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Johnson RJ. Post-cold war United Nations peacekeeping operations: a review of the case for a hybrid level 2+ medical treatment facility. DISASTER AND MILITARY MEDICINE 2015; 1:15. [PMID: 28265430 PMCID: PMC5329960 DOI: 10.1186/s40696-015-0006-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 06/25/2015] [Indexed: 11/10/2022]
Abstract
Post-Cold War, UN peacekeeping operations (UN PKOs) have become larger, more mobile, multi-faceted and conducted over vast areas of remote, rugged, and harsh geography. They have been increasingly involved in dangerous areas with ill-defined boundaries, simmering internecine armed conflict, and disregard on the part of some local parties for peacekeepers' security and role. Yet progressively there have been expectations of financial restraint and austerity. Additionally, UN PKOs have become more "robust," that is, engaged in preemptive, assertive operations. A statistically positive and significant relationship exists between missions' size, complexity, remoteness, and aggressive tenor and a higher probability of trauma or death, especially as a result of hostile actions or disease. Therefore, in the interest of "force protection" and optimizing operations, a key component of UN PKOs is health care and medical treatment. The expectation is that UN PKO medical support must conform to the general intent and structure of current UN PKOs to become more streamlined, portable, mobile, compartmentalized, and specialized, but also more varied and complex to address the medical aspects of these missions cost-efficiently. This article contends that establishing a hybrid level 2-a level 2 with level 3 modules and components (i.e., level 2+)-is a viable course of action when considering trends in the medical aspects of Post-Cold War UN PKOs. A level 2 medical treatment facility has the potential to provide needed forward mobile medical treatment, especially trauma care, for extended, complex, large-scale, and comprehensive UN PKOs. This is particularly the case for missions that include humanitarian outreach, preventive medicine, and psychiatry. The level 2 treatment facility is flexible enough to expand into a hybrid level 2+ with augmentation of modules based on changes in mission requirements and variation in medical aspects.
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Affiliation(s)
- Ralph Jay Johnson
- Bravo Branch, 1st BDE, 1 Southern Training Division, 75th Training Command, 10949 Aerospace Ave., Houston, TX 77034 USA
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Johnson RJ. A literature review of medical aspects of post-cold war UN peacekeeping operations: trends, lessons learnt, courses of action and recommendations. J ROY ARMY MED CORPS 2015; 162:250-5. [PMID: 26085654 DOI: 10.1136/jramc-2015-000421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/23/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Post-Cold War United Nations Peace Keeping Operations (UN PKOs) have been increasingly involved in dangerous areas with ill-defined boundaries, harsh and remote geographies, simmering internecine armed conflict and disregard on the part of some local parties for peacekeepers' security and role. In the interest of 'force protection' and optimising operations, a key component of UN PKOs is healthcare and medical treatment. The expectation is that UN PKO medical support will conform to the general intent and structure of UN PKOs. To do so requires effective policies and planning informed by a review of medical aspects crucial to UN PKOs. The intent of this article is to report on a review of principal medical aspects practical to post-Cold War UN PKOs. METHODS This review was assembled through a comprehensive, grounded, systematic iterative inquiry of open-source articles. RESULTS This inquiry revealed that the principal medical aspects in post-Cold War UN missions were the following: (1) the changed nature of UN PKOs, (2) new challenges in terms of proximity and distance to medical care, (3) expanded need for preventive medicine and disease contagion prevention and (4) increased propensity for psychological morbidity and need for intervention. CONCLUSIONS Post Cold War, the dramatically changed nature of UN PKOs has resulted in new challenges mainly in terms of medical logistics, preventive medicine and psychiatry. The changed nature of post-Cold War UN PKOs altered the character of medical support most notably regarding (1) a need for emphasis on immediate response proximate to medical events and rapid transport over long distances and traversing barriers to higher levels of care, (2) proactive contagion and hazard identification and prevention and (3) interventions designed to reduce psychological morbidity. Recommendations are offered about possible courses of action in terms of addressing trends found in identified medical aspects of PKOs.
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Manning JE, Satharath P, Gaywee J, Lopez MN, Lon C, Saunders DL. Fighting the good fight: the role of militaries in malaria elimination in Southeast Asia. Trends Parasitol 2014; 30:571-81. [PMID: 25455566 DOI: 10.1016/j.pt.2014.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/07/2014] [Accepted: 10/08/2014] [Indexed: 11/26/2022]
Abstract
Despite significant progress in malaria control in the Greater Mekong Subregion (GMS), malaria is still endemic, with more than 30 million people infected annually. Important gaps remain in case management, service delivery, prevention, and vector control, particularly in hard-to-reach mobile populations. Rapidly evolving drug resistance has created a new urgency to move aggressively toward elimination. However, no clear and cost-effective strategy has been identified. Although GMS militaries are under-recognized as a malaria transmission reservoir, they are an important focal point for elimination activities, given their high mobility, frequent malaria exposure, and potential for asymptomatic carriage. At the same time, military organizational capacity and proximity to other mobile populations could facilitate elimination efforts if relevant political barriers could be overcome. Here, we review considerations for military involvement in regional malaria elimination efforts.
