The impact of supervision on stock management and adherence to treatment guidelines: a randomized controlled trial

Ensuring the availability of essential drugs and using them appropriately are crucial if limited resources for health care are to be used optimally. While training of health workers throughout Zimbabwe in drug management (including stock management and rational drug use) resulted in significant improvements in a variety of drug use indicators, these achievements could not be sustained, and a new strategy was introduced based on the supervision of primary health care providers. This was launched in 1995 with a training course in supervisory skills for district pharmacy staff. In order to evaluate the impact of the supervision and the effectiveness of the training programme, adherence to standard treatment guidelines (STG) and stock management protocols was evaluated in a randomized controlled trial. The study compared three different groups of health facilities: those that received supervision for either use of STG (n = 23) or stock management (n = 21) - each facility acting as control for the other area of supervision - and a comparison group of facilities which received no supervision (n = 18). On-the-spot supervision by a specially trained pharmacy staff, based around identified deficiencies, took place at the start of the study and 3 months later. The evaluation compared performance on a variety of drug management indicators at baseline and 6-8 months after the second supervisory visit. The results of the study showed that, following supervision, overall stock management improved significantly when compared with the control and comparison groups. Similar improvements were demonstrated for adherence to STG, although the effect was confounded by other interventions. The study also showed that supervision has a positive effect on improving performance in areas other than those supervised, and demonstrated that pharmacy technicians with limited clinical skills can be trained to influence primary health care workers to positively improve prescribing practices. Allocating resources to supervision is likely to result in improved performance of health workers with regard to the rational use of essential drugs, resulting in improved efficiency and effectiveness.     

Association between plasma CC16 levels, the A38G polymorphism, and asthma

The effect of the A38G polymorphism on Clara cell secretory protein (CC16) gene expression and asthma was investigated by measuring plasma CC16 levels in 100 asthmatic and nonasthmatic children. Restriction digestion determined the A38G genotype and plasma CC16 levels were analyzed using a sensitive latex immunoassay. Asthmatics had lower mean plasma CC16 levels adjusted for age and gender (7.96 microg/L; 95% confidence interval [CI] = 6.79 to 9.31) than nonasthmatic subjects (9.98 microg/L; 95% CI = 8.83 to 11.26) (p = 0. 006). Similarly adjusted, mean plasma CC16 levels were also lower in 38A/38A (6.79 microg/L; 95% CI = 4.56 to 9.02) than 38G/38G subjects (10.01 microg/L; 95% CI = 7.90 to 12.12; p = 0.003). The odds ratio for asthma diagnosis of 38A/38A subjects was 4.78 (95% CI = 1.08 to 21.18; p = 0.04) compared with 38G/38G subjects. However, this was reduced when corrected from plasma CC16 level, suggesting that the odds of asthma was largely mediated through altered plasma CC16 levels. The 38A sequence was associated with reduced plasma CC16 levels and individuals with lower plasma CC16 levels were more likely to have asthma. This provides further evidence for a significant role of the CC16 gene, 38A allele in the development of asthma.     

Percutaneous transhepatic occlusion for bleeding oesophageal varices in polycystic disease.

A 7-year-old boy with congenital polycystic disease of the kidneys and liver developed portal hypertension and gastro-oesophageal varices. After two episodes of upper gastrointestinal bleeding, percutaneous transhepatic occlusion of varices and of the left gastric vein was carried out. During the next year there was no evidence of further haemorrhage.     

Detection of carbamyl phosphate synthetase 1 deficiency using duodenal biopsy samples

The activity of urea cycle enzymes was assayed in duodenal biopsy specimens obtained from a female infant who presented with neonatal hyperammonaemia. All enzyme levels were normal except N-acetyl glutamate-dependent carbamyl phosphate synthetase 1 (CPS1) which was half the mean activity in normal control specimens. A similar deficiency of CPS1 was also shown in duodenal specimens from the patient's mother who became slightly symptomatic after relatively high protein meals and during pregnancy, and had spontaneously modified her diet to one with protein restriction. The patient is growing normally on a dietary regimen similar to that spontaneously adopted by her mother. Urea cycle enzyme activity in the duodenal biopsy material from the controls was similar to that found in the normal human liver and appears to have distinct advantages as a means of assaying for urea cycle defects in patients with hyperammonaemia and their relatives.     

