Cross-sectional Study on the Impact of Discount Pricing and Price Competition on Community Pharmacy Practice.

Background Without stipulated legislation, a free pricing policy can lead to a disparity in prices among private healthcare setups. Competition is especially rampant among community pharmacies, especially in the Sabah state of Malaysia, where the recent years have witnessed the steady growth of pharmacy players from Peninsular Malaysia. Thus, this study aimed to examine the impact of price competition and discount pricing on the practice of community pharmacy in Sabah, Malaysia. Methods This was a cross-sectional study using an online questionnaire. Survey participants included community pharmacists practicing in Sabah. The validated and pilot-tested questionnaire consisted of three parts: background information of the pharmacy, attitudes and perception toward medicine prices, and practice of discount pricing. All required data were collected from community pharmacists practicing only in Sabah. Data were then analyzed by using descriptive, Chi-Square, and Kendall's tau-b tests. Results Of the 150 community pharmacists contacted, only 70 responded, providing a response rate of 47%. In terms of pharmacy type, 71% of the respondents were pharmacist-owned independent pharmacies, while 19% were pharmacy chains owned by community pharmacists. The remaining were pharmacies owned by non-pharmacists (10%). Sixty percent of the community pharmacies had been in existence for more than 10 years, with 12% in existence for less than two years, and 28% in existence for three to 10 years. More than 80% of the respondents stated that the business aspect of community pharmacy had overwhelmed the professional practice aspects and that community pharmacists have become providers of products instead of providers of care. In terms of professionalism, 87% also noted that they are being perceived as profiteering in the medicine business at the expense of patients. Conclusions The free market situation in Malaysia for medicine pricing has brought a detrimental consequence for community pharmacists with each one trying to undercut prices. Differing pricing mechanisms of medicines based on the quantity ordered contribute to the problem of discount pricing and price competition. Most community pharmacists, as indicated by this study, want the problem to be addressed.

Study on the Perception of Staff and Students of a University on Community Pharmacy Practice in Ipoh, Perak, Malaysia.

BACKGROUND: In Malaysia, community pharmacies play an important and vital role in both urban and rural areas with approximately 30% of 12,000 registered pharmacists with annual retention certificate practicing in community pharmacies. The main objective of this study was to find the perception of respondents on the value and necessity of pharmacists. MATERIALS AND METHODS: The questionnaire was divided into two sections: the first section assessed the visits to community pharmacies, purpose, interaction with pharmacy staffs, professional fee, and improvements to pharmacy practices; the second section evaluated the characteristics of respondents including an e-consent form. Data were analyzed using the Statistical Package for the Social Sciences software (version 11.5). RESULTS: The highest number of respondents (66.1%) consulted with the pharmacists for cough and cold, 33.1% for gastric and stomach ailments, and 28.9% for diarrhea and constipation. Only 34% of cases were handled by the pharmacists, whereas 52.1% by the sales assistant. Approximately 88.5% showed satisfaction with the counseling provided. A total of 46.3% did not know whom they dealt with, whereas 51.2% wanted personal attention of the pharmacists instead of the sales assistants. However, 66.9% of respondents preferred to a private consultation room. Records of only 32.2% of respondents were secured by the pharmacies, whereas 42.1% showed interest to pay a professional fee. Moreover, 83.3% agreed the fee of RM5 only, whereas 20.8% agreed to RM10. Among the respondents, majority agreed to pay a fee willingly, but approximately 30% stayed neutral. CONCLUSION: There is a need for the community pharmacists to play vital roles firsthand at the front desk to serve the patients professionally instead of handing over the responsibilities to the sales assistant.

Comparison of the efficacy, safety and cost of cefixime, ceftriaxone and aztreonam in the treatment of multidrug-resistant Salmonella typhi septicemia in children.

