A Report of Clinical Trial Conducted on Toto Ointment and Soap Products C.O

A REPORT OF CLINICAL TRIAL CONDUCTED ON TOTO OINTMENT AND SOAP PRODUCTS C.O. Alebiosu, BSc, MBChB, FWACP, A. Ogunledun, BSc (Hon), MSc, MAAS, MNYAS, and D.S. Ogunleye, BSc Pharm, MSc, PhD, MPSN Ibadan and Sagamu, Nigeria

Objective: The efficacy of Toto ointment and soap on common skin disorders was tested. Methodology: A cohort of Nigerians with common skin conditions such as fungal and bacterial skin infections, scabies, acne vulgaris, and dandruff were selected and followed for a period of 12 weeks. The study is a randomized, comparative, prospective, blinded observational study. Following a placebo run in/wash out period, patients were given either a Toto ointment or soap, or a combination of these, or sulfur ointment alone. Soap use was preferred in patients with Tinea capitis more than patients with any other superficial skin condition for technical reasons-such as ease of application of the soap lather. Expressed preference for either the soap or the cream was at times taken into consideration. Cure rate, adverse drug effects and acceptability of the products were assessed. Results: Out of the 595 patients with common skin diseases selected for the study, 446 (74.9%) had fungal infections, while 64 (10.8%) had scabies infestation. A total of 47 (7.9%) patients had bacterial skin infections, 36 (6.1%) had acne vulgaris, and two (0.3%) had dandruff. At the end of the treatment period, out of the 1 29 patients with fungal infections treated with Toto ointment alone, 92 (71.3)% were successfully treated; while 41 (87.2%) out of the 47 patients with scabies were successfully treated with Toto ointment alone. Although few patients were seen with bacterial skin infections during the study period, these patients responded well to the ointment, the soap or a combination of the two. Overall, the combination of Toto ointment and soap had a better clinical success rate on all diseases when compared to sulfur ointment alone. The study has shown the efficacy and tolerability of Toto products (skin ointment and soap) in the management of common skin disorders. Conclusion: Toto ointment and soap are particularly efficacious in the management of common skin conditions such as fungal and bacterial skin infections, scabies, acne vulgaris and dandruff. U Natl Med Assoc. 2003;95:95-105.)

Key words: Toto products * clinical INTRODUCTION trial * common dermatoses The traditional practices of topically treating dermatological conditions with plant-de-

© 2003. From the Department of Medicine, Ogun State University Teoching Hospital, Ibadan, Nigeria, the Department of Pathology, biosu, Department of Medicine, Ogun State University Teaching Hos- Ogun State University Teaching Hospital, Sagamu, and the Depart- pital, C/0 P.O. Box 4622, Dugbe Post Office, Ibadan, Oyo State, ment of Pharmaceutical/Medicinal Chemistry, Ogun State University Nigeria; phone 02-2310134; fax 02-23101 34; or direct e-mail to Teaching Hospital, Sagamu. Direct correspondence to: C.O. Ale- [email protected].

