RESUMEN
BACKGROUND: Cold-stored low-titer group O whole blood (LTOWB) has become increasingly utilised in both prehospital and in-hospital settings for resuscitation of traumatic haemorrhage. However, implementing the use of LTOWB to ground medical teams has been limited due to logistic challenges. METHODS: In 2022, the Israel Defense Forces (IDF) started using LTOWB in ambulances for the first time in Israel. This report details the initial experience of this rollout and presents a case-series of the first patients treated with LTOWB. RESULTS: Between January-December 2022, seven trauma patients received LTOWB administered by ground IDF intensive care ambulances after presenting with profound shock. Median time from injury to administration of LTOWB was 35 min. All patients had evidence of severe bleeding upon hospital arrival with six undergoing damage control laparotomy and all but one surviving to discharge. CONCLUSIONS: The implementation of LTOWB in ground medical units is in its early stages, but continued experience may demonstrate its feasibility, safety, and effectiveness in the prehospital setting. Further research is necessary to fully understand the indications, methodology, and benefits of LTOWB in resuscitating severely injured trauma patients in this setting.
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Personal Militar , Heridas y Lesiones , Humanos , Transfusión Sanguínea/métodos , Ambulancias , Israel , Hemorragia/terapia , Sistema del Grupo Sanguíneo ABO , Heridas y Lesiones/terapiaRESUMEN
INTRODUCTION: Pre-malignant cervical disease and invasive cervical cancer present a significant global health burden with respect to morbidity and mortality, mostly in low- and middle-income countries. Human papillomavirus (HPV) infection typically manifests for the first time in adolescence. We aimed to identify adolescent sociodemographic and anthropometric characteristics associated with subsequent risk for pre-malignant cervical disease and cervical cancer, in a country that offers free screening and HPV vaccines. METHODS: This historical cohort study included 969 123 Israeli women examined and anthropometrically measured at age 17 years between January 1967 and December 2011. Data on pre-malignant disease and invasive cervical tumors were obtained from the national cancer registry by linkage. We excluded non-Jewish minorities (a total of 25 472 women) and orthodox/ultraorthodox Jewish women since these populations are not required by law to serve in the military, as well as women with a pre-examination diagnosis of cancer. Cox proportional hazards regression models were applied per each lesion type, adjusted for origin, measured body mass index, height, education, dwelling type, birth year, and age at examination. RESULTS: In total, 5094 and 859 incident pre-malignant cervical disease and cervical cancer cases, respectively, were diagnosed during a median follow-up of 17.6 years. Risk for both lesions was origin-dependent, with higher incidence in women of North-African origin (HR (pre-malignant cervical disease) 1.22, 95% CI 1.04 to 1.42; HR (cervical cancer) 1.87, 95% CI 1.30 to 2.69) compared with European origin. Height, lower education, and later birth year were associated with higher pre-malignant cervical disease and cervical cancer risk also. Adolescent overweight (HR 0.81, 95% CI 0.74 to 0.90) and obesity (HR 0.56, 95% CI 0.43 to 0.71) status were associated with reduced pre-malignant cervical disease but not cervical cancer incidence, as did urban (vs rural) residence. DISCUSSION: Ethnic background, tall stature, and education were associated with pre-malignant cervical disease and cervical cancer incidence, while adolescent overweight and obesity were inversely associated with only pre-malignant cervical disease. Despite free screening and HPV vaccines, these findings suggest that there is still a need for appropriate safe sex and screening education in adolescence.
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Lesiones Precancerosas/epidemiología , Neoplasias del Cuello Uterino/epidemiología , Adolescente , Adulto , África del Norte/etnología , Estudios de Cohortes , Femenino , Humanos , Incidencia , Israel/epidemiología , Judíos/estadística & datos numéricos , Análisis Multivariante , Invasividad Neoplásica , Modelos de Riesgos Proporcionales , Factores Socioeconómicos , Adulto JovenRESUMEN
OBJECTIVE: The aim of this study was to evaluate obstetric outcomes in relation to the extent of donor sperm exposure with and without egg donation. MATERIALS AND METHODS: This is a retrospective cohort study in a single tertiary care center. All women with a singleton pregnancy who conceived following sperm donation (SD) were included. Obstetrics and neonatal outcomes for pregnancies following single SD were compared with pregnancies following repeat SD from the same donor. In a secondary analysis, we compared pregnancy outcomes among three modes of assisted reproductive technology (intrauterine insemination [IUI-SD], in vitro fertilization [IVF-SD], and IVF sperm + egg donation [IVF-SD + ED]). RESULTS: A total of 706 pregnant women met the inclusion criteria, 243 (34.4%) following the first SD and 463 (65.6%) following repeat donations. Compared with repeat SDs, single donation was not associated with higher rates of preterm delivery (12.8 vs. 12.7%, respectively, p = 0.99), preeclampsia (7.0 vs. 6.9%, p = 0.999), and intrauterine growth restriction (4.1 vs. 3.9%, p = 0.88). Pregnancies following IVF-SD + ED had increased risk for preeclampsia (adjusted odds ratio [AOR], 3.1; 95% confidence interval [CI], 1.5-6.6), preterm labor (AOR, 2.4; 95% CI, 1.1-5.4), and cesarean section (AOR, 2.1; 95% CI, 1.0-4.3) compared with IUI-SD and IVF-SD. CONCLUSION: The extent of donor sperm exposure did not correlate with obstetrics complications, but double gamete donation was associated with increased risk for preeclampsia, preterm labor, and cesarean section.
