Changing microbiological profile of pathogenic bacteria in diabetic foot infections: time for a rethink on which empirical therapy to choose?

AIMS/HYPOTHESIS

We studied the bacterial aetiology and antibiotic sensitivity pattern of diabetic foot ulcers in India.

METHODS

Records of 447 hospitalised patients between 1991 and 2008 were retrospectively analysed between two time periods (before and after 1999) to compare bacterial aetiology and antimicrobial sensitivity patterns. The first three consecutive cultures from the same wound during treatment were evaluated.

RESULTS

Of 1,632 cultures, 66% were polymicrobial, 23% monomicrobial and 11% sterile. In the monomicrobial group, 14% (n = 228) of cultures were Gram-negative, whereas 9% (n = 147) were Gram-positive. The most common pathogens in the first culture were Pseudomonas aeruginosa (20.1%), Staphylococcus aureus (17.2%) and Escherichia coli (16.3%). Results for the third cultures showed persistence of P. aeruginosa (15.3%) and E. coli (14.2%). Gram-negative isolates dominated over Gram-positive ones (25.3% vs 15.1%, p < 0.05). Antibiotic sensitivity patterns before and after 1999 were: piperacillin-tazobactam 74% vs 66% (p < 0.005), imipenem 77% vs 85% (NS), cefoperazone-sulbactam 47% vs 44% (p < 0.005), amikacin 62% vs 78% (NS), ceftriaxone 41% vs 36% (p < 0.005), amoxicillin-clavulanate 51% vs 43% (p < 0.05) and clindamycin 43% vs 36% (p < 0.005), respectively.

CONCLUSIONS/INTERPRETATION

Unlike in the West, in India Gram-negative bacteria were found to have always been dominant in the wounds of patients with diabetic foot infections. Infection with polymicrobial multidrug-resistant Gram-negative bacilli is common. The policy of empirical antimicrobial therapy at tertiary care needs to be changed.

Submerged and Impacted Primary Molars

Submerged tooth is the one that is depressed below the occlusal plane. Dental ankylosis is thought to be a major cause of submergence. Submerged deciduous teeth have the potential to cause malocclusion not only by prevention of their exfoliation and subsequent replacement by permanent teeth but also by causing tilting of proximal teeth and extrusion of opposing tooth. The purpose of this report is to present three different cases of submerged deciduous teeth and their clinical effects.

Gedunin and photogedunin of Xylocarpus granatum show significant anti-secretory effects and protect the gastric mucosa of peptic ulcer in rats

In the present study, the gastroprotective mechanism of Xylocarpus granatum fruit and its active constituents gedunin and photogedunin was investigated. Chloroform fraction (Fr-CHCl(3)) of X. granatum fruit was evaluated against cold restraint (CRU), aspirin (AS), alcohol (AL) and pyloric ligation (PL) induced gastric ulcer models in rats and histamine (HA) induced duodenal ulcer model in guinea pigs. Potential anti-ulcer activity of Fr-CHCl(3) was observed against CRU (58.28%), AS (67.81%), AL (84.38%), PL (65.66%) and HA (61.93%) induced ulcer models. The standard drug omeprazole (10mg/kg, p.o.) showed 68.25% protection against CRU, 57.08% against AS and 69.42% against PL model and 70.79% against HA induced duodenal ulcer. Sucralfate, another standard drug (500 mg/kg, p.o.) showed 62.72% protection in AL induced ulcer model. Fr-CHCl(3) significantly reduced free acidity (51.42%), total acidity (30.76%) and upregulated mucin secretion by 58.37% respectively. Phytochemical investigations of Fr-CHCl(3) yielded gedunin (36%), photogedunin (2%). Further, Fr-CHCl(3) and its compounds gedunin and photogedunin significantly inhibited H(+) K(+)-ATPase activity in vitro with IC(50) of 89.37, 56.86 and 66.54 microg/ml respectively as compared to the IC(50) value of omeprazole (30.24 microg/ml) confirming their anti-secretory activity. Conclusively, Fr-CHCl(3) of Xylocarpus granatum was found to possess anti-ulcerogenic activity which might be due to its anti-secretory activity and subsequent strengthening of the defensive mechanism. This study is the first of its kind to show significant anti-secretory effect of gedunin and photogedunin. Therefore it could act as a potent therapeutic agent against peptic ulcer disease.

