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September 11 th events taught us, members of the medical community, that we need to prepared for the worst. Nuclear terror is no longer science fiction. Radiological weapons of mass terror come in three flavors: The first one is nuclear. Since 1992, there have been six known cases of highly enriched uranium or plutonium being intercepted by authorities as it passed in or out of the former Soviet Union. Constructing a nuclear fission weapon requires high-level expertise, substantial facilities, and lots of money. All three of which would be difficult, although not impossible, for a terrorist group to pull off without state support. However, terrorists could carry out potential mass destruction without sophisticated weaponry by targeting nuclear facilities using conventional bombs or hijacked aircrafts. Terror attacks could also carry out mass panic and radioactive contamination of people and environment by dispersal of radioactive materials with or without the use of conventional explosive devices. Most medical and para-medical personnel are not familiar with CBRN terror and radiation casualties. To lessen the impact of those potential attacks and provide care for the greatest number of potential survivors, the community as a whole - and the medical community in particular - must acquire the knowledge of the various signs and symptoms of exposure to irradiation and radioactive contamination as well as have a planned response once such an attack has occurred. Based on knowledge of radiation hazards, medical emergency planers should analyze the risks of each scenario, offer feasible solutions and translate them into internationally accepted plans that would be simple to carry out once such an attack took place. The planned response should be questioned and tested by drills. Those drills should check the triage, evacuation routes, decontamination posts, evacuation centers and receiving hospitals. It is crucial that the drill will consist of simulated casualties that will follow the evacuation route from point zero to the ED. Knowledge and exercise will reduce terror (fear) from radiation and help the community as a whole better cope with such an event. This article will review the general information of radiation types, their biological damage, clinical appearance and general concepts of nuclear event planning, focusing on medical response and focus on the Israeli perspective.

Background: Treatment of paediatric trauma requires specialized infrastructure, medical equipment, medical staff and ancillary support personnel that have been specifically trained for such tasks. Aims and Objectives: To examine the perceptions and attitudes of physicians and nurses in general and paediatric emergency departments (PEDs) on training, confidence, and management of paediatric trauma in order to facilitate the establishment of an optimal model for admitting and treating paediatric trauma patients. Design: Drawing on published literature and a previously conducted qualitative study that explored the provision of medical care to paediatric trauma patients, we conducted an attitude survey. Methods: A 26‐item paper‐based questionnaire was distributed by nurse managers to all staff working within general EDs and PEDs of 22 medical centres across Israel. Results: Of 843 physicians and nurses who completed the survey, 61.1% considered PEDs the most appropriate facility for treating both minor and severe paediatric trauma, 88.5% believed that minor paediatric trauma should be treated in designated paediatric trauma centres, and 53.6% deemed that paediatric emergency medicine specialists are the most suitable primary decision makers in paediatric trauma. PED teams expressed greater professional confidence for treating paediatric trauma and multiple casualty incident patients. Greater professional confidence was positively correlated with paediatric trauma training, greater exposure to paediatric trauma cases, and working in larger medical centres. Conclusions: The results of the current study suggest that PEDs are perceived to be more appropriate for dealing with paediatric trauma. Also, treatment of severe trauma may be more appropriate in centres that admit large numbers of paediatric trauma cases. Relevance to clinical practice: Emergency medicine teams should undergo training for dealing with paediatric trauma. Such training would develop their skills, increase their confidence, and enhance their emotional abilities to cope with paediatric trauma. [ABSTRACT FROM AUTHOR]

