Treatment regimens for pregnant women with falciparum malaria

INTRODUCTION

With increasing parasite drug resistance, the WHO has updated treatment recommendations for falciparum malaria including in pregnancy. This review assesses the evidence for choice of treatment for pregnant women.

AREAS COVERED

Relevant studies, primarily those published since 2010, were identified from reference databases and were used to identify secondary data sources. Expert commentary: WHO recommends use of intravenous artesunate for severe malaria, quinine-clindamycin for uncomplicated malaria in first trimester, and artemisinin combination therapy for uncomplicated malaria in second/third trimesters. Because fear of adverse outcomes has often excluded pregnant women from conventional drug development, available data for novel therapies are usually based on preclinical studies and cases of inadvertent exposure. Changes in antimalarial drug disposition in pregnancy have been observed but are yet to be translated into specific treatment recommendations. Such targeted regimens may become important as parasite resistance demands that drug exposure is optimized.

Metabolic memory and all-cause death in community-based patients with type 2 diabetes: the Fremantle Diabetes Study

AIMS

To validate the findings, in a usual care setting, of glycaemic intervention trials, which have shown that tight control in patients with recently diagnosed type 2 diabetes protects against death during post-study monitoring, but that it may be deleterious in long-duration diabetes with vascular complications.

METHODS

A subset of 531 patients with type 2 diabetes from the community-based observational Fremantle Diabetes Study Phase 1, who attended ≥5 annual reviews (mean follow-up 15.9 years), were categorized by baseline diabetes duration [<1 year (Group 1); 1 to <5 years (Group 2); and ≥5 years (Group 3)]. Glycated haemoglobin (HbA1c) trajectories over the first 5 years were determined [low, medium and high; equivalent to mean HbA1c ≤6.6% (<49 mmol/mol), 6.7-8.0% (50-64 mmol/mol) and ≥8.0% (>64 mmol/mol), respectively]. Kaplan-Meier analysis was used to assess survival by duration and HbA1c trajectory. Cox proportional hazards modelling identified predictors of all-cause death.

RESULTS

There was greater mortality in patients with a medium versus those with a low trajectory in Group 1: hazard ratio (HR) 1.99 [95% confidence interval (CI) 1.003-3.94; p = 0.049], and in patients with a high versus a low trajectory in Group 2: HR 2.02 (95% CI 1.11-3.71; p = 0.022). In Group 3, both medium [HR 0.57 (95% CI 0.35-0.92; p = 0.022)] and high [HR 0.56 (95% CI 0.32-0.96); p = 0.035] trajectories were independently and inversely associated with death.

CONCLUSIONS

In community-based patients with newly or recently diagnosed type 2 diabetes, poor glycaemic control was an adverse prognostic indicator. Tight control was independently associated with death in patients with diabetes duration ≥5 years. These data parallel intervention trial findings and support individualization of HbA1c targets.

Lifetime depression history and depression risk in type 2 diabetes: A case-control study

AIMS

To assess whether a personal history of depression assists in risk prediction for depression in type 2 diabetes.

METHODS

Age- and sex-matched participants with and without diabetes from the Busselton Health Survey were assessed for current and previous depression using the 9-item Patient Health Questionnaire and the Brief Lifetime Depression Scale (BLDS). In the diabetic participants, the temporal relationship between first depression episode and diabetes onset was also explored.

RESULTS

In 184 paired participants (age 70.2±10.1years, 50% female), those with diabetes had a higher prevalence of any current depression (12.5% vs 4.3%, P<0.01) and lifetime history of major depression (30.6% vs 21.1%, P=0.06) compared to those without diabetes. After adjustment, lifetime major depression history was independently associated with any current depression in the combined sample (odds ratio (95% CI): 5.55 (3.09-9.98), P<0.001), in those with diabetes (4.17 (2.00-8.71), P<0.001), in those without diabetes (8.29 (3.24-21.23), P<0.001) and in diabetes whether sub-divided by depression first occurring before or after diabetes onset (before: 3.16 (1.38-7.24), P=0.007; after: 2.77 (1.00-7.70), P=0.051).

CONCLUSIONS

Obtaining a lifetime history of major depression using the BLDS assists in depression risk prediction in type 2 diabetes regardless of whether depression preceded diabetes onset or not.

Changes in characteristics and management of Asian and Anglo-Celts with type 2 diabetes over a 15-year period in an urban Australian community: The Fremantle Diabetes Study

BACKGROUND

The aim of the present study was to determine temporal changes in characteristics and management of Asians with type 2 diabetes (T2D) compared with those of the majority Anglo-Celt (AC) patients in an urban Australian community.