Response surface optimization of the critical medium components for the production of alpha-galactosidase from Aspergillus parasiticus MTCC-2796

Response surface methodology was used to evaluate the effect of main variables such as concentration of galactose, yeast extract and wheat bran on alpha-galactosidase production from Aspergillus parasiticus MTCC-2796 under submerged fermentation conditions. A full factorial Central Composite Design was applied to study these main factors that affected alpha-galactosidase production. The experimental results showed that the optimum concentration of galactose, yeast extract and wheat bran were 1.5 %, 0.06 % and 1.5 %, respectively. This method was efficient as only 20 experiments were necessary to asses these conditions, and model adequacy was very satisfactory as the coefficient of determination was 0.9921.

Role of Transpupillary Thermotherapy in Central Serous Chorio-Retinopathy

BACKGROUND

To assess the efficacy of transpupillary thermo therapy (TTT) in cases of chronic central serous chorio- retinopathy (CSCR).

METHODS

A prospective evaluation was carried out on 25 cases of chronic CSCR who were subjected to TTT. Resolution of CSCR and improvement in visual acuity was noted after six weeks of therapy.

RESULT

Out of 25 patients, 13 (52%) had complete success (resolution of CSCR and improvement in visual acuity > 2 lines on Snellen's chart), 10 (42%) had qualified success (resolution of CSCR but no improvement in visual acuity) and two (8%) had failure to therapy (no resolution of CSCR or improvement in visual acuity).

CONCLUSION

TTT maybe a good modality in aiding resolution of subretinal fluid in cases of chronic CSCR. However, improvement in visual function is dependent upon integrity of photo receptor layer of retina which is not influenced by this modality. A controlled study could be undertaken to compare outcome of TTT with conservative management in cases of early CSCR such that deleterious effects of chronic CSCR on the retinal photoreceptor layer are avoided.

Extracellular calcium protects against verapamil-induced metaphase-II arrest and initiation of apoptosis in aged rat eggs

Non-specific L-type calcium channel blockers, such as verapamil (> or =50 microM), induce metaphase-II (M-II) arrest and apoptosis in aged rat eggs cultured in Ca(2+)-deficient medium. However, the effects of extracellular Ca(2+) on verapamil-induced M-II arrest and apoptosis have not yet been reported. We have demonstrated that postovulatory aging induced exit from M-II arrest by extruding a second polar body, a morphological sign of spontaneous egg activation (SEA). Verapamil inhibited SEA and induced egg apoptosis in a dose-dependent manner in Ca(2+)-deficient medium. The initiation of apoptotic features was observed at 50 microM of verapamil. Extracellular Ca(2+) (1.80 mM) reduced intracellular H2O2 level, bax protein expression, caspase-3 activity, DNA fragmentation and protected against 50 microM, but not higher concentrations of > or =100 microM in verapamil-induced egg apoptosis. These results suggest that extracellular Ca(2+) ions have a role during SEA and protect against verapamil induced apoptosis in aged rat eggs.

Pulmonary function profile in patients with benign goiters without symptoms of respiratory compromise and the early effect of thyroidectomy

BACKGROUND

A large number of patients in our country develop goiters which seem to be apparently asymptomatic. Conventional radiography does not address the abnormal air flow dynamics. Flow volume loop studies have shown characteristic dampening of both inspiratory and expiratory curves. Pulmonary function tests (PFT) can provide a simple noninvasive method of assessing airway compromise.

AIM

To address the effect of longstanding asymptomatic, benign goiter by performing PFT on the preoperative airway dynamics and the early postoperative changes at six weeks.

SETTING AND DESIGN

Tertiary care center, Prospective study.

MATERIALS AND METHODS

Sixty-four patients with benign goiters were included after they satisfied the necessary exclusion and inclusion criteria. Pulmonary function tests were performed in the pre and postoperative period.

STATISTICAL ANALYSIS USED

SPSS ver. 10 software, Pearson's Bivariate correlation and students T test.