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Fertilización In Vitro/efectos adversos , Inseminación Artificial/efectos adversos , Donación de Oocito , Complicaciones del Embarazo/etiología , Espermatozoides , Donantes de Tejidos , Adulto , Cesárea/estadística & datos numéricos , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Preeclampsia/etiología , Embarazo , Complicaciones del Embarazo/epidemiología , Resultado del Embarazo , Nacimiento Prematuro/epidemiología , Nacimiento Prematuro/etiología , Estudios RetrospectivosRESUMEN
PURPOSE: Information regarding the use of barbed suture in gynecologic surgery is limited. Our aim was to compare maternal morbidity following caesarean deliveries performed with barbed compared with non-barbed suture for uterine closure. METHODS: A historical cohort study from a single tertiary institution. The study group composed of all women that underwent term, uncomplicated singleton caesarean deliveries, where uterine closure was performed with ETHICON's Stratafix®, a polydioxanone barbed suture, compared with caesarean deliveries where uterine closure was performed with ETHICON's VICRYL®, a Polyglactin 910 non-barbed suture. The primary outcomes were the rate of maternal morbidity including the rate of red packed cells transfusion and a composite of infectious morbidity. Operation duration was also evaluated. An analysis restricted to elective caesarean deliveries was performed comparing the suture types. RESULTS: Three thousand and sixty patients were included in the study; 1337 in the study group and 1723 in the control group. There was no significant difference in the rate of the primary outcomes (red packed cells transfusion: 2.5% in the barbed suture vs. 2.1% in the non-barbed suture groups; p = 0.47; composite maternal morbidity: 3.8% vs. 4.8%, respectively; p = 0.18). Barbed suture was associated with reduced risk of postoperative ileus compared with the non-barbed suture (0.3% vs. 1.0%, respectively; p = 0.02) and a longer operation time (31 vs. 29 min, respectively; p < 0.001). In the analysis restricted to elective caesarean deliveries only the duration of operation remained significantly different between the groups. CONCLUSIONS: The rate of short term maternal morbidities among patients undergoing uterine closure with barbed suture during caesarean delivery is similar to the non-barbed suture.
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Cesárea/mortalidad , Complicaciones Posoperatorias/mortalidad , Técnicas de Sutura/efectos adversos , Útero/cirugía , Adulto , Estudios de Cohortes , Femenino , Humanos , Embarazo , Estudios RetrospectivosRESUMEN
OBJECTIVE: Tourniquet application is a lifesaving skill taught worldwide in first aid bleeding control courses. We observed performance among non-medical users of tourniquets in their confidence, competence, and reasons for failure. METHODS: 179 Israeli military recruits without prior medical training underwent their standard first aid course where they learned Combat Application Tourniquet (CAT; Composite Resources, Rock Hill, SC, USA) use. After course completion, they self-reported confidence in tourniquet use. User performance was assessed 7-14 days later using a HapMed™ mannequin that assessed time, pressure, and blood loss. Competent performance required in aggregate: 1) use with pressure of 200 mmHg or more, 2) hemorrhage volume of less than 638 mL, and 3) correct placement of the tourniquet. For failed performance, a reason for failure was reported independently by both the user and an expert observer. RESULTS: 45 of 179 user performances (25%) were competent. Users who reported high confidence had only a slightly higher chance of achieving competence in tourniquet application (r = 0.17, p = 0.022). The most common reason for failure was excess slack in the CAT's strap (experts 55%, users 39%), and too few turns of the windlass (23% and 31%, respectively) was the second most common reason. Expert and user evaluations had poor agreement (κ = 0.44, 95% CI 0.32-0.56). CONCLUSION: The most common reason for failed use of tourniquets among non-medical users was excess slack in the tourniquet strap. Users self-evaluated their performance inaccurately and demonstrated a confidence-competence mismatch. These pitfalls in performance may help tourniquet instructors improve training of caregivers.
