THE DANGER OF HIGH VAGINAL AND THE VALUE OF ENDO CERVICAL SWABS
High vaginal swabs are not very reliable in picking organisms causing pelvic infectious. Endocervical swabs taken properly in aseptic conditions are more likely to reflect what is happening in the pelvis. High vaginal swabs pick mainly normal vaginal flora (germs that live normally in the vargina and not causing problems). Clearing such normal flora with antibiotics can even lead to emergence of resistant organisms that can cause a life threatening infection in the people concerned or lead to inability to actually treat the real germs causing a pelvic infection for example.
Picture – How swabs are taken
Collecting endocervical swabs is the job of a Gynaecologist.
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VTS 01 2

HAEMOGLOBIN ESTIMATION – A WAY TO AVOID WRONG PRACTICE

HAEMOGLOBIN ESTIMATION – A WAY TO AVOID WRONG PRACTICE
When the haemoglobin estimation of a patient is low it is said that the patient has anaemia (lack of blood).
Anaemia is very prevalent in our society. Majority of people when tested are found to be anaemic (have less than 10g% or 70% haemoglobin estimation). The incidence of anaemia is worse among those who are sick as many of them do not have appetite for food and so are unable to take enough proteins, vegetables, vitamins and minerals
which are raw materials for the formation of Heamoglobin. Heamoglobin carries oxygen from the lungs to the various organs and tissues of the body. Heamoglobin is present in red blood cells found in the blood stream. Oxygen is needed by the cells of the body to release energy trapped in the food we eat. Energy is required for the metabolic processes of the body. That is why people who are anaemic complain of tiredness and difficulty in breathing. They also complain of lack of appetite which worsens the anaemia as they are unable to eat food that can give them blood. They look pale and can have swollen leys and face.
When people who are anaemic are given drugs to treat some other ailments like malaria or typhoid fever they don’t recover fast or can even get worse.
This is because energy is needed to metabolize or handle the drugs given and when such energy is in short supply on account of anaemia, the drugs given are unable to work as the body does not have the capacity to handle the drugs. It is very important that health care providers should have the habit of checking the heamoglobin (HB) or packed cell volume (PCV) of people they are treating.
The patients that are very anaemic such as people with haemoglobin that is 6g% or (42%) or less should be given blood transfusion before treating the other problems they have. Those that reject blood on religious or personal grounds can be given erythropoietin injection to boost their haemoglobin levels. Those who are not very anaemic can be treated with haematinics (drugs that improve haemoglobin). These include:
 Folic acid
 Iron tablets like fersolate, ferrous gluconate etc
 B. Complex tablets
 Multivites
 Vitamin C. This helps the patient absorb iron from the stomach and intestines. Such patients can also be encouraged to take a lot of green leavy vegetables, fruits and food high in protein like fish, meat, beans, periwinkles, crayfish, snails, oysters, etc.
Such people can also be given treatment for the illness for which they came. It is wrong practice to be giving people drugs and injections when they are anaemic without treating the anaemia first or together with the other treatments. It is difficult to know who is anaemic except haemoglobin estimation is done. The use of blotted paper where a little blood of the patient is put and checked against a chart is not a reliable way to know those who are anaemic. Collecting the patient’s blood and doing a haemoglobin estimation and/or packed cell volume (PCV) is the standard way to rule out anaemia.

