Adjunctive Dexamethasone in HIV-Associated Cryptococcal Meningitis.

BACKGROUND: Cryptococcal meningitis associated with human immunodeficiency virus (HIV) infection causes more than 600,000 deaths each year worldwide. Treatment has changed little in 20 years, and there are no imminent new anticryptococcal agents. The use of adjuvant glucocorticoids reduces mortality among patients with other forms of meningitis in some populations, but their use is untested in patients with cryptococcal meningitis. METHODS: In this double-blind, randomized, placebo-controlled trial, we recruited adult patients with HIV-associated cryptococcal meningitis in Vietnam, Thailand, Indonesia, Laos, Uganda, and Malawi. All the patients received either dexamethasone or placebo for 6 weeks, along with combination antifungal therapy with amphotericin B and fluconazole. RESULTS: The trial was stopped for safety reasons after the enrollment of 451 patients. Mortality was 47% in the dexamethasone group and 41% in the placebo group by 10 weeks (hazard ratio in the dexamethasone group, 1.11; 95% confidence interval [CI], 0.84 to 1.47; P=0.45) and 57% and 49%, respectively, by 6 months (hazard ratio, 1.18; 95% CI, 0.91 to 1.53; P=0.20). The percentage of patients with disability at 10 weeks was higher in the dexamethasone group than in the placebo group, with 13% versus 25% having a prespecified good outcome (odds ratio, 0.42; 95% CI, 0.25 to 0.69; P<0.001). Clinical adverse events were more common in the dexamethasone group than in the placebo group (667 vs. 494 events, P=0.01), with more patients in the dexamethasone group having grade 3 or 4 infection (48 vs. 25 patients, P=0.003), renal events (22 vs. 7, P=0.004), and cardiac events (8 vs. 0, P=0.004). Fungal clearance in cerebrospinal fluid was slower in the dexamethasone group. Results were consistent across Asian and African sites. CONCLUSIONS: Dexamethasone did not reduce mortality among patients with HIV-associated cryptococcal meningitis and was associated with more adverse events and disability than was placebo. (Funded by the United Kingdom Department for International Development and others through the Joint Global Health Trials program; Current Controlled Trials number, ISRCTN59144167.).

Effect of cataract surgery in patients with neovascular age-related macular degeneration: further evidence from disciform scars.

PURPOSE: To evaluate the effect of cataract surgery on disease activation and visual outcomes in neovascular age-related macular degeneration (AMD). METHODS: In this retrospective case-control study, study arm consisted of neovascular AMD patients, who underwent phacoemulsification surgery. Patients did not have any disease activation at least 6 months before the inclusion, and all had at least 12-month follow-up thereafter. Control group consisted of phakic patients, who did not undergo eye surgery during the study period. Primary outcomes were the presence of the disease activation and the change in best-corrected visual acuity (BCVA). RESULTS: A total of 114 neovascular AMD patients [55 (48%) in exudative group and 59 (52%) in disciform group] were included. Preoperative logMAR BCVA was significantly improved after cataract surgery [0.8 (0.6-1.0) vs. 0.4 (0.4-0.7), P < 0.001 in exudative AMD; 1.85 (1.1-1.9) vs. 1.09 (0.8-1.9), P = 0.001 in disciform scar], but this improvement was not maintained during the study period in patients with both exudative AMD and disciform scar [0.6 (0.3-1.1), P = 0.313 in exudative AMD; 1.30 (1-1.9), P = 0.03 in disciform scar]. The incidence of disease activation was not statistically significant between surgery and control groups in patients with exudative AMD [5 (25%) patients in surgery group and 8 (22%) patients in the control group, P = 0.886, Cox proportional hazards regression analysis]. In disciform scar, disease activation was observed in 4 (17%) patients in the surgery group; however, no patient in the control group had disease activation (P = 0.009, HRs could not be estimated, 95% CI 0.001-43.49, Cox proportional hazards regression analysis). CONCLUSION: Cataract surgery has benefit on early postoperative visual improvement in patients with neovascular AMD. The incidence of disease activation was not affected after surgery in exudative AMD.

Randomized trial of primaquine hypnozoitocidal efficacy when administered with artemisinin-combined blood schizontocides for radical cure of Plasmodium vivax in Indonesia.

