The effect of malaria on mortality in a cohort of HIV-infected Ugandan adults

OBJECTIVES: To investigate the effects of malaria parasitaemia and clinical malaria on mortality in HIV seropositive and seronegative adults. METHODS: A cohort of adults in rural Uganda were followed from 1990 to 1998. Participants attended routine clinic visits every 3 months and also when sick (interim visits). Information was collected on HIV serostatus, history of fever, current fever and malaria parasite levels. Malaria was categorized as any parasitaemia, significant parasitaemia (>/=1.25 x 10(6) parasites/ml at routine or >/=50 parasites per 200 white blood cells at interim visits) or clinical malaria. The effect of malaria on all-cause mortality was assessed using Cox models. RESULTS: The 222 HIV seropositive participants made 2762 routine visits and 1522 interim visits. During follow-up, of the 211 participants with full records, 69% had at least one episode of parasitaemia, 51% experienced significant parasitaemia and 28% had clinical malaria. There were 90 deaths in 922 person-years of observation. There were no significant associations between numbers of visits with any parasitaemia, significant parasitaemia or clinical malaria on mortality rates. The highest mortality rates were observed in those making four or more routine visits with significant parasitaemia [adjusted mortality rate ratio (RR) 3.27 compared with those making 0 such visits; P=0.078] and those making two or more visits with clinical malaria (adjusted RR 2.23; P=0.093). There was no significant interaction between any malaria category and HIV serostatus. Conclusion We found no evidence of a strong detrimental effect of malaria on all-cause mortality in HIV seropositive adults in this setting.     

Clinical predictors of malaria and other febrile illnesses in children under five on Pemba Island, Tanzania

Under the current guidelines of presumptive treatment of all children with reported fever, the risk of over-prescribing antimalarial drugs and missing other important causes of fever, like acute respiratory tract infection (ARI), is substantial. Clinical algorithms have been shown to be useful in diagnosing malaria, but often with differing results, due to regional variations. We set out to explore the clinical features associated with malaria compared with other febrile illnesses and specifically severe malaria with ARI in children under five in Pemba. Two hundred and seven children aged six months to five years presenting to a hospital clinic with fever were studied in Pemba. Clinical findings were related to the presence of malaria parasitaemia. Malaria accounted for 67.7% of the febrile episodes investigated. Five symptoms and signs, including pallor, drowsiness, splenomegaly, fever duration and no chest crackles, could accurately predict a case of malaria with a sensitivity of 91.3% and specificity of 53% and positive predictive value of 80.3%. Several clinical features were found to differentiate severe malaria from ARI. These results confirm that clinical algorithms can increase the diagnostic accuracy of malaria, although not sufficiently to replace microscopy, and by promoting the use of clinical skills other treatable causes of febrile illnesses may be identified.These findings could have implications in optimizing treatment and malaria control in children on Pemba.     

Effects of age on the performance of common diagnostic tests for pulmonary embolism

PURPOSE: The diagnosis of pulmonary embolism in the elderly is often difficult because of comorbid medical conditions, and perhaps also because diagnostic tests have a lower yield. We analyzed the diagnostic performance of common diagnostic tests for pulmonary embolism in different age groups. METHODS: We analyzed data from two large studies that enrolled 1,029 consecutive patients presenting to the emergency department with clinically suspected pulmonary embolism. The clinical probability of pulmonary embolism (high [>/=80%], intermediate, or low [/=80 years of age. The positive predictive value of a high clinical probability of pulmonary embolism was greater in the elderly (71% to 78% in those >/=60 years old versus 40% to 64% in those /=80 years old. The diagnostic yield of lower limb compression ultrasonography was greater in the elderly. The proportion of lung scans that were diagnostic (normal, near-normal, or high probability) decreased from 68% to 42% with increasing age. CONCLUSIONS: Age affects the performance of common diagnostic tests for pulmonary embolism and should be kept in mind when evaluating patients suspected of having this condition.     

