Current Status of Artemisinin-Resistant falciparum Malaria in South Asia: A Randomized Controlled Artesunate Monotherapy Trial in Bangladesh

Objective

Recent reports indicate that first cases of genuine artemisinin resistance have already emerged along the Thai-Cambodian border. The main objective of this trial was to track the potential emergence of artemisinin resistance in Bangladesh, which in terms of drug resistance forms a gateway to the Indian subcontinent.

Methods

We conducted an open-label, randomized, controlled 42-day clinical trial in Southeastern Bangladesh to investigate the potential spread of clinical artemisinin resistance from Southeast Asia. A total of 126 uncomplicated falciparum malaria patients were randomized to one of 3 treatment arms (artesunate monotherapy with 2 or 4 mg/kg/day once daily or quinine plus doxycycline TID for 7 days). Only cases fulfilling a stringent set of criteria were considered as being artemisinin-resistant.

Findings

The 28-day and 42-day cure rates in the artesunate monotherapy (2 and 4 mg/kg) and quinine/doxycyline arms were 97.8% (95% confidence interval, CI: 87.8–99.8%), 100% (95% CI: 91.1–100%), and 100% (95% CI: 83.4–100%), respectively. One case of re-infection was seen in the artesunate high dose arm, and a single case of recrudescence was observed in the low dose group on day 26. No differences in median parasite and fever clearance times were found between the 2 artesunate arms (29.8 h and 17.9 h vs. 29.5 h and 19.1 h). Not a single case fulfilled our criteria of artemisinin resistance. Parasite clearance times were considerably shorter and ex vivo results indicate significantly higher susceptibility (50% inhibitory concentration for dihydroartemisinin was 1.10 nM; 95% CI: 0.95–1.28 nM) to artemisinins as compared to SE-Asia.

Conclusion

There is currently no indication that artemisinin resistance has reached Bangladesh. However, the fact that resistance has recently been reported from nearby Myanmar indicates an urgent need for close monitoring of artemisinin resistance in the region.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00639873","term_id":"NCT00639873"}}NCT00639873.     

A freeze/thaw technique for estimation of nitrogenase activity in detached nodules of Vigna mungo

The Ivory Coast and Nigerian strains of okra mosaic virus (OMV) were transmitted by the flea-beetle Podagrica decolorata, a serious pest of okra in the southern Ivory Coast. The Ivory Coast strain was also transmitted by the orthopteran, Zonocerus variegatus. The Ivory Coast strain was acquired faster than it was inoculated by P. decolorata. When groups of five beetles were given acquisition and inoculation access periods of 24 and 48 h, respectively, 60% of the okra test plants were infected. OMV-carrying P. decolorata remained infective for up to 6 days. The virus was readily detected in extracts of crushed beetles that had fed on infected plants for 20 h. The beetle was also able to transmit to and from plants of Hibiscus sabdariffa and Corchorus olitorius; as a food source it preferred C. olitorius to okra or H. sabdariffa. The beetle is active throughout the year, and presumably can spread OMV at any time between plants of these species. A considerable and unexplained decrease in frequency of transmission was observed in experiments done in the rainy season. The revised cryptogram of OMV is R/l:*/32:S/S:S/Ve/Cl.     

Evaluation of anti-nociceptive,anti-inflammatory and antipyretic potential of Mikania cordata (Burm. f.) Robinson in experimental animal model

