Psychological Autopsy in Small Penis Syndrome: Determining the Manner and Circumstance of Death Following a Vehicular Accident.

Road traffic accidents and related deaths are on the rise, especially in developing countries. Even though uncommon and probably under-recognized, predisposing psychiatric states may be contributory, posing the question of whether these could be avoided. Psychological autopsy, despite not being performed routinely, might play a pivotal role in such instances, in reconstructing events leading to the catastrophe and determining the role played by the parties involved. The legal implications, such as the exoneration of the wrongly accused, might be substantial. This case report presents a death of a middle-aged South Asian male with strong history and evidence of small penis anxiety following a direct collision in a road traffic accident. It highlights the careful evaluation of the clinical history of the deceased by a psychological autopsy and reiterates the importance of the former in suspected cases.

A conjunctival myxoid stromal tumor (COMST) mimicking phlyctenulosis: A case report and brief review of the literature.

Purpose: This is a case report of a patient with a conjunctival myxoid stromal tumor (COMST), mimicking a phlyctenulosis. Tumors of the conjunctiva and cornea occupy a large spectrum ranging from benign lesions of myxoma to aggressive, life-threatening malignancies. Phlyctenulosis and phlyctenular keratoconjunctivitis are hypersensitivity reactions to a foreign antigen. Observations: A 64-year-old male presented with six-month history of non-painful lump in the conjunctiva of the left eye. It was a mobile, non-tender, non-ulcerated, non-hemorrhagic, non-pigmented lesion and was non-adherent to the sclera. The differential diagnosis of phlyctenulosis or a soft tissue tumor was considered. The lesion was completely excised. The microscopy showed an ill-defined hypocellular myxoid lesion composed of stellate and spindle-shaped cells with eosinophilic cytoplasm, containing round-ovoid and spindle-shaped nuclei with a vesicular chromatic pattern. The tumor cells were diffusely and strongly positive for vimentin and CD 34 and were negative for S100. The immunomorphological features were compatible with a conjunctival myxoid stromal tumor. Complete systemic evaluation excluded the possible association with systemic myxomas. Conclusions and importance: Myxoid tumors of the conjunctiva are benign tumors, however, they can mimic other benign conditions like phlyctenulosis or more sinister lesions like malignant tumors. Therefore, it is important to do an excisional biopsy to ascertain the definitive pathology of an indeterminate conjunctival lesion. COMST may be the index presentation for the detection of previously undiagnosed myxoma syndromes. One such association is with cardiac myxomas, which can result in vascular embolic events. Therefore, it is important to do cardiac screening in all patients diagnosed with a COMST.

Perceptions of Seasonal Influenza Vaccine Among U.S. Army Civilians and Dependents in the Kaiserslautern Military Community: A Mixed-Methods Survey.

INTRODUCTION: Influenza is a globally occurring viral respiratory infection that can lead to hospitalizations and death. An influenza outbreak can interfere with combat readiness in a military setting, as the infection can incapacitate soldiers. Vaccination remains the most effective tool to prevent and mitigate seasonal influenza. Although influenza vaccinations for U.S. Army soldiers can be monitored through military health systems, those systems cannot capture DoD civilians and Army dependents who may not use military health services. This study aims to gauge flu vaccine uptake and perceptions in U.S. Army civilians and dependents. MATERIALS AND METHODS: An online survey was e-mailed to civilian and dependent enrollees of Landstuhl Regional Medical Center. The survey contained 24 questions pertaining to demographics, vaccine history, history of the flu, and beliefs toward vaccines. Chi-square tests, t-tests, and logistic regressions were performed to investigate the association between demographic, behavior, and belief factors with vaccine uptake. Free-text answers were coded and categorized by themes. RESULTS: Over 70% of respondents were vaccinated for the flu. There were differences between vaccinated and unvaccinated respondents regarding their perceptions of barriers to vaccination, benefits of the flu vaccine, severity of flu symptoms, and personal risk of getting ill with the flu. After controlling for confounders, flu vaccination in the previous season and healthcare worker status were associated with increased vaccine uptake, while perceived barriers to influenza vaccination were associated with decreased vaccine uptake. CONCLUSIONS: Flu vaccine uptake may be increased by increasing access to vaccination, promoting vaccination and addressing concerns at the provider level, and engaging positively framed public messaging. Increasing flu vaccine uptake is of particular importance as the flu season approaches during the COVID-19 (Coronavirus disease 2019) pandemic.

