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Chen J, Tsur AM, Nadler R, Beit Ner E, Sorkin A, Radomislensky I, Peleg K, Ben Avi R, Shushan G, Glassberg E, Benov A. Ten-year reduction in thoracic injury-related mortality among Israel Defense Forces soldiers. BMJ Mil Health 2023; 169:510-516. [PMID: 34930818 DOI: 10.1136/bmjmilitary-2021-001986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/06/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION This study aims to describe injury patterns, prehospital interventions and mortality rates of combat-related thoracic injuries during the past decade among Israel Defense Forces (IDF) soldiers before and after implementation of the 2012 IDF-Military Corps 'My Brother's Keeper' plan which included the publication of clinical practice guidelines (CPGs) for thoracic injuries, emphasis on adequate torso protection, introduction of modern life-saving procedures and encouragement of rapid evacuation. METHODS The IDF prehospital trauma registry was reviewed to identify all patients who sustained thoracic injuries from January 2006 to December 2017. IDF soldiers who were injured, died of wounds or killed in action (KIA) were included. These were cross-referenced with the Israel National Trauma Registry. The periods before and after the plan were compared. RESULTS 458 (12.3%) of 3733 IDF soldiers wounded on the battlefield sustained combat-related thoracic injuries. The overall mortality was 44.3% before the CPG and 17.3% after (p<0.001). Most were KIA: 97% (95 of 98) died by 30 June 2012, and 83% (20 of 24) after (p<0.001). Casualties treated with needle thoracostomy before and after CPG were 6.3% and 18.3%, respectively (p=0.002). More tube thoracostomies were performed after June 2012 (16.1% vs 5.4%, p=0.001). Evacuation was faster after June 2012 (119.4 min vs 560.8 min, p<0.001), but the rates of casualties evacuated within 60 min were similar (21.1% vs 25%, p=0.617). CONCLUSIONS Among military casualties with thoracic injuries, the rate of life-saving interventions increased, evacuation time decreased and mortality dropped following the implementation of My Brother's Keeper plan.
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Affiliation(s)
- Jacob Chen
- Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
- Hospital Management, Meir Medical Center, Kefar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A M Tsur
- Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases Israel, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - R Nadler
- Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- General Surgery B, Sheba Medical Center, Ramat Gan, Israel
| | - E Beit Ner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Orthopedic, Shamir Medical Center, Zerifin, Israel
| | - A Sorkin
- Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - I Radomislensky
- Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
- Gertner Institute for Health Policy and Epidemiology, Tel HaShomer, Israel
| | - K Peleg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Gertner Institute for Health Policy and Epidemiology, Tel HaShomer, Israel
| | - R Ben Avi
- Cardiovascular Department and Research Center, Poriya Medical Center, Tiberias, Israel
| | - G Shushan
- Ground Forces Technology Unit, Tel Hashomer, Israel Defense Forces, Ramat Gan, Israel
| | - E Glassberg
- Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
- The Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - A Benov
- Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
- The Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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Gofrit SG, Ohayon-Cohen S, Tsur AM, Rabkin V, Michael Shapira M, Finestone AS. Compliance compromises an interventional study on iron supplementation in female combatants. BMJ Mil Health 2023; 169:27-31. [PMID: 31235618 DOI: 10.1136/jramc-2019-001245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Low iron levels are related to overuse injuries, poor physical performance and cognitive impairments in female recruits. The aim of this study was to evaluate iron supplement compliance in female combatants during basic training, and its effect on haemoglobin (Hgb), ferritin and injuries. METHODS 329 female recruits to light infantry units filled induction questionnaires regarding smoking status, previous overuse injuries and iron deficiency. Blood was drawn for Hgb and ferritin. Subjects with ferritin levels below 20 ng/mL were considered iron depleted and were prescribed a ferrous fumarate supplement. After 4 months of basic training, the subjects completed a follow-up questionnaire regarding overuse injuries, reasons for failure to complete basic training and compliance with iron supplementation. Blood tests were repeated. RESULTS Mean ferritin levels declined during training (from 18.1±18.2 to 15.3±9.6, p=0.01). Compliance with iron supplementation was observed in 26 (26.3%) of the subjects. In compliant subjects, Hgb levels remained constant and ferritin levels increased by 2.9±5.4 (p=0.07). The main reasons for reported non-compliance were forgetfulness, 26 (35.6%), and gastrointestinal side effects, 17 (23.3%). Injuries during training were not found to be associated with iron status. Smokers had a significantly higher rate of reported injuries prior to training (p<0.01). CONCLUSIONS Ferritin levels decline during training. Compliance with iron supplementation is low. Iron supplementation has a significant effect on ferritin levels, even in the non-compliance group. Injuries were not related to iron status in this group. Further research is needed in order to clarify the most appropriate iron supplementation method.