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Hemorragia/prevención & control , Torniquetes , Adolescente , Competencia Clínica , Servicios Médicos de Urgencia , Diseño de Equipo , Extremidades/irrigación sanguínea , Humanos , Masculino , Maniquíes , Insuficiencia del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: During resuscitation in the field, intraosseous (IO) access may be achieved using a variety of available devices, often attempted by inexperienced users. AIM: We sought to examine the success rate and ease-of-use ratings of an IO device, the NIO® (New Intraosseous Persys Medical, Houston, TX, USA) in comparison to the Arrow® EZ-IO® (Teleflex Medical Research Triangle Park, NC, USA) by novice users. METHODS: We performed a randomized crossover trial. The study model was a porcine hind leg which was cut distally in order to expose the marrow. The Study population was composed of pre-graduate medical students without prior experience in IO use, all designated future field physicians. The students underwent instruction and practiced the use of both devices. After practice completion, each student attempted a single IO insertion with both devices sequentially in randomized fashion. Success was defined as a flow of fluid through the bone marrow after a single IO attempt. Investigators which determined the success rate were blinded to the used device. RESULTS: 50 users (33 males, 17 females) participated in the trial, mean age of 21.7 years (±1). NIO users were successful in 92% (46/50) attempts while EZ-IO user success rate was 88% (44/50). NIO success rates were comparable to those of EZ-IO (p = NS). Results were similar when examining only the initial device used. Median score of ease of use was 4 (5 point Likert scale) in both devices (p = NS). 54% (27/50) of the participants preferred using the EZ-IO over the NIO (p = NS). CONCLUSION: Novice users were equally successful in establishing IO access with the NIO® in comparison to the EZ-IO® in a porcine model.
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Fluidoterapia/instrumentación , Infusiones Intraóseas/instrumentación , Animales , Estudios Cruzados , Servicios Médicos de Urgencia , Femenino , Miembro Posterior , Humanos , Masculino , Resucitación/educación , Resucitación/métodos , Método Simple Ciego , Porcinos , Adulto JovenRESUMEN
INTRODUCTION: Although a lifesaving skill, currently, there is no consensus for the required amount of practice in tourniquet use. We compared the effect of 2 amounts of practice on performance of tourniquet use by nonmedical personnel. METHODS: Israeli military recruits without previous medical training underwent their standard tactical first aid course, and their initial performance in use of the Combat Application Tourniquet (CAT; Composite Resources, Rock Hill, SC) was assessed. The educational intervention was to allocate the participants into a monthly tourniquet practice program: either a single-application practice (SAP) group or a triple-application practice (TAP) group. Each group practiced according to its program. After 3 months, the participants' tourniquet use performance was reassessed. Assessments were conducted using the HapMed Leg Tourniquet Trainer (CHI Systems, Fort Washington, PA), a mannequin which measures time and pressure. RESULTS: A total of 151 participants dropped out, leaving 87 in the TAP group and 69 in the SAP group. On initial assessment, the TAP group and the SAP group performed similarly. Both groups improved their performance from the initial to the final assessment. The TAP group improved more than the SAP group in mean application time (faster by 18 vs 8 seconds, respectively; P = .023) and in reducing the proportion of participants who were unable to apply any pressure to the mannequin (less by 18% vs 8%, respectively; P = .009). CONCLUSION: Three applications per monthly practice session were superior to one. This is the first prospective validation of a tourniquet practice program based on objective measurements.
