Analysis of price discrepancies and its impact on rational use of medicines

The concept of rational use of medicines requires that patients receive quality efficacious medicines appropriate to their needs, in doses that meet their individual requirements, for the adequate period of time and at the lowest cost to them and to the community. The objectives of the study were to: 1] Analyze drug price differences between brands included in Sudan Drug Index [2009], 2] compare current drug prices with prices available in the international market [WHO drug price guide 2010], 3] assess the impact of price discrepancy on rational drug use by prescribers, dispensers and patients. A descriptive, analytical, one time study was done in Khartoum capital, including 54 drugs selected via a pilot study. Questionnaire was designed to elect the perception, attitude, and behavior of prescribers and dispensers, toward price discrepancy and its impact on rational drug use. Information from patients was taken via a structured interview, using a probability value of 0.07; the sample size was 184 pharmacists, 196 doctors and 196 patients. The discrepancy level was very high in Diclofenac Na 75 mg/3 ml inj with an H/L ratio of 73.7. Drug price comparison with the international guide reveled 92.31% of drug prices included in the study were higher than the guide. The impact of price discrepancy on rational drug use by prescribers, dispensers and patients is confusing, indicating a high degree of irrationality. Price discrepancies haven't been explained neither by the national regulatory authority nor by the local agents. The state of confusion on prescribers, dispensers, and patients would be a source of irrational practice with all its implications on rational use of medicines particularly on the end user having the current scarce financial resources. To ensure availability, accessibility and affordability of medicines establishment of a new drug policy becomes of paramount importance

Anterior reconstruction of thoracolumbar burst fractures

Seventy-seven patients [average age of 32.4 years] with thoracolumbar burst fractures [type A3 [68] and type C3 [9]] were treated and prospectively evaluated both clinically and radiologically at two- month interval. The mean follow-up period was 13.2 months. The results showed that the average neurologic improvement was 1.8 Frankel grades per patient. At the latest follow up, 53 patients were neurologically free, 47 patients had no or occasional minimal back pain, 43 patients returned to their previous jobs or the level of activity and 15 patients returned to less strenuous jobs. The mean encroachment of the spinal canal improved from 74.6% preoperatively to 7% postoperatively. The kyphotic angle improved from a mean of 32.3 degrees preoperatively to a mean of 6.8 degrees at the follow up. All patients showed radiographic solid fusion at an average of six months after surgery. No major complications were encountered

Arthroscopic arthrolysis of knee arthrofibrosis after anterior cruciate ligament reconstruction

Arthrofibrosis following anterior cruciate ligament [ACL] reconstruction may result in a greater functional deficit than the original ACL deficiency especially when both flexion and extension may be limited. Arthroscopic arthrolysis for such cases is the treatment of choice because the pathology is intraarticular. This study represents the results of arthroscopic arthrolysis followed by immediate utilization of continuous passive motion [CPM] in 16 male patients who presented with knee stiffness after ACL reconstruction. The mean age was 27 years [range 19-34], and the mean interval between ACL reconstruction and arthrolysis was 6.2 months [ranged 3-11]. In all cases arthrolysis included cutting of the intraarticular adhesions followed by handling of other associated pathology, like excision of cyclops fibrous nodule, notchplasty or partial release of tight misplaced graft. The last step was forced manipulation of the knee into flexion. CPM was used immediately after arthrolysis for 2 hours 4 times daily interrupted by isometric quadriceps and hamstring setting exercises, and leg lifts in the first postoperative 4 days, then active and active assistive exercises, were allowed. According to the criteria of Parisien we had 14 excellent and 2 good cases. The average flexion range improved from 97[0] preoperatively to 133[0] postoperatively. One complication occurred in this series in the form of avulsion of the inferior pole of the patella that occurred during the final manipulation of the knee into flexion after arthrolysis. Internal fixation using tension band wiring was done and this patient went to a final quite satisfied range of motion [0[0]-125[0]] at 5 months follow up. Arthroscopic arthrolysis for knee arthrofibrosis after ACL reconstruction is a safe effective procedure with low morbidity that sequentially facilitates an accelerated postoperative intensive physiotherapy of passive [CPM], active assistive and active exercises

Surgical treatment of neglected ankle fracture dislocation: mid term follow-up

Sixteen patients with neglected ankle fractures were treated by osteosynthesis following AO principles. The average delay between injury and reconstruction was 2.2 months. The average follow-up period was 5.5 years. Excellent and good results were obtained in 10 patients [62.5%], a fair result in 5 patients and a poor result was reported in only one patient. The quality of reduction obtained and state of articular cartilage before surgery were factors influencing the end results

