Biomedical subjects
A M Croft
Publications and source records attributed to A M Croft.
[Cutaneous leishmaniasis following military deployment to Iraq].
Cutaneous leishmaniasis (CL) is a parasitic disease of the tropics and subtropics, transmitted by bites of infected female phlebotonine sandflies. Although CL lesions are normally self-healing they may be disfiguring or potentially disabling, and in field conditions may become secondarily infected; clinical intervention is appropriate in these circumstances. We describe two soldiers normally stationed in British Forces Germany who following deployment to Iraq presented with Leishmania tropica infection. The primary prevention of CL is discussed, together with the epidemiology of the disease, and its treatment under deployed conditions. Old World CL rarely requires aggressive antimonial terapy. Antiiosis with or without curettage is a simple, safe and effective field treatment.
Preventing injuries through redesigning military training programmes.
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Hospitalisation due to Lyme disease: case series in British Forces Germany.
Lyme disease is a tick-transmitted infection with disabling sequelae and important occupational health implications for a military workforce. It is likely that some military patients with typical clinical signs remain undiagnosed and untreated. Prompt treatment with an antibiotic is essential, besides targeted education on preventing infection through avoiding exposure to tick bites. We describe four British Forces Germany personnel (two serving military personnel, one adult civilian, one child) who during 2002--2003 required hospital inpatient treatment for Lyme disease. The epidemiology, pathogenesis, clinical features, diagnosis and treatment of the disease are discussed.
Smoking rates in the staff of a military field hospital before and after wartime deployment.
In the past, high rates of cigarette smoking have been reported in the British Armed Forces. We conducted an anonymous questionnaire survey in the 623 employees and attached staff of 34 Field Hospital on their sixth week of deployment to Iraq, in the course of Gulf War II. Information was sought on smoking status before and during the deployment, and self-declared reasons for smoking. 556 questionnaires were returned (response rate 89%). The median age of respondents was 33.3 SD 7.9 years (range 18-62) and 61% were male. Before deployment the number of regular smokers was 160 (29%) but it had now risen by 52 to 212 (38%). Of the extra smokers 33 were restarting an old habit but 19 were first-timers. Moreover, those who were regular smokers before deployment increased their daily consumption from a mean of 15 cigarettes to 21. Smoking rates did not differ between clinical and non-clinical staff or between men and women; the rates were lower in officers than in non-officers, and in reservists than in regular Army personnel. The reasons most commonly cited for starting smoking or increasing consumption were boredom, social factors and stress. Few respondents could recall having received smoking-related health education during previous service with the military. Smoking rates in this medical unit increased substantially during the overseas deployment. There were no data on cigarette consumption after return to ordinary duties, so we cannot say whether these effects are short-term or long-term. However, even the pre-existing rate of 42% in regular army personnel is high enough to demand urgent action by an employer.
Does military service damage females? An analysis of medical discharge data in the British armed forces.
There is anecdotal and some scientific evidence that females in military service experience an excess of work-related injuries, compared with males. To investigate this more fully, we analysed data collected routinely by the Defence Analytical Services Agency on medical discharges in male and female personnel in the British armed forces. We found that for all disease and injury categories of medical discharge there is a statistically significant excess in females; this disparity is particularly marked for discharges on account of injury [relative risk (RR) = 1.65, 95% confidence interval (95% CI) = 1.30-2.10] and musculoskeletal disease (RR = 3.34, 95% CI = 2.75-4.06). Royal Navy females are eight times more likely (RR = 7.92, 95% CI = 3.03-20.66) and Army females seven times more likely (RR = 6.53, 95% CI = 2.60-16.42) than Royal Air Force females to be medically discharged on account of injury. Over the period 1993-1996, there was a statistically significant increase in the rate of medical discharge for both musculoskeletal disease and injury in female personnel in the British armed forces. During the period 1996-2000, a marked gender differential was maintained, but the rate of increase in females reached a plateau. We concur with previous investigators that mixed-sex training imposes particular ergonomic stresses on females and that it is a major risk factor for overuse injury. We discuss other possible explanations for the marked gender differential in medical discharge rates in the military. Some changes to training programmes are now being introduced to correct this health inequality, but further interventions are needed. Modifications to training programmes must be audited systematically and candidate interventions tested through randomized controlled trials.
Developing evidence-based clinical guidelines for military use: case study of smoking cessation guidelines.