An increase in the incidence of Salmonella typhi strains resistant to chloramphenicol, ampicillin and trimethoprim-sulfamethoxazole causing enteric fever in Egyptian children stimulated the evaluation of alternative drugs. Children with positive blood cultures were treated with cefixime, ceftriaxone or aztreonam, and the efficacy, safety and cost of these regimens were evaluated and compared. Cefixime (7.5 mg/kg) was given orally twice daily to 50 children for 14 days, ceftriaxone (50 to 70 mg/kg) was given im once daily for 5 days to 43 children and aztreonam (50 to 70 mg/kg) was given im every 8 hours for 7 days to 31 children. Children in the 3 groups were comparable with regard to age, sex, duration and severity of illness before admission. All children were cured. A significant difference (P < 0.05) in duration of treatment before becoming afebrile seemed to favor ceftriaxone (3.9 days) over aztreonam (5.5 days) and cefixime (5.3 days). During the 4-week follow-up period relapses occurred in 3 (6%) children in the cefixime group, in 2 (5%) in the ceftriaxone group and in 2 (6%) in the aztreonam group. Safety and efficacy were comparable for all 3 drugs. Ceftriaxone was most cost-effective on an inpatient basis, because of a more rapid clinical cure, and cefixime was the most cost-effective on an outpatient basis, because of drug cost.

Dexamethasone treatment for bacterial meningitis in children and adults.

Four hundred twenty-nine patients with bacterial meningitis were assigned on a nonselective alternating basis into one of two therapeutic regimens. Patients in Group I received dexamethasone in addition to standard antibacterial chemotherapy of ampicillin and chloramphenicol whereas those in Group II received antibacterial chemotherapy alone. Dexamethasone was given intramuscularly (8 mg to children younger than 12 years and 12 mg to adults every 12 hours for 3 days). Both treatment groups were comparable with regard to age, sex, duration of symptoms and state of consciousness at the time of hospitalization. A significant reduction in the case fatality rate (P less than 0.01) was observed in patients with pneumococcal meningitis receiving dexamethasone; only 7 of 52 patients died compared with 22 of 54 patients not receiving dexamethasone. A reduction in the overall neurologic sequelae (hearing impairment and paresis) was observed in patients receiving dexamethasone. This reduction was significant only in patients with Streptococcus pneumoniae meningitis; none of the 45 surviving patients receiving steroids had hearing loss whereas 4 of 32 patients not receiving dexamethasone had severe hearing loss (P less than 0.05). No significant difference was observed between the two groups with regard to time for patients to become afebrile or to regain consciousness or in the mean admission and 24- to 36-hour cerebrospinal fluid leukocyte count, glucose or protein content.

Dexamethasone adjunctive treatment for tuberculous meningitis.

During a 5-year period, 280 of 2010 patients admitted to the meningitis ward of a referral hospital in Cairo, Egypt, were clinically diagnosed as having tuberculous meningitis and were treated with either antituberculous chemotherapy and dexamethasone or antituberculous chemotherapy alone. Fatality rates and neurologic sequelae were compared for the 2 treatment groups in the 160 patients who had cerebrospinal fluid cultures positive for Mycobacterium tuberculosis. The overall mortality rate of 51% reflects the delay in receiving appropriate therapy (79% with symptoms for more than 2 weeks) and the severity of illness on admission (56% in coma, 39% drowsy). The fatality rate was significantly lower in the group receiving dexamethasone (43% vs. 59%, P less than 0.05), particularly in the drowsy patients (15% vs. 40% P less than 0.04), and in patients surviving long enough to receive at least 10 days of treatment (14% vs. 33%, P less than 0.02). Development of neurologic complications after initiation of therapy (4 vs. 10) and permanent sequelae (6 vs. 13) were significantly lower in the dexamethasone-treated group (P less than 0.02).

Azithromycin compared with rifampin for eradication of nasopharyngeal colonization by Neisseria meningitidis.

OBJECTIVES: To evaluate the efficacy and safety of azithromycin compared with rifampin for eradication of nasopharyngeal carriage of Neisseria meningitidis METHODS: Pharyngeal swabs were obtained from 500 students attending nursing school in Cairo, Egypt, to determine the colonization rate with N. meningitidis. Colonized individuals were randomized to receive azithromycin (500 mg once) or rifampin (600 mg twice daily for four doses). Subjects were then recultured 1 and 2 weeks posttreatment to determine the effectiveness of the antibiotic therapy for eradication of meningococcal nasopharyngeal colonization. RESULTS: Individuals treated with azithromycin had a 93% eradication rate at 1 and 2 weeks posttreatment comparable with 95 and 91%, respectively, for rifampin. No significant side effects were reported by any subjects treated with either antibiotic. CONCLUSION: Azithromycin is effective in the eradication of N. meningitidis from the nasopharynx of asymptomatic colonized individuals and deserves further evaluation for use as prophylaxis against N. meningitidis.

