<table cellspacing="0" cellpadding="0" border="0" ><tr><td valign="top" style="font: inherit;"><DIV>Dear Ms. Gena,</DIV>
<DIV> </DIV>
<DIV>It is nice to hear from you. This is to let you know that I have completed a RCT comparing thermotherapy with Glucantim for the treatment of Cutanouse Leishmanisis in Kabul. The report has been accepted for publication. If you are interested, I could share it with you.</DIV>
<DIV> </DIV>
<DIV>Regards <BR><BR></DIV>
<DIV>
<DIV>
<DIV>
<DIV>
<DIV>
<DIV>
<DIV><FONT size=1>
<DIV><FONT style="BACKGROUND-COLOR: #ffffff" face=verdana color=#00007f><STRONG>Najibullah Safi, MD, MSc. HPM</STRONG></FONT></DIV>
<DIV><FONT color=#000000> </FONT></DIV>
<DIV><FONT face=verdana color=#000000></FONT></DIV>
<DIV><FONT color=#000000><FONT style="BACKGROUND-COLOR: #ffffff" face=verdana>Mobile: 0093(0) 777 890 855</FONT></FONT></DIV>
<DIV><FONT face=Verdana color=#000000>Skype: najibullahsafi</FONT></DIV>
<DIV> </DIV>
<DIV><FONT face=Verdana><A href="http://www.moph.gov.af/" target=_blank rel=nofollow></A></FONT> </DIV>
<DIV>
<P class=MsoPlainText style="MARGIN: 0in 0in 0pt"><B><SPAN style="FONT-SIZE: 10pt; COLOR: #0070c0"><FONT color=#0000bf>The selfless leader is willing to risk his or her own fate in order to do what is right.</FONT></SPAN></B></DIV>
<P class=MsoPlainText style="MARGIN: 0in 0in 0pt"><B><SPAN style="FONT-SIZE: 10pt; COLOR: #0070c0"><FONT color=#0000bf></FONT></SPAN></B> </DIV><SPAN>
<P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B><SPAN style="FONT-SIZE: 18pt; COLOR: #002060; FONT-FAMILY: Webdings">P</SPAN><SPAN style="COLOR: #002060"><FONT size=3> </FONT></SPAN></B><B><SPAN lang=EN-GB style="FONT-SIZE: 9pt; COLOR: #002060; FONT-FAMILY: 'serif'">Please don't print unless necessary</SPAN></B></DIV></SPAN></DIV></FONT></DIV>
<DIV><FONT face="comic sans ms"></FONT> </DIV>
<DIV><STRONG><FONT color=#4040ff></FONT></STRONG> </DIV></DIV></DIV></DIV></DIV></DIV></DIV><BR><BR>--- On <B>Tue, 7/12/11, gzischke@thermosurgery.com <I><gzischke@thermosurgery.com></I></B> wrote:<BR>
<BLOCKQUOTE style="PADDING-LEFT: 5px; MARGIN-LEFT: 5px; BORDER-LEFT: rgb(16,16,255) 2px solid"><BR>From: gzischke@thermosurgery.com <gzischke@thermosurgery.com><BR>Subject: Re: [Leish-l] miltefosine for diffuse leishmaniasis<BR>To: "Carlos Costa" <chncosta@gmail.com>, "Abhay Satoskar" <Abhay.Satoskar@osumc.edu>, "John David" <jdavid@hsph.harvard.edu>, generhedin@thermosurgery.com<BR>Cc: "Josh Berman" <Jbe9320457@aol.com>, dagobertosilveira@superig.com.br, "Dorcas Lamounier Costa" <dorcas.lc@gmail.com>, "Leish-L" <Leish-l@lineu.icb.usp.br>, jurbina@mac.com, "Pierre BUFFET" <pierre.buffet@upmc.fr>, joseanegodinho@yahoo.com.br, "Raimunda Sampaio" <rsampaio@unb.br>, "Shyam Sundarmail" <Drshyamsundar@hotmail.com>, robertobadaro768@gmail.com, "Mark Nawacki" <mnawacki@paladinlabs.com>, "Fernando Koremblum" <fkorembl@paladinlabs.com>, "Robert Vinson" <rvinson@paladinlabs.com><BR>Date:
Tuesday, July 12, 2011, 10:16 PM<BR><BR>
<DIV id=yiv1949286788><SPAN style="FONT-SIZE: 10pt; COLOR: #000000; FONT-FAMILY: Verdana">
<DIV><SPAN><SPAN style="CLEAR: both; FONT-SIZE: 10pt; COLOR: rgb(0,0,0); FONT-FAMILY: Verdana">
<DIV>Dear Dr. Costas,</DIV>
<DIV>Thermosurgery is committed to the research and treatment of leishmaniasis. We are pleased to work with you and assist your patients. We can lend you an instrument to use in your program. Our biggest hurdle is getting the equipment into the country. If you work with an NGO or government agency that can assist us in the importation that would be helpful. </DIV>
<DIV>Lets discuss the logistics to see if it is feasible to get you the equipment. I would suggest that you work with Dr David and Dr Satoskar on the recommended treatment protocol. </DIV>
<DIV>We would want to receive documentation regarding the use of the equipment and a paper so that we can educate others on the value of this treatment. </DIV>
