Background The World Health Organization (WHO) in 2015 stated atovaquone‐proguanil can be used in travellers, and is an option in malaria‐endemic areas in combination with artesunate, as an alternative treatment where first‐line artemisinin‐based combination therapy (ACT) is not available or effective. This review is an update of a Cochrane Review undertaken in 2005. Objectives To assess the efficacy and safety of atovaquone‐proguanil (alone and in combination with artemisinin drugs) versus other antimalarial drugs for treating uncomplicated Plasmodium falciparum malaria in adults and children. Search methods The date of the last trial search was 30 January 2020. Search locations for published trials included the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, and LILACS. To include recently published and unpublished trials, we also searched ClinicalTrials.gov, the meta Register of Controlled Trials and the WHO International Clinical Trials Registry Platform Search Portal. Selection criteria Randomized controlled trials (RCTs) reporting efficacy and safety data for atovaquone‐proguanil or atovaquone‐proguanil with a partner drug compared with at least one other antimalarial drug for treating uncomplicated Plasmodium falciparum infection. Data collection and analysis For this update, two review authors re‐extracted data and assessed certainty of evidence. We meta‐analyzed data to calculate risk ratios (RRs) with 95% confidence intervals (CI) for treatment failures between comparisons, and for safety outcomes between and across comparisons. Outcome measures include unadjusted treatment failures and polymerase chain reaction (PCR)‐adjusted treatment failures. PCR adjustment differentiates new infection from recrudescent infection. Main results Seventeen RCTs met our inclusion criteria providing 4763 adults and children from Africa, South‐America, and South‐East Asia. Eight trials reported PCR‐adjusted data to distinguish between new and recrudescent infection during the follow‐up period. In this abstract, we report only the comparisons against the three WHO‐recommended antimalarials which were included within these trials. There were two comparisons with artemether‐lumefantrine, one trial from 2008 in Ethiopia with 60 participants had two failures with atovaquone‐proguanil compared to none with artemether‐lumefantrine (PCR‐adjusted treatment failures at day 28). A second trial from 2012 in Colombia with 208 participants had one failure in each arm (PCR‐adjusted treatment failures at day 42). There was only one comparison with artesunate‐amodiaquine from a 2014 trial conducted in Cameroon. There were six failures with atovaquone‐proguanil at day 28 and two with artesunate‐amodiaquine (PCR‐adjusted tr...

IntroductionDiabetes mellitus (DM) is present in 10–15% of the surgical population. It is a known risk factor for adverse postoperative outcomes. UK perioperative guidance recommends optimizing glycemic control preoperatively, aiming for a target glycated hemoglobin (HbA1c) of < 69 mmol/mol. However, real-world compliance with this guidance remains unknown. The aim of our study was to determine how many patients with DM undergoing elective orthopedic and vascular surgery had a preoperative HbA1c of < 69 mmol/mol. We also reviewed the surgical reasons for non-concordance with the recommended preoperative HbA1c target.MethodsThis was a retrospective observational study of 1000 consecutive patients who had been referred for elective vascular and orthopedic surgery at a large tertiary center. Data were collected on these patients, both those with and without DM, between January 2016 and February 2017. Electronic databases were used to collect information on the patients’ preoperative HbA1c concentration and to determine whether there was a resulting delay in surgery when the preoperative HbA1c target of < 69 mmol/mol was exceeded.ResultsOf the 1000 patients referred for surgery (500 orthopedic and 500 vascular patients) included in the study, 201 (20%) had diabetes. Among these 201 people with DM, 155 (77%) had a preoperative HbA1c < 69 mmol/mol. Among the 46 people with DM whose HbA1c exceeded the recommended target, 41 were operated on despite the high HbA1c level, and only five had their surgery deferred or canceled due to suboptimal preoperative glycemic control.ConclusionsOur data shows that the majority (77% ) of people undergoing elective vascular and orthopedic surgery were able to achieve a target HbA1c of < 69 mmol/mol. The current preoperative guidance is therefore achievable in a real-life setting. However, as is stated in the national guidance, this target should only be used where it is safe to do so and a degree of clinical discretion is necessary.

