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Objective To estimate the potential influence of pre-operative patient condition on the benefit of earlier hip fracture surgery for elderly patients. Background Many studies emphasize the benefit of earlier hip fracture surgery for patient survival. However less is known regarding how this relationship is influenced by clinical factors which could serve as potential contra-indicators for earlier surgery. Rushed surgery of patients with contra-indications may even compromise their survival. Methods A retrospective study of patients aged 65 and above with an isolated hip fracture following trauma, based on data from 19 hospitals of the national trauma registry available for the years 2015–2016. Registry data was crossed with data on co-morbidities and medication intake from the biggest health insurance agency in the country, serving more than 50% of the country's population. Mediation analysis was performed on a wide list of co-morbidities, medications and clinical test results in order to establish the mediation of their relationship with inhospital mortality by earlier hip fracture surgery. Factors found significant in the mediation analysis were utilized to adjust a logistic regression for predicting inhospital mortality by function of waiting time to surgery and patient's sex and age. Results Anti-coagulant and anti-platelet intake; test results pointing to decreased kidney function and being diagnosed with diabetes or Ischemic Heart Disease were found to be significantly mediated in their influence on inhospital mortality by hip fracture surgery. Despite anti-platelet intake and kidney function having a significant impact on mortality in the multi-variate analysis, the positive effect of earlier hip surgery on survival remained unchanged after adjustment. Conclusions Earlier hip fracture surgery was found to be beneficial for elderly patients even when their co-morbidities and medication intake are taken into account.

Purpose::There is a common opinion that spinal fractures usually reflect the substantial impact of injuries and therefore may be used as a marker of significant associated injuries, specifically for intra-abdominal injury (IAI). The impact of concomitant spinal cord injury (SCI) with the risk of associated IAI has not been well clarified. The aim of this study was to evaluate the incidence and severity of IAIs in patients suffering from spinal fractures with or without SCI.Methods::A retrospective cohort study using the Israeli National Trauma Registry was conducted. Patients with thoracic, lumbar and thoracolumbar fractures resulting from blunt mechanisms of injury from January 1, 1997 to December 31, 2018 were examined, comparing the incidence, severity and mortality of IAIs in patients with or without SCI. The collected variables included age, gender, mechanism of injury, incidence and severity of the concomitant IAIs and pelvic fractures, abbreviated injury scale, injury severity score, and mortality. Statistical analysis was performed using GraphPad InStat ? Version 3.10, with Chi-square test for independence and two sided Fisher’s exact probability test.Results::Review of the Israeli National Trauma Database revealed a total of 16,878 patients with spinal fractures. Combined thoracic and lumbar fractures were observed in 1272 patients (7.5%), isolated thoracic fractures in 4967 patients (29.4%) and isolated lumbar fractures in 10,639 patients (63.0%). The incidence of concomitant SCI was found in 4.95% (63/1272), 7.65% (380/4967) and 2.50% (266/10639) of these patients, respectively. The overall mortality was 2.5%, proving higher among isolated thoracic fracture patient than among isolated lumbar fracture counterparts (11.3% vs. 4.6%, p < 0.001). Isolated thoracic fractures with SCI were significantly more likely to die than non-SCI counterparts (8.2% vs. 3.1%, p < 0.001). There were no differences in the incidence of IAIs between patients with or without SCI following thoracolumbar fractures overall or in isolated thoracic fractures; although isolated lumbar fractures patients with SCI were more likely to have renal (3.4% vs. 1.6%, p = 0.02) or bowel injuries (2.3% vs. 1.0%, p = 0.04) than the non-SCI counterparts. Conclusion::SCI in the setting of thoracolumbar fracture does not appear to be a marker for associated IAI. However, in a subset of isolated lumbar fractures, SCI patient is associated with increased risks for renal and bowel injury.

BackgroundThe outbreak of a new Coronavirus disease (COVID-19) poses dramatic challenges to public health authorities worldwide. One measure put in place to contain the spread of the disease is self-quarantine of individuals who may have been exposed to the disease. While officials expect the public to comply with such regulation, studies suggest that a major obstacle to compliance for self-quarantine is concern over loss of income or employment due to the prolonged absence from work.MethodsA cohort study of the adult population of Israel was conducted in two time points during the COVID-19 outbreak, the last week of February and the third week of March 2020, in order to assess public attitudes. In particular, public compliance rates to self-quarantine with and without State-sponsored compensation for lost wages were assessed.ResultsThe results suggest that public attitudes changed as the threat increased, making people more compliant with regulations. In February 2020, compliance rate for self-quarantine dropped from 94% to less than 57% when monetary compensation for lost wages was removed; however, in March 2020 this drop became more moderate (from 96 to 71%). The multivariate logistic regression revealed that older, non-Jewish, worried over COVID-19, and trusting the Ministry of Health were more likely than their counterparts to comply with self-isolation, even when monetary compensation was not assumed.ConclusionsDespite the effects of threat on people’s obedience with regulations, this study demonstrates that providing people with assurances about their livelihood during absence from work remains an important component in compliance with public health regulations.