BACKGROUND: Safety and efficacy of primaquine against repeated attacks of Plasmodium vivax depends upon co-administered blood schizontocidal therapy in radical cure. We assessed primaquine (PQ) as hypnozoitocide when administered with dihydroartemisinin-piperaquine (Eurartesim®, DHA-PP) or artesunate-pyronaridine (Pyramax®, AS-PYR) to affirm its good tolerability and efficacy. A third arm, artesunate followed by primaquine, was not intended as therapy for practice, but addressed a hypothesis concerning primaquine efficacy without co-administration of blood schizontocide. METHODS: During March to July 2013, an open-label, randomized trial enrolled Indonesian soldiers with vivax malaria at Sragen, Central Java, after six months duty in malarious Papua, Indonesia. No malaria transmission occurred at the study site and P. vivax recurrences in the 12 months following therapy were classified as relapses. A historic relapse control derived from a cohort of soldiers who served in the same area of Papua was applied to estimate risk of relapse among randomized treatment groups. Those were: 1) AS followed 2d later by PQ (0.5 mg/kg daily for 14d); 2) co-formulated AS-PYR concurrent with the same regimen of PQ; or 3) co-formulated DHA-PP concurrent with the same regimen of PQ. RESULTS: Among 532 soldiers, 219 had vivax malaria during the four months following repatriation to Java; 180 of these were otherwise healthy and G6PD-normal and enrolled in the trial. Subjects in all treatment groups tolerated the therapies well without untoward events and cleared parasitemia within three days. First relapse appeared at day 39 post-enrollment, and the last at day 270. Therapeutic efficacy of PQ against relapse by incidence density analysis was 92 % (95 %CI = 83-97 %), 94 %(95 %CI = 86-97 %), and 95 %(95 %CI = 88-98 %) when combined with AS, AS-PYR, or DHA-PP, respectively. CONCLUSIONS: This trial offers evidence of good tolerability and efficacy of PQ against P. vivax relapse when administered concurrently with DHA-PP or AS-PYR. These offer alternative partner drugs for radical cure with primaquine. The AS arm demonstrated efficacy with a total dose of 7 mg/kg PQ without concurrently administered blood schizontocide, another option when primaquine therapy is removed in time from the treatment of the acute malaria or applied presumptively without an attack. TRIAL REGISTRATION: Current Controlled Trials ISRCTN82366390, assigned 20 March 2013.

Randomized, open-label trial of primaquine against vivax malaria relapse in Indonesia.

Radical cure of Plasmodium vivax infection applies blood schizontocidal therapy against the acute attack and hypnozoitocidal therapy against later relapse. Chloroquine and primaquine have been used for 60 years in this manner. Resistance to chloroquine by the parasite now requires partnering other blood schizontocides with primaquine. However, the safety and efficacy of primaquine against relapse when combined with other drugs have not been demonstrated. This randomized, open-label, and relapse-controlled trial estimated the efficacy of primaquine against relapse when administered with quinine or dihydroartemisinin-piperaquine for treatment of the acute infection. Among 650 soldiers who had returned to their malaria-free base in Java, Indonesia, after 12 months in malarious Papua, Indonesia, 143 with acute P. vivax malaria were eligible for study. One hundred sixteen enrolled subjects were randomized to these treatments: artesunate (200-mg dose followed by 100 mg/day for 6 days), quinine (1.8 g/day for 7 days) plus concurrent primaquine (30 mg/day for 14 days), or dihydroartemisinin (120 mg) plus piperaquine (960 mg) daily for 3 days followed 25 days later by primaquine (30 mg/day for 14 days). Follow-up was for 12 months. One hundred thirteen subjects were analyzable. Relapse occurred in 32 of 41 (78%) subjects administered artesunate alone (2.71 attacks/person-year), 7 of 36 (19%) administered quinine plus primaquine (0.23 attack/person-year), and 2 of 36 (6%) administered dihydroartemisinin-piperaquine plus primaquine (0.06 attack/person-year). The efficacy of primaquine against relapse was 92% (95% confidence interval [CI] = 81% to 96%) for quinine plus primaquine and 98% (95% CI = 91% to 99%) for dihydroartemisinin-piperaquine plus primaquine. Antirelapse therapy with primaquine begun a month after treatment of the acute attack with dihydroartemisinin-piperaquine proved safe and highly efficacious against relapse by P. vivax acquired in Papua, Indonesia.

