District health systems: users' preferences for services in Benin

The function of district health systems in Benin Republic wascritically assessed, and special consideration was given tothe acceptability of available health services from the users'point of view. Using a representative household survey, servicerecords, a survey amongst service users, participant observationand qualitative interviews, we obtained data on the use of differentservices offered by the modern public health system, as wellas on reasons for non-use and preference for treatment by traditionalpractitioners or within the family. Although in the last 15 years accessibility to health serviceshas improved remarkably, services are not fully accepted. Under-utilizationof services seems to be due to their low quality, and users'reluctance to consult them. Users are faced with prohibitivecosts, and staff attitudes have further decreased confidence.A major reason for this seems to be staff incompetence in counsellingpatients and clients. Health systems research studies focusing on the clients' viewsmay provoke a critical reflection of everyday practices, providea review of the objectives of district health systems, and leadto discussions on how to improve the performance and qualityof district health teams. This paper gives an account of thepositive experience with participatory workshops at differentlevels of the health system, which constitute a way of ensuringthat study results will be discussed and used at district andnational level.     

Cisapride increases gallbladder volume in gallstone patients before and after extracorporeal shock wave lithotripsy

We have previously shown that oral cisapride causes a dose-related increase of fasting gallbladder volume in healthy subjects. The present study investigates the effect of cisapride on gallbladder motility in 16 patients with gallbladder stones: 8 patients had no biliary symptoms, but the other 8 patients with symptomatic gallstone disease were studied before and 6 weeks after extracorporeal shock wave lithotripsy (ESWL). For each study the patients received a single oral dose of 20 mg cisapride; fasting gallbladder volume was measured by ultrasound before, and for 120 minutes after, drug administration. In the 8 asymptomatic patients a mean maximal increase of the fasting volume to 152.7 ± 7.6% of the initial value was observed at a mean 97.5 ± 8.3 minutes after cisapride ingestion. Similarly, in the 8 patients with biliary pain mean fasting volume after cisapride ingestion increased to 141.3 ± 5.7% before ESWL treatment and to 145.0 ± 5.8% after ESWL and 6 weeks of oral litholytic therapy. There were no significant differences between the results in the symptomatic and asymptomatic patients. Our results indicate that cisapride increases the gallbladder volume in gallstone patients regardless of biliary symptoms. Similar volume changes were observed before therapy and after ESWL with bile acid therapy. The therapeutic efficacy of litholytic agents could be diminished by simultaneous cisapride administration.     

Percutaneous Pacemaker Lead-Transsecting Catheter

We describe the development and successful use of a percutaneous lead-transsection catheter. It was used in two patients in whom removal of chronically implanted atrial pacing leads could not be accomplished by traction.     

Acid-labile anchoring linkages for solid phase synthesis of C-terminal asparagine peptides using the Fmoc strategy

Two acid-labile substituted benzylamine type anchoring linkages, 4-benzoxy-2,6-dimethoxybenzylamine and 2-benzoxy-4,6-dimethoxybenzylamine, for solid phase synthesis of peptide amides were prepared. The N^a-9-fluorenylmethyloxycarbonyl (Fmoc) amino acids could be easily attached to the resins with DCC/HOBt (loading 0.5–0.6 mmol/g resin). After final removal of the N^a-protecting groups, treatment with TFA (50–95%) yielded amino acid and peptide amides in high purity. As we could show for the synthesis of thymulin (FTS, pGlu-Ala-Lys-Ser-Gln-Gly-Gly-Ser-Asn), these two resins with anchoring linkages are well suited for the synthesis of C-terminal Asn peptides using protected aspartic acid derivative as starting material.     

HAEMODYNAMIC RESPONSES TO INDUCTION OF ANAESTHESIA USING MIDAZOLAM IN CARDIAC SURGICAL PATIENTS

The cardiovascular effects of midazolam 0.2 mg kg^–1 l.v.were studied during the induction of anaesthesia in 16 premedicatedpatients subjected to cardiac surgery. In eight patients withcoronary artery disease in whom global resting left ventricularfunction was normal the haemodynamic changes were small andobservations on arterial pressure, cardiac index, stroke index,cardiac filling pressures, systemic and pulmonary vascular resistanceappeared to parallel those accompanying deep sleep in healthyvolunteers. In eight patients with valvular heart disease andhaemodynamic evidence of moderately impaired cardiac performance,pump function during induction with midazolam was maintained,probably as a result of the tendency towards a decrease in systemicvascular resistance. Midazolam appears to be a valuable alternativeto conventional induction agents without adverse effects onthe cardiovascular system.     