Mikania cordata is widely used for the treatment of cuts, wounds, and dengue fever in Bangladesh. In the present study, essential oil (12.5, 25 and 50?mg/kg) and two extracts, viz., chloroform and ethyl acetate extracts (200, 400, 800?mg/kg b.w.) were tested for peripheral and central anti-nociceptive activity by acetic acid-induced writhing and hot plate method, respectively. Carrageenan-induced rat paw edema assay and yeast-induced hyperthermia assay were also carried out to evaluate anti-inflammatory and antipyretic properties of oil and extracts, respectively at aforesaid doses. The essential oil (50?mg/kg), chloroform extract (800?mg/kg) and ethyl acetate extract (800?mg/kg) showed potent peripheral anti-nociceptive activity having 47.33%, 29.33% and 16.65% of writhing inhibition, respectively, comparable with standard diclofenac (52.0%). Essential oil (50?mg/kg), chloroform extract (800?mg/kg) and ethyl acetate extract (800?mg/kg) presented promising central anti-nociceptive activity as well having 95.86%, 79.18% and 42.37% elongation of reaction time, respectively, at 90?min after administration of essential oil, ethyl acetate extract and 60?min after administration of chloroform extract. In anti-inflammatory activity screening, the essential oil (50?mg/kg) produced the highest 72.80% edema inhibition at 4?h after administration of carrageenan which was comparable with that of standard phenylbutazoe (87.87%). On the other hand, chloroform extract (800?mg/kg) and ethyl acetate extract (800?mg/kg) showed up to 34.31% and 15.27% of edema inhibition, respectively, at 4?h after administration of carrageenan. In antipyretic assay, the essential oil and chloroform extract displayed a strong antipyretic effect in yeast-induced rats, whereas the ethyl acetate extract had no antipyretic activity. The present study revealed anti-nociceptive, anti-inflammatory and antipyretic potential of M. cordata which could be the therapeutic option against fever, inflammations as well as painful conditions and confirmed the traditional use of M. cordata.     

Detection of Mycobacterium ulcerans DNA in the Environment,Ivory Coast

Background

Ivory Coast is a West African country with the highest reported cases of Buruli ulcer, a disabling subcutaneous infection due to Mycobacterium ulcerans. However, the prevalence of environmental M. ulcerans is poorly known in this country.

Methods

We collected 496 environmental specimens consisting of soil (n = 100), stagnant water (n = 200), plants (n = 100) and animal feces (n = 96) in Ivory Coast over five months in the dry and wet seasons in regions which are free of Buruli ulcer (control group A; 250 specimens) and in regions where the Buruli ulcer is endemic (group B; 246 specimens). After appropriate total DNA extraction incorporating an internal control, the M. ulcerans IS2404 and KR-B gene were amplified by real-time PCR in samples. In parallel, a calibration curve was done for M. ulcerans Agy99 IS2404 and KR-B gene.

Results

Of 460 samples free of PCR inhibition, a positive real-time PCR detection of insertion sequence IS2404 and KR-B gene was observed in 1/230 specimens in control group A versus 9/230 specimens in group B (P = 0.02; Fisher exact test). Positive specimens comprised seven stagnant water specimens, two feces specimens confirmed to be of Thryonomys swinderianus (agouti) origin by real-time PCR of the cytb gene; and one soil specimen. Extrapolation from the calibration curves indicated low inoculums ranging from 1 to 10² mycobacteria/mL.

Conclusion

This study confirms the presence of M. ulcerans in the watery environment surrounding patients with Buruli ulcer in Ivory Coast. It suggests that the agouti, which is in close contacts with populations, could play a role in the environmental cycle of M. ulcerans, as previously suggested for the closely related possums in Australia.     

Histoire d’un itinéraire épidémiologique entre le Burkina Faso et la C?te d’Ivoire : le cas des foyers de maladie du sommeil de Koudougou

In the first half of the XXth century, while Upper-Volta (now Burkina Faso) was suffering a terrible epidemic of sleeping sickness, the French colonial administration encouraged the movement of people from Upper-Volta to Ivory Coast to meet their demands for labour. This led to the establishment of Mossi villages, such as those of Koudougou, in the Ivorian forest with populations originating from areas of Upper-Volta that were not only densely populated but also severely affected by sleeping sickness. Since 2000, most cases of sleeping sickness in the Koudougou district of Burkina Faso have been in people originally from Ivory Coast. Who are they? Where did they settle in Burkina Faso? Where do they come from in Ivory Coast? After having retraced the epidemiological history of Koudougou villages in Burkina Faso and Ivory Coast, the history of ten cases of sleeping sickness detected passively at Koudougou hospital since 2000 were analysed. All cases originated from the forest area of Ivory Coast. Understanding the spread of sleeping sickness between Burkina Faso and Ivory Coast will assist in the identification of areas of disease risk.     

