Safety and efficacy of ultra-high-dose, short-term thrombolysis with rt-PA for acute lower limb ischemia.

OBJECTIVES: The evaluation of success and complication rates of ultra high-dose recombinant tissue plasminogen activator (rt-PA) administered over a short time frame in the treatment of acute lower limb ischemia. METHODS: This was a prospective single-center study. The outcome of treatment in 97 patients with acute limb ischemia (<14 days) with the use of catheter directed rt-PA infusion was evaluated. The mean total dose of rt-PA was 54.1 mg (50-60 mg) and was administered for a mean of 2.51 hours (2-4 hours). Thrombolytic success was defined as 95% thrombolysis of an occluded segment with return of antegrade flow. Thirty-day complication and amputation-free survival rates were calculated. RESULTS: Thrombolytic success was achieved in 83.5%. Overall clinical success was 88.7%. The 30-day amputation-free survival rate was 93.8%. Major bleeding complications occurred in 10 patients (10.3%). There were two deaths (2.1%) and four amputations (4.1%). Long-term amputation-free survival was 70%. CONCLUSIONS: Administration of ultra-high doses of rt-PA over a short time period gives promising results. Such delivery improves patient tolerance by rapid restoration of limb perfusion; however further studies are required to confirm these results.

An open randomized controlled trial to compare the efficacy of two fixed dose combinations of artemesinin based combinations for uncomplicated falciparum malaria in Bangladesh.

National Malaria Control Program (NMCP) of Bangladesh has introduced Artemisinin Based Combination (ACT), Coartem(R) (Artemether-Lumefantrine (AL), fixed dose combination, in the confirmed cases of uncomplicated P. falciparum malaria since 2004. Despite the reduction of mortality due to malaria, the development and spread of anti-malarial drug resistance wordwide posing a threat to the health services and will make it difficult to control malaria in Bangladesh in future. We need to have an alternative to Coartem which could be Artesunate-amodiaquine (AA) in a fixed dose combination (FDC), a cheaper altenative not yet evidenced to be effective and safe to our population. In this study we compared the efficacy and safety of Artemether + Lumefantrene (FDC, Coartem) with Artesunate +Amodiaquine tablets (100/270 mg FDC) for the treatment of uncomplicated P. falciparum malaria in three high risk multi-drug resistant malaria prevalent areas of Bangladesh. It was an open label randomized controlled trial conducted between December 2008 and November 2009 in 4 upazillas in patients over the age 12 to 60 years diagnosed as a case of uncomplicated P. falciparum malaria. The outcome of the cases were measured as clinical response, parasitological response, defervescence time and parasite clearance time. Drug safety was assessed by comparing the adverse events. A total of 252 cases were randomized to receive Artesunate + Amodiaquine (AA group, 147 cases) and Artemether + Lumefantrene (AL group, 106 cases), one lost to follow up at day 28 in AA group. The distribution of the cases was comparable by age, sex and study sites. Treatment success' response was observed 100% in the AL group and AA group had 99%, two failures with AA were late treatment failures and the difference was not statistically significant (p > .1). The parasitological sensitive (S) response was observed in 97% of cases in AL group and 95% in the AA group, and was not a statistically significant difference. There was no significant difference in deffervescence time and parasite clearance time between two groups of cases. No serious adverse events were observed. The frequencies of minor adverse events were insignificantly different between the two treatment groups. The two ACT regimen, AA and AL had no significant difference in efficacy and safety for treatment of Uncomplicated Malaria in Bangladesh. However, there were few more failures with AA regimen compared to AL regimen, which was not statistically significant. Both these regimens can be used alternatively by the NMCP of Bangladesh as first-line treatment option.

MiniSOX9, a dominant-negative variant in colon cancer cells.

Inherited and acquired changes in pre-mRNA processing have significant roles in human diseases, especially cancer. Characterization of aberrantly spliced mRNAs may thus contribute to understand malignant transformation. We recently reported an anti-oncogenic potential for the SOX9 transcription factor in the colon. For instance, the Sox9 gene knock out in the mouse intestine results in an excess of proliferation with appearance of hyperplasia. SOX9 is expressed in colon cancer cells but its endogenous activity is weak. We looked for SOX9 variants that may impair SOX9 activity in colon cancer cells and we discovered MiniSOX9, a truncated version of SOX9 devoid of transactivation domain as a result of retention of the second intron. A significant overexpression of MiniSOX9 mRNA in human tumor samples compared with their matched normal tissues was observed by real-time reverse transcriptase-PCR. Immunohistochemistry revealed that MiniSOX9 is expressed at high levels in human colon cancer samples whereas it is undetectable in the surrounding healthy tissues. Finally, we discovered that MiniSOX9 behaves as a SOX9 inhibitor, inhibits protein kinase Cα promoter activity and stimulates the canonical Wnt pathway. This potential oncogenic activity of the SOX9 locus gives new insights on its role in colon cancer.

