A cross-sectional study to determine the use of alternative medicines during pregnancy in the district hospitals in Manicaland, Zimbabwe.

BACKGROUND: Traditional medicines are widely used in the rapidly growing health system and are of economic importance. The study aimed at determining the frequency, pattern of use and factors that influence traditional medicines use during pregnancy. MATERIALS AND METHODS: A cross-sectional study was carried out at four district hospitals in Manicaland, Zimbabwe, using questionnaire based convenience sampling. RESULTS: Traditional medicines use was found to be high with 54% (n = 337) of pregnant women using traditional medicines during pregnancy. The major purpose of use of traditional medicine was found to be preparation for delivery; cervical dilation in particular. The following factors showed a significant statistical association for use of traditional medicines: previous mode of delivery (p = 0.006), level of education (p = 0.016), family income (p = 0.007), and residential settlement (p =0.026). Some of the common traditional medicines used during pregnancy include Camellia sinensis, Aloe, Spirostachys Africana, Thumbergia lancifolia, Dalbergiella nyasae, Steganotaenia oraliacea, Stomatostemma monteiroae and Cussonia arborea. CONCLUSION: A number of pregnant women use traditional medicines as partus preparators (labour aids) throughout the entire pregnancy period. This calls for obstetricians, general practitioners and midwives to inquire about use of traditional medicine in history.

Microbiology of diabetic foot infections in three district hospital in Malaysia and comparison with South East Asian Countries.

INTRODUCTION: Diabetic foot infection, a complication that is associated with lower-limb amputation, incurs a huge economic burden to the hospital and health care system of Malaysia. The bacteriological profile of pathogens in diabetic foot infections in Malaysia has been sparsely studied. We investigated the microbiology of diabetic foot infections in patients admitted to the district hospitals on the east coast of Malaysia. METHODS: A retrospective analysis was conducted in three district hospitals (Hospital Kuala Lipis, Hospital Bentong and Hospital Raub) in Malaysia from 1st of January 2016 to 31st December 2016. The clinical specimens were cultured using Clinical and Laboratory Standards Institute (CLSI) guidelines. Antibiotic sensitivity testing to different antibiotics was carried out using the disc diffusion method. RESULT: A total of 188 pathogens were isolated from 173 patients, with an average of 1.09 pathogens per lesion. Majority of the pathogens isolated were gram negative pathogens (73.4%). The most commonly isolated pathogens were Staphylococcus aureus (17.5%). This was followed by Klebsiella spp. (17%), Pseudomonas spp. (15.4%) and Proteus spp. (13.8%). Gram positive pathogens were sensitive to most of the antibiotics tested except penicillin and fusidic acid. Gram negative pathogens were sensitive to all antibiotics tested except ampicillin and amoxicillin/clavulanic acid. Amikacin provide coverage for all gram negative pathogens in DFI. CONCLUSION: For the management of patient with infection in diabetic foot, the choice of antibiotic therapy depends on the sensitivity of the pathogens, the severity of the infection, the patient's allergies history, toxicity and excretion of the antibiotics.

Modifiable antenatal risk factors for stillbirth amongst pregnant women in the Omusati region, Namibia.

BACKGROUND: Reduction of stillbirth rates is important because of the social and economic implications. Access to quality antenatal care is important in preventing the risk factors associated with stillbirth. AIM: To determine the prevalence of modifiable antenatal risk factors associated with stillbirth so as to determine possible gaps in their prevention. SETTING: The study was conducted at four district hospitals in the Omusati Region of Namibia. METHODS: A descriptive study using recorded antenatal data was used. Data were collected from the records of 82 women at the time that they had a stillbirth, during the period October 2013 to December 2014. Data were collected for modifiable risk factors related to maternal characteristics, antenatal care received, medical conditions and obstetric complications. RESULTS: The average prevalence of each category of risk factors was as follows: quality of antenatal care (19.8%), maternal characteristics (11.4%), medical conditions (8.9%) and obstetric complications (6.5%). The most prevalent individual risk factors included: no folate supplementation (30.5%), HIV infection (25.6%), late booking (16.7%), intrauterine foetal growth retardation (13.4%) and alcohol use (12.5%). CONCLUSION: Amongst the 14 modifiable risk factor included in the present study, 11 (78.6%) were prevalent amongst women who had a stillbirth. Risk factors associated with quality of antenatal care were the most prevalent. Whilst further investigation is needed to determine the causes behind this prevalence, health education on the availability and benefits of antenatal care, pregnancy timing and spacing may contribute to reducing the prevalence of these risk factors.