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Educación no Profesional/métodos , Personal Militar/educación , Práctica Psicológica , Torniquetes , Adolescente , Primeros Auxilios , Humanos , Israel , Masculino , Maniquíes , Presión , Estudios Prospectivos , Entrenamiento Simulado , Análisis y Desempeño de Tareas , Factores de Tiempo , Adulto JovenRESUMEN
Behind armor blunt trauma (BABT) is a non-penetrating injury caused by energy transfer and rapid deformation of protective body armor. Although modern military body armor is designed to prevent penetrating trunk injuries, high-energy projectiles can produce a significant energy transfer to tissues behind the armor and inflict injuries such as fractures or organ contusions. However, knowledge of BABT is limited to biomechanical and cadaver modeling studies and rare case reports. We report two cases of BABT resulting from close-range fire and discuss the potential implications for triaging patients with BABT in battlefield scenarios. In the first case, a 19-year-old male soldier sustained a single close-range 5.56-mm assault rifle gunshot to his chest body armor. The soldier initially reported mild pain in the parasternal region and assessment revealed a 4 cm × 3 cm skin abrasion. Following emergency department evaluation, the soldier was diagnosed with a non-displaced transverse fracture of the sternal body. In the second case, a 20-year-old male sustained five machine gun bullets (7.62 mm) to his body armor. Computed tomography of the chest revealed pulmonary contusions in the right lower and middle lobes. Both soldiers achieved full recovery and returned to combat duty within several weeks. These cases highlight the potential risks of energy transfer from high-velocity projectiles impacting body armor and the need for frontline providers to be aware of the risk of underlying blunt injuries. Further reporting of clinical cases and modeling studies using high-velocity projectiles could inform recommendations for triaging, evacuating, and assessing individuals with BABT.
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Contusiones , Traumatismos Torácicos , Heridas por Arma de Fuego , Heridas no Penetrantes , Masculino , Humanos , Adulto Joven , Adulto , Ropa de Protección , Heridas por Arma de Fuego/complicaciones , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/diagnóstico , Contusiones/complicacionesRESUMEN
Thyroid autoimmunity is the most prevalent autoimmune state that affects up to 4% of women during the age of fertility. A growing body of clinical studies links thyroid autoimmunity as a cause of infertility and adverse pregnancy outcomes that includes miscarriage or preterm deliveries. Importantly, these adverse effects are persistent in euthyroid women. In the current review we elaborate on the pathogenesis that underlies infertility and increased pregnancy loss among women with autoimmune thyroid disease. Such mechanisms include thyroid autoantibodies that exert their effect in a TSH-dependent but also in a TSH-independent manner. The later includes quantitative and qualitative changes in the profile of endometrial T cells with reduced secretion of IL-4 and IL-10 along with hypersecretion of interferon-γ. Polyclonal B cells activation is 2-3 time more frequent in thyroid autoimmunity and is associated with increased titers of non-organ specific autoantibodies. Hyperactivity and Increased migration of cytotoxic natural killer cells that alter the immune and hormonal response of the uterus is up to 40% more common in women with thyroid autoimmunity. Lack of vitamin D was suggested as a predisposing factor to autoimmune diseases, and was shown to be reduced in patients with thyroid autoimmunity. In turn, its deficiency is also linked to infertility and pregnancy loss, suggesting a potential interplay with thyroid autoimmunity in the context of infertility. In addition, thyroid autoantibodies were also suggested to alter fertility by targeting zona pellucida, human chorionic gonadotropin receptors and other placental antigens.
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Aborto Habitual/inmunología , Autoinmunidad , Infertilidad/inmunología , Glándula Tiroides/inmunología , Autoanticuerpos/inmunología , Reacciones Cruzadas/inmunología , Femenino , Humanos , Hipotiroidismo/inmunología , Inmunidad Humoral/inmunología , Inmunidad Innata/inmunología , Embarazo , Glándula Tiroides/patologíaRESUMEN
Patients with five or more unexplained recurrent pregnancy losses (RPL) have a poor prognosis for a subsequent delivery compared to patients with two to three RPL. Treatment guidelines are needed to address this select group of patients.
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Aborto Habitual/etiología , Pérdida del Embrión/etiología , Medicina de Precisión , Aborto Habitual/diagnóstico , Aborto Habitual/prevención & control , Anomalías Congénitas/embriología , Anomalías Congénitas/fisiopatología , Pérdida del Embrión/diagnóstico , Pérdida del Embrión/prevención & control , Medicina Basada en la Evidencia , Femenino , Enfermedades Fetales/fisiopatología , Enfermedades Fetales/prevención & control , Enfermedades Genéticas Congénitas/embriología , Enfermedades Genéticas Congénitas/fisiopatología , Humanos , Guías de Práctica Clínica como Asunto , Embarazo , Complicaciones del Embarazo/fisiopatología , Complicaciones del Embarazo/prevención & control , Pronóstico , Prevención SecundariaRESUMEN
OBJECTIVE: To analyse the correlation between COVID-19 vaccination percentage and socioeconomic status (SES). METHODS: A nationwide ecologic study based on open-sourced, anonymized, aggregated data provided by the Israel Ministry of Health. The correlations between municipal SES, vaccination percentage and active COVID-19 cases during the vaccination campaign were analysed by using weighted Pearson correlations. To assess the adequacy of first dose vaccination rollout relative to the municipality COVID-19 disease burden, a metric termed the vaccination need ratio was devised by dividing the total number of active cases (per 10 000 people) by the vaccination percentage of the population over 60 in each municipality, and its correlation with the SES was examined. RESULTS: 23 days after initiation of the vaccination campaign, 760 916 (56.8%) individuals over the age of 60 were vaccinated in Israel with the first dose of the BNT162b2 COVID-19 vaccine. A negative correlation was found between the COVID-19 active case burden and the vaccination percentage of the study population in each municipality (r = -0.47, 95% CI -0.59 to -0.30). The vaccination percentage significantly correlated with the municipal SES (r = 0.83, 95% CI 0.79 to 0.87). This finding persisted but was attenuated over a 5-week period. A negative correlation between the vaccination need ratio and municipal SES (r = -0.80, 95% CI -0.88 to -0.66) was found. DISCUSSION: Lower COVID-19 vaccination percentage was associated with lower SES and high active disease burden. Vaccination efforts should focus on areas with lower SES and high disease burden to assure equality of vaccine allocation and potentially provide a more diligent disease mitigation.
