Association Between Body Mass Index and Nonspecific Recurrent Low Back Pain in Over 600,000 Healthy Young Adults.

An association between body mass index (BMI; weight (kg)/height (m)2) and low back pain (LBP) has long been debated, but inconsistent measurements of BMI and varying definitions of LBP have produced conflicting findings. We explored this association using measured BMI and physician documentation of recurrent LBP among healthy young adults. Data were extracted from the Israel Defense Forces electronic medical record system. All Israeli citizens with compulsory military service during January 2008-March 2019 were included (n = 705,840). Exclusion criteria were spine deformities, disc pathologies, spinal surgeries, arthropathies, connective tissue diseases, pain syndromes, low bone density disorders, cancers, and psychiatric illnesses. LBP was defined as electronic medical record system documentation of 1) 2 medical visits at least 6 weeks apart with a diagnosis of LBP or "LBP with radiation" or 2) 1 medical visit resulting in referral to an orthopedic surgeon. Logistic regression models were used to explore the association between BMI category and LBP; 619,969 (87.8%) individuals (mean age = 18.9 (standard deviation, 0.97) years; 56.9% male) were included. LBP prevalence was 9.2% (n = 56,918) and higher among males (9.7%) than females (8.5%). Overweight (odds ratio = 1.123, 95% confidence interval: 1.096, 1.151) and obesity (odds ratio = 1.137, 95% confidence interval: 1.096, 1.179) were associated with LBP. The association remained significant after accounting for various sociodemographic factors. Maintaining a healthy BMI may aid in the prevention of LBP in young adults.

Occupational Exposure to Nonionizing Radiation and Risk for Malignancy in Young Adults.

INTRODUCTION: Nonionizing radiation (NIR) is considered "possibly carcinogenic to humans," and therefore, exposure of young military personnel raises concerns regarding increased risk for cancer. The aim of our study was to compare the cancer incidence in exposed and nonexposed populations in order to gain better understanding of their risk. MATERIALS AND METHODS: A longitudinal retrospective cohort study, between 2009 and 2018, was conducted. Israel Defense Forces (IDF) aerial defense units service members, with NIR exposure (range of 2-300 GHz, below the International Commission of Non-Ionizing Radiation Protection guidelines), were compared with a similar sociodemographic group of service members without NIR exposure. Both groups were followed for cancer incidence (all-cause and specific malignancies). Kaplan-Meier analysis of cancer-free survival and univariate and multivariable logistic regressions for possible confounders and risk factors were performed. This analysis was repeated on a matched 1:1 control group. RESULTS: Exposure and comparison groups included 3,825 and 11,049 individuals, respectively. Forty-one cases diagnosed with cancer were identified during the follow-up time (mean 4.8 [±2.7] years), 13 (0.34%) of which were reported in the exposure group, and 28 (0.25%) were reported in the comparison group. The odds ratio (OR) for cancer incidence in the exposure vs. control groups was 1.34 (95%CI, 0.70-2.60), P-value = 0.3807. The results remained unchanged after adjustment for sex, age at enrollment, service length, socioeconomic status, and military occupation (adjOR = 1.38 [95%CI, 0.67-2.82], P = 0.3818). CONCLUSIONS: Our study did not find an increased short-term risk for cancer in young adults exposed to NIR radiation as compared with unexposed young adults.

B.1.1.7 Variant Outbreak in an Air Force Military Base-Real-World Data.

