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BACKGROUND: A significant factor for the high prevalence of traumatic brain injury (TBI) among U.S. service members is their exposure to explosive munitions leading to blast-related TBI. Our understanding of the specific clinical effects of mild TBI having a component of blast mechanism remains limited compared to pure blunt mechanisms. OBJECTIVE: The purpose of this review is to provide a synopsis of clinical research findings on the long-term effects of blast-related mild TBI derived to date from the Long-Term Impact of Military-Relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC). METHODS: Publications on blast-related mild TBI from LIMBIC-CENC and the LIMBIC-CENC prospective longitudinal study (PLS) cohort were reviewed and their findings summarized. Findings from the broader literature on blast-related mild TBI that evaluate similar outcomes are additionally reviewed for a perspective on the state of the literature. RESULTS: The most consistent and compelling evidence for long-term effects of blast-related TBI is for poorer psychological health, greater healthcare utilization and disability levels, neuroimaging impacts on brain structure and function, and greater headache impact on daily life. To date, evidence for chronic cognitive performance deficits from blast-related mild TBI is limited, but futher research including crucial longitudinal data is needed. CONCLUSION: Commentary is provided on: how LIMBIC-CENC findings assimilate with the broader literature; ongoing research gaps alongside future research needs and priorities; how the scientific community can utilize the LIMBIC-CENC database for independent or collaborative research; and how the evidence from the clinical research should be assimilated into clinical practice.
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INTRODUCTION: Emergency airway management is critical in trauma care. Cricothyroidotomy (CRIC) is a salvage procedure commonly used in failed endotracheal intubation (ETI) or difficult airway cases. However, more data is needed regarding the short and long-term complications associated with CRIC. This study aimed to evaluate the Israel Defense Forces experience with CRIC over the past 2 decades and compare the short-term and long-term sequelae of prehospital CRIC and ETI. METHODS: Data on patients undergoing either CRIC or ETI in the prehospital setting between 1997 and 2021 were extracted from the Israel Defense Forces trauma registry. Patient data was then cross-referenced with the Israel national trauma registry, documenting in-hospital care, and the Israel Ministry of Defense rehabilitation department registry, containing long-term disability files of military personnel. RESULTS: Of the 122 patients with short-term follow-up through initial hospitalization, 81% underwent prehospital ETI, while 19% underwent CRIC. There was a higher prevalence of military-related and explosion injuries among the CRIC patients (96% versus 65%, P = 0.02). Patients who underwent CRIC more frequently exhibited oxygen saturations below 90% (52% versus 29%, P = 0.002). Injury Severity Score was comparable between groups.No significant difference was found in intensive care unit length of stay and need for tracheostomy. Regarding long-term complications, with a median follow-up time of 15 y, CRIC patients had more upper airway impairment, with most suffering from hoarseness alone. One patient in the CRIC group suffered from esophageal stricture. CONCLUSIONS: This retrospective comparative analysis did not reveal significant short or long-term sequelae among military personnel who underwent prehospital CRIC. The long-term follow-up did not indicate severe aerodigestive impairments, thus suggesting that this technique is safe. Along with the high success rates attributed to this procedure, we recommend that CRIC remains in the armamentarium of trauma care providers. The findings of this study could provide valuable insights into managing difficult airway in trauma care and inform clinical decision-making in emergency settings.