RESULTS

The preoperative PFT showed significant reduction in the Vital capacity (VC), Forced Vital Capacity (FVC), Forced expiratory volume in one second (FEV1), mid expiratory flow (MEF 25) and MEF 50 in the females and VC, FVC and FEV1 in males. Postoperatively significant improvement was observed in the tidal volume (VT) and FEV1 in the females and airway resistance in males.

CONCLUSIONS

Pulmonary function tests can demonstrate the unmanifested abnormal airflow dynamics in benign asymptomatic goiters, which would have otherwise taken years to manifest. This abnormality improved after thyroidectomy, especially the forced expiratory maneuvers. The duration and weight of the goiter correlated well with reduction in FEV1 and its subsequent improvement after surgery in females.

Training-induced positive exchange bias in NiFe/IrMn bilayers

Positive exchange bias has been observed in the Ni81Fe19/Ir20Mn80 bilayer system via soft-x-ray resonant magnetic scattering. After field cooling of the system through the blocking temperature of the antiferromagnet, an initial conventional negative exchange bias is removed after training, i.e., successive magnetization reversals, resulting in a positive exchange bias for a temperature range down to 30 K below the blocking temperature (450 K). This new manifestation of magnetic training is discussed in terms of metastable magnetic disorder at the magnetically frustrated interface during magnetization reversal.

Coexistence of carcinoma breast and Paget's disease of bone

We report a case of a patient with carcinoma breast who was incidentally diagnosed to be also suffering from Paget's disease of bone on a routine radionuclide bone scan. CT-guided biopsy and histopathology later confirmed the diagnosis.

Prevalence & potential significance of vitamin D deficiency in Asian Indians

Studies from our center and other parts of India have drawn attention towards wide prevalence of vitamin D deficiency (VDD) in our country. VDD has been reported in all age groups including toddlers, school children, pregnant women and their neonates and adult males and females residing in rural and urban India. We reviewed implications of VDD in our population based on the preliminary data available from Indian studies on skeletal health. Besides, a brief review is made on the importance of VDD in various other disorders prevalent in equivalent proportions among Indians such as type 2 diabetes mellitus (DM), cardiovascular diseases (CVD), immune competence including relation to tuberculosis, malignancy and osteoarthritis. Data from the West have also associated VDD with increased prevalence of type 2DM, CVD, autoimmune disorders, tuberculosis, prostate, breast and colon malignancy and osteoarthritis. Such association has not been studied to date in our country. Overall results of various studies conducted to date in urban and rural Indians indicate that widely prevalent VDD is functionally relevant to skeletal health including osteomalacia and rickets. However, there is a need to explore its association with osteoporosis related fractures and various other non skeletal disorders linked with VDD.

Minithyroidectomy: a preliminary report from a specialised thyroid unit

In the past few years, minimally invasive surgery has replaced the open conventional surgery as the gold standard for many procedures. Here a modified technique was used for thyroid surgery with a 2.5-4.0 cm incision and the results of this technique have been evaluated. During the 3 years of study period, 14 patients underwent hemithyroidectomy using a small incision (2.5-4 cm), placed higher than the conventional incision in selected patients. Mean operative time was 86.2 minutes with an average blood loss of 42.5 ml with two conversions. Mean hospital stay was 32 hours and no drains were used. All patients were satisfied with the scar mark. We found this technique of minithyroidectomy to be feasible and easily reproducible.

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.

Safety and efficacy of surgical management of hyperthyroidism: 15-year experience from a tertiary care center in a developing country

BACKGROUND

Ideal management of toxic goiter still remains elusive. Though surgical management of toxic multinodular goiter (MNG) is well accepted, surgical treatment of Graves' disease (GD) is still controversial in view of the presumed increased incidence of complications. In this paper, we discuss the experience of the surgical management of hyperthyroidism at a specialized tertiary care endocrine center in a developing country, highlighting the minimal morbidity and satisfactory outcome in experienced hands.

