Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone.

BACKGROUND: Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting. METHODS: Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015. RESULTS: A total of 44 EVD patients were admitted (median age 37 years (range 17-63), 32/44 healthcare workers), and excluding those evacuated, the case fatality rate was 49% (95% CI 33%-65%). No pregnant women were admitted. At admission 9/44 had stage 1 disease (fever and constitutional symptoms only), 12/44 had stage 2 disease (presence of diarrhoea and/or vomiting) and 23/44 had stage 3 disease (presence of diarrhoea and/or vomiting with organ failure), with case fatality rates of 11% (95% CI 1%-58%), 27% (95% CI 6%-61%), and 70% (95% CI 47%-87%) respectively (p = 0.009). Haemorrhage occurred in 17/41 (41%) patients. The majority (21/40) of patients had hypokalaemia with hyperkalaemia occurring in 12/40 patients. Acute kidney injury (AKI) occurred in 20/40 patients, with 14/20 (70%, 95% CI 46%-88%) dying, compared to 5/20 (25%, 95% CI 9%-49%) dying who did not have AKI (p = 0.01). Ebola virus (EBOV) PCR cycle threshold value at baseline was mean 20.3 (SD 4.3) in fatal cases and 24.8 (SD 5.5) in survivors (p = 0.007). Mean national early warning score (NEWS) at admission was 5.5 (SD 4.4) in fatal cases and 3.0 (SD 1.9) in survivors (p = 0.02). Central venous catheters were placed in 37/41 patients and intravenous fluid administered to 40/41 patients (median duration of 5 days). Faecal management systems were inserted in 21/41 patients, urinary catheters placed in 27/41 and blood component therapy administered to 20/41 patients. CONCLUSIONS: EVD is commonly associated life-threatening electrolyte imbalance and organ dysfunction. We believe that the enhanced levels of protocolized care, scale and range of medical interventions we report, offer a blueprint for the future management of EVD in resource-limited settings.

Safety and feasibility of a strategy of early central venous catheter insertion in a deployed UK military Ebola virus disease treatment unit.

PURPOSE: Early central venous catheter (CVC) insertion in Ebola virus disease (EVD) is a novel approach and has not previously been described. This report delineates the safety, feasibility and clinical implications of early CVC insertion as the optimum means of vascular access in patients with EVD, in the setting of a deployed military Ebola virus disease treatment unit in Sierra Leone. METHODS: In the gastrointestinal phase of EVD, a 7-French 20-cm triple-lumen CVC was inserted using aseptic technique. Data were collected prospectively on all cases to include baseline and subsequent blood test variables, insertion site and technique, and complications associated with CVC placement. RESULTS: Twenty-three patients underwent CVC insertion as follows: subclavian, 21 (88 %); internal jugular, 2 (8 %); axillary, 1 (4 %). The mean duration of CVC placement was 5 days. There were no significant procedure-related adverse events. Despite coagulopathy being present in 75 % of cases, CVC insertion was safe, and there was only 1 case of significant catheter site bleeding. A total of 152 needle venepunctures were avoided owing to the presence of a CVC, a mean of 7 (±3.8) per case over the average stay. CONCLUSION: The early use of CVCs in Ebola virus disease is safe, effective and facilitates patient care. It should be considered a feasible additional route of venous access, where physician expertise and resources allow.

Survival of HIV-infected patients in the intensive care unit in the era of highly active antiretroviral therapy.

BACKGROUND: Several studies have described improved outcomes for HIV-infected patients admitted to the intensive care unit (ICU) since the introduction of highly active antiretroviral therapy (HAART). A study was undertaken to examine the outcome from the ICU for HIV-infected patients and to identify prognostic factors. METHODS: A retrospective study of HIV-infected adults admitted to a university affiliated hospital ICU between January 1999 and December 2005 was performed. Information was collected on patient demographics, receipt of HAART (no patient began HAART on the ICU), reason for ICU admission and hospital course. Outcomes were survival to ICU discharge and to hospital discharge. RESULTS: 102 patients had 113 admissions to the ICU; HIV infection was newly diagnosed in 31 patients. Survival (first episode ICU discharge and hospital discharge) was 77% and 68%, respectively, compared with 74% and 65% for general medical patients. ICU and hospital survival was 78% and 67% in those receiving HAART, and 75% and 66% in those who were not. In univariate analysis, factors associated with survival were: haemoglobin (OR = 1.25, 95% CI 1.03 to 1.51, for an increase of 1 g/dl), CD4 count (OR = 1.59, 95% CI 0.98 to 2.58, for a 10-fold increase in cells/microl), APACHE II score (OR = 0.51, 95% CI 0.29 to 0.90, for a 10 unit increase) and mechanical ventilation (OR = 0.29, 95% CI 0.10 to 0.83). CONCLUSIONS: The outcome for HIV-infected patients admitted to the ICU was good and was comparable to that in general medical patients. More than a quarter of patients had newly diagnosed HIV infection. Patients receiving HAART did not have a better outcome.