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 95, NO. 1, JANUARY 2003 95 TOTO OINTMENT/SOAP TRIAL rived medicines predate the cultures of an- amu, and throughout the surrounding commu- cient Egypt and remain vital today in the nity. industrialized cultures of both the United States and Europe.' Recent scientific studies METHODOLOGY lend support to some of the claims of herbal This clinical trial was carried out in the practitioners for the safety and efficacy of medical outpatient department of the Ogun many herbal remedies."2 Dermatologists are State University Teaching Hospital (OS- largely unfamiliar with herbal remedies and UTH), Sagamu. Study participants also were may harbor some misconceptions. recruited from area schools. Local ethical There has been little research done on committee approval was obtained. This is a complementary and alternative medicine randomized, comparative, parallel, prospec- (CAM) even in Western countries.3 However, tive, and blinded observational study. CAM is used in a huge array of practices, including herbal remedies, acupuncture, chi- * Inclusion criteria: Patient must be Nigerian ropractic, and hypnosis, among others. Re- and have any of the common skin diseases such cently, it was noted that as much as 42% of as acne vulgaris, dandruff, scabies, fungal and Americans have tried some sorts of CAM3 at bacterial skin infections. one time or other. Many plants have been found to be of medicinal value in Nige- * Exclusion Criteria: Patients with known hy- ria,4'5'6'7 especially in treating skin diseases.5 persensitivity/contraindication to sulfur; re- In such treatment, plants were previously nal impairment; clinically significant abnor- found to be useful simply by rubbing the mality of haematopoietic, hepatic, endocrine crushed leaves on the affected skin. or cardiac function and existence of any con- Toto ointment and soap are such products current disease, which in the investigator (see Figure 1) produced from herbs that have opinion would make it undesirable for the acclaimed medicinal value. The products are patient to participate in the study. Others currently being evaluated for registration include women of childbearing age who are with Nigeria's National Agency for Food and not using an acceptable method of birth con- Drug Administration and Control. Toto is trol; breast-feeding mothers; presence of psy- described by the manufacturers as purely of chosis, antagonist personality or poor moti- indigenous (Nigerian) origin and effective vation, emotional or intellectual property against common skin diseases such as fungal that is likely to impair compliance with trial and bacterial infections, scabies, acne vul- procedures or validity of consent. garis (pimples) and dandruff. The claim suggests a broad spectrum of ac- Consecutive subjects presenting with acne tivity, but to the best of our knowledge, no vulgaris, dandruff, scabies, fungal and bacte- report on the clinical efficacy of the products rial skin infections were recruited. Informed was available. The objective of this study was to consent was obtained from the patients. The evaluate the efficacy and tolerability of a CAM- study was conducted in accordance with the Toto ointment and soap in the management of declaration of Helsinki, Hong Kong Revision common skin disorders seen at the Ogun State (1989). All patients had baseline physical ex- University Teaching Hospital (OSUTH), Sag- amination and diagnosis of skin ailment

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TOTO OINTMENT * PARABEN * ELAEIS GUINEESIS * BUTYROSPERMUM PARADOXUM OILS * PARAFFIN 80% * TITANIUM DIOXIDE BP * SULFUR BP * H20 6% * FRAGRANCE

TOTO SOAP * ELAEIS GUINEESIS * BUTYROSPERMUM PARADOXUM OILS * SODIUM HYDROXIDE BP a TITANIUM DIOXIDE BP * HALOGENATED PHENOL BP * H20 * FRAGRANCE

Figure 1. COMPOSITION/INGREDIENTS OF TOTO OINTMENT AND SOAP.

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CLINICAL SUCCESS: COMPLETE RESOLUTION OF SKIN LESION THAT NO ADDITIONAL THERAPY IS REQUIRED.

CLINICAL FAILURE: LACK OF RESOLUTION OF SKIN LESION SUCH THAT STUDY MEDICATION SHOULD BE STOPPED AND ALTERNATIVE THERAPY GIVEN.

INDETERMINABLE: A VALID ASSESSMENT OF CLINICAL EFFICACY COULD NOT BE MADE. Figure 2. EVALUATION OF CLINICAL RESPONSE. made. Blood samples were taken for routine transported to the laboratory in an appropri- investigations at first contact. Prior medica- ate transport media. tions were documented. Subjects (patients) At the end of four weeks, the patients were discontinued any skin medication (both oral reevaluated. Returned containers were used and local) and were given placebo daily for to ascertain compliance. At each visit, all pa- two weeks. Newly diagnosed patients were tients were reviewed to assess cure (clinical placed on placebo for one week. success) rates. Clinical success (Figure 2) was Following the placebo run in/wash out pe- taken as disappearance of lesions and/or riod, patients were given either a Toto oint- negative mycological/bacteria results. Ad- ment, or a Toto Soap, or a combination of verse drug effects were recorded after the the ointment and soap, or sulfur ointment run-in period in response to the question, consecutively. The ointment and the soap "have you had any symptoms, problems, were used twice daily. Soap use was preferred or feeling of being unwell since your last in patients with Tinea capitis more than pa- visit?" tients with any other superficial skin condi- A questionnaire was administered to each tion for technical reasons-ease of applica- patient to obtain information on the progress tion of the soap lather. Expressed preference of healing, presence of observable side ef- for either the soap or the cream was at times fects and the acceptability of the ointment taken into consideration. Baseline symptoms and the soap (appearance, smell, dosing and and signs were documented. Photographs of method of administration). The patients skin lesions, bacterial or fungal sampling (as were reviewed after 12 weeks further assess- indicated) were taken. Samples taken from ing cure rates, relapse, and laboratory param- patients in the surrounding schools were eters were repeated.

