Research in action: the training approach of the Joint Health Systems Research Project for the Southern African Region.

Over the last two decades, capacity-building in health research has been recognized as a priority by the international research community. Since 1987 the Joint Health Systems Research (HSR) Project for the Southern African Region has been making efforts to increase the national expertise for operational health research, starting in ten Southern African countries, in order to strengthen decision-making in health care at all levels. Initially, its targets were health managers and public health staff. Step-by-step, staff of different levels and disciplines have, in small groups, developed and implemented research protocols on problems experienced in their own working environment. The recommendations resulting from over 200 studies could, to a large extent, be implemented by the teams themselves. The Project was characterized by a flexible approach, allowing countries to participate at their own speed and to determine their own activities and the support they needed. As Ministries of Health as well as research institutions, in an increasing number of Southern and Eastern African countries, choose to actively participate in HSR, this has contributed to bridge the gap between the academic world and the health field. Still, sustainability of HSR activities remains a challenge. This paper describes the approach of the Joint HSR Project over the first 10 years of its operation, and its major strengths and limitations.

A study of prescribing patterns at different health care facilities in Dar es Salaam, Tanzania.

A survey of outpatient prescriptions in three district hospitals, four health centres, and ten dispensaries in Dar es Salaam region has been undertaken, and the significance of the data especially as it relates to prescribing patterns is discussed. The data indicate that the average number of items (drugs) per prescription in hospitals, health centres, and dispensaries was 2.4 +/- 0.16, 2.1 +/- 0.5, and 1.9 +/- 0.2 (+/- SD) respectively, while injections accounted for 18, 20, and 32 percent of all prescriptions in hospitals, health centres and dispensaries respectively. On the other hand, antibiotics accounted for 40, 35 and 36 percent of all prescriptions in hospitals, health centres and dispensaries respectively. Generic prescribing was very high in all health facilities and accounted for approximately 80% of all prescriptions. Prescriptions containing fixed drug combinations were not common.

Some characteristics of serum phenytoin concentration, in black Zimbabwean volunteers.

A study of phenytoin pharmacokinetics in 15 black healthy Zimbabwean volunteers with an average age of 22 to 44 years was performed. A dose of 200 mg (capsules) sodium phenytoin was administered orally to each subject. Peak phenytoin serum levels were detected six hours post-dosing at 2.98 +/- 0.53 micrograms/ml. The mean elimination half life (t1/2) was calculated at 40.2 hours with a range of 36.7 to 40.5 hours. The area under the curve was calculated to be 142.5 with a range of 118 to 192. Comparison of our results with those obtained by other workers is discussed.

The essential drugs in Tanzania: a ten year (1979-1988) review following the Alma Ata declaration.

In this paper the essential drugs concept/policy/lists (EDLs) particularly in Tanzania, has been reviewed. In Tanzania, 1974 was the beginning of national expression for the need of an essential drugs/policy/list. It is noted that while the primary health care workers are knowledgeable of EDLs, the secondary and tertiary workers need to be trained. There must be a decision that such a list must now be used nationally by all the health institutions. The Tanzania pharmaceutical manufacturing companies must be given national backing to release the country from the chronic habit of relying on imported drugs. The Ministry of Health (MOH) should follow the World Health Organization's (WHO) example of regular and constant review of the EDLs in updating its own lists. An assessment should be made of the essential drugs list system in terms of the content versus disease pattern in various region of the country.

Therapeutic drug monitoring (TDM): an aid to anti-epileptic drug (AED) therapy in Zimbabwe: a review.

Therapeutic drug monitoring as an aid to maximal anti-epileptic drug therapy in Zimbabwe was reviewed. The rationale behind therapeutic drug monitoring is that the therapeutic response to most anti-epileptic drugs correlates with the concentration in the blood rather than with the dose and that within an optimum therapeutic range, the majority of patients experience maximum benefit with minimum toxicity. This review highlights the fact that therapeutic drug monitoring is required to optimise anti-epileptic drug therapy because it is a predictor of drug compliance; it is ideal for dosage adjustment: it is a good indicator for confirming clinical diagnosis of intoxication and in poly-pharmacy it can be used to identify a culprit compound and in pregnancy and paediatric populations it is ideal for dosage individualization since changes are rapid. TDM of AED is recommended in the 'intractable' seizure group for our setting.