METHODS

Cross-sectional data from the observational Fremantle Diabetes Study (FDS) collected in 1993-96 (Phase I; FDS1) and 2008-11 (Phase II; FDS2) were analyzed for patients classified as Asian (n = 44 and 65 in FDS1 and FDS2, respectively) or AC (n = 796 and 793, respectively). Between-group differences in changes in key variables between FDS phases were analyzed by generalized linear modeling with adjustment for age and gender.

RESULTS

Asians patients were significantly younger at diagnosis and recruitment and had a lower body mass index and smaller waist circumference than the AC participants in both FDS phases. They were also less likely to be treated for hypertension. Cardiovascular risk factors and their management and macrovascular complications were similar in the two groups over time. A greater propensity to retinopathy with Asian ethnicity in FDS1 (27.3% vs 13.5%; P = 0.23) was attenuated in FDS2 (23.7% vs 19.0%; P = 0.39). Asians had a significantly lower prevalence of peripheral sensory neuropathy in FDS2 (33.8% vs 63.3%; P < 0.001; adjusted P = 0.011 for between-group temporal change).

CONCLUSIONS

There were persistent differences between the phenotypic features of Asian migrants with T2D versus AC patients in an Australian urban community over 15 years of follow-up, but management of diabetes and non-glycemic risk factors remained comparable. Ethnicity-specific differences in susceptibility to microvascular complications should be considered in clinical management.

Temporal changes in the prevalence and associates of diabetes-related lower extremity amputations in patients with type 2 diabetes: the Fremantle Diabetes Study

Background

To determine temporal changes in the prevalence and associates of lower extremity amputation (LEA) complicating type 2 diabetes.

Methods

Baseline data from the longitudinal observational Fremantle Diabetes Study (FDS) relating to LEA and its risk factors collected from 1296 patients recruited to FDS Phase 1 (FDS1) from 1993 to 1996 and from 1509 patients recruited to FDS Phase 2 (FDS2) from 2008 to 2011 were analysed. Multiple logistic regression was used to determine associates of prevalent LEA in individual and pooled phases. Generalised linear modelling was used to examine whether diabetes related LEA prevalence and its associates had changed between Phases.

Results

There were 15 diabetes-related LEAs at baseline in FDS1 (1.2 %) and 15 in FDS2 (1.0 %; P = 0.22 after age, sex and race/ethnicity adjustment). In multivariable analysis, independent associates of a baseline LEA in FDS1 were a history of vascular bypass surgery or revascularisation, urinary albumin:creatinine ratio, peripheral sensory neuropathy and cerebrovascular disease (P ≤ 0.035). In FDS2, prevalent LEA was independently associated with a history of vascular bypass surgery or revascularisation, past hospitalisation for/current foot ulcer and fasting serum glucose (P ≤ 0.001). In pooled analyses, a history of vascular bypass or revascularisation, past hospitalisation for/current foot ulcer at baseline, urinary albumin:creatinine ratio (P < 0.001), as well as FDS Phase as a binary variable [odds ratio (95 % confidence interval): 0.28 (0.09–0.84) for FDS2 vs FDS1, P = 0.023] were associated with a lower risk of LEA at study entry.

Conclusions

The risk of prevalent LEA in two cohorts of patients with type 2 diabetes from the same Australian community fell by 72 % over a 15-year period after adjustment for important between-group differences in diabetes-related and other variables. This improvement reflects primary care foot health-related initiatives introduced between Phases, and should have important individual and societal benefits against a background of a progressively increasing diabetes burden.

A Toll-like receptor-1 variant and its characteristic cellular phenotype is associated with severe malaria in Papua New Guinean children

Genetic factors are likely to contribute to low severe malaria case fatality rates in Melanesian populations, but association studies can be underpowered and may not provide plausible mechanistic explanations if significant associations are detected. In preparation for a genome-wide association study, 29 candidate single-nucleotide polymorphisms (SNPs) with minor allele frequencies >5% were examined in a case-control study of 504 Papua New Guinean children with severe malaria. In parallel, an immunological substudy was performed on convalescent peripheral blood mononuclear cells (PBMCs) from cases and controls. Following stimulation with a Toll-like receptor (TLR) 1/2 agonist, effector cytokines and chemokines were assayed. The only significant genetic association observed involved a nonsynonymous SNP (TLR1rs4833095) in the TLR1 gene. A recessive (TT) genotype was associated with reduced odds of severe malaria of 0.52 (95% confidence interval (0.29-0.90), P=0.006). Concentrations of pro-inflammatory cytokines interleukin-1β and tumour necrosis factor α were significantly higher in severe malaria cases compared with healthy controls, but lower in children with the protective recessive (TT) genotype. A genetic variant in TLR1 may contribute to the low severe malaria case fatality rates in this region through a reduced pro-inflammatory cellular phenotype.