This study was primarily aimed at establishing the incidence and impact of hypotension in patients with blunt traumatic brain injury based on National Trauma Registry Database.A retrospective cohort study using the National Trauma Registry was conducted. Patients with TBI following blunt mechanisms of injury were examined, comparing those with and without hypotension (SBP90 mm Hg) on arrival.During the period from 1998 to 2017, the registry included 437.354 blunt trauma patients. Of them, 7818 patients were hemodynamically unstable (SBP90 mm Hg) on admission. 513 met the inclusion criteria. Significant percentages of patients with high grade injures (ISS≥16) and low admission's GCS 3-12 (46% vs 16.4%), were found in the group of hypotensive TBI patients (p0.0001). 323 (62.9%) patients had head AIS score 3-4 and only 190 (37.1%) patients AIS 5-6 (p0.0001). Mortality in the hypotensive TBI group was 32.3%, whereas 6.1% patients died in the TBI hemodynamically stable group (p0.0001).TBI patients presenting with hypotension represent an appreciable portion blunt trauma patients. Prompt brain CT, expedient efforts at optimal resuscitation and possibly early inotropic and vasopressors agents use may have an impact on final outcome in these patients.

Purpose: Pelvic fracture evaluation with abdominopelvic computed tomography (CT) and formal CT cystography for rule out of urine bladder injury have been commonly employed in pediatric trauma patients. The additional delayed imaging required to obtain optimal CT cystography is, however, associated with increased doses of ionizing radiation to pelvic organs and represent a significant risk in the pediatric population for future carcinogenic risk. We hypothesized that avoidance of routine CT cystography among pediatric pelvic fracture victims would not result in an appreciable rate of missed bladder injuries and would aid in mitigating the radiation exposure risk associated with these additional images. Methods: A retrospective cohort study involving blunt trauma pelvic fractures among pediatric trauma patients (age

To contain the novel coronavirus disease (COVID-19) pandemic, health and government authorities have imposed sweeping self-quarantine orders for communities worldwide. Health officials assume that the public will have high rates of compliance. However, studies suggest that a major obstacle to compliance for household quarantine is concern about loss of income. A cross-sectional study of the adult population of Israel was conducted in the last week of February 2020 to assess public attitudes toward the COVID-19 outbreak. In particular, public compliance rates with self-quarantine were assessed, depending on whether lost wages would be compensated for. When compensation was assumed, the compliance rate was 94 percent. When compensation was removed, the compliance rate dropped to less than 57 percent. This study demonstrated that providing people with assurances about their livelihoods during self-quarantine is an important component of compliance with public health regulations.

Early application of tourniquets has reduced injury death rates. At the end of 2013, the Israel Defense Forces Medical Corps completed a military-wide introduction of the Combat Application Tourniquet as the standard-issued tourniquet. The accompanying clinical practice guideline encouraged combat soldiers and medical teams towards a liberal use of tourniquets for extremity injuries, even when in doubt.This study aimed to assess the effects of the wide introduction of advanced tourniquets on the rate of tourniquet applications, the type of tourniquet applied, and the differences in hospitalisation outcomes following the introduction.The study population was composed of hospitalised military casualties with an extremity injury treated by military medical teams between 2006 and 2015. Prehospital data were extracted from the Israel Defense Forces Trauma Registry and matched to corresponding hospital data from the Israeli National Trauma Registry. Two periods were compared: 2006-2013 "pre-intervention period" and 2014-2015 "post-intervention period".A total of 1,578 casualties were recorded during the study period. Of these, 320 (20.3%) occurred between 2014-2015. Characteristics of casualties in the post-intervention period were similar to those in the pre-intervention period including the rate of traumatic amputations (2.5% vs 2.2%, p = 0.93) and Injury Severity Score of 16 or above (12.8% vs 14.9%, p = 0.40). The rate of tourniquet application was more than four-fold in the post-intervention period compared to the pre-intervention period (22.8% vs 5.5%, p 0.001). Nevertheless, rates of in-hospital amputations (1.6% vs 1.6%, p = 1.00) and death (0.9% vs 1.3%, p = 0.53) were similar in the two periods.Following the IDF military-wide introduction of advanced tourniquets, the tourniquet application rate rose sharply, the use of old tourniquets ceased over time, and in-hospital amputation rate did not increase. These findings suggest that the awareness for haemorrhage control using advanced tourniquets rose.