Subject(s)
Cricoid Cartilage , Intubation, Intratracheal , Military Personnel , Humans , Retrospective Studies , Intubation, Intratracheal/statistics & numerical data , Intubation, Intratracheal/adverse effects , Intubation, Intratracheal/methods , Military Personnel/statistics & numerical data , Male , Adult , Female , Cricoid Cartilage/surgery , Israel/epidemiology , Airway Management/methods , Airway Management/statistics & numerical data , Treatment Outcome , Young Adult , Thyroid Cartilage/surgery , Emergency Medical Services/statistics & numerical data , Registries/statistics & numerical data , Middle Aged , Follow-Up StudiesABSTRACT
OBJECTIVE: To examine the association between late adolescence ADHD and the risk of serious injury in early adulthood. METHOD: A nationwide cohort study utilizing data from the Military Health Examinations Database for potential military recruits (age 16.5-18 years), cross-referenced with the Israeli National Trauma Registry (2008-2020). Individuals with and without ADHD (mild/severe) were compared for early adulthood injury risk using Cox models. RESULTS: This study compared 76,403 participants with mild ADHD (18.76%) and 330,792 without (81.24%), alongside 2,835 severe ADHD participants (1.11%) versus 252,626 without (98.89%). Adjusted hazard ratios for injury-related hospitalization were 1.27 (95% CI [1.17, 1.37]) for mild ADHD and 1.40 (95% CI [1.09, 1.79]) for severe ADHD, compared to non-ADHD. CONCLUSIONS: Adolescents with ADHD, regardless of severity, had a significantly higher risk of hospitalization due to injury that persists into early adulthood, underscoring the importance of recognizing ADHD as an injury risk and incorporating it into injury prevention strategies.
Subject(s)
Attention Deficit Disorder with Hyperactivity , Hospitalization , Wounds and Injuries , Humans , Attention Deficit Disorder with Hyperactivity/epidemiology , Israel/epidemiology , Adolescent , Male , Female , Wounds and Injuries/epidemiology , Cohort Studies , Hospitalization/statistics & numerical data , Young Adult , Military Personnel/statistics & numerical data , Military Personnel/psychology , Adult , Registries , Risk FactorsABSTRACT
Background: Trauma laparotomy (TL) remains a cornerstone of trauma care. We aimed to investigate prehospital measures associated with in-hospital mortality among casualties subsequently undergoing TLs in civilian hospitals. Methods: This retrospective cohort study cross-referenced the prehospital and hospitalization data of casualties treated by Israel Defense Forces-Medical Corps teams who later underwent TLs in civilian hospitals between 1997 and 2020. Results: Overall, we identified 217 casualties treated by IDF-MC teams that subsequently underwent a TL, with a mortality rate of 15.2% (33/217). The main mechanism of injury was documented as penetrating for 121/217 (55.8%). The median heart rate and blood pressure were within the normal limit for the entire cohort, with a low blood pressure predicting mortality (65 vs. 127, p < 0.001). In a multivariate analysis, prehospital endotracheal intubation (ETI), emergency department Glasgow coma scores of 3-8, and the need for a thoracotomy or bowel-related procedures were significantly associated with mortality (OR 6.8, p < 0.001, OR = 48.5, p < 0.001, and OR = 4.61, p = 0.002, respectively). Conclusions: Prehospital interventions introduced throughout the study period did not lead to an improvement in survival. Survival was negatively influenced by prehospital ETI, reinforcing previous observations of the potential deleterious effects of definitive airways on hemorrhaging trauma casualties. While a low blood pressure was a predictor of mortality, the median systolic blood pressure for even the sickest patients (ISS > 16) was within normal limits, highlighting the challenges in triage and risk stratification for trauma casualties.
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BACKGROUND: Pelvic fractures resulting from high-energy trauma can frequently present with life-threatening hemodynamic instability that is associated with high mortality rates. The role of pelvic exsanguination in causing hemorrhagic shock is unclear, as associated injuries frequently accompany pelvic fractures. This study aims to compare the incidence of hemorrhagic shock and in-hospital outcomes in patients with isolated and non-isolated pelvic fractures. METHODS: Registries-based study of trauma patients hospitalized following pelvic fractures. Data from 1997 to 2021 were cross-referenced between the Israel Defense Forces Trauma Registry (IDF-TR), documenting prehospital care, and Israel National Trauma Registry (INTR) recording hospitalization data. Patients with isolated pelvic fractures were defined as having an Abbreviated Injury Scale (AIS) <3 in other anatomical regions, and compared with patients sustaining pelvic fracture and at least one associated injury (AIS ≥ 3). Signs of profound shock upon emergency department (ED) arrival were defined as either a systolic blood pressure <90 mmHg and/or a heart rate >130 beats per min. RESULTS: Overall, 244 hospitalized trauma patients with pelvic fractures were included, most of whom were males (84.4%) with a median age of 21 years. The most common injury mechanisms were motor vehicle collisions (64.8%), falls from height (13.1%) and gunshot wounds (11.5%). Of these, 68 (27.9%) patients sustained isolated pelvic fractures. In patients with non-isolated fractures, the most common regions with a severe associated injury were the thorax and abdomen. Signs of shock were recorded for 50 (20.5%) patients upon ED arrival, but only four of these had isolated pelvic fractures. In-hospital mortality occurred among 18 (7.4%) patients, all with non-isolated fractures. CONCLUSION: In young patients with pelvic fractures, severe associated injuries were common, but isolated pelvic fractures rarely presented with profound shock upon arrival. Prehospital management protocols for pelvic fractures should prioritize prompt evacuation and resuscitative measures aimed at addressing associated injuries.