Prospective study on dental extractions carried out for paediatric patients under general anaesthetic in a district general hospital.

BACKGROUND: The first line approach to managing healthy anxious children requiring dental extractions should include behavioural management and treatment under local anaesthetic. This can be coupled with conscious sedation. AIM: To evaluate alternative methods attempted prior to treatment under general anaesthesia (GA), to establish the incidence of repeat GA procedures. METHOD: Paediatric cases requiring dental extractions under GA were audited from October 2014 - December 2014 in the Oral and Maxillofacial Department, Great Western Hospital, Swindon. RESULTS: 78 paediatric cases requiring dental extractions were carried out during the study period. 91% of referrals came from local general dental practitioners (GDPs). The indication for the GA was included in 59% of the referral letters. The number of teeth extracted per case ranged from 1 - 14. In 18% of cases treatment under local anaesthetic had been attempted previously. Conscious sedation had not been attempted in any of the cases. There were 5 cases (6.4%) of repeat general anaesthetic procedures. CONCLUSION: Local guidance regarding appropriate paediatric referrals should be distributed to primary care referrers. Treatment under conscious sedation should be considered for paediatric cases and an improved referral pathway to the community dental service should be developed. Preventative advice should be reinforced to the referrer and to the patient.

A population-based assessment of melanoma: Does treatment in a regional cancer center make a difference?

BACKGROUND: Regionalization of care to specialized centers has improved outcomes for several cancer types. We sought to determine if treatment in a regional cancer center (RCC) impacts guideline adherence and outcomes for patients with melanoma. METHODS: In Alberta, Canada, 561 patients with stage I-IIIC primary melanoma were diagnosed between January 2009 and December 2010. The electronic health record was used to capture demographic and pathologic data. Provincial guidelines for sentinel lymph node biopsy (SLNB) and wide local excision (WLE) are based on recommendations of several pre-existing guidelines including the National Comprehensive Cancer Network. RESULTS: 148 of 561 patients were identified as having been treated at a RCC. Median follow-up was 45 months. Patients treated at the RCC presented with higher stage melanomas. The RCC was more likely to follow guideline recommendations for performing SLNB (81.3% vs. 55.4%, P < 0.0001) but not for the extent of WLE (76.6% vs. 84.1%, P = 0.054). Overall survival was impacted by tumor thickness (HR 1.14, P < 0.0001), ulceration (HR 5.58, P < 0.0001), and mitoses (HR 0.59, P = 0.05). CONCLUSIONS: The RCC more closely followed guidelines for SLNB but not for WLE. Despite patients treated at the RCC presenting with a more advanced stage, overall survival and disease-free survival appear to not be affected by treatment center.

Status of the dental health care workforce in Shanghai, China.

OBJECTIVES: The status of the dental health care workforce in Shanghai was investigated in order to support and improve regional planning of this workforce. METHODS: Questionnaires were used to survey all dental medical units in Shanghai. Data were collected on the quantity, structure and levels of dental health personnel. RESULTS: A total of 852 dental medical units and 3,218 dentists were identified in Shanghai. The ratio of dentists to population is 1 : 5,201. CONCLUSIONS: Presently, the total dental health workforce in Shanghai is relatively sufficient, but its distribution is inequitable because there are fewer dental health personnel employed in the suburbs. Moreover, the structure of the dental health workforce in Shanghai is inequitable and specialists in preventive dentistry are lacking. The results of this study can be applied to help Shanghai achieve the rational distribution and efficient utilisation of the dental health workforce available.

