Tuberculosis of the Sternoclavicular Joint: Report of Three cases.

Ebstein's anomaly accounts for 0.3% to 0.7% of all cases of congenital heart disease. The condition is characterized by abnormal tricuspid valve and right ventricle with apical displacement of tricuspid valve leading to atrialization of right ventricle. There have been case reports of patients surviving up to ninth decade. It is unusual for these patients to be asymptomatic in adulthood for long duration. We describe a patient with Ebstein's anomaly in the ninth decade with coronary artery disease.

A Phase 3, Double-Blind, Randomized Study of Arterolane Maleate-Piperaquine Phosphate vs Artemether-Lumefantrine for Falciparum Malaria in Adolescent and Adult Patients in Asia and Africa.

BACKGROUND: Artemisinins, which are derived from plants, are subject to risk of supply interruption due to climatic changes. Consequently, an effort to identify a new synthetic antimalarial was initiated. A fixed-dose combination of arterolane maleate (AM), a new synthetic trioxolane, with piperaquine phosphate (PQP), a long half-life bisquinoline, was evaluated in patients with uncomplicatedPlasmodium falciparummalaria. METHODS: In this multicenter, randomized, double-blind, comparative, parallel-group trial, 1072 patients aged 12-65 years withP. falciparummonoinfection received either AM-PQP (714 patients) once daily or artemether-lumefantrine (A-L; 358 patients) twice daily for 3 days. All patients were followed up until day 42. RESULTS: Of the 714 patients in the AM-PQP group, 638 (89.4%) completed the study; of the 358 patients in the A-L group, 301(84.1%) completed the study. In both groups, the polymerase chain reaction corrected adequate clinical and parasitological response (PCR-corrected ACPR) on day 28 in intent-to-treat (ITT) and per-protocol (PP) populations was 92.86% and 92.46% and 99.25% and 99.07%, respectively. The corresponding figures on day 42 in the ITT and PP populations were 90.48% and 91.34%, respectively. After adjusting for survival ITT, the PCR-corrected ACPR on day 42 was >98% in both groups. The overall incidence of adverse events was comparable. CONCLUSIONS: AM-PQP showed comparable efficacy and safety to A-L in the treatment of uncomplicatedP. falciparummalaria in adolescent and adult patients. AM-PQP demonstrated high clinical and parasitological response rates as well as rapid parasite clearance. CLINICAL TRIALS REGISTRATION: India. CTRI/2009/091/000101.

Arterolane maleate plus piperaquine phosphate for treatment of uncomplicated Plasmodium falciparum malaria: a comparative, multicenter, randomized clinical trial.

BACKGROUND: Artemisinin-based combination therapy is the first-line treatment for uncomplicated falciparum malaria. This study assessed the antimalarial efficacy and safety of a combination of 150 mg of arterolane maleate and 750 mg of piperaquine phosphate (AM-PQP) in comparison to Coartem (artemether and lumefantrine) in patients with acute uncomplicated P. falciparum malaria. METHODS: In this open-label, randomized, multicentric, parallel group clinical trial, 240 patients were randomized to receive AM-PQP (160 patients) or Coartem (80 patients). Patients with P. falciparum monoinfection and initial parasite densities ranging from 1000 to 100 000 asexual parasites/µL of blood were followed for 28 days. Polymerase chain reaction-corrected adequate clinical and parasitologic response on day 28, parasite clearance time, and fever clearance time were evaluated. RESULTS: A total of 151 (94.4%) of 160 patients in the AM-PQP group completed the trial, while 77 (96.3%) of 80 patients in the Coartem group completed the trial. No treatment failure was noted in the AM-PQP group, while one patient receiving Coartem failed treatment on day 28. There was no difference in the median parasite clearance time (30 hours in both groups) or median fever clearance time (24 hours in both groups) after administration of the 2 study treatments. CONCLUSIONS: The available data support the evaluation of a drug combination in a larger population as a fixed-dose combination. Clinical Trials Registration. CTRI/2007/091/000031.

Reduction of mechanical heart valve thrombosis through a clinical audit.

BACKGROUND AND AIM OF THE STUDY: Patients with mechanical heart valves implanted at four cardiothoracic centers were followed up in a hospital in Eastern India. Despite successful surgery and regular hospital visits, long-term survival was compromised by anticoagulation-related complications. METHODS: Systematic analysis revealed under-anticoagulation in most patients. Thrombosis risk in 80 patients on regular follow up from 1989 to 1997 was 8.68 per 100 patient years (pt-yr). The incidence of both thrombotic and bleeding complications was reported as less than two per 100 pt-yr, when prothrombin time was consistently in the range of INR 2.5 to 3.9. In targeting this low event rate, impediments to optimum anticoagulation in the local set-up were identified. International Normalized Ratio (INR) was introduced to report prothrombin time (PT). Patients and doctors were educated about drug and diet interactions with oral anticoagulants (OAC) and the early features of valve thrombosis. Treatment protocols were evolved. The impact of the remedial measures was studied in 81 patients (64 old, 17 new) over a total of 254 pt-yr of follow up, from 1998 to 2001. RESULTS: Thrombosis risk was reduced from 8.68 to 5.12 per 100 pt-yr, while non-fatal bleeding events increased from 0.28 to 1.96 per 100 pt-yr. Due to early recognition of occlusive prosthetic valve thrombosis and institution of fibrinolytic therapy, fatal events were reduced from 3.8 per 100 pt-yr to none for four consecutive years (statistically significant at 99% CI). CONCLUSION: The clinical audit proved to be a valuable tool for understanding the problems in health care delivery, and bringing about improvement.