Subject(s)
Fractures, Bone , Pelvic Bones , Registries , Shock, Hemorrhagic , Humans , Shock, Hemorrhagic/etiology , Shock, Hemorrhagic/epidemiology , Male , Female , Pelvic Bones/injuries , Israel/epidemiology , Adult , Fractures, Bone/epidemiology , Middle Aged , Emergency Medical Services/statistics & numerical data , Incidence , Adolescent , Young Adult , Abbreviated Injury Scale , Injury Severity ScoreABSTRACT
BACKGROUND: Prehospital traumatic cardiac arrest (TCA) is associated with a poor prognosis and requires urgent interventions to address its potentially reversible causes. Resuscitative efforts of TCA in the prehospital setting may entail significant resource allocation and impose added tolls on caregivers. The Israel Defense Forces Medical Corps (IDF-MC) instructs clinicians to perform a set protocol in the case of TCA, providing prompt oxygenation, chest decompression and volume resuscitation. This study investigates the settings, interventions, and outcomes of TCA resuscitation by IDF-MC teams over 25 years in both combat and civilian settings. METHODS: Retrospective study of the IDF-MC Trauma Registry between 1997-2022. Search criteria were applied to identify cases where the TCA protocol was initiated. A manual review of cases matching the search criteria was performed by two curators to determine the indications, interventions, and outcomes of casualties with prehospital TCA. Patients for whom interventions were performed outside of the TCA protocol, such as with measurable vital signs, were excluded. The primary outcome was survival to hospital admission, with the secondary outcome being return of vital signs in the prehospital setting. RESULTS: Following case review, 149 patients with prehospital TCA were included, with a median age of 21 (interquartile range 19-27). Eighty-four (56.4%) presented with TCA in military or combat settings, with gunshot wounds and blast injuries being the most common mechanisms in this group. For 56 casualties (37.8%), all components of the protocol were performed (oxygenation, chest decompression, and volume resuscitation). Five (3.4%) casualties had return of vital signs in the prehospital setting, but none survived to hospital admission. CONCLUSION: The prognosis of prehospital TCA is poor, and efforts to address its potentially reversible causes may often be futile. These notions may be further emphasized in military settings, where resources are limited, and extensive penetrating injuries are more common.
Subject(s)
Emergency Medical Services , Heart Arrest , Wounds, Gunshot , Humans , Retrospective Studies , Israel , Wounds, Gunshot/complications , Wounds, Gunshot/therapy , Emergency Medical Services/methods , RegistriesABSTRACT
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.