Abstract Background During the last decade there has been a need to respond and recover from various types of emergencies including mass casualty events (MCEs), mass toxicological/chemical events (MTEs), and biological events (pandemics and bio-terror agents). Effective emergency preparedness is more likely to be achieved if an all-hazards response plan is adopted. Objectives To investigate if there is a relationship among hospitals' preparedness for various emergency scenarios, and whether components of one emergency scenario correlate with preparedness for other emergency scenarios. Methods Emergency preparedness levels of all acute-care hospitals for MCEs, MTEs, and biological events were evaluated, utilizing a structured evaluation tool based on measurable parameters. Evaluations were made by professional experts in two phases: evaluation of standard operating procedures (SOPs) followed by a site visit. Relationships among total preparedness and different components' scores for various types of emergencies were analyzed. Results Significant relationships were found among preparedness for different emergencies. Standard Operating Procedures (SOPs) for biological events correlated with preparedness for all investigated emergency scenarios. Strong correlations were found between training and drills with preparedness for all investigated emergency scenarios. Conclusions Fundamental critical building blocks such as SOPs, training, and drill programs improve preparedness for different emergencies including MCEs, MTEs, and biological events, more than other building blocks, such as equipment or knowledge of personnel. SOPs are especially important in unfamiliar emergency scenarios. The findings support the adoption of an all-hazards approach to emergency preparedness.

Introduction: The Emergency Department (ED) is the hospital's main gateway, as well as the initial site for diagnosis and emergency medical care. In recent years, ED overcrowding is worsening in Israel and world-wide. Overcrowding has been shown to adversely affect patient service and care, fostering patient and caregiver dissatisfaction, as well as lowering quality of care and even increasing mortality. A main driver of ED overcrowding is ED patient boarding due to limited inpatient bed availability in conjunction with hospital policy. Measuring median length of ED stay (LOS) for admitted vs. discharged patients can serve as a simple indicator for the severity of the access block over time and between facilities. Method: ED operational data from the computerized system of four hospitals in Israel were collected over a year and analyzed. In parallel data was collected regarding hospital capacity and ED volumes. Data were analyzed using SPSS. Results: The Mean ED LOS was significantly higher for ED patients needing admission in all hospitals. Mean ED LOS for admitted vs. discharged patients was 227 min vs.431 in hospital A, 215 min vs. 222 in hospital B, 198 min vs. 440 in hospital C and 167 min vs. 190 in hospital D. The discrepancy in LOS for admitted patients was not related to the total hospital bed capacity or the hospital ED patient volume. Conclusion: ED boarding is a major challenge for ED's and hospitals worldwide and a significant contributor to ED overcrowding. A tool to assess boarding is proposed. The tool calculates the ratio of median ED LOS between patients admitted to the hospital and those discharged. Slightly higher LOS among those admitted is to be expected, considering the fact that they usually present with more complex medical problems. In this study the LOS ratios were 1.03, 1.12, 1.90 and 2.22. [ABSTRACT FROM AUTHOR]

The widespread utilization of social media in recent terror attacks in major European cities should raise a "red flag" for the emergency medical response teams. The question arises as to the impact of social media during terror events on the healthcare system. Information was published well before any emergency authority received a distress call or was requested to respond. Photos published at early stages of the attacks, through social media were uncensored, presenting identifiable pictures of victims. Technological advancements of recent years decrease and remove barriers that enable the public to use them as they see fit. These attacks raise ethical considerations for the patients and their rights as they were outsourced from the medical community, into the hands of the public. The healthcare system should leverage social media and its advantages in designing response to terror, but this requires a re-evaluation and introspection into the current emergency response models. [ABSTRACT FROM AUTHOR]

An increase in the exposure and predisposition of civilian populations to disasters has been recorded in the last decades. In major disasters, as demonstrated recently in Nepal (2015) and previously in Haiti (2010), external aid is vital, yet in the first hours after a disaster, communities must usually cope alone with the challenge of providing emergent lifesaving care. Communities therefore need to be prepared to handle emergency situations. Mapping the needs of the populations within their purview is a trying task for decision makers and community leaders. In this context, the elderly are traditionally treated as a susceptible population with special needs. The current study aimed to explore variations in the level of community resilience along the lifespan. The study was conducted in nine small to mid-size towns in Israel between August and November 2011 (N = 885). The Conjoint Community Resiliency Assessment Measure (CCRAM), a validated instrument for community resilience assessment, was used to examine the association between age and community resilience score. Statistical analysis included spline and logistic regression models that explored community resiliency over the lifespan in a way that allowed flexible modeling of the curve without prior constraints. This innovative statistical approach facilitated identification of the ages at which trend changes occurred. The study found a significant rise in community resiliency scores in the age groups of 61–75 years as compared with younger age bands, suggesting that older people in good health may contribute positively to building community resiliency for crisis. Rather than focusing on the growing medical needs and years of dependency associated with increased life expectancy and the resulting climb in the proportion of elders in the population, this paper proposes that active "young at heart" older people can be a valuable resource for their community. [ABSTRACT FROM AUTHOR]

