WHO, the Global Fund, and medical malpractice in malaria treatment

Combating multidrug-resistant Plasmodium falciparum malaria

Over the past 50 years, Plasmodium falciparum has developed resistance against all antimalarial drugs used against it: chloroquine, sulphadoxine-pyrimethamine, quinine, piperaquine and mefloquine. More recently, resistance to the artemisinin derivatives and the resulting failure of artemisinin-based combination therapy (ACT) are threatening all major gains made in malaria control. Each time resistance has developed progressively, with delayed clearance of parasites first emerging only in a few regions, increasing in prevalence and geographic range, and then ultimately resulting in the complete failure of that antimalarial. Drawing from this repeated historical chain of events, this article presents context-specific approaches for combating drug-resistant P. falciparum malaria. The approaches begin with a context of drug-sensitive parasites and focus on the prevention of the emergence of drug resistance. Next, the approaches address a scenario in which resistance has emerged and is increasing in prevalence and geographic extent, with interventions focused on disrupting transmission through vector control, early diagnosis and treatment, and the use of new combination therapies. Elimination is also presented as an approach for addressing the imminent failure of all available antimalarials. The final drug resistance context presented is one in which all available antimalarials have failed; leaving only personal protection and the use of new antimalarials (or new combinations of antimalarials) as a viable strategy for dealing with complete resistance. All effective strategies and contexts require a multipronged, holistic approach.

A review and analysis of intensive care medicine in the least developed countries

OBJECTIVE

To give critical care clinicians in Western nations a general overview of intensive care medicine in less developed countries and to stimulate institutional or personal initiatives to improve critical care services in the least developed countries.

DATA SOURCE

In-depth PubMed search and personal experience of the authors.

DATA SYNTHESIS

In view of the eminent burden of disease, prevalence of critically ill patients in the least developed countries is disproportionately high. Despite fundamental logistic (water, electricity, oxygen supply, medical technical equipment, drugs) and financial limitations, intensive care medicine has become a discipline of its own in most nations. Today, many district and regional hospitals have units where severely ill patients are separately cared for, although major intensive care units are only found in large hospitals of urban or metropolitan areas. High workload, low wages, and a high risk of occupational infections with either the human immunodeficiency virus or a hepatitis virus explain burnout syndromes and low motivation in some health care workers. The four most common admission criteria to intensive care units in least developed countries are postsurgical treatment, infectious diseases, trauma, and peripartum maternal or neonatal complications. Logistic and financial limitations, as well as insufficiencies of supporting disciplines (e.g., laboratories, radiology, surgery), poor general health status of patients, and in many cases delayed presentation of severely sick patients to the intensive care unit, contribute to comparably high mortality rates.

CONCLUSION

More studies on the current state of intensive care medicine in least developed countries are needed to provide reasonable aid to improve care of the most severely ill patients in the poorest countries of the world.

[The specialty of anesthesia outside Western medicine with special consideration of personal experience in the Democratic Republic of the Congo and Mongolia]

During the last decades anesthesia has developed into a wide ranging specialty in western countries, whereas in most developing and newly industrializing nations it still focuses on its core discipline, the perioperative care of the surgical patient. Poor socioeconomic status and inadequate financing of health systems result in a high burden of disease, a high rate of self-financing of healthcare costs by the patients, as well as insufficient personnel, infra-structural and material equipment of most healthcare facilities. Important limiting factors for anesthesia are low educational standards and a widespread lack of oxygen and medical gas supplies, as well as locally serviceable medical equipment. Studies evaluating the status of anesthesia in developing and newly industrializing nations in detail are urgently needed in order to provide aid on national and international as well as institutional and private levels for the development of anesthesia in poor countries.

Falciparum malaria: current therapeutic challenges

PURPOSE OF REVIEW

Malaria remains a major cause of death in much of the world. The routine treatment of malaria is currently threatened by rising rates of drug resistance. Moreover, mortality among children with severe and complicated malaria remains unacceptably high. Here we review trends in antimalarial drug resistance and report on the progress of newer drugs and drug combinations. We then review some recent literature regarding the pathological processes involved in the aetiology of severe malaria that may lead to improvements in the management of children with severe disease.

RECENT FINDINGS

Resistance to first line therapies, including chloroquine and sulphadoxine/pyramethamine, continues to rise in many parts of the world. The availability of newer and more effective drugs and fixed drug combinations is hampered by financial and political considerations. Nevertheless, a number of promising drugs and supportive treatments for both mild and severe malaria are at various stages of development.

SUMMARY

A range of newer drugs and fixed drug combinations are now available that are safe and effective. However, these drugs remain expensive and their introduction will require political and financial support at every level. Considerable work is still required to achieve a better understanding of the processes involved in the pathogenesis of severe and complicated malaria. Only then will it be possible to develop new and appropriate therapies that will be widely applicable.