''Health assessment'' at school entry: performance of a system based on school nurse interviews

OBJECTIVES: To describe the performance of a school entry 'health assessment' based on school nurse interviews. BACKGROUND: Universal medical examination at school entry has largely been replaced by a 'health assessment' led by the school nurse, based on screening tests, a health interview, eliciting parental and professional concern and past history. As a result children with possible problems are selected for school medicals, reviewed in school or referred to a range of health professionals and other agencies. SETTING: Inner city south-east London. SUBJECTS: Children born between 1/3/89 and 31/8/89 who were on the class lists of 21 randomly selected primary schools. DATA COLLECTION: A form for each subject was distributed to the school nurse and completed as children were invited for screening, school health interviews and medical examinations. MAIN OUTCOME MEASURES: Proportion of subjects attending, patterns and proportions of reviews and referrals. RESULTS: 426 children were eligible for inclusion and 419 (98%) forms were returned. 232 children were seen for a health interview and a further 50 were screened for vision, hearing and growth problems only. 124 had no contact with the school nurse or doctor. Following health interview or screening, 180 children were reviewed and/or discussed with other health professionals. 71 external referrals were made. CONCLUSION: Adequate coverage at school entry is difficult to obtain. The objectives of school entry health assessment and the relationship between selection criteria and health needs require clarification.     

Acute epiglottitis in the adult

GPs are often the first to see adults with acute epiglottitis, yet the information on how to treat them is not usually available. The seven cases presented here demonstrate a wide spectrum of severity with characteristic signs and symptoms. Diagnosis and management are discussed.     

Correlation of redox fluorometry and analytical measurements of pyridine nucleotide

Pyridine nucleotide levels in the corneal epithelium were measured using redox fluorometry, a noninvasive method for monitoring the metabolic status of corneal tissue, and a sensitive bioluminescent assay and an improved extraction procedure that allows the simultaneous extraction and measurement of both NADH and NAD. The same corneas were measured using each of the two methods to enable comparison of the results. The NADH/(NADH + NAD) fraction in the normal epithelium measured by the bioluminescent assay was 0.14 +/- 0.06. Incubation of corneas in 1 mM potassium cyanide (KCN) to mimic the anoxic state increased the NADH/(NADH + NAD) fraction significantly to 0.24 +/- 0.03 (P less than 0.001). The autofluorescence from reduced pyridine nucleotide measured by redox fluorometry also increased with KCN from 2840 +/- 605 to 5147 +/- 738 (P less than 0.0001). A plot of the fluorescence and analytical data for each cornea showed a positive correlation between the two methods, with a correlation coefficient (r value) of 0.80. The correlation was improved but was not dependent on the high values of the KCN treated corneas; an r value of 0.73 was obtained for the non-KCN treated corneas alone. Additional measurements of the temperature dependence of the fluorescence intensity of an NADH solution and the cornea gave a decrease in intensity of 17% from 25 degrees C to 35 degrees C for the NADH solution and 11% (P = 0.0004) for the reduced pyridine nucleotide fluorescence in the cornea over the same temperature range.     

Autoantibodies to acetylcholine receptor in myasthenia gravis: light chains

We studied the light chain type of autoantibodies to acetylcholine receptor (AChR) by affinity chromatography with monoclonal anti-kappa and anti-lambda antibodies. The autoantibodies in four of eight myasthenic patients were of a single light chain type; the others comprised both types. In Graves' disease and cold-reactive hemolytic anemia, the pathogenic autoantibodies are confined to a single light chain type in individual patients, and in other diseases, doubtfully pathogenic autoantibodies are invariably mixtures of both light chain types. AChR antibodies may comprise both pathogenic and nonpathogenic types of autoantibody.