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Clinical Presentation and Management of Severe Ebola Virus Disease.

Clinicians caring for patients infected with Ebola virus must be familiar not only with screening and infection control measures, but also with management of severe disease.

By integrating experience from several Ebola epidemics with best practices for managing critical illness, this report focuses on the clinical presentation and management of severely ill infants, children, and adults with Ebola virus disease. Fever, fatigue, vomiting, diarrhea, and anorexia are the most common symptoms of the 2014 West African outbreak. Profound fluid losses from the gastrointestinal tract result in volume depletion, metabolic abnormalities (including hyponatremia, hypokalemia, and hypocalcemia), shock, and organ failure. Overt hemorrhage occurs rarely. The case fatality rate in West Africa is at least 70% and individuals with respiratory, neurological, or hemorrhagic symptoms have a higher risk of death.

There is no proven anti-viral agent to treat Ebola virus disease, although several experimental treatments may be considered. Even in the absence of anti-viral therapies, intensive supportive care has the potential to markedly blunt the high case fatality rate reported to date. Optimal treatment requires conscientious correction of fluid and electrolyte losses. Additional management considerations include searching for co-infection or superinfection, treatment of shock (with intravenous fluids and vasoactive agents), acute kidney injury (with renal replacement therapy), and respiratory failure (with invasive mechanical ventilation), provision of nutrition support, pain and anxiety control, psychosocial support, and use of strategies to reduce complications of critical illness. Cardiopulmonary resuscitation may be appropriate in certain circumstances but extracorporeal life support is not indicated.

Among other ethical issues, patients' medical needs must be carefully weighed against healthcare worker safety and infection control concerns. However, meticulous attention to use of personal protective equipment and strict adherence to infection control protocols should permit the safe provision of intensive treatment to severely ill patients with Ebola virus disease.

Clinical Presentation of Patients with Ebola Virus Disease in Conakry, Guinea.

In March 2014, the World Health Organization was notified of an outbreak of Zaire ebolavirus in a remote area of Guinea. The outbreak then spread to the capital, Conakry, and to neighboring countries and has subsequently become the largest epidemic of Ebola virus disease (EVD) to date.

Methods From March 25 to April 26, 2014, we performed a study of all patients with laboratory-confirmed EVD in Conakry. Mortality was the primary outcome. Secondary outcomes included patient characteristics, complications, treatments, and comparisons between survivors and nonsurvivors.

Results Of 80 patients who presented with symptoms, 37 had laboratory-confirmed EVD. Among confirmed cases, the median age was 38 years (interquartile range, 28 to 46), 24 patients (65%) were men, and 14 (38%) were health care workers; among the health care workers, nosocomial transmission was implicated in 12 patients (32%). Patients with confirmed EVD presented to the hospital a median of 5 days (interquartile range, 3 to 7) after the onset of symptoms, most commonly with fever (in 84% of the patients; mean temperature, 38.6°C), fatigue (in 65%), diarrhea (in 62%), and tachycardia (mean heart rate, >93 beats per minute). Of these patients, 28 (76%) were treated with intravenous fluids and 37 (100%) with antibiotics. Sixteen patients (43%) died, with a median time from symptom onset to death of 8 days (interquartile range, 7 to 11). Patients who were 40 years of age or older, as compared with those under the age of 40 years, had a relative risk of death of 3.49 (95% confidence interval, 1.42 to 8.59; P=0.007).

Conclusions 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%.

Ebola Virus Disease in West Africa - Clinical Manifestations and Management.

In resource-limited areas, isolation of the sick from the population at large has been the cornerstone of control of Ebola virus disease (EVD) since the virus was discovered in 1976.(1) Although this strategy by itself may be effective in controlling small outbreaks in remote settings, it has offered little hope to infected people and their families in the absence of medical care. In the current West African outbreak, infection control and clinical management efforts are necessarily being implemented on a larger scale than in any previous outbreak, and it is therefore appropriate to reassess traditional efforts at disease management. Having . . .

Ebola virus disease epidemic.

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The Ebola virus disease epidemic now constitutes an international public health emergency. Occupational and environmental health nurses can collaborate with international colleagues to halt Ebola virus transmission within Africa, protect workers from exposures, and prevent another pandemic. [Workplace Health Saf 2014;62(11):484.].

Low FEV1, smoking history, and obesity are factors associated with oxygen saturation decrease in an adult population cohort.

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Low FEV1, smoking history, and obesity are factors associated with oxygen saturation decrease in an adult population cohort.

Int J Chron Obstruct Pulmon Dis. 2014;9:1225-33

Authors: Vold ML, Aasebø U, Melbye H

Abstract
BACKGROUND: Worsening of pulmonary diseases is associated with a decrease in oxygen saturation (SpO2). Such a decrease in SpO2 and associated factors has not been previously evaluated in a general adult population.
AIM: We sought to describe SpO2 in a sample of adults, at baseline and after 6.3 years, to determine whether factors predicting low SpO2 in a cross-sectional study were also associated with a decrease in SpO2 in this cohort.
METHODS: As part of the Tromsø Study, 2,822 participants were examined with pulse oximetry in Tromsø 5 (2001/2002) and Tromsø 6 (2007/2008). Low SpO2 by pulse oximetry was defined as an SpO2 ≤95%, and SpO2 decrease was defined as a ≥2% decrease from baseline to below 96%.
RESULTS: A total of 139 (4.9%) subjects had a decrease in SpO2. Forced expiratory volume in 1 second (FEV1) <50% of the predicted value and current smoking with a history of ≥10 pack-years were the baseline characteristics most strongly associated with an SpO2 decrease in multivariable logistic regression (odds ratio 3.55 [95% confidence interval (CI) 1.60-7.89] and 2.48 [95% CI 1.48-4.15], respectively). Male sex, age, former smoking with a history of ≥10 pack-years, body mass index ≥30 kg/m(2), and C-reactive protein ≥5 mg/L were also significantly associated with an SpO2 decrease. A significant decrease in FEV1 and a new diagnosis of asthma or chronic obstructive pulmonary disease during the observation period most strongly predicted a fall in SpO2. A lower SpO2 decrease was observed in those who quit smoking and those who lost weight, but these tendencies were not statistically significant.
CONCLUSION: A decrease in SpO2 was most strongly associated with severe airflow limitation and a history of smoking. Smoking cessation and reducing obesity seem to be important measures to target for avoiding SpO2 decreases in the general population.

PMID: 25364242 [PubMed - in process]

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