Subject(s)
Contusions , Thoracic Injuries , Wounds, Gunshot , Wounds, Nonpenetrating , Male , Humans , Young Adult , Adult , Protective Clothing , Wounds, Gunshot/complications , Wounds, Nonpenetrating/complications , Wounds, Nonpenetrating/diagnosis , Contusions/complicationsABSTRACT
BACKGROUND: Posttraumatic stress disorder (PTSD) is prevalent among military personnel and may arise following a wide range of traumatic exposures. Consciousness level following traumatic injury may play a role in the development of PTSD, but its effects have been primarily investigated in the context of traumatic brain injury. METHODS: Registry-based study surveying three databases documenting care from point of injury to long-term rehabilitation of traumatic injuries among military personnel. The study population was divided according to Glasgow Coma Scale (GCS) scores upon emergency department admission (GCS scores 15, 13 and 14, 9-12, and 3-8), with PTSD diagnoses being determined according to disability claim records. Multivariable logistic regression was utilized to determine the association between GCS score at admission and PTSD. RESULTS: Overall, 3,376 military personnel hospitalized following traumatic injuries between 1997 and 2020 were included. The majority were male (92.3%), with a median age of 20 (interquartile range 19-22) at the injury time. Of these, 569 (16.9%) were diagnosed with PTSD according to disability claims, with a median follow-up time of 10.9 years. PTSD diagnosis was most prevalent (30.3% of patients), with a GCS score of 13 and 14. In the adjusted multivariable model, a GCS score of 13 and 14 was associated with significantly higher odds of PTSD diagnosis when compared to a GCS score of 15 (odds ratio 2.19, 95% CI, 1.21-3.88). The associations of other GCS groupings with PTSD diagnosis were nonsignificant. CONCLUSIONS: Minimally impaired consciousness following traumatic injuries is associated with increased odds of PTSD. The role of patient awareness, analgesia, and sedation following an injury in developing PTSD warrants further investigation and could guide early diagnosis and preventive interventions.
Subject(s)
Brain Injuries, Traumatic , Military Personnel , Stress Disorders, Post-Traumatic , Humans , Male , Female , Glasgow Coma Scale , Stress Disorders, Post-Traumatic/complications , Stress Disorders, Post-Traumatic/epidemiology , Brain Injuries, Traumatic/diagnosisABSTRACT
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.
Subject(s)
Military Personnel , Wounds and Injuries , Humans , Blood Transfusion/methods , Ambulances , Israel , Hemorrhage/therapy , ABO Blood-Group System , Wounds and Injuries/therapyABSTRACT
BACKGROUND: Trauma care teams play a crucial role in determining the outcomes of trauma victims. The composition and training of these teams can vary. Our study seeks to examine the characteristics of successful military Advanced Life Support (ALS) teams and the factors that affect them. METHODS: A retrospective study was conducted at the Israel Defense Force (IDF) Military Medical Academy throughout 2021, where prehospital medical teams were observed in trauma care simulations. Teams were led by ALS providers (military physicians or paramedics) trained in IDF Military Trauma Life Support. Demographic and training data were collected. Teams were categorized into high or subpar performance groups based on simulation scores. Specific skills were assessed by trauma instructors using a points system. Scores were compared between the groups and analyzed for correlations with demographic and training data. RESULTS: Overall, 63 team simulations were analyzed, with teams led by a military paramedic in 78% of simulations. The mean overall simulation performance was 81% ±6.2, and there were no differences in scores of single or multicasualty simulations. A total 3% of the teams achieved successful results and were more likely to have a paramedic as the ALS provider ( p = 0.028). A sensitivity analysis excluding physicians was conducted and showed that high-performance teams had significantly higher skill assessments for primary survey ( p = 0.004), injury recognition ( p = 0.002), exposure ( p = 0.006), adherence to clinical practice guidelines ( p = 0.032), and medical device use ( p = 0.002). CONCLUSION: Our study found that ALS provider is associated with overall simulation performance in prehospital ALS teams, with military paramedics more likely to be successful. These findings have implications for the training and staffing of prehospital ALS teams, suggesting that teams should be composed accordingly and that training should focus on skills affected by the ALS provider type. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.
