Pelvic lymph node dissection before or after laparoscopic radical cystectomy: An ambispective study comparing ease of surgery and operative outcomes.

Introduction: It is unclear when pelvic lymph node dissection (PLND) should be performed during laparoscopic radical cystectomy. Proponents of PLND performed before cystectomy claim that early PLND skeletonizes the urinary bladder's vascular pedicles, making cystectomy easy. Others contend that an early cystectomy provides space and flexibility during subsequent PLND. This first-of-its-kind study compared PLND before and after cystectomy for the ease of performing surgery (total operative time, cystectomy time, and PLND time) and the operative outcomes (number of lymph nodes removed, blood loss, and complication rates). Methods: This ambispective cohort study included a predetermined sample size of 44 patients. The first 22 patients underwent PLND after cystectomy (Group 1), and the following 22 underwent PLND before cystectomy (Group 2). The primary outcome was total operative time. Secondary outcomes included cystectomy time, PLND time, number of lymph nodes removed, blood loss, and complication rates. Results: The baseline characteristics were similar in both groups. The total operative time (344.23 ± 41.58 min vs. 326.95 ± 43.63 min, P = 0.19), cystectomy time (119.36 ± 34.44 min vs. 120.91 ± 35.16 min, P = 0.53), PLND time (126.82 ± 18.75 min vs. 119.36 ± 23.34 min, 0.25), number of dissected lymph nodes (13.27 ± 4.86 vs. 14.5 ± 4.76, P = 0.40), and blood loss (620.45 ± 96.23 ml vs. 642.27 ± 131.8 ml, P = 0.20) were similar in the two groups. The complication rates categorized by Clavien-Dindo grading were identical in the two groups. Conclusions: PLND done after cystectomy was comparable to PLND done before cystectomy regarding the ease of surgery and the operative outcomes.

Thrombus Masquerading a Double J Ureteric Stent.

Renal cell carcinoma (RCC) is the most common renal parenchymal malignancy found in adults. When these tumors are located centrally in the kidney and do not enhance well on contrast imaging, they may be mistaken to be urothelial in origin, and the diagnosis is established on histopathology. We present an interesting case of RCC with an atypical vermiform thrombus projecting into the urinary bladder.

Neutrophils dominate in opsonic phagocytosis of P. falciparum blood-stage merozoites and protect against febrile malaria.

Antibody-mediated opsonic phagocytosis (OP) of Plasmodium falciparum blood-stage merozoites has been associated with protection against malaria. However, the precise contribution of different peripheral blood phagocytes in the OP mechanism remains unknown. Here, we developed an in vitro OP assay using peripheral blood leukocytes that allowed us to quantify the contribution of each phagocytic cell type in the OP of merozoites. We found that CD14 + +CD16- monocytes were the dominant phagocytic cells at very low antibody levels and Fc gamma receptor (FcγR) IIA plays a key role. At higher antibody levels however, neutrophils were the main phagocytes in the OP of merozoites with FcγRIIIB acting synergistically with FcγRIIA in the process. We found that OP activity by neutrophils was strongly associated with protection against febrile malaria in longitudinal cohort studies performed in Ghana and India. Our results demonstrate that peripheral blood neutrophils are the main phagocytes of P. falciparum blood-stage merozoites.

Identification of Single-Nucleotide Polymorphisms in the Mitochondrial Genome and Kelch 13 Gene of Plasmodium falciparum in Different Geographical Populations.