A clinical algorithm for the diagnosis of malaria: results of an evaluation in an area of low endemicity

We conducted a study of 1945 children and 2885 adults who presented with fever to a hospital outpatients clinic in an urban area of India order to develop and evaluate a clinical algorithm for the diagnosis of malaria. Only 139 (7%) children and 349 (12%) adults had microscopically confirmed malaria. None of the symptoms or signs elicited from the respondents were good predictors of clinical malaria. Simple scores were derived through combining clinical features which were associated with slide positivity or were judged by clinicians to be important. The best-performing algorithms were a score of 4 clinical features in children (sensitivity 60.0% and specificity 61.2%) and a score of 5 in adults (sensitivity 54.6% and specificity 57.5%). The clinical features differed and algorithm performances were poorer than in previous studies in highly endemic areas. The conclusion is that malaria diagnosis in areas of low endemicity requires microscopy to be accurate.     

A prospective evaluation of a clinical algorithm for the diagnosis of malaria in Gambian children

Diagnosis of clinical malaria remains difficult, especially in areas where a high proportion of the asymptomatic population have parasitaemia, for the symptoms and signs of malaria overlap with those of other common childhood diseases, such as acute lower respiratory tract infections. However, a study of symptoms and signs in a group of children who presented to Farafenni Health Centre, The Gambia with a history of recent fever identified a group of signs and symptoms which were strong predictors of malaria as opposed to other febrile illnesses. Using these predictors, an algorithm was developed which could be used by fieldworkers and which had a similar sensitivity and specificity for the diagnosis of malaria as that of an experienced paediatrician working without laboratory support. This algorithm has been validated prospectively on 518 children who presented to the Medical Research Council clinic at Basse, The Gambia with fever or a history of recent fever during a 10-month period. A fieldworker obtained a detailed history from the parent or guardian of each child and performed a clinical examination which included measurement of axillary temperature and respiratory rate. Packed cell volume was measured and a thick smear was examined for malaria parasites. A malaria score, based on the presence or absence of malaria-related signs and symptoms, was determined for 382 children who were seen at the clinic during the high transmission season. Using the cut-off score which was optimal during the previous retrospective study, a sensitivity of 70% and a specificity of 77% for a diagnosis of malaria was obtained. The optimal cut-off score for the Basse population was a score of 7; this gave a sensitivity of 88% and a specificity of 62%, figures comparable to those obtained by an experienced paediatrician without laboratory support.     

Acute undifferentiated fever in Binh Thuan province, Vietnam: imprecise clinical diagnosis and irrational pharmaco-therapy

OBJECTIVES: To describe the characteristics of patients consulting commune primary healthcare posts for acute undifferentiated fever not being malaria (AUF), and to explore the diagnostic and therapeutic responses of the healthcare workers. METHODS: All patients presenting with AUF at 12 commune health posts and one clinic at the provincial malaria station, Binh Thuan, a dengue endemic province in southern Vietnam, were included. Record forms were used to fill in patient and diseases characteristics, pre-referral treatment, signs and symptoms, provisional diagnosis and installed treatment, referral and final outcome. RESULTS: Two thousand ninety-six patients were included from April 2001 to March 2002. The median delay to attend the health posts was, 0.87 day for > 5, 1.15 days for children aged 5-15 years and 1.41 days for adults (P < 0.001). Sixty-five per cent of patients took some measures before consulting the health post, of whom 82% applied self-medication and 69% took antibiotics. Pre-referral medication with antibiotics increased with age (RR 1.012 per year of age; 95% CI: 1.004-1.019). The diagnostic and therapeutic response of healthcare workers was very unspecific. The tourniquet test was inappropriately used as general discriminating test, not only for detecting dengue haemorrhagic fever. Empiric antibiotic therapy was installed in 77.2% of cases. CONCLUSIONS: Management of uncomplicated fever, not being malaria, at the primary healthcare level in Vietnam is non-specific, dominated by searching signs of hemorrhagic dengue and empiric antibiotic treatment. This can probably be improved by better education.     

