Italian Ministry of Health; Italian Ministry of Foreign Affairs; EMERGENCY's private donations; and Royal Engineers for DFID-UK.

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.

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.

Over a period of 14 months between 1990 and 1992, 73 Afghan war wounded with penetrating colon injuries were admitted and treated by a single surgical team in a field hospital of the International Committee of the Red Cross (ICRC). There were 67 males and 6 females, with a mean age of 23 years (range 6 to 80 years). Fifty six (77%) patients had multiple associated injuries; admission was delayed longer than 12 hours in 39 (44%); hypotension or deep shock was present at admission in 34 (47%) and 12 (16%) respectively. At laparotomy faecal contamination was limited to one quadrant in 58 (79.5%) cases and major in 15 (20.5%). Fifty-two (71.2%) patients underwent resection and primary anastomosis and 21 (28.8%) primary repair. Exteriorisation or diverting colostomy were never used. Four (5.5%) patients died and 11 (15%) had postoperative complications. Overall failure rate was 2.7%, including one faecal fistula conservatively treated and one colostomy raised as a precaution in a patient undergoing relaparotomy for intra-abdominal abscess. No primary repair leaked Deaths were significantly related to delay in admission and age, but not to surgical treatment. One stage primary treatment of large bowel injuries from penetrating abdominal wounds has low mortality, failure and colostomy rates suggesting its wider use regardless of risk factors.

PurposeWe 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).MethodsThe 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.ResultsData 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.ConclusionsProvision of critical care to patients with EVD is feasible in resource-limited settings and was associated with improved survival and less time in hospital.Electronic supplementary materialThe online version of this article (10.1007/s00134-018-5308-4) contains supplementary material, which is available to authorized users.