A feature of malaria in pregnancy is accumulation of P. falciparum-infected erythrocytes (IEs) in the placenta, which is associated with adverse outcomes for mothers and infants. Infection appears to involve parasite adhesion to molecules such as chondroitin sulfate A, hyaluronic acid, and immunoglobulins. In vitro, adhesion is predominantly a property of mature asexual forms of IEs; however, adhesion of immature or ring forms has recently been reported. We have assessed the parasitemia and developmental stages of IEs in the placenta by examination of placental blood and histological sections with comparison to parasites in the peripheral blood from the same individuals. Approximately 90% of IEs in the placenta were mature forms. Compared to peripheral blood, the placental parasitemia was 10-fold higher and the density of mature IEs was over 200-fold higher. By contrast, the average peripheral and placental ring-stage parasitemias were not significantly different. In 2 of 14 cases, the density of ring forms was higher in placental than in peripheral blood. These findings demonstrate prominent selective accumulation of mature asexual-stage IEs but infrequent accumulation of ring stages in the placental blood spaces, consistent with an important role for mature-stage IE adhesion.
Objective Head injury is a common presentation to the emergency department yet adherence to guidelines for management is suboptimal. Our study assesses adherence to National Institute for Health and Care Excellence (NICE) computed tomography (CT) head guidelines at a teaching hospital in the United Kingdom. It critically evaluates the efficacy of interventions. Methods We performed a quality improvement project to improve adherence to NICE CT head scan guidelines following head injury. Data was collected over one-month in 2014, and 2017. Interventions included education of the multidisciplinary team, information sheets, team engagement and tri-annual education sessions for junior doctors. The success of these interventions in the adult population was assessed objectively during the second cycle and subjectively via a junior doctor survey. Results 171 patients were included in the study. Following interventions, there was a statistically significant decrease of 23% in the number of CT heads requested with no clear indication (P=0.00027). The mean time to scan for the one-hour indications decreased from 73 to 55 minutes. The mean time to report all scans decreased from 89 to 57 minutes. The survey results were encouraging. Conclusion Adherence to NICE guidelines for head injury is inadequate but can be improved by interventions.
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