Artesunate-atovaquone-proguanil rescue treatment of multidrug-resistant Plasmodium falciparum malaria in pregnancy: a preliminary report

Pregnant women are particularly vulnerable to malaria infections. Multidrug resistance in Plasmodium falciparum seriously compromises treatment in some endemic areas. Between April 1999 and October 2001, we treated and prospectively followed 27 Karen pregnant women with multiple recrudescent P. falciparum infections who were resistant to all other antimalarials with a triple combination of artesunate-atovaquone-proguanil. The treatment was well tolerated and we found no evidence of toxicity for the mothers and the fetus. All but 1 woman were cured (cure rate 96%, 95% CI 89-100). The triple combination of artesunate (4 mg/kg/d), atovaquone (20 mg/kg/d), and proguanil (8 mg/kg/d) may provide a much needed, albeit expensive, 3-d rescue treatment for pregnant women exposed to multidrug- resistant P. falciparum malaria.     

Initial clinical experience with the 4-F self-expanding XPERT stent system for infrapopliteal treatment of patients with severe claudication and critical limb ischemia

PURPOSE: To evaluate the primary success and short-term patency associated with a new 4-F sheath-compatible self-expanding nitinol stent after failed conventional angioplasty of distal popliteal and infrapopliteal lesions in severe lifestyle-limiting claudication (LLC) and chronic critical limb ischemia (CLI). MATERIALS AND METHODS: Between May 2003 and July 2005, 35 patients with Rutherford category 3-5 disease (16 patients with CLI, 19 patients with LLC) underwent percutaneous transluminal angioplasty (PTA) and stent implantation. Indications for stent placement were residual stenosis, flow-limiting dissections, or elastic recoil after PTA. Before and after the intervention and during the 6-month follow-up, clinical investigation, color-flow and duplex Doppler ultrasonography, and digital subtraction angiography were performed. Technical success, primary patency at 6 months, clinical improvement as defined by Rutherford with clinical and hemodynamic measures, and complications were evaluated. RESULTS: A total of 22 patients underwent distal popliteal artery stent placement and 13 underwent tibioperoneal artery stent placement. Stent implantation was successfully performed in all patients. After stent placement, the primary cumulative patency rate for the study group at 6 months was 82%. The mean resting ankle-brachial index at baseline was 0.50 +/- 0.16 and significantly increased to 0.90 +/- 0.17 at 12-24 hours after intervention and 0.82 +/- 0.24 at latest follow-up (P < .001 for both). The sustained clinical improvement rate was 80% at the 6-month follow-up. The 6-month limb salvage rate regarding major amputation was 100%. The rate of major complications was 17%. CONCLUSIONS: Infrapopliteal application of the new nitinol stent is a safe, feasible, and effective method with good short-term patency rate in the treatment of severe LLC and chronic CLI.     

Oral sirolimus for prevention of recurrent infrainguinal arterial obstructions after surgical and endovascular revascularizations

No data are currently available on the role of oral sirolimus in the prevention of recurrent stenosis in the periphery. We report the effects of oral sirolimus in the prevention of recurrent infrainguinal obstructions in patients with complex peripheral arterial disease. Three patients with ischemic rest pain of the lower limbs and repeated short-term need for surgical and/or endovascular revascularization: 9 times within 12 months, 7 times within 15 months, 11 times within 26 months, respectively. Oral sirolimus on a case by case basis, resulted in less frequent restenosis and longer intervention-free intervals: three re-interventions within 37 months in the first patient, one balloon angioplasty within 17 months in the second, and three re-interventions within 21 months in the third patient, respectively. Side effects, in particular dyspepsia and diarrhoea, were mild and tolerable. To our knowledge, this is the first report to show that oral sirolimus was successfully administered in patients with recurrent excessive neointimal proliferation after revascularization of peripheral arterial lesions lowering the necessity of re-intervention and hence prolonging intervention-free intervals.     

Screening of EEG referrals by neurologists leads to improved healthcare resource utilization.

The objective of this study was to determine if screening by a neurologist of all non-neurologist electroencephalogram (EEG) referrals prior to approval reduces the number of inappropriate requests. This retrospective survey included 600 consecutive EEG requisitions referred to the Anaheim Kaiser Permanente Neurodiagnostic Laboratory to rule out epilepsy. Patients with established epilepsy referred for a repeat EEG for management issues were excluded. Three groups of EEG referrals were analyzed. Each group consisted of 200 EEGs (100 pediatric and 100 adult EEGs). The first group was referred directly by non-neurologists, the second group was referred by non-neurologists with scrutiny by a neurologist, and the third group was referred by a neurologist directly. In the pediatric group, the ratio of abnormal EEG vs normal EEG was 1:3.35 in the first group, 1:0.69 in the second group and 1:0.33 in the third group. In the adult group, the ratio of abnormal EEGs vs normal EEGs was 1:2.23 in the first group, 1:0.82 in the second group and 1:0.45 in the third group. In the combined pediatric and adult groups, the ratio of abnormal EEG vs normal EEG was 1:2.70 in the first group, 1:0.75 in the second group and 1:0.39 in the third group. There was a significant difference between the results of the EEGs ordered by non-neurologists directly versus non-neurologists with scrutiny (p=.334, chi-square test). Scrutiny by a neurologist of EEG referrals from non-neurologists led to a reduction in the number of normal EEG results. This suggests that inappropriate EEG requests for non-epileptic patients that yield normal EEG results are significantly reduced with scrutiny. This can help reduce the indiscriminate overuse of EEGs by non-neurologists thereby leading to better utilization of healthcare resources.     

