About 40% of the world’s population is at risk of malaria, which kills one child in Africa every 30 seconds. However, malaria chemoprophylaxis has received some bad press lately, with international reports of neuropsychiatric problems in soldiers taking mefloquine (itself a product of US Army research). Where does the truth lie? For the inside story on the Australian military experience, turn to the article by Kitchener et al (→ Mefloquine and doxycycline malaria prophylaxis in Australian soldiers in East Timor). Their report of the side effect profile of mefloquine in about a thousand soldiers deployed to East Timor is one of the largest available. Adverse events in some soldiers taking mefloquine were also compared with those in others taking doxycycline.
McCarthy’s editorial puts this in the context of the general literature on mefloquine, describes alternatives for prophylaxis, and reminds us that malaria can have disabling, if not downright deadly, consequences (→ Malaria chemoprophylaxis in war and peace).
On this note, Howden and colleagues describe the detective work involved in diagnosing Plasmodium falciparum infection years after a patient had left a malarious area (→ Chronic falciparum malaria causing massive splenomegaly 9 years after leaving an endemic area). This is the most deadly (and increasingly resistant) type of infection, and appears to be on the rise in cases "imported" to Western Australia, say Charles et al (→ Notifications of imported malaria in Western Australia, 1990-2001: incidence, associated factors and chemoprophylaxis).
So, what’s new in the war against malaria? We can now treat malaria with the artemisinin group of drugs, derived from a plant used in China for centuries to treat fever. Davis and colleagues tell us why artemisinin-based combination therapy is now the WHO-preferred choice for all areas where P. falciparum is the dominant malarial species (→ Artemisinin-based combination therapies for uncomplicated malaria).
Name a town with few GPs per population and difficulty attracting more — London doesn’t usually spring to mind. However, says Jamrozik et al’s Postcard from the UK, metropolitan medicine in the UK is just Australian rural health turned upside-down. The problems are similar and, they argue, so are the solutions (→ Rural health turned upside-down).
Dowton and colleagues turn the tables yet again by suggesting that we might learn from other countries (including the UK) when it comes to our fragmented system of postgraduate medical education. They describe overseas models that show how we can aim for a more coordinated, better-governed system (→ Postgraduate medical education: rethinking and integrating a complex landscape).
The stroke team
For the small hospital without enough resources to set up a stroke unit, a mobile stroke service might be the answer. That’s the message from van der Walt and colleagues, who found that such a service significantly improved their care of patients with stroke (→ Quality of stroke care within a hospital: effects of a mobile stroke service).
Sounding out DVTs
Nearly 6000 patients undergoing total hip or knee replacements at a Sydney hospital had ultrasound imaging of both legs before discharge. O'Reilly et al report that the prevalence of DVT in these patients ranged from 9% to 37%, despite short-term thromboprophylaxis (→ The prevalence of venous thromboembolism after hip and knee replacement surgery).
Gallus’s editorial discusses the reliability of ultrasonography in detecting DVT, the evidence for pre-discharge screening, and whether we should actually be focusing more on extended prophylaxis (→ Screening for venous thrombosis by ultrasonography before hospital discharge after major joint surgery).
As promised, our MJA Practice Essentials — Paediatrics series is sticking closely to its practical mandate. With a state-of-the-art article on bedwetting and other problems of urinary incontinence in children, Caldwell et al prove that it’s possible to be both down to earth and scientific (→ 4. Bedwetting and toileting problems in children). Look out for a continuation of the toileting theme in the next issue . . .
Learning from experience
Metabolic imaging with PET scans is of limited use without more detailed anatomical scans. New scanners incorporating PET and CT scans are now available, and Lau et al discuss the pros and cons of these scanners, based on their own experience with over 5500 such scans (→ Clinical experience with the first combined positron emission tomography/computed tomography scanner in Australia).
After the recall of rofecoxib last year, the MJA published an editorial on the safety of COX-2-selective drugs (→ Langton et al, Med J Aust 2004; 181: 524-525). Follow the ensuing debate among our readers in Matters Arising.
Another time ... another place
Now there follows the treatment of fevers, a class of disease which both affects the body as a whole, and is exceedingly common. Of fevers, one is quotidian, another tertian, a third quartan.
Aulus Aurelius Cornelius Celsus, 25BC–AD50