A comparison of variation between a MHC pseudogene and microsatellite loci of the little greenbul (<Emphasis Type="Italic">Andropadus virens</Emphasis>)

Background  

We investigated genetic variation of a major histcompatibility complex (MHC) pseudogene (Anvi -DAB1) in the little greenbul (Andropadus virens) from four localities in Cameroon and one in Ivory Coast, West Africa. Previous microsatellite and mitochondrial DNA analyses had revealed little or no genetic differentiation among Cameroon localities but significant differentiation between localities in Cameroon and Ivory Coast.     

The decline of malaria in Finland – the impact of the vector and social variables

Background

Resistance to anti-malarial drugs hampers control efforts and increases the risk of morbidity and mortality from malaria. The efficacy of standard therapies for uncomplicated Plasmodium falciparum and Plasmodium vivax malaria was assessed in Chumkiri, Kampot Province, Cambodia.

Methods

One hundred fifty-one subjects with uncomplicated falciparum malaria received directly observed therapy with 12 mg/kg artesunate (over three days) and 25 mg/kg mefloquine, up to a maximum dose of 600 mg artesunate/1,000 mg mefloquine. One hundred nine subjects with uncomplicated vivax malaria received a total of 25 mg/kg chloroquine, up to a maximum dose of 1,500 mg, over three days. Subjects were followed for 42 days or until recurrent parasitaemia was observed. For P. falciparum infected subjects, PCR genotyping of msp1, msp2, and glurp was used to distinguish treatment failures from new infections. Treatment failure rates at days 28 and 42 were analyzed using both per protocol and Kaplan-Meier survival analysis. Real Time PCR was used to measure the copy number of the pfmdr1 gene and standard 48-hour isotopic hypoxanthine incorporation assays were used to measure IC₅₀ for anti-malarial drugs.

Results

Among P. falciparum infected subjects, 47.0% were still parasitemic on day 2 and 11.3% on day 3. The PCR corrected treatment failure rates determined by survival analysis at 28 and 42 days were 13.1% and 18.8%, respectively. Treatment failure was associated with increased pfmdr1 copy number, higher initial parasitaemia, higher mefloquine IC₅₀, and longer time to parasite clearance. One P. falciparum isolate, from a treatment failure, had markedly elevated IC₅₀ for both mefloquine (130 nM) and artesunate (6.7 nM). Among P. vivax infected subjects, 42.1% suffered recurrent P. vivax parasitaemia. None acquired new P. falciparum infection.

Conclusion

The results suggest that artesunate-mefloquine combination therapy is beginning to fail in southern Cambodia and that resistance is not confined to the provinces at the Thai-Cambodian border. It is unclear whether the treatment failures are due solely to mefloquine resistance or to artesunate resistance as well. The findings of delayed clearance times and elevated artesunate IC₅₀ suggest that artesunate resistance may be emerging on a background of mefloquine resistance.     

Aggressiveness and Damage Potential of Central American and Caribbean Populations of Radopholus spp. in Banana

Monoxenic cultures of burrowing nematode populations extracted from banana roots from Belize, Guatemala, Honduras, and Costa Rica were established on carrot discs. Cultures of Radopholus spp. were also obtained from Florida, Puerto Rico, Dominican Republic, and Ivory Coast. The aggressiveness (defined as reproductive fitness and root necrosis) of these populations was evaluated by inoculating banana plants (Musa AAA, cv. Grande Naine) with 200 nematodes/plant. Banana plants produced by tissue culture were grown in 0.4-liter styrofoam cups, containing a 1:1 mix of a coarse and a fine sand, at ca. 27 °C and 80% RH. Banana plants were acclimated and allowed to grow for 4 weeks prior to inoculation. Plant height, fresh shoot and root weights, root necrosis, and nematode population densities were determined 8 weeks after inoculation. Burrowing-nematode populations varied in aggressiveness, and their reproductive fitness was generally related to damage reported in the field. Plant height and fresh shoot and root weight did not reflect damage caused by nematodes under our experimental conditions. Necrosis of primary roots was closely related to the reproductive fitness of the nematode populations. Variation in aggressiveness among nematode populations followed a similar trend in the two susceptible hosts tested, Grande Naine and Pisang mas. All nematode populations had a low reproductive factor (Rf ≤2.5) in the resistant host except for the Ivory Coast population which had a moderate reproductive factor (Rf ≤ 5) on Pisang Jari Buaya. This is the first report of a burrowing nematode population parasitizing this important source of resistance to R. similis.     