Study objective The latest wave of terrorism worldwide has seen significant use by terrorists of mundane, "low-technology" weapons, such as utility knives and civilian vehicles. How do the injuries they produce compare with that of more conventional terrorism mechanisms, such as use of firearms and explosives? We compare injury patterns of the most frequent terrorism-related injury mechanisms in an Israeli data set. Methods This was a retrospective study of 1,858 patients hospitalized because of terrorism events, which were recorded in the Israeli National Trauma Registry between January 1997 and December 2016. The events were divided into 4 groups based on weapon used: explosions, shootings, stabbings, and vehicular attacks. The groups were compared in terms of injuries sustained, use of hospital resources, and clinical outcomes. Results Explosion-related and vehicular terrorism resulted in a higher proportion of multiple injuries, whereas stabbings and shootings mostly led to isolated injuries. Victims of vehicular attacks had a high proportion of severe head injuries, whereas stabbing victims had a high volume of vascular injuries. All mechanisms involved significant damage to extremities; however, among stabbing victims injury was mainly to the upper extremities, whereas among vehicular attack victims it was mostly to the lower extremities. The overall injury severity of the compared groups was similar, leading to comparable levels of intensive care use and inhospital mortality. Certain similarities in victims' characteristics were observed between the shootings and stabbings and between explosions and vehicular attacks. Conclusion Despite differences between various terrorist attack mechanisms, the resulting injury severity and inhospital mortality are very similar, with stabbings and vehicular attacks causing injuries as serious as those caused by conventional weapons.

Work absenteeism following an injury creates an economic burden on society and the individual. Programs encouraging return to work (RTW) should be implemented for high risk populations. The aim of this study was to identify the predictors for duration until RTW following an injury. The Israeli National Trauma Registry and the National Insurance Institute database (2008-2013) were linked. Logistic-regression models tested the probability not RTW within 1 month, 1 year and 2 years among 67% of the population and the quality of the model was examined among 33% of the population. The study population comprised 45,291 casualties (aged 21-67 and employed prior to injury as salaried workers). The majority of the study population (61%) RTW within 1 month from the injury event. Injury severity, multiple injuries, brain injury, traffic related injuries and fall injuries were significantly associated with work absenteeism. A dose-response relationship was found between income and not RTW: the lower the income the greater was the chance of not RTW. Among casualties with occupational injuries the odds for not RTW within a month, a year and 2 years were respectively, 3.7, 2.4 and 2 times significantly greater in comparison with casualties not injured at work. Underprivileged ethnic groups (Arabs and immigrants from Ethiopia) had a greater chance for long out of work stay following an injury. The outcomes of this study identified casualties at high risk for not RTW and enables health professionals to develop intervention programs focusing on returning to a productive lifestyle.

Objective: The objective of this study was to conduct a comprehensive analysis of demographics, injury characteristics and hospital resource utilization of significant pediatric electric bicycle (e-bike) injuries leading to hospitalization following an emergency department visit in comparison to pediatric injuries caused by other traffic related mechanisms.Methods: A retrospective review of all pediatric traffic injury hospitalizations following an emergency department visit to a level I trauma center between October 2014 and September 2016 was conducted. Data regarding age, sex, number of computed tomography (CT) scans obtained, number of major procedures, length of hospital stay (LOS), Injury Severity Score (ISS), and number of injuries per patient were collected and compared between e-bike injuries and other traffic injuries.Results: Three hundred thirty-seven admissions were analyzed: 46 (14%) were due to e-bike injuries (29% of patients >12 years). Age, proportion of brain injuries, and use o...

Introduction Bus public transportation is preferred for its perceived safety. Data from several countries, however, alarm of non-collision injuries associated with bus use. The aim of the current study was to estimate the prevalence of non-collision bus injuries, and compare and identify population group at high risk for severe injuries, to serve as a basis for policy makers. Methods A retrospective analysis of the Israeli National Trauma Registry cohort for the years 2015–2017 was carried out. Database consists of 20 hospitals nationwide. Casualties hospitalized following a non-collision injury on a bus were identified. Demographic, injury characteristics, and hospital resources utilization were compared according to the place of injury; inside the bus or during boarding or alighting. Results During follow up, 704 hospitalized non-collision related bus casualties were recorded. Most of the casualties (75%) fell inside the bus and 25% during boarding or alighting. The majority (67%) of hospitalized patients were 60 years old or above, mostly injured while boarding or alighting the bus, and 72% were women. Frequent injured body regions were lower extremities, head and torso. Passengers injured inside bus sustained more chest injuries, but less lower extremities injuries, compared to those boarding or alighting the bus. More hospital resources were required to treat passengers injured while boarding or alighting the bus. Conclusions This systematic registry-based analysis of non-collision bus injuries confirms the greater risk of being injured while using bus transportation among women and older passengers. Primary attention for prevention policies should be given to injuries occurring during boarding or alighting of the bus. Additional policy recommendations are discussed.