The emergence of artemisinin-resistant Plasmodium falciparum parasites in Southeast Asia threatens malaria control and elimination. The interconnectedness of parasite populations may be essential to monitor the spread of resistance. Combining a published barcoding system of geographically restricted single-nucleotide polymorphisms (SNPs), mainly mitochondria of P. falciparum with SNPs in the K13 artemisinin resistance marker, could elucidate the parasite population structure and provide insight regarding the spread of drug resistance. We explored the diversity of mitochondrial SNPs (bp position 611-2825) and identified K13 SNPs from malaria patients in the districts of India (Ranchi), Tanzania (Korogwe), and Senegal (Podor, Richard Toll, Kaolack, and Ndoffane). DNA was amplified using a nested PCR and Sanger-sequenced. Overall, 199 K13 sequences (India: N = 92; Tanzania: N = 48; Senegal: N = 59) and 237 mitochondrial sequences (India: N = 93; Tanzania: N = 48; Senegal: N = 96) were generated. SNPs were identified by comparisons with reference genomes. We detected previously reported geographically restricted mitochondrial SNPs (T2175C and G1367A) as markers for parasites originating from the Indian subcontinent and several geographically unrestricted mitochondrial SNPs. Combining haplotypes with published P. falciparum mitochondrial genome data suggested possible regional differences within India. All three countries had G1692A, but Tanzanian and Senegalese SNPs were well-differentiated. Some mitochondrial SNPs are reported here for the first time. Four nonsynonymous K13 SNPs were detected: K189T (India, Tanzania, Senegal); A175T (Tanzania); and A174V and R255K (Senegal). This study supports the use of mitochondrial SNPs to determine the origin of the parasite and suggests that the P. falciparum populations studied were susceptible to artemisinin during sampling because all K13 SNPs observed were outside the propeller domain for artemisinin resistance.

Acute respiratory distress syndrome (ARDS) as an adverse event following immunization: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data.

This is a Brighton Collaboration Case Definition of the term "Acute Respiratory Distress Syndrome - ARDS" to be utilized in the evaluation of adverse events following immunization. The Case Definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of vaccines for SARS-CoV-2 vaccines and other emerging pathogens. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and defined levels of certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network and by selected Expert Reviewers prior to submission. The comments of the reviewers were taken into consideration and edits incorporated in this final manuscript.

Diversity of native larvivorous fish fauna during pre- and post-tsunami in Car Nicobar, Andaman & Nicobar Islands, India.

BACKGROUND & OBJECTIVES: Malaria is a serious public health problem in Car Nicobar Island, Andaman & Nicobar Islands, India. Using larvivorous fishes has proved to be the cheapest method for vector management approach, with long suppression of mosquito population. This study aims to scale-up the diversity of larvivorous fishes and their potential larvivoracity to evolve an appropriate biological intervention strategy against the immature stages of malaria vectors. METHODS: During 2003 (pre-tsunami) and 2014-2016 (post-tsunami), an ecological descriptive survey was carried out in the water bodies around Car Nicobar Island. Fishes were captured using fishing nets and cast nets; and placed in plastic jars and preserved in formalin solution. Fishes were identified and classified according to the available keys. Their abundance and data on the current conservation status was recorded and analyzed. Their potential larvivoracity was graded according to their feeding intensity. RESULTS: Pre-tsunami, a total of 27 larvivorous fish species belonging to 11 orders, 23 families and 23 genera were identified. Order Perciformes and the family Cyprinidae were the most ascendant group constituting 51.9 and 11.1%, respectively. While, 80.8% of species were preferred to inhabit the freshwater region, only 37% of species were surface feeders (SF). According to the conservation, assessment and management plan (CAMP, 1998), 44.4% species were at lower risk least concern (LRlc), while 55.6% species were at least concerned (LC) as per the IUCN, 2017 categorization. However, after the tsunami, 17 fish species had gone extinct and 10 fish species were found to remain alive in the local water bodies. INTERPRETATION & CONCLUSION: Post-tsunami, the larvivoracity analysis indicated that Ophiocara aporos, Ophiocara procephala, Valamugil seheli, Channa punctata, Kuhlia rupestris, Khulia mugil, and Terapon jarbua possess high-level larvivorous potentiality in nature and are recommended for vector control in the study area. These fish species were facing several anthropogenic threats, such as human interference, loss of habitat, trade, overexploitation, and fishing. Therefore, it is important to protect the water bodies from external impact and implement the conservation strategies. Further, periodic fish fauna surveys, identification of breeding sites, scale-up of the larvivorous potentiality at the field level, creating public awareness through health education on establishment of larvivorous fish ponds and planning for mass rearing of the native fish species should be adopted as part of vector management approach in the endemic malarious region of Car Nicobar Island.

Peripheral Merozoite Surface Proteins Are Targets of Naturally Acquired Immunity against Malaria in both India and Ghana.

