UMEM Educational Pearls - By Jon Mark Hirshon

General Information:

Ebola is a deadly hemorrhagic fever of the virus family Filoviridae. 

• The largest outbreak known is currently affecting multiple countries in West Africa (especially Guinea, Liberia and Sierra Leone).
• As of July 23^rd, the WHO has recorded a total of 1,201 cases and 672 deaths (case fatality rate of 56%).

Clinical Information:

• Spread by close contact (direct contact with body fluids)
  • Primarily seen in family members of those infected and health care workers
• Incubation is usually from 8-10 days (can be from 2-21 days)
• Typical signs and symptoms include: fever, headaches, muscle/joint aches, abdominal pain, vomiting, diarrhea
• Additionally, some patients may experience: rash, red eyes, chest pain, difficulty breathing, difficulty swallowing, bleeding from multiple areas

Treatment and Public Health

• Supportive care and treatment of complications
• Contact isolation
• Immediately report to the local health authorities

Bottom Line:

            While the likelihood of general dissemination to the general U.S. population is very low, U.S. healthcare workers need to be aware and alert for the signs and symptoms of Ebola for patients recently returned from West Africa.

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·      Smallpox (Variola):

o   Only eradicated human infectious disease. 

o   Prior to the advent of vaccination, it killed an estimated 400,000 Europeans annually and was a major cause of blindness.

·      Major potential as a bioterrorism agent:  

o   Now only supposed to exist in two laboratories in the world (at the CDC in Atlanta, Georgia and in the Vector Institute in Koltsovo, Russia).

·      Recently, previously unknown vials of active virus from the 1950s were found in a NIH laboratory in Maryland.

·      Clinical Presentation:

o   Incubation is usually 10-12 days (range 7-17 days)

o   Signs and symptoms include:

§  Febrile (38.8-40.0C) prodome lasting 1-4 days, headache, myalgia (esp. back/spinal pain), pharyngitis, chills, abdominal pain

§  Rash: classically round and well circumscribed.  May be confluent or umbilicated. The rash evolves slowly: macules to papules to pustules to scabs.

·      It is important to differentiate smallpox from chicken pox (Varicella): 

o   Smallpox: Significant prodrome. Centrifugal rash (trunk to extremities). Can involve soles and palms. Lesions are in the same stage of development on any one part of the body.

o   Chickenpox: Minimal prodrome. Centripetal rash (extremities to trunk). Seldom on soles and palms. Asynchronus evolution of rash.

Bottom Line:

Smallpox is a global public health emergency and requires immediate reporting.  If the clinical presentation is unclear, discuss with local infectious disease experts or public health officials.

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Question

Background:

• With current medical advances and the adoption of healthier lifestyles, people are living longer.
• 65+ years old is the fastest growing segment of the global population
• In 1994:
  • 65+ accounted for 13% of the population
• By 2030:
  • Developed Countries: 65+ age segment of population will be larger than <65 age in many developed countries
  • Developing Countries: 75% of elderly will be living in lower and middle income countries with less well-developed health care systems

Relevance to the EM Physician:

• Elderly account for 12% to 24% of all ED visits
• Older patients present with a higher level of acuity and generally have more serious medical illness.
  • Arrive more often by ambulance
  • Higher rates of test use and longer ED stays
  • 2.5 to 4.6 times higher risk for hospitalization
  • 5-fold higher admission rate to an ICU
  • More likely to be misdiagnosed
  • More frequently discharged with unrecognized / untreated problems.

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