Haemoglobin dynamics in Papuan and non-Papuan adults in northeast Papua, Indonesia, with acute, uncomplicated vivax or falciparum malaria.

BACKGROUND: Haemoglobin (Hb) recovers slowly in malaria and may be influenced by naturally acquired immunity. Hb recovery was compared in malaria immune, indigenous Papuan and non-Papuan adults with limited malaria exposure. METHODS: Hb concentrations were measured on Days (D) 0, 3, 7, and 28 in 57 Papuans and 105 non-Papuans treated with chloroquine, doxycycline or both drugs for acute, uncomplicated Plasmodium vivax (n = 64) or Plasmodium falciparum (n = 98). RESULTS: Mean (SD, range) D0 Hb was 12.7 (2.2, 7­21.3) g/dL and was similar in P. falciparum infected Papuans and non-Papuans: 12.2 vs. 12.8 g/dL (P = 0.15) but significantly lower in: (i) P. vivax-infected Papuans vs. P. vivax-infected non-Papuans: 11.4 vs. 13.47 g/dL [Δ = −2.07 (95% CI: ­3.3 ­ ­0.8), P = 0.0018], (ii) all patients with splenomegaly (vs. those without splenomegaly): 12.16 vs. 13.01 g/dL [Δ = −0.85 (−1.6­ ­0.085), P = 0.029], and (iii) all females vs. all males: 10.18 vs. 13.01 g/dL [Δ = −2.82 (−3.97 ­ ­1.67), P < 0.0001].Multiple regression identified female sex (P = 0.000), longer illness duration (P = 0.015) (P. falciparum patients) and Papuan ethnicity (P = 0.017) (P. vivax patients) as significant factors for a lower D0 Hb. Mean D28 Hb increased to 13.6 g/dL [Δ = 1.01 (0.5-1.5) vs. D0 Hb, P = 0.0001]. It was: (i) positively correlated with the D0 Hb (adjusted R2 = 0.24, P = 0.000), and was significantly lower in P. vivax infected Papuans vs. non-Papuans: 12.71 vs. 14.46 g/dL [Δ = −1.7 (−2.95­ ­0.5, P = 0.006). CONCLUSIONS: Haemoglobin recovery was related to baseline Hb. Vivax-infected malaria immune Papuans had persistently lower Hb concentrations compared to non-Papuans with limited malaria exposure. This haematological disadvantage remains unexplained.

The Effect of Tortuosity on Permeability of Porous Scaffold.

In designing porous scaffolds, permeability is essential to consider as a function of cell migration and bone tissue regeneration. Good permeability has been achieved by mimicking the complexity of natural cancellous bone. In this study, a porous scaffold was developed according to the morphological indices of cancellous bone (porosity, specific surface area, thickness, and tortuosity). The computational fluid dynamics method analyzes the fluid flow through the scaffold. The permeability values of natural cancellous bone and three types of scaffolds (cubic, octahedron pillar, and Schoen's gyroid) were compared. The results showed that the permeability of the Negative Schwarz Primitive (NSP) scaffold model was similar to that of natural cancellous bone, which was in the range of 2.0 × 10-11 m2 to 4.0 × 10-10 m2. In addition, it was observed that the tortuosity parameter significantly affected the scaffold's permeability and shear stress values. The tortuosity value of the NSP scaffold was in the range of 1.5-2.8. Therefore, tortuosity can be manipulated by changing the curvature of the surface scaffold radius to obtain a superior bone tissue engineering construction supporting cell migration and tissue regeneration. This parameter should be considered when making new scaffolds, such as our NSP. Such efforts will produce a scaffold architecturally and functionally close to the natural cancellous bone, as demonstrated in this study.

Computational Contact Pressure Prediction of CoCrMo, SS 316L and Ti6Al4V Femoral Head against UHMWPE Acetabular Cup under Gait Cycle.