Malignant peripheral nerve sheath tumour-A case report.

INTRODUCTION: Malignant peripheral nerve sheath tumors (MPNST) are rare, aggressive sarcomatous tumors that arise from peripheral nerve sheaths and show schwann cell differentiation (Thangadurai, 2017) [1]. They commonly arise among patients with neurofibromatosis I and following radiation therapy (Farid et al., 2014). High resolution PET scans confirm the diagnosis and the definitive treatment is surgical excision. Post operative radiotherapy plays an important role in disease free survival rates. Chemotherapy is offered to people who have a systemic disease. PRESENTATION OF CASE: This case report is on a 47 year old lady, a known case of Von Recklinghausen, who complained of a vague mass in the pelvis with recent history of pain to her right thigh. Pelvic examination revealed a vague mass on the right side of her pelvis. She was planned for excision of the mass. Intraoperative findings were consistent with the clinical and radiological findings. She is currently on regular follow-up and disease free. DISCUSSION: MPNSTs are rare tumours that arise in patients with neurofibromatosis I. Mutations at the genetic level is responsible for the development of MPNST. Early presentation, radiological confirmation, aggressive margin free surgery followed by chemoradiation helps in near complete cure of the disease. CONCLUSION: MPNST are difficult to manage because of their aggressive nature and the limitations in early diagnosis and management. In patients with Von Recklinghausens disease, malignancy must be suspected when a patient presents with the complaints as mentioned in this case report.

Comparison of a Novel Human Rabies Monoclonal Antibody to Human Rabies Immunoglobulin for Postexposure Prophylaxis: A Phase 2/3, Randomized, Single-Blind, Noninferiority, Controlled Study.

Background: Lack of access to rabies immunoglobulin (RIG) contributes to high rabies mortality. A recombinant human monoclonal antibody (SII RMAb) was tested in a postexposure prophylaxis (PEP) regimen in comparison with a human RIG (HRIG)-containing PEP regimen. Methods: This was a phase 2/3, randomized, single-blind, noninferiority study conducted in 200 participants with World Health Organization category III suspected rabies exposures. Participants received either SII RMAb or HRIG (1:1 ratio) in wounds and, if required, intramuscularly on day 0, along with 5 doses of rabies vaccine intramuscualarly on days 0, 3, 7, 14 and 28. The primary endpoint was the ratio of the day 14 geometric mean concentration (GMC) of rabies virus neutralizing activity (RVNA) as measured by rapid fluorescent focus inhibition test for SII RMAb recipients relative to HRIG recipients. Results: One hundred ninety-nine participants received SII RMAb (n = 101) or HRIG (n = 98) and at least 1 dose of vaccine. The day 14 GMC ratio of RVNA for the SII RMAb group relative to the HRIG group was 4.23 (96.9018% confidence interval [CI], 2.59-6.94) with a GMC of of 24.90 IU/mL (95% CI, 18.94-32.74) for SII RMAb recipients and 5.88 IU/mL (95% CI, 4.11-8.41) for HRIG recipients. The majority of local injection site and systemic adverse reactions reported from both groups were mild to moderate in severity. Conclusions: A PEP regimen containing SII RMAb was safe and demonstrated noninferiority to HRIG PEP in RVNA production. The novel monoclonal potentially offers a safe and potent alternative for the passive component of PEP and could significantly improve the management of bites from suspected rabid animals. Clincical Trials Registration: CTRI/2012/05/002709.

Comparison of Dexmedetomidine and Midazolam for Sedation in Mechanically Ventilated Patients Guided by Bispectral Index and Sedation-Agitation Scale.