Advanced life support in obstetrics (ALSO) and post-partum hemorrhage: a prospective intervention study in Tanzania.

OBJECTIVE: To evaluate the impact of Advanced Life Support in Obstetrics (ALSO) training on staff performance and the incidences of post-partum hemorrhage (PPH) at a regional hospital in Tanzania. DESIGN: Prospective intervention study. SETTING: A regional, referral hospital. POPULATION: A total of 510 women delivered before and 505 after the intervention. METHODS: All high- and mid-level providers involved in childbirth at the hospital attended a two-day ALSO provider course. Staff management was observed and post-partum bleeding assessed at all vaginal deliveries for seven weeks before and seven weeks after the training. MAIN OUTCOME MEASURES: PPH (blood loss ≥500ml), severe PPH (blood loss ≥1000ml) and staff performance to prevent, detect and manage PPH. RESULTS: The incidence of PPH was significantly reduced from 32.9 to 18.2%[RR 0.55 (95%CI: 0.44-0.69)], severe PPH from 9.2 to 4.3%[RR 0.47 (95%CI: 0.29-0.77)]. The active management of the third stage of labor was also significantly improved. There was a significant decrease in episiotomies. By visual estimation, staff identified one in 25 of the PPH cases before the ALSO training and one in five after the training. A significantly higher proportion of women with PPH had continuous uterine massage, oxytocin infusion and bimanual compression of the uterus after the training. CONCLUSIONS: A two-day ALSO training course can significantly improve staff performance and reduce the incidence of PPH, at least as evaluated by short-term effects.

Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews.

BACKGROUND: For most of the population in Africa, district hospitals represent the first level of access for emergency and essential surgical services. The present study documents the number and availability of surgical and obstetrical care providers as well as the types of surgical and obstetrical procedures being performed at 10 first-referral district hospitals in Ghana. MATERIALS AND METHODS: After institutional review board and governmental approval, a study team composed of Ghanaian and American surgeons performed on-site surveys at 10 district hospitals in 10 different regions of Ghana in August 2009. Face-to-face interviews were conducted documenting the numbers and availability of surgical and obstetrical personnel as well as gathering data relating to the number and types of procedures being performed at the facilities. RESULTS: A total of 68 surgical and obstetrical providers were interviewed. Surgical and obstetrical care providers consisted of Medical Officers (8.5%), nurse anesthetists (6%), theatre nurses (33%), midwives (50.7%), and others (4.5%). Major surgical cases represented 37% of overall case volumes with cesarean section as the most common type of major surgical procedure performed. The most common minor surgical procedures performed were suturing of lacerations or episiotomies. CONCLUSIONS: The present study demonstrates that there is a substantial shortage of adequately trained surgeons who can perform surgical and obstetrical procedures at first-referral facilities. Addressing human resource needs and further defining practice constraints at the district hospital level are important facets of future planning and policy implementation.

Epidemiological features of infantile hypertrophic pyloric stenosis in Taiwan: a national study 1996-2004.

BACKGROUND AND AIM: The incidence of infantile hypertrophic pyloric stenosis (IHPS) varies among different countries and is supposed to be lower in Asian countries than in Western countries. However, the incidence of IHPS in Taiwan has not been well investigated. METHODS: The National Health Insurance (NHI) program was implemented in Taiwan in 1995 and covers most of the population (>99%). We used the NHI database to investigate the epidemiological features of IHPS in Taiwan and to compare the data with that of other countries. RESULTS: We identified 962 new IHPS cases during the period from 1996 to 2004. The overall incidence of IHPS was 0.39 (0.34-0.50) cases per 1000 live births. The estimation was 0.39-0.59 per 1000 live births after adjustment for the misdiagnosis rate. The peak incidence (0.58 per 1000 live births) occurred in winter in 1999. Rates were consistently higher in male subjects. The 1-year survival rate was not significantly different in the patients receiving pyloromyotomy in medical centers, regional hospitals, and district hospitals (P=0.389). CONCLUSIONS: Taiwan had the second lowest incidence of IHPS reported in the medical literature. IHPS patients can be successfully treated in district and general hospitals with good prognosis.