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Affiliation(s)
- Jessica E Manning
- Department of Immunology and Medicine, US Army Medical Component, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | | | | | - Chanthap Lon
- Department of Immunology and Medicine, US Army Medical Component, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand; US Army Medical Component, Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | - David L Saunders
- Department of Immunology and Medicine, US Army Medical Component, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand.
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Wernsdorfer WH, Noedl H, Rendi-Wagner P, Kollaritsch H, Wiedermann G, Mikolasek A, Karbwang J, Na-Bangchang K. Gender-specific distribution of mefloquine in the blood following the administration of therapeutic doses. Malar J 2013; 12:443. [PMID: 24321055 PMCID: PMC3901017 DOI: 10.1186/1475-2875-12-443] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 12/05/2013] [Indexed: 11/16/2022] Open
Abstract
Background The objectives of the study were to elucidate the gender-specific distribution of mefloquine in cellular and fluid blood compartments when given at therapeutic dosage, to assess its correlation with the occurrence of treatment-related adverse events, and to explore the necessity of adjusting treatment guidelines for females. Methods The distribution of mefloquine following the administration of standard therapeutic doses (1,250 mg mefloquine in split dose) to 22 healthy Caucasian volunteers was assessed in whole blood, serum, plasma, red blood cells (RBCs), white blood cells, and platelets using high performance liquid chromatography. Results Plasma mefloquine concentrations after 14 hours were considerably higher in female subjects than in males (2,778 vs 1,017 ng/ml at H14), concordant with a significantly higher frequency, duration, and severity of adverse reactions. However, mean drug concentrations of RBC appeared slightly higher in male volunteers (857 vs 719 ng/ml). At H48, a similar situation prevailed, and at H168 the mefloquine concentrations in plasma continued to be higher in females compared to males (1,353 vs 666 ng/ml), while the concentrations of RBC were similar in females (389 vs 375 ng/ml). Since the observations relate to healthy individuals, they do not take into account selective uptake of mefloquine by Plasmodium-infected erythrocytes as in the case of therapeutic drug use. Conclusion Although plasma mefloquine concentrations in female healthy volunteers are considerably higher and the concentrations of the RBCs are initially lower compared to males, they do not seem to justify an adjustment of treatment guidelines for mefloquine in female Caucasian individuals.
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Affiliation(s)
| | | | | | | | | | | | | | - Kesara Na-Bangchang
- Chulabhorn International College of Medicine, Thammasat University, Rangsit Campus, Pathumthani, Thailand.
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Meltzer E, Artom G, Marva E, Assous MV, Rahav G, Schwartz E. Schistosomiasis among travelers: new aspects of an old disease. Emerg Infect Dis 2007; 12:1696-700. [PMID: 17283619 PMCID: PMC3372337 DOI: 10.3201/eid1211.060340] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Schistosomiasis is increasingly encountered among travelers returning from the tropics; signs and symptoms of travelers may differ from those of local populations. During 1993–2005, schistosomiasis was diagnosed in 137 Israeli travelers, most of whom were infected while in sub-Saharan Africa. Clinical findings compatible with acute schistosomiasis were recorded for 75 (66.4%) patients and included fever (71.3%), respiratory symptoms (42.9%), and cutaneous symptoms (45.2%). At time of physical examination, 42 patients (37.1%) still had symptoms of acute schistosomiasis, chronic schistosomiasis had developed in 23 (20.4%), and 48 (42.5%) were asymptomatic. Of patients who were initially asymptomatic, chronic schistosomiasis developed in 26%. Diagnosis was confirmed by serologic testing for 87.6% of patients, but schistosome ova were found in only 25.6%. We conclude that acute schistosomiasis is a major clinical problem among travelers, diagnostic and therapeutic options for acute schistosomiasis are limited, and asymptomatic travelers returning from schistosomiasis-endemic areas should be screened and treated.