OBJECTIVE: To assess the clinical features and infectivity of variant B.1.1.7 among healthy young adults in a military setting. MATERIALS AND METHODS: Positive cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a single military base (March 23, 2020 and February 16, 2021) were included. An epidemiological investigation conducted via phone included questions regarding symptoms, exposure history, smoking status, list of contacts, and recently visited places. Symptoms surveyed included fever, cough, shortness of breath, sore throat, loss of smell or taste, gastrointestinal symptoms (GI), headache, chest pain, and constitutional symptoms. Cases were divided before B.1.1.7 first reported case in Israel (December 23, 2020) (period 1) and after its identification (period 2). Symptom distribution and the risk of a contact to be infected were compared between the periods, using a chi-square test, and a negative binominal regression model, respectively. RESULTS: Of 293 confirmed cases, 89 were reported in the first period and 204 in the second. 56.0% were men with a median age of 19.5 years (interquartile range 18.6-20.5). GI symptoms, loss of taste or smell, headache, fever, and chills were more prevalent in the first period (P < .001, P = .026, P = .034, P = .001, and P < .001, respectively), while fatigue was more common in the second period (P = .008). The risk of a contact to be infected was three times higher in the second period (relative risk = 3.562 [2.414-5.258]). CONCLUSION: An outbreak of SARS-CoV-2 in young healthy adults, during a period with high national-wide B.1.1.7 variant prevalence, is characterized by decreased prevalence of fever, loss of taste or smell and GI symptoms, increased reports of fatigue, and more infected contacts for each index case.

Manual Pressure Points Technique for Massive Hemorrhage Control-A Prospective Human Volunteer Study.

BACKGROUND: While commonly thought to be effective for management of limb and junctional hemorrhage, the manual pressure points technique was excluded from leading prehospital guidelines over a decade ago following the publication of a single human-volunteers study presenting unfavorable results. This work aimed to re-assess the efficacy and feasibility of the femoral and supraclavicular pressure points technique for temporary hemorrhage control distal to the pressure point. METHODS: A prospective, non-randomized, human volunteer, controlled environment study. In the study 35 healthy male combat medics (age 21.1 ± 1.3 years) received brief training after which they were requested to apply pressure in the femoral and supraclavicular points in attempts to stop regional blood flow, measured distally by Doppler ultrasound. Success rates in achieving flow cessation in under 2 minutes, time required for achievement of flow cessation, and cumulative flow cessation duration within a 3-minute follow-up after initial success were measured. RESULTS: For the supraclavicular point, success rates were 97.1% with a mean time to success of 12.5 (±20.9) seconds, lasting for 76.2% (±23.7) of the follow-up time. For the femoral point, success rates were 100% with a mean time to success of 5.5 (±4.3) seconds, lasting for 98.7% (±3.8) of the follow-up time. CONCLUSIONS: Manual pressure on the femoral and supraclavicular points is an applicable and efficient method for temporary hemorrhage control distal to the pressure point. As such, with additional study, this method may be considered for re-introduction to prehospital care guidelines and training programs.

Association between SARS-CoV-2 infection and the physical fitness of young-adult cadets: a retrospective case-control study.

OBJECTIVES: To determine the association of symptomatic and asymptomatic mild COVID-19 and the SARS-CoV-2 viral load with the physical fitness of army cadets. DESIGN: A retrospective case-control study. SETTING: Officers' Training School of the Israel Defense Forces. PARTICIPANTS: The study included all cadets (age, 20.22±1.17 years) in the combatant (n=597; 514 males, 83 females; 33 infected, all males) and non-combatant (n=611; 238 males, 373 females; 91 infected, 57 females, 34 males) training courses between 1 August 2020 and 28 February 2021. COVID-19 outbreaks occurred in September 2020 (non-combatants) and January 2021(combatants). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measures were the aerobic (3000 m race) and anaerobic (combatant/non-combatant-specific) physical fitness mean score differences (MSDs) between the start and end of the respective training courses in infected and non-infected cadets. Secondary outcome measures included aerobic MSD associations with various COVID-19 symptoms and SARS-CoV-2 viral loads. RESULTS: SARS-CoV-2 infection led to declined non-combatant and combatant aerobic fitness MSD (14.53±47.80 vs -19.19±60.89 s; p<0.001 and -2.72±21.74 vs -23.63±30.92 s; p<0.001), but not anaerobic. The aerobic physical fitness MSD decreased in symptomatic cadets (14.69±44.87 s) and increased in asymptomatic cadets (-3.79±31.07 s), but the difference was statistically insignificant (p=0.07). Symptomatic cadets with fever (24.70±50.95 vs -0.37±33.87 s; p=0.008) and headache (21.85±43.17 vs 1.69±39.54 s; p=0.043) had more positive aerobic physical fitness MSD than asymptomatic cadets. The aerobic fitness decline was negatively associated with viral load assessed by the RNA-dependent RNA polymerase (n=61; r = -0.329; p=0.010), envelope (n=56; r = -0.385; p=0.002) and nucleus (n=65; r = -0.340; p=0.010) genes. CONCLUSIONS: SARS-CoV-2 infection was associated with a lingering decline in aerobic, but not anaerobic, fitness in symptomatic and asymptomatic young adults, suggesting possible directions for individualised symptom-dependent and severity-dependent rehabilitation plans' optimisation.