Development of a successful blood-stage vaccine against Plasmodium falciparum malaria remains a high priority. Immune-epidemiological studies are effective tools for the identification of antigenic targets of naturally acquired immunity (NAI) against malaria. However, differences in study design and methodology may compromise interstudy comparisons. Here, we assessed antibody responses against intact merozoites and a panel of 24 recombinant merozoite antigens in longitudinal cohort studies of Ghanaian (n = 115) and Indian (n = 121) populations using the same reagents and statistical methods. Anti-merozoite antibodies were associated with NAI in both the Indian (hazard ratio [HR] = 0.41, P = 0.020) and the Ghanaian (HR = 0.17, P < 0.001) participants. Of the 24 antigen-specific antibodies quantified, 12 and 8 were found to be protective in India and Ghana, respectively. Using least absolute shrinkage and selection operator (LASSO) regression, a powerful variable subselection technique, we identified subsets of four (MSP6, MSP3.7, MSPDBL2, and Pf12) and five (cMSP33D7, MSP3.3, MSPDBL1, GLURP-R2, and RALP-1) antigens that explained NAI better than the individual antibodies in India (HR = 0.18, P < 0.001) and Ghana (HR = 0.31, P < 0.001), respectively. IgG1 and/or IgG3 subclasses against five antigens from these subsets were associated with protection. Through this comparative study, maintaining uniformity of reagents and methodology, we demonstrate that NAI across diverse geographic regions may result from antibodies to multiple antigenic targets that constitute the peripheral merozoite surface protein complexes.

Delayed haemolysis after treatment with intravenous artesunate in patients with severe malaria in India.

BACKGROUND: Parenteral artesunate is the treatment of choice for severe malaria. It is safe, efficacious and well tolerated anti-malarial. However, delayed haemolysis has been reported in travellers, non-immune individuals and in African children. METHODS: A prospective, observational study was carried out in admitted severe malaria patients receiving parenteral artesunate. The patients were followed up until day 28 for monitoring clinical as well as laboratory parameters for haemolytic anaemia. RESULTS: Twenty-four patients with severe malaria receiving injection artesunate were enrolled in the study. Post-artesunate delayed haemolysis following parenteral artesunate therapy was observed in three of 24 patients (12.5%, 95% confidence interval 4.5-31.2%). Haemolysis was observed in two more patients possibly due to other reasons. The haemoglobin fall ranged from 13.6 to 38.3% from day 7 to day 28 in these patients. CONCLUSION: The possibility of delayed haemolysis should be considered while treating the severe malaria patients with parenteral artesunate. The study highlights the need for further studies in different epidemiological settings.

Fungal Balls Mimicking Renal Calculi: A Zebra Among Horses.

Background: Fungal masses (fungal ball or bezoars) rarely present as renal calculus. More so, Trichosporon species are even more uncommon among the noncandidial fungal infections affecting urinary tract. We report two such interesting cases that are not yet reported in the current literature. Case Reports: Our first case is a 48-year-old gentleman with diabetes presented with fever and flank pain. He was found to have bilateral obstructing radiolucent renal calculi with azotemia. Initially managed with bilateral Double-J stenting after one session of hemodialysis, and subsequently bilateral percutaneous nephrolithotomy (PCNL) was accomplished. Our second patient is a 37-year-old lady presented with bilateral flank pain with no comorbidity or sepsis. On evaluation, she was found to have bilateral radiolucent staghorn calculi and for which bilateral PCNL was performed. In view of high suspicion of fungal infection, extracted soft floppy materials were sent for fungal culture and were treated with antifungal agents after Trichosporon species was detected. Conclusion: Although renal fungal infections are rare, a strong suspicion and timely definitive management of such entities in patients with radiolucent renal calculus can prevent devastating invasive disease.

Native larvivorous fish diversity as a biological control agent against mosquito larvae in an endemic malarious region of Ranchi district in Jharkhand, India.