<DIV><BR></DIV>
<DIV>Warm regards,</DIV>
<DIV>gena</DIV></SPAN></SPAN><BR></DIV>
<DIV><BR></DIV>
<DIV>Gena Zischke<BR>Business Development<BR>Thermosurgery Technologies, Inc.<BR>2901 W. Indian School Rd.<BR>Phoenix, AZ 85017<BR>Phone: (602) 264-7300<BR><BR><BR>The information in this communication is confidential. It is intended solely for the addressee. Access to this communication by anyone else is unauthorized. If you are not the intended recipient, any disclosure, copying, distribution or any action taken or omitted to be taken in reliance on it, is prohibited and may be unlawful. If you have received this communication in error, please notify us immediately by return email, and destroy this communication and all copies thereof, including all attachments. Thank you. Thermosurgery Technologies, Inc.<BR><BR><BR>Fax: (602) 248-3809<BR><BR></DIV>
<BLOCKQUOTE id=yiv1949286788replyBlockquote style="PADDING-LEFT: 8px; FONT-SIZE: 10pt; MARGIN-LEFT: 8px; BORDER-LEFT: blue 2px solid; COLOR: black; FONT-FAMILY: verdana">
<DIV id=yiv1949286788wmQuoteWrapper>-------- Original Message --------<BR>Subject: Re: [Leish-l] miltefosine for diffuse leishmaniasis<BR>From: Carlos Costa <<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=chncosta@gmail.com" target=_blank rel=nofollow ymailto="mailto:chncosta@gmail.com">chncosta@gmail.com</A>><BR>Date: Sun, July 10, 2011 4:23 pm<BR>To: "Chang, Kwang-Poo" <<A href="http://KwangPoo.Chang@rosalindfranklin.edu" target=_blank rel=nofollow>KwangPoo.Chang@rosalindfranklin.edu</A>><BR>Cc: Josh Berman <<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=Jbe9320457@aol.com" target=_blank rel=nofollow ymailto="mailto:Jbe9320457@aol.com">Jbe9320457@aol.com</A>>, <A href="http://us.mc634.mail.yahoo.com/mc/compose?to=dagobertosilveira@superig.com.br" target=_blank rel=nofollow ymailto="mailto:dagobertosilveira@superig.com.br">dagobertosilveira@superig.com.br</A>,<BR>Raimunda Sampaio <<A
href="http://us.mc634.mail.yahoo.com/mc/compose?to=rsampaio@unb.br" target=_blank rel=nofollow ymailto="mailto:rsampaio@unb.br">rsampaio@unb.br</A>>, Dorcas Lamounier Costa<BR><<A href="http://dorcas.lc@gmail.com" target=_blank rel=nofollow>dorcas.lc@gmail.com</A>>, Mark Nawacki <mnawacki@paladinlabs.com>,<BR><A href="http://us.mc634.mail.yahoo.com/mc/compose?to=jurbina@mac.com" target=_blank rel=nofollow ymailto="mailto:jurbina@mac.com">jurbina@mac.com</A>, Pierre BUFFET <<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=pierre.buffet@upmc.fr" target=_blank rel=nofollow ymailto="mailto:pierre.buffet@upmc.fr">pierre.buffet@upmc.fr</A>>,<BR><A href="http://us.mc634.mail.yahoo.com/mc/compose?to=joseanegodinho@yahoo.com.br" target=_blank rel=nofollow ymailto="mailto:joseanegodinho@yahoo.com.br">joseanegodinho@yahoo.com.br</A>, Robert Vinson <<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=rvinson@paladinlabs.com"
target=_blank rel=nofollow ymailto="mailto:rvinson@paladinlabs.com">rvinson@paladinlabs.com</A>>,<BR>Shyam Sundarmail <<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=Drshyamsundar@hotmail.com" target=_blank rel=nofollow ymailto="mailto:Drshyamsundar@hotmail.com">Drshyamsundar@hotmail.com</A>>,<BR><A href="http://us.mc634.mail.yahoo.com/mc/compose?to=robertobadaro768@gmail.com" target=_blank rel=nofollow ymailto="mailto:robertobadaro768@gmail.com">robertobadaro768@gmail.com</A>, Leish-L <<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=Leish-l@lineu.icb.usp.br" target=_blank rel=nofollow ymailto="mailto:Leish-l@lineu.icb.usp.br">Leish-l@lineu.icb.usp.br</A>>, Fernando<BR>Koremblum <<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=fkorembl@paladinlabs.com" target=_blank rel=nofollow ymailto="mailto:fkorembl@paladinlabs.com">fkorembl@paladinlabs.com</A>><BR><BR>KP, do you have any idea about prices? Please send me the