Subject(s)
Emergency Medical Services , Emergency Medical Technicians , Military Personnel , Humans , Emergency Medical Services/methods , Retrospective Studies , IsraelABSTRACT
BACKGROUND: Warzone humanitarian medical aid missions are infrequent and applying lessons from these missions is vital to ensuring preparedness for future crises. Between 2013-2018, the Israel Defense Forces Medical Corps (IDF-MC) provided humanitarian medical aid to individuals injured in the Syrian Civil War who chose to seek medical assistance at the Israeli-Syrian border. Patients requiring care surgical or advanced care were transferred to civilian medical centers within Israel. This study aims to describe the injury characteristics and management of hospitalized Syrian Civil War trauma patients over a five-year period. METHODS: Retrospective cohort analysis cross-referencing data from the IDF trauma registry, documenting prehospital care, and the Israel National Trauma Registry, documenting in-hospital care, between 2013 and 2018. Syrian trauma patients hospitalized in Israeli hospitals were cross-referenced between the two registries. Multivariable logistic regression was applied to identify independent factors associated with in-hospital mortality. RESULTS: Overall, 856 hospitalized trauma patients were included following definitive cross-matching. The median age was 23 years, and 93.3% were males. Blast (n = 532; 62.1%) and gunshot (n = 241; 28.2%) were the most common injury mechanisms. Injury Severity Score was ≥25 for 28.8% of patients and most common body regions with severe injury (Abbreviated Injury Scale≥3) were the head (30.7%) and thorax (25.0%). Intensive care unit admission was required for 40.1% of patients, and the median hospital stay was 13 days. In-hospital mortality was recorded for 73 (8.5%). Signs of shock upon emergency department admission and severe head injury were significantly associated with mortality in the adjusted model whereas age of <18 years was associated with decreased odds for in-hospital mortality. CONCLUSIONS: Trauma patients hospitalized in Israel following injuries sustained in the Syrian Civil War were characterized by a high prevalence of blast injuries with concomitant involvement of several body regions. Future missions should ensure preparedness for complex multi-trauma, often involving the head, and ensure high intensive care and surgical capacities.
Subject(s)
Refugees , Relief Work , Male , Humans , Young Adult , Adult , Adolescent , Female , Retrospective Studies , Syria/epidemiology , HospitalsABSTRACT
INTRODUCTION: Limb and junctional hemorrhage are leading causes of potentially preventable death among trauma casualties. Hemorrhage control for these regions could be achieved by direct or indirect pressure. The manual pressure points (MPP) involves applying manual pressure on the arterial supply to occlude distal blood flow without the need for specialized equipment. STUDY DESIGN AND METHODS: Prospective, non-randomized, human volunteer, controlled environment study involving 38 healthy military caregivers, with 26 participants attending a short instructional session. During a medical exercise, participants were requested to apply pressure on the supraclavicular and femoral points aiming to stop regional blood flow, measured by distal pulse palpation. The measures recorded included achievement of distal pulse cessation, success in achieving cessation for a full minute, and subjects' pain scores reported after each attempt. RESULTS: All participants succeeded in achieving distal pulse cessation for both the supraclavicular and femoral points for a full minute. The median time to initial success was 3.0 (interquartile range 2.0-5.0) seconds in the supraclavicular point and 4.5 (interquartile range 3.0-6.0) seconds in the femoral point. Pain scores ranging between 0 and 3 were reported by most subjects during supraclavicular (68.4%) and femoral occlusion (84.2%). CONCLUSION: The MPP technique was highly effective in occluding distal palpable pulses in healthy volunteers when applied to the supraclavicular and femoral arteries. Brief instruction on the technique can potentially improve the chances of achieving hemorrhage control within 5 s. Further research is required to determine efficacy among different populations and providers with varying experience levels.
Subject(s)
Hemodynamics , Hemorrhage , Humans , Prospective Studies , Hemorrhage/etiology , Femoral Artery/injuries , PainABSTRACT
BACKGROUND: Remote damage control resuscitation (RDCR) aims to apply the principles of damage control resuscitation to prehospital and austere care, emphasizing early control of compressible hemorrhage, balanced volume resuscitation, and the prevention or correction of coagulopathy, acidosis, hypothermia, and hypocalcemia. Over the past decades, the Israel Defense Forces Medical Corps (IDF-MC) has made significant efforts to integrate the principles of RDCR into prehospital trauma care in the military. STUDY DESIGN AND METHODS: In this article, we reflect on the implementation of RDCR in the prehospital setting by the IDF-MC, sharing successes, challenges, considerations on guideline changes, and their assessment over time. RESULTS: The implementation of RDCR has resulted in changes in clinical practice guidelines and training programs, with increased awareness and adoption of RDCR principles among both medical and non-medical military personnel. The implementation of these principles and adherence to guideline changes have been analyzed using the Israel Defense Forces Trauma Registry. DISCUSSION: By sharing our experiences, we hope to provide valuable insights for other military and civilian organizations seeking to adopt similar protocols for prehospital care. Continuous evaluation and refinement of guidelines and training programs will be essential for ongoing implementation and advancement of RDCR in the prehospital setting.