Effectiveness of REGEN-COV antibody combination in preventing severe COVID-19 outcomes.

REGEN-COV, a combination of the monoclonal antibodies casirivimab and imdevimab, has been approved as a treatment for high-risk patients infected with SARS-CoV-2 within five days of their diagnosis. We performed a retrospective cohort study, and used data repositories of Israel's largest healthcare organization to determine the real-world effectiveness of REGEN-COV treatment against COVID-19-related hospitalization, severe disease, and death. We compared patients infected with Delta variant and treated with REGEN-COV (n = 289) to those infected but not-treated with REGEN-COV (n = 1,296). Demographic and clinical characteristics were used to match patients and for further adjustment as part of the C0x model. Estimated treatment effectiveness was defined as one minus the hazard ratio. Treatment effectiveness of REGEN-COV was 56.4% (95% CI: 23.7-75.1%) in preventing COVID-19 hospitalization, 59.2% (95% CI: 19.9-79.2%) in preventing severe COVID-19, and 93.5% (95% CI: 52.1-99.1%) in preventing COVID-19 death in the 28 days after treatment. In conclusion, REGEN-COV was effective in reducing the risk of severe sequelae in high-risk COVID-19 patients.

Return to Flying Duties Following a COVID-19 Booster Dose.

INTRODUCTION: Israel began vaccinating with the booster dose of the Pfizer-BioNTech vaccine in July 2021, before the Food and Drug Administration (FDA) authorized the vaccine in September 2021. The first and second vaccines were shown to have several side effects that could possibly affect aircrews' fitness to fly. Thus, the Israel Air Force (IAF) decided on a disqualification period of 24 h following the first vaccine, and 48 h following the second vaccine. The aim of this study was to determine the disqualification period following the booster dose of the vaccine.METHODS: A survey was conducted among IAF aviators in the Aeromedical Center (AMC) in order to characterize the side effects and their duration following a Pfizer-BioNTech COVID-19 vaccine booster dose.RESULTS: The most common local side effect was injection site pain. The most common systemic side effects were general weakness, fatigue, and myalgia. Duration of side effects was up to 48 h from vaccine administration among the majority of aircrew members.CONCLUSION: The IAF AMC policy for the Pfizer-BioNTech COVID-19 vaccine booster dose recipients is to disqualify from flight for 48 h following the vaccination.Ekshtein A, Hay G, Shapira S, Ben-Ari O. Return to flying duties following a COVID-19 booster dose. Aerosp Med Hum Perform. 2022; 93(7):593-596.

Remote Damage Control Resuscitation: A Case Report of Hemorrhagic Shock Secondary to Multiple Gunshot Wounds.

Hypovolemic shock is the leading cause of preventable death on the battlefield. Remote damage control resuscitation has evolved dramatically in the past decade by introducing novel treatments and approaches to bleeding in the prehospital setting. This report presents a case of a casualty who sustained multiple gunshot wounds to the chest and gluteal regions and suffered from hemorrhagic shock with an Injury Severity Score of 34. The casualty was treated at the point of injury and during evacuation according to the IDF's remote damage control resuscitation algorithm utilizing the range of blood products available in the IDF. Prompt identification of the mechanism of injury, clinical and tactical decision-making, and immediate advanced medical care through several prehospital medical evacuation platforms culminated in this casualty's survival. This case emphasizes the importance of medical advancements in prehospital field care and guideline-directed treatment to improve casualty survival.