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Affiliation(s)
- Eyal Meltzer
- The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galit Artom
- Maccabi Healthcare Services, Tel Aviv, Israel
| | - Esther Marva
- Central Laboratories Ministry of Health, Jerusalem, Israel
| | | | - Galia Rahav
- The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eli Schwartz
- The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Charles BG, Blomgren A, Nasveld PE, Kitchener SJ, Jensen A, Gregory RM, Robertson B, Harris IE, Reid MP, Edstein MD. Population pharmacokinetics of mefloquine in military personnel for prophylaxis against malaria infection during field deployment. Eur J Clin Pharmacol 2007; 63:271-8. [PMID: 17216435 DOI: 10.1007/s00228-006-0247-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Accepted: 11/29/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the population pharmacokinetics of mefloquine in healthy military personnel during prophylaxis for malaria infections. METHODS The subjects were 1,111 Australian soldiers participating in two studies: a randomised double-blinded study (group A, 161 subjects) and an open-label study (group B, 950 subjects). Following a loading dose (250 mg mefloquine base daily, 3 days), subjects received an oral weekly maintenance dose of 250 mg over 6 months. Blood was collected after the last split loading dose then at weeks 4, 8 and 16 for group A, and at weeks 13 and 26 for group B. Plasma mefloquine concentrations were measured by high-performance liquid chromatography (HPLC). Pharmacokinetic modelling was performed using NONMEM. RESULTS A two-compartment model with inter-occasion variability (IOV) for clearance satisfactorily described the pharmacokinetics. Typical values were clearance (CL/F, 2.09 l/h), central volume of distribution (V1/F, 528 l), absorption rate constant (KA, 0.24 h(-1)), inter-compartmental clearance (Q/F, 12.5 l/h), peripheral volume of distribution (V2/F, 483 l) and elimination half-life (t (1/2), 14.0 days). Weight had a positive influence on central volume but was insufficient to warrant dosage adjustments. The inter-individual variability (coefficient of variation, CV%) for CL/F and V1/F was 24.4% and 29.6%, respectively. The IOV for CL/F was 17.8%. The proportional residual error (CV%) for groups A and B was 11.5% and 19.5%, respectively, and the additive error standard deviation (SD) was 57 ng/ml and 149 ng/ml, respectively. CONCLUSION The typical parameter values were comparable with those estimated in much smaller cohorts of healthy subjects and in malaria patients treated with single-dose mefloquine. The lower unexplained variability in the blinded study suggested these subjects may have been more compliant in taking their medication than soldiers in the open-label study.
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Affiliation(s)
- B G Charles
- School of Pharmacy, The University of Queensland, Brisbane, 4072, QLD, Australia.
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Lessells R, Jones ME, Welsby PD. A malaria outbreak following a British military deployment to Sierra Leone. J Infect 2004; 48:209-10. [PMID: 14720499 DOI: 10.1016/j.jinf.2003.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Palmer CJ, Bonilla JA, Bruckner DA, Barnett ED, Miller NS, Haseeb MA, Masci JR, Stauffer WM. Multicenter study to evaluate the OptiMAL test for rapid diagnosis of malaria in U.S. hospitals. J Clin Microbiol 2004; 41:5178-82. [PMID: 14605156 PMCID: PMC262482 DOI: 10.1128/jcm.41.11.5178-5182.2003] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
More than 1,000 cases of malaria are diagnosed each year in the United States. Reported numbers, however, may be artificially low because many clinicians fail to consider the diagnosis on presentation, U.S. hospital laboratory technologists have very limited experience in detecting and identifying malaria parasites, and reporting of malaria to state health departments is sporadic in many states. In this study, a rapid malaria diagnostic test, the OptiMAL test (DiaMed; under license from Flow Inc., Portland, Oreg.) was evaluated in six U.S. hospitals and compared with results of microscopy. The OptiMAL test is a 15-min rapid immunochromatographic test that both identifies and differentiates Plasmodium falciparum from non-P. falciparum malaria parasites on the basis of the detection of parasite lactate dehydrogenase in a drop of patient blood. A total of 216 specimens from patients suspected of having malaria were tested. Results indicated that 43 samples (20%) were positive for malaria parasites by microscopy (32 P. falciparum, 11 non-P. falciparum) while 42 (19%) were positive by OptiMAL (31 P. falciparum, 11 non-P. falciparum). The sensitivity of the OptiMAL test was 98%; its specificity was 100%, with positive and negative predictive values of 100 and 99%, respectively. Participating hospital physicians and laboratory directors independently reported that the OptiMAL rapid malaria test was accurate, easy to use, and well accepted by those working in their diagnostic laboratories. The overall conclusion was that integration of the OptiMAL rapid malaria test into the U.S. health care infrastructure would provide an important and easy-to-use tool for the timely diagnosis of malaria.
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Stauffer W, Fischer PR. Diagnosis and Treatment of Malaria in Children. Clin Infect Dis 2003; 37:1340-8. [PMID: 14583868 DOI: 10.1086/379074] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2003] [Accepted: 07/09/2003] [Indexed: 11/03/2022] Open
Abstract
Malaria continues to be a problem for children returning or immigrating to industrialized countries from tropical regions. Proper diagnosis begins with clinical suspicion. In nonimmune children, malaria typically presents with high fever that might be accompanied by chills and headache. Symptoms and signs may be more subtle in partially immune children, and anemia and hepatosplenomegaly may also be present. Children may present with respiratory distress and/or rapidly progressing cerebral malaria that manifests as altered sensorium and, sometimes, seizures. Thick blood smears help to determine when infection is present, but a single smear without parasites is not sufficient to rule out malaria. Thin blood smears aid in identifying the species of parasite. Treatment must include careful supportive care, and intensive care measures should be available for treating children with complicated Plasmodium falciparum malaria. Medical regimens can include mefloquine, atovaquone-proguanil, sulfadoxine-pyrimethamine, quinine or quinidine, clindamycin, doxycycline, chloroquine, and primaquine.
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Affiliation(s)
- William Stauffer
- Division of Infectious Disease and International Medicine, Department of Medicine, University of Minnesota, St. Paul, MN, USA
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