BACKGROUND & OBJECTIVES: Mosquitoes are responsible for transmitting several diseases, including malaria, dengue, chikungunya, filariasis, and yellow fever, etc. Release of larvivorous fishes is one of the cheapest method of vector management approach, with long suppression of mosquito population. The present study identifies the native larvivorous fishes and evaluates their potential larvivoracity for biological control of mosquito larvae in an endemic malarious region. METHODS: During the year 2012-13, an ecological descriptive study was carried out in diverse aquatic habitats of fish species found in different areas of Ranchi district, in Jharkhand state of India. Fishes were captured using fishing nets, and identified and classified according to the available keys. Their larvivorous potential was graded according to their feeding potential. Data on current conservation status as well as their abundance were also recorded and analysed. RESULTS: In total, 30 larvivorous fish species belonging to seven orders, 10 families and 21 genera were identified. Order Cypriniformes and the family Cyprinidae were the most ascendant group constituting 66.7 and 60%, respectively. The grading assessment of larvivorous potential for different fish species revealed that, Colisa fasciatus possess maximum larvivoracity (+ + + + +). According to the conservation, assessment and management plan (CAMP, 1998), 60% species were at lower risk near threat (LRnt), while 86.7% species were at least concerned (LC) as per the IUCN, 2017 categorisation. All fish species preferred to inhabit in freshwater. Maximum species occurrence was found in the river (63.3%). Only 30% species were bottom feeders (BF). INTERPRETATION & CONCLUSION: The larvivoracity and habitat distribution analysis indicated that C. fasciatus, Oreochromis mossambica, Esomus danricus, Oryzias melastigma, Puntius sophore, P. ticto, Rasbora daniconius, R. elegans, Aplocheilus panchax, and Danio (B) rerio possess high-level larvivorous potentiality in nature and are recommended for malaria control in the study area. There is an increasing pressure on the fish fauna, of facing several threats, such as fishing, human interference, loss of habitat, overexploitation, pollution, siltation, trade, and diseases. Therefore, periodic survey and monitoring of fish biodiversity, demarcation of breeding sites, field level research study on the efficacy of these fishes, and public awareness on establishment of larvivorous fish ponds should be adopted as a part of the vector management approach in the endemic malarious region of Ranchi district in Jharkhand, India.

Episodes of the epidemiological factors correlated with prevailing viral infections with dengue virus and molecular characterization of serotype-specific dengue virus circulation in eastern India.

BACKGROUND: Dengue is one of the most important and widespread viral infection comprises 4 related serotypes (DEN-1, 2, 3, and 4). Infection with one serotype does not protect against the others, and sequential infections put people at greater risk for dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). This study determines the epidemiology of prevailing viral infections with dengue and molecular characterization of serotype-specific DENV circulation in Odisha of eastern India. METHODS: During the year 2013, 1980 blood samples with suspected dengue cases were obtained between days 1-10 of illness and analyzed by NS1 Ag-RDT, NS1 Ag-ELISA, and RT-PCR. The differential detection of dengue infections and DENV serotyping were carried out by IgM/IgG Ab-ELISA and RT-PCR, respectively. RESULTS: Of the 1980 samples, 733 (37.0%) were positive for dengue RNA by RT-PCR. The confirmed cases of dengue were more in males (73.6%) in comparing to females (26.4%). The age group of 15-44years (527 cases, 71.9%) were more susceptible to dengue infections. 656 (89.5%) cases had infected with monotypic infection by different DENV serotype and 77 (10.5%) cases had multitypic infections by multiple serotypes of DENV. Of the total multitypic infections, there were 74 (10.1%) cases had infected with DENV-2 and DENV-3 serotypes at a time; and only 3 (0.4%) cases had the concurrent infections of all three serotypes that were, DENV-1, DENV-2, and DENV-3. Of the 28 DHF cases, there were 17 (2.3%) cases had infected with multitypic infections and 11 (1.5%) cases had infected with monotypic infection. CONCLUSION: Dengue infections have prevailed from the month of July and grasped it's the peak in September. Rain, temperature and relative humidity have favored the dengue infections. Young adults and males are more susceptible to dengue infections. Serotypes DEN-2 followed by DEN-3 was dominant among the confirmed dengue cases. Co-circulation of multitypic infections with multiple DENV serotypes and the emergence of DHF cases suggested that eastern Indian state Odisha was becoming a hyper-endemic province for dengue; therefore, continuous surveillance is suggested for understanding the epidemiology of the diseases and monitoring the changes in the characteristics of circulating DENV strains.

Monitoring the efficacy of antimalarial medicines in India via sentinel sites: Outcomes and risk factors for treatment failure.