Humanitarian Medical Aid Mission in the Middle of a Pandemic - Israeli Experience in Equatorial Guinea.

INTRODUCTION: In March 2021, a series of explosions shook a military base in Bata, Equatorial Guinea. As a response to government officials' request, the Israel Defense Forces Medical Corps (IDF-MC) deployed an emergency aid team that faced two major challenges: (1) understanding the scenario, the injury patterns, and the needs of the local medical system; and (2) minimizing the coronavirus disease 2019 (COVID-19) outbreak threats. This report describes the team design, the activities performed before and during the deployment, analyzes the pathology encountered, and shares lessons learned from the mission. SOURCES: Data were collected from the delegation protocols and IDF medical records. All activities of the Israeli delegation were coordinated with the local government. OBSERVATIONS: The local authorities reported that a total of 107 people were killed and more than 700 people were wounded. The team was the first international team to arrive at the scene and assisted the local medical teams to treat 231 patients in the three local hospitals and 213 patients in field clinics in the villages surrounding Bata. The COVID-19 pandemic influenced the operation of this mission, and caution measures were activated. ANALYSIS: Unplanned explosions at munitions sites (UEMS) are a growing problem causing the medical teams to face unique challenges. By understanding the expected challenges, the team was reinforced with a plastic surgeon, portable ultrasound devices, a large amount and a variety of antibiotics, whole blood units, and freeze-dried plasma. Rehabilitation experts were needed in some cases in the week following the injury. An important key for the success of this kind of medical aid delegation is the collaboration with the local medical teams, which enhances patient care.

Implementing Lean Techniques to Increase the Efficiency of a Rural Primary Care Clinic: A Prospective Controlled Study.

BACKGROUND: Lean, a management approach focused on identifying and eliminating waste, has been proposed as a solution for shortages in health care. Many studies implementing Lean in health care have lacked adequately designed controls. METHODS: This was a prospective, block randomized, controlled study conducted in a single primary care clinic comprising three primary care providers. A multidisciplinary team constructed a value stream, proposing foci of waste and possible solutions. These were implemented during three consecutive eight-week blocks. A sample was taken of 40 random visits for each physician during each block, and one physician was randomized to implement the interventions while the other two served as controls. RESULTS: Intervention blocks were significantly shorter compared to control blocks, with a mean difference (MD) of -1,190 seconds (s) (95% confidence interval = 1,039-1,342, p < 0.001). This was primarily the result of four interventions: (1) relocating the printer to the front desk (MD -378 s, p < 0.001), (2) adding another parallel working station (MD -258 s uploading the patient's file and MD -138 s uploading the history, p < 0.001 for both), (3) documenting in plain typing (MD -229 s, p < 0.001), and (4) rerouting delayed patients to the next available physician (MD -195 s, p = 0.004). Two steps were modestly lengthened: anamnesis (MD 24 s, p < 0.001) and explaining the diagnosis and treatment plan (MD 11 s, p = 0.001). Average productivity was increased by 1.65 appointments per hour (p < 0.001). Burnout scores decreased from an average of 74 points during control blocks to 63.8 on intervention (p < 0.01). No clinically or statistically significant difference was noted in quality of care, definitivity of treatment, or patient satisfaction (p = 0.83, 0.55, and 0.77, respectively). CONCLUSION: Intrinsically led, multidisciplinary Lean implementation in a rural primary care clinic dramatically shortened the value stream duration, while requiring no extrinsic resources. Widening Lean implementation and research in primary care, particularly in rural settings, may increase the availability and effectiveness of primary care.

COVID-19 Vaccine and Fitness to Fly.