Case definitions of clinical malaria under different transmission conditions in Kilifi District, Kenya

BACKGROUND: Clear case definitions of malaria are an essential means of evaluating the effectiveness of present and proposed interventions in malaria. The clinical signs of malaria are nonspecific, and parasitemia accompanied by a fever may not be sufficient to define an episode of clinical malaria in endemic areas. We defined and quantified cases of malaria in people of different age groups from 2 areas with different rates of transmission of malaria. METHODS: A total of 1602 people were followed up weekly for 2 years, and all the cases of fever accompanied by parasitemia were identified. Logistic regression methods were used to derive case definitions of malaria. RESULTS: Two case definitions of malaria were derived: 1 for children 1-14 years old and 1 for infants (<1 year old) and older children and adults (> or =15 years old). We also found a higher number of episodes of clinical malaria per person per year in people from an area of low transmission of malaria, compared with the number of episodes in those from an area of higher transmission (0.84 vs. 0.55 episodes/person/year; incidence rate ratio, 0.66 [95% confidence interval, 0.61-0.72]; P<.001). CONCLUSIONS: Case definitions of malaria are bound to be altered by factors that affect immunity, such as age and transmission. Case definitions may, however, be affected by other immunity-altering factors, such as HIV and vaccination status, and this needs to be borne in mind during vaccine trials.     

Rapid reappearance of Plasmodium falciparum after drug treatment among Senegalese adults exposed to moderate seasonal transmission

To investigate the relationship between the entomologic inoculation rate (EIR) and time to reappearance of malaria parasites after radical treatment under moderate seasonal transmission conditions, a study was undertaken in a mesoendemic area of Senegal where malaria transmission is concentrated over an annual three-month period and averages 12 infective bites per person per year. A three-day course of quinine was administered to 48 asymptomatic adults between 19 and 66 years of age. Malaria transmission and parasitemia were monitored every week for two months and cases of fever or symptoms were investigated as part of a daily clinical surveillance. The proportion of persons reinfected at Days 28, 35, and 56 was 25%, 38%, and 54%, respectively. Adults less than 40 years of age had a shorter time to reinfection. In this age group, the median Plasmodium falciparum reappearance time was 28 days, and it was estimated that only one infected mosquito bite was able to induce a patent infection among half of the subjects. Only 8% (2 of 26) of the reinfections caused a clinical attack. These data are discussed in the light of previous studies conducted among adults naturally exposed to intense perennial transmission or among naive volunteers receiving artificial challenges. Rapid reinfection occurs at very low EIRs and dramatic differences in actual and cumulated exposure to infected mosquito bites poorly affect the median time to reappearance of malaria parasites in endemic populations.     

Evaluation of a single dose of diphtheria-tetanus toxoids among adults in Odessa, Ukraine, 1995: immunogenicity and adverse reactions

Epidemic diphtheria spread to Ukraine in 1991, where it peaked in 1995 with >5,000 reported cases. To refine epidemic control strategies, immunogenicity of a tetanus-diphtheria toxoids vaccine (Td) containing 2 limits of flocculation (Lf) diphtheria toxoid was evaluated. During a mass vaccination campaign, adults at a clinic in Odessa received one dose of Td. At enrollment, 57.2% of 341 study participants had levels of diphtheria antitoxin (DAT) >/=0.1 IU/mL. Thirty and 180 days after receiving one dose of Td, 91.5% and 84.5% of the participants, respectively, had DAT levels >/=0.1 IU/mL. However, among 40- to 49-year-old participants, only 78.8% and 73.8% had DAT levels >/=0.1 IU/mL at 30 and 180 days, respectively. This study suggests that one dose of 2 Lf diphtheria toxoid is highly effective in raising DAT to protective levels in most adults; however, the study also shows that certain age groups, particularly persons 40-49 and, to a lesser degree, 30-39 years old may require additional doses or a complete three-dose primary vaccination series for optimal protection against diphtheria.     