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COVID-19/epidemiología , Aceptación de la Atención de Salud/estadística & datos numéricos , Vacunación/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , COVID-19/prevención & control , Vacunas contra la COVID-19/administración & dosificación , Humanos , Programas de Inmunización , Israel/epidemiología , Persona de Mediana Edad , Factores de Riesgo , SARS-CoV-2/inmunología , Clase Social , Factores SocioeconómicosRESUMEN
BACKGROUND: Pregestational excessive body mass index (BMI) is linked to an increased risk for gestational diabetes mellitus (GDM), but less is known on the effect of adolescent BMI on GDM occurrence. The study aimed to investigate possible associations of adolescent BMI and changes in BMI experienced before first pregnancy, with gestational diabetes risk. METHODS: This retrospective study was based on linkage of a military screening database of adolescent health status (Israel Defence Forces) including measured height and weight, with medical records (Maccabi Healthcare Services, MHS) of a state-mandated health provider. The latter covers about 25% of the Israeli population; about 90% of pregnant women undergo screening by the two-step Carpenter-Coustan method. Adolescent BMI was categorized according to Center of Disease Control and Prevention percentiles. Only first documented pregnanies were analyzed and GDM was the outcome. FINDINGS: Of 190,905 nulliparous women, 10,265 (5.4%) developed GDM. Incidence proportions of GDM were 5.1%, 6.1%, 7.3%, and 8.9% among women with adolescent normal BMI, underweight, overweight, and obesity (p<0.001), respectively. In models that accounted for age at pregnancy, birth year, and sociodemographic variables, the adjusted odd ratios (aORs) for developing GDM were: 1.2 (95%CI, 1.1-1.3), 1.5 (1.4-1.6), and 1.9 (1.7-2.1) for adolescent underweight, overweight, and obesity (reference group, normal BMI). Adolescent BMI tracked with BMI notes in the pre-pregnancy period (r=63%). Resuming normal pre-pregnancy BMI from overweight or obesity in adolescence diminished GDM risk, but this diminished risk was not observed among those who returned to a normal per-pre-pregnancy BMI from being underweight in adolescence. Sustained overweight or obesity conferred an aOR for developing GDM of 2.5 (2.2-2.7); weight gain from adolescent underweight and normal BMI to pre-pregnancy excessive BMI conferred aORs of 3.1 (1.6-6.2) and 2.6 (2.2-2.7), respectively. INTERPRETATION: Change in BMI status from adolescence to pre-pregnancy may contribute to GDM risk. Identifying at-risk populations is important for early preventive interventions. FUNDING: None.
RESUMEN
BACKGROUND: A survey conducted among Israel Defense Force primary care physicians in 2001 revealed that they consider patients' needs more than they do organizational needs and that the education PCPs currently receive is inadequate. In 2003 the medical corps initiated a multi-format continuous medical education program aimed at improving skills in primary care medicine. OBJECTIVES: To measure and analyze the effect of the tailor-made CME program on PCPs' self-perception 3 years after its implementation and correlate it to clinical performance. METHODS: In 2006 a questionnaire was delivered to a representative sample of PCPs in the IDF. The questionnaire included items on demographic and professional background, statements on self-perception issues, and ranking of roles. We compared the follow-up survey (2006) to the results of the original study (2001) and correlated the survey results with clinical performance as measured through objective indicators. RESULTS: In the 2006 follow-up survey PCPs scored higher on questions dealing with their perception of themselves as case managers (3.8 compared to 4.0 on the 2001 survey on a 5 point scale, P = 0.046), perceived quality of care and education (3.5 vs. 3.8, P = 0.06), and on questions dealing with organizational commitment (3.5 vs. 3.8, P = 0.01). PCPs received higher scores on clinical indicators in the later study (odds ratio 2.05, P < 0.001). CONCLUSIONS: PCPs in the IDF perceived themselves more as case managers as compared to the 2001 survey. A tailor-made CME program may have contributed to the improvement in skills and quality of care.