On September 2013 an attack on the Westgate mall in Kenya led to a four day siege, resulting in 67 fatalities and 175 wounded. During the crisis, Twitter became a crucial channel of communication between the government, emergency responders and the public, facilitating the emergency management of the event. The objectives of this paper are to present the main activities, use patterns and lessons learned from the use of the social media in the crisis. Using TwitterMate, a system developed to collect, store and analyze tweets, the main hashtags generated by the crowd and specific Twitter accounts of individuals, emergency responders and NGOs, were followed throughout the four day siege. A total of 67,849 tweets were collected and analyzed. Four main categories of hashtags were identified: geographical locations, terror attack, social support and organizations. The abundance of Twitter accounts providing official information made it difficult to synchronize and follow the flow of information. Many organizations posted simultaneously, by their manager and by the organization itself. Creating situational awareness was facilitated by information tweeted by the public. Threat assessment was updated through the information posted on social media. Security breaches led to the relay of sensitive data. At times, misinformation was only corrected after two days. Social media offer an accessible, widely available means for a bi-directional flow of information between the public and the authorities. In the crisis, all emergency responders used and leveraged social media networks for communicating both with the public and among themselves. A standard operating procedure should be developed to enable multiple responders to monitor, synchronize and integrate their social media feeds during emergencies. This will lead to better utilization and optimization of social media resources during crises, providing clear guidelines for communications and a hierarchy for dispersing information to the public and among responding organizations. [ABSTRACT FROM AUTHOR]

Perceptions, knowledge and mitigation are factors that might play a role in preventing injury and loss of life during a major earthquake. Little is known about the relationships between different demographic and educational parameters and these factors. A national representative sample of 495 adults was investigated in order to determine the relationship between demographic and educational parameters in terms of the perceived threat, perceived coping, knowledge and mitigation of earthquakes in Israel. Compared to females, males perceived the threat of earthquakes to be lower (t=3.183, p=0.002), manifested higher levels of perceived coping (t=2.55, p=0.011), and had higher levels of earthquake related knowledge (t=2.047, p=0.041). We conclude that there are gender differences in perceptions and knowledge regarding earthquakes. [ABSTRACT FROM AUTHOR]

Knowledge of appropriate behaviour during an earthquake is crucial for prevention of injury and loss of life. The Israeli Home Front Command conducts a yearly earthquake education programme in all Israeli schools, using three types of educational interventions: lectures, drills and a combination of the two. The aim of this study was to evaluate the effectiveness of these interventions in providing students with knowledge. We distributed a questionnaire to 2,648 children from the 5th and 6th grades in 120 schools nationwide. Knowledge scores for both 5th and 6th grades were increased, regardless of type of intervention, compared to the non-exposure group. A combined intervention of lectures and drills resulted in the highest knowledge scores. Our findings suggest that for the age group studied a combination of lectures and drills will likely prepare students best for how to behave in the event of an earthquake. [ABSTRACT FROM AUTHOR]

Terrorist attacks can occur in remote areas causing mass-casualty incidents MCIs far away from level-1 trauma centres. This study draws lessons from an MCI pertaining to the management of primary and secondary evacuation and the operational mode practiced. Data was collected from formal debriefings during and after the event, and the medical response, interactions and main outcomes analysed using Disastrous Incidents Systematic Analysis through Components, Interactions and Results (DISAST-CIR) methodology. A total of 112 people were evacuated from the scene—66 to the nearby level 3 Laniado hospital, including the eight critically and severely injured patients. Laniado hospital was instructed to act as an evacuation hospital but the flow of patients ended rapidly and it was decided to admit moderately injured victims. We introduce a novel concept of a ‘semi-evacuation hospital’. This mode of operation should be selected for small-scale events in which the evacuation hospital has hospitalization capacity and is not geographically isolated. We suggest that level-3 hospitals in remote areas should be prepared and drilled to work in semi-evacuation mode during MCIs. [ABSTRACT FROM AUTHOR]