Due to various concerns about the use of metal-on-metal that is detrimental to users, the use of metal as acetabular cup material was later changed to ultra high molecular weight polyethylene (UHMWPE). However, the wear on UHMWPE releases polyethylene wear particles, which can trigger a negative body response and contribute to osteolysis. For reducing the wear of polyethylene, one of the efforts is to investigate the selection of metal materials. Cobalt chromium molybdenum (CoCrMo), stainless steel 316L (SS 316L), and titanium alloy (Ti6Al4V) are the frequently employed materials. The computational evaluation of contact pressure was carried out using a two-dimensional axisymmetric model for UHMWPE acetabular cup paired with metal femoral head under gait cycle in this study. The results show Ti6Al4V-on-UHMWPE is able to reduce cumulative contact pressure compared to SS 316L-on-UHMWPE and CoCrMo-on-UHMWPE. Compared to Ti6Al4V-on-UHMWPE at peak loading, the difference in cumulative contact pressure to respective maximum contact pressure is 9.740% for SS 316L-on-UHMWPE and 11.038% for CoCrMo-on-UHMWPE.

Effect of Moringa oleifera supplementation during pregnancy on the prevention of stunted growth in children between the ages of 36 to 42 months.

BACKGROUND: The government has made provisions to improve the nutrition of stunted children under the age of five nationally by providing iron folic acid (IFA) tablet since conception. However, these drugs were not able to reduce the incidence of stunted growth. The aim of this study is to assess the effect of moringa intervention during pregnancy on the incidence of stunted growth in children between the ages of 36 to 42 months. DESIGN AND METHODS: This study is a follow-up to an experimental RCT-DB study during pregnancy. The interventions given were PG (Moringa Flour), EG (Moringa Extract) and IG (IFA) which was used as control. RESULTS: The highest number of children that had stunted growth after taking the PG by IG and EG extracts were 66 (41.5%), 53 (33.3%) and 40 (25.2%), respectively. The stunted risk factor analysis did not show a significant relationship to the stunted incidence. Furthermore, the consumption and dietary patterns of children were based on only fat consumption which was associated with stunted incidence (p<0.05). The results of multivariate analysis showed that the EG extract was effective in reducing the incidence of stunted growth (p<0.005) and as a protective factor of 0.431 times the incidence of stunted growth (LL-UL=0.246-0.754). CONCLUSIONS: The administration of Moringa oleifera extract during pregnancy prevents the incidence of stunted growth in children.

Dietary diversity, dietary patterns and dietary intake are associated with stunted children in Jeneponto District, Indonesia.

OBJECTIVE: The most influence of occurrence children stunted are those related to food, both in terms of quantity and quality. The aim of this study is seeing of the relationship between dietary diversity, dietary pattern and dietary intake for children stunted. METHODS: This study is a follow up of the previous study of nutrition interventions in children, where the total sample size children was 340 measured the dietary intake with 24-hour recall. The dietary diversity and dietary patterns was measured by the FFQ (Food Frequency Questioner) form for children. RESULTS: The results showed that a lack of energy intake associated with children stunted was 132 (44.9%) (p=0.050), and lacked fat intake was 125 (45.6%) (p<0.050). For the dietary diversity there is a relationship with stunted at a mean value of 7.51±0.87 (p<0.050). As for the dietary pattern, there is a relationship between insufficient of consumption nuts and stunted (p=0.019) and foods containing sugar (p=0.050) also, namely 135 (45.3%) and 103 (43.8%). CONCLUSION: Stunting in children is related to the quality and quantity of food.

The Effect of Bottom Profile Dimples on the Femoral Head on Wear in Metal-on-Metal Total Hip Arthroplasty.

Wear and wear-induced debris is a significant factor in causing failure in implants. Reducing contact pressure by using a textured surface between the femoral head and acetabular cup is crucial to improving the implant's life. This study presented the effect of surface texturing as dimples on the wear evolution of total hip arthroplasty. It was implemented by developing finite element analysis from the prediction model without dimples and with bottom profile dimples of flat, drill, and ball types. Simulations were carried out by performing 3D physiological loading of the hip joint under normal walking conditions. A geometry update was initiated based on the patient's daily routine activities. Our results showed that the addition of dimples reduced contact pressure and wear. The bottom profile dimples of the ball type had the best ability to reduce wear relative to the other types, reducing cumulative linear wear by 24.3% and cumulative volumetric wear by 31% compared to no dimples. The findings demonstrated that surface texturing with appropriate dimple bottom geometry on a bearing surface is able to extend the lifetime of hip implants.