Treatment of giardiasis with tinidazole.

Fifty-five patients, 51 males and 4 females heavily infected with Giardia lamblia were treated with a single 2 g dose of tinidazole (four tablets); 53 were cured. Of 20 other infected patients kept under the same conditions and given four placebo tablets, 18 continued to pass cysts or trophozoites in the stools during the whole 3- to 4-wk follow-up period in hospital. There were no side effects attributed to the drug.

Renal amyloidosis with nephrotic syndrome in two patients with schistosomiasis mansoni and chronic salmonellosis.

This report describes two Egyptian patients who presented with the nephrotic syndrome and concurrent infections with Schistosoma mansoni and Salmonella paratyphi A. Unlike similar cases previously reported from this unit, these patients did not respond to antimicrobial and antischistosomal therapy, and their renal biopsies demonstrated amyloidosis. These two case reports and several experimental observations suggest that chronic schistosomiasis and salmonellosis may lead to secondary amyloidosis in susceptible individuals.

Schistosomal polyposis of the urinary bladder.

Anatomic, clinical, and digestion analyses were done on 18 human urinary bladder polyps from patients with Schistosoma haematobium infections. Variations in histologic pattern conformed to stages in progression of the disease; most were from active cases with significant egg burdens. The data suggest that polypoid lesions of active schistosomiasis may persist as polyps in the inactive stage if antecedent active infection was heavy.

Nephrotic syndrome in Schistosomiasis mansoni complicated by chronic salmonellosis.

Thirteen patients with concomitant chronic salmonellosis and schistosomiasis and with the nephrotic syndrome were studied. Of the seven patients' sera examined, all had markedly low complement C3 and near normal C4 levels. This indirectly suggests an active role of Salmonella endotoxin in the etiology of the nephrosis.

Treatment of complicated schistosomiasis mansoni with oxamniquine.

Twenty male patients (mean age 23 years) with Schistosoma mansoni infections (mean egg count 429 +/- 311/g feces) were each treated with oxamniquine orally in a single daily dose of 20 mg/kg for 3 consecutive days. Seventeen patients had hepatosplenomegaly, two of these had ascites. Three patients had diffuse colonic polyposis, one of these had ascites. Except for one who developed mild hematemesis 3 days after treatment, all patients tolerated the drug very well. However, 11 patients developed a fever 24 to 48 hours after completing treatment, which lasted for 2-3 days and coincided with increased excretion of schistosomal antigens in urine. Three months after completing therapy, all except one young patient ceased to have live egge in the stools or rectal tissue. Six months after treatment, three patients with colonic polyposis showed marked clinical improvement and sigmoidoscopic and barium enema examination demonstrated almost complete disappearance of all polyps.

Oxamniquine versus niridazole for treatment of uncomplicated Schistosoma mansoni infection.

One hundred sixteen male patients with uncomplicated Schistosoma mansoni infection were randomized to treatment with oxamniquine (20 mg/kg a day for 3 days) or niridazole (15 mg/kg a day for 8 days) in an in-hospital study. Fifty-four patients were treated with oxamniquine; no serious drug side effects were noted. Twenty-six percent of children 16 years old and younger were cured, while 85% of adults were cured. Egg reduction was 89%. Sixty-two patients were treated with niridazole; four patients (one child and three adults) had serious side effects which necessitated discontinuing the drug. Seventy-one percent of children and 84% of adults were cured. Egg reduction was 84%. Minor clinical side effects occurred during therapy with both drugs (26% with oxamniquine, 48% with niridazole) but cleared after completion of therapy. Niridazole is the more effective drug for the child with uncomplicated Schistosomiasis mansoni, but oxamniquine is advised for the adult with this disease.

Serological differentiation of acute and chronic schistosomiasis mansoni by antibody responses to keyhole limpet hemocyanin.