BACKGROUND: Mechanical ventilation and sedation are inextricably linked components of critical care that represent, what we do for the patients during their vulnerable course in Intensive Care Unit (ICU). AIMS: The aim of this study is to compare the efficacy and safety of midazolam and dexmedetomidine in patients on mechanical ventilator with the help of Bispectral Index (BIS) monitoring and correlation of BIS with Sedation-Agitation Scale (SAS). SETTINGS AND DESIGN: Prospective, observational, and comparative study. MATERIALS AND METHODS: In this study, recruited patients were allocated into two groups of 14 patients each. Group A and Group B patients received injection dexmedetomidine and injection Midazolam, respectively. Hemodynamic parameters, time of extubation, duration of mechanical ventilation, and mortality were compared between two groups. STATISTICAL ANALYSIS: Mean and the standard deviation were calculated. Test of analysis between two groups was performed using unpaired t-test. We applied correlation technique, that is, Pearson product-moment correlation coefficient (r) to assess the correlation between BIS and SAS. It varies from + 1-0 to -1. RESULTS: Heart rate and blood pressure were more stable and less in Group A than Group B. Duration of mechanical ventilation was found extremely significant between Group A (77.86 ± 5.71 h) and Group B (95.64 ± 17.00 h) (P = 0.001). There was significant difference found in the time of extubation between Group A (21 ± 6.44 h) and Group B (30.4 ± 10.62 h) P = 0.008. CONCLUSION: It is concluded in this study that sedation with dexmedetomidine resulted in quick extubation and decreased the duration of mechanical ventilation in comparison to midazolam in ICU patients. There was found moderate to high correlation between BIS index and SAS.

New bithiazolyl hydrazones: Novel synthesis, characterization and antitubercular evaluation.

New bithiazolyl hydrazones (6a-l) have been first time synthesized by carrying novel one pot cyclocondensation of 5-acyl thiazoles (1a-b), thiosemicarbazide (2) and substituted phenacyl chlorides (4a-f) in freshly prepared ionic liquid, diisopropyl ethyl ammonium acetate (DIPEAc) at room temperature. The newly synthesized compounds have been evaluated for their antitubercular activity and the compounds 3b, 6a, 6b, 6d, 6e, 6f, 6g, and 6l have displayed noticeable antitubercular activity compared to Rifampicin with tolerable cytotoxicity. All these compounds were also screened for their antibacterial activity and found that, compounds 6j and 6k have exhibited a very good antibacterial activity. Molecular docking study has shown better harmony with the evaluation trend shown by these compounds under in vitro antitubercular screening.

A randomized non-inferiority clinical study to assess post-exposure prophylaxis by a new purified vero cell rabies vaccine (Rabivax-S) administered by intramuscular and intradermal routes.

BACKGROUND: Rabies is a 100% fatal disease but preventable with vaccines and immunoglobulins. We have developed a new purified vero cell rabies vaccine (Rabivax-S) and evaluated its safety and immunogenicity in post-exposure prophylaxis by intramuscular (IM) and intradermal (ID) routes. METHODS: This was a randomized active-controlled non-inferiority study in 180 individuals (age 5years and above) with suspected rabies exposure (90 each with WHO Category II and Category III exposures). The participants received either Rabivax-S (1mL IM; five doses), Rabivax-S (0.1mL ID; eight doses) or purified chick embryo cell vaccine (PCEC, Rabipur®) (1mL IM; five doses). The IM doses were given on Day 0, 3, 7, 14 and 28 while the ID doses were given on days 0, 3, 7 and 28. Category III patients also received a human rabies immunoglobulin (HRIG) on Day 0. Adverse events (AEs) were recorded with diary cards till day 42. Rabies neutralizing antibody levels were measured on day 0, 7, 14, 28 and 42. RESULTS: In both the category II and III patients, the geometric mean concentration (GMC) ratios of Rabivax-S IM and Rabivax-S ID groups to PCEC IM were more than 1, thus proving the non-inferiority. GMCs were similar or higher in Rabivax-S groups at all the time points. Seroresponse against rabies (RFFIT titre⩾0.5IU/mL) was achieved in all participants. Mostly mild local and systemic adverse events were reported across the three groups and all resolved without sequelae. CONCLUSIONS: Rabivax-S was well tolerated and showed immunogenicity comparable to a licensed rabies vaccine by both IM and ID routes in post-exposure prophylaxis. Registry No.: CTRI/2012/11/003135.

Targeting substrate-site in Jak2 kinase prevents emergence of genetic resistance.

Emergence of genetic resistance against kinase inhibitors poses a great challenge for durable therapeutic response. Here, we report a novel mechanism of JAK2 kinase inhibition by fedratinib (TG101348) that prevents emergence of genetic resistance. Using in vitro drug screening, we identified 211 amino-acid substitutions conferring resistance to ruxolitinib (INCB018424) and cross-resistance to the JAK2 inhibitors AZD1480, CYT-387 and lestaurtinib. In contrast, these resistant variants were fully sensitive to fedratinib. Structural modeling, coupled with mutagenesis and biochemical studies, revealed dual binding sites for fedratinib. In vitro binding assays using purified proteins showed strong affinity for the substrate-binding site (Kd = 20 nM) while affinity for the ATP site was poor (Kd = ~8 µM). Our studies demonstrate that mutations affecting the substrate-binding pocket encode a catalytically incompetent kinase, thereby preventing emergence of resistant variants. Most importantly, our data suggest that in order to develop resistance-free kinase inhibitors, the next-generation drug design should target the substrate-binding site.