Improved hypertension management and control: results from the health survey for England 1998

A survey in 1994 showed that among the 20% of the adult English population who were identified as hypertensive, approximately 30% had their blood pressures controlled to <160 mm Hg systolic and <95 mm Hg diastolic. The 1998 Health Survey for England data update the 1994 findings in light of new thresholds and targets for treatment outlined in recent national and international guidelines. This cross-sectional survey is analyzed to describe the prevalence, awareness, treatment, and control of hypertension in a random, nationally representative sample of 11 529 English adults (>/=16 years) living in noninstitutional households in 1998 and to compare these rates with those from 1994. In 1998, 20% and 37% of adults were hypertensive according to the old (systolic >/=160 mm Hg or diastolic >/=95 mm Hg) and new (systolic >/=140 mm Hg or diastolic >/=90 mm Hg) definitions, respectively. Corresponding values in 1994 were 20% and 38%. Treatment and control rates among hypertensive adults (new definition) improved from 26% to 32% and from 6% to 9%, respectively, although 60% of those on treatment received only 1 antihypertensive drug in both years. Among persons with controlled hypertension, 59% reported having received nonpharmacological advice from their physicians in 1998 compared with 30% in 1994. Rates of hypertension treatment and control have increased significantly (P=0.05 and P<0.01, respectively) since 1994 but remain low by international standards. The 1998 data suggest that improved detection, greater use of nonpharmacological measures, and increased use of >1 antihypertensive agent per patient would produce greater success in achieving target levels. This could lead to major reductions in fatal and nonfatal cardiovascular events.     

Plasmodium falciparum clinical malaria in Dielmo, a holoendemic area in Senegal: no influence of acquired immunity on initial symptomatology and severity of malaria attacks.

Six hundred eighty-nine Plasmodium falciparum malaria attacks were observed during a three-year period among 226 inhabitants of the village of Dielmo, Senegal, an area of high malaria transmission. Malaria attacks were defined as clinical episodes with fever (body temperature > or = 38.0 degrees C) or reporting of fever or headache or vomiting, associated with a parasite:leukocyte ratio above an age-dependent pyrogenic threshold identified in this population. The symptom frequencies were tested against age, gender, and parasite density using a random-effect logistic regression model and the study of distinguishable clinical presentations was carried out by multi-correspondence analysis. There was little difference between the severity of symptoms during the initial course of attacks in young children and adults, and this severity was not correlated with the duration of the pathologic episode. It was not possible to distinguish objectively different malaria attack types according to the severity of clinical manifestations. In contrast, the duration of fever, symptoms, and parasite clearance were significantly longer among the youngest children than among the oldest children and adults. These findings suggest that of the two components of protective immunity, anti-parasite immunity and anti-toxic immunity, only the first would play a major role as age increases. They suggest also that the initial clinical presentation of malaria attacks is not predictive of the level of protective immunity.     

Cerebral malaria in adults -- a description of 526 cases admitted to Ispat General Hospital in Rourkela, India

Although the clinical picture of cerebral malaria in children has been reported extensively, scant information is available about cerebral malaria in adults. This report relates to one of the largest series of adult cases of cerebral malaria patients ever described. At Rourkela, in eastern India, 526 adults (aged >12 years) who each satisfied the World Health Organization's criteria for cerebral malaria were admitted to Ispat General Hospital between 1995 and 2001. These cases represented 18% of the 2994 adult patients who were admitted with Plasmodium falciparum malaria over the same period. Most (76%) of the adult cases of cerebral malaria were male, 48% were aged 21-40 years, and only 4% were older than 60 years. The most common presenting symptoms were fever (97.7%), vomiting (54.6%), headache (30.8%) and seizures (17.1%). Most (62.4%) of the cases had associated severe complications: jaundice (47.5%), acute renal failure (28.9%), and/or severe anaemia (9.7%). Overall, 175 (23%) of the cases were fatal, mortality being particularly high (59%) among those with multi-organ failure. Of the fatal cases, 107 (61%) died within the first 24 h of hospitalization, presumably indicative of late presentation. As the management of multiple complications may be inadequate at primary centres, early referral to higher centres is recommended.     