Pre-referral rectal artesunate to prevent death and disability in severe malaria: a placebo-controlled trial.

BACKGROUND: Most malaria deaths occur in rural areas. Rapid progression from illness to death can be interrupted by prompt, effective medication. Antimalarial treatment cannot rescue terminally ill patients but could be effective if given earlier. If patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate can be given before referral and acts rapidly on parasites. We investigated whether this intervention reduced mortality and permanent disability. METHODS: In Bangladesh, Ghana, and Tanzania, patients with suspected severe malaria who could not be treated orally were allocated randomly to a single artesunate (n=8954) or placebo (n=8872) suppository by taking the next numbered box, then referred to clinics at which injections could be given. Those with antimalarial injections or negative blood smears before randomisation were excluded, leaving 12 068 patients (6072 artesunate, 5996 placebo) for analysis. Primary endpoints were mortality, assessed 7-30 days later, and permanent disability, reassessed periodically. All investigators were masked to group assignment. Analysis was by intention to treat. This study is registered in all three countries, numbers ISRCTN83979018, 46343627, and 76987662. RESULTS: Mortality was 154 of 6072 artesunate versus 177 of 5996 placebo (2.5%vs 3.0%, p=0.1). Two versus 13 (0.03%vs 0.22%, p=0.0020) were permanently disabled; total dead or disabled: 156 versus 190 (2.6%vs 3.2%, p=0.0484). There was no reduction in early mortality (56 vs 51 deaths within 6 h; median 2 h). In patients reaching clinic within 6 h (median 3 h), pre-referral artesunate had no significant effect on death after 6 h or permanent disability (71/4450 [1.6%] vs 82/4426 [1.9%], risk ratio 0.86 [95% CI 0.63-1.18], p=0.35). In patients still not in clinic after more than 6 h, however, half were still not there after more than 15 h, and pre-referral rectal artesunate significantly reduced death or permanent disability (29/1566 [1.9%] vs 57/1519 [3.8%], risk ratio 0.49 [95% CI 0.32-0.77], p=0.0013). INTERPRETATION: If patients with severe malaria cannot be treated orally and access to injections will take several hours, a single inexpensive artesunate suppository at the time of referral substantially reduces the risk of death or permanent disability. FUNDING: UNICEF/UNDP/World Bank Special Programme for Research and Training in Tropical Diseases (WHO/TDR); WHO Global Malaria Programme (WHO/GMP); Sall Family Foundation; the European Union (QLRT-2000-01430); the UK Medical Research Council; USAID; Irish Aid; the Karolinska Institute; and the University of Oxford Clinical Trial Service Unit (CTSU).

Evaluation of alternative diagnostic techniques for diagnosis of cerebral malaria in a tertiary referral hospital in Bangladesh.

Five alternative techniques for diagnosis of malaria were evaluated in 124 clinically diagnosed cerebral malaria cases admitted in a tertiary hospital in Bangladesh. Clinical diagnosis of cerebral malaria was done by WHO criteria. The tests were conventional routine malaria microscopy; prolonged microscopy; dipstick antigen capture assay (Para Sight TM-F test); pigments in peripheral leucocytes and routine microscopy repeated at 12 hours interval. First four tests were done at 0 hours of hospital admission and repeat routine microscopy was added at 12 hours interval. Diagnostic capability of the test was 64%, 65%, 69%, 27% and 63% respectively. None of the tests except pigments in peripheral leucocytes was superior at initial evaluation. Only the dipstick test added 5% more diagnostic possibility compared with routine microscopy as standard. Stratification of diagnostic capability in different ways improved diagnosis 15% and 11% in smear negative cases by dipstick and prolonged microscopy respectively. It was increased by 50% (5/10 patients) with dipstick test in the smear negative patients with history of anti-malarials prior to hospital admission.

[Cardiovascular risk associated with urolithiasis]. / Risque cardiovasculaire chez les lithiasiques.