Tresca Stress Simulation of Metal-on-Metal Total Hip Arthroplasty during Normal Walking Activity.

The selection of biomaterials for bearing in total hip arthroplasty is very important to avoid various risks of primary postoperative failure for patients. The current investigation attempts to analyze the Tresca stress of metal-on-metal bearings with three different materials, namely, cobalt chromium molybdenum (CoCrMo), stainless steel 316L (SS 316L), and titanium alloy (Ti6Al4V). We used computational simulations using a 2D axisymmetric finite element model to predict Tresca stresses under physiological conditions of the human hip joint during normal walking. The simulation results show that Ti6Al4V-on-Ti6Al4V has the best performance to reduce Tresca stress by 45.76% and 39.15%, respectively, compared to CoCrMo-on-CoCrMo and SS 316L-on-SS 316L.

Active case detection, treatment of falciparum malaria with combined chloroquine and sulphadoxine/pyrimethamine and vivax malaria with chloroquine and molecular markers of anti-malarial resistance in the Republic of Vanuatu.

BACKGROUND: Chloroquine-resistant Plasmodium falciparum was first described in the Republic of Vanuatu in the early 1980s. In 1991, the Vanuatu Ministry of Health instituted new treatment guidelines for uncomplicated P. falciparum infection consisting of chloroquine/sulphadoxine-pyrimethamine combination therapy. Chloroquine remains the recommended treatment for Plasmodium vivax. METHODS: In 2005, cross-sectional blood surveys at 45 sites on Malo Island were conducted and 4,060 adults and children screened for malaria. Of those screened, 203 volunteer study subjects without malaria at the time of screening were followed for 13 weeks to observe peak seasonal incidence of infection. Another 54 subjects with malaria were followed over a 28-day period to determine efficacy of anti-malarial therapy; chloroquine alone for P. vivax and chloroquine/sulphadoxine-pyrimethamine for P. falciparum infections. RESULTS: The overall prevalence of parasitaemia by mass blood screening was 6%, equally divided between P. falciparum and P. vivax. Twenty percent and 23% of participants with patent P. vivax and P. falciparum parasitaemia, respectively, were febrile at the time of screening. In the incidence study cohort, after 2,303 person-weeks of follow-up, the incidence density of malaria was 1.3 cases per person-year with P. vivax predominating. Among individuals participating in the clinical trial, the 28-day chloroquine P. vivax cure rate was 100%. The 28-day chloroquine/sulphadoxine-pyrimethamine P. falciparum cure rate was 97%. The single treatment failure, confirmed by merozoite surface protein-2 genotyping, was classified as a day 28 late parasitological treatment failure. All P. falciparum isolates carried the Thr-76 pfcrt mutant allele and the double Asn-108 + Arg-59 dhfr mutant alleles. Dhps mutant alleles were not detected in the study sample. CONCLUSION: Peak seasonal malaria prevalence on Malo Island reached hypoendemic levels during the study observation period. The only in vivo malaria drug efficacy trial thus far published from the Republic of Vanuatu showed chloroquine/sulphadoxine-pyrimethamine combination therapy for P. falciparum and chloroquine alone for P. vivax to be highly efficacious. Although the chloroquine-resistant pfcrt allele was present in all P. falciparum isolates, mutant alleles in the dhfr and dhps genes do not yet occur to the extent required to confer sulphadoxine-pyrimethamine resistance in this population.

Impacts of dynamic degradation on the morphological and mechanical characterisation of porous magnesium scaffold.

This study employs a computational approach to analyse the impact of morphological changes on the structural properties of biodegradable porous Mg subjected to a dynamic immersion test for its application as a bone scaffold. Porous Mg was immersed in a dynamic immersion test for 24, 48, and 72 h. Twelve specimens were prepared and scanned using micro-CT and then reconstructed into a 3D model for finite element analysis. The structural properties from the numerical simulation were then compared to the experimental values. Correlations between morphological parameters, structural properties, and fracture type were then made. The relative losses were observed to be in agreement with relative mass loss done experimentally. The degradation rates determined using exact (degraded) surface area at particular immersion times were on average 20% higher than the degradation rates obtained using original surface area. The dynamic degradation has significantly impacted the morphological changes of porous Mg in volume fraction, surface area, and trabecular separation, which in turn affects its structural properties and increases the immersion time.