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Educación Médica Continua/organización & administración , Rol del Médico , Médicos de Atención Primaria , Atención Primaria de Salud , Autoimagen , Adulto , Actitud del Personal de Salud , Competencia Clínica , Femenino , Humanos , Israel , Masculino , Encuestas y CuestionariosRESUMEN
OBJECTIVE: To compare pain during laminaria insertion after lidocaine spray versus placebo spray anesthesia in women about to undergo a surgical abortion procedure. STUDY DESIGN: A double blind, randomized, placebo-controlled trial of women at 12-24â¯weeks gestation one day prior to surgical uterine evacuation procedure. Participants received lidocaine 10% or placebo (saline 0.9%) spray to the endocervix and ectocervix two minutes before laminaria insertion. The primary outcome was participants' pain score immediately after initial laminaria insertion, measured using a 10â¯cm visual analog scale (VAS). Secondary outcomes included scores at speculum removal and 15â¯min after speculum insertion. RESULTS: From 7/2016 through 8/2018, we enrolled 68 and 66 women to the lidocaine and placebo groups, respectively. Baseline characteristics were similar in both groups. The primary outcome did not differ between lidocaine and placebo groups (median VAS 2.0 vs. 2.0 respectively, pâ¯=â¯0.69). Reported VAS after speculum removal and 15â¯min from speculum insertion were similar in the lidocaine and placebo groups (median 2.0, pâ¯=â¯0.99; median 1.0 vs. 1.5 respectively, pâ¯=â¯0.32). In multivariate analyses, lidocaine use was associated with decreased VAS score at 15â¯min from speculum insertion [95%CI -0.96 (-1.74 to -0.18), pâ¯=â¯0.016]. Reported VAS ≥7 at 1st laminaria insertion did not differ between lidocaine and placebo groups (5.88% vs. 10.61% respectively, pâ¯=â¯0.362). CONCLUSION: In women scheduled for laminaria insertion prior to surgical uterine evacuation at 12-24â¯weeks gestation, topical application of lidocaine spray to the cervix before insertion did not result in lower reported pain as compared with placebo. IMPLICATIONS: Our results imply that physicians should not use topical application of lidocaine spray to the cervix before laminaria insertion to reduce women's pain. Continued efforts must be made to find means to relieve pain by using simple, effective analgesia or adjusting the technique, and not using a tenaculum whenever possible.
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Anestesia , Laminaria , Anestésicos Locales , Cuello del Útero , Método Doble Ciego , Femenino , Humanos , Lidocaína , EmbarazoRESUMEN
OBJECTIVES: To assess the association between sleep disorders prevalence and obesity in Israeli adolescents. METHODS: A nationwide, population-based, cross-sectional study of 1,348,817 Israeli adolescents (57% males) who were medically examined prior to military service between 1997 and 2015; height and weight were measured along with assessment of medical status at age 17.3⬰±â¬°0.4 years. The diagnosis of a sleep disorder was made based on objective diagnostic criteria. The prevalence and odds ratio (OR) for a sleep disorder were computed across BMI subgroups and were adjusted for socio-demographic confounders. RESULTS: Overall sleep disorders prevalence was 1.8:1000 (males) and 0.45:1000 (females), with a total of 1601 cases. There was a gradual increase in the odds ratio for sleep disorders with increasing BMI. Multivariable-adjusted ORs for sleep disorders were 1.29 (95% CI 1.10â¬1.52), 1.44 (1.18â¬1.75), 3.03 (2.32â¬3.96) and 3.38 (1.98â¬5.75) for overweight, obese class I, II and III, respectively (5thâ¬49th BMI percentile was the reference). Results persisted in extensive sensitivity analyses including limiting the study sample to participants with unimpaired health. CONCLUSIONS: We found a higher prevalence of sleep disorders in males and a dose-dependent association between sleep disorders and adolescent BMI in both sexes. Our findings warrant clinical awareness among healthcare providers, given the rise in obesity in teenagers, and particularly in light of the obesity epidemic that we are experiencing in this era. Sleep related complaints should be actively screened in adolescents who suffer obesity.