Prevention of bacterial infections in the newborn by pre-delivery administration of azithromycin: Study protocol of a randomized efficacy trial

BACKGROUND

Neonatal deaths, estimated at approximately 4 million annually, now account for almost 40% of global mortality in children aged under-five. Bacterial sepsis is a leading cause of neonatal mortality. Assuming the mother is the main source for bacterial transmission to newborns, the primary objective of the trial is to determine the impact of one oral dose of azithromycin, given to women in labour, on the newborn's bacterial carriage in the nasopharynx. Secondary objectives include the impact of the intervention on bacterial colonization in the baby and the mother during the first month of life.

METHODS/DESIGN

This is a Phase III, double -blind, placebo controlled randomized clinical trial in which 830 women in labour were randomized to either a single dose of 2 g oral azithromycin or placebo (ratio 1:1). The trial included pregnant women in labour aged 18 to 45 years attending study health centres in the Western Gambia. A post-natal check of the mother and baby was conducted at the health centre by study clinicians before discharge and 8-10 days after delivery. Home follow up visits were conducted daily during the first week and then weekly until week 8 after delivery. Vaginal swabs and breast milk samples were collected from the mothers, and the pathogens Streptococcus pneumoniae, Group B Streptococcus (GBS) and Staphylococcus aureus were isolated from the study samples. For bacterial isolates, susceptibility pattern to azithromycin was determined using disk diffusion and E-test. Eye swabs were collected from newborns with eye discharge during the follow up period, and Chlamydial infection was assessed using molecular methods.

DISCUSSION

This is a proof-of-concept study to assess the impact of antibiotic preventive treatment of women during labour on bacterial infections in the newborn. If the trial confirms this hypothesis, the next step will be to assess the impact of this intervention on neonatal sepsis. The proposed intervention should be easily implementable in developing countries.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier--NCT01800942--First received: February 26, 2013.

The interactive effects of type 2 diabetes mellitus and schizophrenia on all-cause mortality: The Fremantle Diabetes Study

In a study of the effects of type 2 diabetes and schizophrenia on mortality in 1296 community-based diabetic patients followed for a mean±SD 12.9±6.1years and in 5159 matched non-diabetic residents, 0.4% of each group had schizophrenia. Patients with both conditions had a six-fold adjusted increased risk of death.

Prevalence, risk factors and sequelae of Staphylococcus aureus carriage in diabetes: the Fremantle Diabetes Study Phase II

AIMS

To determine the prevalence and associates of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) carriage in community-based diabetes, and their relationship to hospitalization with S. aureus infection.

METHODS

A cross-sectional subset of 660 Fremantle Diabetes Study Phase II patients (mean±SD age 65.1±11.5years, 53.1% males) had nasal/axillary swabs as part of biennial review. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were measured in 358 patients. Those with positive swabs were invited back for a repeat swab. Hospitalizations with S. aureus infections were ascertained from validated data linkage. Multiple logistic regression was used to identify associates of carriage, and Cox proportional hazards modelling was used to determine predictors of subsequent hospitalization.

RESULTS

258 patients (39.1%) were positive for S. aureus and eight (3.1%) carried MRSA. S. aureus carriage was independently associated with being married/in a de facto relationship and inversely with older age and being born overseas (P≤0.043). Repeat swabs in 137 patients (53.1% of those with an initially positive swab) grew S. aureus in 113 (82.5%). Five of eight MRSA-positive patients were re-swabbed, and four were MRSA-positive. Independent predictors of hospitalization with staphylococcal infection after the initial swab were S. aureus carriage (hazard ratio (95% CI) 5.42 (1.49-19.79)), prior hospitalization with S. aureus (4.84 (1.19-19.63)) and Aboriginality (7.20 (1.91-27.17) (P≤0.027). Serum 25(OH)D was not associated with S. aureus carriage or subsequent hospitalization.

CONCLUSIONS

S. aureus and MRSA carriage in our patients was consistent with previous general population studies. There were no diabetes-specific risk factors. Persistent colonization may underlie the increased risk of hospitalization with S. aureus.