BACKGROUND & OBJECTIVES: To combat the problem of antimalarial drug resistance, monitoring the changes in drug efficacy over time through periodic surveillance is essential. Since 2009, systematic and continuous monitoring is being done through nationwide sentinel site system. Potential early warning signs like partner drug resistance markers were also monitored in the clinical samples from the study areas. METHODS: A total of 1864 patients with acute uncomplicated malaria were enrolled in therapeutic efficacy studies of artesunate plus sulphadoxine-pyrimethamine (AS+SP) for Plasmodium falciparum; those infected with P. vivax were given chloroquine (CQ). Polymerase chain reaction (PCR) was used to distinguish post-treatment reinfection from treatment failures. Isolates of P. falciparum were also analysed for dihydropteroate synthase (dhps) and dihydrofolate reductase (dhfr) gene mutations. RESULTS: Overall, 1687 (91.7%) patients completed the follow-up. In most of the falciparum patients the parasitaemia was cleared within 24 h of treatment, except 12 patients who remained parasite positive after 72 h. Presence of dhfr and dhps quintuple mutation was observed predominantly in treatment failure samples. A daily dose of artesunate of < 3 mg/kg of body weight, age of <5 yr, and fever at enrolment were associated with an increased risk of treatment failure. The AS+SP in P. falciparum was effective in > 95% cases in all the sentinel sites except in Northeastern region (NE). Chloroquine remained 100% efficacious in case of P. vivax infections. INTERPRETATION & CONCLUSION: Till 2012, India's national antimalarial drug resistance monitoring system proved highly efficacious and safe towards first-line antimalarials used in the country, except in Northeastern region where a decline in efficacy of AS+SP has been observed. This led to change in first-line treatment for P. falciparum to artemether-lumefantrine in Northeastern region.

A Prospective Randomized Comparison Between Shock Wave Lithotripsy and Flexible Ureterorenoscopy for Lower Caliceal Stones ≤2 cm: A Single-Center Experience.

AIMS AND OBJECTIVES: The optimal management method of lower caliceal calculi is still undefined. We performed a prospective randomized comparison to evaluate safety and efficacy of shock wave lithotripsy (SWL) and flexible ureteroscopy (RIRS) for lower caliceal calculus ≤2 cm. MATERIALS AND METHODS: Between December 2011 and January 2012, 195 patients with single radio-opaque lower caliceal calculi ≤2 cm were included in the study. Randomization was done into two groups-group A: SWL performed as an outpatient procedure using the electromagnetic lithotripter (Dornier compact delta) and group B: RIRS was performed using the 6F/7.5F flexible ureteroscope (Richard Wolf) with holmium laser intracorporeal lithotripsy. Demographic characteristics, success, retreatment, and auxiliary procedure rates and complications were analyzed statistically. RESULTS: Of 195 patients, 97 and 98 patients were enrolled in group A and B, respectively. Mean stone size was 12.1 mm in group A vs 12.3 mm in group B (p=0.52). The overall 3 month stone-free rate was (74/90) 82.2% for group A vs (78/90) 86.6% for group B (p=0.34); for stones <10 mm, it was (45/55) 84.9% for group A vs (43/51) 87.7% for group B (p=0.32) and for 10-20 mm stones, it was (29/35) 78.4% for group A vs (35/39) 85.4% for group B (p=0.12). Retreatment rate was significantly greater in group A compared with group B (61.1% vs 11.1%; p<0.001). Auxiliary procedure rate was comparable (21.1% vs 17.7%; p=0.45). The complication rate was 6.6% in group A vs 11.1% in group B (p=0.21). CONCLUSIONS: Both SWL and RIRS are safe and efficacious for lower caliceal calculi ≤20 mm. For stones <10 mm, SWL was less invasive and safer than RIRS with efficacy comparable to it. However, for 10-20 mm stones, RIRS was more effective, with lesser retreatment rate.

Multiple carboxylase deficiency (late onset) due to deficiency of biotinidase.

Biotinidase is a ubiquitous mammalian cell enzyme occurring in liver, serum and kidney. It cleaves biotin from biocytin, which is a cofactor for biotin dependent enzymes, namely the human carboxylases. Biotinidase deficiency is associated with a wide spectrum of neurological, dermatological, immunological and ophthalmological abnormalities. This is a case of a 3-year-old boy presenting with delayed developmental milestones, tachypnea, progressively increasing ataxia, alopecia and dermatitis, all which dramatically responded to high doses of biotin.

Insights following change in drug policy: a descriptive study for antimalarial prescription practices in children of public sector health facilities in Jharkhand state of India.