Subject(s)
Military Medicine , Military Personnel , Humans , Israel , Hemorrhage/drug therapy , Resuscitation/methods , Registries , Military Medicine/methodsABSTRACT
BACKGROUND: Hemorrhage is the leading cause of preventable death in trauma patients, and establishment of intravenous (IV) access is essential for volume resuscitation, a key component in the treatment of hemorrhagic shock. IV access among patients in shock is generally considered more challenging, although data to support this notion are lacking. METHODS: In this retrospective registry-based study, data were collected from the Israeli Defense Forces Trauma Registry (IDF-TR) regarding all prehospital trauma patients treated by IDF medical forces between January 2020 and April 2022, for whom IV access was attempted. Patients younger than 16 years, nonurgent patients, and patients with no detectable heart rate or blood pressure were excluded. Profound shock was defined as a heart rate >130 or a systolic blood pressure <90 mm Hg, and comparisons were made between patients with profound shock and those not exhibiting such signs. The primary outcome was the number of attempts required for first IV access success, which was regarded as an ordinal categorical variable: 1, 2, 3 and higher and ultimate failure. A multivariable ordinal logistic regression was performed to adjust for potential confounders. Patients' sex, age, mechanism of injury and best consciousness level, as well as type of event (military/nonmilitary), and the presence of multiple patients were included in the ordinal logistic regression multivariable analysis model based on previous publications. RESULTS: Five hundred thirty-seven patients were included, 15.7% of whom were recorded as having signs of profound shock. Peripheral IV access establishment first attempt success rates were higher in the nonshock group, and there was a lower rate of unsuccessful attempts in this group (80.8% vs 67.8% for the first attempt, 9.4% vs 16.7% for the second attempt, 3.8% vs 5.6% for the third and further attempts, and 6% vs 10% unsuccessful attempts, P = .04). In the univariable analysis, profound shock was associated with requirement for an increased number of IV attempts (odds ratio [OR], 1.94; confidence interval [CI], 1.17-3.15). The ordinal logistic regression multivariable analysis demonstrated that profound shock was associated with worse results regarding primary outcome (adjusted odds ratio [AOR], 1.84; CI, 1.07-3.10). CONCLUSIONS: The presence of profound shock in trauma patients in the prehospital scenario is associated with an increased number of attempts required for IV access establishment.
Subject(s)
Emergency Medical Services , Shock, Hemorrhagic , Wounds and Injuries , Humans , Retrospective Studies , Emergency Medical Services/methods , Hemorrhage/complications , Shock, Hemorrhagic/diagnosis , Shock, Hemorrhagic/therapy , Infusions, Intravenous , Wounds and Injuries/complications , Wounds and Injuries/diagnosis , Wounds and Injuries/therapyABSTRACT
PURPOSE: The analysis of exome and genome sequencing data for the diagnosis of rare diseases is challenging and time-consuming. In this study, we evaluated an artificial intelligence model, based on machine learning for automating variant prioritization for diagnosing rare genetic diseases in the Baylor Genetics clinical laboratory. METHODS: The automated analysis model was developed using a supervised learning approach based on thousands of manually curated variants. The model was evaluated on 2 cohorts. The model accuracy was determined using a retrospective cohort comprising 180 randomly selected exome cases (57 singletons, 123 trios); all of which were previously diagnosed and solved through manual interpretation. Diagnostic yield with the modified workflow was estimated using a prospective "production" cohort of 334 consecutive clinical cases. RESULTS: The model accurately pinpointed all manually reported variants as candidates. The reported variants were ranked in top 10 candidate variants in 98.4% (121/123) of trio cases, in 93.0% (53/57) of single proband cases, and 96.7% (174/180) of all cases. The accuracy of the model was reduced in some cases because of incomplete variant calling (eg, copy number variants) or incomplete phenotypic description. CONCLUSION: The automated model for case analysis assists clinical genetic laboratories in prioritizing candidate variants effectively. The use of such technology may facilitate the interpretation of genomic data for a large number of patients in the era of precision medicine.