Objectives To analyse the impact of hospital quality indicators on hip fracture mortality in Israel. Study design A retrospective observational study. Methods Data were collected on all patients aged ≥65 years with an isolated hip fracture in the years 2010–2016 from the Israel's National Trauma Registry. These data were then cross checked with information on co-morbidities and medication intake from the Clalit medical fund. All successfully matched patients constituted the study population. The main outcome measures were in-hospital and 1-year mortality. Trend analysis of surgery on hip fractures within 48 h of hospitalisation (referred to as early hip fracture surgeries) and mortality was performed. The introduction of the proportion of early hip fracture surgeries as an official quality parameter in 2013 was considered an intervention. Results The proportion of early hip fracture surgeries continuously increased during the study period and, after the introduction of the quality measure, a significant increase in the uniformity of practice among hospitals was observed. The mortality trend was not related to the early surgeries trend, with a sharp upward spike detected in 2014, followed by a gradual return to previous levels in the subsequent years. The analysis has shown that when adjusting for demographic factors and co-morbidity, both in 2010–2013 and in 2015–2016, a clear benefit in survival existed for patients who were operated on within the first 48 h. In 2014, which was the first year of open publication of achieved quality measures reported in the media, no such benefit was found. Conclusions Even when an improvement in a promoted practice is achieved, its positive impact on clinical outcomes may be delayed, possibly indicating the need for a learning period.

Study design A retrospective cohort study. Objective This study aims to assess the potential value of very early trauma variables such as Abbreviated Injury Scale and the Injury Severity Score for predicting independent ambulation following a traumatic spinal cord injury (TSCI). Summary of background data Several models for prediction of ambulation early after TSCI have been published and validated. The vast majority rely on the initial examination of American Spinal Injury Association)ASIA) impairment scale and level of injury, however, in many locations and clinical situations this examination is not feasible early after the injury. Methods Patient characteristics, trauma data and ASIA scores on admission to rehabilitation were collected for each of the 144 individuals in the study. Outcome measure was the indoor mobility item of the Spinal Cord Independence Measure (SCIM) taken upon discharge from rehabilitation. Univariate and multivariable models were created for each predictor, Odds Ratios (OR) were obtained by a multivariable logistic regression analysis, and Area Under the receiver operator Curve (AUC) was calculated for each model. Results We observed a significant correlation between the trauma variables and independent ambulation upon discharge from rehabilitation. Of the early variables, the Abbreviated Injury Scale for the spine region showed the strongest correlation. Conclusions These findings support using preliminary trauma variables for early prognostication of ambulation following a TSCI, allowing for tailored individual interventions.Level of Evidence: 3.

Introduction:Injury patterns are closely related to changes in behavior. Pandemics and measures undertaken against them may cause changes in behavior; therefore, changes in injury patterns during the coronavirus disease 2019 (COVID-19) outbreak can be expected when compared to the parallel period in previous years.Study Objective:The aim of this study was to compare injury-related hospitalization patterns during the overall national lockdown period with parallel periods of previous years.Methods:A retrospective study was completed of all patients hospitalized from March 15 through April 30, for years 2016-2020. Data were obtained from 21 hospitals included in the national trauma registry during the study years. Clinical, demographic, and circumstantial parameters were compared amongst the years of the study.Results:The overall volume of injured patients significantly decreased during the lockdown period of the COVID-19 outbreak, with the greatest decrease registered for road traffic collisions (RTCs). Patients’ sex and ethnic compositions did not change, but a smaller proportion of children were hospitalized during the outbreak. Many more injuries were sustained at home during the outbreak, with proportions of injuries in all other localities significantly decreased. Injuries sustained during the COVID-19 outbreak were more severe, specifically due to an increase in severe injuries in RTCs and falls. The proportion of intensive care unit (ICU) hospitalizations did not change, however more surgeries were performed; patients stayed less days in hospital.Conclusions:The lockdown period of the COVID-19 outbreak led to a significant decrease in number of patients hospitalized due to trauma as compared to parallel periods of previous years. Nevertheless, trauma remains a major health care concern even during periods of high-impact disease outbreaks, in particular due to increased proportion of severe injuries and surgeries.