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URINALYSIS – A SIMPLE WAY TO ASSESS PATIENTS

URINALYSIS – A SIMPLE WAY TO ASSESS PATIENTS
Every person that takes care of the sick should use urinalysis – a simple test to check his patients. Combi 9 Dip Stixs that can check various parameters in the urine are available and should be used by all health care providers.
Urinalysis is a very important investigation used to depict the state of health of a pregnant mother or any other sick person. It can draw attention of a health worker to the possibility of the following health concerns
 Diabetes
 Pregnancy - induced hypertension
 Urinary treat infection
 Hepatitis (inflammation of the liver)
 Chronic Renal (Kidney) disease
 Malaria.
DIABETES MELLITUS
When there is glucose in the urine further tests can now be performed to establish the diagnosis of diabetes in pregnancy. Such tests include fasting blood sugar and oral glucose tolerance test (OGTT).
PREGNANCY INDUCED HYPERTENSION
Protein in urine may mean pregnancy – induced hypertension in a pregnant woman if her blood pressure is also high. It protein in urine is up to three to four pluses (+++ or ++++) and the woman’s blood pressure is high coupled with swelling of the hands and legs the woman has severe pregnancy – induced hypertension. Such women need immediate specialist care. If the woman’s blood pressure is normal, urine – microscopy, culture and sensitivity should be done to rule out urinary tract infection which is another reason for protein in urine.
URINARY TRACT INFECTION
This disease can show in urine as:
 Protein in urine
 Presence of pus cells or white blood cells
 Presence of bacteria
 Nitrites positive in urinalysis.
When there indices are seen in urine, a microscopy, culture and sensitivity should be done to discover the organism responsible for the infection and the drugs that can kill such organisms. This helps the health care provider give the appropriate medications that can lead to a cure.
KIDNEY DISEASES
Excessive protein in the urine like three or four pluses, (+++ or ++++) can be a signal of a serious kidney disease like renal failure or Nephrotic syndrome. In nephrotic syndrome the patient is swollen all over.
Red blood cell casts seen on urine microscopy, is a signal of intrinsic kidney disease.
Red Cell Casts, leucocytes (white blood cells) and epithelial casts are found in acute glomerolonephritis (inflammation of the glomeruli (filtering apparatus) of the kidneys).
Hyaline Casts consist of coagulated (congelled) protein without cellular elements. They are found in glomerolonephritis and occasionally in small numbers in normal urine especially after vigorous exercise.
Epithelial and Granular Casts are indicative of inflammation and degeneration of renal (Kidney) tubules. Granular Casts are formed by degeneration of the impressed cells.
In such cases in order to assess the kidney function further tests are required like kidney scan and serum urea and creatinine estimation.
HEPATITIS
Inflammation of the liver known as hepatitis can cause the following symptoms:
 Severe fatigue or weakness
 Loss of appetite
 Headaches
 Jaundice [Yellowness of the skin and conjunctiva (white of the eyes)]
 Dark urine
 Muscle or general body aches
 Joint pains
It can be caused by hepatitis viruses A,B,C,D, or E. Some poisons or toxins can also damage the liver and cause hepatitis.
Hepatitis can cheaply be detected in the urine. Bilirubin seen in the urine is a sign of hepatitis. This will alert a health care provider of its presence.
MALARIA
Can even be suspected by doing a urinalysis. The presence of urobilinogen in significant quantity in urine can be a sign of malaria. During acute malarial attacks red blood cells that carry oxygen are haemolyzed (broken down) by the malaria parasites.
These broken down fragment of red blood cells can be seen in the urine as urobilinogen.
KIDNEY STONES (RENAL CALCULUS)
Crystals (e.g Calcium oxalate, cysteine (an amino acid) or urate (derived from nucleic acid metabolism) may be seen in renal calculus (stone in the kidney or urinary tract). The patient with renal calculus can have episodic or severe colicky pain in the flanks, some times radiating towards the tip of the penis in males.
Red blood cells can also be noted in the urine of people with renal calculus.
NB: It is important to note that the fact that some body is passing urine frequently is not synonymous with a diagnosis of diabetes mellitus. It can also mean urinary tract infection. It is only a urinalysis and microscopy, culture and sensitivity that can settle the issue and give a sense of direction of treatment. Even though frequent urination can be a symptom of diabetes mellitus, health care providers should not give patients with such complaints drugs for diabetes when they have not confirmed the diagnosis through the relevant tests already mentioned.
FASTING STATE OR MATERNAL DISTRESS FOR A WOMAN IN LABOUR
The presence of acetone in the urine of a pregnant woman indicates a fasting state and in a woman in labour can mean maternal distress following prolonged labour, which has depleted her energy reserve.
Acetone is a product of fat metabolism. Fat is usually called in to provide energy when glucose the primary energy provider is exhausted. Such a woman will benefit from an intravenous infusion of dextrose or energy giving food intake if not contraindicated.
A comprehensive examination of the urine of a pregnant woman is therefore very useful to assess her baseline state of health or make accurate diagnosis of any body sick that needs medical attention. Every health care provider should know the enormous information that can be got from checking the urine of a client. It is also important to note that people who take care of the sick can easily carry out urinalysis on their patients using a dip stix like combi 9. they can also send the urine of their clients to the laboratory using sterile urine bottles for microscopy, culture and sensitivity. These will make a lot of information available to them for the correct handling of their patients. It will also enable them refer patients with serious problems like kidney diseases, diabetes mellitus, hepatitis to specialists that can handle them instead of delaying such patients.