brand name to see if I can easily import them. Best wishes to Jean, Carlos<BR><BR>
<DIV class=yiv1949286788gmail_quote>2011/7/10 Chang, Kwang-Poo <SPAN dir=ltr><<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=KwangPoo.Chang@rosalindfranklin.edu" target=_blank rel=nofollow ymailto="mailto:KwangPoo.Chang@rosalindfranklin.edu">KwangPoo.Chang@rosalindfranklin.edu</A>></SPAN><BR>
<BLOCKQUOTE class=yiv1949286788gmail_quote style="PADDING-LEFT: 1ex; MARGIN: 0pt 0pt 0pt 0.8ex; BORDER-LEFT: rgb(204,204,204) 1px solid"><U></U><U></U><U></U>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face=Arial color=navy size=2><SPAN style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Carlos will undoubtedly go with those, which are clinically acceptable and feasible for the sake of expediency. <U></U><U></U></SPAN></FONT></DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face=Arial color=navy size=2><SPAN style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial"><U></U> <U></U></SPAN></FONT></DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face=Arial color=navy size=2><SPAN style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">In a separate message, the causative agent was said to have been identified as L amazonensis. Thermosensitivity of this species has been well-documented, suggestive of thermotherapy. There is already the suggestion of hot bath. One-use heat pad/heat wrap available over-the-counter in the <U></U><U></U>USA<U></U><U></U> drug stores is just as innocuous to consider as some topical ointments suggested.<U></U><U></U></SPAN></FONT></DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face=Arial color=navy size=2><SPAN style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial"><U></U> <U></U></SPAN></FONT></DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face=Arial color=navy size=2><SPAN style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">KP<U></U><U></U></SPAN></FONT></DIV>
<DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><B><FONT face=Tahoma size=2><SPAN style="FONT-WEIGHT: bold; FONT-SIZE: 10pt; FONT-FAMILY: Tahoma">From:</SPAN></FONT></B><FONT face=Tahoma size=2><SPAN style="FONT-SIZE: 10pt; FONT-FAMILY: Tahoma"> <A href="http://us.mc634.mail.yahoo.com/mc/compose?to=leish-l-bounces@lineu.icb.usp.br" target=_blank rel=nofollow ymailto="mailto:leish-l-bounces@lineu.icb.usp.br">leish-l-bounces@lineu.icb.usp.br</A> [mailto:<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=leish-l-bounces@lineu.icb.usp.br" target=_blank rel=nofollow ymailto="mailto:leish-l-bounces@lineu.icb.usp.br">leish-l-bounces@lineu.icb.usp.br</A>] <B><SPAN style="FONT-WEIGHT: bold">On Behalf Of </SPAN></B>Carlos Costa<BR><B><SPAN style="FONT-WEIGHT: bold">Sent:</SPAN></B> Saturday, July 09, 2011 10:07 AM</SPAN></FONT></DIV><FONT face=Tahoma size=2>
<DIV class=yiv1949286788im><BR><B><SPAN style="FONT-WEIGHT: bold">To:</SPAN></B> Leish-L<BR><B><SPAN style="FONT-WEIGHT: bold">Cc:</SPAN></B> Josh Berman; <A href="http://us.mc634.mail.yahoo.com/mc/compose?to=dagobertosilveira@superig.com.br" target=_blank rel=nofollow ymailto="mailto:dagobertosilveira@superig.com.br">dagobertosilveira@superig.com.br</A>; Dorcas Lamounier Costa; <A href="http://us.mc634.mail.yahoo.com/mc/compose?to=jurbina@mac.com" target=_blank rel=nofollow ymailto="mailto:jurbina@mac.com">jurbina@mac.com</A>; Pierre BUFFET; Robert Vinson; Raimunda Sampaio; Shyam Sundarmail; <A href="http://us.mc634.mail.yahoo.com/mc/compose?to=robertobadaro768@gmail.com" target=_blank rel=nofollow ymailto="mailto:robertobadaro768@gmail.com">robertobadaro768@gmail.com</A>; Mark Nawacki; Fernando Koremblum; <A href="http://us.mc634.mail.yahoo.com/mc/compose?to=joseanegodinho@yahoo.com.br" target=_blank rel=nofollow
ymailto="mailto:joseanegodinho@yahoo.com.br">joseanegodinho@yahoo.com.br</A><BR></DIV><B><SPAN style="FONT-WEIGHT: bold">Subject:</SPAN></B> Re: [Leish-l] miltefosine for diffuse leishmaniasis</FONT><U></U><U></U>