MATERIALS AND METHODS

We retrospectively reviewed 325 consecutive patients with hyperthyroidism managed surgically from 1990 to 2005. The etiologic diagnoses were Graves' disease (185), toxic MNG (105), and autonomously functioning thyroid nodules (AFTN) (n = 35). The indications for surgery in Graves' patients were large goiter, relapse after antithyroid drug therapy (ATD), Graves' ophthalmopathy, and presence of nodule. The indications for surgery in toxic MNG were retrosternal extension (n = 15), compressive symptoms (n = 20), and large size (grade II). Among the AFTN nodule size, those greater than 4 cm (85%) formed the major indication for surgery. Subjects with GD and toxic MNG were subjected to subtotal thyroidectomy (n = 93 prior to 1995) or total thyroidectomy (n = 205 post-1995). Hemithyroidectomy was the procedure of choice in patients with AFTN.

RESULTS

Patients with Graves' disease were younger in age, with shorter mean duration of goiter when compared with the other 2 groups. Eight percent of patients with Graves' disease without a clinically palpable nodule and 25% of those with nodules had associated differentiated carcinoma, including papillary, follicular, and medullary thyroid cancer. Four percent of patients with toxic MNG had malignancy. Complications included temporary hypocalcemia (24%), permanent hypocalcemia (3%), and permanent vocal-cord palsy (1%).

CONCLUSIONS

Surgery for hyperthyroidism has negligible mortality and acceptable morbidity in experienced hands. It is a definite option in selected cases. Immediate and permanent cure of hyperthyroidism is achieved, with no recurrences, after total thyroidectomy. The cosmetic outcome is good, with excellent patient satisfaction and acceptance.

Outcome of Adrenalectomy for Cushing’s Syndrome: Experience from a Tertiary Care Center

Adrenalectomy continues to play an important role in the management of Cushing's syndrome (CS). Untreated CS causes considerable physical and mental morbidity and mortality. However, little information is available on the effect of adrenalectomy in ameliorating functional disabilities in CS patients. Our study assesses the long-term outcome of adrenalectomy in patients with CS. This is a retrospective analysis of CS patients managed during 1990-2005 at a tertiary care center. We analyzed the clinical presentation, endocrine evaluation, and surgical management preoperatively and following adrenalectomy. The subjects were 37 patients with CS (age 24.5 +/- 15 years, range 1-60 years; male:female 1.0:1.2). There were various etiologies--unilateral adrenocortical adenoma (n = 11), adrenocortical carcinoma (n = 13), pituitary ACTH-secreting adenoma with failed transsphenoidal surgery (n = 4), ectopic unidentified ACTH source (n = 7), bilateral adrenal macronodular hyperplasia (n = 1), primary pigmented nodular adrenal hyperplasia (n = 1) --for which the patients underwent adrenalectomy: unilateral (n = 22), bilateral (n = 13), or adrenonephrectomy (n = 2). Two patients died during the perioperative period owing to chest infection and sepsis. At the median follow-up of 60 months (range 6-144 months), the patients exhibit significant persistence of obesity (41%), proximal muscle weakness (44%), menstrual irregularity (8%), hypertension (31%), and insulin-dependent diabetes (29%). Hirsutism and psychological abnormalities persisted to a lesser extent. All patients had biochemical cure of CS following surgery evidenced by the 8 a.m. basal cortisol < or = 5 microg/dl. The hypothalamic-pituitary-adrenal axis recovered as shown by normalization of the short synacthen-stimulated cortisol level (peak level > or = 20 microg/dl) after a median follow-up of 9 months (range 6-18 months). Incomplete clinical recovery following adrenalectomy emphasizes the need of early recognition and prompt treatment of CS. Surgery for adrenocortical adenoma is safe and effective; however, survival of patients with CS due to adrenocortical carcinoma remains poor. Bilateral adrenalectomy provides early control of hypercortisolism in selected cases of unlocalized ectopic ACTH syndrome or failed transsphenoidal surgery. Even though functional recovery is incomplete after adrenalectomy, quality of life improves considerably.

Myocardial dysfunction in rheumatic carditis--does it really exist?

OBJECTIVES

Acute rheumatic fever (ARF) continues to affect millions of children in developing countries. Aim of the present study was to evaluate the role of myocardial dysfunction in the genesis of heart failure in patients with rheumatic carditis. There are limited studies on this subject.