Reduction of in-hospital mortality following regionalisation of pancreatic surgery in the south-east of the Netherlands.

BACKGROUND: In the late nineties of the former century, surgery for pancreatic and peri-ampullary cancer in the southern part of The Netherlands was performed mainly in low-volume hospitals (<5 resections/year). Results reported by the Comprehensive Cancer Center South (CCCS) in 2005 revealed the clearly disappointing results of this practice. The former stimulated the regionalisation of pancreatic surgery by 3 collaborating surgical units into one non-academic teaching hospital in the eastern part of the CCCS-region starting from July 2005. METHODS: All of the 76 patients in this regional cohort group in whom a resection of a (peri-)pancreatic tumour was performed with curative intent have been followed up prospectively. The results of surgical morbidity and in-hospital mortality were compared with the results of the CCCS cohort group which were reported previously. RESULTS: Ever since the regionalisation the annual number of patients undergoing resection of a pancreatic tumour increased from 10 to 33, resulting in a total number of 76 patients. Post-operative complications, reoperation rate and in-hospital mortality decreased significantly to 34.2%, 18.4% and 2.6% respectively, as compared to 71.9%, 37.8 and 24.4% in the time period before regionalisation (p < 0.01). CONCLUSION: These unique comparative prospective data derived from daily practice in a collaborative surgical region in The Netherlands (CCCS) support the need for centralisation of pancreatic surgery in order to improve standard of care in pancreatic surgery. This can be achieved by collaboration in a large regional hospital.

Stenting for large bowel obstruction - evolution of a service in a district general hospital.

INTRODUCTION: Stenting for obstructing large bowel malignancy is a technique that is gradually increasing in popularity. The two main indications are for palliation and as a 'bridge to surgery'. Some of the proposed advantages of colonic stenting are safety, reduced morbidity and mortality, avoidance of a stoma and shorter hospital stay. PATIENTS AND METHODS: This was a retrospective study of consecutive patients who had self-expanding metal stents deployed between February 2001 and June 2006. Data were collected from the MEDITECH electronic integrated healthcare information support system and case note review. Data concerning demographics, primary diagnosis, and location of malignant stricture, indication for stenting, method of stenting, outcome, complications and mortality rates were obtained and analysed on Microsoft Excel. RESULTS: Colonic stenting was first performed in the Countess of Chester Hospital in 2001. Thirty-two procedures have been performed since then. The median age was 80 years and the majority of cases were palliative (28 of 32), with three of the remaining cases successfully stented as a 'bridge to surgery'. Initially, this was performed as a radiological procedure; however, the success rate was noted to be better if a surgical endoscopist was also involved. We recorded a 57% clinical success rate in the group of patients that had the colonic stent inserted radiologically; however, the group where this was inserted as a combined radiological and endoscopic procedure yielded a clinical success rate of 78%. We experienced stent-migration in four patients (13%) and rectal perforation in one patient (3%). There was no tumour re-obstruction or stent-related mortality. CONCLUSIONS: A colonic stenting service can be introduced into a district general hospital with low morbidity and mortality. A well-motivated team is required and combined endoscopic and radiological approach in our hands appears to offer the best results.

Inguinal hernia repair: local or general anaesthesia?