Analysis of paracetamol using solid-phase extraction, deuterated internal standards, and gas chromatography-mass spectrometry.

A rapid method for determining paracetamol (acetaminophen) in whole blood and liver tissue samples is described. Blank plus single-point calibration gives reliable quantitation at therapeutic and higher concentrations. Whole blood and liver tissue samples containing a deuterated internal standard were extracted using Bond Elut Certify columns. Butyl derivatives were formed using n-iodobutane and tetramethyl ammonium hydroxide under mild conditions and were extracted into ethyl acetate as a cleanup step. Recovery was better than 90%, and sample preparation time was less than 2 h. Gas chromatograph run time was less than 20 min. SIM of two ion pairs formed by electron impact ionization resulted in intraday coefficients of variation (CV) less than 3.03% (7.48% in liver) and interday CVs less than 8.93% (for midtherapeutic concentrations in whole blood). Linearity was observed from subtherapeutic to high, fatal levels. This method has been applied to forensic cases and has significantly reduced analytical time while improving casework quality. Results of a case study involving paracetamol are given.

Analysis of six anticonvulsant drugs using solid-phase extraction, deuterated internal standards, and gas chromatography-mass spectrometry.

A rapid method for simultaneously determining the anticonvulsant drugs carbamazepine, ethosuximide, phenobarbitone, phenytoin, primidone, and valproic acid is described. Blank plus single-point calibration gives reliable quantitation from therapeutic to high fatal concentrations, except for ethosuximide, for which it gives semiquantitative results. Whole blood and liver tissue samples containing deuterated internal standards were extracted using Bond Elut Certify columns. Butyl derivatives were formed using n-iodobutane and TMAH under mild conditions and were extracted into ethyl acetate as a cleanup step. Recoveries were greater than 50%, except for valproic acid (42%). Sample preparation time was less than 2 h, and the GC run time was less than 20 min per injection. At least two ion pairs formed by electron impact ionization were monitored for each drug. Intraday CVs were less than 6.28% (4.20%) and interday CVs less than 14.1% (for midtherapeutic concentrations in blood [liver], except for ethosuximide). Linearity was observed from subtherapeutic to high fatal levels for all drugs. This method has been applied to forensic cases and has significantly reduced analytical time while improving case-work quality. Results of a case study involving anticonvulsant drugs are given.

Volatile N-nitrosamines in urinary catheters.

Levels of volatile N-nitrosamines were measured in 10 brands of latex and 2 brands of silicone catheters using high performance liquid chromatography. The cytotoxicity of catheters from identical batches was determined by measuring the inhibitory effect of catheter extracts on the uptake of 3H-labelled thymidine into L-929 fibroblasts in culture (IC50). The most frequently encountered nitrosamines were N-nitrosodi-n-butylamine and N-nitrosodiethylamine. Total N-nitrosamine levels in excess of 100 ng/g were found in 6 of the 16 catheters tested. When compared with the cytotoxicity of the catheters a significant correlation was found, with increasing nitrosamine content being associated with greater cytotoxicity. In view of the reported toxic and carcinogenic effects of these compounds it is suggested that the nitrosamine content of catheters be routinely monitored and safe regulatory limits be imposed.

Rapid determination of glyphosate in postmortem specimens using 31P NMR.

Glyphosate was quantified, using 31P NMR, in postmortem blood, liver, and urine specimens taken from two suicide victims. Apart from addition of D2O to give an NMR lock signal, the only pretreatment required of any of the specimens was an enzymic digestion of the liver. Glyphosate was confirmed by its characteristic 31P chemical shift and proton spin coupling and by a downfield shift on addition of NH4OH. Quantitation can be achieved either by comparison with an external standard or by spiking the specimen with glyphosate. Levels of 1 mg/mL could be detected in less than a minute.

Extraction and quantification of paraquat in liver and hemolyzed blood.

A procedure for the extraction and quantification of paraquat from enzyme digested liver and hemolyzed blood is reported. Paraquat is extracted as an ion-pair with sodium dodecyl sulphate and quantified by reverse phase ion-pair high performance liquid chromatography (HPLC) with ultraviolet (UV) detection.

The relative efficiency of drug extraction procedures for enzyme digested livers.

Three different extraction procedures were used to determine drug levels in liver samples subjected to alcalase digestions. A micro-scale 1-chlorobutane extraction produced the most consistent results for a wide range of drug types.

Post-mortem digoxin levels--two unusual case reports.

Digoxin levels in post-mortem specimens are reported for two unusual cases. The blood level of digoxin in one of these cases was five times greater than any previously reported. The other case involved specimens from an embalmed body.