Pharmacokinetic studies of antimalarials: recent developments

Pharmacokinetic studies are essential for the development of safe and effective antimalarial treatment regimens, but there are clinical situations in which there are limited data on drug disposition. These include very young children, pregnant women, and where drug interactions may alter treatment response. New approaches such as sampling methods involving low volumes and minimal preparation such as dried blood spots, highly sensitive and specific multidrug assays, and population PK analyses which can evaluate the influence of covariates such as age, pregnancy and coadministered therapies, can generate robust data that inform treatment in the most challenging situations in the tropics.

The metabolic syndrome and cancer: Is the metabolic syndrome useful for predicting cancer risk above and beyond its individual components?

AIMS

The metabolic syndrome (MetS) is a risk factor for cancer. However, it is not known if the MetS confers a greater cancer risk than the sum of its individual components, which components drive the association, or if the MetS predicts future cancer risk.

MATERIALS AND METHODS

We linked 20,648 participants from the Australian and New Zealand Diabetes and Cancer Collaboration with complete data on the MetS to national cancer registries and used Cox proportional hazards models to estimate associations of the MetS, the number of positive MetS components, and each of the five MetS components separately with the risk for overall, colorectal, prostate and breast cancer. Hazard ratios (HR) and 95% confidence intervals (95%CI) are reported. We assessed predictive ability of the MetS using Harrell's c-statistic.

RESULTS

The MetS was inversely associated with prostate cancer (HR 0.85; 95% CI 0.72-0.99). We found no evidence of an association between the MetS overall, colorectal and breast cancers. For those with five positive MetS components the HR was 1.12 (1.02-1.48) and 2.07 (1.26-3.39) for overall, and colorectal cancer, respectively, compared with those with zero positive MetS components. Greater waist circumference (WC) (1.38; 1.13-1.70) and elevated blood pressure (1.29; 1.01-1.64) were associated with colorectal cancer. Elevated WC and triglycerides were (inversely) associated with prostate cancer. MetS models were only poor to moderate discriminators for all cancer outcomes.

CONCLUSIONS

We show that the MetS is (inversely) associated with prostate cancer, but is not associated with overall, colorectal or breast cancer. Although, persons with five positive components of the MetS are at a 1.2 and 2.1 increased risk for overall and colorectal cancer, respectively, and these associations appear to be driven, largely, by elevated WC and BP. We also demonstrate that the MetS is only a moderate discriminator of cancer risk.

Ultrasonographic assessment of splenic volume at presentation and after anti-malarial therapy in children with malarial anaemia

Background

Splenic enlargement is a component of the host response to malaria and may also influence the genesis and progression of malarial anaemia. Few cross-sectional and no longitudinal studies have assessed the relationship between splenic volume measured ultrasonographically and haemoglobin concentrations in children with malaria.

Methods

Fifteen Papua New Guinean children with severe malarial anaemia (SMA; haemoglobin <50 g/L) and ten with moderate malarial anaemia (MMA; 51–99 g/L) were recruited. The SMA patients were given intramuscular artemether followed by oral artemisinin combination therapy (ACT), and were transfused one unit of packed cells 0.3-4.0 days post-admission. The MMA patients were treated with ACT. Splenic enlargement (Hackett’s grade, subcostal distance and ultrasonographically determined volume) and haemoglobin concentrations were measured on days 0, 1, 2, 3, 7, 14, 28, and 42.

Results

Associations between Hackett’s grade, subcostal distance and splenic volume were modest (r_s ≤ 0.62, P <0.001). Baseline splenic volume was not associated with age or haemoglobin (P ≥0.90). Mean splenic volume had fallen by approximately 50 % at day 14 in children with MMA (P ≤0.011 vs days 0, 1 and 2), but there was no change in the SMA group (P ≥0.30). There was no change in haemoglobin in the MMA group during follow-up but a rise in the SMA group to day 7 (P ≤0.05 vs days 0, 1, 2, and 3) which paralleled the packed cell volume transfused.

Conclusions

Clinical assessment of splenomegaly is imprecise compared with ultrasonography. Serial splenic volumes and haemoglobin concentrations suggest that the spleen does not influence post-treatment haemoglobin, including after transfusion.