INTRODUCTION: Specialist hernia centres and public hospitals with a dedicated hernia service (Plymouth Hernia Service) have achieved remarkable results for inguinal hernia repair with the use of local anaesthesia and set the standards for groin hernia surgery. There is minimal data in the literature as to whether such results are reproducible in the National Health Service in the UK. PATIENTS AND METHODS: A retrospective analysis of all inguinal hernia repairs performed in one district general hospital over a 9-year period was performed. The outcome measures were type of anaesthesia used, early and late postoperative complications and recurrence. A postal questionnaire survey was conducted to obtain satisfaction rates. In addition, a postal questionnaire survey of consultant surgeons in Wales was performed to determine the use of local anaesthesia and day-case rates for inguinal hernia repair. RESULTS: A total of 577 hernia repairs were performed during the study period. Of these, 369 (64%) repairs were performed under local anaesthesia (LA) and 208 (36%) under general anaesthesia (GA). Day-case repair was achieved in 70% (400) of cases. The day-case rates were significantly higher under LA compared to GA (82.6% versus 42.6%; P < 0.05). Patients operated under LA had lower postoperative analgesic requirements and lower incidence of urinary retention compared with the GA group (P < 0.05). There were 7 (1.2%) recurrences at a median follow-up of 5.1 years (range, 10.3-2.5 years). Postal questionnaire revealed higher satisfaction rates with LA compared to GA repair. Only 15% of surgeons in Wales offer the majority of their patients local anaesthetic repair. CONCLUSIONS: The use of LA results in increased day-case rates, lesser postoperative analgesic requirements and fewer micturition problems. The excellent results obtained by specialist hernia centres can be reproduced by district general hospitals by increasing the use of LA to repair inguinal hernias.

Role of Acute Illness Observation Scale (AIOS) in managing severe childhood pneumonia.

OBJECTIVE: In the perspective of integrated management of childhood illness (IMCI) strategy and recent evidence favoring use of oral antibiotics in severe pneumonia, a generic illness severity index--Acute Illness Observation Scale (AIOS)--was prospectively validated in children with severe pneumonia in a civil hospital in remote hilly region. METHODS: AIOS was used in quantifying overall severity of illness for eighty-nine consecutive children (age, 2-59 months) hospitalized with community-acquired severe pneumonia. A detailed clinimetric evaluation of scale was carried out and logistic regression analyses predicted the following outcomes: 1) mode of initial antimicrobial therapy (oral vs. parenteral); and 2) need for intravenous fluids at admission. RESULTS: Majority of children (80.9%) with severe pneumonia scored abnormally (AIOS score> 10) at initial evaluation. Children with abnormal AIOS scores (>10) had significantly greater severity of respiratory distress and higher incidence of radiological pneumonia. Outcome measures i.e. time to defervescence and length of hospital stay were also positively and significantly correlated with the scores. The six-item scale had good internal consistency (Cronbach's alpha 0.81); and its factor analysis yielded a single latent factor explaining 54% of variance in illness severity at admission. Furthermore, logistic regression analyses revealed an independent predictive ability of AIOS in aiding clinician to decide the mode of initial antimicrobial therapy (oral or parenteral), as well as need for intravenous fluids. CONCLUSION: Authors study indicates the clinimetric validity of AIOS in managing, Severe childhood pneumonia and suggests its role in further enriching IMCI strategy.

Cesarean births in Taiwan.

OBJECTIVE: To evaluate the use of cesarean delivery in Taiwan by comparing local clinical indications with those in international cohorts. METHODS: In-patient claims from the National Health Insurance (NHI) in Taiwan were analyzed. Indications for cesarean delivery were evaluated with primary diagnosis codes and procedure codes from the NHI dataset. To produce a stable numerator for cesarean section, 3 years (1998-2000) of claims for cesarean delivery were abstracted and annualized. RESULTS: Rates ranged between 27.3% and 28.7% for primary cesarean delivery and were below 5% for vaginal birth after a cesarean section (VBAC). Compared with rates in other countries, rates for overall and primary cesarean section as well as for VBAC were significantly higher in medical centers in Taiwan (P<0.001). However, the clinics contributed the most to the difference in both overall and primary cesarean rates. The most common indication for cesarean section was prior cesarean section (43.3%-45.5%), followed by malpresentation (19.6%-23.4%). The proportion of fetuses with malpresentation delivered by cesarean section in Taiwan was 7.9%, almost twice the upper limit expected for all pregnancies as indicated in international studies. CONCLUSION: It is important to use appropriately documented data and to compare them with international data when monitoring local obstetric practices. The disproportionately high cesarean delivery rates in Taiwan may hold major lessons for the many countries contemplating or having universal health insurance coverage with a similar mix of providers.