Peer Reviewed: The Incidence and Health Economic Burden of Ischemic Amputation in Minnesota, 2005-2008

Introduction

Critical limb ischemia (CLI) is the most severe manifestation of peripheral artery disease (PAD), is associated with high rates of myocardial infarction, stroke, and amputation, and has a high health economic cost. The objective of this study was to estimate the incidence of lower limb amputation, the most serious consequence of CLI, and to create a surveillance methodology for the incidence of ischemic amputation in Minnesota.

Methods

We assessed the incidence of ischemic amputation using all inpatient hospital discharge claims in Minnesota from 2005 through 2008. We identified major and minor ischemic amputations via the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes for lower limb amputation not due to trauma or cancer and assessed geographic and demographic differences in the incidence of ischemic amputation.

Results

The age-adjusted annual incidence of lower limb ischemic amputation in Minnesota during the 4-year period was 20.0 per 100,000 (95% confidence interval, 19.4-20.6). Amputations increased significantly with age, were more common in men and in people with diabetes, and were slightly more common in rural residents. The number of amputation-related hospitalizations was steady over 4 years. The median total charge for each amputation was $32,129, and cumulative inpatient hospitalization charges were $56.5 million in 2008.

Conclusion

The incidence of ischemic amputation is high and results in major illness and health economic costs. These data represent the first population-based estimate of ischemic amputation at the state level and provide a national model for state-based surveillance.     

Persistence and Change in Marriage Practices among Syrian Refugees in Jordan

Early marriage, which is associated with a wide range of negative health and socioeconomic outcomes, may be a response to conflict and displacement. Since the onset of the Syrian conflict in 2011, there has been considerable attention to reports of high and potentially increasing rates of early marriage among Syrian refugee women. Using nationally representative survey data from Jordan in 2016 and Syria in 2009, as well as qualitative interviews with Syrian refugee youth in Jordan, we examine changes in age at marriage and drivers of early marriage. We find no evidence of an increase in early marriage rates after refugees’ arrival to Jordan. Rates of early marriage among the Syrians now in Jordan were higher than preconflict national rates and have remained similar postdisplacement, although poverty and security concerns have created new drivers for accelerating marriage for young women. Other dynamics of the Syrian marriage market in displacement may act to decelerate marriage rates, including declining rates of consanguinity and inability to meet marriage costs. Analysis of early marriage in displacement must be placed within the context of change in marriage practices among refugees more broadly.     

Portable measurement system for the objective evaluation of the spasticity of hemiplegic patients based on the tonic stretch reflex threshold

The clinical scales used for the evaluation of the spasticity have some drawbacks, in spite of their simplicity and ease of assessment, and their inter- and intra-rater reliability remains controversial. The aim of this study is to develop a portable system for the objective and reliable evaluation of the spasticity based on the K-means clustering of the tonic stretch reflex threshold (TSRT) and to compare the discrimination performance of the level of spasticity determined by our method with that by the conventional modified Ashworth scale (MAS). Fifteen hemiplegic patients (7 males and 8 females, age: 63.5±15.6) participated in the study. The average and standard deviation values of the TSRTs were 127.9±1.6, 121.8±1.5 and 117.9±1.3 in groups G1, G2 and G3, respectively, and there were significant differences between the TSRTs of each group (p<0.05). Also, our groups classified by the criteria of the TSRT had a strong negative correlation (r=-0.95, r(2)=0.90, p<0.05) between the level of spasticity and TSRTs. These results demonstrated that our system could be clinically more useful for the quantitative and reliable discrimination of the spasticity than the conventional MAS.     

Carotid plaque and intima-media thickness and the incidence of ischemic events in patients with atherosclerotic vascular disease

We aimed to evaluate whether carotid intima-media thickness (CIMT) or the presence of plaque can confer additional predictive value of future cardiovascular (CV) ischemic events in patients with pre-existing atherosclerotic vascular disease. We identified 2317 patients enrolled in the REduction of Atherothrombosis for Continued Health (REACH) registry who had atherosclerotic vascular disease and baseline CIMT measurements. The entire range of CIMT was divided into quartiles and the fourth quartile (≥ 1.5 mm) was defined as carotid plaque. Mean ± standard deviation baseline CIMT was 1.31 ± 0.65 mm. Associated CV ischemic events and vascular-related hospitalizations were evaluated over a 2-year follow-up. There was a positive increase in adjusted hazard ratios (HRs) for all-cause mortality (p = 0.04 for trend) and the quadruple endpoint (CV death, myocardial infarction (MI), stroke, hospitalization for CV events) with increasing quartiles of CIMT (p = 0.0008 for trend), which was mainly driven by the fourth quartile (carotid plaque). HRs for all-cause mortality, CV death, CV death/MI/stroke and the quadruple endpoint comparing the highest (carotid plaque) with the lowest CIMT quartile were 2.09 (95% CI, 1.07-4.10; p = 0.03); 2.49 (1.10-5.67; p = 0.03); 1.71 (1.10-2.67; p = 0.02); and 1.73 (1.31-2.27; p = 0.0001). In conclusion, our analyses suggest that the presence of carotid plaque, rather than the thickness of intima-media, appears to be associated with increased risk of CV morbidity and mortality, but confirmation of these findings in other population and prospective studies is required.