OBJECTIVE: To develop evidence-based clinical guidelines on smoking cessation, for use throughout the British military. METHOD: A ten-member, multiprofessional smoking cessation working group met five times between October 2000 and July 2001 to develop targeted smoking cessation guidelines for use by military health professionals in the clinical setting. The guidelines were based on the best available scientific evidence at that time, mainly systematic review of controlled trials, and individual randomised trials. RESULTS: The agreed military guidelines on smoking cessation were promulgated in July 2001. Three tiers of support were defined. Military health professionals have a key role as nonsmoking models and advocates, and should be trained to use 'brief intervention' at every clinical encounter with a military smoker. 'Intermediate support' (defined as a specialist service delivered by military health professionals who have undergone specific training and continuation training) is to be available at local level. The most heavily addicted military smokers will require referral to civilian smoking cessation clinics. Effective technologies for use at any one of the three levels of care are: nicotine skin patches, nicotine gum, nicotine lozenges and bupropion. CONCLUSIONS: These are the first ever clinical guidelines for military use which meet accepted modern quality criteria. Informal monitoring of the uptake of these guidelines between July 2001 to December 2001 suggests that they have been well received by military health professionals. An audit of their impact on smoking patterns within the UK Armed Forces will commence in 2002. The guidelines will be updated 5-yearly, or sooner.
Pityocampal erucism in a British serviceman in Croatia--a case report.
We present a case of erucism (caterpillar dermatitis) in a British serviceman deployed in Croatia on Operation Resolute. The aetiology, clinical features and diagnosis of erucism are discussed. Erucism should be highlighted as an environmental hazard in future troop deployments to the Mediterranean area.
The malaria threat.
The British experience of the past two decades indicates that fixed-schedule chemoprophylaxis is difficult because of the variety of epidemiological situations and increasing incidence of drug resistance. Of the 110 cases of malaria contracted in Kenya between 1982 and 1996, 74% were due to Plasmodium falciparum. Of the 45 malaria infections contracted in Belize, 84% were due to Plasmodium vivax. In 1985 the fixed drug combination of chloroquine base 300 mg weekly plus proguanil 200 mg daily was adopted as standard chemoprophylaxis for use in all parts of the world where chemoresistant Plasmodium falciparum had been observed. Mefloquine was recommended as first-line prophylaxis in Papua New Guinea in 1986 and in East Africa in 1993. Doxycycline hyclate was prescribed in September 1999 when a Gurkha company was deployed on peacekeeping duties to East Timor, but its effectiveness has not yet been evaluated. Chemoprophylaxis must be combined with non-drug antimalaria technologies, especially insecticide-treated bed nets.
An evidence-based vector control strategy for military deployments: the British Army experience.
We describe the British Army's current strategy for controlling arthropod vectors of disease during overseas deployments. Military commanders and medical officers have different, but complementary responsibilities in achieving vector control. In this paper we define a hierarchy of evidence-based vector control guidelines. Field guidelines must be based on the best available research evidence, preferably that derived from pragmatic randomised controlled trials (RCTs), and from systematic reviews of trials. Assessing the effectiveness of different vector control measures involves a trade-off between the relative benefits and harm of different technology options. There is compelling scientific evidence that bed nets and screens treated with a pyrethroid insecticide are highly effective in protecting against nocturnally active, anthropophilic arthropods (including ectoparasites), and will reduce the incidence of malaria, leishmaniasis, lymphatic filariasis and Chagas' disease. Etofenprox and deltamethrin are the safest pyrethroids, and permethrin the least safe. Vector control strategies of probable effectiveness are the use of insecticide-treated clothing, the wearing of protective clothing, and the correct use of DEET-based topical insect repellents. Aerosol insecticides are of debatable effectiveness. Other effective vector control measures, of limited usefulness during deployments, include electric fans, mosquito coils/vaporising mats, and smoke. "Biological" vector control measures, and insect buzzers/electrocuters are ineffective. Practical insect avoidance measures, based on an understanding of vector biology, complete the military vector-control arsenal. We conclude that practical insect avoidance measures, combined with pyrethroid-treated nets and clothing, and DEET-based topical repellents, can achieve almost 100% protection against biting arthropods.
Mefloquine for preventing malaria in non-immune adult travellers.
OBJECTIVES: Mefloquine has now largely replaced earlier malaria prophylaxis drugs which are no longer considered to be effective against all Plasmodium species, due to parasite resistance. However mefloquine may be associated with neuropsychological harmful effects. The objective of this review was to assess the effects of mefloquine in adult travellers. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group trials register, Medline, Embase, Lilacs, Science Citation Index and reference lists of articles. We contacted researchers in the subject of malaria chemoprophylaxis, and drug companies. SELECTION CRITERIA: Randomised trials comparing mefloquine with other standard prophylaxis or placebo in non-immune adult travellers. DATA COLLECTION AND ANALYSIS: The two reviewers independently assessed trial quality and extracted data. Study authors were also contacted. MAIN RESULTS: Ten trials involving 2750 non-immune adult travellers were included. One trial comparing mefloquine with placebo showed mefloquine prevented malaria episodes in an area of drug resistance (odds ratio 0.04, 95% confidence interval 0.02 to 0.08). Withdrawals in the mefloquine group were consistently higher in four placebo controlled trials (odds ratio 3. 56, 95% confidence interval 1.67 to 7.60). In five trials comparing mefloquine with other chemoprophylaxis, no difference in tolerability was detected. REVIEWER'S CONCLUSIONS: Mefloquine prevents malaria, but there is not enough evidence to evaluate its tolerability and toxicity, particularly for general travellers.