DRUGS AND PREGNANCY

DRUGS AND PREGNANCY
Some drugs can cause damage to the baby when given during pregnancy. Some cause miscarriages or kill the babies. For example, tetracyclines may cause yellow or brown discolouration of deciduous teeth. Gestation is divided into three periods. (1) The ovum, from fertilization to implantation; (2) the embryonic period, from the 2nd through the 8th week; and (3) the fetal period, from after 8 completed weeks until term. The embryonic period is the most critical with regard to malformations since it encompasses organogenesis (period when the various parts or organs of the baby are formed). Drugs should not be given to pregnant women especially in the first three months of pregnancy except those recognized as safe during pregnancy.
Every care giver should find out from every woman in her reproductive age whether she is pregnant or not or when she had her last menstrual flow.
The following agents should be avoided during pregnancy.
 alcohol
 Cigarettes
 Phenytoin (drug used to treat epilepsy)
 Diethylstilbesterol
 Sports performance enhancing drugs like androgenic hormones
 Antibiotics like tetracyclines, ciprofloxacin, ofloxacin, chloramphenicol, ciproxin, septrin (co-trimoxazole), norfen, peflacin, Tarivid, streptomycin, rifampicin, laevofloxacin.
 Megavitamins that contain high doses of vitamin A, D, E and K.
No drug or medication should be taken during pregnancy unless clearly indicated and it is wise to advise the woman of the specific reasons for the use of such medications.

DRUGS THAT CAN BE USED DURING PREGNANCY

Drugs that can be used during pregnancy are in 4 categories.
Category A:
These are drugs for which controlled studies in humans have demonstrated no fetal risks. These include prenatal vitamins such as folic acid, multivites, B complex tablets, fersolate, vitamin C tablets.
Category B:
These are drugs for which animal or human studies have not demonstrated a significant risk. There are, however, no controlled human studies. These include the penicillins such as:
 Ampicillin
 Ampiclox
 Cloxacillin
 Procaine Penicilline
 Crystalline Penicilline
 Amoxycillin
Other category B drugs include
 Cephelosporins like Ceftriaxone (Rocephine, Oframax)
 Metronidazole (Flagyl)
 Erythromycin
 Nitrofurantoin
 Nystatin
 Chloroquine
Others are
 Digoxin (used to treat heart failure)
 Insulin (used to control diabetes mellitus)
 Antihistamines like Avomine, chlorpheniramine (piriton)
 Acetaminophen (Paracetamol)
 Alpha methyl Dopa (aldomet)
Category C
These are drugs for which there are no adequate studies either animal or human or drugs in which there are adverse fetal effects in animal studies but no available human data.
Such drugs can only be used by doctors when they feel the patient needs them to stay alive. They should not be used by other categories of health workers.
They include:
 Corticosteroids such as prednisolone
 Adrenaline
 Ephedrine
 Furosemide (lasix)
 Carbamazepine (Tegretol) used to treat epilepsy
 Chlorpromazine (largactil)
 Aspirin
 Phenothiazines (used to treat psychiatric patients)
Category D
Drugs for which there is evidence of fetal risks but benefits are thought to outweigh these risks. Such drugs should only be used by medical practitioners when they think it is absolutely necessary to do so.
Many anti cancer drugs are in this category including
 Methotrexate
 Vincristine
 Melphalan
 Cyclophosphamide
 Chlorambucil
 Cis platin
Other drugs in this category include:
 Phenytoin (used to treat epilepsy)
 Progestins
 Tetracyclines
 Amitriptyline (used to treat depression)
 Diazepam
 Imipramine (used to treat depression)