Chloroquine Is Grossly Under Dosed in Young Children with Malaria: Implications for Drug Resistance

Background

Plasmodium falciparum malaria is treated with 25 mg/kg of chloroquine (CQ) irrespective of age. Theoretically, CQ should be dosed according to body surface area (BSA). The effect of dosing CQ according to BSA has not been determined but doubling the dose per kg doubled the efficacy of CQ in children aged <15 years infected with P. falciparum carrying CQ resistance causing genes typical for Africa. The study aim was to determine the effect of age on CQ concentrations.

Methods and Findings

Day 7 whole blood CQ concentrations were determined in 150 and 302 children treated with 25 and 50 mg/kg, respectively, in previously conducted clinical trials. CQ concentrations normalised for the dose taken in mg/kg of CQ decreased with decreasing age (p<0.001). CQ concentrations normalised for dose taken in mg/m² were unaffected by age. The median CQ concentration in children aged <2 years taking 50 mg/kg and in children aged 10–14 years taking 25 mg/kg were 825 (95% confidence interval [CI] 662–988) and 758 (95% CI 640–876) nmol/l, respectively (p = 0.67). The median CQ concentration in children aged 10–14 taking 50 mg/kg and children aged 0–2 taking 25 mg/kg were 1521 and 549 nmol/l. Adverse events were not age/concentration dependent.

Conclusions

CQ is under-dosed in children and should ideally be dosed according to BSA. Children aged <2 years need approximately double the dose per kg to attain CQ concentrations found in children aged 10–14 years. Clinical trials assessing the efficacy of CQ in Africa are typically performed in children aged <5 years. Thus the efficacy of CQ is typically assessed in children in whom CQ is under dosed. Approximately 3 fold higher drug concentrations can probably be safely given to the youngest children. As CQ resistance is concentration dependent an alternative dosing of CQ may overcome resistance in Africa.     

Morphological and growth altering effects of Cisplatin in C. albicans using fluorescence microscopy

Background

Extrapulmonary manifestations of tuberculosis have become increasingly important in the era of HIV/AIDS.

Case presentation

We describe a case of tuberculosis (TB) dactylitis in a patient with AIDS who originated from the Ivory Coast. The diagnosis was established by direct visualization of acid-fast bacilli on joint fluid and bone biopsy of the proximal phalanx. Imaging of the chest revealed multiple bilateral nodules. Confirmation of the diagnosis was made by isolation of Mycobacterium tuberculosis from sputum and bone cultures.

Conclusion

Tuberculosis should be considered in patients with unusual soft tissue or skeletal lesions, especially when an immunosuppressive condition is present. Ziehl-Neelsen staining and culture of tissue obtained via surgical biopsy offer the most direct approach to diagnosis.     

Effects of patient-controlled analgesia with hydromorphone or sufentanil on postoperative pulmonary complications in patients undergoing thoracic surgery: a quasi-experimental study

Objective

To compare the analgesic effects of patient-controlled intravenous analgesia (PCA) with hydromorphone and sufentanil after thoracic surgery on postoperative pulmonary complications (PPCs).

Methods

A total of 142 patients who were scheduled for thoracic surgery were randomly allocated to receive PCA with hydromorphone (group A: experimental group): hydromorphone 0.2?mg/kg?+?dezocine 0.5?mg/kg?+?ramosetron 0.6?mg diluted with normal saline to 200?mL; or with sufentanil (group B: control group): sufentanil 3.0μg/kg?+?dezocine 0.5?mg/kg?+?ramosetron 0.6?mg diluted with normal saline to 200?mL. The parameters of intravenous analgesia pump were set as background dose 4?ml/h, PCA dose 1?mL, locking time 15?min. Pain NRS (numerical rating scale), Ramsay sedation score, nausea or vomiting score were evaluated at 0?h, 6?h, 12?h, 24?h, 48?h after operation. The cases of PPCs (atelectasis, pulmonary infection, respiratory failure), CRP (C-reaction protein) and inflammatory cells (white cell count and percentage of neutrophils) and blood gas analysis at 12?h after operation, length of ICU and postoperative stay were recorded for each patient.