Mass casualty incidents (MCIs) tax the available resources of the healthcare system and impact on the capacity to provide optimal treatment to all casualties. To assure an integrated care approach before, during and following MCIs, Israel maintains ongoing coordination and collaboration among the various stakeholders. Emergency preparedness consists of five main measures including national guidelines and standard operating procedures; training programs; ongoing monitoring systems; information systems; and, procurement of vital equipment and infrastructure. The response phase is based on five components including an automatic response; central control and coordination; connectivity between responders; collaboration between military and civilian entities; and coordinated risk communication. The post-response phase consists of learning lessons through After Action Reviews.

BackgroundEthnic disparities have been associated with injury and mortality. The impact of ethnicity on head and neck injury (HNI), traumatic brain injury (TBI), in-hospital mortality and resource utilization following a motorcycle crash (MCC) is undetermined. This study explored the influence of ethnicity in these aspects and the effect of helmet use on HNI and TBI following a MCC.MethodsThe National Trauma Registry provided hospitalization data on motorcycle riders and passengers between 2008 and 2017. Ethnicity was classified as Jews or Arabs, the two major ethnic groups in Israel. Univariate followed by multivariable logistic models were applied to examine ethnic disparities. Mediation effect was tested by structural equation modeling.ResultsAmong 6073 MCC casualties, Arabs had increased odds of HNI (OR = 1.37,95% CI = 1.12–1.65) and TBI (OR = 1.51,95%CI = 1.12–1.99), and a six-fold decreased odds of helmet use (OR = 0.16,95%CI = 0.12–0.22). The HNI and TBI associations with ethnicity were mediated by helmet use. Arabs had significantly higher odds for admission to intensive care unit (OR = 1.36,95%CI = 1.00–1.83), and lower odds for ambulance evacuation (OR = 0.73,95%CI = 0.61–0.89) and discharge to rehabilitation (OR = 0.55,95%CI = 0.39–0.7). In-hospital mortality was not associated with ethnicity.ConclusionsHelmet non-use is an important etiologic factor associated with motorcycle-related HNI and TBI among Arabs. While in Israel, ethnic equality exists in in-hospital health care, disparities in ambulance and rehabilitation utilization was found. Intervention programs should target the Arab population and focus on helmet compliance.

Background Road traffic collisions (RTC) are known to be one of the major causes of maxillofacial trauma (MFT). The road user factor is of crucial importance in the prevalence, severity and treatment of the maxillofacial injuries. The aim of the study was to determine the prevalence of maxillofacial trauma among road users as well as to illustrate injury patterns and identify road users at high risk. Methods This historical prospective multi-center study was based on Israel's Trauma Registry between 2008-2018, which included 4,829 hospitalized patients following RTC with MFT. Data were analyzed according to six road user types (vehicle driver, passenger, bicyclist, motorcyclist, pedestrian and e-bike/scooter), maxillofacial injury location and maxillofacial treatment. Results MFT, which accounts for 5% of the hospitalized RTC injuries, was not equally distributed among road users, as bicyclists and e-bike/scooters were more prone to maxillofacial trauma (7.2% and 10.1%, respectively) than vehicle drivers (3.2%). Children (age 0-14 years) comprised almost half of the cyclists, 25% of the pedestrians and 20% of the passengers. Some MFT patients experienced multiple injuries, with the majority involving jaw and facial bones and to a lesser extent the mouth, teeth, gingiva and alveolar bone (mouth and dento-alveolar (DA) trauma). Approximately 30% of hospitalized road casualties with MFT underwent MF surgery, with the need for surgery lowest among pedestrians. Conclusion Hospitalized road casualties had different types of MFT in terms of prevalence, location, severity and treatment, depending on the road user type. Appropriate preventive measures and the proper use of restraints are recommended to reduce maxillofacial injuries.

Background End-of-life decisions are highly complex socio-normative and ethical phenomena. The goal of this study was to provide an assessment of public opinions in Israel concerning aspects of end-of-life decisions. Methods An online cross sectional study was performed in February 2020. The primary tool including items pertaining to death assistance and truth telling to patients. A sample of 515 participants representative of the adult Israeli population was obtained. Results The majority of participants (71%) supports telling the entire truth to patients even in harsh conditions. Support for truth telling decreases with affiliation to religion, with as little as 40% support among ultra-orthodox. People with vocational education are the least supportive of truth telling. Concerning doctor assisted death, almost half (49%) of the sample were supportive. Opposition is positively associated with religiosity, with 90% of ultra-orthodox and 58% of religious participants opposing doctor-assisted death, compared to only 18% among seculars. Non-Jews were 3.35 times (95%CI: 1.90, 5.91) more likely to oppose doctor assisted death than Jews (p Conclusions Israelis are overwhelmingly supportive of truth telling to patients. In contrast, Israeli public opinions on doctor assisted death are divided. For both attitudes, religiousness plays a crucial role as a catalyst for conservatism and opposition to change. Almost a half of the public is also supportive of an autonomist approach that would allow patients to decide on ending their own lives.