Background Complications of urogenital schistosomiasis include acute inflammatory and chronic fibrotic changes within the urogenital tract. Disease burden of this neglected tropical disease is often underestimated, as only active, urine egg-patent Schistosoma infection is formally considered. Previous studies have focussed on short-term effects of praziquantel treatment on urinary tract pathology, demonstrating that acute inflammation is reversible. However, the reversibility of chronic changes is less well studied. Methods Our study compared, at two time points 14 y apart, urine egg-patent infection and urinary tract pathology in a cohort of women living in a highly endemic area having intermittent praziquantel treatment(s). In 2014 we matched 93 women to their findings in a previous study in 2000. Results Between 2000 and 2014 the rate of egg-patent infection decreased from 34% (95% confidence interval [CI] 25 to 44) to 9% (95% CI 3 to 14). However, urinary tract pathology increased from 15% (95% CI 8 to 22) to 19% (95% CI 11 to 27), with the greatest increase seen in bladder thickening and shape abnormality. Conclusions Despite praziquantel treatment, fibrosis from chronic schistosomiasis outlasts the presence of active infection, continuing to cause lasting morbidity. We suggest that future efforts to eliminate persistent morbidity attributable to schistosomiasis should include intensified disease management.

BackgroundBone mineral density (BMD) of the femoral neck is used as part of the FRAX Tool to calculate a patient's 10 year probability of having a fragility fracture. Risk factors for a reduction in BMD include reduction in oestrogen in female patients. Amenorrhoea is a reliable clinical indicator of oestrogen deficiency as its occurrence coincides with a more rapid reduction in BMD (1). Patients with the onset of menopause before the age of 45 have previously been shown to be at risk of low BMD, but studies have not addressed whether a history of amenorrhoea was associated with a reduction in BMD.ObjectivesTo investigate whether secondary amenorrhoea causes a reduction in BMD compared to normal healthy controls after adjustment for possible confounders.MethodsData of female individuals that underwent Dual-energy X-ray Absorptiometry scan at a District hospital in the North West of England between 1992 and 2010 were used. The age of patients was recorded as well as the BMD in femoral neck and lumbar spine. Other characteristics recorded included height and weight to calculate body mass index (BMI) and percentage body fat. Patients with secondary amenorrhoea or a history of amenorrhoea were compared to a female only control group with no identifiable risk factors for scanning. Initially, differences in age at scan, BMI and body fat were compared using a Student's T test. Logistic regression modelling, adjusted for age, BMI and body fat was used to examine any reduction in BMD of the lumbar spine or femoral neck between patients and controls.Results277 patients were identified that had secondary amenorrhoea or previous amenorrhoea. Median age was 44.2 years (IQR 34.9,50.75) compared to 4763 female controls median age 57.9 years (IQR 51.4,67.00). 53 (19.13%) of the patients had sustained a fracture. BMI in cases was significantly less than controls (23.4 kg/m2 vs 26.6 kg/m2 p<0.001). Body fat was also less in cases than controls (23.1% vs 29.1% p<0.001). The unadjusted odds ratio for a reduction of BMD of the lumbar spine was 0.36 (95% CI 0.18, 0.70) and in the femoral neck the odds were 3.52 (95% CI 1.19, 10.42). After adjusting for age, the odds ratio for a reduction in BMD of the lumbar spine was 0.05 (95% CI 0.02,0.11) and 0.08 (95% CI 0.01,0.33) for the femoral neck. Adjusting for age and BMI showed an OR of 0.09 (95%CI 0.04, 0.22) in the lumbar spine and OR 0.25 (95%CI 0.05,1.15) in the femoral neck. When adjusting for body fat and age at scan the odds were 0.15 (95%CI 0.05,0.46) in the lumbar spine and 0.13 (95%CI 0.03,0.56) in the femoral neck. Adjusting for both BMI and body fat gave odds of 0.21 (95%CI 0.07,0.68) and 0.21 (0.04,0.99) respectively.ConclusionsAfter adjusting for age and BMI, secondary amenorrhoea appears to have a detrimental effect on the BMD of the lumbar spine and a trend of effect on the femoral neck. When adjusting for percentage body fat it shows a reduction in both sites. As the FRAX tool uses femoral neck BMD and BMI as a predictor for fracture, not using percent body fat could lead t...

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