Clinical presentation and surgical quality in treatment of ductal carcinoma in situ of the breast.

To assess quality of surgical treatment of ductal carcinoma in situ (DCIS) and to compare teaching and non-teaching hospitals that constitute the Comprehensive Cancer Centres of the Middle Netherlands (IKMN), we retrospectively reviewed 499 patients with 502 DCIS lesions treated in the period 1989-2002. In teaching hospitals fewer patients presented with clinical symptoms compared to non-teaching hospitals (15% versus 24.0%, p = 0.01). Finally, 65% of patients underwent breast-conserving surgery and 35% of patients a mastectomy (no significant differences between the two types of hospitals). In teaching hospitals 19% of the patients had a disease-involved or unknown surgical margins versus 13% in non-teaching hospitals (p = 0.04). Twenty patients (4%) received radiation therapy postoperatively with no differences between teaching and non-teaching hospitals (p = 0.98). Quality of surgical treatment is the most important prognostic factor in treatment of DCIS. The quality of excisions should be improved and the exact status of margins should be recorded in pathology reports.

An audit of electroencephalography requests: use and misuse.

OBJECTIVE: To investigate whether electroencephalogram (EEG) requests at St George's Hospital (SGH) are being made according to clinical guideline recommendations. METHODS: A retrospective audit at a regional neurology and neurosurgery referral centre, also serving a district population. All adult National Health Service patients undergoing standard EEG between 1st November 2003 and 31st January 2004, for whom the request originated within the hospital, were identified. Data was collected from each subject's case notes, request form and EEG report and compared to predetermined criteria. RESULTS: Fifty sets of notes from ninety patients meeting the inclusion criteria were available for review. Twenty-six percent of requests were considered 'inappropriate', with respect to clinical guidelines, of which 92% were for 'funny turns' where there appeared to be insufficient clinical evidence to justify the request. The EEG contributed to diagnosis or management in only 22% of cases, all of which had been appropriately requested. Neurologists/epileptologists appeared better than non-specialists in terms of appropriateness of referrals, though the numbers were too small to reach significance (p = 0.173, Fisher's exact). Forty-two percent of all patients, and less than 10% of outpatients, had their EEG within the guideline target wait of 4 weeks. CONCLUSIONS: Over a quarter of EEG referrals are not being made in accordance with guidelines, mainly because of the misconception that an EEG can confirm or exclude a diagnosis of epilepsy in patients with "funny turns". In addition, less than 10% of out patient requests are being met within 4 weeks. Strategies to maximise service utilisation are discussed.

The effects of outpatient co-payment policy on healthcare usage by the elderly in Taiwan.

Aging and declining health are intrinsically related and are resulting in increasing healthcare spending in many countries. Control of healthcare spending and patient usage behavior are linked. This study examines the healthcare usage behavior of chronically ill elderly patients in Taiwan following an increase in co-payments. The differences in usage behavior are interpreted by comparing the frequency of hospital visits and the types of hospitals chosen by patients before and after the implementation of the new co-payment policy. Claim data of the Taipei branch of the National Health Insurance Bureau (NHIB) is used as a basis for this analysis. Analysis results indicate that choice of hospital type by the elderly is affected by an increase in co-payment, but that difference of the hospital type choice before and after the co-payment increase is too small to be practically significant. However, the frequency of visits decreased significantly after the implementation of the new co-payment policy. Medical care costs per visit for individual patients and for the National Health Insurance system both increased significantly. Visit frequency and hospital type choice, as well as diagnosis and treatment cost and co-payment, all show significant differences among different age groups of the elderly. The effects of co-payment increases are also discussed from the viewpoint of patients and of governmental policy.