INTRODUCTION: On December 2020 the U.S. Food and Drug Administration (FDA) authorized the emergency use of Pfizer-BioNTech COVID-19 vaccine. This new vaccine has several side effects that can potentially impair function, which warrants special attention regarding aircrews fitness to fly following vaccination.METHODS: A survey was conducted in the Israeli Air Force (IAF) Aeromedical Center in order to characterize the side effects and their duration following Pfizer-BioNTech COVID-19 vaccine administration to aviators.RESULTS: The most common side effect was injection site pain. Headache, chills, myalgia, fatigue, and weakness were more common following the second dose administration. The difference is statistically significant. Following the second vaccine, duration of side effects was longer compared to the first vaccine (P-value 0.002).CONCLUSION: The IAF Aeromedical center policy for Pfizer-BioNTech COVID-19 vaccine recipients among aircrew members, based on side effects duration and severity, is to temporarily ground from flight duties for 24 and 48 h following the first and the second dose, respectively.Gabbai D, Ekshtein A, Tehori O, Ben-Ari O, Shapira S. COVID-19 vaccine and fitness to fly. Aerosp Med Hum Perform. 2021; 92(9):698701.

Military Aviators with Inflammatory Bowel Diseases Continued Flying.

INTRODUCTION: Military aviators are likely to be first diagnosed with inflammatory bowel diseases (IBD) during military service. Current recommendations support continuing flying with restrictions, but risks may be significant. The aim of the study was to document the long-term results of aviators newly diagnosed with IBD. METHODS: A prospective observational study over a 23-yr period included all Israeli Air Force (IAF) aviators with IBD. Primary end point was the qualification and safety to continue operational flying following IBD diagnosis. RESULTS: Subjects were 16 male aviators with an average follow-up of 130 mo. Average age was 27 (2045) and average time from symptoms onset to final diagnosis was 7.3 mo. Eight (50%) patients had Crohns disease (CD), and the other eight had ulcerative colitis (UC). Eight (50%) were high performance platform aviators. Two patients received biologic treatment, two were treated with repeated corticosteroid courses, and four with immunosuppressive therapy. Two patients underwent surgery and four needed different lengths of hospitalizations. Eight (50%) aviators (3 CD, 5 UC) were grounded for a mean of 177 d (5590). Altogether grounding for IBD aviators was 46/2087 mo (2.2%). Most grounding periods were short term and reversible. All aviators continued flying under annual monitoring or as needed and no compromise of their abilities was documented. CONCLUSIONS: All aviators were able to continue flying and no events of sudden incapacitation or severe disabling flares have been seen among patients. Our study findings support the current recommendation to continue flying when IBD is in stable remission. Tehori O, Koslowsky B, Gabbai D, Shapira S, Ben-Ari O. Military aviators with inflammatory bowel diseases continued flying. Aerosp Med Hum Perform. 2021; 92(10):831834.

Data Empowerment of Decision-Makers in an Era of a Pandemic: Intersection of "Classic" and Artificial Intelligence in the Service of Medicine.

BACKGROUND: The COVID-19 outbreak required prompt action by health authorities around the world in response to a novel threat. With enormous amounts of information originating in sources with uncertain degree of validation and accuracy, it is essential to provide executive-level decision-makers with the most actionable, pertinent, and updated data analysis to enable them to adapt their strategy swiftly and competently. OBJECTIVE: We report here the origination of a COVID-19 dedicated response in the Israel Defense Forces with the assembly of an operational Data Center for the Campaign against Coronavirus. METHODS: Spearheaded by directors with clinical, operational, and data analytics orientation, a multidisciplinary team utilized existing and newly developed platforms to collect and analyze large amounts of information on an individual level in the context of SARS-CoV-2 contraction and infection. RESULTS: Nearly 300,000 responses to daily questionnaires were recorded and were merged with other data sets to form a unified data lake. By using basic as well as advanced analytic tools ranging from simple aggregation and display of trends to data science application, we provided commanders and clinicians with access to trusted, accurate, and personalized information and tools that were designed to foster operational changes and mitigate the propagation of the pandemic. The developed tools aided in the in the identification of high-risk individuals for severe disease and resulted in a 30% decline in their attendance to their units. Moreover, the queue for laboratory examination for COVID-19 was optimized using a predictive model and resulted in a high true-positive rate of 20%, which is more than twice as high as the baseline rate (2.28%, 95% CI 1.63%-3.19%). CONCLUSIONS: In times of ambiguity and uncertainty, along with an unprecedented flux of information, health organizations may find multidisciplinary teams working to provide intelligence from diverse and rich data a key factor in providing executives relevant and actionable support for decision-making.

