Resolution of parasitemia was inadequate with monotherapy with either azithromycin or chloroquine, but combination therapy provided substantially improved clinical and parasitologic outcomes. The combination of azithromycin and chloroquine may be an effective alternative treatment for falciparum malaria and deserves further study.

Azithromycin has demonstrated activity in a prevention of Plasmodium vivax infection, but no controlled treatment studies have been performed. We conducted a double-blinded trial in P. vivax malaria in which patients were randomized to either azithromycin 1,000 mg q.d. x 3 or chloroquine 600 mg q.d. x 2 then 300 mg on Day 3 followed by primaquine on Days 7 through 20. Eighty-five of 97 (88%) of those on azithromycin and 101 of 102 (99%) of those on chloroquine [difference 11%; 95% CI: -18, -4] were clinically cured at Day 7. The Day 28 results were similar [89% versus 99%, azithromycin versus chloroquine, respectively]. Parasitologic success was seen in 81 of 97 (84%) on azithromycin and 100 of 102 (98%) on chloroquine [difference 14%; 95% CI: -22, -6]. The median parasite clearance time was 55 hours on azithromycin and 20 hours on chloroquine (P < 0.001). Drug-related adverse events were seen in 13 of 98 (13%) on azithromycin and 24 of 102 (24%) on chloroquine (P = 0.062). Resolution of parasitemia was significantly faster with chloroquine compared with azithromycin, but azithromycin was better tolerated. These data provide support for further study of azithromycin to better define its role in the treatment of P. vivax malaria, either alone as second-line treatment or in combination with other active therapies.

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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.

BackgroundThe provision of high-quality maternity services is a priority for reducing inequalities in health outcomes for mothers and infants. Best practice includes women having their initial antenatal appointment within the first trimester of pregnancy in order to provide screening and support for healthy lifestyles, well-being and self-care in pregnancy. Previous research has identified inequalities in access to antenatal care, yet there is little evidence on interventions to improve early initiation of antenatal care. The Community REACH trial will assess the effectiveness and cost-effectiveness of engaging communities in the co-production and delivery of an intervention that addresses this issue.Methods/designThe study design is a matched cluster randomised controlled trial with integrated process and economic evaluations. The unit of randomisation is electoral ward. The intervention will be delivered in 10 wards; 10 comparator wards will have normal practice. The primary outcome is the proportion of pregnant women attending their antenatal booking appointment by the 12th completed week of pregnancy. This and a number of secondary outcomes will be assessed for cohorts of women (n = approximately 1450 per arm) who give birth 2–7 and 8–13 months after intervention delivery completion in the included wards, using routinely collected maternity data. Eight hospitals commissioned to provide maternity services in six NHS trusts in north and east London and Essex have been recruited to the study. These trusts will provide anonymised routine data for randomisation and outcomes analysis. The process evaluation will examine intervention implementation, acceptability, reach and possible causal pathways. The economic evaluation will use a cost-consequences analysis and decision model to evaluate the intervention. Targeted community engagement in the research process was a priority.DiscussionCommunity REACH aims to increase early initiation of antenatal care using an intervention that is co-produced and delivered by local communities. This pragmatic cluster randomised controlled trial, with integrated process and economic evaluation, aims to rigorously assess the effectiveness of this public health intervention, which is particularly complex due to the required combination of standardisation with local flexibility. It will also answer questions about scalability and generalisability.Trial registrationISRCTN registry: registration number 63066975. Registered on 18 August 2015.Electronic supplementary materialThe online version of this article (10.1186/s13063-018-2526-6) contains supplementary material, which is available to authorized users.

ABSTRACr The diffusing capacity of the lung, or transfer factor, for carbon monoxide (TLco) was measured in 12 patients with polycythaemia rubra vera. This was significantly raised (mean 152% predicted, SEM + 14%) and remained so even after correction to a standard haemoglobin concentration of 14-6 g/dl (mean 139% predicted, SEM + 13%). Serial measurements of TLCO on two patients after treatment of polycythaemia rubra vera showed a greater fall in relation to haemoglobin concentration than would have been predicted on theoretical grounds if the increases in TLco had been due entirely to the increased haemoglobin concentration. The pulmonary capillary blood volume (estimated from TLco) also fell in these two patients after treatment. There was a strong correlation between TLco and the technetium-99m-labelled red cell volume for the seven men (r = 0.92; p < 0-01) and five women (r = 0.99; p < 0-001) when studies were performed on the same day. In patients with polycythaemia rubra vera who have no evidence of coexistent pulmonary disease the pulmonary capillary bed appears to share in the expansion of the body blood volume. The single-breath TLco test may act as a convenient and simple monitor for the response of the disease to treatment.The total lung diffusing capacity, or transfer factor, for carbon monoxide (TLco) is determined by the membrane-diffusing capacity (DM), the reaction rate of carbon monoxide with oxyhaemoglobin (0), and the pulmonary capillary blood volume (Vc). Roughton and Forster' proposed the equation 1 1 1 TLco DM 0.Vc to describe this relation. In polycythaemia rubra vera the increased haemoglobin concentration should result in an increase in the reaction rate of carbon monoxide with oxyhaemoglobin, which would lower the red cell resistance and increase the TLco. Early observations2 did not support this prediction but full methodological and clinical details were not given. Later workers have demonstrated an elevated TLCO.3 4 Both groups attributed the elevated diffusing capacity to the high haemoglobin concentration. We had observed that some patients with polycythaemia rubra vera had an elevated TLco even after correction for the high haemoglobin con-

The story of The Raja's Big Ears, as we encountered it, has been on a long journey. In the course of a wider study of the language use and literacy practices of Gujerati-speaking Muslim children in a North London community, children were recorded retelling the tale both in English and Gujerati. The present study explores how the story travelled: from Gujerat, in India, where it is a well-known folk tale, via a skilled story-teller, to London, where it was transformed through contact with the multicultural world of London schoolchildren. The study is situated within the theoretical framework of language shift, social networks and the Cummins' concept of the Common Underlying Proficiency. As the children in the study retold the tale, we looked more closely at how they -third generation Londoners and speakers of a dialect of Gujerati -came to terms with the very formal and unfamiliar standard Gujerati of the story, and how they made it their own.

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