Results

Data of 136 patients were analyzed. Compared with group B (4[IQR:2,2]), the pain NRS in group A (2[IQR:4,4]) was significantly lower at 6?h after operation (P?=?0.000). The CRP in group A (69.79?±?32.13?mg/L) were lower than group B (76.76?±?43.42?mg/L) after operation, but the difference was not significant (P?=?0.427). No difference of nausea or vomiting was found between group A (7.3%) and group B (5.8%) postoperatively (P?=?0.999). The PPCs were happened in 11 patients in group A (16.2%) and 22 patients in group B (32.4%) and the difference between two groups was significant (P?=?0.027). Seven patients in group A (10.3%) and eighteen patients in group B (26.5%) had clinical evidence of pneumonia and the difference between two groups was significant (P?=?0.014). The length of ICU and postoperative stay in group A were 2.73?h and 1.82?days less than group B respectively but the differences were not significant (P?=?0.234, P?=?0.186 respectively).

Conclusion

Compared with sufentanil, hydromorphone may provide better postoperative analgesic effect with less pulmonary complications for patients undergoing thoracic surgery, and it may accelerate patients’ rehabilitation.

Trial registration

Randomized Controlled Trials ChiCTR1800014282c. Registered 3 January 2018.

     

Anthelmintic therapy of equine cyathostomin nematodes – larvicidal efficacy,egg reappearance period,and drug resistance

Cyathostomins are ubiquitous in grazing horses across the world, and anthelmintic resistance has been reported with increasing levels over past decades. The aims of the present study were (i) to investigate the efficacy against encysted larval stages of moxidectin (0.4?mg/kg) and fenbendazole (10?mg/kg daily for five consecutive days) and compare these regimens at 2 and 5?weeks post-treatment, (ii) to investigate individual cyathostomin species associated with shortened egg reappearance periods, and (iii) to document species exhibiting decreased susceptibility to the evaluated compounds. Thirty-six ponies were allocated to treatment groups with half euthanatized 2?weeks post-treatment, and the remainder necropsied after 5?weeks. Luminal and mucosal worm counts were conducted and strongyle egg counts were determined at weekly intervals. At 2?weeks, mean reductions of early L3s were 50.4% and 73.8% for fenbendazole and moxidectin, respectively. At 5?weeks, the respective efficacies were 51.3% and 71.8%. Two week efficacies against late L3s and L4s (LL3s/L4s) were 70.8% and 74.6% for fenbendazole and moxidectin, respectively, whereas very low numbers were found in all three groups at 5?weeks. None of the mucosal counts were significantly different between treatment groups. Fenbendazole and moxidectin reduced luminal worm counts by 93.2% and 98.3% at 2?weeks following administration, with moxidectin group adult counts being significantly lower than the other two groups (P?<?0.0001). Both treatment groups had increased counts 3?weeks later (P?=?0.0415). A moxidectin ERP of 4?weeks was associated with surviving luminal L4s, and adult species contributing to this were Cyathostomum catinatum, Cylicostephanus longibursatus, Cylicocyclus ashworthi and Cylicocyclus nassatus. This study documented (i) larvicidal efficacy of fenbendazole much lower than historical standards, (ii) survival of luminal immatures (L4) following moxidectin administration, and (iii) new information about cyathostomin species associated with these phenomena.     

Intramuscular loading dose of quinine for falciparum malaria: pharmacokinetics and toxicity.