<DIV></DIV></DIV>
<DIV>
<DIV></DIV>
<DIV class=yiv1949286788h5>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face=Verdana color=black size=4><SPAN style="FONT-SIZE: 13.5pt; COLOR: black; FONT-FAMILY: Verdana">Dear friends,</SPAN></FONT><U></U><U></U></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face=Verdana color=black size=4><SPAN style="FONT-SIZE: 13.5pt; COLOR: black; FONT-FAMILY: Verdana">This is really a such touching and motivated community, and leish-l is proving to be an excellent tool for solving the leishmaniasis toughest problems throughout the world. The word "together" sounds really powerful in such a cases.</SPAN></FONT><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face=Verdana color=black size=4><SPAN style="FONT-SIZE: 13.5pt; COLOR: black; FONT-FAMILY: Verdana">What os showing up from these kind emails is a face of science coming not only from the bench, the hospitals, the field, but a science coming straight from the heart.</SPAN></FONT><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">Let me summarize some of the lessons and suggestions. Please correct me if I skip some.</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">1) Hot bath - <U></U><U></U>Teresina<U></U><U></U> is very hot, and hot showers are rare here. However, we can easily provide her an electric shower. Should it be a tube? How long the bath would last?</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">2) BCG - one or two shots. We will do it. Any hint about the intervals between the shots?</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">3) Previous drug therapy: ImunoglucanTM (cell wall of <I><SPAN style="FONT-STYLE: italic">Saccharomyces cerevisiae</SPAN></I>), and saquinavir, after her delivery (</SPAN></FONT></SPAN><A href="http://www.ncbi.nlm.nih.gov/pubmed/18816190" target=_blank rel=nofollow>Intracellular survival of Leishmania species that cause visceral leishmaniasis is significantly reduced by HIV-1 protease inhibitors.</A>).<U></U><U></U></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">4) Besides miltefosine we got a good hint where to find it (<U></U><U></U>Paladino<U></U>, <U></U>Canada<U></U><U></U>), which has excellent temporary effect (Zerpa et al, 2006), we should consider: </SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">a) lower/corrected doses of paramomycin (Bryceson) - we have also to find the drug outside <U></U><U></U>Brazil<U></U><U></U>, since it is not distributed/approved here; </SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">b) gamma-interferon (who produces/sells it?).</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">c) fluconazol/itraconazol/(voriconazol?).</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">d) amiodarone - <I><SPAN style="FONT-STYLE: italic">in vitro</SPAN></I> testing does not sounds so good.</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">e) topic imiquimod (IxiumTM cream) - apparently easy to find. concentration of 5%?</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">f) photodynamic therapy - with Dr. Dagoberto Silveira, we are investigating where to do it around.</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
<DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">g) immunotherapy with suicide photo-inactivated <I><SPAN style="FONT-STYLE: italic">Leishmania</SPAN></I> (KP Chang).</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">Please check what really seems reasonable. My feeling is that most of the suggestions can be tried.</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">My warmest regards,</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><SPAN><FONT face=Verdana size=5><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana">Carlos.