Changes in the total leukocyte and platelet counts in Papuan and non Papuan adults from northeast Papua infected with acute Plasmodium vivax or uncomplicated Plasmodium falciparum malaria.

BACKGROUND: There are limited data on the evolution of the leukocyte and platelet counts in malaria patients. METHODS: In a clinical trial of chloroquine vs. chloroquine plus doxycycline vs. doxycycline alone against Plasmodium vivax (n = 64) or Plasmodium falciparum (n = 98) malaria, the total white cell (WCC) and platelet (PLT) counts were measured on Days 0, 3, 7 and 28 in 57 indigenous Papuans with life long malaria exposure and 105 non Papuan immigrants from other parts of Indonesia with limited malaria exposure. RESULTS: The mean Day 0 WCC (n = 152) was 6.492 (range 2.1-13.4) x 10(9)/L and was significantly lower in the Papuans compared to the non Papuans: 5.77 x 10(9)/L vs. 6.86 x 10(9)/L, difference = -1.09 [(95% CI -0.42 to -1.79 x 10(9)/L), P = 0.0018]. 14 (9.2%) and 9 (5.9%) patients had leukopaenia (<4.0 x 10(9)/L) and leukocytosis (>10.0 x 10(9)/L), respectively. By Day 28, the mean WCC increased significantly (P = 0.0003) from 6.37 to 7.47 x 10(9)/L (73 paired values) and was similar between the two groups. Ethnicity was the only WCC explanatory factor and only on Day 0.The mean Day 0 platelet count (n = 151) was 113.0 (range 8.0-313.0) x 10(9)/L and rose significantly to 186.308 x 10(9)/L by Day 28 (P < 0.0001). There was a corresponding fall in patient proportions with thrombocytopaenia (<150 x 10(9)/L): 119/151 (78.81%) vs. 16/73 (21.92%, P < 0.00001). Papuan and non Papuan mean platelet counts were similar at all time points. Only malaria species on Day 0 was a significant platelet count explanatory factor. The mean D0 platelet counts were significantly lower (P = 0.025) in vivax (102.022 x 10(9)/L) vs. falciparum (122.125 x 10(9)/L) patients. CONCLUSION: Changes in leukocytes and platelets were consistent with other malaria studies. The Papuan non Papuan difference in the mean Day 0 WCC was small but might be related to the difference in malaria exposure.

Atovaquone/proguanil therapy for Plasmodium falciparum and Plasmodium vivax malaria in Indonesians who lack clinical immunity.

Thirty-eight of 295 subjects participating in a randomized, double-blind, placebo-controlled trial of the efficacy of daily administration of atovaquone/proguanil for malaria prevention developed malaria at some time during the 20-week prophylaxis period. These subjects (3 atovaquone/proguanil recipients and 35 placebo recipients) were treated with 4 tablets of atovaquone/proguanil per day for 3 days. Atovaquone/proguanil provided safe, well-tolerated, and effective therapy for uncomplicated malaria in nonimmune Indonesians.

Assessing the Parasight-F test in northeastern Papua, Indonesia, an area of mixed Plasmodium falciparum and Plasmodium vivax transmission.

User-friendly, reliable, and inexpensive methods for diagnosing malaria are needed at the primary health care level. During a randomized treatment trial, the Parasight-F test was assessed on days 0, 3, 7, and 28 against standard light microscopy of Giemsa-stained thick blood smears for diagnosing Plasmodium falciparum parasitemia in patients with P. falciparum (n = 84) or P. vivax (n = 59) malaria. The median P. falciparum parasite count on day 0 was 2,373/microL (range = 20-74,432/microL). At the start of treatment, the Parasight-F test had a sensitivity of 95.2% (80 of 84; 95% confidence interval [CI] = 88.2-98.7), and a specificity of 94.9% (56 of 59; 95% CI = 85.8-98.9). On day 7, this test showed false-positive results in 17 (16.3%) of 104 patients (95% CI = 9.8-24.9). The Parasight-F test performed well when compared with light microscopy in detecting P. falciparum parasitemia in patients presenting with clinical malaria. However, the high false-positive rate on day 7 limits its use for patient follow-up.