DRUGS USED INAPPROPRIATELY CAN BE DESTRUCTIVE PAIN KILLERS

DRUGS USED INAPPROPRIATELY CAN BE DESTRUCTIVE
PAIN KILLERS
The major problem with non-steroidal anti-inflammation agents (NSAIDS) like butazolidine, indomethacin (indocid), diclofenac, naproxen, piroxicam, ketoprofen is gastro intestinal toxicity.
Prostaglandins of the E series play a major role in gastrointestinal defence mechanisms. By depleting mucosal prostaglardin levels, aspirin and NSAIDS impair this cytoprotection resulting in mucosal injury, erosions and ulceration.
NSAIDs can lead to gastric ulcers (ulcers of the stomach). They also reduce the integrity of the duodenal mucosa (inner lining of the duodenum).
They are responsible for some cases of duodenal ulcer.
They greatly increase the risk of bleeding or perforation from pre-existing gastric (stomach) and duodenal ulcers.
Giving these drugs to the following people increase these risks:
 Over the age of 60
 With a past history of peptic ulcer
 Using a corticosteroid such as prednisolone
 Using a high dose of the drug or using multiple NSAIDs
Individual NSAIDs with the highest risk for ulcer include
 Piroxicam
 Ketoprofen
Individual NSAIDs with the least risk is Ibuprofen.
These NSAIDs and aspirin are pain killers. Many elderly people especially in the rural areas have various degrees of joint and bone pains for which they take pain killers regularly. Some patent medicine dealers and health workers occasionally combine these drugs and give people. This has led to an upsurge in cases of ulcer or gastrointestinal disturbances noticed these days.
It is important to note the following:
 Paracetamol remains the safest pain killer and can be used in the elderly and those who have ulcer
 Ulcer must be ruled out before a NSAID or Aspirin is prescribed.
 There is need to avoid prescribing two or more NSAIDs for one patient at the same time. Feldene and Ibuprofen should not be prescribed at the same time.
 There is need to use NSAIDs with least toxicity as much as possible like ibuprofen.
 Omeprazole is more effective than either misoprostol or ranitidine (Zantac) in healing peptic ulcers in patients taking NSAIDs.
 Omeprazole also prevents NSAIDs – induced ulcer formation.
TRADITIONAL HERBAL CONCOTIONS
Some Traditional Herbal Practitioners have claimed that they have remedies that can cure AIDS (acquired immune deficiency syndrome), diabetes mellitus, asthma, hypertension, peptic ulcer disease, etc. They give various concoctions to effect such cure. It has been observed that many people who take such treatments end up in the Teaching Hospitals with renal failure or liver failure and many die. Some had injury to the urinary bladder with bloody urine in taking herbal remedies.
There is need to standardize traditional herbal practice. Dosages of drugs should be standardized to avoid over-dosage which can damage the kidneys and/or the liver.
Chemical Constituents of each herbal concoction should be known and toxic substances that can damage the kidney and/or the liver cells or other cells of the body removed. Only chemical constituents necessary to cure a particular ailment should be given to patients. There is need to develop this sector to meet the criteria for standard medical practices across the World.
CHAPETR