In a study of intramuscular injection of quinine eight adults with moderately severe falciparum malaria resistant to chloroquine were treated with quinine dihydrochloride, being given a loading dose of 20 mg salt (16.7 mg base)/kg followed by three or four eight hourly maintenance doses of 10 mg salt (8.3 mg base)/kg injected into the anterior thigh. All patients responded to treatment. Fever and parasite clearance times (mean (SD) 60 (23) h and 53 (22) h respectively) were comparable with those obtained with intravenous quinine. The mean peak plasma quinine concentration of 11.0 mg/l (34.4 mu mol/l) [corrected] was reached a median of five hours after administration of the loading dose. In all patients plasma quinine concentrations exceeded the high minimum inhibitory concentration for Plasmodium falciparum malaria prevalent in Thailand within four hours of the start of treatment but did not cause toxicity other than mild cinchonism. When intravenous infusion is not possible an intramuscular quinine loading dose is an effective means of starting treatment in patients with moderately severe falciparum malaria who cannot swallow tablets.     

Review: life cycle assessments in Nigeria,Ghana, and Ivory Coast

Purpose

Life cycle assessments (LCAs) are considered common quantitative environmental techniques to analyze the environmental impact of products and/or services throughout their entire life cycle. A few LCA studies have been conducted in West Africa. This study aimed to discuss the availability of LCA (and similar) studies in Nigeria, Ghana, and Ivory Coast.

Methods

An online literature review of reports published between 2000 and 2016 was conducted using the following keywords: “life cycle assessment,” “carbon footprinting,” “water footprinting,” “environmental impact,” “Nigeria,” “Ghana” and “Ivory Coast.”

Results and discussion

A total of 31 LCA and environmental studies in Nigeria, Ghana, and Ivory Coast were found; all but one were conducted after 2008. These were mainly academic and most were publicly available. The industries studied included energy sector, waste management, real estate, food sector, and others such as timber and gold. The minimal number of studies on LCAs and environmental impacts in these West African states could be because companies are failing to promote quantitative environmental studies or studies are kept internally for the use of other assessment techniques. Furthermore, it could be that academic research institutions lack cutting-edge research resources for LCA, environmental impact, carbon, and water footprinting studies.

Conclusions

Further quantitative environmental studies should be conducted in Nigeria, Ghana, and Ivory Coast to increase the understanding of environmental impacts. In these countries, the existence of LCA studies (and by association the localized life cycle inventory (LCI) datasets) is crucial as more companies request this information to feed into background processes.

     

Phytochemical investigation of the leaves of Leptoderris fasciculata

Leptoderris fasciculata (Benth.) Dunn is a woody liana that grows in the tropical zone of West Africa, where it is exploited in traditional medicine for a number of uses. In the south-eastern Ivory Coast, it is applied to stop bleeding in women after childbirth or in cases of menorrhagia. The phytochemistry of this plant has received little previous attention. We report the isolation of 4′,5,6,7-tetramethoxyisoflavone and dihydrochalcone, new as natural products, together with 10 known compounds from the leaves of L. fasciculata collected in the Ivory Coast.     

Répartition verticale du phytoplancton,des bactéries et du zooplancton dans un milieu stratifié en Baie de Biétri (Lagune Ebrié, Cote d'Ivoire). Relations trophiques

During the period of September–November 1981, a stratified condition was observed in Biétri Bay, a part of Ebrié Lagoon (Ivory Coast, Africa). The epilimnion was oxidised and in the hypolimnion, high concentrations of hydrogen sulfide were noted (200–400 mg · l^?1). At the surface of the hypolimnion, a large population of phototrophic bacteria developed, constituting a brown layer composed of the purple and green bacteria Rhodopseudomonas sp., Chromatium gracile, Chlorobium vibrioforme, C. phaeobacteroides and Pelodictyon sp. These bacteria can be considered as particulate organic matter producers. Their production is estimated at about 1 530 mg C · m^?2 · day^?1. In the epilimnion, the algal production is 2 200 mg C · m^?2 · day^?1. Therefore, phototrophic bacterial production represented 41% of the total photosynthetic production. In the epilimnion, the zooplankton community (composed of copepods, rotifers and some cyclopids) was particularly concentrated near the chemocline where only low concentration of dissolved oxygen was available. Analysis of gut contents of the copepod Acartia clausi, which is the dominant species of the zooplankton, shows the importance of phototrophic bacteria and especially Rhodospirillaceae and Chromatium in its diet. This copepod seems to prefer phototrophic bacteria to both heterotrophic bacteria and phytoplancton. The vertical migration of the zooplankton community is partly conditioned by the search for nutrients i.e. phototrophic bacteria. Thus, bacteria contribute to the first trophic level of the food chain in this lagoon. Since they derive part of their energy from organic matter formed by primary producers, they cannot be considered as pure primary producers. However, in respect to the food chain they form food material for secondary producers (zooplankton).     

