Cutaneous ulcers in a returning traveller: a rare case of imported diphtheria in the UK.

We describe a case of cutaneous diphtheria in the UK, presenting as lower leg ulcers in a returning traveller, and discuss the epidemiology, significance and public health implications of this disease and the therapeutic options available. A 65-year-old woman presented with a 6-week history of multiple ulcers appearing on her legs following a holiday in Kenya. Culture of biopsy tissue grew Corynebacterium diphtheriae. A cascade of therapeutic and public health interventions followed, many of which were terminated once the isolate was confirmed as nontoxigenic. Cutaneous diphtheria is a rare, notifiable disease in the UK, but is common in tropical countries, and is most often seen in the West as a traveller's disease. Corynebacteria are common skin commensals, and without appropriate clinical details, laboratories may not recognize C. diphtheriae/Corynebacterium ulcerans. This is likely to have led to under-reporting and under-recognition of the condition.

To refer or not to refer: a qualitative study of reasons for referral from Role 1.

OBJECTIVES: There are currently over 9000 British soldiers serving in Afghanistan. The Defence Medical Services provide primary health care to soldiers at forward locations using Regimental Medical Officers (RMOs) and General Duties Medical Officers (GDMOs). If required, GDMOs can refer patients to senior colleagues. Currently, little is known about the reasons for referrals by GDMOs. This study aims to identify the main factors affecting why GDMOs refer from forward locations. METHODS: Nine GDMOs, who deployed on Operation HERRICK 13, were invited to join the study. They maintained a log of their referrals for two 14 day periods, one in each half of their tour. In addition, a semi-structured interview was performed with each GDMO in order to elicit the common themes surrounding referrals. RESULTS: The mean referral rate was 0.9 referrals/GDMO/week. The main reasons for referral were dental problems, musculoskeletal injuries, abdominal pain of unknown cause, and ano-genital problems. Factors that influenced referrals included availability of forwardly projected services (dentist and physiotherapist), manpower availability at the locations, the availability of flights (affected by weather, enemy action, and schedule of routine flights), and the timing of the tour in relation to leave. CONCLUSIONS: Referrals from GDMOs were due to doctor inexperience in the treatment of a particular condition, lack of access to investigations and the potential for deterioration in a location without adequate support. The referral decision process was affected by the patient's importance with regards to the mission, the weather and access to safe transportation. The introduction of clinical guidelines for common conditions in conjunction with minor alterations to GDMO training could help reduce referrals from Role 1, preserving manpower, reducing costs, and minimising risk to evacuation aircraft.

Contact irritant dermatitis in Kenya.

Kenya is one of the British Army's main training areas outside of the UK and the flora and fauna present the physicians with several challenges. A 22 year old infantry soldier presented with a vesicular, linear painful rash across his chest caused by the chemical excreted from the Staphylinid or rove beetle, known locally as the Nairobi fly. Treatment included topical antibiotic and steroid creams to good effect. This report highlights the recognition, treatment and complications of the Nairobi Fly.

Dermatology on Operation HERRICK.

OBJECTIVES: To identify the dermatological conditions affecting British troops in Afghanistan, understand how they are treated and identify potential areas for improvement. METHODS: Data was collected from the Defence Analytical Services and Advice agency and the Operational Emergency Department Attendance Register via the Disease and Non Battle Injury working group. Additional data was collected from J4 - Medical Permanent Joint Headquarters. Treatment information from Clinical Guidelines on Operations (CGOs), Medics' protocols, and primary care module composition was reviewed. RESULTS: Dermatological conditions accounted for 1 in 5 attendances to a Role 1 Medical Treatment Facility during the study period. They were consistently in the top five reasons for working days lost, and had a comparatively high hospital admission rate (0.3/1000 Population at Risk (PAR)/month) and a repatriation rate similar to other medical specialties such as respiratory and neurology (0.1/1000 PAR/month). Treatment appeared to be adequate based on declining return attendance numbers, although CGOs were found to lack dermatological protocols and medic protocols were eight years old and not specific to the current operational requirements. CONCLUSIONS: Although treatments are working for dermatological conditions, areas for optimisation of health care have been identified, such as updating medic protocols to include campaign specific information and latest guidelines in the CGOs. Pre-deployment dermatologist-devised treatment plans and tele-consults may also help keep soldiers with pre-existing skin complaints in theatre.

Op HERRICK primary care casualties: the forgotten many.

OBJECTIVE: The number of battle casualties generated during war is far outnumbered by non-battle casualties. Each year the current conflict in Afghanistan sees hundreds of service personnel medically evacuated direct from the front line to the care of their home units' primary care facility. To date these casualties remain undiscovered by medical research. This is the first study to look at the care pathway of primary care casualties from Operation HERRICK using information from the Defence Patient Tracking System (DPTS). METHODS: Information relating to all casualties from Afghanistan discharged at the airhead between 1 January 2009 and 31 December 2010 was collected from the DPTS. Common conditions were identified and information relating to the follow up care extracted to provide an overview of the care pathway. RESULTS: 387 aeromedical evacuations were identified as primary care casualties. The three commonest conditions were musculoskeletal (183 cases), mental health (29) and noise-induced hearing loss (26). 205 (53%) were not seen outside of primary care for the tracked condition. 166 (81%) of those that remained under primary care had two or less consultations during the time period of the study. The mean time frame between the 1st and 2nd consultation was 5.4 weeks. CONCLUSIONS: A significant number of aeromedical evacuations from Afghanistan are for primary care casualties. The DPTS can be used to provide a basic overview of the care pathway of repatriated personnel. Little contact with the medical services would appear to occur for these types of casualties. There is a significant gap in military medical research looking at primary care casualties repatriated from operations.

Colon and rectal cancer in the young adult.

801 patients with colon and rectal cancer were studied to assess the behavior of this cancer in the patient under 40 years of age as contrasted to the more commonly seen older patient. The younger patient had a greater frequency of advanced signs, later stages of cancer and mucoid carcinoma. However, when compared by clinical staging, the younger patient did as well or better than his older counterpart. Clinical staging was the most important prognostic factor irrespective of age. No inherent difference was found in the virulence of the cancer in the young, as the five-year survival in the younger patient (31 percent) was essentially the same as in the older patient (32 percent).