Two clusters of human infection with influenza A/H5N1 virus in the Republic of Azerbaijan, February-March 2006.

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.

Two clusters of human infection with influenza A/H5N1 virus in the Republic of Azerbaijan, February-March 2006.

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.

Reduced quality of clot formation with gelatin-based plasma substitutes.

We 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 gelatin-based 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.

A computer model of major haemorrhage and resuscitation.

An interactive computer model is described which uses 'blood volume deficit' and 'bleeding duration' together with rates of infusion to simulate the first two hours of haemorrhage. It allows multiple infusions of various fluids to be specified and includes an estimation of the volumes added by the transcapillary refill mechanism. The output is expressed graphically in terms of blood pressure and haematocrit at intervals of one minute. This computer model has proved useful for assessing the effects of a range of variables in hypovolaemic shock. It has considerable potential for investigating the relative efficacy of various clinical protocols and could provide an alternative to animal experimentation which has so far been the primary method of obtaining data on acute haemorrhage. It is also a useful teaching aid.

Micronutrient status of the besieged residents of Sarajevo: May 1993.

OBJECTIVE: To assess micronutrient status indices in blood and plasma of subjects subjected to siege conditions. DESIGN: Whole blood and serum samples were taken from subjects, sampled from 30 clusters in four Municipal Areas of Sarajevo. The blood samples were flown, under appropriate refrigeration, to the UK for analysis. SETTING: The study was conducted in besieged Sarajevo and laboratory analyses were carried out at Department of Clinical Chemistry, Aberdeen Royal Infirmary and at Rowett Research Institute, Aberdeen, Scotland. SUBJECTS: 202 subjects, aged from 1 to 82 years were included in the sample. INTERVENTIONS: Serum folate, ferritin, transferrin, retinol, retinol-binding protein, beta-carotene, alpha-tocopherol, 25-hydroxycholecalciferol, C-reactive protein, haemoglobin and mean corpuscular volume of blood were determined. Micronutrient status was assessed by comparison with a range of values derived from multinational data sets from both pathologically malnourished and normal subjects. RESULTS: Haemoglobin, ferritin, folate, retinol and 25-hydroxycholecalciferol levels were lower in the Sarajevan sample than in normal reference populations. Serum alpha-tocopherol was low in children and adolescents while a low beta-carotene level probably reflected the scarcity of green vegetables. No consistent evidence of protein/energy deficits were detected. CONCLUSIONS: Data for retinol binding protein and transferrin, when considered in association with BMI and Z-score data, provided no significant evidence of protein-energy undernutrition. However, the prevailing food aid rations failed to maintain adequate reserves of several micronutrients, particularly iron, folate and vitamin D. The significance of low values for serum retinol and beta-carotene and of low serum alpha-tocopherol in children must be investigated further.

Validation of a computer model of haemorrhage and transcapillary refill.

A computer model is described which uses blood volume deficit and its duration to simulate the first two hours of haemorrhage, including an estimation of the blood volume added by Starlings transcapillary refill mechanism. Computer prediction of the haematocrit was compared with published data on haemorrhage in animals. There was close correlation with data on the haemodilution caused by Starling's transcapillary refill mechanism in conscious swine (r = 0.84).

Intravenous pyridoxine in acute ethanol intoxication.

Intravenous pyridoxine was evaluated as an agent for the reversal of ethanol-induced central nervous depression in a randomised double blind controlled study of 108 patients presenting with a clinical diagnosis of acute ethanol intoxication to two accident and emergency departments. Level of consciousness, measured by a modified Glasgow coma scale, showed no significant change after a single 1 g dose of intravenous pyridoxine when compared to controls given saline. The mean fall in blood alcohol concentration after one hour was 33 mg dl-1 (7.2 mmol l-1) in both groups suggesting that pyridoxine has no antidotal action and no short term effect on the rate of metabolism of ethanol.

Cervical collars: a potential risk to the head-injured patient.

Interface pressures beneath six types of collar in volunteers were measured. Under certain types of collar mean interface pressures of more than 10 mmHg were obtained, with several individual readings around 30 mmHg. By causing jugular venous obstruction a similar rise in intracranial pressure may be produced inadvertently. The mechanisms of action for this are discussed. Those collars with the least tendency to produce jugular venous obstruction were of the moulded variety which extend support to the occiput, mandible and shoulder girdle. The authors therefore recommend this type of cervical splintage device where injury of the cervical spine is suspected. This paper emphasizes the potential danger to head-injured patients when the other devices are applied too tightly, producing a 'venous tourniquet' effect.

Management of the moribund carbon monoxide victim.

Carbon monoxide (CO) poisoning is the commonest single cause of fatal poisoning in the U.K. (Broome & Pearson, 1988). The clinical features are numerous and include headache, fatigue, dizziness, confusion, memory loss, paraesthesia, chest pain, abdominal pain, nausea, and diarrhoea as well as coma, convulsions and death. Without adequate treatment many patients develop neuropsychiatric sequelae including headaches, irritability, memory loss, confusion and personality changes. The diagnosis of CO poisoning is often suggested only by circumstances surrounding the victim, and remains a challenge to the A&E department. Hyperbaric oxygen therapy (HBO) is internationally accepted as the most powerful form of treatment in severe cases (Drug & Therapeutics Bulletin, 1988; Lowe-Ponsford & Henry, 1989). However, in the U.K. treatment with HBO is often not considered due to lack of hyperbaric facilities (Meredith & Vale, 1988; Anand et al., 1988), and due to inadequate awareness on the part of hospital staff. We report a case of a patient deeply unconscious as a result of CO poisoning, in which serial treatments with HBO over a period of 14 days, produced dramatic results.

Adductor pollicis. The missing interosseous.

This paper highlights the many similarities between the adductor pollicis and the palmar interossei. In particular it compares their anatomy, innervation and function. It suggests that adductor pollicis should be considered as the first palmar interosseous and that this view simplifies the teaching of hand anatomy and the tests of ulnar nerve function. Further support for the view that adductor pollicis is the thenar counterpart of the second, third and fourth palmar interossei is gained from studies of the literature on hand evolution, in particular published details of fossil records and dissection of primate hands.

Removal of foreign bodies from the foot, a technique using high elevation and local anaesthesia.

The use of a steep Trendelenburg position is described in removing foreign bodies from the foot. Bleeding at the site is sufficiently reduced to allow removal without a tourniquet. Retrospective analysis of theatre records demonstrates a considerable reduction in the number of general anaesthetics given since the introduction of this technique.

Blood alcohol concentration measurement using a salivary reagent stick: a reliable tool for emergency departments?

Measurements of blood alcohol concentration (BAC) were made on patients who presented to an accident and emergency department with acute alcohol intoxication. A correlation of r = 0.418 was noted to exist between BAC as measured by sampling saliva and blood. Blood alcohol concentrations as measured by salivary reagent strip (ALCO-SCREEN, Chem Elec.) were significantly lower (p less than 0.0001) than those determined by gas chromatography of serum. Although such reagent strips offer a rapid measurement of BAC, it is concluded that they are unreliable for the quantitative measurement of BAC in accident and emergency departments.