BackgroundSelf-inflicted injury is a leading cause of death worldwide. It is hypothesized that due to instincts for self-preservation, the severity of abdominal injury would be decreased following suicidal self-stabbing in comparison to stab wounds from assault, and therefore a more conservative management might be considered.MethodsAll patients with isolated abdominal stab wound (SW) admitted to 19 Trauma Centers in Israel between the years 1997 and 2018 were included in the study. Patients with self-inflicted abdominal SW (Group I) were compared to victims with abdominal SW following assault (Group II).ResultsGroup I included 9.4% (314/3324) of patients eligible for this study. Compared to Group II, Group I patients were older (median: 39 years, IQR 28,52 vs. 24 years, IQR 19,33; p

Background Traumatic injury is one of the main reasons for temporary and permanent occupational disability. The objective of this study was to define the role of socio-economic position on post-injury occupational absenteeism. Methods This was a nationwide retrospective cohort study, based on linking The Israeli National Trauma Registry (INTR) and the National Insurance Institute (NII) databases. The study population included 44,740 injured workers (residents of Israel, aged 21–67, hospitalized between 2008 and 2013 and employed prior to injury as salaried workers). Logistic-regression models tested the probability of not returning to work (RTW). Results The majority of the study population (61%) RTW within 1 month following the injury event. Income prior to injury was significantly associated with longer out of work stay, explaining 9% variance. A significant interaction (p value

In response to increasing violent attacks, the Stop the Bleed campaign recommends that everyone have access to both personal and public bleeding-control kits. There are currently no guidelines about how many bleeding victims public sites should be equipped to treat during a mass casualty incident. We conducted a retrospective review of intentional mass casualty incidents, including shootings, stabbings, vehicle attacks, and bombings, to determine the typical number of people who might benefit from immediate hemorrhage control by a bystander before professional medical help arrives. On the basis of our analysis, we recommend that planners at public venues consider equipping their sites with supplies to treat a minimum of 20 bleeding victims during an intentional mass casualty incident.

Background/aims Electric-Powered Bikes and powered scooters present a new method of transportation and are becoming commonly used worldwide. However, the reports on traumatic dental injuries related to their use are scarce. The aim of this study was to report the frequency and severity of dental and maxillofacial injuries associated with electric-powered bikes and scooters in Israel between the years 2014 and 2019. Methods This was a retrospective cohort study based on data from the Israeli National Trauma Registry (INTR). The INTR provides comprehensive data on hospitalized patients from all six Level I trauma centers (TC) and 15 of the 20 Level II TCs in Israel. All injured patients who were hospitalized due to a traffic collision between 2014 and 2019 were identified. The data for those hospitalized due to an e-bike or motorized scooter accident were extracted as well as for pedestrians who were injured as a result of a crash with these vehicles. Results A total of 3,686 hospital admissions were related to electric-powered bikes and scooters. Of those, 378 (10.3%) were oral and maxillofacial injuries. Most of the oral and maxillofacial injuries were attributed to powered bikes (321 out of 378; 84.92%) and the rest to powered scooters. There was a constant increase in general as well as the oral and maxillofacial injuries during the study years. Almost 20% of the cases involved injuries to the teeth. Overall, 291 pedestrians were reported to be injured due to electric-powered bikes and scooters; 29 (9.97%) of them, suffered from oral and maxillofacial injuries. Most of those were children aged 0-15 years (41.38%) and elders older than 60 years (37.39%). Conclusions Trauma related to electric-powered bikes and scooters is an increasing concern. Dental professionals should be actively involved in educational and legislative efforts focusing on the prevention of e-bike and scooter-related injuries, in general, and specifically maxillofacial injuries.