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Fungi were demonstrated in specimens on Table 1. PATTERN OF SKIN DISEASE TYPES microscopic observation of wet mounts in Number 10% potassium hydroxide solution and also Skin Disease Type of Patients % Total isolated in pure cultures on Sabouraud 2% FUNGAL dextrose agar (SAB) containing 0.5mg/ml of (i) Tinea Capitis 258 43.5 (ii) Pityriasis versicolor 129 21.6 cycloheximide and 0.016mg/ml of chloram- (iii) Tinea corporis 21 3.4 phenicol. Isolates were identified using stan- (iv) Tinea unguium 13 2.2 dard (v) Tinea pedis 13 2.2 mycology methods.89"10 Bacteriologic (vi) Intertrigo 12 2.0 cultures were made on Oxoid blood agar and Scabies 64 10.8 Biotec MacConkey agar plates by the streak Bacterial (i) Septic spots 37 6.2 plate method using sterile standard 4mm in- (ii) Folliculitis 10 1.7 ternal diameter platinum wire loops, and in- Acne Vulgaris 36 6.1 cubating at 370 C aerobically for 24 to 48 Dandruff 2 0.3 Total 595 100 hours. Bacteria were identified using standard microbiologic techniques.13 Data analysis was done by comparing means using the Chi-square test and signifi- tions, acne vulgaris and dandruff, respec- cant differences taken as p < 0.05. tively. The median values of disease duration are as follows:

RESULTS (1) Fungal: five months (range 0.25-180 A total of 607 patients were seen at the months) beginning of the study period but 12 (1.8%) (2) Bacterial: five months (range 0.25-48 could not satisfy the inclusion criteria fully. months) Five hundred and ninety-five patients partic- (3) Scabies: four months (range 0.1- 60 ipated in the clinical trial, all of which were months) Nigerians. Their ages ranged from six years (4) Acne vulgaris: six months (range 1.0- to seventy-five years (mean 13.87 ± 10.55 48.0 months) years) with a sex ratio M/F of 1:1, (302 males (5) Dandruff: four months (range 3.0-9.0 and 293 females), and a mean body mass months) index of 17.2 ± 5.5. Description of treatment given

a) Distribution pattern: Table 2 shows the Description of skin diseases distribution pattern of patients' vis-a-vis Table 1 shows the pattern of skin disease therapy. One hundred and ninety (31.7%) types seen during the clinical trial. Out of the patients were placed on Toto ointment 595 patients seen, 446 (74.9%) had fungal alone, 123 patients (20.6%) had Toto soap infections while 64 (10.8%) had scabies in- alone, and 133 patients (22.7%) were festation. Forty-seven (7.9%), 36 (6.1%), and placed on sulfur ointment alone, while 149 2(0.3%) patients had bacterial skin infec- (25.0%) patients had Toto ointment com-

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Table 2. DISTRIBUTION OF PATIENTS VIS-A-VIS THERAPY GIVEN Toto Sulfur Toto Toto Ointment Ointment Ointment Soap + Soap Total %) Fungal 129 (28.9) 121 (27.1) 107 (23.9) 89 (19.9) 446 (74.9) Bacterial 12 (25.5) 7 (14.9) 10 (21.3) 1 8 (38.3) 47 (7.9) Scabies 47(73.4) 0 (0) 5 (7.8) 12 (18.8) 64 (10.8) Acne v. 1 (2.8) 4 (11.1) 1 (2.8) 30 (83.3) 36 (6.1) Dandruff 1 (25) 1 (25) 0 (0) 0 (0) 2 (0.3) Total (%) 190 (31.7) 133 (22.7) 123 (20.6) 149 (25.0) 595

bined with Toto soap. No patient with sca- the clinical trial. Out of the 129 patients bies had sulfur ointment deliberately, with fungal skin infections treated with since sulfur ointment is not known to be Toto ointment alone, 92 (71.3%) showed very active against scabies. clinical success, while 69 (77.5%) out of 89 b) Period of treatment: The mean period of patients treated with combination of Toto treatment for each disease to clinical suc- ointment and soap showed clinical success. cess is as follows: Only 46 (38.7%) out of 121 of patients (i) Fungal infection: 5.8 weeks (1.0-16.0 + treated with sulfur ointment alone showed 3.9) clinical success. However, 55 (51.4%) of (ii) Bacterial infection: 11.6 weeks (2.0- 107 patients were successfully treated with 16.0 ± 3.8) Toto soap alone. Similarly, 11 (91.6%) out (iii) Scabies: 6.1 weeks (2.0-8.0 + 1.5) of 12 patients showed clinical success in (iv) Acne vulgaris: 3.8 weeks (2.0-15 + the treatment of bacterial skin infections 4.9) with Toto ointment alone while 12 (v) Dandruff: 3.8 weeks (4.0-6.0 ± 0.8) (66.7%) out of 18 patients were successfully treated with Toto ointment combined Generally, the median period of usage of with soap, (Table 4). Among the patients Toto ointment, Toto soap, combined Toto treated for scabies (Table 5), 41 (87.2%) ointment and soap and sulfur ointment are out of 47 were cured with Toto ointment five weeks (range 1-16 + 3.9), six weeks alone, while all (12 [100%]) patients were (range 2-8 + 1.5), six weeks (1-15 ± 4.9), and 12 weeks (range2-16 ± 3.9), respec- cured with the combination of the oint- tively. ment and the soap. Patients with scabies were not placed on sulfur ointment.