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Obesidad , Trastornos del Sueño-Vigilia , Adolescente , Índice de Masa Corporal , Estudios Transversales , Femenino , Humanos , Masculino , Sobrepeso , PrevalenciaRESUMEN
BACKGROUND: Obesity has been established as a causal factor for several types of cancer, and adolescent obesity is increasing worldwide. We examined associations between measured body-mass index (BMI) at age 17 years and cancer incidence, and with mortality among those who developed cancer. METHODS: In a nationwide, population-based cohort of adolescents, height and weight were measured at pre-recruitment mandatory medical examination during 1967-2010. BMI was classified according to US Center for Disease Control and Prevention percentiles. We applied Cox proportional hazard models to estimate the hazard ratios (HRs) and 95% CIs for incident cases of cancer using the 5th-49th BMI percentile group as a reference. The primary outcome was any cancer diagnosis between Jan 1, 1967, and Dec 31, 2012, as recorded in the Israeli National Cancer Registry. Participants with a diagnosis of cancer at baseline (before military recruitment assessment) were excluded from this analysis. The secondary outcome of this study was all-cause mortality among cohort members who had cancer, between Jan 1, 1967, and Dec 31, 2017. FINDINGS: Of the 2â458â170 participants examined between Jan 1, 1967, and Dec 31, 2010, 160â040 were excluded. 2â298â130 participants of which 928â110 were women and 1â370â020 were men. During 29â542â735 person-years of follow-up in men, 26â353 incident cases of cancer were recorded and in 18â044â863 person-years of follow-up in women, 29â488 incident cases of cancer were recorded. Cancer incidence increased gradually across BMI percentiles. The adjusted HR was 1·26 (95% CI 1·18-1·35) among men with adolescent obesity. Among women, we found no association between obesity and overall cancer, driven by inverse associations of obesity with cervical and breast cancers. When these cancers were excluded, the adjusted HR for cancer was 1·27 (1·13-1·44) among women with adolescent obesity. In both sexes, high BMI (≥85th percentile) was associated with an increased cancer risk after 10 years. This association was accentuated in the late period of the cohort versus the early period of the cohort. BMI was positively associated with a higher risk of mortality. The projected population attributable risk for high BMI was 5·1% (4·2-6·1) for men and 5·7% (4·2-7·3) for women. INTERPRETATION: The increasing prevalence of adolescent obesity and the possible association between adolescent BMI and cancer incidence might increase the future burden of obesity-related cancers. BMI among adolescents could constitute an important intervention target for cancer prevention. FUNDING: None.
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Índice de Masa Corporal , Neoplasias/etiología , Sobrepeso/complicaciones , Obesidad Infantil/complicaciones , Sistema de Registros/estadística & datos numéricos , Adolescente , Adulto , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Israel/epidemiología , Masculino , Neoplasias/epidemiología , Pronóstico , Factores de Riesgo , Tasa de Supervivencia , Adulto JovenAsunto(s)
Defensa Civil , Medicina Militar , Personal Militar , Servicios de Salud del Trabajador , Guerra , Heridas y Lesiones , Defensa Civil/métodos , Defensa Civil/organización & administración , Femenino , Humanos , Israel , Masculino , Incidentes con Víctimas en Masa , Medicina Militar/educación , Medicina Militar/métodos , Medicina Militar/normas , Evaluación de Necesidades , Servicios de Salud del Trabajador/métodos , Servicios de Salud del Trabajador/organización & administración , Mejoramiento de la Calidad , Enseñanza , Heridas y Lesiones/etiología , Heridas y Lesiones/terapiaRESUMEN
INTRODUCTION: The aim of this study was to assess the correlation between fetal lateral ventricle width and biometric measurements. MATERIAL AND METHODS: A prospective study on 335 fetuses, 101 fetuses with isolated mild ventriculomegaly and a control group of 234 fetuses with a normal US examination. All fetuses underwent a detailed brain ultrasound scan and a full biometric evaluation. To further compare biometric parameters, we matched, according to gestational week and gender, 91 fetuses from the study group to 91 fetuses from the control group. RESULTS: The mean gestational week during the exam was significantly different between the groups (29.6 weeks in the study group versus 28.3 in the control group, p = .001). The mean maternal age, obstetrical history, mode of conception, or fetal gender did not differ between the groups. After matching according to gestational age and fetal gender, the mean gestational week between the matched groups did not differ and was 29 + 5 weeks in both groups. The study group had significantly larger head circumference (p = .009), biparietal diameter (p < .001), femur length (p = .023), and estimated fetal weight (p = .024) compared with the control group. CONCLUSIONS: Isolated mild ventriculomegaly could be related to other larger fetal biometric measurements and does not necessarily mean a pathological condition.