Subacute Toxicity of a Purine Nucleoside Phosphorylase Inhibitor in Rats

Rats received daily oral doses of 15, 50, 150, or 200 mg/kgCI-1000 for 4 weeks. Doses were selected based on findings froma 2-week range-finding study where doses of 250 and 500 mg/kgresulted in mortality. In the 4-week study, females given 200mg/kg were sacrificed during Week 2 due to poor condition. Serumcreatinine and urea nitrogen increased 2- to 2.5-fold in femalesgiven 200 mg/kg. Dose-related increases in urine volume, urinaryprotein excretion, and osmolar excretion occurred in both sexesbeginning at 50 mg/kg. Kidney weights increased 9–40%in both sexes at 50 mgkg; histopathologic changes were confinedto the 150 and 200 mg/kg groups. At Week 4, T-suppressor/cytotoxiclymphocytes were reduced 43% and T-helper/inducer lymphocyteswere reduced 22% in males given 200 mg/kg. In females, T-suppressor/cytotoxic lymphocytes were significantly decreased (approximately40%) at 50 and 150 mg/kg, with no significant effects on T-helper/inducerlymphocyte populations. At Week 8, following 4 weeks withouttreatment, T-lymphocyte subpopulations were similar in controland drug-treated groups. B-lymphocyte counts and percentageswere increased at Weeks 4 and 8 in males receiving 150 or 200mg/kg. Thymic weights decreased at Week 4 at doses of 150 and200 mg/kg. Plasma CI-1000 levels were higher in females thanin males at all doses except 15 mg/kg; C_max and AUC values werelargely dose proportional in both sexes. In summary, CI-1000was well-tolerated at doses of 15, 50, and 150 mg/ kg with noadverse effects occurring at 15 mg/kg. Drug-induced changesin the kidney were mild and reversible. Immunomodulatory effectswere noted at doses of 50 mg/kg or higher.     

CLINICAL AND HISTOPATHOLOGIC SPECTRUM OF PILOMATRICOMAS IN ADULTS

Background. Pilomatricomas are benign cutaneous neoplasms with differentiation toward hair matrix. Although previously reported to occur mostly in children and young adults, Taaffe et al. recently observed a second onset peak in adults and the elderly. Methods. To study the clinical and histopathologic features of pilomatricomas in adults we analyzed files and histologic sections of all cases of pilomatricomas seen at the Department of Dermatology, University of Graz, Graz, Austria, between January 1980 and December 1990. Results. A total of 118 patients were identified, 58 of whom were >45 years of age. The clinical features of patients >45 years of age were generally similar to those of patients <45 years of age. Differential diagnoses in both groups were also comparable except in some cases of the older study-group where differential diagnoses included basal cell carcinoma, keratoacanthoma, and metastasis. Recurrence of the lesions after simple excision was observed in one patient >45 years of age. Histopathologically, lesions in both age groups showed similar features except in four lesions of the older patients where “atypical” features were present. The histopathologic differential diagnosis of the lesions with “atypical” features included pilomatrical carcinoma, basal cell carcinoma with matrical differentiation, and matricoma. Conclusions. Our study reveals the relatively frequent occurrence of pilomatricomas in adults and the elderly. Pilomatricoma should be considered along with other benign and malignant conditions in the clinical differential diagnosis of solitary, firm skin nodules presenting in adults and the elderly, especially on the head and neck.     