A new blood glucose management algorithm for type 2 diabetes: a position statement of the Australian Diabetes Society

Lowering blood glucose levels in people with type 2 diabetes has clear benefits for preventing microvascular complications and potential benefits for reducing macrovascular complications and death. Treatment needs to be individualised for each person with diabetes. This should start with selecting appropriate glucose and glycated haemoglobin targets, taking into account life expectancy and the patient's wishes. For most people, early use of glucose-lowering therapies is warranted. A range of recently available therapies has added to the options for lowering glucose levels, but this has made the clinical pathway for treating diabetes more complicated. This position statement from the Australian Diabetes Society outlines the risks, benefits and costs of the available therapies and suggests a treatment algorithm incorporating the older and newer agents.

Comparison of anthropometric measures as predictors of cancer incidence: A pooled collaborative analysis of 11 Australian cohorts

Obesity is a risk factor for cancer. However, it is not known if general adiposity, as measured by body mass index (BMI) or central adiposity [e.g., waist circumference (WC)] have stronger associations with cancer, or which anthropometric measure best predicts cancer risk. We included 79,458 men and women from the Australian and New Zealand Diabetes and Cancer Collaboration with complete data on anthropometry [BMI, WC, Hip Circumference (HC), WHR, waist to height ratio (WtHR), A Body Shape Index (ABSI)], linked to the Australian Cancer Database. Cox proportional hazards models assessed the association between each anthropometric marker, per standard deviation and the risk of overall, colorectal, post-menopausal (PM) breast, prostate and obesity-related cancers. We assessed the discriminative ability of models using Harrell's c-statistic. All anthropometric markers were associated with overall, colorectal and obesity-related cancers. BMI, WC and HC were associated with PM breast cancer and no significant associations were seen for prostate cancer. Strongest associations were observed for WC across all outcomes, excluding PM breast cancer for which HC was strongest. WC had greater discrimination compared to BMI for overall and colorectal cancer in men and women with c-statistics ranging from 0.70 to 0.71. We show all anthropometric measures are associated with the overall, colorectal, PM breast and obesity-related cancer in men and women, but not prostate cancer. WC discriminated marginally better than BMI. However, all anthropometric measures were similarly moderately predictive of cancer risk. We do not recommend one anthropometric marker over another for assessing an individuals' risk of cancer.

A comparison of two methods of foot health education: the Fremantle Diabetes Study Phase II

AIMS

To compare the effectiveness of two different methods of education on foot health, behaviours and attitudes in patients with type 2 diabetes.

METHODS

Community-based patients were consecutively allocated to written education (Group A) or an interactive educator-led session (Group B). A quantitative Foot Score (maximum 90 points score based on severity of treatable pathology), the Nottingham Assessment of Functional Foot Care (NAFFC) survey score (maximum 30 points reflecting frequency of foot care behaviours) and a 6-question survey of attitudes to foot complications were administered at baseline and 3 months.

RESULTS

154 patients (mean±SD age 68±10 years, 59.7% males, median [interquartile range] diabetes duration 11.5 [5.6-18.9] years) were recruited. There was a greater change (Δ) in Foot Score from baseline to 3 months in Group A (8.3±3.6, Δ-1.8 (95% CI: -2.4 to -1.2) vs Group B (6.8±2.6, Δ-0.1 (-0.7 to 0.4); P<0.001), but no change in NAFFC survey score in either group (P=0.13). In the attitudes survey, Group B felt they better understood how to prevent foot complications than Group A after education (P=0.031).

CONCLUSIONS

Written information was more effective at improving foot health while interactive education improved confidence in undertaking preventive measures, suggesting that the most effective foot care education should include both components.

Temporal changes in the prevalence and associates of foot ulceration in type 2 diabetes: the Fremantle Diabetes Study

AIMS

To assess temporal changes in foot ulceration and its risk factors in community-based people with type 2 diabetes.

METHODS

Baseline data from the longitudinal observational Fremantle Diabetes Study collected from 1993 to 1996 (Phase I) and 2008 to 2011 (Phase II) were analyzed. Generalized linear modeling was used to examine changes in foot ulcer prevalence and its associates between phases. Multiple logistic regression was used to determine associates of prevalent foot ulceration in individual and pooled phases.

RESULTS

There were 16 foot ulcers among 1296 patients in Phase I (1.2%) and 23 in 1509 Phase II patients (1.5%; P=0.86 after age, sex and race/ethnicity adjustment). Glycemic and non-glycemic cardiovascular risk factors were better in Phase II, but diabetes duration was longer, peripheral sensory neuropathy (PSN) was more prevalent and more patients were Aboriginal (P<0.001) than in Phase I. In multivariable analysis of both phases and pooled data, diabetes duration and peripheral sensory neuropathy (PSN) were independent associates of foot ulceration (P≤0.026). Prior hospitalization for ulcer, intermittent claudication, any absent pedal pulse and Aboriginality were also significant in the pooled model (P≤0.009).