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Affiliation(s)
- Shany Guly Gofrit
- Israel Defense Forces Ground Command, Medical Division, Israel Defense Forces Medical Corps, Ramat Gan, Israel
| | - S Ohayon-Cohen
- Department of Internal Medicine J, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - A M Tsur
- Israel Defense Forces Ground Command, Medical Division, Israel Defense Forces Medical Corps, Ramat Gan, Israel
| | - V Rabkin
- Israel Defense Forces Ground Command, Medical Division, Israel Defense Forces Medical Corps, Ramat Gan, Israel
| | - M Michael Shapira
- Israel Defense Forces Ground Command, Medical Division, Israel Defense Forces Medical Corps, Ramat Gan, Israel
| | - A S Finestone
- Department of Orthopaedic Surgery, Assaf Harofeh MC, affiliated to the Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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Fishman B, Sharon A, Itelman E, Tsur AM, Fefer P, Barbash IM, Segev A, Matetzky S, Guetta V, Grossman E, Maor E. Invasive management in elderly patients with non-ST elevation myocardial infarction is beneficial regardless of frailty status. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Elderly patients are underrepresented in clinical trials evaluating the management of non-ST elevation myocardial infarction (NSTEMI) patients. Moreover, frailty status is often not reported in these trials.
Purpose
To evaluate the association of invasive management with outcome among elderly (≥80) patients presenting with NSTEMI by frailty status.
Methods
Retrospective cohort of consecutive elderly patients who were hospitalized with NSTEMI as a primary clinical diagnosis between 2008 to 2019. Primary outcome was all-cause mortality. Frailty status was estimated as a continuous variable as well as categorized to low, medium, and high. Cox regression models were applied with stratification by frailty status. Additional sensitivity analyses were conducted including propensity score matching (PSM) and inverse probability treatment weighting (IPTW) models.
Results
Study population included 2,317 patients with median age of 86 years (IQR 83–90) of whom 1,243 (54%) were men. Patients who were managed invasively (n=581 [25%]) were less likely to be frail (7% vs. 44%, p<.001). During the follow up (median of 19 months, [IQR 4–41]), 1,599 (69%) patients died. Kaplan Meier survival curves (Figure 1) show that the cumulative probability of death at 19 months was 50% among patients who were managed conservatively compared with 21% among invasively managed patients (p Log rank <.001). In the multivariable Cox model, invasive approach was associated with a significant 39% decrease in the risk of death (95% CI 0.53–0.71). The benefit of invasive approach was consistent among low, medium, and high frailty subgroups with adjusted HRs of 0.74 [0.58–0.93], 0.65 [0.50–0.85] and 0.52 [0.34–0.78], respectively; p for interaction NS). Results were consistent with PSM and IPTW analyses (HR of 0.6 [0.50–0.71] and 0.67 [0.55–0.82], respectively). Additional sensitivity analysis addressing potential immortal time bias and residual confounding yielded similar results.
Conclusions
Invasive approach is associated with improved survival among elderly patients with NSTEMI irrespective of frailty status. Our results support and extend recent ESC recommendations for the management of elderly patients with NSTEMI
Funding Acknowledgement
Type of funding sources: None. Figure 1
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Affiliation(s)
- B Fishman
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - A Sharon
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - E Itelman
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - A M Tsur
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - P Fefer
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - I M Barbash
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - A Segev
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - S Matetzky
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - V Guetta
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - E Grossman
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - E Maor
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
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Epstein D, Strashewsky R, Furer A, Tsur AM, Chen J, Lehavi A. Endotracheal tube fixation time: a comparison of three fixation methods in a military field scenario. BMJ Mil Health 2020; 168:109-111. [PMID: 32205331 DOI: 10.1136/bmjmilitary-2020-001402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/25/2020] [Accepted: 03/01/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Endotracheal intubation is required in many emergency, trauma and prehospital scenarios. Endotracheal tube (ETT) fixation must be stable and quick to apply to enable rapid evacuation and patient transport. This study compares performance times of three common ETT securement techniques which are practical for out-of-hospital and combat scenarios. METHODS We compared the time required by military medics to complete ETT fixation in three techniques-fixation of a wide gauze roll wrapped twice around the head and tied twice around the ETT (GR), using a Thomas Tube Holder (TH) and using a pre-tied non-adhesive tape (PT). 300 military medics were randomised to apply one technique each on a manikin, and time to completion was recorded. RESULTS 300 ETTs were successfully fixated by 300 military medics. Median times to complete ETT fixation by PT and TH techniques were 24 s (IQR (19 to 31) and (IQR 20 to 33), respectively). Both were significantly shorter to apply than the GR technique, with a median time of 57 s (IQR 47 to 81), p<0.001. CONCLUSIONS In time critical situations such as combat, severe trauma, mass casualties and whenever rapid evacuation might improve the clinical outcome, using a faster fixation technique such as Thomas Tube Holder or a pre-tied non-adhesive tape might enable faster evacuation than the use of traditional endotracheal tube fixation techniques.
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Affiliation(s)
- Danny Epstein
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel .,Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - R Strashewsky
- Department of Anesthesiology, Rambam Health Care Campus, Haifa, Haifa, Israel
| | - A Furer
- Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - A M Tsur
- Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - J Chen
- Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - A Lehavi
- Department of Anesthesiology, Rambam Health Care Campus, Haifa, Haifa, Israel.,Department of Anesthesiology, Technion Israel Institute of Technology Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Haifa, Israel
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