OBJECTIVE: Urolithiasis appears to be associated with several cardiovascular risk factors (excess salt and animal proteins, hypertension, metabolic syndrome) and, more recently, the development of stroke. The authors describe the frequency of cardiovascular risk factors and cardiovascular events before and after management of urolithiasis. METHOD: The authors retrospectively collected data from patients born before 1956 and managed surgically or instrumentally for urolithiasis in our establishment in 1994 concerning the frequency of cardiovascular risk factors and the incidence of acute coronary syndrome, stroke or acute lower limb ischaemia before or after treatment of urolithiasis. RESULTS: Data were obtained for 33 patients, revealing 12 events including five previous events (four cases of acute coronary syndrome, one ischaemic stroke) and seven subsequent events (five cases of acute coronary syndrome with one death, one ischaemic stroke, one case of acute lower limb ischaemia) an average of 5.7 years after management. These 33 patients had an average of more than two risk factors. CONCLUSION: This retrospective study based on a small sample size demonstrated a high frequency of risk factors and cardiovascular events. This correlation needs to be studied in more detail. Urolithiasis could constitute an indirect cardiovascular risk factor dependent on "classical" risk factors, suggesting the need for integrated management of stone patients, in the same way as for patients with erectile dysfunction.

Malaria in southeast Bangladesh: a descriptive study.

Malaria in Asia is thought to be grossly under-reported and this is evident from previously published statistics from Bangladesh. Malaria screening data from four Upazillas was analysed alongside census data to assess the trends in malaria incidence over time and distribution of malaria by age and gender. Malaria incidence in this area has decreased by around two thirds since 2003, although control measures were not significantly increased until 2005. Malaria occurred in people of all ages with the highest incidence being in young adults. This is consistent with higher occupational exposure in this group. The probability of being screened for malaria decreased with age suggesting significant numbers of adults with malaria may be being missed.

Drug-resistant malaria in Bangladesh: an in vitro assessment.

Forty-four Plasmodium falciparum isolates from Bangladesh and 22 from western Thailand were successfully tested for their drug susceptibility. High degrees of resistance were observed against chloroquine with geometric mean IC50s of 114.25 and 120.5 nM, respectively, for Bangladesh and western Thailand. Most isolates from both sites were sensitive to quinine, and all were sensitive to artesunate. Many isolates were considered in vitro resistant to mefloquine, but the geometric mean IC50 for the Thai isolates (98.79 nM) was 1.6 times (P = 0.002) higher than that of isolates from Bangladesh (60.3 nM). The high prevalence of in vitro mefloquine resistance in Bangladesh suggests that close surveillance is necessary to delay widespread multidrug resistant problems in the area.

Prognostic factors relating to outcome of severe malaria among children in Bangladesh.

This study was done in the Paediatric in-patient department of Chittagong Medical College Hospital (CMCH), Chittagong, Bangladesh to identify and quantify the prognostic factors associated with increased mortality in severe malaria (SM) cases. All the patients with parasitologically confirmed clinical syndromes of SM, admitted between June 1997 and May 1998, were included. A total of 53 consecutive cases were studied. Cerebral malaria (CM) was the commonest type of SM, observed in 36(68%) cases, second commonest type was severe anaemia 13(25%). More than one type of severe manifestations were present in 23(44%) cases. Overall case fatality rate (CFR) was 17% and it was 30% among those who had multi-organ manifestations. Important poor prognostic clinical variables were Blantrye coma score (BCS) score of 0 and 1 on day 1 (OR = 7.78) and day 2(OR = 40.0), multi-organ manifestations (OR = 6.8) and in-hospital complications (OR = 5.18). Important poor prognostic laboratory variables were day 2 parasite count > 50,000/cmm (OR = 5.5), blood glucose < 2.2 mmol/l (OR = 21.5) and raised CSF protein > 50 mg/dl (OR = 7.0). It can be concluded that certain clinical variables e.g. low BCS on day 1 & 2, multi-organ manifestations, in-hospital complications; and laboratory variables e.g. high parasite count, low blood glucose level, raised CSF protein levels are associated with increased mortality rate in SM cases.

A randomized controlled trial comparing artemether and quinine in the treatment of cerebral malaria in Bangladesh.