Comparative study on the immunogenicity and safety of a purified chick embryo cell rabies vaccine (PCECV) administered according to two different simulated post exposure intramuscular regimens (Zagreb versus Essen).

Despite availability of effective rabies vaccines, India has the highest global mortality rate for rabies. Low socio-economic communities are most affected due to lack of awareness of the disease and poor compliance to post-exposure prophylactic regimens. Currently, the only approved intramuscular regimen for post-exposure prophylaxis (PEP) against rabies in India is the Essen regimen, which consists of 5 injections administered over 5 separate days in a period of one month. The high number of doses and clinical visits, however, are major reasons for non-compliance, and thus a shorter regimen would be beneficial. In a simulated PEP trial in healthy, adult subjects, this study evaluated whether purified chick embryo cell vaccine (PCECV), administered according to the WHO-recommended 4-dose/3 visit Zagreb vaccination regimen is of equal immunogenicity and safety as the standard Essen regimen in Indian subjects. Two hundred and 50 healthy adults were enrolled and randomized into a Zagreb or Essen group, each receiving PCECV according to their respective regimen. Blood samples were collected on Days 0, 7, 14 and 42 and analyzed using the rapid fluorescent focus inhibition test (RFFIT). By Day 14, all subjects across both groups attained rabies virus neutralizing antibody (RVNA) concentrations of ≥ 0.5IU/ml. The Zagreb regimen was then demonstrated to be immunologically non-inferior to the Essen regimen by Day 14, which was the primary endpoint of the study. No safety issues were noted and the occurrence of adverse events was similar in both groups (17% and 15%, respectively). NCT01365494. CTRI No.: CTRI/2011/07/001857.

Detection of t(14;16)(q32;q22) and Monosomy 13 by FISH Analysis in a Patient with Multiple Myeloma Associated with Sjögren's Syndrome: The First Case Report from India.

Sjögren's syndrome (SS) is a chronic slowly progressive autoimmune disorder characterized by symptoms of oral and ocular dryness, exocrine dysfunction, and lymphocytic infiltration of exocrine glands. Multiple myeloma (MM) is a bone-marrow-based malignant neoplasm of plasma cells associated with serum/urine monoclonal paraproteins and lytic skeletal lesions. There have been very few reported cases of MM, who had SS as the first presentation. We report a case of a woman diagnosed with Sjögren's syndrome, who was later suspected to have multiple myeloma on serum protein electrophoresis. Fluorescence in situ hybridization (FISH) was carried out to check for deletions of loci 13q14.3, ATM, p53, and IGH (14q32) rearrangements on a bone marrow aspirate. Monosomy 13 was observed in 49% of cells, and a rearrangement at the IGH locus was seen in 42% of cells. To determine the partner chromosome associated with the IGH rearrangement, further FISH tests were set up for t(4;14)(p16;q32) followed by t(14;16)(q32;q22) on fresh slides. The test was negative for t(4;14) but positive for t(14;16) in 27% of cells. This confirmed the diagnosis of MM. We report the first case from India, having an association of Sjögren's syndrome with multiple myeloma, which showed t(14;16) and monosomy 13 by FISH analysis.

Health improvement for disadvantaged people in Nepal - an evaluation.

BACKGROUND: An evaluation of progress with participatory approaches for improvement of health knowledge and health experiences of disadvantaged people in eight Districts of Eastern Nepal has been undertaken. METHODS: A random selection of Village Development Committees and households, within the eight Districts where participation and a Rights-based Approach had been promoted specifically by local NGOs were compared with similar villages and households in eight Districts where this approach had not been promoted. Information was sought by structured interview and observation by experienced enumerators from both groups of householders. Health knowledge and experiences were compared between the two sets of households. Adjustments were made for demographic confounders. RESULTS: Complete data sets were available for 628 of the 640 households. Health knowledge and experiences were low for both sets of households. However, health knowledge and experiences were greater in the participatory households compared with the non-participatory households. These differences remained after adjustment for confounders. CONCLUSIONS: The study was designed to evaluate progress with participatory processes delivered by non-governmental organisations over a five year period. Improvements in health knowledge and experiences of disadvantaged people were demonstrated in a consistent and robust manner where interventions had taken place.