</SPAN></FONT></SPAN><U></U><U></U></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt">2011/7/8 Pierre BUFFET <<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=pierre.buffet@upmc.fr" target=_blank rel=nofollow ymailto="mailto:pierre.buffet@upmc.fr">pierre.buffet@upmc.fr</A>><U></U><U></U></SPAN></FONT></DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt">Anthony,<BR><BR><BR>because there are only a few options left, would you consider at one point low dose pentamidine (3 mg/kg every week or so, as you did in DCL patinets in <U></U><U></U>Ethiopia<U></U><U></U> in the 70s if I remember)? Could be used either to stabilize the situation before starting on a coadministration, or as a maintenance after the co-administration, in both cases with careful monitoring of kidney function ?<BR><BR><U></U><U></U>Pierre<U></U><U></U><BR><BR><BR> Anthony Bryceson <<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=a.bryceson@doctors.org.uk" target=_blank rel=nofollow ymailto="mailto:a.bryceson@doctors.org.uk">a.bryceson@doctors.org.uk</A>> a écrit :<U></U><U></U></SPAN></FONT></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt; MARGIN-BOTTOM: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt">Dear Carlos<BR>As you are well aware DCL is very difficult to treat. The big problem is that the defect in specific CMI is more profound than that in VL and may never recover, in contrast with the defect in VL which bounces back quickly.<BR><BR>To have any chance of curing the patient, treatment should be monitored by quantitative slit skin smears (as for splenic aspirates in VL) from multiple pre-selected sites, every week or two weeks, and treatment continued until negativity and for some weeks or months longer. When slit skin smears become negative, hunt for any nodular or infiltrated lesions and take deep biopsies and look for amastigotes there. Keep on hunting and smearing. Sometimes, at the end of all this, evidence of CMI may appear, and cure becomes a possibility. I am sure that the method of
treating is more important than the choice of drug - so long of course that the parasite is susceptible to the drug.<BR><BR>Hannah Akuffo has sent you the abstract relating to 3 patients treated by Sabawork Teklemariam in Addis Abeba. That article details this approach.<BR><BR>Do you know the species of Leishmania causing Maria's DCL, and its sensitivities? In Addis Abeba parasites were cultured from two of the patients and sensitivities determined and isobolograms drawn to look for synergy. The isolates were sensitive to paromomycin and sodium stibogluconate was synergistic. It would be worth while to make cultures before you start any new treatment and have the isolate tested in this way. I expect that you have a lab that could do this; if not, Simon Croft might be able to advise.<BR><BR>Miltefosine has been very successful in a number of situations in South American CL and showed promise for DCL, but patients relapsed despite prolonged
treatment.<BR>1. Zerpa O, Ulrich M, Blanco B, et al. Diffuse cutaneous leishmaniasis responds to miltefosine but then relapses. Br J Dermatol. 2007;156:1328-1335.<BR><BR>In a few patients with VL-HIV confection whom I treated in <U></U><U></U>London<U></U><U></U>, miltefosine worked well at first, but the patients relpased while still on treatment and drug resistance was supected but not tested. Miltefosine has a pharmacokinetic profile with a long tail that might make it susceptible to the devlopment of resistance, especially if the therapeutic window for a given isolate was narrow. So you might want to think about adding a second drug to go with miltefosine from the beginning. I am not sure what might be the best drug for combination; perhaps Josh Berman might have an opinion. It is of course essential to ensure contraception.<BR><BR>You could also consider the combination of paromomycin and low dose SSG. In view of Maria's poor renal function you