The Effect of Dosing Regimens on the Antimalarial Efficacy of Dihydroartemisinin-Piperaquine: A Pooled Analysis of Individual Patient Data

Background

Dihydroartemisinin-piperaquine (DP) is increasingly recommended for antimalarial treatment in many endemic countries; however, concerns have been raised over its potential under dosing in young children. We investigated the influence of different dosing schedules on DP''s clinical efficacy.

Methods and Findings

A systematic search of the literature was conducted to identify all studies published between 1960 and February 2013, in which patients were enrolled and treated with DP. Principal investigators were approached and invited to share individual patient data with the WorldWide Antimalarial Resistance Network (WWARN). Data were pooled using a standardised methodology. Univariable and multivariable risk factors for parasite recrudescence were identified using a Cox''s regression model with shared frailty across the study sites. Twenty-four published and two unpublished studies (n = 7,072 patients) were included in the analysis. After correcting for reinfection by parasite genotyping, Kaplan–Meier survival estimates were 97.7% (95% CI 97.3%–98.1%) at day 42 and 97.2% (95% CI 96.7%–97.7%) at day 63. Overall 28.6% (979/3,429) of children aged 1 to 5 years received a total dose of piperaquine below 48 mg/kg (the lower limit recommended by WHO); this risk was 2.3–2.9-fold greater compared to that in the other age groups and was associated with reduced efficacy at day 63 (94.4% [95% CI 92.6%–96.2%], p<0.001). After adjusting for confounding factors, the mg/kg dose of piperaquine was found to be a significant predictor for recrudescence, the risk increasing by 13% (95% CI 5.0%–21%) for every 5 mg/kg decrease in dose; p = 0.002. In a multivariable model increasing the target minimum total dose of piperaquine in children aged 1 to 5 years old from 48 mg/kg to 59 mg/kg would halve the risk of treatment failure and cure at least 95% of patients; such an increment was not associated with gastrointestinal toxicity in the ten studies in which this could be assessed.

Conclusions

DP demonstrates excellent efficacy in a wide range of transmission settings; however, treatment failure is associated with a lower dose of piperaquine, particularly in young children, suggesting potential for further dose optimisation. Please see later in the article for the Editors'' Summary     

Skeletal muscle post-conditioning by diazoxide, anti-oxidative and anti-apoptotic mechanisms

Pretreatment with diazoxide, K_ATP channel opener, increases tissue tolerance against ischemia reperfusion (IR) injury. In clinical settings pretreatment is rarely an option therefore we evaluated the effect of post-ischemic treatment with diazoxide on skeletal muscle IR injury. Rats were treated with either saline, diazoxide (K_ATP opener; 40?mg/kg) or 5-hydroxydecanoate (5-HD; mitochondrial K_ATP inhibitor; 40?mg/kg) after skeletal muscle ischemia (3?h) and reperfusion (6, 24 or 48?h). Tissue contents of malondialdehyde (MDA), superoxide dismutase (SOD) and catalase (CAT) activities, Bax and Bcl-2 protein expression and muscle histology were determined. Apoptosis was examined (24 and 48?h) after ischemia. IR induced severe histological damage, increased MDA content and Bax expression (24 and 48?h; p?<?0.01) and decreased CAT and SOD activities (6 and 24?h, p?<?0.01 and 48?h, p?<?0.05), with no significant effect on Bcl-2 expression. Diazoxide reversed IR effects on MDA (6 and 24?h; p?<?0.05), SOD (6 and 24?h; p?<?0.01) and CAT (6 and 48?h, p?<?0.05 and 24?h p?<?0.01) and tissue damage. Diazoxide also decreased Bax (24 and 48?h; p?<?0.05) and increased Bcl-2 protein expression (24 and 48?h; p?<?0.01). Post-ischemic treatment with 5-HD had no significant effect on IR injury. Number of apoptotic nuclei in IR and 5-HD treated groups significantly increased (p?<?0.001) while diazoxide decreased apoptosis (p?<?0.01). The results suggested that post-ischemic treatment with diazoxide decrease oxidative stress in acute phase which modulates expression of apoptotic proteins in the late phase of reperfusion injury. Involvement of KATP channels in this effect require further evaluations.     

