William A. Fischer

Clinical presentation of patients with Ebola virus disease in Conakry, Guinea.

BACKGROUND 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%.

Caring for Critically Ill Patients with Ebola Virus Disease. Perspectives from West Africa

The largest ever Ebola virus disease outbreak is ravaging West Africa. The constellation of little public health infrastructure, low levels of health literacy, limited acute care and infection prevention and control resources, densely populated areas, and a highly transmissible and lethal viral infection have led to thousands of confirmed, probable, or suspected cases thus far. Ebola virus disease is characterized by a febrile severe illness with profound gastrointestinal manifestations and is complicated by intravascular volume depletion, shock, profound electrolyte abnormalities, and organ dysfunction. Despite no proven Ebola virus-specific medical therapies, the potential effect of supportive care is great for a condition with high baseline mortality and one usually occurring in resource-constrained settings. With more personnel, basic monitoring, and supportive treatment, many of the sickest patients with Ebola virus disease do not need to die. Ebola virus disease represents an illness ready for a paradigm shift in care delivery and outcomes, and the profession of critical care medicine can and should be instrumental in helping this happen.

The role of structural factors in determining project management success

Despite all of the attention that has been paid to the strategic concerns of more repetitive operational contexts over the past few years, almost all of the research on project management has remained focused on various aspects of network manipulation. For any project where the simple application of network techniques could be inappropriate or dysfunctional, the continued oversight of strategic issues is unfortunate. This paper addresses several strategic issues involved with the structural aspects of project management and finds several of them significantly interrelated with project success and the implication of particular project management control systems. The structural variables that are studied include: organizational structure, managerial authority, and scale of the project. The study draws on data collected by a mail survey of 103 development projects in 30 different firms.

Microcomputer adoption—the impact of organizational size and structure

Abstract Data collected from twenty-one firms were used to study the impact of organizational size and structure on the adoption of microcomputers in those firms. The results show that both size and structure had a significant impact on the adoption of microcomputers. Organizational size was measured as the organizations annual sales. The structural characteristics were measured as organizational links (lateral relations) between the information systems area and users of microcomputer technology.

Molecular Typing of Neisseria gonorrhoeae Causing Repeated Infections: Evolution of Porin during Passage within a Community

Thirty-three Neisseria gonorrhoeae isolates from 15 persons infected multiple times with the same serovar were compared using por gene sequencing, opa-typing, and arbitrarily primed-polymerase chain reaction. All three molecular techniques were more discriminatory than serotyping and identified differences between some isolates belonging to the same serovar. Although there were differences among Por sequences within some serovars, 10 of 15 subjects became reinfected with gonococci expressing identical Por proteins. Sequence analysis of por genes revealed evidence of horizontal genetic exchange and point mutations in potential surface-exposed regions during passage in the community.

Doing Today's Work Superbly Well — Treating Ebola with Current Tools

Its possible to save many patients who have Ebola virus disease, since supportive care is also specific care for EVD and in all likelihood reduces mortality. Yet many patients in West Africa continue to die for lack of the opportunity to receive such basic care.

The diminishing utility of the product/process matrix

Advanced processing technologies, managerial practices, and information systems have merged as vital elements of modern day production. It has been argued that these changes in practice and technology have yielded a strategic manufacturing environ‐ment in the 1990s which is very different from that which existed in the 1970s and 1980s. Examines and documents these changes through the findings of a study in the US power tool industry of the effectiveness of the product‐process matrix in explaining the operations strategies of firms over the period 1970‐1990. Utilizes data from a detailed literature‐based survey, from on‐site interviews with executives and tours of manufacturing plants in the industry to explore the strategies followed over time by main and niche power tool firms competing in the US market. Shows that, while the Hayes and Wheelwright product‐process model captures many aspects of strategic operations decisions through 1980, changes have dramatically altered the competitive landscape and that many of the trade‐offs central to the model are no longer central to the articulation and formulation of operations strategy.

Culturing of human nasal epithelial cells at the air liquid interface

In vitro models using human primary epithelial cells are essential in understanding key functions of the respiratory epithelium in the context of microbial infections or inhaled agents. Direct comparisons of cells obtained from diseased populations allow us to characterize different phenotypes and dissect the underlying mechanisms mediating changes in epithelial cell function. Culturing epithelial cells from the human tracheobronchial region has been well documented, but is limited by the availability of human lung tissue or invasiveness associated with obtaining the bronchial brushes biopsies. Nasal epithelial cells are obtained through much less invasive superficial nasal scrape biopsies and subjects can be biopsied multiple times with no significant side effects. Additionally, the nose is the entry point to the respiratory system and therefore one of the first sites to be exposed to any kind of air-borne stressor, such as microbial agents, pollutants, or allergens. Briefly, nasal epithelial cells obtained from human volunteers are expanded on coated tissue culture plates, and then transferred onto cell culture inserts. Upon reaching confluency, cells continue to be cultured at the air-liquid interface (ALI), for several weeks, which creates more physiologically relevant conditions. The ALI culture condition uses defined media leading to a differentiated epithelium that exhibits morphological and functional characteristics similar to the human nasal epithelium, with both ciliated and mucus producing cells. Tissue culture inserts with differentiated nasal epithelial cells can be manipulated in a variety of ways depending on the research questions (treatment with pharmacological agents, transduction with lentiviral vectors, exposure to gases, or infection with microbial agents) and analyzed for numerous different endpoints ranging from cellular and molecular pathways, functional changes, morphology, etc. In vitro models of differentiated human nasal epithelial cells will enable investigators to address novel and important research questions by using organotypic experimental models that largely mimic the nasal epithelium in vivo.

Being ready to treat Ebola virus disease patients.

As the outbreak of Ebola virus disease (EVD) in West Africa continues, clinical preparedness is needed in countries at risk for EVD (e.g., United States) and more fully equipped and supported clinical teams in those countries with epidemic spread of EVD in Africa. Clinical staff must approach the patient with a very deliberate focus on providing effective care while assuring personal safety. To do this, both individual health care providers and health systems must improve EVD care. Although formal guidance toward these goals exists from the World Health Organization, Medecin Sans Frontières, the Centers for Disease Control and Prevention, and other groups, some of the most critical lessons come from personal experience. In this narrative, clinicians deployed by the World Health Organization into a wide range of clinical settings in West Africa distill key, practical considerations for working safely and effectively with patients with EVD.

The acquisition of technical information by R&D managers for problem solving in nonroutine contingency situations

Explores the effects of nonroutine requirements and a high-pressure situation on the process of technological information acquisition by R&D managers for problem solving in R&D groups. A survey of R&D managers in 116 firms in four industries reveals that nonroutine requirements in a contingency situation do affect their technical information acquisition behavior. Firm size and the direction of past involvement with the nonroutine requirements appear to be particularly important determinants of the degree of change experienced in technological information acquisition. Information sources that are informal and which provide access to a wide variety of experience appear to be the most valuable sources in such situations.