c) Outcome of treatment: Figure 3 shows clinical photographs of patients with various Although few patients were seen with acne common skin diseases before and after vulgaris (36) and dandruff (2), patients therapy with Toto products. Tables 3 showed good response to Toto ointment or through 5 show treatment outcome of pa- soap, as well to the combination of both. tients with the skin diseases seen during Generally, there is a significant difference

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Figure 3. CLINICAL PHOTOGRAPHS OF PATIENTS WITH VARIOUS SKIN DISEASES Before Treatment & After Treatment with TOTO Products (A) Tinea~~~~~~~~~~.capitisW.

Note that the Tinea capitis lesions on the head has cleared after treatment, leaving area of alopecia. (B) Septic Spots

The septic skin lesions on the buttocks and the legs have cleared after treatment. (C) Pityrlasis Veslcolor

Pityriasis versicolor lesions cleared after treatment leaving a smooth healthy skin. (D) Scabies

_~~~~~~~~~~~~~~~~~~~~~~~~~-..._~ ~~~~~~~~~~~~~~~~~~...... '

Periumbilical scabies lesions cleared after treatment leaving a healthy skin.

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Table 3. TREATMENT OUTCOME OF PATIENTS WITH FUNGAL SKIN INFECTIONS Partial Clinical Clinical Clinical Lost to Non Total Failure Success Success Indeterminable Follow Up Compliance (%) Toto ointment 11 (8.5) 7 (6.97) 92 (71.3) 0 (0) 10 (7.8) 7 (5.4) 129 (28.9) Sulfur ointment 21 (1.7) 41 (33.9) 46 (38.7) 3 (2.5) 5 (4.2) 5 (4.2) 121 (27.1) Toto soap 15 (14.8) 33 (38.8) 55 (51.4) 1 (0.9) 0 (0) 3 (2.9) 107 (23.9) Toto ointment + toto 6 (6.7) 10 (11.2) 69 (77.5) 3 (3.4) 1 (1.1) 0 (0) 89 (19.9) soap Total (%) 53 (11.8) 93 (20.8) 262 (58.7) 7 (1.5) 17 (3.8) 15 (3.4) 446

(better effect) in the clinical success rate outcome of treatment is not affected by the of Toto products on all diseases studied, duration of disease. The site of fungal compared to the effect of sulfur ointment lesions, however, affected the outcome. alone (X2 = 27.78, df = 5, p < 0.0001); The few cases of Tinea ungium seen (13 likewise, the effects of Toto ointment com- [2.2%] ) and Tinea pedis (13 [2.2%] ) bined with Toto soap compared with sulfur showed little improvement during the clini- ointment alone, (X2 = 35.19 df = 5 p < cal trial period. 0.000001). d) Side effects: There were no significant Comparing the overall effects of Toto soap differences between the mean values of with sulfur ointment, although the propor- haematocrit, electrolytes, urea, creatinine tion of the patients that showed clinical suc- and the liver function tests at the beginning cess were 60 (39%) and 76 (54.3%), respec- and at the end of the study (Table 6). None tively, about 74 (48.1%) of the patients on of the patients reported any side effects dur- Toto soap and 43 (30.7%) of the patients on ing the clinical trial. The acceptability of the sulfur ointment showed partial clinical suc- ointment and soap in terms of appearance, cess to all disease types studied, (X2 = smell, frequency of dosing, and method of 32.31,df = 5, p < 0.00001). Generally, the application was 100%.