Changes in acid-base, electrolyte and hemoglobin concentrations during infusion of hydroxyethyl starch 130/0.42/6 : 1 in normal saline or in balanced electrolyte solution in children

Introduction: A balanced volume replacement strategy is a well established concept for correcting hypovolemia using plasma adapted isotonic crystalloid solutions with a physiological electrolyte pattern and acetate as bicarbonate precursor. Recently, third‐generation hydroxyethyl starch (HES) has also become available in a balanced electrolyte solution instead of normal saline. Therefore, in this prospective non‐interventional clinical study, the perioperative administration of HES 130/0.42/6 : 1 in normal saline (ns‐HES) and in balanced electrolyte solution (bal‐HES) was evaluated in children with a focus on acid‐base, electrolyte and hemoglobin changes. Methods: Following local ethics committee approval, pediatric patients aged up to 12 years with an ASA risk score of I–III undergoing perioperative administration of HES (ns‐HES from May 2006 to December 2007, bal‐HES from January 2008 to January 2009) were included. Patient demographics, the performed procedure, adverse drug reactions, hemodynamic data and the results of blood gas analysis were documented with a focus on changes in acid‐base, electrolyte and hemoglobin concentrations. Results: Of 396 enrolled patients (ASA I–III; age 2.3 ± 3, range day of birth – 12 years; body weight 10.8 ± 9, range 0.9–52 kg), 249 received ns‐HES and 147 bal‐HES (mean volume infused 9.9 ± 4 and 9.4 ± 6.9 ml·kg^?1, respectively). After HES infusion, hemoglobin decreased in both groups, whereas bicarbonate and base excess (BE) decreased only with ns‐HES and remained stable with bal‐HES (BE before infusion: ns‐HES ?1.8 ± 2.8, bal‐HES ?1.7 ± 2.7 mmol·l^?1; after infusion: ns‐HES ?2.6 ± 2.4; bal‐HES ?1.6 ± 2.6 mmol·l^?1, P < 0.05). Chloride (Cl) concentrations increased in both groups and were significantly higher with ns‐HES (Cl before infusion: ns‐HES 105.6 ± 3.7, bal‐HES 105.1 ± 2.8 mmol·l^?1; after infusion: ns‐HES 107.7 ± 3.2, bal‐HES 106.3 ± 2.9 mmol·l^?1, P < 0.01). No serious adverse drug reactions were observed. Conclusion: Infusion related iatrogenic acid‐base and electrolyte alterations can be minimized by using hydroxyethyl starch in a balanced electrolyte solution instead of normal saline.     

Chronic antiepileptic monotherapy,bone metabolism,and body composition in non‐institutionalized children

Aim The aim of this study was to determine the influence of chronic monotherapy with antiepileptic drugs (AEDs) on vitamin D levels, bone metabolism, and body composition. Method Eighty‐five children (38 males, 47 females; mean age 12y 5mo, SD 3y 4mo) were treated with valproate and 40 children (28 males, 12 females; mean age 11y 10mo, SD 3y) were treated with other AEDs (lamotrigine, sulthiame, or oxcarbazepine), comprising the non‐valproate group. Forty‐one healthy children (29 males 12 females; mean age 12y 1mo, SD 3y 5mo) served as a comparison group. Height, weight, body impedance analysis, 25‐hydroxyvitamin D, calcium, phosphate, two bone resorption markers (receptor activator of nuclear factor κB ligand [RANKL] and tartrate‐resistant acid phosphatase 5b [TRAP5b]), osteoprotegerin, and leptin were measured. Results No child was vitamin D deficient as defined by a 25‐hydroxyvitamin D (25OHD) level of less than 25nmol/l (<10ng/ml). Leptin, body fat, weight standard deviation score (SDS), and body mass index (BMI) SDS were all significantly higher (each p<0.001) in valproate‐treated children than in the non‐valproate group, as were calcium (p=0.027) and RANKL (p=0.007) concentrations. Similarly, leptin was significantly higher in the valproate group than in control participants (p<0.001), as were body fat (p=0.023), weight SDS (p=0.046), BMI SDS (p=0.047), calcium (p<0.001), and RANKL (p<0.001), whereas TRAP5b concentrations were significantly lower in the valproate‐treated group (p=0.002). Furthermore, calcium and RANKL levels were significantly higher in the non‐valproate group than in comparison participants (p<0.001 and p=0.016 respectively). Interpretation Non‐enzyme‐inducing or minimal enzyme‐inducing AED monotherapy does not cause vitamin D deficiency in otherwise healthy children with epilepsy. Valproate therapy is associated with increases in weight, body fat, and leptin concentration, as well as with a bone metabolic profile that resembles slightly increased parathyroid hormone action.