Short report: therapeutic efficacy of chloroquine combined with primaquine against Plasmodium falciparum in northeastern Papua, Indonesia.

Chloroquine combined with primaquine was evaluated for therapy of uncomplicated malaria caused by Plasmodium falciparum in nonimmune Javanese migrants to northeastern Papua, Indonesia. Subjects were randomized to treatment with standard chloroquine therapy (25 mg/kg in 3 doses over the course of 48 hours) with 30 mg primaquine administered daily for 28 days (n = 25) or a placebo of primaquine (n = 28). The 14-day cumulative incidence of therapeutic failure was 56% with primaquine and 79% with placebo (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.1-1.3; P = 0.08). Primaquine administered daily created a marginally significant improvement in therapeutic efficacy at day 14, but not at day 7 (20% versus 36%; OR, 0.2; 95% CI, 0.1-1.8; P = 0.2) or day 28 (82% versus 93%; OR, 0.31; 95% Cl, 0.04-2.1; P = 0.23). This report corroborates studies suggesting that therapeutic doses of primaquine exert no discernible effect on parasitemia by P. falciparum.

Demographic risk factors for severe and fatal vivax and falciparum malaria among hospital admissions in northeastern Indonesian Papua.

Between January 1998 and December 2000, the Jayapura Provincial Public Hospital in northeastern Indonesian New Guinea (Papua) admitted 5,936 patients with a diagnosis of malaria. The microscopic diagnosis at admission was Plasmodium falciparum (3,976, 67%), Plasmodium vivax (1,135, 19%), Plasmodium malariae (8, < 1%), and mixed species infections (817, 14%). Approximately 9% (367) of patients were classified as having severe malaria (277 P. falciparum, 36 P. vivax, 53 mixed infections, and 1 P. malariae) and 88 died (79 P. falciparum/mixed infections and 9 P. vivax). Risk of fatal outcomes among severe malaria patients was indistinguishable between those with falciparum versus vivax malaria (OR = 0.89; P = 0.771). Compared with non-pregnant women, pregnant women showed no higher risk of severe malaria (P = 0.643) or death caused by severe malaria (P = 0.748). This study compares admissions per population (based on census data), parasitemia, morbidity, and mortality among children versus adults, pregnant versus non-pregnant women, and urban/suburban versus rural residents.

Observation of the relationship between the shape of skeletal muscles and their nerve distribution patterns: a transparent and microanatomic study.

BACKGROUND: There are many gaps in the understanding of the neuroanatomy of skeletal muscles with regards to the nerve distribution pattern and shape of the muscles. This study was designed to examine the entire intramuscular nerve-distribution patterns of various human skeletal muscles. METHODS: The relationships among nine skeletal muscles with various architecture (rhomboid major, biceps brachii, flexor pollicis longus, rectus femoris, sternohyoid, trapezius, masseter, digastric muscles) and their nerve-distribution patterns were investigated in four fetal cadavers using the Sihler staining method. The diameter and number of extramuscular (main) and major nerve branches, the number of minor nerve branches, and anastomoses were examined and evaluated statistically. RESULTS: With regards to the number of extramuscular (main) nerve branches, the rhomboid major muscle resembled the flexor pollicis longus, trapezius, masseter, and sternohyoid muscles, and the anterior belly of the digastricus muscle (p > 0.05), whereas it was significantly different from the rectus femoris, the posterior belly of digastricus, and the long and short heads of the biceps brachii (p < 0.05). Trapezius and masseter muscles were different from all of the skeletal muscles that were studied with regards to the diameter of main branches (p < 0.05). The masseter muscle had the largest diameter (p < 0.05). With regards to the number of minor nerve branches, the sternohyoid muscle was significantly different from all the skeletal muscles that were studied (p < 0.05) except the short head of the biceps brachii, rectus femoris, and the posterior belly of digastricus (p > 0.05). As for the number of neural anastomoses, the sternohyoid muscle was statistically different from all skeletal muscles that were studied (p < 0.05) except the masseter and trapezius muscles (p > 0.005). CONCLUSIONS: A surgeon's thorough knowledge of the relationship between the shape and nerve distribution pattern of skeletal muscles is important in successful reinnervation and regeneration of these muscles. It might also be useful in the field of muscle transplantation.