Background: The primary care physicians in the Israeli Defense Forces, as in the Israeli civilian health system, have two major subpopulations. Graduates of Israeli schools of medicine, and graduates of foreign medical schools, most of them in Eastern Europe. Objective: To evaluate differences in the referral patterns of primary care physicians according to their graduation institution and demographic characteristics. Methods: The study took place in one primary care practice in central Israel. The referrals to consultations and laboratory tests over a period of I year were evaluated. Physicians that had less than 37 encounters were excluded from the study. Data were extracted from the central computerized databases of the Medical Corps and Israeli Defense Forces. Results: Sixty-eight physicians had a total of 18,402 encounters that resulted in 23,845 outcomes. There were no associations between demographic and training backgrounds of the physicians and their actual referral rates to consultations and laboratory tests. Conclusion: The background data of the primary care physicians does not predict their referral patterns and their role as "gate keepers." [ABSTRACT FROM AUTHOR]

Objectives: On 1 November 2004 a suicide bomber detonated himself in Tel Aviv, in a crowded open market space, resulting in 3 dead victims and 34 casualties. This event in a central urban area was handled quickly by experienced emergency medical service (EMS) teams. We analysed evacuation destinations of urgent casualties in order to learn whether severe casualties should all be evacuated to the closest trauma centre. Alternatively, they might be distributed to all nearby hospitals, both trauma and non‐trauma centres. A third possibility is directing urgent casualties only to trauma centres, dividing them between the close trauma centre and a ‘second cycle’ distant level A trauma centre. Methods: Data were collected from formal debriefings carried out after the event in the Ministry of Health, in the Israeli Defense Forces Medical Corps (IDF MCs) and in the Home Front Command (HFC). Other debriefings, in which we took part, were those of the EMS and participating hospitals. We analysed these data to learn about the timetable of the event, the number of EMS ambulances and medical personnel involved in the event, the number of casualties evacuated to each hospital (both primary and secondary evacuation), and the major medical problems (resuscitations, operations) encountered by EMS and by the hospital personnel. Results: Casualties were rapidly treated and evacuated: within 25 minutes of the blast (19 minutes after the arrival of the first ambulance), all urgent casualties had been administered airway and haemorrhage control and evacuated from the site. Seven of eight urgent casualties were evacuated to the closest trauma centre. Reviewing the trauma centre ER work found no bottlenecks either outside or inside the ER. All seven ‘immediate’ victims were treated simultaneously at the emergency department (ED). Two casualties arrived at the ED while being ventilated manually with a bag‐valve‐mask device, and required urgent tracheal intubation. Two urgent laparotomies and two orthopaedic operations were performed. The only immediate victim who was referred to the smaller nearby hospital needed secondary evacuation to a neurosurgical centre. Conclusion: The decision to send almost all severely injured patients to the nearest level A trauma centre, using a ‘save and run’ mode of evacuation, was life‐saving in this event. As this is a study of a single case, further analysis of multiple similar events is needed, to examine whether the PHTLS guidelines regarding preferable evacuation to level A trauma centres can also be applied to small‐scale multi‐casualty incidents in an urban setting. [ABSTRACT FROM AUTHOR]