Parasitic infections in Malaysia: changing and challenges

A total of 1,885 blood and stool samples of four main protozoan parasitic infections were retrospectively reviewed from January, 2000 to April, 2004. Eleven of the 1,350 stool samples were shown positive for Cryptosporidium and Giardia infections; one of the 5 cases was clinically diagnosed as gastrointestinal cryptosporidiosis, while 6 cases were giardiasis. In patients with giardiasis, children were among the high-risk groups, making up 66.7% of these patients. The common presenting signs and symptoms were: diarrhea (83.3%), loss of appetite (83.3%), lethargy (83.3%), fever (66.7%), nausea/vomiting (50.0%), abdominal pain (16.7%), dehydration (16.7%) and rigor and chills (16.7%). Metronidazole was the drug of choice and was given to all symptomatic patients (83.3%). For the blood samples, 28 of the 92 peripheral smears for Plasmodium spp infection were diagnosed as malaria. The age range was from 4 to 57, with a median of 32.5 years. The sex ratio (M:F) was 3.6:1, while the age group of 30-44 years was the most commonly affected in both sexes. The majority of patients were foreigners (60.7%) and non-professional (39%). Plasmodium vivax (71%) infection was the most common pathogen found in these patients, along with a history of traveling to an endemic area of malaria (31%). The predominant presenting signs and symptoms were: fever (27%), rigor and chills (24%), nausea/vomiting (15%) and headache (8%). Chloroquine and primaquine was the most common anti-malarial regimen used (78.6%) in these patients. The seroprevalence of toxoplasmosis in different groups was 258/443 (58%): seropositive for IgG 143 (32.3%); IgM 67 (15%); and IgG + IgM 48 (10.8%). The age range was from 1 to 85, with a mean of 34 (+/- SD 16.6) years. The predominant age group was 21 to 40 years (126; 28.4%). The sex ratio (M:F) was 1.2:1. Subjects were predominantly male (142; 32%) and the Malay (117; 26.4%). Of these, 32 cases were clinically diagnosed with ocular toxoplasmosis. The range of age was from 10 to 56 years with a mean of 30.5 (+/- SD 12.05) years. The sex ratio (M:F) was 1:1.7. The majority were in the age group of 21 to 40 years, female (20; 62.5%), and Malay (17; 53%). They were also single (16; 50%), unemployed (12; 37%), and resided outside Kuala Lumpur (21; 65.6%). The more common clinical presentations were blurring of vision (25; 78%), floaters (10; 31%) and pain in the eye (7; 22%). We found that funduscopic examination (100%) and seropositivity for anti-Toxoplasma antibodies (93.7%) were the main reasons for investigation. Choroidoretinitis was the most common clinical diagnosis (69%), while clindamycin was the most frequently used antimicrobial in all cases. Among HIV-infected patients, 10 cases were diagnosed as AIDS-related toxoplasmic encephalitis (TE) (9 were active and 1 had relapse TE). In addition, 1 case was confirmed as congenital toxoplasmosis.     

Clinical investigation on adult inpatients contracted measles; comparing with pediatric measles inpatients

Age distribution, history of vaccination against measles, clinical signs and symptoms were investigated among a total of 113 adult measles patients admitted in our hospital between January, 2000 and December, 2002. The maximum body temperature, duration of fever, presence of Koplik spot and exanthema among these adult inpatients were compared with those among 1-to-5-year-old inpatients having measles. Concerning age distribution, the peak was found at the age of 20-24 years. Most of adult inpatients had not contracted measles until then and had not been vaccinated against measles. The infection route was unknown except a small number of inpatients. Clinical signs and symptoms among adult inpatients were about the same of those in pediatric inpatients except a sore throat. Complications occurred in 17 cases out of 113 adult inpatients, 4 of them had encephalitis or acute disseminated encephalomyelitis and the other 4 cases contracted pneumonia. Among the 45 child inpatients, whereas, 23 had complications, 13 of them had pneumonia, 3 contracted otitis media, and an additional 3 suffered from both pneumonia and otitis media. From the results it is reasonably concluded that clinical signs and symptoms among adults impatients with measles are comparable with those of pediatric measles inpatients or slightly severer.     