might need to modify the dose of paromomycin and to monitor function.<BR><BR>Robert Vinson is CEO of Paladin Labs, and would I am sure help you locate miltefosine. <<A href="http://us.mc634.mail.yahoo.com/mc/compose?to=rvinson@paladin-labs.com" target=_blank rel=nofollow ymailto="mailto:rvinson@paladin-labs.com">rvinson@paladin-labs.com</A>><BR><BR>Richard Chin is CEO of One World Health, and would, I am equally sure, help you locate paromomycin, should you consider that path. <A href="http://www.oneworldhealth.org/contact-us" target=_blank rel=nofollow>http://www.oneworldhealth.org/contact-us</A> Phone: +1 415-421-4700 Fax: +1 415-421-4747<BR><BR>I wish you and Maria all the best in this venture.<BR>Anthony<BR><BR><BR>Dear Jennie<BR>Immunotherapy proved rather disappointing in VL. It seems that the patient needs a decent immune response in the first place to benefit from immuno-boosting.<BR>Sadly<BR>Anthony<BR><BR><BR>On 6 Jul
2011, at 20:04, Carlos Costa wrote:<U></U><U></U></SPAN></FONT></DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt">Dear all,<BR><BR>Maria Cleudimar has cutaneous diffuse leishmaniasis due to Leishmania amazonensis. She used to be a long time patient form Dr. Jackson Costa, in the countryside of <U></U><U></U>Maranhão State<U></U>, <U></U>Brazil<U></U><U></U>, since she was 10 years old, after a disease that started when she was just five. Now, she is under my and Dorcas care, at the age of 30, living in the city of <U></U><U></U>Teresina<U></U><U></U>.<BR><BR>Her long time DCL does not respond to the treatment antimonium anymore. Although we still prescribe liposomal amphotericin B at very low dose (3mg/kg/once a week), her situation is deteriorating progressively, her renal function does not allow any additional dosing since creatinine is presently above 3mg/dL, and previous biopsy had shown tubular damage apparently secondary to the drug,
without evidence of amyloidosis. We tried several combinations of different drugs, without success. Her situation worsened a lot during her recent pregnancy (the baby is eight months old now).<BR><BR>Our hope now stands only in miltefosine, for oral chronic use, but the drug is not licensed or available in <U></U><U></U>Brazil<U></U><U></U> yet (to my knowledge).<BR><BR>With her permission I attached some of her pictures, hoping to sensitize critical people in order to help me to get miltefosine and the permission for prescription in <U></U><U></U>Brazil<U></U><U></U> (or any other oral drug with promising efficacy, and without nephrotoxicity, if known). Moreover, we need to know about the dose adjustment for the renal impairment, and how long the drug could safely be used.<BR><BR>One picture shows her face before treatment, and another after the pregnancy, with the baby. One shows the situation of her thighs, another the calf of the leg and the last
one the infiltration of the palate.<BR><BR>Hoping a little from friends, my kindest regards,<BR><BR>Carlos.<BR><BR>PS. Please understand that the pictures are allowed not for publication or public presentation. Cleudimar permission is restricted to this forum.<BR><BR><BR>--<BR>Carlos H. N. Costa, MD, DSc.<BR>President<BR>Sociedade Brasileira de Medicina Tropical<BR>(Brazilian Society of Tropical Medicine)<BR>Instituto de Doenças Tropicais Natan Portella<BR>Universidade Federal do Piauí<BR>Rua Artur de Vasconcelos 151-Sul<BR>64049-750 Teresina-PI<BR><U></U><U></U>Brazil<U></U><U></U><BR>Telephones: +55 86 3221-3413 (work); +55 86 8838-3303 (mobile).<BR><BR>Aviso: As informações contidas nesta mensagem são CONFIDENCIAIS, protegidas pelo sigilo legal, por direitos autorais e destinadas exclusivamente à pessoa ou organização para a qual a mensagem foi destinada.<BR>Warning: This message is meant only for the intended recipient of the transmission.