Subject(s)
Laboratories, Clinical , Rare Diseases , Humans , Rare Diseases/diagnosis , Rare Diseases/genetics , Laboratories , Artificial Intelligence , Retrospective Studies , Prospective Studies , Exome/geneticsABSTRACT
OBJECTIVES: Tranexamic acid (TXA) administration confers a survival benefit in bleeding trauma patients; however, data regarding its use in pediatric patients are limited. This study evaluates the prehospital treatment with TXA in pediatric trauma patients treated by the Israel Defense Forces Medical Corps (IDF-MC). DESIGN: Retrospective, cohort study using the Israel Defense Forces registry, 2011-2021. PATIENTS: Pediatric trauma patients less than 18 years old. We excluded patients pronounced dead at the scene. INTERVENTIONS: None. SETTING: All cases of pediatric trauma in the registry were assessed for treatment with TXA. Propensity score matching was used to assess the association between prehospital TXA administration and mortality. MEASUREMENTS AND MAIN RESULTS: Overall, 911 pediatric trauma patients were treated with TXA by the IDF-MC teams; the median (interquartile) age was 10 years (5-15 yr), and 72.8% were male. Seventy patients (7.6%) received TXA, with 52 of 70 (74%) receiving a 1,000 mg dose (range 200-1,000 mg). There were no prehospital adverse events associated with the use of TXA (upper limit of 95% CI for 0/70 is 4.3%). Compared with pediatric patients who did not receive TXA, patients receiving TXA were more likely to suffer from shock (40% vs 10.7%; p < 0.001), sustain more penetrating injuries (72.9% vs 31.7%; p < 0.001), be treated with plasma or crystalloids (62.9% vs 11.4%; p < 0.001), and undergo more lifesaving interventions (24.3% vs 6.2%; p < 0.001). The propensity score matching failed to identify an association between TXA and lesser odds of mortality, although a lack of effect (or even adverse effect) could not be excluded (non-TXA: 7.1% vs TXA: 4.3%, odds ratio = 0.584; 95% CI 0.084-3.143; p = 0.718). CONCLUSIONS: Although prehospital TXA administration in the pediatric population is feasible with adverse event rate under 5%, more research is needed to determine the appropriate approach to pediatric hemostatic resuscitation and the role of TXA in this population.
Subject(s)
Antifibrinolytic Agents , Tranexamic Acid , Wounds and Injuries , Humans , Male , Child , Adolescent , Female , Tranexamic Acid/adverse effects , Israel , Cohort Studies , Retrospective Studies , Antifibrinolytic Agents/therapeutic use , Registries , Wounds and Injuries/drug therapyABSTRACT
BACKGROUND/AIMS: Maxillofacial trauma poses a distinct challenge on the modern battlefield, and data on its long-term implications are scarce. The aim of this study was to investigate maxillofacial injury characteristics, outcomes, and complications along the continuum of care among hospitalized military personnel from the pre-hospital setting through long-term rehabilitation. MATERIALS AND METHODS: A registry-based study was undertaken of three national trauma and rehabilitation registries: The Israel Defense Forces Trauma Registry (IDF-TR), which records pre-hospital data. The Israeli National Trauma Registry for in-hospital data and the Israel Ministry of Defense Rehabilitation Department (MOD-RD) registry contain long-term disability data. The cohort comprised IDF soldiers who suffered maxillofacial injuries between 1997 and 2020. RESULTS: A total of 672 patients with maxillofacial injuries were included in the study, and 6.4% of all trauma admissions were related to maxillofacial injuries. Of these, 366 (54%) were injured in non-military (NMC) circumstances, and 306 (46%) were wounded in military circumstances (MC). The mechanisms of injury were mainly traffic-related among the NMC group compared with an explosion in the MC group. Maxillofacial fractures were frequently associated with traumatic brain injuries with higher rates in the NMC group than in the MC group (55% vs. 30%, p < .001). In a multivariate analysis, zygomatic and orbital fractures were associated with higher odds of concomitant head injury. The most common categories of long-term disability included central nervous system disorders, skull injuries, epilepsy, hearing impairment, ophthalmologic conditions, and post-traumatic stress disorder. CONCLUSIONS: Maxillofacial injuries are often associated with concomitant traumatic brain injury. Long-term disabilities associated with these injuries included the central nervous system, hearing, ophthalmologic impairments, and post-traumatic stress disorder.