CONCLUSIONS

Strong associations between foot ulcer and diabetes duration, PSN, symptomatic and clinically-detectable peripheral vascular disease were observed. Aboriginality also proved an independent risk factor. Since all these risk factors apart from intermittent claudication and impalpable foot pulses were more prevalent in Phase II, improved community- and hospital-based foot care between phases are likely to have attenuated the risk of foot ulcers in Phase II patients.

Artemether-lumefantrine versus artemisinin-naphthoquine in Papua New Guinean children with uncomplicated malaria: a six months post-treatment follow-up study

BACKGROUND

In a recent trial of artemisinin-naphthoquine (artemisinin-NQ) and artemether-lumefantrine (AM-LM) therapy in young children from Papua New Guinea (PNG), there were no treatment failures in artemisinin-NQ-treated children with Plasmodium falciparum or Plasmodium vivax compared with 2.2% and 30.0%, respectively, in AM-LM-treated children during 42 days of follow-up. To determine whether, consistent with the long elimination half-life of NQ, this difference in efficacy would be more durable, clinical episodes of malaria were assessed in a subset of trial patients followed for six months post-treatment.

METHODS

For children completing trial procedures and who were assessable at six months, all within-trial and subsequent clinical malaria episodes were ascertained, the latter by clinic attendances and/or review of hand-held health records. Presentations with non-malarial illness were also recorded. Differences between allocated treatments for pre-specified endpoints were determined using Kaplan-Meier survival analysis.

RESULTS

Of 247 children who were followed to Day 42, 176 (71.3%) were included in the present sub-study, 87 allocated to AM-LM and 89 to artemisinin-NQ. Twenty children in the AM-LM group (32.8%) had a first episode of clinical malaria within six months compared with 10 (16.4%) in the artemisinin-NQ group (P = 0.033, log rank test). The median (interquartile range) time to first episode of clinical malaria was 64 (50-146) vs 116 (77-130) days, respectively (P = 0.20). There were no between-group differences in the incidence of first presentation with non-malarial illness (P = 0.31).

CONCLUSIONS

The greater effectiveness of artemisinin-NQ over conventional AM-LM extends to at least six months post-treatment for clinical malaria but not non-malarial illness.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12610000913077 .

Prevalence of depression and its associations with cardio-metabolic control in Aboriginal and Anglo-Celt patients with type 2 diabetes: the Fremantle Diabetes Study Phase II

AIMS

To determine the prevalence and associates of depression in Aboriginal and Anglo-Celt (AC) Australians with type 2 diabetes.

METHODS

Community-based patients were screened using the Patient Health Questionnaire (PHQ-9) as part of detailed assessment. The prevalence of any current depression, major depression and antidepressant use by racial group was compared after adjustment for age, sex, educational attainment and marital status. Multiple logistic regression was used to determine associates of current depression.

RESULTS

The 107 Aboriginal participants were younger (mean±SD 54.3±11.8 vs. 67.2±10.6 years), less often male (34.6% vs. 50.9%) and married (39.3% vs. 61.7%), and more likely to smoke (44.6% vs. 8.1%) than the 793 AC subjects (P≤0.002). Fifty-two Aboriginal (48.5%) and 772 AC participants (97.4%) completed the PHQ-9; these Aboriginals had similar socio-demographic, anthropometric and diabetes-related characteristics to those without PHQ-9 data. A quarter of the Aboriginals had current depression vs 10.6% of ACs (P=0.16), 15.4% vs. 4.1% had major depression (P=0.029), and 68.8% vs. 29.7% had untreated depression (P=0.032). Compared with non-depressed participants, patients with current depression were younger and more likely to smoke, to be overweight/obese and to have worse glycaemic control (P≤0.024). Significant independent associates of current depression were educational attainment (inversely), smoking status, body mass index and fasting plasma glucose in the AC group and alcohol use in the Aboriginal group.

CONCLUSIONS

Although prevalence of depression was not significantly increased in the Aboriginal patients, it was more likely to be major and untreated. Depression complicating type 2 diabetes is associated with adverse cardiovascular risk.