METHODS AND RESULTS

In this prospective study, 108 consecutive patients of ARF were evaluated by echocardiography and assay of cardiac troponin I blood levels. The patients were divided into three groups. Group A (n = 30): patients with no evidence of carditis; Group B (n = 45): patients with first attack of carditis; and group C (n = 33): patients with recurrent attacks of carditis. Left ventricular dimensions tended to be larger in Group B and C patients. Left ventricular ejection fraction did not differ between the groups (Group A: 63 +/- 8.1%, Group B: 58 +/- 7.9%, Group C: 61.2 +/- 9%, p = ns). Heart failure was present in 37.7% patients of Group B, and in 60.6% patients of Group C (p = < 0.05). Ejection fraction was normal in majority of heart failure patients (75.7%). It was reduced in 29.4% of patients in Group B and in 20% of Group C patients with heart failure (p = ns). All patients with low ejection fraction had hemodynamically significant regurgitant valvular lesions. Mean cardiac troponin I values, an index of myocardial damage, did not differ between the three groups (Group A: 0.062 +/- 0.027 ng/ml, Group B: 0.068 +/- 0.019 ng/ml, Group C: 0.071 +/- 0.031 ng/ml, p = ns).

CONCLUSION

The present study did not demonstrate any echocardiographic abnormalities or cardiac troponin I elevation suggesting significant myocardial involvement during acute rheumatic fever. This lends credence to the view that myocardial involvement does not play any significant role in the genesis of heart failure in patients with rheumatic carditis.

The external laryngeal nerve in thyroid surgery: the 'no more neglected' nerve

AIMS

To describe a novel surgical technique of 'lateralization' of superior pole to identify and save external branch of superior laryngeal nerve (EBSLN) during thyroidectomy.

SETTINGS AND DESIGN

Prospective, nonrandomized at a tertiary care hospital in a specialized unit.

MATERIAL AND METHODS

Over 30 months, 46 patients underwent thyroidectomy using technique of 1) 'Lateralization' of upper pole and dissection of avascular cricothyroid space 2) identification of EBSLN 3) skeletonization and individual ligation of superior thyroid vessels. Identified nerves were classified according to Cernea's classification. Outcomes were number of nerves identified, number of 'at risk' nerves' bilateral asymmetry and incidence of injury assessed by subjective interview and indirect laryngoscopy.

RESULTS

Of the 78 dissected superior poles, nerves could be identified in 72 (92.31%). There were 22 (28.2%) type I, 42 (53.54%) IIa and 8 (10.25%) IIb 'at risk' nerves. In 32 patients with bilateral dissections, asymmetry of nerve was noted in 15%. Injury to nerve was not recorded in any of the patients. Average weight of glands was 69.59 g. Thyroidectomy was performed for benign disease in 28, malignancy in 4 and thyrotoxicosis in 14 patients.

CONCLUSIONS

With technique of 'lateralization' and 'skeletonization and individual ligation of the superior vessels,' EBSLN identification increases and injury can be prevented. These results relate to the utilization of specific surgical technique and it is reasonable to expect that most surgeons, once familiar with the technique, should be able to achieve similar outcomes.

Effects of oxidizing and reducing agents on ovine pulmonary artery responses to nitric oxide donors, sodium nitroprusside and 3-morpholino-sydnonimine

Nitrovasodilators-sodium nitroprusside (SNP; 10(-9)-10(-4) M) and 3-morpholino-sydnonimine (SIN-1; 10(-9)-10(-4) M) produced concentration-dependent relaxation of the fourth generation sheep pulmonary artery, preconstricted with 5-hydroxytryptamine (1 microM). Oxidizing agents [oxidized glutathione (GSSG, 1 mM) and CuSO4 (5 and 20 microM)] and reducing agents [dithiothreitol (DTT, 0.1 mM), ascorbic acid (1 mM) and reduced glutathione (GSH, 1 mM)] caused opposite effects on nitric oxide (NO)-induced vasodilation in the artery. Ascorbic acid and GSH potentiated the NO responses, while GSSG and CuSO4 inhibited relaxation caused by the nitrovasodilators. DTT, however, reduced the relaxant potency and efficacy of SNP and SIN-1. Pretreatment of the pulmonary artery strips with DTT (0.1 mM) inhibited SNP (10 microM)-induced Na(+)-K(+)-ATPase activity, while ascorbic acid (1 mM) and GSH (1 mM) had no effect either on basal or SNP (10 microM)-stimulated 86Rb uptake, an index of Na(+)-K(+)-ATPase activity, in ovine pulmonary artery. The results suggest that reducing agents like ascorbic acid may have beneficial effect in improving the vascular function under oxidative stress.