AVOIDING DRUG RESISTANCE AND TREATMENT FAILURES

AVOIDING DRUG RESISTANCE AND TREATMENT FAILURES
Some germs can so get used to a drug that the drug when ever it is introduced will not be able to kill those germs that have developed such resistance to it. Initially, the drugs were able to kill the germs. One of the reasons for drug resistance is exposing micro organisms to inadequate quantity of the drug. When people started taking a lower dosage of chloroquine than what was recommended the malaria parasites developed resistance to it. Chloroquine is no longer used for malaria treatment in all the places where such resistances exist. Due to inadequate intake of recommended drug regimen malaria parasites have developed resistance to common drugs used to kill them. That is why the World Health Organization (WHO) recommends combination therapy for malaria treatment. Most physicians combine fansidar or camoquine with an artemisinine product like artesunate and add quinine hydrochloride to it. Single drug treatment of malaria is no longer recommended because of wide spread drug resistance.
The frequent abuse of malaria drugs by people who generally under treat it occasioned the emergence of resistance of malaria parasites to common malaria medications.
Artemisinine drugs should be given for at least six days with a loading dose on the first day of treatment. Health care providers should ensure that in treating malaria the full course of treatment is given to prevent resistance to drugs.
The same advice goes for antibiotics, used for the treatment of infections. Salmonella the organism that causes typhoid and paratyphoid infections is commonly treated with amoxicillin or ciproxin. Because of abuse of these drugs by patients who take less than adequate quantities of the drug, salmonella in many places have developed resistance to these drugs. Drug companies who manufacture drugs with less quantity
of the drug than what was advertised have not helped matters. Such companies are also helping to cause the emergence of drug resistance and treatment failures, some care givers have given what can be considered adequate amounts of the drugs only to discover that the patients are not recovering. Urine cultures or stool cultures that isolate salmonella giving a sensitivity profile has helped in tackling these issues of drug resistance. It has even been discovered in my practice that in many of such sensitivity report, salmonella has been found responding to gentamicin instead of the popular amoxicillin. This has led to result oriented treatment of typhoid fever.
Boiling of drinking water is one single important way to avoid typhoid and paratyphoid infection.
Typhoid and paratyphoid infection should be treated for at least ten days. No body should treat them for less than seven days. Under treatment of these infections are the main reasons for multiple drug resistance. Under treatment of pelvic infections is one major reason for infertility in women whose fallopian tubes eventually get blocked by the same organisms for which treatment has been given. Pelvic infections should not be treated for less than seven days and both partners should be treated. Otherwise one partner can be re-infected by the other.

AVOIDING INAPPROPRIATE PRESCRIPTIONS OR DISPENSING OF DRUGS

SECTION 1
AVOIDING INAPPROPRIATE PRESCRIPTIONS OR DISPENSING OF DRUGS
Dispensing antibiotics such as ampicillin, ampiclox, chlorophenicol, tetracycline, septrin, erythromycin, amoxicillin at inadequate doses to clients do no good to them and cause much harm to them. It is wrong practice. This poor exposure of germs to antibiotics leads to formation of resistance strains of such germs. When such a client has a real challenge to his life by such resistant strains the person can die as some of such germs cannot respond to any antibiotic.
Ampicillin, ampiclox, erythromycin, tetracycline and chloromphenicol should be given every 6 hours and treatment should last for at least 5 to 7 days. Amoxicillin can be given eight hourly.
Giving high caliber antibiotics like ceftriaxone (rocephine, Oframax) for minor respiratory infections or skin infections is wrong practice. This has led to development of resistant strains of many organisms. Many people have died who had severe infections for which such high caliber antibiotics were used for their treatment only to discover that they could not respond to them leaving the physicians very little options.
Polypharmacy is a situation in which several drugs are prescribed or given to a patient at the same time. Some complaints may require two or three drugs but some care givers can give up to seven to ten different drugs for that same complaint. This is poly-pharmacy and it is not good for the health of the patients.
Drugs go through a process of metabolism like food. They are swallowed into the stomach where some of them are broken down and get absorbed mostly from the small intestine into the blood stream from where they enter the liver and the kidneys
and are taken to all parts of the body. Some of them are excreted by the liver into the bile and passed out in combination with faeces. Some are excreted by the kidneys into the urine.
Excessive load of drugs can damage the liver and/or the kidneys. A lot of people are suffering from chronic liver diseases such as cirrhosis of the liver which are not caused by hepatitis B. This can be due to excessive assault on the liver by drugs that are toxic to the liver. Many people have died from such liver diseases for which no body knows the reason for them. Poly pharmacy can be the reason in view of the fact that many people hardly go to physicians for prescriptions and depend on over the counter drugs.
There is also an upsurge in the number of cases of kidney failures which are not due to infection or high blood pressure or diabetes mellitus.
Many health care providers give excessive amounts of drugs that can damage the kidneys to patients. Streptomycin injection, gentamicin injection and other drugs in the class of the amino glycosides are toxic to the kidneys and the ears and if taken for long periods can lead to kidney failure and/or deafness. These drugs should be the exclusive preserve of physicians who understand these therapeutic principles.
Some herbs or roots when taken in excessive amounts can damage the liver and/or the kidneys. Some can even cause injury to the urinary bladder leading to bloody urine. Dosages of herbs, roots or alternative medical, preparations should be standardized to avoid liver and/or kidney failure in people that take them.
Giving drugs meant for adults to children is wrong practice. Drugs like ciprofloxacin, tarivid should not be given to people less than 17 years of age. Some health care providers give children less than 10 years with diarrhea ciprofloxacin. That is wrong
practice. This can damage their livers. Tetracycline should not be given to children less than 8 years as it will discolour their teeth.
Children are better treated by paediatricians (Specialists in the care of children). Drugs especially in syrup or suspension form for very young children are given based on the weight of the child like in milligram/kilogram of body weight.
Drips used for very young children are different from the ones used for adults. Children should be properly examined before treatment.
Some children with pneumonia (a lung infection) can present symptoms that look like malaria or gastroenteritis (inflammation of the stomach and intestines presenting with diarrhea and vomiting). A lot of health care providers keep treating such children for malaria or abdominal problems while the conditions of such children deteriorate. It is wrong practice to keep treating a child for malaria when that child is not getting better. That child needs to be examined by doctors that treat children. Many children have lost their lives because of delays in getting properly examined and treated or over dosage of relevant drugs.
A child was receiving treatment in one clinic in a rural area for malaria. The child was one year old and had received 1 ml of chloroquine daily for two days. The child was already recovering when he was brought to the clinic on the third day for the last injection. Another nurse was on duty who gave 4ml of chloroquine instead of 1ml and the child died instantly.

