Orthopedic trauma surgeon in Sierra Leone: how to keep one's head over water.

PURPOSE: Developing a guideline for orthopedic trauma surgeons working in civilian trauma hospitals in low-income countries. METHODS: This is a retrospective data analysis in a non-governmental organizational trauma hospital in Sierra Leone, Africa. Trauma victims (282), with 349 fractures, were admitted to the hospital 10/2015-01/2016. The incidence of open and closed fractures and the use of implants were evaluated. RESULTS: The most common fractures were open and closed tibial shaft fractures and closed femoral shaft fractures in adults, and closed supracondylar humerus fractures in children. The most used implants were external fixators, K-wires, and intramedullary nails. External fixators were used for open fractures, K-wires for closed fractures in children, hand and foot, and nails for closed fractures of the lower extremity in adults. Plates were used the least and mostly for fractures of the upper extremity, the proximal tibia and malleolar region in adults. The complication rate was 5.67%. CONCLUSION: Surgeons in low-income country trauma hospitals should treat conservatively on outpatient basis only, to reduce the amount of stationary patients. Open fractures should be treated with external fixators, and closed fractures in children, hand and foot, with K-wires. Closed fractures in adults of the lower extremity should be nailed, and closed fractures in adults of the upper extremity can be treated with plates.

Relationship Between Viremia and Specific Organ Damage in Ebola Patients: A Cohort Study.

Background: Pathogenesis of Ebola virus disease remains poorly understood. We used concomitant determination of routine laboratory biomarkers and Ebola viremia to explore the potential role of viral replication in specific organ damage. Methods: We recruited patients with detectable Ebola viremia admitted to the EMERGENCY Organizzazione Non Governativa Organizzazione Non Lucrativa di Utilità Sociale (ONG ONLUS) Ebola Treatment Center in Sierra Leone. Repeated measure of Ebola viremia, alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, creatine phosphokinase (CPK), lactate dehydrogenase (LDH), activated prothrombin time (aPTT), international normalized ratio (INR), creatinine, and blood urea nitrogen (BUN) were recorded. Patients were followed up from admission until death or discharge. Results: One hundred patients (49 survivors and 51 nonsurvivors) were included in the analysis. Unadjusted analysis to compare survivors and nonsurvivors provided evidence that all biomarkers were significantly above the normal range and that the extent of these abnormalities was generally higher in nonsurvivors than in survivors. Multivariable mixed-effects models provided strong evidence for a biological gradient (suggestive of a direct role in organ damage) between the viremia levels and either ALT, AST, CPK LDH, aPTT, and INR. In contrast, no direct linear association was found between viremia and either creatinine, BUN, or bilirubin. Conclusions: This study provides evidence to support that Ebola virus may have a direct role in muscular damage and imbalance of the coagulation system. We did not find strong evidence suggestive of a direct role of Ebola virus in kidney damage. The role of the virus in liver damage remains unclear, but our evidence suggests that acute severe liver injury is not a typical feature of Ebola virus disease.

Short-term economic impact of the Zika virus outbreak.

Zika virus (ZIKV) is mainly transmitted by mosquitoes bites. However, transmission by sexual contacts has been reported in 11 non endemic countries. The rapid spread of ZIKV in Latin American and Caribbean Countries (LCR), person-to-person transmission and perceived risk on people's well being can affect the emerging economies of LCR which historically dependent on truism. Here we present an analysis on economic outputs for assessing the current impact of ZIKV on markets. Our analysis show an unexpected resilience of LCR markets to international alerts. This positive response represents an opportunity to scale-up interventions for preventing the further spreading of the ZIKV epidemic.

Treating Children With Advanced Rheumatic Heart Disease in Sub-Saharan Africa: The NGO EMERGENCY's Project at the Salam Centre for Cardiac Surgery in Sudan.

Rheumatic heart disease is endemic in Sub-Saharan Africa and while efforts are under way to boost prophylaxis and early diagnosis, access to cardiac surgery is rarely affordable. In this article, we report on a humanitarian project by the NGO EMERGENCY, to build and run the Salam Centre for Cardiac Surgery in Sudan. This hospital is a center of excellence offering free-of-charge, high-quality treatment to patients needing open-heart surgery for advanced rheumatic and congenital heart disease. Since it opened in 2007, more than 8,000 patients have undergone surgery there; most of them Sudanese, but ~20% were admitted from other countries, an example of inter-African cooperation. The program is not limited to surgical procedures. It guarantees long-term follow-up and anticoagulant treatment, where necessary. By way of example, we report clinical features and outcome data for the pediatric cohort: 1,318 children under the age of 15, operated on for advanced rheumatic heart disease between 2007 and 2019. The overall 5-year survival rate was 85.0% (95% CI 82.7-87.3). The outcomes for patients with mitral valves repaired and with mitral valves replaced are not statistically different. Nevertheless, observing the trend of patients undergoing valve repair, a better outcome for this category might be assumed. RHD in children is an indicator of poor socio-economic conditions and an inadequate health system, which clearly will not be cured by cardiac surgery alone. Nevertheless, the results achieved by EMERGENCY, with the crucial involvement and participation of the Sudanese government over the years, show that building a hospital, introducing free cardiac surgery, and offering long-term post-operative care may help spread belief in positive change in the future.