BACKGROUND & OBJECTIVES: Widespread resistance to chloroquine was the mainstay to implement artemisinin-based combination therapy (ACT) in the year 2007 in few malaria endemic states in India including Jharkhand as the first line of treatment for uncomplicated Plasmodium falciparum malaria. This study was conducted in Jharkhand state of the country just after the implementation of ACT to assess the prevailing antimalarial drug prescribing practices, availability of antimalarial drugs and the acceptability of the new policy by the health professionals for the treatment of uncomplicated P. falciparum malaria patients particularly in children ≤ 15 yr of age. METHODS: This is a cross-sectional study in children aged ≤ 15 yr with malaria or to whom antimalarial drug was prescribed. Main outcome measure was prescription of recommended ACT in children aged ≤ 15 yr with malaria in the selected areas of Jharkhand. RESULTS: In the year 2008, artemisinin-based combination therapy (ACT) was implemented in 12 districts of the studied state; however, the availability of ACT was confirmed only in five districts. Antimalarial prescription was prevalent amongst the undiagnosed (8.4%), malaria negative (64.3%) and unknown blood test result (1.2%) suggesting the prevalence of irrational treatment practices. ACT prescription was very low with only 3.2% of confirmed falciparum malaria patients receiving it while others received either non-artesunate (NA) treatment (88.1%) including chloroquine (CQ) alone, CQ + Primaquine (PQ)/other drugs, sulphadoxine-pyrimethamine (SP) alone, SP + other drugs or artemisinin monotherapy (AM) treatment (6.3%). Still others were given non-antimalarial treatment (NM) in both malaria positive (0.3%) and malaria negative (2.1%) cases. INTERPRETATION & CONCLUSION: Despite the change in drug policy in the studied state the availability and implementation of ACT was a major concern. Nevertheless, the non-availability of blister packs for children aged ≤ 15 yr was the main hindrance in the implementation of the recommended antimalarial. Availability, training and participation of health professionals in decision-making are the key elements to improve adherence to new treatment guidelines. This study provided evidence for the requirement of age-specific blister packs in the country and the national programme has introduced age-specific blister packs in the country in 2010. This baseline information will be useful to monitor the progress in ACT implementation in the country.

Prescription practices and availability of artemisinin monotherapy in India: where do we stand?

BACKGROUND: The World Health Organization has urged all member states to deploy artemisinin-based combination therapy and progressively withdraw oral artemisinin monotherapies from the market due to their high recrudescence rates and to reduce the risk of drug resistance. Prescription practices by physicians and the availability of oral artemisinin monotherapies with pharmacists directly affect the pattern of their use. Thus, treatment practices for malaria, with special reference to artemisinin monotherapy prescription, in selected states of India were evaluated. METHODS: Structured, tested questionnaires were used to conduct convenience surveys of physicians and pharmacists in eleven purposively selected districts across six states in 2008. In addition, exit interviews of patients with a diagnosis of uncomplicated malaria or a prescription for an anti-malarial drug were also performed. Logistic regression was used to determine patient clinical care, and institutional factors associated with artemisinin monotherapy prescription. RESULTS: Five hundred and eleven physicians from 196 health facilities, 530 pharmacists, and 1,832 patients were interviewed. Artemisinin monotherapy was available in 72.6% of pharmacies and was prescribed by physicians for uncomplicated malaria in all study states. Exit interviews among patients confirmed the high rate of use of artemisinin monotherapy with 14.8% receiving such a prescription. Case management, i.e. method of diagnosis and overall treatment, varied by state and public or private sector. Treatment in the private sector (OR 8.0, 95%CI: 3.8, 17) was the strongest predictor of artemisinin monotherapy prescription when accounting for other factors. Use of the combination therapy recommended by the national drug policy, artesunate + sulphadoxine-pyrimethamine, was minimal (4.9%), with the exception of one state. CONCLUSIONS: Artemisinin monotherapy use was widespread across India in 2008. The accessible sale of oral artemisinin monotherapy in retail market and an inadequate supply of recommended drugs in the public sector health facilities promoted its prescription. This study resulted in notifications to all state drug controllers in India to withdraw the oral artemisinin formulations from the market. In 2010, artesunate + sulphadoxine-pyrimethamine became the universal first-line treatment for confirmed Plasmodium falciparum malaria and was deployed at full scale.