Emergency Department Presentation and Misdiagnosis of Imported Falciparum Malaria

Study objective: To review the travel history, clinical presentation, laboratory findings, diagnostic accuracy, management, and outcome of the largest reported series of emergency department patients with imported falciparum malaria in the United States. Methods: This is a retrospective case series at a large, inner-city medical center in Los Angeles. Twenty cases of falciparum malaria with initial medical evaluation in the ED were identified from the period 1979 through 1993. Results: Fifteen male and 5 female patients were identified, with an age range of 5 to 55 years. All had a recent history (within 2 months) of international travel in regions endemic for malaria. Most (85%) were recent immigrants or expatriates returning from a recent visit to their native country. The most common documented symptoms were fever (100%), chills (65%), vomiting (60%), anorexia (45%), and headache (45%). Tachycardia (85%) and hyperpyrexia (>39°C) (65%) were the most common presenting signs. Malaria was considered in the ED diagnoses in only 12 cases (60%). The specification of falciparum (malignant) malaria was established in only 2 cases (10%). Hepatitis and gastroenteritis were the most common misdiagnoses. Only four patients received antimalarial medication in the ED. There were no deaths, and complications were limited to thrombocytopenia and anemia. Two patients required transfusion. Conclusion: Imported falciparum malaria presenting to EDs in the United States is frequently misdiagnosed. Emergency physicians improve their ability to diagnose falciparum malaria by obtaining a thorough travel history on all patients with clinical features suggesting an infectious origin and considering this diagnosis in any patient with a history of travel to or migration from malaria-endemic areas. [Kyriacou DN, Spira AM, Talan DA, Mabey DCW: Emergency department presentation and misdiagnosis of imported falciparum malaria. Ann Emerg Med June 1996;27:696-699.]     

Validation of a surveillance case definition for arthritis

OBJECTIVE: To assess whether self-reports of chronic joint symptoms or doctor-diagnosed arthritis can validly identify persons with clinically verifiable arthritis. METHODS: The Behavioral Risk Factor Surveillance System (BRFSS), a telephone health survey, defines a case of arthritis as a self-report of chronic joint symptoms (CJS) and/or doctor-diagnosed arthritis (DDx). A sample of health plan enrollees aged 45-64 years and >/= 65 years with upcoming annual physical examinations were surveyed by telephone using the 2002 BRFSS CJS and DDx questions. Based on responses (CJS+, DDx-; CJS-, DDx+; CJS+, DDx+; CJS-, DDx-), respondents were recruited to undergo a standardized clinical history and physical examination for arthritis (the gold standard for clinical validation). Weighted sensitivities and specificities of the case definition were calculated to adjust for sampling. RESULTS: Of 2180 persons completing the telephone questionnaire, 389 were examined; of these, 258 met the case definition and 131 did not. For those examined and aged 45 to 64 years (n = 179), 96 persons had arthritis confirmed, of whom 76 met the case definition. Among those examined and aged >/= 65 (n = 210), 150 had arthritis confirmed, of whom 124 met the case definition. Among those without clinical arthritis, 45 of 83 of those aged 45 to 64 years and 40 of 60 of those aged >/= 65 did not meet the case definition. For those aged 45 to 64 years, the weighted sensitivity of the case definition in this sample was 77.4% and the weighted specificity was 58.8%; for those aged >/= 65, the sensitivity was 83.6% and specificity 70.6%. CJS+ had higher sensitivity and lower specificity than DDx+ in the younger age group; CJS+ and DDx+ behaved more comparably in the older age group. CONCLUSION: The case definition based on self-reported CJS and/or DDx appeared to be sensitive in identifying arthritis, but specificity was lower than desirable for those under age 65 years. Better methods of ascertaining arthritis by self-report are needed. Until then, a change in the surveillance case definition for arthritis appears warranted.     

Parasite density and malaria morbidity in the Pakistani Punjab

The relationship between quantitative Plasmodiumfalciparum or P. vivax parasitemia and clinical illness has not been defined in Pakistan or in other areas where malaria transmission is not highly endemic. Standardized questionnaires were given to and physical examinations and parasitologic tests were performed in 8,941 subjects seen in outpatient clinics in 4 villages for 13 consecutive months in the Punjab region of Pakistan. The results, based on multivariable analysis, showed that a clinical diagnosis of malaria, a history of fever, rigors, headache, myalgia, elevated temperature, and a palpable spleen among children were all strongly associated with the presence and density of P. falciparum or P. vivax malaria in a monotonic dose-response fashion. The malaria attributable fraction of a clinical diagnosis of malaria, and the same symptoms and signs also increased with increasing P. falciparum and, to a lesser extent, P. vivax, parasitemia. Unlike in sub-Saharan Africa, clinical illness due to malaria often occurs in the Punjab among adolescents and adults and in patients with parasite densities less than 1,000/microl. Clinical guidelines based upon parasitemia and symptomatology must be adjusted according to the intensity of transmission and be specific for each geographic area.     