Temporal changes in Plasmodium falciparum anti-malarial drug sensitivity in vitro and resistance-associated genetic mutations in isolates from Papua New Guinea

Background

In northern Papua New Guinea (PNG), most Plasmodium falciparum isolates proved resistant to chloroquine (CQ) in vitro between 2005 and 2007, and there was near-fixation of pfcrt K76T, pfdhfr C59R/S108N and pfmdr1 N86Y. To determine whether the subsequent introduction of artemisinin combination therapy (ACT) and reduced CQ-sulphadoxine-pyrimethamine pressure had attenuated parasite drug susceptibility and resistance-associated mutations, these parameters were re-assessed between 2011 and 2013.

Methods

A validated fluorescence-based assay was used to assess growth inhibition of 52 P. falciparum isolates from children in a clinical trial in Madang Province. Responses to CQ, lumefantrine, piperaquine, naphthoquine, pyronaridine, artesunate, dihydroartemisinin, artemether were assessed. Molecular resistance markers were detected using a multiplex PCR ligase detection reaction fluorescent microsphere assay.

Results

CQ resistance (in vitro concentration required for 50% parasite growth inhibition (IC₅₀) >100 nM) was present in 19% of isolates. All piperaquine and naphthoquine IC₅₀s were <100 nM and those for lumefantrine, pyronaridine and the artemisinin derivatives were in low nM ranges. Factor analysis of IC₅₀s showed three groupings (lumefantrine; CQ, piperaquine, naphthoquine; pyronaridine, dihydroartemisinin, artemether, artesunate). Most isolates (96%) were monoclonal pfcrt K76T (SVMNT) mutants and most (86%) contained pfmdr1 N86Y (YYSND). No wild-type pfdhfr was found but most isolates contained wild-type (SAKAA) pfdhps. Compared with 2005–2007, the geometric mean (95% CI) CQ IC₅₀ was lower (87 (71–107) vs 167 (141–197) nM) and there had been no change in the prevalence of pfcrt K76T or pfmdr1 mutations. There were fewer isolates of the pfdhps (SAKAA) wild-type (60 vs 100%) and pfdhfr mutations persisted.

Conclusions

Reflecting less drug pressure, in vitro CQ sensitivity appears to be improving in Madang Province despite continued near-fixation of pfcrt K76T and pfmdr1 mutations. Temporal changes in IC₅₀s for other anti-malarial drugs were inconsistent but susceptibility was preserved. Retention or increases in pfdhfr and pfdhps mutations reflect continued use of sulphadoxine-pyrimethamine in the study area including through paediatric intermittent preventive treatment. The susceptibility of local isolates to lumefantrine may be unrelated to those of other ACT partner drugs.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12610000913077.

Artemisinin-naphthoquine versus artemether-lumefantrine for uncomplicated malaria in Papua New Guinean children: an open-label randomized trial

BACKGROUND

Artemisinin combination therapies (ACTs) with broad efficacy are needed where multiple Plasmodium species are transmitted, especially in children, who bear the brunt of infection in endemic areas. In Papua New Guinea (PNG), artemether-lumefantrine is the first-line treatment for uncomplicated malaria, but it has limited efficacy against P. vivax. Artemisinin-naphthoquine should have greater activity in vivax malaria because the elimination of naphthoquine is slower than that of lumefantrine. In this study, the efficacy, tolerability, and safety of these ACTs were assessed in PNG children aged 0.5-5 y.

METHODS AND FINDINGS

An open-label, randomized, parallel-group trial of artemether-lumefantrine (six doses over 3 d) and artemisinin-naphthoquine (three daily doses) was conducted between 28 March 2011 and 22 April 2013. Parasitologic outcomes were assessed without knowledge of treatment allocation. Primary endpoints were the 42-d P. falciparum PCR-corrected adequate clinical and parasitologic response (ACPR) and the P. vivax PCR-uncorrected 42-d ACPR. Non-inferiority and superiority designs were used for falciparum and vivax malaria, respectively. Because the artemisinin-naphthoquine regimen involved three doses rather than the manufacturer-specified single dose, the first 188 children underwent detailed safety monitoring. Of 2,542 febrile children screened, 267 were randomized, and 186 with falciparum and 47 with vivax malaria completed the 42-d follow-up. Both ACTs were safe and well tolerated. P. falciparum ACPRs were 97.8% and 100.0% in artemether-lumefantrine and artemisinin-naphthoquine-treated patients, respectively (difference 2.2% [95% CI -3.0% to 8.4%] versus -5.0% non-inferiority margin, p = 0.24), and P. vivax ACPRs were 30.0% and 100.0%, respectively (difference 70.0% [95% CI 40.9%-87.2%], p<0.001). Limitations included the exclusion of 11% of randomized patients with sub-threshold parasitemias on confirmatory microscopy and direct observation of only morning artemether-lumefantrine dosing.