AVOIDING WRONG PRACTICES

THE SAFE MOTHERHOOD EMPOWERMENT & ENLIGHTENMENT INITIATIVE (SMEEI) PARTNERING WITH HEALTH CARE PROVIDERS FOR SAFE DELIVERY AND GOOD HEALTH

AVOIDING WRONG PRACTICES

INTRODUCTION:

Giving medical attention to people is a great responsibility.  When people are given the wrong drugs or the wrong advice they can die or be seriously hurt.  When the right advice and/or medications and care are given life is preserved.  You cannot give what you don’t have.  The much you have is the much you give.  Your progress depends on the quality of care you give to people.  The quality of care you offer depends on the quality of knowledge and understanding available to you.

The Safe Motherhood Empowerment and Enlightenment Initiative (SMEEI) working for safe delivery of women recognize the strategic role patent medicine dealers and other health workers working among the people play in issues pertaining to the health of the people.  The patent medicine dealer or the health worker living among the people is the first port of cell of the sick including those pregnant but sick.  Their services are relatively cheap and they are very close to the people and many of them treat people on compassionate grounds as majority of our people are poor and can hardly afford the fees charged by hospitals.

SMEEI is a medical literacy outfit run by highly skilled specialists who have been called by God to make their medical knowledge available to the people including the patent medicine dealers and other health workers.  This is to enable them make informed decisions about how to treat and advice people that come to them on daily basis so as to ensure the safety of such people.  Diagnosis or knowing what is wrong with a patient is the key to knowing what to do for such a person, knowing the proper use of drugs to avoid harm to the patient and the drugs that are safe in pregnancy will enhance the well being of our people.

This package will increase the medical knowledge profile of patent medicine dealers and other health workers in order to help them make correct diagnosis and so give appropriate care to their clients.  It will also enable them choose wisely clients to treat and those to refer to hospitals – those whose conditions are severe enough to warrant further investigations and care by specialists.  This will help avoid delaying patients with serious medical conditions in their outfits. 

My name is Dr. Michael Uche-Obasi M.B.,B.S(NIG.); FWACS

Email on; info@smeei.com

Call us on: +2348063389935

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