Background Road traffic accidents (RTA) are not equally distributed between ethnic groups, disproportionately affecting minorities. In Israel, Arabs are at higher risk of involvement in RTA relative to their proportion in the population. This study aims to compare the risk of in-hospital mortality from RTA between Arabs and Jews in Israel and to identify the factors associated with mortality in each population group. Methods This study is based on the Israeli National Trauma Registry of patients hospitalized due to road traffic injuries (Injury Severity Score 16+) between 2008 and 2017. Demographic, injury and hospitalization characteristics, evacuation means and in-hospital mortality were analyzed. Hierarchical multivariate logistic regression with random intercept for the treating hospital was performed to estimate the risk of mortality. Results Of the 11,523 hospitalizations reported, 29% were Arabs, which is higher than their proportion in the Israeli population (21%). When comparing Arabs with Jews they were younger (ages 0–24 years - 61% vs 30%), injured as a car driver (28% vs 20%) or passenger (21% vs 15%) and less likely to be a motor cyclist (8.8% vs. 19.2%). In addition, Arabs were more likely to suffer from critical injuries (51% vs 44%) and head injuries (71% vs 66%). Although Arabs were less likely to be evacuated by ambulance (68% vs 80%), they were more likely to be evacuated by a private vehicle or an emergency medical helicopter. Transfers between hospitals were greater among Arabs (14% vs 22%), as were hospital admissions “outside official work hours” (70% vs 78%) and hospital resource utilization. After accounting for demographic, injury, and hospitalization characteristics the risk of in-hospital mortality was significantly higher among Arabs compared to Jews (OR: 1.63, 95% CI: 1.14–2.32). The significantly higher mortality among Arabs was apparent in the sub-group of patients who were critically injured and in those who arrived at the hospital “outside official work hours”. Conclusions This study suggests the need for developing appropriate interventions focusing on the Arab community in general, and according to the analysis of risk groups and areas of injury in particular, including rapid access to emergency medical services and definitive care.

Objective To evaluate and compare, at the national level, injury trends and, characteristics and to identify high risk groups of electric bike (E-bike) and mechanical bicycle (M-bike) related hospitalizations as a key message for public policy. Methods Historic prospective study based on data from the Israel National Trauma Registry (INTR), between 1.1.2013 and 31.12.2017. All hospitalized casualties were E-bikers and M-bikers. Results During the study period, 1733 E-bikers and 7259 M-bikers were hospitalized. Arab children (age 0–15) and young adults (age 16–29) were at higher risk for E-bike and M-bike casualties respectively. The hospitalization rate per 1000 vehicles was lower for E-bikers in comparison to M-biker. However, during the five year period a dramatic increase in E-bike related hospitalizations was reported coinciding with a decrease of M-bike related casualties. Among M-bikers, the decrease in hospitalization rate was for accidents on both inter and intra-city roads, but not on unpaved roads, which remained stationary, suggesting that the transportation mode is changing. In comparison to the M-bikers, E-bikers were at greater risk for enduring head injuries (OR 1.16 95% CI 1.00–1.25) and lower extremity injuries (OR 1.37 95% CI 1.23–1.52), to undergone surgery (OR 1.13 95% CI 1.00–1.26), having longer hospital stays (OR 1.44 95% CI 1.23–1.68) and being discharged to rehabilitation center (OR 1.43 95% CI 1.09–1.86). Conclusion During the last five years in Israel there is a dramatic increase in E-bike related hospitalized casualties corresponding to a substantial increase in E-bike usage. In comparison to M-bikers, there is a lower casualty rate but these casualties are more severely injured and utilize more hospital resources. It is of utmost importance to identify these high risk groups in an effort to develop culturally appropriate interventions for these road users, including training, awareness and helmet enforcement. Policy change recommendations are discussed.

To examine the relationship between neighborhood socioeconomic level (NSEL) and injury-related hospitalization. The National Trauma Registry (INTR) and the National Population Census (NPC), including NSEL, were linked by individual identity number. Age-adjusted logistic regression predicted injury hospitalization. Mantel–Haenszel X2 was used for linear trends. NSEL was divided into 20 clusters. The population comprised 7,412,592 residents, of which 125,829 (1.7%) were hospitalized due to injury. The injury hospitalization rate was at least 42 per 10,000 per year. Except for the very low SEL, an inverse relationship between NSEL and all-cause injury was found: 46.1/10,000 in cluster 3 compared to 22.9/10,000 in cluster 20. Hip fracture-related hospitalizations among ages 65 + decreased as SEL increased (2.19% o in cluster 2 compared to 0.95% in cluster 19). In comparison with Jews, non-Jews were 1.5 times more likely to have an injury-related hospitalization [OR 1.5 (95% CI 1.50–1.55)]. The INTR and the NPC were successfully linked providing individual and injury hospitalization data. The outcomes confirm the strong relationship between injury mechanism and NSEL.