Coitus induced vaginal evisceration in a premenopausal woman: a case report.

Vaginal evisceration in premenopausal women after trans-abdominal hysterectomy is extremely rare in occurrence and only few cases have been documented in worldwide literature. Here we report a premenopausal woman with coitus induced trans-vaginal evisceration who had undergone trans-abdominal hysterectomy two years ago.This article highlights coitus as a trigger event for inducing vaginal evisceration and that vaginal evisceration caused by sexual intercourse should be considered in the field of surgery when a pre-menopausal woman presents with acute abdominal pain with no history of any other traumatic episode.

Primary large cell neuroendocrine carcinoma of the vagina: cytomorphology of previously unreported case.

Squamous carcinoma is the most common malignancy of the vagina. Other malignancies include adenocarcinoma, melanoma, lymphoma, and very rarely, neuroendocrine carcinoma/small-cell carcinoma. Large cell neuroendocrine carcinoma (LCNEC) has not been reported in this location. In this report, we describe a case of LCNEC of the vagina, which is believed to be the first case to date in the English literature. The patient is a 53-year old gravida 3, para 2, African-American woman who had a 4 month history of severe pelvic pain and difficulty voiding and was found to have a firm plate-like mass on the anterior vaginal wall. Thin prep of vaginal swap was interpreted as atypical glandular cells; however, the biopsies showed a large cell neuroendocrine carcinoma which was confirmed by diffuse strong immunoreactivity to AE1/3, CAM5.2, CK7, and CD56 in the tumor cells. Subsequent clinical workup showed that the patient also had numerous metastatic nodules in the bilateral lungs and a vaginal-urethral fistula caused by the tumor. The patient underwent palliative radiation of pelvis for local pain control and then chemotherapy. Although the vaginal tumor increased in size even after radiation, her symptoms were under control and she was doing well for a short period of time. The patient is still alive but developed brain metastasis a year later after initial diagnosis. Despite its rarity, large cell neuroendocrine cell carcinoma should be included in the differential diagnosis when cytomorphology shows features suggestive of neuroendocrine differentiation.

A prospective randomized, controlled study comparing low pressure versus high pressure pneumoperitoneum during laparoscopic cholecystectomy.

BACKGROUND: The increase in intra-abdominal pressure by insufflation of carbon dioxide during laparoscopy brings certain changes in function of organ systems and also leads to postoperative pain. Degree of intra-abdominal pressure is directly related with such change. Laparoscopic cholecystectomy can be performed at low pressure pneumoperitoneum. However, available space for dissection is less than the high pressure pneumoperitoneum. METHODS: Twenty-six patients for elective laparoscopic cholecystectomy were studied in a prospective, randomized, patient, and surgeon blinded manner. The intra-abdominal pressure was kept either in low pressure (8 mm Hg) or in high pressure (12 mm Hg). All patients underwent two dimensional echocardiography, pulmonary function test and color Doppler examination of lower limb vessels preoperatively and postoperatively. Arterial blood gas analysis and End Tidal CO2 monitored before insufflation, during surgery and after deflation. Pain score was measured by visual analog scale and surgeon's comfort level was recorded. Postoperative analgesia requirement, complications, and hospital stay were recorded. Student t test used for the statistical analysis. RESULTS: Both groups match for the demographic parameters. Four patients required conversion to high pressure. Intraoperative pO2 level, postoperative pain, analgesic requirement, pulmonary function, and hospital stay were favoring low pressure pneumoperitoneum in a statistically significant manner. There was no difference between 2 groups for duration of surgery, intraoperative, and postoperative complications. However, the technical difficulties were graded more (statistically nonsignificant) with low pressure pneumoperitoneum. CONCLUSIONS: An uncomplicated gall stone disease can be treated by low pressure laparoscopic cholecystectomy with reasonable safety by an experienced surgeon. Though surgeons experience more difficulty in dissection during low pressure pneumoperitoneum, it is significantly advantageous in terms of postoperative pain, use of analgesics, preservation of pulmonary function, and hospital stay.

Aspiration biopsy cytology of ectopic thyroid tissue in the lateral chest wall: a case report.