Intensive care support and clinical outcomes of patients with Ebola virus disease (EVD) in West Africa.

PURPOSE: We investigate the impact on outcome of different levels of supportive treatment in Ebola virus disease (EVD). The NGO EMERGENCY delivered care sequentially at two Ebola Treatment Centres (ETC) in Sierra Leone: first at Lakka (fluids, symptomatic, antibiotic, antimalaria treatment, and hospital level medical care), and thereafter in Goderich, adding organ support in the only African ETC with an equipped and staffed intensive care unit (ETC-ICU). METHODS: The primary outcome in this retrospective cohort study was in-ETC mortality. Secondarily, we used multivariable logistic regression to investigate the independent impact of the IC on mortality by comparing patients in two ETCs, adjusting for potential confounders, including the viral load (base-10 logarithm in copies/ml) (LVL), modelled as a piecewise linear function. Mortality was plotted versus LVL. Confidence bands were constructed by a bootstrap technique. The number of hospital-free days within 28 was computed to assess the burden of EVD. RESULTS: Data from 229 EVD patients were analysed (123 in Lakka, 106 in Goderich). Crude analysis showed a non-statistically significant difference in mortality (57.7% in Lakka vs 50.0% in Goderich; p = 0.19). Age and LVL were associated with mortality. Adjusted mortality was lower at the Goderich ICU-ETC (p = 0.055). This difference was observed with 80% confidence for patients with LVL between 7.5 and 8.5 copies/ml. Hospital-free days (of 28 days) were greater (7.7 vs 5.5; p = 0.03) for patients treated in the ICU-ETC. CONCLUSIONS: Provision of critical care to patients with EVD is feasible in resource-limited settings and was associated with improved survival and less time in hospital.

Molecular Signature of the Ebola Virus Associated with the Fishermen Community Outbreak in Aberdeen, Sierra Leone, in February 2015.

We report the complete genome sequence of Ebola virus from a health worker linked to a cluster of cases occurring in the fishing community of Aberdeen, Sierra Leone (February 2015), which were characterized by unusually severe presentation. The sequence, clustering in the SL subclade 3.2.4, harbors mutations potentially relevant for pathogenesis.

Are adaptive randomised trials or non-randomised studies the best way to address the Ebola outbreak in west Africa?

The Ebola outbreak that has devastated parts of west Africa represents an unprecedented challenge for research and ethics. Estimates from the past three decades emphasise that the present effort to contain the epidemic in the three most affected countries (Guinea, Liberia, and Sierra Leone) has been insufficient, with more than 24,900 cases and about 10,300 deaths, as of March 25, 2015. Faced with such an exceptional event and the urgent response it demands, the use of randomised controlled trials (RCT) for Ebola-related research might be both unethical and infeasible and that potential interventions should be assessed in non-randomised studies on the basis of compassionate use. However, non-randomised studies might not yield valid conclusions, leading to large residual uncertainty about how to interpret the results, and can also waste scarce intervention-related resources, making them profoundly unethical. Scientifically sound and rigorous study designs, such as adaptive RCTs, could provide the best way to reduce the time needed to develop new interventions and to obtain valid results on their efficacy and safety while preserving the application of ethical precepts. We present an overview of clinical studies registered at present at the four main international trial registries and provide a simulation on how adaptive RCTs can behave in this context, when mortality varies simultaneously in either the control or the experimental group.

Blood kinetics of Ebola virus in survivors and nonsurvivors.

BACKGROUND: Infection with Ebola virus (EBOV) results in a life-threatening disease, with reported mortality rates between 50%-70%. The factors that determine patient survival are poorly understood; however, clinical observations indicate that EBOV viremia may be associated with fatal outcome. We conducted a study of the kinetics of Zaire EBOV viremia in patients with EBOV disease (EVD) who were managed at an Ebola Treatment Centre in Sierra Leone during the recent West African outbreak. METHODS: Data from 84 EVD patients (38 survivors, 46 nonsurvivors) were analyzed, and EBOV viremia was quantified between 2 and 13 days after symptom onset. Time since symptom onset and clinical outcome were used as independent variables to compare EBOV viral kinetics in survivors and nonsurvivors. RESULTS: In all patients, EBOV viremia kinetics was a quadratic function of time; however, EBOV viremia was 0.94 logarithm (log) copies per ml (cp/ml) (P = 0.011) higher in nonsurvivors than in survivors from day 2 after the onset of symptoms. Survivors reached peak viremia levels at an earlier time after symptom onset than nonsurvivors (day 5 versus day 7) and had lower mean peak viremia levels compared with nonsurvivors (7.46 log cp/ml; 95% CI, 7.17-7.76 vs. 8.60 log cp/ml; 95% CI, 8.27-8.93). Before reaching peak values, EBOV viremia similarly increased both in survivors and nonsurvivors; however, the decay of viremia after the peak was much stronger in survivors than in nonsurvivors. CONCLUSION: Our results demonstrate that plasma concentrations of EBOV are markedly different between survivors and nonsurvivors at very early time points after symptom onset and may be predicative of outcome. Further studies focused on the early phase of the disease will be required to identify the causal and prognostic factors that determine patient outcome. FUNDING: Italian Ministry of Health; Italian Ministry of Foreign Affairs; EMERGENCY's private donations; and Royal Engineers for DFID-UK.

