Background. Dengue outbreaks are occurring with increasing frequency and intensity. Evidence-based epidemic preparedness and effective response are now a matter of urgency. Therefore, we have analysed national and municipal dengue outbreak response plans. Methods. Thirteen country plans from Asia, Latin America and Australia, and one international plan were obtained from the World Health Organization. The information was transferred to a data analysis matrix where information was extracted according to predefined and emerging themes and analysed for scope, inconsistencies, omissions, and usefulness. Findings. Outbreak response planning currently has a considerable number of flaws. Outbreak governance was weak with a lack of clarity of stakeholder roles. Late timing of responses due to poor surveillance, a lack of combining routine data with additional alerts, and lack of triggers for initiating the response weakened the functionality of plans. Frequently an outbreak was not defined, and early response mechanisms based on alert signals were neglected. There was a distinct lack of consideration of contextual influences which can affect how an outbreak detection and response is managed. Conclusion. A model contingency plan for dengue outbreak prediction, detection, and response may help national disease control authorities to develop their own more detailed and functional context specific plans.
Left ventricular outflow tract obstruction (LVOTO) is a common cardiogenic shock (CS) mimic. We present 3 cases of patients presenting with CS following myocardial infarction, exhibiting a poor response to conventional treatment with inotropy and mechanical circulatory support. This triggered echocardiographic assessment by critical care physicians using focused 2-dimensional (2D) echocardiography. This timely assessment identified anterior mitral valve leaflet entrainment into the left ventricular outflow tract (LVOT), causing LVOTO as the underlying shock mechanism. Echocardiographic findings have led to significant changes in management. The patients underwent fluid administration, weaning from inotropy, and mechanical circulatory support explantation, leading to relief of LVOTO and improved hemodynamics. Critical care basic 2D echocardiography accreditations focus on myocardial function and pericardial effusions. Relevant societies administering these accreditations should consider adding LVOT assessment to enable timely diagnosis of this life-threatening CS mimic.
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