The challenges of meeting rural Bangladeshi women's needs in delivery care.

Despite initiatives and interventions undertaken at national and international levels, maternal health is still neglected in Bangladesh, and the maternal mortality ratio remains one of the highest in the world. In order to improve rural women's access to maternity care, in 1996 the Bangladesh Rural Advancement Committee (BRAC) instituted services for birthing women in 21 health facilities in each Thana. This paper reports on research conducted three years later, based on interviews with women who gave birth in one BRAC Health Centre (BHC) and women who gave birth at home, interviews with staff of the BHC and observation of provider-patient relations. Acceptance of delivery in a health facility by rural women is still minimal. Most women only attended the BHC due to complications, yet the BHC was unable to handle most complications and referred women to the district hospital, where they received poor quality care. Cost, fear of hospitals and the stigma of an 'abnormal' birth were also important constraints. Female paramedics who attended normal deliveries were praised for being caring, but made women deliver lying down, did not always use aseptic procedures and were too busy to give information, making birth a passive experience. Recommendations to provide comprehensive emergency obstetric care at the BHC and upgrade staff skills, introduce rural health insurance and others have already begun to be implemented.

Human behavior in relation to selection of malaria treatment.

People in rural areas usually help themselves when malaria attacks by using a drug preparation under the name of "ya-chud" bought from the grocery in the village. The objective of this study was to determine the behavior towards malarial treatment of local inhabitants in two malarious areas in eastern Thailand. Groups of 271 and 131 local inhabitants in villages in Pong Nam Ron and Bo Thong Districts, respectively, aged more than 15 years were interviewed regarding health behavior in seeking care when they became ill with malaria. Forty-two percent of the population at Pong Nam Ron and fifteen percent at Bo Thong went to drug-stores or groceries when they developed minor illness, while 85.2% of the subjects interviewed at Bo Thong went to the local health center. However, when they became severely ill, treatment-seeking patterns were similar in the two study areas. Ninety-four percent of the subjects interviewed at Bo Thong and eighty-seven percent at Pong Nam Ron gave a history of having used ya-chud in the past. On average, a set of ya-chud for malaria infection consists of 3-5 drugs: antimalarial drugs together with others such as analgesic-antipyretics, steroids, anti-histamines, vitamins and antimicrobial agents (tetracycline). The price of one ya-chud varied from 3-9 baht. Such improperly use of antimalarial drugs in malarious areas can result in treatment failure and cause the development of drug resistance, which is a problem in the malaria control program in Thailand.

Total care for rheumatic disorders in an integrated health care system.

Utilization of care for rheumatic disorders (chapt XIII of ICD) was studied in an area of Sweden during 1978. In the total health care system, approximately 16 to 18% of the population with a rheumatic disorder were seen. The majority (12% of the population) of these patients were treated at the primary care centres. Only 1% were registered as in-patients, 1/4 of whom were admitted to the rheumatology department. Cases with back disorders constituted the largest diagnostic group of rheumatic disorders, both in primary care and in the departments of internal medicine, at the district level as well as in the regional hospital. The most important contribution of the rheumatology department was the care of a select group of patients--those with rheumatoid arthritis and systemic rheumatic diseases. However, primary care saw more patients also within the whole group of inflammatory rheumatic diseases. In the department of orthopaedic surgery, osteoarthritis was the major diagnosis among rheumatic disorders, totalling 38% of their rheumatic in-patients. Selection of patients for specialized care depended upon diagnosis, age, sex and distance to the hospital.