms? To what extent are genetic and environmental factors involved in the ageing process? How does the immune system behave during ageing and especially against infectious agents? Answers to these questions were discussed against the background of major improvements in life expectancy in most parts of the world except for sub-Saharan Africa where the HIV/AIDS pandemic has reversed the trend.

Conclusion: Biological and clinical studies over the past century clearly reflect a better understanding of the major factors involved in human senescence. It is appreciated that human life expectancy has improved dramatically over the period through achievements in public health, therapy, nutrition and general living standards. A great deal remains to be done through multidisciplinary research before the quality of life can be improved further.

 

 

 

MULTIPLE CRANIAL NERVE PALSIES COMPLICATING TYMPANOMASTOIDITIS:  CASE REPORT

D.P.O. Oyatsi, MBChB, MMed(Paeds) Nairobi, Dip(Neurology), London, Lecturer, Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, P.O. Box 19676, Nairobi, Kenya

SUMMARY

Otitis media either acute or chronic, is not uncommon in childhood. Multiple cranial nerve palsies occuring as a complication of either form of otitis media is unusual. A case of a nine year old boy with chronic suppurative otitis media with associated mastoiditis complicated with ipsilateral multiple cranial nerve palsies is presented. A skull X-ray and MRI scan showed sclerotic mastoids. The outcome on antibiotic treatment was good.

 

 

PNEUMATOSIS CYSTOIDES INTESTINALIS ASSOCIATED WITH ASCITES AND PYLORIC STENOSIS SECONDARY TO A CHRONIC DUODENAL ULCER:  CASE REPORT

V.M. Muyembe, MBChB, MMed(Surg), Consultant Surgeon, Nyeri Provincial General Hospital, P.O. Box 12485, Nyeri, Kenya

SUMMARY

A thirty eight year old female with a long standing history of a chronic duodenal ulcer presented at the Nyeri Provincial General Hospital with vomiting, abdominal pain and abdominal distension. Oesophago-gastro-duodenoscopy revealed a tight pyloric stenosis while abdominal ultrasonography showed ascites. At laparatomy, she was coincidentally found to have pneumatosis cystoides intestinalis(PCI). The recent literature is reviewed and this case of PCI associated with ascites and pyloric stenosis secondary to a chronic duodenal ulcer is reported.