In recent years, the status of complementary medicine in Israel has appeared frequently on the public agenda. The debates and the newspaper headlines concerned with this subject usually deal with legal aspects of the subject, including the relation between complementary medicine and the medical establishment. With the enactment in 1995 of the Compulsory Health Insurance Law, debate over the issue intensified, with the public divided over any proposal to make complementary medicine part of the services guaranteed by law. This paper addresses the current status of complementary medicine in Israel, describes the introduction of complementary medicine to Israel, attitudes toward it of both consumers and medical professionals, and the question of its legal status. While no comprehensive survey describing all aspects of this subject in Israel has yet been undertaken, this paper is based on a survey of the professional literature in Israel, especially that of the Israeli scientific-medical community, a survey of the general press, and an analysis of the health insurance law and its position with respect to the complementary medicine. [ABSTRACT FROM AUTHOR]

Introduction: Pregnancy is the time in our life representing more than any other period the continuation of life and expectations for a brighter future. Any threat to the well-being of the individual, loss of life in the family or significant property damage may affect the physical and emotional well-being. An earthquake disaster is a rare and unique life-threatening state of major emotional stress; however, the emotional and behavioural effects of this unique scenario have not yet been described in the medical literature. Objective: To study some of the effects of an earthquake disaster experience on pregnant women's behaviour and emotions during and after the earthquake. Patients and Methods: We conducted a survey, using a questionnaire prepared by Israeli and Turkish physicians during the IDF field hospital stay in Adapazari in August 1999. The questionnaire focused on some behavioural and emotional aspects that were experienced by these women during and after the earthquake. The questionnaire was filled in by 15 pregnant women who attended the IDF field hospital after the earthquake in Turkey in August 1999. Results: We found that initially the patients were very concerned about their own lives but instinctively they protected their pregnancy by shielding the abdomen with their hands (53%). The stressful state temporarily affected their perception of fetal movements. Nine patients graded their state as being concerned to extremely concerned on a scale of 1 to 5. Conclusion: Pregnant women are concerned about their own lives as well as about their fetus. A reduction in the perception of fetal movements with a recovery after several hours is common. The psychological effects of a life-threatening disaster on pregnant women should be further investigated by large studies. [ABSTRACT FROM AUTHOR]

The Israel Defense Forces (IDF) Medical Corps provides medical services--routine and emergency--to all IDF personnel (conscripts, career personnel, and reservists). Despite the fact that there are no differences in prevalence of disease in the IDF compared with the civil sector, health consumer appraisal, in the military, of the medical services they receive during peacetime at IDF medical clinics is not high. The objective of this research was to develop an effective and differential tool for monitoring the quality of medical service at IDF clinics drawn from service quality indexes based on the perspective of the soldier patient. The research tool used was an anonymous questionnaire comprised of five demographic questions and 21 components of quality index measurements that participants were asked to rank in terms of importance during a visit to their IDF medical clinic. Those categories found to influence the client's perception of quality medical service were accessibility and availability of services, information provided by the clinic, and the efficiency of staff. The factors found to be less influential in the clients' perceptions of quality were staffing and infrastructure. Quality control using these significant indexes will allow monitoring programs to focus on components that are important from the soldier's perspective, without overlooking other significant aspects of the soldier's perceptions of the quality of medical service as a client. [ABSTRACT FROM AUTHOR]

Community resilience offers a conceptual framework for assessing a community's capacity for coping with environmental changes and emergency situations. It is perceived as a core element of sustainable lifestyle, helping to mitigate the community's reaction to crises by facilitating purposeful and collective action on the part of its’ members. The conjoint community resilience assessment measure (CCRAM) provides a standard measure of community resilience including five factors: leadership, collective efficacy, preparedness, place attachment, and social trust. The mean scores of each the factors portray a community resilience profile and the overall CCRAM score is calculated as the average of the scores of the 21 survey items with an equal weight. Two regression models were employed. Logistic regression, a commonly used tool in the field of applied statistics, and quantile regression, which is a non-parametric method that facilitates the detection of the effect of a regressor on various quantiles of the dependent variable. The study aims to demonstrate the innovative use of quantile regression modeling in community resilience analysis. The results demonstrate that the quantile regression was significantly more sensitive to sub-populations than the logistic regression. Having an income below average, which was negatively correlated with perceived community resilience in the logistic model was found to be significant only in the lower (Q10, Q25) resilience quantiles. Age (per year) and previous involvement in emergency situations which were not noted as significant in the logistic regression, were found to be positively associated with perceived community resilience in the lowest quantile. A difference between quantiles of perceived community resilience was noted in regard to size of community. The association between size of community and perceived community resilience which was negative in the logistic regression (residents of larger towns had lower community resilience), was found to be such only up to quantile 75, but it reversed in the highest quantile. It was concluded that the utilization of quantile regression analysis in studies of community resilience can facilitate the creation of tailored response plans, adapted to the needs of sub (such as weaker) populations and help enhance overall community resilience in crises. [ABSTRACT FROM AUTHOR]