Injury Severity Score versus New Injury Severity Score for penetrating injuries.

INTRODUCTION: The New Injury Severity Score (NISS) was introduced in 1997 to improve outcome prediction based on anatomical severity scoring in trauma victims. Studies on populations of blunt trauma victims indicate that the NISS, predicts better than the Injury Severity Score (ISS) mortality post-injury, which is why the NISS has been recommended as the new "gold standard" for severity scoring. However, so far the accuracy of the NISS for penetrating injuries has not been validated against the ISS. METHODS: ISS and NISS scores were collected retrospectively for 1,787 war- and landmine victims in North Iraq. All victims only had penetrating injuries. The two tests were compared for prediction of short-term mortality and post-operative complications using Receiver Operating Characteristics (ROC) analysis. RESULTS: Both the ISS and the NISS predicted mortality with high accuracy (ROC area under curve 0.9). There were no significant differences between the two tests. The predictive accuracy for post-operative complications was moderate for both tests (ROC-AUC < 0.8), with the NISS performing significantly better than the ISS. CONCLUSION: The NISS does not perform better than the ISS in penetrating injuries. However, this study was done on a low-risk trauma population, thus the results should not be extrapolated to high severity trauma. Due to statistical shortcomings in studies previously published, studies on far larger cohorts are necessary before the NISS should be adopted as the new "gold standard" for severity scoring.

Aorta-to-right ventricular outflow tract fistula with coronary cusp prolapse.

We describe a rare case of aorta-to-right ventricular fistula in a 20-year-old man who presented with signs and symptoms of congestive heart failure. He was successfully treated by closing the fistula with a Dacron patch from the aortic side. At follow-up, he was asymptomatic with no left-to-right shunt.

Management of severe open ankle-foot trauma by a simple external fixation technique: an alternative during war and in resource-poor and low-technology environments.

Severe open foot and ankle injuries are still a challenge for the orthopaedic surgeon. Their treatment is even more difficult in third world countries and in war settings where high-energy trauma with severe soft tissue damage is more frequent. Lack of equipment, poor resources and hygiene, and different cultural systems make most of the standard proposed treatments difficult to apply. The authors describe an inexpensive, rapid, minimally invasive, and easy-to-apply external fixation technique for the treatment of severe open ankle-foot fractures. With the main goal of soft tissue management rather than definitive treatment of any bony injuries, this technique was developed over time during many consecutive missions in Sierra Leone and Afghanistan as an alternative to more appropriate treatments with surprisingly satisfactory short- and long-term results.

Features and management of esophageal corrosive lesions in children in Sierra Leone: lessons learned from 175 consecutive patients.

PURPOSE: This study aims to highlight the peculiar presentation and management of children's corrosive ingestions in developing countries associated with malnutrition, delay in management, lack of technology, and sporadic follow-up. METHODS: An observational study was carried out since 2005 on all children (<15 years old) admitted for caustic soda ingestion to the "Emergency" Surgical Center in Sierra Leone, either in the acute postinjury phase or for dilatation of esophageal strictures. Complications, mortality, stricture recurrence, and ability to swallow were the main outcome measures. Improvement in nutritional status (ie, gaining weight) and sustained esophageal patency were both considered reference points to successful treatment. RESULTS: In 4 years (2005-2009), 175 children were admitted, 53.7% at more than 1 month after ingestion. Dilatations were carried out in 77.7%, and a gastrostomy was placed in 64%. Perforations and death rate were 4.5% and 2.8%, respectively. Sixty-two patients (35.4%) required more than 7 dilatations, whereas 15 (8.5%) were unable to maintain a satisfactory luminal diameter. Follow-up (range, 1-36 months; median, 7 months) was possible in 52.7%. Long-term success according to the aforementioned criteria was observed in only 16%. CONCLUSIONS: Delayed presentations and complex strictures with repeated postdilatation recurrence are characteristics of children's corrosive ingestion in developing countries. Malnutrition is common, and gastrostomy is frequently compulsory. Esophageal patency with improvement in nutritional state is achieved only in a small percentage of patients.

Percutaneous transcatheter balloon valvuloplasty for severe tricuspid valve stenosis in Ebstein's anomaly.

A 26-year-old woman was admitted to our hospital because of exertional dyspnea (New York Heart Association III), general fatigue and palpitations over the past 2 months. She had normal psychosomatic development until adulthood, no previous pregnancies and a history of rheumatic fever at young age. Although she referred a slow gradual worsening of general conditions for 2 years, no clinical evaluations were previously performed.