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Saving lives without new drugs

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SCIENCE        By Jon Cohen                                                                                         Nov. 21, 2014

...Just a handful of basic interventions to fight the killer effects of Ebola, including dehydration and secondary infections, could dramatically lower the CFR there, says Michael Callahan, an infectious disease specialist at Massachusetts General Hospital in Boston..

With so much room for improvement in supportive care, the current international focus on drugs is “misguided,” says Callahan, who has recently worked in Monrovia and provided care in four previous Ebola outbreaks. “While we wait for months for forthcoming experimental therapies, many lives can be saved, certainly hundreds and possibly thousands, using inexpensive and simple therapies,” he says.

Callahan is helping an international team develop guidelines dubbed Maximum Use of Supportive Therapy (MUST), aimed at keeping more patients alive. It includes intravenous (IV) drips to replace massive fluid loss from diarrhea and vomiting, a risk factor for shock; balancing of electrolytes such as calcium or potassium, which prevents kidney and heart failure; nasogastric tubes for feeding; and testing and treatment of secondary infections such as malaria. Introducing MUST will also make it easier to study new treatments, Callahan says...

It's an important proposal, but Ebola clinics will need more resources to offer MUST, says John Fankhauser, an American clinician who has worked at the ELWA hospital in Monrovia since before the outbreak surfaced.

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http://www.sciencemag.org/content/346/6212/911.full?intcmp=collection-ebola

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nejm.org

Daniel S. Chertow, M.D., M.P.H., Christian Kleine, M.D., Jeffrey K. Edwards, M.D., M.P.H., Roberto Scaini, M.D., Ruggero Giuliani, M.D., and Armand Sprecher, M.D., M.P.H.

N Engl J Med 2014; 371:2054-2057November 27, 2014DOI: 10.1056/NEJMp1413084

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 cared for more than 700 patients with EVD between August 23 and October 4, 2014, in the largest Ebola treatment unit in Monrovia, Liberia (see diagrams), we believe that our cumulative clinical observations support a rational approach to EVD management in resource-limited settings. . .

. . . Our observations support aggressive use of antiemetics, antidiarrheal medications, and rehydration solution to reduce massive gastrointestinal losses and the consequences of hypovolemic shock. Selective use of intravenous fluid therapy in the population that is most likely to benefit is a rational approach under the current circumstances. When possible, broader use of intravenous fluid therapy and electrolyte replacement, guided by point-of-service laboratory testing, is likely to significantly improve outcomes.

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