Abstract: Disasters or hazardous incidents, either natural or man-made, continue to increase in frequency and affect more and more citizens of the world community. Many of these are published in the medical literature, each being a “case report” of a single event. In clinical medicine, a common nomenclature and uniform reporting of data enables the collection of similar cases to series studies, with clinical conclusions being drawn. Such a platform is lacking in the field of disaster medicine, impairing the ability to learn from past experiences. In the Medical Department of the Israeli Home Front Command, we coordinate the operation of various medical units and forces in a wide array of events. By doing so, we collect and analyze the relevant data related to disaster management, various components of the medical response, interactions between different components, and the ensuing results. We developed a systematic method of analyzing and describing disaster management issues in various events—DISAST-CIR—Disastrous Incidents Systematic AnalysiS Through Components, Interactions, Results. In this article, we describe this method by presenting the components, interactions, and results of a large-scale train accident that resulted in 270 casualties, 35 of whom were evacuated by helicopters from the accident site. Casualties were distributed among 10 different hospitals. The death toll was 7 people, 5 of whom died at the scene and 2 who died in hospitals. We recommend this method as a standard for scientific reporting of hazardous incidents. Accumulation of data, reported in a similar standardized fashion, would enable comparison and reporting of series, improving our understanding regarding the optimal medical response to various events. [Copyright &y& Elsevier]

Background: The use of magnetic resonance (MR) imaging (MRI) among many medical professions is growing. Many health care systems have formed control mechanisms to ensure proper utilization of MRI. This western world trend is also valid in the Israeli Air Force (IAF). At the time of the study, two methods existed for consideration of MR requests in the IAF: (1) consideration by a primary reviewer, no clinical guidelines (applied to all MR examination requests, knee MR excluded). (2) Consideration by a primary reviewer according to basic clinical guidelines established by the Israeli Defense Forces medical section and by communication with an orthopedic specialist (applied to knee MR requests). Both methods did not include consultation with established criteria (such as American College of Radiology (ACR) appropriateness criteria).Objective: To evaluate the appropriateness of the current regulatory methods of MRI utilization in the IAF by comparing approval/rejection decisions to established ACR criteria.Methods: The study is a retrospective analysis of written records of air force personnel, for whom MRI was requested by a specialist. We gathered information regarding the clinical problem and the final decision concerning approval or rejection of the MRI request. We then consulted with the ACR appropriateness criteria. In case a matching ACR clinical variant was found, an appropriateness value was assigned to the request. Otherwise, the request was noted as "ACR irrelevant". We predetermined to label all studies with an ACR value of 1 to 3 as inappropriate, 4 to 6 as "gray zone," and 7 to 9 as appropriate. We then compared the ACR-based decision to the original outcome of the request.Results: The overall approval rate for MRI requests evaluated by a primary reviewer only was 96%. The overall approval rate for MRI requests evaluated by a primary reviewer, basic clinical guidelines, and specialist consultation was 51%. Among the four most prevalent MR requests types (brain, knee, spine, and shoulder), requests in the 7 to 9 scale (appropriate requests) accounted for 52%. Regarding appropriate requests, there was a 100% approval rate by a primary reviewer only compared with 17% for requests considered by a primary reviewer, basic guidelines, and specialist consultation (83% of appropriate requests were rejected by this method). Requests in the 1 to 3 scale (inappropriate requests) accounted for 3% of all requests. In this group, there was a 100% approval rate by both methods of consideration. Requests in the 4 to 6 scale (gray zone requests) also accounted for 3% of the total and requests which could not be assigned an ACR appropriateness value (ACR-irrelevant requests) accounted for 42% of total requests. The rate of approval of these requests by a primary reviewer only and by a primary reviewer, guidelines, and consultant was 97% and 83%, respectively.Conclusions: Both MR approval mechanisms that were applied in the IAF have not shown a strong correlation with ACR appropriateness criteria, with significant rates of both overuse and underuse of MRI. The high rate of requests that could not be assigned an ACR appropriateness value may indicate a need to broaden the appropriateness criteria coverage of clinical conditions and variants. [ABSTRACT FROM AUTHOR]