The existence of a shared epitope between the hemocyanin of the marine mollusk Megathura crenulata, better known as the keyhole limpet, and schistosomula has been reported. This epitope has been shown to be a major immunogen in human infection. In this study, keyhole limpet hemocyanin (KLH) was used to measure antibodies recognizing the cross-reacting epitopes in sera from patients with acute and chronic schistosomiasis using an enzyme-linked immunosorbent assay (ELISA). Marked differences in IgG and IgM antibody response were noted between acutely and chronically infected patients at a reciprocal serum dilution of up to 2,560. The acute sera had a mean +/- SD OD490 nm values for IgG and IgM of 1.0 +/- 0.44 and 1.34 +/- 0.6 compared to mean +/- SD IgG and IgM absorbance for the chronic sera of 0.22 +/- 0.10 and 0.22 +/- 0.11 respectively. Setting our lowest positive limit at greater than 2 SD above the mean of the chronic sera, 28 of the 30 patients previously diagnosed as having acute schistosomiasis were correctly identified by their IgG and IgM response. Of 5 patients studied longitudinally, IgG persisted at the same levels 10-13 weeks after treatment. IgM levels, on the other hand, showed a tendency to decrease but remained above the established cut-off level. This study provides further evidence for the association of schistosomulum surface carbohydrate antibody with acute infection and demonstrates the ability of a simple non-competitive ELISA using microtiter plates coated with minute quantities of KLH to differentiate serologically between cases of acute and chronic schistosomiasis.

Hepatic amebiasis: diagnostic counterimmunoelectrophoresis and metronidazole (flagyl) therapy.

In an ongoing study of obscure fevers in Cairo, Egypt which is presently in its 6th year, 12 cases of hepatic amebiasis have been diagnosed. Three were diagnosed during the period 1971-1974. With the introduction of amebic serologic techniques, particularly counterimmunoelectrophoresis, nine additional cases have been diagnosed in 1975-1976. Of 9 patients treated with metronidazole 6 were rapidly cured, 2 had a recurrence of fever necessitating surgical drainage of the abscess, and 1 died suddenly on the 3rd day of therapy.

Treatment of schistosomiasis mansoni with oxamniquine--five years' experience.

During a 5-year period (1975-1980), 171 male patients aged eight to 58 years infected with Schistosoma mansoni have been treated with oxamniquine on an in-hospital basis. The patients comprised three clinical groups--uncomplicated S. mansoni infection, colonic polyposis due to S. mansoni, and hepatic decompensation due to S. mansoni--all with active infection. After treatment all patients were observed for 12 weeks then evaluated for cure. In the uncomplicated group 40 of 73 children (55%) and 39 of 45 adults (87%) were cured. In the polyps group 24 of 29 patients (83%) were cured and in the decompensated group all 24 patients were cured. The only side effect was a febrile reaction occurring in 65 patients (38%) 3-4 days after treatment was started. This 5 years' experience showed that oxamniquine results in a low cure rate in children but is effective in adults with uncomplicated S. mansoni. In patients with colonic polyposis oxamniquine is safe and well tolerated as initial therapy, particularly in the very ill, debilitated patient. Oxamniquine is clearly the drug of choice in patients with decompensated liver disease and active S. mansoni infection.

Bacteriuria in urinary schistosomiasis in Egypt a prevalence survey.

An epidemiologic survey to assess the prevalence of bacteriuria in urinary schistosomiasis was carried out in a region endemic for urinary schistosomiasis in Egypt. Twenty of 390 (5.1%) school boys aged 5--16 years were bacteriuric. This prevalence rate is more than 10 times greater than that found in comparable surveys in areas non-endemic for urinary schistosomiasis. In this endemic population bacteriuria was found in 6.5% of active egg excreters and 2.3% of non-egg excreters.

Meningitis and encephalitis at the Abbassia Fever Hospital, Cairo, Egypt, from 1966 to 1989.

A total of 7,809 patients with meningitis or encephalitis were admitted to the Abbassia Fever Hospital in Cairo, Egypt from November 1, 1966 to April 30, 1989. The etiology was Neisseria meningitidis (mostly group A) in 27.3% of the patients, Mycobacterium tuberculosis in 19.7%, Streptococcus pneumoniae in 7.3%, and Haemophilus influenzae in 4.1%. Almost 27% of the cases had purulent meningitis but without detectable etiology; however, the epidemiologic data suggest that most of these had meningococcal meningitis. Encephalitis was suspected in 12.5% of the patients. Most of the meningococcal, pneumococcal, and Haemophilus cases occurred during the winter months. The number of meningococcal and culture-negative purulent cases per year reached a maximum three times during the 22.5 years of this study. There were more males than females in all etiologic groups, with the ratio for the total patient population being 1.6:1. The average age ranged between 11.7 and 16.5 years for all groups except for Haemophilus patients, who had a mean age of 2.5 years. The mortality rate was almost 55% for tuberculous patients and was approximately 40% for both pneumococcal and Haemophilus patients; it was 8.5% in patients with meningococcal disease.