A randomized controlled trial on 51 patients receiving artemether and 54 patients receiving quinine was undertaken to compare the effectiveness of intramuscular artemether and parenteral quinine in the treatment of cerebral malaria in adults in Bangladesh. Case fatality, fever and parasite clearance times were not significantly different in the two treatment groups. Coma resolution time was significantly delayed in artemether recipients. Results of the study suggest that treatment with artemether is as effective as parenteral quinine in the treatment of cerebral malaria in adults.

Monitoring efficacy of commonly used antimalarials by a 14-day in-vivo test in a new settler's camp in endemic zone at Cox's Bazar.

The study was done in a new settler's camp "Barachara" under Sadar thana of Cox's Bazar district. It has a total population of 784 of all age groups, registered in the middle of the study period. A prospective evaluation of all cases of fever were done over 12 months, to see the pattern of febrile illness among the population and to compare the therapeutic efficacy of two alternative drug regimens for uncomplicated falciparum malaria (UM). Blood for malarial parasite (MP) was done in all cases of fever and was treated in line with the new clinical case definitions and treatment guidelines for malaria in Bangladesh. Slide positive UM cases were subjected to a "14-day in-vivo test" for therapeutic efficacy testing of antimalarial agents. The two drug regimens were randomised by lottery--a) 3 days oral chloroquine plus single dose sulphadoxin/pyrimethamine (CQ + SP) and, b) 3 days oral quinine plus single dose sulphadoxin/pyrimethamine (Q3 + SP). Drug administration was supervised by the field assistant and was followed up on days 3, 7 and 14 for blood slide examinations and clinical assessment. Sensitive response was observed in 79% of the cases in the CQ + SP group and 84% in the Q3 + SP group. Early treatment failure (persistently febrile and parasitaemic on days 3 or 7) was observed in 16% in the CQ + SP group and 9% in the Q3 + SP group. Both the evaluated drug regimens had less than 20% failures and can be used as alternative first line agents and Q3 + SP regimens can also be used as the second line agents for treatment failure (to chloroquine and/or SP) UM cases in the study area.

The effect of sera from cats infected with Brugia pahangi and subsequently treated with levamisole on the infectivity of third-stage larvae of B. pahangi.

Cats were treated with levamisole and the infective (L3) stage of Brugia pahangi. Serum from infected cats was subsequently tested for its ability to infect jirds. Jirds autopsied at 33 days postmortem showed significant levels of parasitemia. This is contrary to reports of a previous study wherein serum from humans infected with B. malayi was found to induce cell adherence and death of the L3.

Brugia pahangi infections in cats: antibody responses which correlate with the change from the microfilaraemic to the amicrofilaraemic state.

The humoral responses of eight cats infected with Brugia pahangi to somatic antigens from all life-cycle stages were examined quantitatively by ELISA and qualitatively by immunoblotting for almost a year post infection. Six cats spontaneously became amicrofilaraemic: their production of IgG antibodies against somatic antigens of microfilariae, adults, and infective larvae was not statistically higher than that of the two cats which remained microfilaraemic. However, immunoblotting revealed that those cats which spontaneously became amicrofilaraemic selectively recognized certain microfilarial, adult and infective larval somatic antigens prior to disappearance of microfilariae from the peripheral circulation. The data suggest that selective recognition of antigens by some cats is responsible for the production of antibodies which may then promote microfilarial death.

The anthelmintic effects of flubendazole on Brugia pahangi.

The anthelmintic effects of flubendazole (methyl [5-(4-fluorobenzoyl)-1-H-benzimidazol-2-yl] carbamate) (Janssen Pharmaceutica) were evaluated in jirds (Meriones unguiculatus) and cats (Felis cattus) infected with Brugia pahangi. Flubendazole was macrofilaricidal at 5 x 2.5 mg/kg and 1 x 25 mg/kg in jirds and 1 x 100 mg/kg in cats when administered by subcutaneous injection. It also killed developing larvae in jirds. It was not microfilaricidal.

Cations in component reactions of 'malic' enzyme catalysis.

The ;malic' enzyme (EC 1.1.1.40) has been purified (300-fold) from wheat germ and its abilities to catalyse the decarboxylation and the hydrogenation of oxaloacetic acid and oxaloacetate esters was studied. The free 1-carboxyl group is essential for the interaction of oxaloacetates and substituted oxaloacetates with the enzyme via cations. The free 4-carboxyl group is required for the decarboxylation but is not indispensable for the hydrogenation. At high concentrations, cations inhibit the enzymic hydrogenation of oxaloacetic acid but not that of 4-ethyl oxaloacetate. A plausible inhibitory mechanism is proposed.