No abstract

Background Malaria infection continues to be a major cause of human morbidity and mortality globally (1). Four main species of malaria commonly infect humans, of which two (Plasmodium falciparum and P. vivax) have reported effects on the nervous system (2, 3). A wide range of therapeutic agents are used to prevent and treat malaria, some of which have documented deleterious effects on the nervous system. It is often difficult to differentiate between the effects of malaria and the drugs on the nervous system. One of the difficulties of identifying effects of antimalarial drugs on the nervous system is that malaria itself may result in neurological impairment, cerebral malaria (CM) being the most common severe neurological complication. In adults, cerebral malaria is a diffuse encephalopathy in which focal neurological signs are relatively unusual (4). In African children growing up in malaria endemic areas, it manifests as seizures, impaired consciousness and metabolic acidosis presenting as respiratory distress or severe anemia (4). Compared with adults,

1. Kenyan children with uncomplicated malaria given oral halofantrine (HF; non‐micronised suspension; 8 mg base kg‐1 body weight 6 hourly for three doses) showed wide variation in the disposition of HF and desbutylhalofantrine (HFm). 2. Eight Kenyan children with severe (prostrate) falciparum malaria who were receiving intravenous quinine, were given the same HF regimen by nasogastric tube. One patient had undetectable HF and two had undetectable HFm at all times after drug administration. 3. The mean AUC(0,24 h) of HF in prostrate children was half (7.54 compared with 13.10 micrograms ml‐1 h) (P = 0.06), and that for HFm one‐third (0.84 compared with 2.51 micrograms ml‐1 h) (P < 0.05) of the value in children with uncomplicated malaria. 4. Oral HF may be appropriate for some cases of uncomplicated falciparum malaria in Africa, but in patients with severe malaria, the bioavailability of HF and HFm may be inadequate.

PurposeTo implement the research‐based Ottawa Ankle Rules in a district hospital and audit their impact on the number and appropriateness of X‐rays for ankle injuries in A&E.Design/methodology/approachThe method used was retrospective data collection, followed by education and prospective data collection on the management of subsequent ankle injuries. The computer records of the first 150 people presenting to A&E with ankle/foot injuries in one month were reviewed to determine whether the patient underwent an X‐ray, and what the results were. Every doctor working in A&E was then educated using a hand‐out giving the Ottawa Ankle Rules. The management of 150 people presenting with ankle/foot injuries in the month after this intervention was assessed.FindingsThere was a reduction in the number of patients receiving X‐rays (83/150 or 55 per cent versus 128/150 or 85 per cent pre‐intervention; p<<0.001). There was also an increase in the proportion of X‐rays showing fractures (17/83 or 20 per cent versus 16/128 or 12.5 per cent; difference not statistically significant).Research limitations/implicationsPossible to stimulate good practice with audit.Practical implicationsImprovement in practice stimulated by a motivated trainee doctor with appropriate support. Factors contributing to success discussed.Originality/valueEncouraging example of successful audit, of interest to those interested in using clinical audit to improve care.

gender was associated with lower need for support with anxiety (OR: 0.42; 95% CI: 0.20, 0.88). Older age was associated with increased needs for support managing pain (p¼0.02). Religiosity was protective regarding needs for support with sadness (OR: 0.41; 95% CI: 0.18, 0.94) and pain management (OR: 0.34; 95% CI: 0.15, 0.78). Conclusion. Adults with CF report significant unmet needs for support in a number of physical and emotional domains; many of these associations were associated with various sociodemographic characteristics, most notably, income.