Artesunate dose escalation for the treatment of uncomplicated malaria in a region of reported artemisinin resistance: a randomized clinical trial

Background

The emergence of artemisinin resistance has raised concerns that the most potent antimalarial drug may be under threat. The currently recommended daily dose of artesunate (AS) is 4 mg/kg, and is administered for 3 days together with a partner antimalarial drug. This study investigated the impact of different AS doses on clinical and parasitological responses in malaria patients from an area of known artemisinin resistance in western Cambodia.

Methods

Adult patients with uncomplicated P. falciparum malaria were randomized into one of three 7-day AS monotherapy regimens: 2, 4 or 6 mg/kg/day (total dose 14, 28 and 42 mg/kg). Clinical, parasitological, pharmacokinetic and in vitro drug sensitivity data was collected over a 7-day inpatient period and during weekly follow-up to 42 days.

Results

143 patients were enrolled (n = 75, 40 and 28 to receive AS 2, 4 and 6 mg/kg/day respectively). Cure rates were high in all treatment groups at 42 days despite almost half the patients remaining parasitemic on Day 3. There was no impact of increasing AS dose on median parasite clearance times, median parasite clearance rates or on the proportion of patients remaining parasitemic on Day 3. However at the lowest dose used (2 mg/kg/d) patients with parasitemia >10,000/µL had longer median (IQR) parasite clearance times than those with parasitemia <10,000/µL (63 (48–75) vs. 84 (66–96) hours, p<0.0001). 19% of patients in the high-dose arm developed neutropenia (absolute neutrophil count <1.0×10⁹/L) by Day 14 and resulted in the arm being halted early.

Conclusion

There is no pharmacodynamic benefit of increasing the daily dose of AS (4mg/kg) currently recommended for short-course combination treatment of uncomplicated malaria, even in regions with emerging artemisinin resistance, as long as the partner drug retains high efficacy.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00722150","term_id":"NCT00722150"}}NCT00722150.     

Efficacy and safety of artemether in the treatment of chronic fascioliasis in Egypt: exploratory phase-2 trials

Background

Fascioliasis is an emerging zoonotic disease of considerable veterinary and public health importance. Triclabendazole is the only available drug for treatment. Laboratory studies have documented promising fasciocidal properties of the artemisinins (e.g., artemether).

Methodology

We carried out two exploratory phase-2 trials to assess the efficacy and safety of oral artemether administered at (i) 6×80 mg over 3 consecutive days, and (ii) 3×200 mg within 24 h in 36 Fasciola-infected individuals in Egypt. Efficacy was determined by cure rate (CR) and egg reduction rate (ERR) based on multiple Kato-Katz thick smears before and after drug administration. Patients who remained Fasciola-positive following artemether dosing were treated with single 10 mg/kg oral triclabendazole. In case of treatment failure, triclabendazole was re-administered at 20 mg/kg in two divided doses.

Principal Findings

CRs achieved with 6×80 mg and 3×200 mg artemether were 35% and 6%, respectively. The corresponding ERRs were 63% and nil, respectively. Artemether was well tolerated. A high efficacy was observed with triclabendazole administered at 10 mg/kg (16 patients; CR: 67%, ERR: 94%) and 20 mg/kg (4 patients; CR: 75%, ERR: 96%).

Conclusions/Significance

Artemether, administered at malaria treatment regimens, shows no or only little effect against fascioliasis, and hence does not represent an alternative to triclabendazole. The role of artemether and other artemisinin derivatives as partner drug in combination chemotherapy remains to be elucidated.