[IMPLEMENTING AMBULATORY BLOOD PRESSURE MONITORING (ABPM) IN THE PRIMARY CLINIC].

BACKGROUND: Hypertension (HTN) is the leading reversible risk factor for cardiovascular morbidity and all-cause mortality. Screening is currently based on office blood pressure measurement (OBPM) - a method that is neither sensitive nor specific in detecting true HTN. Home blood pressure monitoring, which is often used to confirm and follow-up the diagnosis of HTN, is limited in its ability to detect certain blood pressure (BP) patterns that are harmful, and not covered by Israeli health insurers. Over the last two decades, the alternative and gold standard - 24 hours ambulatory blood pressure monitoring (ABPM) has become cheap and easy to use, but it is virtually nonexistent in primary care clinics. METHODS: This research aims to assess the clinical and distributional benefits of operating an ABPM in the primary clinic, without utilising any additional external resources besides the ABPM monitor, which was borrowed for this purpose from the regional Israeli Defense Force's Medical Corps (IDFMC) health-care center. All service-members in a medium sized Israeli Air Force (IAF) airbase were screened for HTN using OBPM. Inclusion criteria were BP over 130/85 at least once during the past two years or a personal or family history of HTN. Exclusion criteria were any antihypertensive medication taken over the past 6 months, renal dysfunction or secondary HTN. RESULTS: A total of 2167 patients were screened, of whom 64 (2.9%) met selection criteria. Of these, 56 (87.5%) responded to our invitation and performed full OBPM on three separate occasions. During an 8 weeks long lease 46 of 47 (96.4%) available slots were utilized - 2.19 times more efficient than the regional clinic average utilization rate. Of 18 patients who have been diagnosed with HTN in the past, 13 (72.2%) met the criteria on OBPM but only 6 (46.1%) of these were confirmed as having HTN on ABPM. The positive predictive value (PPV) of abnormally high BP on OBPM for the diagnosis of HTN on ABPM averaged 41.3%. The negative predictive value (NPV) of normal OBPM was 80% and 83.4%, for patients diagnosed in the past with HTN or having risk factors (obesity and family history), respectively. CONCLUSIONS: The therapeutic, prognostic and economic implications of the diagnosis of HTN necessitate the utilization of an accurate diagnostic tool. Recent advancements, making ABPM affordable and easy to use, combined with the immediate and dramatic clinical implications witnessed when ABPM was used in our clinic, necessitate a closer look at the need to make ABPM available at the primary clinic.

Emergency Care Provided by the Israeli Military Airborne Combat Evacuation Unit during Helicopter Winch Rescue Operations.

OBJECTIVES: The objective of this study was to evaluate the emergency care provided by the Israeli Military Airborne Combat Evacuation Unit (MACEU) during helicopter winching operations. Methods: A retrospective cohort study was performed of all patients rescued by winching by the MACEU between December 2011 and October 2018. Data were extracted from the electronic medical records of the unit registry. The data collected included helicopter type, scene times, demographics, mechanism of injury, interventions, medications, and survival. Results: During the study period, 208 civilians with a mean age of 36.8 ± 19.2 years were evacuated from inaccessible areas, 192 were from difficult terrain, 10 from sea vessels, and 5 from floods. All patients were winched up with a crewmember. No patient or crewmember was injured during winching. Overall, 156/208 (75%) had a traumatic injury, and 52/208 (25%) had a medical emergency. Sikorsky UH-60 "BlackHawk" helicopters and Sikorsky CH-53 "Sea Stallion" helicopters were used in 179 and 28 operations, respectively. Eighteen different procedures were performed by the medical personnel of the unit on scene and en route. The most performed procedures were peripheral vascular access establishment (60.6%), fluids administration (57.7%), oxygen supplementation (42.8%), analgesia (39.9%) and spine immobilization (37.5%). On scene, none of the patients was treated with a physician-only intervention. Thirty/208 (14.5%) patients were winched-up in darkness conditions. Eleven/208 (5.3%) apneic breathing patients were winched up ventilated by a crewmember. All the six patients who had oxygen saturation ≥89% after entrance into the cabin, survived. Conclusions: The reported MACEU experience provides useful information on the clinical characteristics, medical interventions, and outcomes of patients rescued using a winching operation. Study findings emphasize the importance of airway management and ventilation during winching.