Table 4. TREATMENT OUTCOME OF PATIENTS WITH BACTERIAL SKIN INFECTIONS Partial Clinical Clinical Clinical Lost to Non Failure Success Success Indeterminable Follow Up Compliance Totol (%) Toto ointment 0 (0) 0 (0) 11 (91.6) 0 (0) 1 (8.3) 0 (0) 12 (25.5) Sulfur ointment 0(0) 1 (14.3) 4 (57.1) 0(0) 2 (28.6) 0 (0) 7(14.9) Toto soap 0 (0) 0 (0) 10(100) 0 (0) 0 (0) 0 (0) 10(21.3) Toto ointment + soap 0(0) 0 (0) 12 (66.7) 0 (0) 5 (27.7) 1 (5.6) 18 (38.3) Total (%) 0 (0) 1 (2.1) 37(78.7) 0 (0) 8 (17.0) 1 (2.1) 47

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Table 5. TREATMENT OF OUTCOME OF PATIENTS WITH SCABIES INFECTIONS Partial Clinical Clinical Clinical Lost to Non Failure Success Success Indeterminable Follow Up Compliance Total (%) Toto ointment 0 (0) 1 (2.1) 41 (87.2) 0 (0) 5 (10.6) 0 (0) 47 (73.4) Sulfur ointment 0 (0) 0 (0) 1 (100) 0 (0) 0 (0) 0 (0) 1 (20) Toto soap 0 (0) 0 (0) 5 (100) 0 (0) 0 (0) 0 (0) 5 (7.8) Totoointment+totosoap 0(0) 0(0) 11 (100) 0(0) 0(0) 0(0) 11 (18.8) Total (%) 0 (0) 1 (1.6) 58 (90.6) 0 (0) 5 (7.8) 0 (0) 64

DISCUSSION cruris, corporis, pubis, and capitis. In treating The study has shown the efficacy and tol- tinea unguium and tinea pedis however, al- erability of Toto products (skin ointment and though the products have some effects, a de- soap) in the management of common skin finitive statement is difficult to make con- disorders. It also has a superior outcome as cerning the efficacy because of the few compared with sulfur ointment, a commonly patients and duration of treatment. We sug- used skin product. It is particularly effica- gest application of the ointment for a longer cious in the management of skin conditions period in the management of tinea unguium such as fungal and bacterial skin infections and tinea pedis. Very few cases of dandruff and and scabies. The products are particularly acne vulgaris were seen to allow for determi- effective in treating fungal infections and sca- nation of the effects of the products, al- bies. Such fungal skin infections include tinea though the clinical trial recorded good ef-

Table 6. MEAN LABORATORY VALUES OF PATIENTS AT THE BEGINNING AND END OF STUDY Laboratory Value at the Beginning of Value at the Parameter Study End of Study P-Value Haematocrit 35 ± 3.2 mEq/L 34.5 ± 3.2 mEq/L >0.05 Na+ 131.7 ± 0.6 mEq/L 131.2 ± 0.7 mEq/L >0.05 Cl- 103.1 ± 0.6 mEq/L 103 ± 0.4 mEq/L >0.05 K+ 3.6 ± 0.1 mEq/L 3.5 ± 0.1 mEq/L >0.05 HCO3 26.5 ± 0.4 mEq/L 25.3 ± 0.2 mEq/L >0.05 Urea 35.8 ± 5.2 mEq/L 36.1 ± 3.2 mEq/L >0.05 Creatinine 0.5 ± 0.1 mg% 0.5 ± 0.3 mg% >0.05 Sgot 26 ± 0.3 lu/I 27 ± 0.2 iu/I >0.05 Sgpt 24 ± 0.1 iu/L 23 ± 0.3 iu/L >0.05 Total bilirubin 0.8 ± 0.3 iu/L 0.85 ± 0.1 iu/L >0.05 Indirect bilirubin 0.6 ± 0.3 lu/I 0.7 ± 0.1 lu/I >0.05 Total protein 7.8 ± 0.4 mg% 7.9 ± 0.2 mg% >0.05 Albumin 4.6 ± 0.2 mg% 4.4 ± 0.3 mg% >0.05 Globulin 7.5 ± 0.2 mg% 7.6 ± 0.4 mg% >0.05

