Prometheus' spirit: quality survival in advanced hepatocellular carcinoma after gemcitabine and cisplatin-based chemotherapy.

In advanced virus-induced hepatocellular carcinoma (HCC) associated with cirrhosis, the average survival is four months. We report a 56-year-old man with a large-volume advanced HCC, in whom gemcitabine and cisplatin-based chemotherapy resulted in near-complete regression, and quality survival of 24 months.

Leadership, management and technical lessons learnt from a successful public-private partnership for TB control in Nepal.

BACKGROUND: There is considerable interest in involving private practitioners (PPs) in tuberculosis (TB) control, but little experience. OBJECTIVE: To describe and discuss leadership, management and technical lessons learnt from the successful implementation of a public-private partnership (PPP) for TB control in Nepal. METHODS: Description and discussion of implementation of the PPP is based on feedback from the working group charged with developing the PPP, PPs involved in diagnosis and referral, NGOs providing direct observation of treatment and tracing of late patients, and members of the Nepal National TB Programme. FINDINGS: The process of building the partnership was slow and demoralising, yet with perseverance partners gradually increased their involvement and commitment to the PPP. Leadership was needed to foster communication and openness between partners. It was not necessary to involve all PPs: many patients bypassed PPs and went directly to the free DOTS centres. CONCLUSION: An understanding of issues that arose during development of the Lalitpur PPP may assist assessment of the feasibility of PPPs in other settings, and increase the likelihood of successful implementation. The wider literature on partnerships may be useful to further inform the development of PPPs for health in developing countries.

Dosages of anti-tuberculosis medications in the national tuberculosis programs of Kenya, Nepal, and Senegal.

SETTING: National tuberculosis programs in Kenya, Nepal, and Senegal. OBJECTIVES: To ascertain adequacy of initial prescriptions of dosages of anti-tuberculosis medications in the three national tuberculosis programs. METHODS: Collection of patient treatment cards in a representative sample of treatment centers in Kenya, Nepal, and Senegal. Calculation of drug dosages in milligram per kilogram body weight of isoniazid, rifampicin, and pyrazinamide and comparison with international recommendations for dosage of these medications. RESULTS: A total of 12,346 patient treatment cards were available. Yet of these only 8640 were analyzed: 5575 (65% of total) from Kenya, 612 (53% of total) from Nepal, and 2453 (95% of total) from Senegal had the patient's weight recorded and were given a nationally recommended treatment regimen. The proportions of patients receiving an internationally recommended isoniazid dosage were 34%, 15%, and 15%, respectively in Kenya, Nepal and Senegal; the corresponding figures for rifampicin were 77%, 77%, and 93% and for pyrazinamide 25%, 3% and 75%, respectively, in the three countries. The majority of errors were over-dosage, but some cases of under-dosage were also identified. CONCLUSIONS: This study shows that over-dosage was a frequent event in all three countries. Two major reasons for this error are inadequate drug combinations in Kenya and Senegal, and in all three countries recommendations for weight brackets that did not ideally fit internationally recommended dosages. It is vital to address these problems to reduce both the risk of unnecessary drug toxicity on one end of the spectrum, and suboptimal drug levels on the other.

Tuberculosis treatment in nepal: a rapid assessment of government centers using different types of patient supervision.

SETTING: Urban and periurban government tuberculosis (TB) treatment clinics in Nepal. OBJECTIVE: To assess TB treatment supervision strategies and outcomes. DESIGN: Three types of treatment centers were selected according to intensity of treatment supervision: Group A-all patients supervised by directly observed therapy (DOT) at the treatment center during the intensive phase; Group B-flexible DOT where patient-nominated treatment supervisors include community or family members; Group C-drugs dispensed monthly and no supervised treatment. The cohort studied comprised all new patients starting treatment during a 5-month period in 1996 (n = 759). RESULTS: At group A treatment centers, 100% of patients had daily DOT supervised by treatment center staff during the intensive phase. At group B sites, 75% of nominated supervisors were family or community members and 13% of patients had no supervisor. At group C sites 93% of patients were unsupervised. Bacteriologically confirmed cure rates for smear-positive patients were 91% (95%CI 80.3-97.2) for A sites, 57% (95%CI 48.8-64.0) for B, and 34% (95%CI 25.1-40.4) for C. Treatment centers with the best results had good access to laboratory facilities, uninterrupted drug supply, longer clinic hours, standardized TB case management, and support from a non-governmental organization. CONCLUSION: At government facilities in Nepal, only group A treatment centers achieved World Health Organization global targets for cure. Group B treatment centers showed better outcomes than unsupervised therapy but did not achieve cure targets. Rapid low-cost assessments to collect data that are not routinely reported can improve the evaluation of program aspects such as supervision strategies.

Anti-tuberculosis treatment in private pharmacies, Kathmandu Valley, Nepal.

SETTING: Urban municipality of 150000 citizens in Kathmandu Valley, Nepal. OBJECTIVE: To determine 1) the perceptions among private pharmacists of characteristics of tuberculosis (TB) patients visiting private pharmacies in the area, 2) the sales of different anti-tuberculosis drugs, and 3) the interaction between private health providers and pharmacists. DESIGN: Between January and April 1998, semi-structured interviews were conducted with 98% (49/50) of the private drug-retailers in the area. RESULTS: Thirty-two (65%) pharmacies had sold anti-TB drugs during the last month. Forty-three (88%) said that most TB patients were of low socio-economic status and rarely bought drugs for more than a week at a time. Only eight (16%) reported that TB patients usually returned to buy the full course of drugs. Seventy-two per cent of total spending on anti-tuberculosis drugs was for different kinds of combinations of drugs. Nine per cent was spent on plain rifampicin, believed to be sold only to tuberculosis/leprosy patients. During the previous month, 5/13 (38%) of pharmacies with no doctors attached had sold anti-tuberculosis drugs compared with 27/38 (71%) of pharmacies with doctors attached to them (P < 0.05). CONCLUSION: The private sector offers an available and acceptable but non-affordable service for many TB patients. A substantial amount of anti-TB drugs are being sold in the private pharmacies. There is therefore a potential role for pharmacists to play in collaborative efforts between the private and public sector in TB control activities.

Sputum examination for acid-fast bacilli in private laboratories, Kathmandu Valley, Nepal.

OBJECTIVE: To investigate the characteristics of private laboratories and the process of sputum examination for acid-fast bacilli (AFB). DESIGN: A door-to-door survey of private laboratories in an urban municipality of Kathmandu valley was conducted during the first quarter of 1998. Semi-structured interviews were conducted with staff of 14/20 (70%) identified laboratories. RESULTS: All 14 private laboratories conducted sputum examination for AFB. The majority (71%) of staff lacked special training for AFB examinations. Monocular microscopes were commonly used (36%). Reagents were prepared irregularly, without quality control, and kept for as long as they lasted, often up to 4-6 months (43%). Laboratory registers were usually present (86%), but lacked information on patient's address and the purpose of the test. A median of 12.5 slides per laboratory had been examined during the previous month (range 0-70). A total of 235 AFB slides were examined, of which 18 (7.7%) were reported as positive. CONCLUSION: AFB examinations were widely available. Lack of training and quality control suggest a variable standard of AFB test results. It is recommended that the National Tuberculosis Programme (NTP) provide support and quality control to two to three (i.e., one for every 10) private laboratories in the area to secure private doctors' confidence in sputum testing.