Prophylaxis against malaria. More studies of mefloquine prophylaxis must be done in tourists.
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Dermatological adverse effects with the antimalarial drug mefloquine: a review of 74 published case reports.
Mefloquine is a relatively new antimalarial drug which has been associated with a wide variety of adverse effects, including skin reactions. In order to evaluate the range and frequency of mefloquine's dermatological effects, we searched the scientific literature for published case reports of such effects. We found 74 case reports, published between the years 1983 and 1997. Pruritus and maculopapular rash are the dermatological effects most commonly associated with mefloquine: their approximate frequency is 4-10% for pruritus, and up to 30% for nonspecific maculopapular rash. Adverse effects associated less commonly with mefloquine include urticaria, facial lesions and cutaneous vasculitis. One case of Stevens-Johnson syndrome and one fatal case of toxic epidermal necrolysis occurred. Appropriate primary studies of mefloquine use should be carried out to elucidate the epidemiology and aetiology of dermatological and other adverse effects of the drug.
Epidemiology of malaria in the British Army from 1982-1996.
An epidemiological review was carried out of all known cases of malaria involving British soldiers between 1982-1996. Hospital records of 213 confirmed cases of malaria were obtained from the Defence Analytical Services Agency (DASA). More than half of the infections (52%) occurred as a result of military training in Kenya and 74% of these were due to Plasmodium falciparum which is potentially life-threatening. Mefloquine has been used as chemoprophylaxis by the British Army in Kenya since 1993 and the implications of this are discussed. There were no deaths in the series but malaria nevertheless remains a serious threat to the health of the British Soldier. The importance of adherence to chemoprophylaxis and of simple bite avoidance measures must continue to be emphasised.
Handsearching the Journal of the Royal Army Medical Corps for trials.
As part of the Cochrane Collaboration's international research endeavour, the authors carried out a handsearch of the RAMC Journal from 1948 to 1998, searching for randomised controlled trials (RCTs) and controlled clinical trials (CCTs). Ten trials were identified, of which 6 were RCTs and 4 were CCTs. The first trial was published in 1967. Four of the 10 identified trials were in the field of respiratory medicine, and 2 were in obstetrics and gynaecology. Of the 10 trials, only 3 had been found through a rigorous interrogation of Medline. The 7 newly identified trials were reported to the UK Cochrane Centre, and summary details of these trials were entered into Medline for use by clinicians and investigators in the future.
World Health Organization "Roll Back Malaria" Campaign--report on a visit to the Central Drug Research Institute, Lucknow, India.
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Hospitalization of British troops during Operation Joint Endeavor (Bosnia).
Of 414 recorded hospitalizations among British troops during Operation Joint Endeavor (Bosnia) in 1996, 2% were attributable to battle injuries, 46% to routine injuries, and 52% to disease; most injuries were to the lower limbs, and most diseases were of the skin and musculoskeletal system. The median length of inpatient stay was 4 days for injury (range, 1-146 days) and 3 days for disease (range, 1-60 days). Correcting for uncaptured data, the number of hospitalizations attributable to both injury and disease was significantly lower than the number predicted from the NATO planning figures (p < 0.0001). The NATO planning estimates for expected hospitalizations need to be revised. The electronic recording at source of all patient information should be introduced during military deployments to optimize data capture, facilitate the audit of clinical activity, and inform future medical planning. All hospitalizations occurring during military missions should be recorded, and surgical interventions during deployments should be coded at source. Ineffective paper-based morbidity surveillance procedures such as Jefferson 97 (or J97) must be discontinued and replaced by an electronic, fully integrated, NATO-wide clinical information system. This clinical information system should encompass primary care, secondary care, medical training, and medical supply. It should be built on a Microsoft Office platform and should be capable of interfacing electronically with existing civilian databases. Important clinical outcomes should be structured hierarchically within the data set. The database should be configured so that it can be accessed locally by clinicians and remotely by epidemiologists and planners.
A strategic approach to implementing clinical governance.
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