Background: In military basic training, stress fractures are a common orthopedic problem. Female recruits have a significantly higher incidence of stress fractures than do male recruits. Because the Israeli Defense Forces opened traditionally male roles in combat units to female recruits, their high risk for stress fractures is of concern.Objective: To compare the prevalence of stress fractures during Israeli Defense Forces anti-aircraft basic training among otherwise healthy young male and female recruits, in terms of anatomic distribution and severity.Design: Ten mixed gender batteries, including 375 male recruits and 138 female recruits, carried out basic training in the Israeli anti-aircraft corps between November 1999 and January 2003. Each battery was monitored prospectively for 10 weeks of a basic training course. During that time, recruits who were suspected of having an overuse injury went through a protocol that included an orthopedic specialist physical examination followed by a radionuclide technetium bone scan, which was assessed by consultant nuclear medicine experts. The assessment included the anatomic site and the severity of the fractures, labeled as either high severity or low severity.Results: Stress fractures were significantly more common among female recruits than among male recruits. A total of 42 male (11.2%) and 33 female (23.91%) recruits had positive bone scans for stress fractures (female:male relative ratio, 2.13; p < 0.001). Pelvic, femur, and tibia fractures were significantly more common among female recruits than among male recruits (p < 0.005). Female recruits had significantly more severe fractures in the tibia (p < 0.05). However, there was no significant difference in the severity of stress fractures in the femur or metatarsals between male and female recruits, as assessed by radionuclide uptake.Conclusions: We recommend that different training programs be assigned according to gender, in which female recruits would have a lower level of target strain or a more moderate incline of strain in the training program throughout basic training. [ABSTRACT FROM AUTHOR]

Background: In military basic training, stress fractures are a common orthopedic problem. Female recruits have a significantly higher incidence of stress fractures than do male recruits. Because the Israeli Defense Forces opened traditionally male roles in combat units to female recruits, their high risk for stress fractures is of concern. Objective: To compare the prevalence of stress fractures during Israeli Defense Forces anti-aircraft basic training among otherwise healthy young male and female recruits, in terms of anatomic distribution and severity. Design: Ten mixed gender batteries, including 375 male recruits and 138 female recruits, carried out basic training in the Israeli anti-aircraft corps between November 1999 and January 2003. Each battery was monitored prospectively for 10 weeks of a basic training course. During that time, recruits who were suspected of having an overuse injury went through a protocol that included an orthopedic specialist physical examination followed by a radionuclide technetium bone scan, which was assessed by consultant nuclear medicine experts. The assessment included the anatomic site and the severity of the fractures, labeled as either high severity or low severity. Results: Stress fractures were significantly more common among female recruits than among male recruits, A total of 42 male 111.2%) and 33 female (23.91%) recruits had positive bone scans for stress fractures (female:male relative ratio, 2.13: p < 0.001). Pelvic, femur, and tibia fractures were significantly more common among female recruits than among male recruits (p < 0.005). Female recruits had significantly more severe fractures in the tibia (p < 0.05). However, there was no significant difference in the severity of stress fractures in the femur or metatarsals between male and female recruits, as assessed by radionuclide uptake. Conclusions: We recommend that different training programs be assigned according to gender, in which female recruits would have a lower level of target strain or a more moderate incline of strain in the training program throughout basic training. [ABSTRACT FROM AUTHOR]