BACKGROUND: Ectopic thyroid tissue is a rare abnormality that mainly occurs in the midline of the neck but also in other unusual locations. Because fine needle aspiration biopsy (FNAB) is a widely used procedure for evaluating head and neck and other palpable masses, sampling of these lesions may be encountered. CASE: A 66-year-old woman presented with left lateral chest wall mass during follow-up for chronic obstructive pulmonary disease, hypertension and diabetes mellitus. Initial evaluation by FNAB suggested ectopic thyroid tissue, which was confirmed later by tissue biopsy and immunostains. This is the first reported case of ectopic thyroid tissue in the lateral chest wall area. CONCLUSION: Awareness of this abnormality and the possibility of ectopic thyroid tissue in erratic locations will help cytopathologists make the correct interpretation on FNAB sampling.

Chondroblastic osteosarcoma of the cuboid: a literature review and report of a rare case.

UNLABELLED: Chondroblastic osteosarcoma accounts for about 25% of all cases of osteosarcoma, which is the most common primary malignancy of the skeleton. Currently, only a few cases of chondroblastic osteosarcoma have been reported to involve the bones of the foot. In this report, we describe the previously unreported occurrence of chondroblastic osteosarcoma involving the left tarsal cuboid in a 15-year-old male. Histologically, the tumor showed an unusually extensive osteoclastic giant cell reaction that initially led to an erroneous diagnosis of giant cell tumor of bone. Because treatment and prognosis are very different for chondroblastic osteosarcoma as compared to giant cell tumor of bone, it is important to make the distinction between these 2 different bone tumors. In this report, we wish to draw attention to occurrence of chondroblastic osteosarcoma in the small bones of the foot, and to the possibility of an extensive giant cell reaction making accurate diagnosis difficult. We also provide a comprehensive review of the literature related to chondroblastic osteosarcoma. LEVEL OF CLINICAL EVIDENCE: 4.

An immunogenicity, safety and post-marketing surveillance of a novel adsorbed human diploid cell rabies vaccine (Rabivax) in Indian subjects.

In 1999, Serum Institute of India indigenously developed an adsorbed human diploid cell rabies vaccine (Rabivax). During 2000-04, this new vaccine was subjected to a series of immunogenecity and safety studies. Initially, an experimental batch of Rabivax (adsorbed) was assessed on ten healthy adult volunteers and its response was comparable with that of Merieux inactivated rabies vaccine (MIRV, lyophilized) which was used as a control. Subsequently, Rabivax (adsorbed) was assessed on forty-five suspect rabid dog bite cases with MIRV as control. The vaccine was found to be equally safe and immunogenic as MIRV and showed better rabies virus neutralizing antibody (RVNA) response on day 90 than MIRV. A post-licensing study conducted on 150 cases of suspect rabid animal bites showed it to be safe and immunogenic. To assess its long-term sero-efficacy some of these subjects tested after one year of follow up showed that 84% of them had adequate RVNA titers. In addition, a routine post-marketing surveillance done on 1608 animal bite cases demonstrated that Rabivax (adsorbed) was safe and efficacious. The adverse events to Rabivax (adsorbed) included pain at injection site (3.4%), swelling with induration (2.8%), fever and headache (1.4%). No serious adverse event was reported from the studies. In conclusion, Rabivax (adsorbed) is an immunogenic, safe and efficacious vaccine for rabies prophylaxis in humans.

Comparison of artemether-lumefantrine with sulfadoxine-pyrimethamine for the treatment of uncomplicated falciparum malaria in eastern Nepal.

Because available data suggest that resistance of Plasmodium falciparum to sulfadoxine-pyrimethamine (SP) is increasing in Nepal, an open-label, parallel-group efficacy/safety study was conducted in 99 Nepalese patients with uncomplicated falciparum malaria randomized 2:1 to artemetherlumefantrine (AL) or SP. Efficacy was assessed from clinical and microscopic evidence of treatment failure. Four SP-treated patients (12.1%; 95% CI, 4.0-29.1%) redeveloped parasitemia during the 28-day follow-up versus 0% (95% CI, 0-6.9%) in the AL group (P = 0.011), a difference that was confirmed by polymerase chain reaction (PCR) analysis of parasite DNA. PCR detected an additional six patients (two SP and four AL) with sub-microscopic gametocytemia or breakthrough parasitemia between Days 14 and 28, suggesting that AL efficacy was lower than estimated by microscopy. Dhfr and dhps mutations were not associated with outcome. AL is more effective than SP for uncomplicated malaria in Nepal, but regular monitoring of its efficacy should be carried out if this combination therapy is introduced.