Malaria in British military personnel deployed to Sierra Leone: a case series.

From December 2014 to April 2015, seven cases of malaria were seen in 1530 military personnel deployed to Sierra Leone on Operation GRITROCK in response to the West African Ebola outbreak, despite predeployment briefings, prescription of chemoprophylactic agents and bite prevention measures. The cases have prompted discussion regarding the efficacy of current measures and how to prevent future cases in deployed military personnel or more widely, those working in malaria-risk environments. All of the cases have made a full recovery and returned to work. We discuss what can be learnt concerning the choice of chemoprophylactic agent and whether anything further be added to standard operating procedures regarding bite prevention and treatment of cases.

Anti-malarial chemoprophylaxis following evacuation from Afghanistan.

UK forces deployed to Afghanistan between March and November are prescribed anti-malarial chemoprophylaxis (AMC). In 2007 an audit showed poor pre-injury AMC compliance and a prescription rate of 50% amongst those casualties evacuated to Role 4. We re-audited the post-deployment AMC prescribing practice for casualties from Afghanistan for the 2008 and half of the 2009 malaria season. Using the Role 4 prescribing information and communication system (PICS), a retrospective AMC search for Proguanil, Chloroquine, Doxycycline, Mefloquine and Malarone was performed on these casualties. Only five out of 305 (1.64%) inpatients were prescribed appropriate post-deployment AMC medication. Awareness of the need to prescribe AMC following evacuation remains poor, and may be improved by recording AMC compliance in field medical records and modifying the PICS software.

Plasmodium knowlesi malaria: assessing the risk to the British Armed Forces.

Plasmodium knowlesi is a zoonosis and is now recognised as the fifth commonly occurring form of human malaria. It is endemic in South East Asia, including some areas previously declared malaria free or at low risk for malaria. The epidemiology of the disease is very different to other forms of malaria which are determined by transmission by anthrophilic mosquitoes from human reservoirs. In contrast Plasmodium knowlesi malaria has a monkey reservoir and disease is transmitted to humans by mosquitoes that normally feed on animals. People become accidentally infected when they enter the ranges of the vector mosquitoes and animal hosts. Improved and novel diagnostic methods have indicated that human disease is much more common than previously thought. Although the greatest disease burden falls on local populations living in endemic areas, visitors entering such zones are also at risk. The changing nature of tourism with deep jungle expeditions being more heavily marketed, and short visits to endemic zones now common, mean that new populations are increasingly recognised as being at risk. One such group are military personnel undergoing jungle training or deployed on Operations. The potential for severe disease in areas previously considered at low risk for malaria means that risk assessment needs to be reviewed, coupled with communication strategies to address prevention of a zoonotic form of the disease. The role of chemoprophylaxis in some specific groups may need to be considered.

The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial.

OBJECTIVES: To test the hypothesis that nurse led follow-up programmes are effective and cost effective in improving quality of life after discharge from intensive care. DESIGN: A pragmatic, non-blinded, multicentre, randomised controlled trial. SETTING: Three UK hospitals (two teaching hospitals and one district general hospital). PARTICIPANTS: 286 patients aged >or=18 years were recruited after discharge from intensive care between September 2006 and October 2007. INTERVENTION: Nurse led intensive care follow-up programmes versus standard care. Main outcome measure(s) Health related quality of life (measured with the SF-36 questionnaire) at 12 months after randomisation. A cost effectiveness analysis was also performed. RESULTS: 286 patients were recruited and 192 completed one year follow-up. At 12 months, there was no evidence of a difference in the SF-36 physical component score (mean 42.0 (SD 10.6) v 40.8 (SD 11.9), effect size 1.1 (95% CI -1.9 to 4.2), P=0.46) or the SF-36 mental component score (effect size 0.4 (-3.0 to 3.7), P=0.83). There were no statistically significant differences in secondary outcomes or subgroup analyses. Follow-up programmes were significantly more costly than standard care and are unlikely to be considered cost effective. CONCLUSIONS: A nurse led intensive care follow-up programme showed no evidence of being effective or cost effective in improving patients' quality of life in the year after discharge from intensive care. Further work should focus on the roles of early physical rehabilitation, delirium, cognitive dysfunction, and relatives in recovery from critical illness. Intensive care units should review their follow-up programmes in light of these results. TRIAL REGISTRATION: ISRCTN 24294750.

Fas and Fas ligand messenger ribonucleic acid and protein expression in the rat corpus luteum during apoptosis-mediated luteolysis.

Apoptosis has been found to occur during regression of the corpus luteum (CL) in many species. The Fas (APO-1/CD95) receptor, a transmembrane protein that induces apoptosis in the cell when bound to Fas ligand (FasL), may be involved. This study established and quantitated the presence and regulation of Fas receptor and FasL in the rat CL during pregnancy and postpartum. Using immunohistochemistry, FasL was localized in CL during pregnancy and postpartum. Fas was localized at Day 1 of pregnancy and at the time of luteolysis. Both Fas and FasL mRNA were found to be expressed throughout pregnancy and postpartum using reverse transcription-polymerase chain reaction (RT-PCR). Relative quantitative RT-PCR established that expression of FasL mRNA increased significantly at Day 22 of pregnancy and decreased by Day 3 postpartum. Spontaneous apoptosis of rat CL placed in an in vitro culture model with serum-free medium was examined by analysis of extracted DNA using 3' end-labeling. Treatment with an anti-rat Fas monoclonal antibody demonstrated a reduction in the occurrence of spontaneous apoptosis. These data support a role for Fas receptor and FasL in rat CL apoptosis during luteolysis.

The ideal compliance world: integrating physicians into the compliance program.

Compliance officers are in a unique position to provide guidance to physicians and will succeed in gaining physician support and buy-in when appropriate steps are taken to integrate physicians into the compliance program. First and foremost, the compliance officer's primary responsibility is to apprise physicians of the seriousness nature of current compliance issues. When physicians are provided with clear information through a variety of media, they will understand that compliance program goals and objectives will resolve compliance-related issues dilemmas. Next, the compliance officer should expect no less than the ideal compliance world. Recruit physician champions who will actively participate in compliance program planning and development. Call upon medical staff members to get involved in implementation stages of compliance action plans and engage physician leaders to educate and train their physician peers on compliance-related issues. Most importantly, minimize individual physician liability by providing adequate education programs to physicians. Help them to master the art of coding and documentation and to mitigate any prospect of fraud and abuse or compliance-related concerns. Last, collaboration is the key--the compliance officer must provide guidance to the physician so that the physician may continue to fulfill the role of leader and healer. In turn, the physician must recognize that his or her actions and those of the hospital and system are inseparable and that they must actively participate in compliance program initiatives.