Mental Adaptation to Capsule Work During COVID-19 Outbreak: The Case of Israeli Air Force Career Personnel.

OBJECTIVE: Dealing with the COVID-19 outbreak required a rapid adjustment to an unfamiliar and unique situation. The current study aimed to identify the challenges faced by Israeli Air Force (IAF) career personnel. METHOD: A survey was conducted on 550 participants during the first wave of the COVID-19 outbreak. The participants completed a questionnaire that dealt with unique challenges (personal, family, and command). RESULTS: Of 550 respondents, 54% reported low mood and irritability, 44% reported a constant feeling of anxiety, and 29% reported having sleep problems. Most of them (66%) were mainly concerned about infecting their family. The shift from normal work conditions to an unfamiliar capsule configuration concerned 58% of respondents. Functional continuity concerned 55% of respondents. Managing subordinates concerned 50% of the participants. Of the three types of challenges analyzed (personal, family, and command), the command challenge was the only one where the personal variables (military role, rank, and marital status) made no difference. Finally, about 30% of all respondents reported they needed professional support in dealing with the new circumstances. Their preferred platform was an easily accessible hotline. CONCLUSIONS: Life under the COVID-19 threat increased stress factors in the military career population. While reporting greater challenges and higher levels of stress, most of the respondents preferred a brief, focused consultation adjusted to the situation rather than conventional psychological help. The command challenge and the perceived responsibility stood above and beyond all variables examined in the present study.

Severe pediatric war trauma: A military-civilian collaboration from retrieval to repatriation.

BACKGROUND: Modern conflicts take a disproportionate and increasing toll on civilians and children. Since 2013, hundreds of Syrian children have fled to the Israeli border. Severely injured children were triaged for military airborne transport and brought to civilian trauma centers in Israel. After recovery, these patients returned to their homes in Syria.We sought to describe a unique model of a coordinated military-civilian response for the stabilization, transport, and in-hospital management of severe pediatric warzone trauma. METHODS: Prehospital and in-hospital data of all severe pediatric trauma casualties transported by military helicopters from the Syrian border were extracted. Data were abstracted from the electronic medical records of military and civilian medical centers' trauma registries. RESULTS: Sixteen critically injured children with a median age of 9.5 years (interquartile range [IQR], 6.5-11.5) were transported from the Syrian border to Level I and Level II trauma centers within Israel. All patients were admitted to intensive care units. Eight patients underwent lifesaving procedures during flight, 7 required airway management, and 5 required thoracostomy. The median injury severity score was 35 (IQR, 13-49). Seven laparotomies, 5 craniotomies, 3 orthopedic surgeries, and 1 skin graft surgery were performed. The median intensive care unit and hospital length of stay were 6 days (IQR, 3-16) and 34 days (IQR, 14-46), respectively. Fifteen patients survived to hospital discharge and returned to their families. CONCLUSION: The findings of this small cohort suggest the benefits of a coordinated military-civilian retrieval of severe pediatric warzone trauma. LEVEL OF EVIDENCE: Therapeutic, Level V.

Injuries associated with the use of ejection seats: a systematic review, meta-analysis and the experience of the Israeli Air Force, 1990-2019.