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fects on all the cases seen. Toto products School, St. Columcile Primary School, Ansarudeen Pri- were also effective in treating common bac- mary School Isale Oko, and the School for the Handi- terial skin infections such as folliculitis and cap, all in Sagamu Ogun State. septic spots caused especially by Staphylococ- Our appreciation also goes to Dr. 0. Adelowo, MBBS, MMed, FMCP, FWACP, (reader and consultant has shown that cus aureus. The clinical trial physician) head of the Department of Medicine, OS- there is an added advantage in combining UTH, Sagamu. The authors also show grate apprecia- Toto skin ointment and soap over and above tion to Dr. O.B. Familoni, MBBS, FMCP, (lecturer and those conferred by the individual agents, consultant physician) of the Department of Medicine, while treating fungal skin infections. OSUTH, Sagamu, for reviewing this manuscript. In none of the patients were any side ef- In addition, we appreciate the various roles played fects observed. The absence of observable by Drs. S.A. Oguntona, MBChB, C.O. Oladele, MBBS, side effects showed that Toto ointment and 0. Odubena, MBChB, and K.O. Kolapo, MBChB, soap are safe and acceptable. The twice-daily all from the Department of Medicine, OSUTH, Sag- amu. administration of Toto products was well ac- cepted by all patients, thus reducing chances of non-compliance. In conclusion, Toto products (ointment and soap) are effective in treating common REFERENCES skin conditions such as scabies; pityriasis ver- 1. Brown DJ & Dattner AM: Phytotherapeutics approaches sicolor, tinea capitis, tinea corporis, tinea pubis; to common dermatological conditions. Archives of Dermatology. bacterial skin infections due to Staphylococcus 1998;134:1401-4. aureus such as folliculitis and septic spots. 2. Koo J, Arain S. Traditional Chinese Medicine for the The combined products are particularly very treatment of dermatological disorders. Archives of Dermatology. effective for pityriasis versicolor, tinea corporis! 1998;134:1388-93. capitis and scabies. 3. Health Agencies Update: New CAM Database Online. We recommend that efforts be made at JAMA, 2001;285:1435. 4. Ayim, JSK. Studies in Casia alata leaves in the state of comparing the product with other estab- medicinal plant research in Nigeria (Sofowora A-ed.) Proceed- lished, new generation antifungals and anti- ings of conference, 1987:213-21. bacterials on a long-term basis. Further stud- 5. Oliver B: Medicinal plants in Tropical West Africa. Cam- ies are required to study the effects of the bridge University Press. 1986, 123-143. products on acne vulgaris (pimples) and dan- 6. Benjamin TV. Analysis of volatile constituents of local druff. plants used in skin diseases. African medicinal plants in Nigeria. 1980:135-139. 7. Ogunti EO. MSc Thesis, Obafemi Awolowo University, Ile-Ife, Nigeria. Antimicrobial Constituents of the leaf of Casia ACKNOWLEDGEMENTS alata Linn, 1990. The authors are grateful to Smooford International 8. Campbell MC, StewartJL. The Medical Mycology Hand- Nigeria Ltd. for providing Toto products and financial book. New York, NY. John Wiley and Sons, 1980:60-9. backing for this, clinical trial. 9. Cooper BH, Silva-Hunter M. Yeast of Medical Impor- We thank the management and staff of the schools tance. In: Lenette E, Balows A, Hauster AJJr., Shadomy HJ (eds.). involved in the clinical trial: the Sagamu Model School, Manual of Clinical Microbiology. 4th ed. Washington, DC, 1985: Sagamu Model College, Golden Gate International 526-541.

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10. Rippon JW. Medical Mycology: The Pathogenic Fungi and the Pathogenic Actinomycetes. Philadephia, WB Saunders We Welcome Your Co., 1980:175-185. Comments 11. Lanette EH, Spraulding EH, and TrauntJP. Manual of Clinical Microbiology. Amer. Soc. Microb. Publ. Washington, Journal of the National Medical Association DC. 1974. welcomes your Letters to the Editor about 12. Akinde BE, Okeke I, and Orafidiya 00. Phytochemical articles that appear in the JNMA or issues and antibacterial evaluation of Cassia Alata leaves-extracts. Afr relevant to minority health care. JMed &Pharm Sci. 1999;1:38-43. Address correspondence to Editor-in-Chief, 13. Finegold SM and Martin WJ. Methods for identification ]iVMA, 1012 Tenth St, NW, Washington, DC of pathogenic microorganisms. In Bailey and Scott's Diagnostic 20001; fax (202) 371-1162; or Microbilogy, 6th ed. The CV Mosby Co., St. Louis, Toronto, Lon- [email protected]. don, 1982.

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