Treatment of gap non-union of fore-arm bones

This study was carried out on 19 patients with gap nonunion of the radius and/or ulna. The average time passed since the original trauma and the treatment of gap nonunion was 4.5 months. All patients were suffering from pain, instability, limitation of elbow and wrist movements, partial loss of pronation supination, hand stiffness and three of them had discharging sinuses. All cases with diaphyseal gap nonunion were treated by dynamic compression plates together with tricortical strut iliac bone grafts 1 to 5 cm in length. After an average of 16 months follow up, 17 cases showed bony healing, a remarkable improvement of elbow and wrist motion, an improvement of pronation supination and a noticeable improvement of hand function. Excellent results were obtained in three cases, good in seven, fair in four and poor in three

Treatment of ipsilateral fractures of the arm and forearm bones [floating elbow]

Between August 1994 and June 1997, the results of management of 16 patients with ipsilateral fractures of the humerus and forearm bones were prospectively studied. They were 13 males and 3 females with an average age of 24.5 years [ranged 14-40 years]. The right upper limb was involved in six, while the left upper limb was involved in ten patients. These injuries encompass a spectrum of bone and soft tissue injuries and thus the treatment was individualized in each patient. Various combinations of internal fixation and/or external fixation were carried out in addition to an appropriate management of neurovascular and soft-tissue injuries. The follow up period ranged from 6 to 30 months [average 16 months]. The results were assessed according to the clinical scoring system of steel and Graham 1992 in addition to neurovascular assessment and cosmesis; they were acceptable in 14 and poor in 2 patients

Treatment of non-union of fractures of the distal end of the hummerus in adults

Thirteen cases of un-united fractures of the distal end of the humerus were treated by open reduction and internal fixation. Two cases were excluded from the study due to lack of follow up records. Eight cases were open fractures [two were fire arm injuries, six were motor care accidents], two cases were closed fractures and in the last case non- union developed after corrective osteotomy to treat cubitus varus deformity. The initial treatment was above elbow plaster cast in four patients, external fixation in three, debridement and immobilization in three and intra-medullary rod in one. Before treatment of non- union, all patients had pain, disability and stiffness of the elbow and two had discharging sinuses. Radiologically, ten were considered to have a non-reactive non- union and only one showed reactive non- union. The average time from the original fracture to the treatment of the non-union was 18 months [range from 3 to 60 months]. In all cases, double plate fixation and iliac bone graft through a posterior approach was done. At follow up [average 31.5 months], all the non- unions got united and the function was rated as excellent in two, good in seven and fair in two

Radical excision and grafting with pedicular fixation for the treatment of tuberculous kyphosis

In the last four years, twenty-five cases of tuberculous spondylitis with kyphotic deformity were treated by radical excision operation and transpedicular screw fixation [TPSF]. In eighteen cases, one stage approach, lateral rachotomy, radical excision of the lesion, strut iliac bone graft and TPSF were done. In the remaining seven cases, two stages produced was done. In the first stage, left thoracotomy, anterior radical excision and iliac bone graft were carried out, followed by posterior TPSF as a second stage two weeks later. Before surgery, nine cases were paraplegic, while the remaining sixteen cases were neurologically free. The maximum preoperative angle of kyphosis was 70 degrees, while the minimum was 30 with a mean of 52 degrees. An average correction of 28 degrees of the kyphotic angle was achieved immediately after surgery. A mean loss of 14 degrees of the obtained correction was noticed after an average of 31 months follow up with solid bony fusion of the spinal lesions. All but one of the paraplegic patients showed full neurological recovery. This approach combining internal fixation with debridement-fusion of the spine proved to be effective in correction of tuberculous kyphosis, avoiding increase of the kyphotic deformity and providing sufficient rest and protection during healing of the tuberculous spinal lesion

Replating femoral shaft fracture

Replating of the femoral shaft fracture was used in 18 patients. 16 cases were studied and 2 cases were excluded because the follow-up period was less than one year. The study comprises 7 cases with broken plate and 7 cases with pulling out of the screws and 2 cases with nonunion not associated with mechanical failure. Mild infection was found in 4 cases- In all cases revision surgery was done by replating and in 14 cases we applied autogenous cancellous iliac bone graft. Preoperative, operative and follow-up data were discussed. However we didn't study the causes of failure of previous operations. All cases showed union within an average period of 5 months after the revision surgery. Persistent mild infection was observed in the cases that were previously infected. Metal removal after bony union was performed and infection subsided. We concluded that mechanical failure or nonunion after plating of the femoral shaft fracture can by treated successfully by replating with the addition of bone graft