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Peso Fetal/fisiología , Ventrículos Laterales/diagnóstico por imagen , Malformaciones del Sistema Nervioso/diagnóstico , Adulto , Estudios de Casos y Controles , Femenino , Edad Gestacional , Humanos , Ventrículos Laterales/embriología , Masculino , Malformaciones del Sistema Nervioso/epidemiología , Malformaciones del Sistema Nervioso/patología , Embarazo , Valores de Referencia , Índice de Severidad de la Enfermedad , Ultrasonografía PrenatalRESUMEN
OBJECTIVES: No study thus far has evaluated the LUS thickness in active labor. In this study, we endeavored to assess the LUS during active labor. METHODS: Using transabdominal sonography in the mid-sagittal position with a full urinary bladder, the thickness of the LUS was measured during active labor phase in women with or without a history of a previous cesarean section. RESULTS: A total of 28 women with a previous cesarean delivery were compared to 29 women without a history of uterine surgery. The median LUS was significantly thinner in women with a uterine scar both during (4 versus 5 mm, p = .001) and between contractions (5 versus 7 mm, p = .011). Paired comparison of LUS thickness between and during contractions within each group showed that thinning of LUS during contraction was significant for both the previous CS group (p < .001) and the control group (p < .001). We found no correlation between LUS thickness and chances of successful TOLAC. CONCLUSIONS: In this study, we characterized for the first time the LUS during active labor. We found that LUS was significantly thinner in women after a previous CS and that the LUS was significantly thinner during contraction.
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Cicatriz/diagnóstico por imagen , Trabajo de Parto , Contracción Uterina , Útero/diagnóstico por imagen , Adulto , Cesárea/efectos adversos , Cicatriz/etiología , Cicatriz/fisiopatología , Femenino , Humanos , Embarazo , Estudios Prospectivos , Ultrasonografía Prenatal , Útero/fisiologíaRESUMEN
BACKGROUND: Hemorrhage is a leading cause of preventable death on the battlefield. Timely tourniquet application to massively bleeding extremity wounds is critical for casualty survival albeit with reported adverse effects to extremity integrity. The aim of this study was to describe the immediate- and short-term outcomes of point of injury (POI) tourniquet applications during "Operation Protective Edge" (OPE). METHODS: A case series study regarding tourniquet application at the POI during OPE was collected. The data gathered included reports by medical providers at the POI, aerial and land evacuation vehicles, and receiving hospitals. Variables collected included, the number of tourniquet applications, caregiver level, tourniquet type, limb characters, tourniquet effectiveness, in-hospital procedures, complications, and short-term limb outcome. RESULTS: During OPE, the Israeli Defense Forces Medical Corps treated 704 casualties. Of these, 90 casualties were treated with 119 tourniquets of which 79 survived. Penetrating trauma was the mechanism of injury in 97.8% (88 of 90) of the casualties. Injuries sustained from improvised explosive devices and shrapnel were related to the use of more than one tourniquet per casualty and per limb (p = 0.034). The success rate of the first tourniquet was reported to be 70% (84 of 119), regardless of caregiver level (p = 0.56), tourniquet type (p = 0.16), or limb characters (p = 0.48). Twenty-seven (25.7%) of 105 of the tourniquets were converted to direct pressure dressings enroute to receiving hospitals two of the conversions failed and thus a new tourniquet was applied. Fasciotomy was performed on eight casualties (a single limb in each). Vascular injury was presumed to be the indication for fasciotomy in three of these cases, in the other five limbs (6%, 5 of 85), no vascular involvement was discovered during surgery, and the fasciotomy is suspected as tourniquet related. 7%) 6 of 85) suffered from neurological sequela that could not be explained by their primary injury. Total complication rate was 11.7% (10 of 85) (one patient had both fasciotomy and neural complication without vascular injury). CONCLUSION: Tourniquet use on the battlefield is a simple method of eliminating preventable death, we believe that clinical practice guidelines should promote liberal use of tourniquets by trained combatants and medical personnel with abilities to convert to direct pressure hemorrhage control when possible since an unjustified tourniquet application risks low rates minor morbidity, whereas a justifiable tourniquet not applied may be lethal. LEVEL OF EVIDENCE: Epidemiologic study, level III; Therapeutic study, level IV.