Patients with EVD presented with evidence of dehydration associated with vomiting and severe diarrhea. Despite attempts at volume repletion, antimicrobial therapy, and limited laboratory services, the rate of death was 43%.

Background An outbreak of Marburg hemorrhagic fever was first observed in a gold-mining village in northeastern Democratic Republic of the Congo in October 1998.

The largest ever Ebola virus disease outbreak is ravaging West Africa. The constellation of little public health infrastructure, low levels of health literacy, limited acute care and infection prevention and control resources, densely populated areas, and a highly transmissible and lethal viral infection have led to thousands of confirmed, probable, or suspected cases thus far. Ebola virus disease is characterized by a febrile severe illness with profound gastrointestinal manifestations and is complicated by intravascular volume depletion, shock, profound electrolyte abnormalities, and organ dysfunction. Despite no proven Ebola virus-specific medical therapies, the potential effect of supportive care is great for a condition with high baseline mortality and one usually occurring in resource-constrained settings. With more personnel, basic monitoring, and supportive treatment, many of the sickest patients with Ebola virus disease do not need to die. Ebola virus disease represents an illness ready for a paradigm shift in care delivery and outcomes, and the profession of critical care medicine can and should be instrumental in helping this happen.

Following the appearance of influenza A/H5 virus infection in several wild and domestic bird species in the Republic of Azerbaijan in February 2006, two clusters of potential human avian influenza due to A/H5N1 (HAI) cases were detected and reported by the Ministry of Health (MoH) to the World Health Organization (WHO) Regional Office for Europe during the first two weeks of March 2006. On 15 March 2006, WHO led an international team, including infection control, clinical management, epidemiology, laboratory, and communications experts, to support the MoH in investigation and response activities. As a result of active surveillance, 22 individuals, including six deaths, were evaluated for HAI and associated risk infections in six districts. The investigations revealed eight cases with influenza A/H5N1 virus infection confirmed by a WHO Collaborating Centre for Influenza and one probable case for which samples were not available. The cases were in two unrelated clusters in Salyan (seven laboratory confirmed cases, including four deaths) and Tarter districts (one confirmed case and one probable case, both fatal). Close contact with and de-feathering of infected wild swans was considered to be the most plausible source of exposure to influenza A/H5N1 virus in the Salyan cluster, although difficulties in eliciting information were encountered during the investigation, because of the illegality of some of the activities that might have led to the exposures (hunting and trading in wild birds and their products). These cases constitute the first outbreak worldwide where wild birds were the most likely source of influenza A/H5N1 virus infection in humans. The rapid mobilisation of resources to contain the spread of influenza A/H5 in the two districts was achieved through collaboration between the MoH, WHO and its international partners. Control activities were supported by the establishment of a field laboratory with real-time polymerase chain reaction (RT-PCR) capacity to detect influenza A/H5 virus. Daily door-to-door surveillance undertaken in the two affected districts made it unlikely that human cases of influenza A/H5N1 virus infection remained undetected.

The objective of the present study was to describe day of onset and duration of symptoms of Marburg hemorrhagic fever (MHF), to summarize the treatments applied, and to assess the quality of clinical documentation. Surveillance and clinical records of 77 patients with MHF cases were reviewed. Initial symptoms included fever, headache, general pain, nausea, vomiting, and anorexia (median day of onset, day 1-2), followed by hemorrhagic manifestations (day 5-8+), and terminal symptoms included confusion, agitation, coma, anuria, and shock. Treatment in isolation wards was acceptable, but the quality of clinical documentation was unsatisfactory. Improved clinical documentation is necessary for a basic evaluation of supportive treatment.

SummaryWe have studied, over a wide range of dilutions using techniques of clot weight, thrombelastography and scanning electron microscopy, the physical properties of a blood clot formed in vitro when fresh blood was diluted with gelatinbased colloid solutions compared with crystalloid controls. The colloid solutions tested (3.5% polygeline (Haemaccel) and 4% succinylated gelatin (Gelofusine)) produced clots that had reduced median weight (P:0.001 and P:0.018, respectively) and reduced mean shear modulus (P:0.001) compared with crystalloid controls. Scanning electron microscopy showed that the fibrin formed a less extensive mesh in the presence of the gelatin-based colloids compared with crystalloid. Reduction in clot quality with gelatin-based colloids has not been noted previously and further work is needed to ascertain if this occurs in vivo as these solutions are used frequently in patients who require full haemostatic competence. (Br. J. Anaesth. 1998; 80: 204-207) Keywords: blood, coagulation; blood, colloids; fluids, i.v.; blood, haemostasis; blood, replacement; measurement techniques, thrombelastography Plasma substitutes containing degraded and modified gelatin are being used increasingly in prehospital, resuscitation, perioperative and intensive care situations. Often they are the fluid of choice in patients with uncontrolled haemorrhage both before blood transfusion and in conjunction with transfusion of packed cells. Unlike the dextran and starch solutions, so far they have been considered as having no significant effect on clotting mechanisms following studies based principally on clotting times. [1][2][3][4] While measuring whole blood coagulation times after in vitro dilution with colloids we noted a striking difference in clot quality compared with that seen with dilution using crystalloid. Our preliminary findings have been reported previously.5 In this article we describe more detailed investigations using clot weights, haematological analysis, thrombelastography and scanning electron microscopy, and include a description of the dose-response effect of varying degrees of dilution using regression analysis. Materials and methodsWherever fresh whole blood was used, care was taken to avoid prolonged venous stasis, venepuncture from the same site or delays in pipetting, and experiments were conducted under strict temperature control.CLOT WEIGHTS A total of 35 fresh whole blood samples were diluted to 15%, 30%, 45%, 60% and 75% with 0.9% sodium chloride and Ringer's solution (controls) or the test substances, 4% succinylated gelatin (Gelofusine, B. Braun (Medical) Ltd) and 3.5% polygeline solution (Haemaccel, Hoescht UK Ltd). After dividing each sample into test and control, the total volume of each sample after dilution was 5 ml. Clot weights were measured using the method described by Macfarlane.6 Because the clots would not adhere to a glass rod the test was modified by separating the clot from plasma on gauze in a funnel. Clots were weighed on an electronic balance and then examined physica...

This study showed that challenges for emergency medical response during the Haiti Earthquake involved issues of accountability, professional ethics, standards-of-care, unmet needs, patient agency and expected outcomes for patients in such settings:

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