Use of clinical algorithms for diagnosing malaria

Several attempts have been made to identify symptoms and signs based algorithms for diagnosing malaria. In this paper, we review the results of published studies and assess the risks and benefits of this approach in different epidemiological settings. Although in areas with a low prevalence the risk of failure to treat malaria resulting from the use of algorithms was low, the reduction in the wastage of drugs was trivial. The odds of wastage of drugs increased by 1.49 (95% confidence limit 1.45-1.51) for each 10% decrease in the prevalence of malaria. In highly endemic areas the algorithms had a high risk of failure to treat malaria. The odds of failure to treat increased by 1.57 (95% confidence limit 1.50-1.65) for each 10% increase in the prevalence. Furthermore, the best clinical algorithms for diagnosing malaria were site-specific. We conclude that the accuracy of clinical algorithms for diagnosing malaria is not sufficient to determine whether antimalarial drugs should be given to children presenting with febrile illness. In highly endemic areas where laboratory support is not available, the policy of offering antimalarial drugs to all children presenting with a febrile illness recommended by the integrated child management initiative is appropriate.     

Determinants of long-term survival after isolated aortic valve replacement: a 10- to 17-year follow-up

During a 9-year period from January 1965 through December 1973, we performed isolated aortic valve replacement (AVR) for aortic stenosis (AS) or aortic regurgitation (AR) in 165 patients. All operations were done during total cardiac arrest using chemical cardioplegia according to the method of Bretschneider. The prostheses used were predominantly Starr-Edwards caged ball valves. One hundred thirty-nine patients were alive 30 days after operation. The 5-, 10-, and 15-year cumulative survival rates (+/- SE) were 78 +/- 4%, 62 +/- 4%, and 29 +/- 9%, respectively. In comparison to a sex- and age-matched control population, our patients had an excess mortality in the first postoperative year and again after the twelfth year. Patients who underwent AVR in 1972 and 1973 had better results than those who had operations in 1965 through 1971 (p < 0.05); the 1972-1973 patients had 5- and 10-year survival rates of 81 +/- 5% and 72 +/- 5%, respectively. The 1-year survival rate was 91% for patients with AS and 71% for those with AR (p < 0.05). In AS patients, long-term survival was adversely affected by a history of left ventricular failure, inclusion in NYHA functional class IV, cardiothoracic index of >/= 0.56, cardiac index of < 3.0 L/min/m(2), age > 55 years, previous myocardial infarction, systemic pulse pressure of /= 15 mm Hg, and mean pulmonary artery pressure of >/= 24 mm Hg. In AR patients, an adverse prognosis was associated with left ventricular failure, syncope, age >/= 60 years, and NYHA class IV status. These results indicate that, in both AS and AR patients, operation should be performed early, before severely limiting symptoms and signs arise.     

Study comparing the clinical profile of complicated cases of Plasmodium falciparum malaria among adults and children

ObjectiveTo compare the clinical profile of Plasmodium falciparum (P. falciparum) malaria in adults and children.MethodsIn this retrospective study, data were collected from case records of patients admitted with P. falciparum malaria to the paediatric and adult critical care facility of a tertiary care hospital in an endemic area. A total of 20 adults and children were compared for their symptoms.ResultsIn this study, among all adults and children with P. falciparum malaria, the commonest symptom was fever with chills and rigors. Among children, the next common symptoms were altered sensorium and irritability. Nine children (45%) had cerebral malaria, among which five had seizures. Other common manifestations were reduced urine output (35%) and vomiting (35%). Among adults, vomiting (65%) was the most common symptom followed by headache (60%). Eight (40%) adults had jaundice while nine (45%) had complaints of decreased urine output. Among adults, 4 had altered sensorium, of which 2 had seizures and jaundice; and all 4 had renal impairment.ConclusionsClinical symptoms and profile of P. falciparum malaria differ among age groups. Early recognition of symptoms and treatment of malaria is paramount especially in children who tend to have higher rates of complications compared to adults.