Combination of a thiazide, a vasodilator and reserpine compared with methyldopa plus hydrochlorothiazide in the treatment of hypertension in Zimbabwe.

Brinerdin (Sandoz), a combination of a diuretic (clopamide 5 mg), a vasodilator (dihydro-ergocristine 0.5 mg) and reserpine (0.1 mg) (CDR) was compared with methyldopa (MD) plus hydrochlorothiazide (HCT) for antihypertensive effect, adverse reactions, compliance and patient preference in an open cross-over trial. Eighteen patients completed both arms of the trial and 5 patients who completed the CDR arm were withdrawn while on the MD arm because of adverse effects in 4 and poor control in 1. On HCT 50 mg daily the mean baseline systolic blood pressure was 163.9 +/- 16.3 mmHg and the diastolic blood pressure was 105.9 +/- 6.7 mmHg. On CDR these were reduced to systolic blood pressure 140.3 +/- 15.1 mmHg and diastolic blood pressure 87.8 +/- 9.3 mmHg. On MD + HCT the systolic blood pressure was reduced to 138.5 +/- 16.9 mmHg and the diastolic blood pressure to 88.9 +/- 10.3 mmHg. The differences between the two treatment periods in systolic blood pressure (1.8 mmHg; 95% confidence interval (CI) - 4.1 + 7.7 mmHg) and diastolic blood pressure (1.1 mmHg; 95% CI - 4.6 + 2.4 mmHg) were not significant with P values of 0.6 and 0.7 respectively. Compliance was 98.2% for CDR and 94.7% for MD + HCT (P = 0.02). Unusual sleepiness occurred more frequently in the MD arm (P less than 0.01). Thirteen patients chose to continue on CDR, 2 on MD + HCT and 3 had no preference (P = 0.005). CDR is similar in antihypertensive effect to MD + HCT but is better tolerated with fewer withdrawals, fewer adverse effects, better compliance and has more patients electing to continue taking it.

Mechanism of the indirect sympathomimetic effect of 5-hydroxytrypt-amine on the isolated heart of the rabbit.

1 Rabbit isolated hearts, perfused by the Langendorff technique, were used to investigate the indirect sympathomimetic effects of 5-hydroxytryptamine (5-HT). Comparisons were made with noradrenaline and with two indirectly acting sympathomimetic agents with entirely different mechanisms of action, tyramine and dimethylphenylpiperazinium (DMPP). 2 The cardiac stimulant effects of 5-HT, tyramine and DMPP were inhibited by propranolol and practolol and the pA2 values obtained were similar to those obtained with noradrenaline as the agonist. 3 Responses to 5-HT, tyramine and DMPP were greatly reduced on hearts from rabbits pretreated with 6-hydroxydopamine. Such hearts had less than 7% of their normal catecholamine concentration and no fluorescence characteristic of noradrenaline in the cardiac sympathetic nerves could be demonstrated. 4 Rapid, reversible and selective tachyphylaxis to 5-HT was demonstrated during perfusion with 5-HT. In hearts desensitized to DMPP by perfusion with DMPP, responses to 5-HT were also reduced. 5 Perfusion of hearts with colchicine inhibited stimulant responses to 5-HT and DMPP but had little effect on responses to noradrenaline or tyramine. 6 Desmethylimipramine enhanced cardiac stimulant responses to noradrenaline and to a lesser extent, those to 5-HT and DMPP. Responses to tyramine were consistently inhibited by desmethylimipramine. 7 Tetrodotoxin abolished responses of the heart to electrical nerve stimulation but left responses to noradrenaline, 5-HT and DMPP unaffected. 8 5-HT, tyramine and DMPP evoked 3H-release from hearts whose neuronal noradrenaline stores had been labelled by perfusion with [3H]-(-)-noradrenaline. The pattern of release evoked by 5-HT was similar to that of DMPP but differed from that of tyramine. 9 Reducing the calcium concentration in the Tyrode solution from 3.6 to 0.2 mEq/1 did not affect 3H-overflow after tyramine but greatly inhibited that evoked by 5-HT and DMPP. 10 The results confirm that the stimulatn effects of 5-HT on the rabbit isolated heart are the result of noradrenaline release. They further suggest that the site of the release is the terminal sympathetic nerve network. The mechanism of release shows more similarities to that of DMPP (calcium-dependent depolarization and exocytosis) than to that of tyramine (neuronal uptake and stoichiometric displacement).