Management of severe and complicated malaria

Severe malaria is invariably caused by Plasmodium falciparum. In India, both adults and children are affected by severe malaria. However, children are more prone for developing anemia and convulsions as manifestations of severe malaria, while acute renal failure and jaundice are more common among adults. Pregnant women are vulnerable to hypoglycemia, anemia and pulmonary complications. The case-fatality rate due to severe malaria is 10-15% in spite of therapy but it increases in the presence of renal failure or respiratory distress (pulmonary edema or ARDS). Of late, multi-organ failure and high mortality figures are being reported increasingly from different parts of India. Early diagnosis and prompt treatment will reduce the mortality due to malaria. Cerebral malaria should always be suspected in a patient with altered sensorium in a malaria-endemic area. However, other causes of unconsciousness such as encephalitis, meningitis or hepatic coma should also be excluded. Parenteral quinine is the mainstay of therapy. A recent multi-centric study has demonstrated the efficacy of intravenous artesunate in reducing the mortality by 30%. The usefulness of adjunct therapy is still controversial.

Adjuvant therapy in cerebral malaria

Cerebral malaria is the most common cause of non-traumatic encephalopathy in the world. The mainstay of therapy is either quinine or artemisinin, both of which are effective antimalarials. The clinical picture of cerebral malaria may persist or even become worse in spite of the clearance of parasites from blood. The death rate is unacceptably high even with effective antimalarials in tertiary care hospitals. The mortality increases in presence of multi organ failure (renal failure, jaundice, respiratory distress, severe anaemia, lactic acidosis, etc.). The pathogenesis of cerebral malaria is multifactorial and includes clogging, sequestration, rosette formation, release of cytokines, cerebral oedema, increased intracranial hypertension, etc. Attempts are made to use adjuvant therapy which will act through alternate mechanisms and address one or more of the pathogenetic processes. In this review, we have discussed the role of corticosteroids, pentoxifylline, desferrioxamine, mannitol and newer agents in the treatment of cerebral malaria. Though the literature on adjuvant therapy in cerebral malaria is large enough, there are a number of shortcomings in the clinical trials, many being open and non randomized or of very small sample size. Further research is of utmost importance through large multicentric, double-blind controlled trials to show the efficacy of any of these drugs.

Efficacy and safety of beta-arteether and alpha/beta-arteether for treatment of acute Plasmodium falciparum malaria

One hundred thirty-eight adult patients with acute Plasmodium falciparum malaria were randomized to receive either beta-arteether or alpha/beta-arteether. The drugs were administered in the dose of 150 mg once a day intramuscularly for three consecutive days in hospitalized patients. After one week of hospitalization, patients were followed-up for three weeks after release from the hospital. There was no statistically significant difference between cure rates, mean fever clearance time (FCT), mean parasite clearance time (PCT), and occurrence of side effects in either group. The cure rate was 97.14% for beta-arteether and 97.01 for alpha/beta-arteether (P = 0.9660). The mean PCT was 38.49 hours for beta-arteether and 36.90 hours for alpha/beta-arteether (P = 0.6054), and the mean FCT was 37.27 hours for beta-arteether and 37.9 hours for alpha/beta-arteether (P = 0.8718). Both arteether formulations were safe and efficacious in reducing the clinical symptoms of acute falciparum malaria. There was also rapid clearance of parasitemia with both formulations. Thus, either beta-arteether or alpha/beta-arteether can be used in the treatment of acute falciparum malaria.