Subject(s)
Maxillofacial Injuries , Military Personnel , Skull Fractures , Humans , Follow-Up Studies , Hospitalization , Retrospective StudiesABSTRACT
The surge of breakthrough COVID-19 among fully vaccinated individuals has raised the prospects of booster dose administration. In Israel, concerns of waning immunity and dominance of the B.1.617.2 (delta) variant resulted in approval of a third-dose (booster) vaccination for the entire eligible population starting on August 29, 2021. This study aims to evaluate vaccine uptake for booster doses among a population of previously vaccinated individuals during a rapid rollout and to analyze socio-demographic characteristics associated with vaccine uptake. A cross-sectional study among Israel Defense Forces soldiers with high access to booster doses of BNT162b2. Subjects eligible for booster doses were voluntarily vaccinated at three vaccine sites constructed within soldiers' bases. We analyzed associations between subjects' socio-demographic characteristics and booster vaccine uptake at the culmination of vaccine rollout using logistic regression models. 1157 soldiers from an IDF brigade were eligible for third dose vaccination (received second dose > 5-months before rollout), with 978 (84.5%) receiving a third, booster dose during the study's timeframe. Subjects' median age was 20.5 (IQR 19.7-21.5) and 791 (68.4%) were male. Notable socio-demographic characteristics associated with increased vaccine uptake in a multivariable model included increased age (OR 1.16, 95% CI 1.02-1.31), high socio-economic status (OR 2.12, 95% CI 1.25-3.59) and female sex (OR 1.87, 95% CI 1.26-2.74). Below-average cognitive function score was associated with decreased vaccine uptake (OR 0.61, 95% CI 0.39-0.95). This study demonstrates that real-world vaccine hesitancy remains a major obstacle, even among a population previously acceptant to COVID-19 vaccines. Decreased uptake for vaccines may be associated with socio-demographic variables in-spite of high-access vaccine rollouts. Reasons for vaccine hesitancy among previously vaccinated individuals, along with the benefits of population-wide booster administration should be further investigated.
Subject(s)
COVID-19 , Military Personnel , Female , Male , Humans , Young Adult , Adult , COVID-19 Vaccines/therapeutic use , BNT162 Vaccine , Cross-Sectional Studies , Israel/epidemiology , COVID-19/epidemiology , SARS-CoV-2ABSTRACT
INTRODUCTION: Combat ground maneuvers consist of various platforms and have several environmental characteristics, influenced by the terrain, the operational mission, and the force's capabilities. This study assesses data on injuries sustained during urban warfare, aiming to evaluate the relationship between injury characteristics, maneuver platform, and personal protective gear on the battlefield. MATERIALS AND METHODS: IDF soldiers injured infantry soldiers from the "Cast Lead" and the "Protective Edge" operations in the Gaza Strip (2008-2009 and 2014, respectively) were divided into four groups according to the maneuver platform and the environment: mounted infantry (armored and unarmored vehicle) and dismounted infantry (urban and open area). The primary outcome was the severity of the injury, and the secondary outcome was the injured body part. RESULTS: Overall, 588 casualties were included in the final analysis, of whom 507 were dismounted infantry soldiers (265 in open terrain and 242 in urban area) and 81 were mounted infantry soldiers (20 in unarmored and 61 were injured in armored vehicles). The Injury Severity Score was similar in all subgroups. Open terrain subgroups were found to have fewer head injuries and higher levels of lower extremity injuries, similar to the unarmored vehicle group. More facial injuries were documented in the urban area group. CONCLUSIONS: The Injury Severity Score was not influenced by environmental protection. Although we found differences in the injured body parts, further studies on the exact mechanism of injury are needed to elucidate further the relationship and differences between the various platforms used and injuries seen in urban warfare, aiming for tailor-made protection.