Diary Prequel Package — page 435

March 21, 2015 - Good news. Creatinine stabilized for 3 determinations in a row at around 6 with BUN at around 115. We may get away without having to dialyze. Main problem now is meningoencephalitis. Avi Nath (NINDS- neurologist) helping out with neuron-management. He can only do so by history and video since he is not trained to enter room. We cannot fully evaluate this until we lighten up his sedation, given what happened the other night, we will do this very slowly. We have started low dose heparin now that his platelets are coming up. CT (Cycle threshold) is now 34.5! All we need to do is avoid PEs and bleeding. More later. Now the Norwegians and to some extent the Canadians (much less so) are getting upset with us since we are working with the Guineans via INSERM (Delfraissy/Levy) and the interaction between the Liberians and Guineans to expand the vaccine RCT to Guinea, where there are still cases. The Norwegians are trying to do a "Ring Vaccination" study around cases similar to what was done with smallpox. However, the smallpox situation was using a proven, highly effective vaccine. You do not "test" a vaccine in a ring "study". The Norwegians are concerned that our introduction of an RCT where they are doing a Ring study would be a problem. I can understand what their concern is; however, the elephant in the room is the fact that there study is not a study. It is a "distribution" of an unproven product. This is the same European mentality that just because this is a serious disease, then there is no room for research; just distribute what you have. This same mentality led to Guinea adopting Favipiravir as standard of care based on an open access study that claimed benefit; however, when the data was presented at the CROI meeting, it was clear that there was no indication of efficacy since the outbreak incidence was shifting during the study and historical controls were not valid. God bless Cliff for sticking to his guns about RCT and good science. In this regard, my old friend Tore Godal from Norway e-mailed me with concern about our study since he is one of the Norwegians who are pushing the Ring study. Of note, in their communications, nowhere are there any Guineans. Sounds like the old paternalism. March 22, 2015 (Sunday)- Spent all of the day at NIH and hours in the SCSU in with patient and doing AM and PM rounds. Danny Jaswal was the ICU attending and Tuan was the ID person. Avi Nath did neuro exam and actually wwent into the room after getting trained in PPE March 23, 2015 - . I have some good news. His renal function continues to improve with a creatinine today of 3.6. He is in the polyuric phase of ATN with a urine output after stopping Lasix over the past 24 hours of >100 cc/hr. His LFTs have normalized. His cardiopulmonary function is good. On neuro exam today, his boardlike stiff neck can now bend by 45 degrees and his sustained clonus is now down to 5 beats. We had our ophthalmologist (Rachel Bishop) examine him today with a neat gadget hooked onto a cell phone, which together with a hand lens gave us a good look at his retina. Good news is that he has no papilledema and no evidence of clinically significant uveitis. Tomorrow morning we will attempt to stop his ketamine and fentanyl and gradually taper off his propofol. If he wakes up without being combative and is stable for a period of time, we will consider pulling his endotracheal tube. His CT is 37 and so he is almost cleared of virus from his blood. Fingers crossed.