INTRODUCTION: All modern military jet aircraft are equipped with rocket-assisted ejection systems. Jet aircraft operate in the majority of the conflict regions throughout the world, and in nearly all modern countries during peacetime. Civilian and military emergency services may be called upon to treat aircrews that have ejected and should be familiar with the common injury patterns associated with aircraft ejection. METHODS: A systematic review and meta-analysis of the literature were undertaken using the preferred reporting for systematic reviews and meta-analyses (PRISMA) methodology. Peer-reviewed journal and conference papers published between 1 January 1971 and 15 June 2019 were included. Our primary outcomes of interest were mortality and major injury rates. The I2 test was used to assess heterogeneity among the included studies, and data were pooled under random effects models. In addition, all ejection cases in the Israeli Air Force (IAF) between 1990 and 2019 were studied. The data were manually extracted from the accident records and the electronic medical records system. RESULTS: We identified 14 studies that included 1710 aircrew ejections. Heterogeneity was high (I2>75%). Pooled mean mortality and major injury rates were 10.5% (95% CI 6.8-14.8%) and 29.8% (95% CI 20.1-40.6%), respectively. The major injuries included spinal fractures (61.6%), extremity trauma (27.3%), and head trauma (8.9%). During the IAF study period, a total of 37 aircrew ejected from 26 IAF aircraft. The fatality rate was 5.4% and 18.9% suffered major injuries. CONCLUSIONS: Although ejection is lifesaving, it is associated with unique injury patterns that should be addressed during clinical evaluation. Because of their high prevalence, spinal precautions are paramount until spinal injury can be ruled out, generally by advanced imaging. Looking forward, injury patterns will continue to evolve in parallel with improving ejection seat systems.

Effect of High-Dose, Short-Duration ß-Alanine Supplementation on Circulating IL-10 Concentrations During Intense Military Training.

Hoffman, JR, Gepner, Y, Hoffman, M, Zelicha, H, Shapira, S, and Ostfeld, I. Effect of high dose, short-duration ß-alanine supplementation on circulating IL-10 concentrations during intense military training. J Strength Cond Res 32(10): 2978-2981, 2018-This study examined the effect of ß-alanine as a potential anti-inflammatory agent during intense military training. Twenty soldiers (20.1 ± 0.6 years) from an elite combat unit were randomly assigned to either a ß-Alanine (BA) or placebo (PL) group. Soldiers were provided with 12 g·d of either BA or PL for 7 days between 2 intensive periods of navigational training and restricted sleep. During the initial training period, soldiers navigated on average 27.8 km·d with ∼50% of their body mass in their packs for 5 days. Soldiers returned to base and began a 7-day supplementation program before departing for an additional period of intense field training. During the second period of field training, soldiers navigated 10 km·d for an additional 5 days, carrying similar loading as the initial week, performed tactical missions, and slept approximately 5 hours per day. Blood samples were obtained after the initial training period and after the second training period and analyzed for IL-10. Magnitude-based inferences that were used to provide inferences on the true effect BA may have had on IL-10 concentrations compared with PL, calculated from 90% confidence intervals. Data analysis indicated that changes in circulating IL-10 concentrations (mean difference 0.86 pg·ml) were possibly greater (57%) for BA than PL. Results of this study suggest that 1 week of high-dose BA ingestion may enhance the anti-inflammatory response during intense military training, suggesting a potential therapeutic role of BA during intense training.

Prevalence of Iron Deficiency and Iron Deficiency Anemia in Strenuously Training Male Army Recruits.

OBJECTIVES: The objectives of our study were to determine the effect of strenuous physical training on the prevalence of iron deficiency anemia (IDA), iron deficiency (ID) with normal hemoglobin (Hb), and anemia without ID. METHODS: Our study was a prospective observational study. We followed 115 healthy male recruits in the Israel Defense Forces elite units during 15 months of training. Blood samples were collected at recruitment and at 6-, 9- and 15-month follow-ups. RESULTS: Upon recruitment, anemia (Hb < 14 g/dL), ID, and ID anemia (IDA) were diagnosed in 28, 31, and 9% of individuals, respectively. Sixty-three subjects (54%) were followed for 6 months; 9 of them (14%) developed new-onset IDA. Among them, the prevalence of anemia rose from 19 to 52%, and ID from 33 to 35%. At the 15-month follow-up, 29% had developed new-onset IDA and 65% showed evidence of ID. CONCLUSION: We report a high prevalence of anemia, ID, and IDA among young healthy males participating in prolonged strenuous training programs. These findings can be partly explained by the physiological changes associated with strenuous physical activity. Further investigations aiming to develop specific diagnostic guidelines for this unique population are warranted.