It is forbidden any unauthorized use, alteration, reproduction and distribution. If you are not the correct recipient, please notify us immediately by return e-mail and delete this message from your system.<BR><BR><cleu antes grav 13jan09.jpg><cleu e nene.jpg><cleu santada recorte.jpg><cleu panturrilhas.jpg><cleu palato.jpg>_______________________________________________<BR>Leish-l mailing list<BR><A href="http://us.mc634.mail.yahoo.com/mc/compose?to=Leish-l@lineu.icb.usp.br" target=_blank rel=nofollow ymailto="mailto:Leish-l@lineu.icb.usp.br">Leish-l@lineu.icb.usp.br</A><BR><A href="http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/leish-l" target=_blank rel=nofollow>http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/leish-l</A><U></U><U></U></SPAN></FONT></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><BR><BR clear=all><BR>-- <BR></SPAN></FONT><B><FONT face=Verdana><SPAN style="FONT-WEIGHT: bold; FONT-FAMILY: Verdana">Carlos H. N. Costa, MD, DSc.</SPAN></FONT></B><U></U><U></U></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><B><FONT face=Verdana size=3><SPAN style="FONT-WEIGHT: bold; FONT-SIZE: 12pt; FONT-FAMILY: Verdana">President</SPAN></FONT></B><U></U><U></U></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><B><FONT face=Verdana size=3><SPAN style="FONT-WEIGHT: bold; FONT-SIZE: 12pt; FONT-FAMILY: Verdana">Sociedade Brasileira de Medicina Tropical </SPAN></FONT></B><U></U><U></U></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><B><FONT face=Verdana size=3><SPAN style="FONT-WEIGHT: bold; FONT-SIZE: 12pt; FONT-FAMILY: Verdana">(Brazilian Society of Tropical Medicine)</SPAN></FONT></B><U></U><U></U></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><B><FONT face=Verdana size=3><SPAN style="FONT-WEIGHT: bold; FONT-SIZE: 12pt; FONT-FAMILY: Verdana">Instituto de Doenças Tropicais Natan Portella<BR>Universidade Federal do Piauí</SPAN></FONT></B><U></U><U></U></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><B><FONT face=Verdana size=3><SPAN style="FONT-WEIGHT: bold; FONT-SIZE: 12pt; FONT-FAMILY: Verdana">Rua Artur de Vasconcelos 151-Sul</SPAN></FONT></B><U></U><U></U></DIV></DIV>
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<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><B><FONT face=Verdana size=3><SPAN style="FONT-WEIGHT: bold; FONT-SIZE: 12pt; FONT-FAMILY: Verdana">64049-750 Teresina-PI<BR><U></U><U></U>Brazil<U></U><U></U><BR>Telephones: +55 86 3221-3413 (work); +55 86 8838-3303 (mobile).<BR></SPAN></FONT></B><FONT face=Verdana><SPAN style="FONT-FAMILY: Verdana"><BR></SPAN></FONT><FONT face=Verdana size=2><SPAN style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana">Aviso: As informações contidas nesta mensagem são CONFIDENCIAIS, protegidas pelo sigilo legal, por direitos autorais e destinadas exclusivamente à pessoa ou organização para a qual a mensagem foi destinada.<BR>Warning: This message is meant only for the intended recipient of the transmission. It is forbidden any unauthorized use, alteration, reproduction and distribution. If you are not the correct recipient, please notify us immediately by return e-mail and delete this message from your system.
</SPAN></FONT><U></U><U></U></DIV></DIV></DIV>
<DIV class=yiv1949286788MsoNormal style="FONT-SIZE: 12pt"><FONT face="Times New Roman" size=3><SPAN style="FONT-SIZE: 12pt"><U></U> <U></U></SPAN></FONT></DIV></DIV></DIV></DIV></DIV></DIV></BLOCKQUOTE></DIV><BR><BR clear=all><BR>-- <BR><FONT face="verdana, sans-serif"><B>Carlos H. N. Costa, MD, DSc.</B></FONT>
<DIV><FONT face="verdana, sans-serif"><B>President</B></FONT></DIV>
<DIV><SPAN style="FONT-FAMILY: verdana, sans-serif"><B>Sociedade Brasileira de Medicina Tropical </B></SPAN></DIV>
<DIV><B><SPAN style="FONT-FAMILY: verdana, sans-serif"></SPAN></B><SPAN style="FONT-FAMILY: verdana, sans-serif"><B>(Brazilian Society of Tropical Medicine)</B></SPAN></DIV>
<DIV><FONT face="verdana, sans-serif"><B>Instituto de Doenças Tropicais Natan Portella<BR>Universidade Federal do Piauí</B></FONT>
<DIV><FONT face="verdana, sans-serif"><B>Rua Artur de Vasconcelos 151-Sul</B></FONT></DIV>
<DIV><FONT face="verdana, sans-serif"><B>64049-750 Teresina-PI<BR>Brazil<BR>Telephones: +55 86 3221-3413 (work); +55 86 8838-3303 (mobile).<BR></B><BR><SPAN style="FONT-SIZE: x-small">Aviso: As informações contidas nesta mensagem são CONFIDENCIAIS, protegidas pelo sigilo legal, por direitos autorais e destinadas exclusivamente à pessoa ou organização para a qual a mensagem foi destinada.<BR>Warning: This message is meant only for the intended recipient of the transmission. It is forbidden any unauthorized use, alteration, reproduction and distribution. If you are not the correct recipient, please notify us immediately by return e-mail and delete this message from your system. </SPAN></FONT></DIV></DIV><BR>
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