Short-course norfloxacin and trimethoprim-sulfamethoxazole treatment of shigellosis and salmonellosis in Egypt.

In a double-blind clinical study, 109 adult Egyptian patients infected with Shigella spp. and 45 infected with Salmonella spp. were randomly assigned to three treatment groups: 1) norfloxacin in a single 800-mg dose, 2) norfloxacin, 400 mg twice a day for three days, and 3) trimethoprim (160 mg)-sulfamethoxazole (800 mg) (TMP-SMX), twice a day for three days. Among Shigella-infected patients, diarrheal symptoms had resolved in 86-97% and bacteriologic failure (repeat positive stool culture) occurred in only two patients five days after the start of the three treatment regimens. Among Salmonella-infected patients, diarrheal symptoms had resolved in 76-82% of patients and bacteriologic failure was common (18-36%) five days after the start of therapy. These data indicate that short-course therapy with either norfloxacin or TMP-SMX can be effectively used to treat shigellosis in adults in developing countries. However, for uncomplicated Salmonella spp. infection, short-course therapy with norfloxacin and TMP-SMX may not lead to a rapid resolution of symptoms or consistently eliminate this enteropathogen.

Tuberculosis meningitis, Abbassia Fever Hospital-Naval Medical Research Unit No. 3-Cairo, Egypt, from 1976 to 1996.

A total of 1,430 patients with the presumptive diagnosis of tuberculous meningitis were admitted to the U.S. Naval Medical Research Unit No. 3/Abbassia Fever Hospital in Cairo, Egypt from January 1976 to January 1996. Diagnosis was confirmed by culture of the mycobacteria from the cerebrospinal fluid CSF of 857 patients and these patients are included in the final analysis. There were 497 males and 360 females. The patients ranged in age from five months to 55 years. The number of patients admitted during the months of March, April, and May were more than double those admitted during October, November, and December. The duration of symptoms prior to admission ranged from seven to 90 days (mean = 29.5 days). Upon admission, 4% of the patients were alert, 34% were drowsy, and 62% were in a coma. Of the 857 patients studied, 490 (57%) died, 256 (30%) recovered completely, and 11 (13%) recovered with sequelae. The mortality and neurologic sequelae were directly related to the stage of disease and duration of symptoms prior to admission. Mortality was significantly lower in patients admitted in stage II and or with short duration of disease compared with those in stage III and or with prolonged duration of symptoms prior to admission. The use of dexamethasone in patients with tuberculous meningitis significantly reduced the ocular complications that occur in these patients and also significantly reduced the fatality rate.

Abdominal tuberculosis in Cairo, Egypt.

Twenty-two abdominal tuberculosis patients seen at Abbassia Fever Hospital in Cairo, Egypt from January 1990 to August 1992 are described; their mean age was 21.5 years, range 9-54 years; 17 were female. Common symptoms were fever, malaise, abdominal pain (64%) and weight loss (82%). Chest X-rays were normal in 14 patients (64%), but ultrasonography/computerized tomography of the abdomen was abnormal in 20 patients (91%), with adenopathy the usual finding. Anaemia and a raised erythrocyte sedimentation rate were present in all patients, and purified protein derivative skin test (5 Tu) was positive in 82%. Predominant abnormal physical findings were abdominal (86%), including hepatomegaly/splenomegaly and abdominal mass. Diagnosis was made from biopsy material (caseating granulomas) in 6 patients by laparotomy, 1 by laparoscopy, and 3 by cervical or supraclavicular node biopsy; and from laboratory examination of excretions in only 4 patients (acid-fast bacilli in stools of 2, mycobacteria in urine and menstrual fluid). Eight patients required presumptive diagnosis after response to specific isoniazid (+ethambutol) antituberculous therapy.