CONCLUSIONS

Artemisinin-naphthoquine is non-inferior to artemether-lumefantrine in PNG children with falciparum malaria but has greater efficacy against vivax malaria, findings with implications in similar geo-epidemiologic settings within and beyond Oceania.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12610000913077. Please see later in the article for the Editors' Summary.

Viral pathogens in children hospitalized with features of central nervous system infection in a malaria-endemic region of Papua New Guinea

BACKGROUND

Viral central nervous system (CNS) infections are common in countries where malaria is endemic but, due to limited laboratory facilities, few studies have systematically examined the prevalence and clinical consequences of the presence of viruses in cerebrospinal fluid (CSF) from children with suspected CNS infection.

METHODS

We performed a prospective study of Papua New Guinean children hospitalized with signs and symptoms of CNS infection. CSF samples from 300 children without proven bacterial/fungal meningitis were analyzed for human herpes viruses (HHV), picornaviruses, influenza, adenoviruses, flaviviruses and bacteria.

RESULTS

Fifty-five children (18%) had viral (42), bacterial (20) or both viral and bacterial (7) nucleic acids (NA) identified in their CSF. Human herpes viruses accounted for 91% of all viruses found. The identification of viral or bacterial NA was not associated with any characteristic clinical features. By contrast, malaria was associated with increased identification of viral and bacterial NA and with impaired consciousness, multiple convulsions and age. Malaria was also inversely associated with an adverse outcome. Amongst children with HHV infection, those with HHV-6 and -7 were younger, were more likely have impaired consciousness and had a higher proportion of adverse outcomes than children with CMV. Dengue and enteroviral infections were infrequent. Adenoviral and influenza infections were not identified.

CONCLUSION

Infections with HHV-6, HHV-7, dengue and enterovirus have the potential to cause serious CNS disease in young PNG children. However most HHVs in this malaria-endemic setting should be considered to be the result of reactivation from a latent reservoir without clinical sequelae.

Diagnostic criteria for depression in type 2 diabetes: a data-driven approach

Background

While depression is a frequent psychiatric comorbid condition in diabetes and has significant clinical impact, the syndromal profile of depression and anxiety symptoms has not been examined in detail.

Aims

To determine the syndromal pattern of the depression and anxiety spectrum in a large series of patients with type 2 diabetes, as determined using a data-driven approach based on latent class analysis (LCA).

Method

Type 2 diabetes participants from the observational community-based Fremantle Diabetes Study Phase II underwent assessment of lifetime depression using the Brief Lifetime Depression Scale, the Patient Health Questionnaire 9-item version (PHQ-9) for current depression symptoms, and the Generalized Anxiety Disorder Scale that was specifically developed and validated for this study. The main outcome measure was classes of patients with a specific syndromal profile of depression and anxiety symptoms based on LCA.

Results

LCA identified four classes that were interpreted as “major anxious depression”, “minor anxious depression”, “subclinical anxiety”, and “no anxious depression”. All nine DSM-IV/5 diagnostic criteria for major depression identified a class with a high frequency of major depression. All symptoms of anxiety had similar high probabilities as symptoms of depression for the “major depression-anxiety” class. There were significant differences between classes in terms of history of depression and anxiety, use of psychoactive medication, and diabetes-related variables.

Conclusions

Patients with type 2 diabetes show specific profiles of depression and anxiety. Anxiety symptoms are an integral part of major depression in type 2 diabetes. The different classes identified here provide empirically validated phenotypes for future research.

Population pharmacokinetics of intravenous artesunate: a pooled analysis of individual data from patients with severe malaria

There are ~660,000 deaths from severe malaria each year. Intravenous artesunate (i.v. ARS) is the first-line treatment in adults and children. To optimize the dosing regimen of i.v. ARS, the largest pooled population pharmacokinetic study to date of the active metabolite dihydroartemisinin (DHA) was performed. The pooled dataset consisted of 71 adults and 195 children with severe malaria, with a mixture of sparse and rich sampling within the first 12 h after drug administration. A one-compartment model described the population pharmacokinetics of DHA adequately. Body weight had the greatest impact on DHA pharmacokinetics, resulting in lower DHA exposure for smaller children (6–10 kg) than adults. Post hoc estimates of DHA exposure were not significantly associated with parasitological outcomes. Comparable DHA exposure in smaller children and adults after i.v. ARS was achieved under a dose modification for intramuscular ARS proposed in a separate analysis of children.