Background Management of stable patients with abdominal stab wound remains controversial, particularly for those with no clear indications for explorative laparotomy. We evaluated the risk of intra-abdominal injury in stab wound victims concomitantly stabbed in other anatomical body areas. Methods We performed a retrospective cohort study of patients with abdominal stab wounds recorded in the Israeli National Trauma Registry from January 1st, 1997, to December 31st, 2013. Patients with an isolated abdominal stab wound were compared to those with concomitant stab wounds to other anatomical areas. Intra-abdominal organ injury was defined by imaging or surgery findings. Multivariate analysis using a logistic regression model was conducted to assess independent risk for intra-abdominal organ injury. Results The study included 3964 patients. After controlling for age, gender and hypotension on arrival, patients with multi-regional stab wounds had an increased risk of intra-abdominal injury (OR = 1.3, CI 95% 1.1–1.6, p

Purpose: Early diagnosis of traumatic brain injury (TBI) is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale (GCS) of 12 or less can predict the presence of TBI and the severity of associated injuries in blunt trauma patients. Methods: A retrospective cohort study including 303,435 blunt trauma patients who were transferred from the scene to hospital from 1998 to 2013. The data was obtained from the records of the National Trauma Registry maintained by Israel's National Center for Trauma and Emergency Medicine Research, in the Gertner Institute for Epidemiology and Health Policy Research. All blunt trauma patients with GCS 12 or less were included in this study. Data collected in the registry include age, gender, mechanism of injury, GCS, initial blood pressure, presence of TBI and incidence of associated injuries. Patients younger than 14 years old and trauma victims with GCS 13-15 were excluded from the study. Statistical analysis was performed by using Statistical Analysis Software Version 9.2. Statistical tests performed included Chi-square tests. A p-value less than 0.05 was considered statistically significant. Results: There were 303,435 blunt trauma patients, 8731 (2.9%) of them with GCS of 3-12 that including 6351 (72%) patients with GCS of 3-8 and 2380 (28%) patient with GCS of 9-12. In these 8731 patients with GCS of 3-12, 5372 (61.5%) patients had TBI. There were total 1404 unstable patients in all the blunt trauma patients with GCS of 3-12, 1256 (89%) patients with GCS 3-8, 148 (11%) patients with GCS 9-12. In the 5095 stable blunt trauma patients with GCS 3-8, 32.4% of them had no TBI. The rate in the 2232 stable blunt trauma patients with GCS 9-12 was 50.1%. In the unstable patients with GCS 3-8, 60.5% of them had TBI, and in subgroup of patients with GCS 9-12, only 37.2% suffered from TBI. Conclusion: The utility of a GCS 12 and less is limited in prediction of brain injury in multiple trauma patients. Significant proportion of trauma victims with low GCS had no TBI and their impaired neurological status is related to severe extra-cranial injuries. The findings of this study showed that using of GCS in initial triage and decision making processes in blunt trauma patients needs to be re-evaluated. Key words: Multiple trauma; Transfer; Glasgow Coma Scale

Purpose: Investigation of injury patterns epidemiology among car occupants may help to develop different therapeutic approach according to the seat position. The aim of the study was to evaluate and compare differences in the incidence of serious injuries, between occupants in different locations in private cars. Methods: A retrospective study including trauma patients who were involved in motor vehicle accidents and admitted alive to 20 hospitals (6 level Ⅰ trauma centers and 14 level Ⅱ trauma centers). We examined the incidence of injures with abbreviated injury score 3 and more, and compared their occurrence between seat locations. Results: The study included 28,653 trauma patients, drivers account for 60.8% (17,417). Front passenger mortality was 0.47% higher than in drivers. Rear seat passengers were at greater risk (10.26%) for traumatic brain injuries than front seat passengers (7.48%) and drivers (7.01%). Drivers are less likely to suffer from serious abdominal injuries (3.84%) compared to the passengers (front passengers - 5.91%, rear passengers — 5.46%). Conclusion: Out of victims who arrived alive to the hospital, highest mortality was found in front seat passengers. The rate of serious chest injuries was higher as well. Rear seat passengers are at greater risk for serious traumatic brain injuries. All passengers have a greater incidence of abdominal injuries. These findings need to be addressed in order to develop "customized" therapeutic policy in trauma victims. Key words: Traffic accidents; Injury pattern; Seat position

To demonstrate the gap between injury epidemiology of terror-related stabbings (TRS) and non-terror-related intentional stabbings.Terror attacks with sharp instruments have multiplied recently, with many victims of these incidents presented to hospitals with penetrating injuries. Because most practical experience of surgeons with intentional stabbing injuries comes from treating victims of interpersonal violence, potential gaps in knowledge may exist if injuries from TRS significantly differ from interpersonal stabbings (IPS).A retrospective study of 1615 patients from intentional stabbing events recorded in the Israeli National Trauma Registry during the period of "Knife Intifada" (January 2013-March 2016). All stabbings were divided into TRS and IPS. The 2 categories were compared in terms of sustained injuries, utilization of hospital resources, and clinical outcomes.TRS patients were older, comprised more females and were ethnically homogenous. Most IPS incidents happened on weekdays and at night hours, whereas TRS events peaked midweek during morning and afternoon hours. TRS patients had more injuries of head, face, and neck, and severe head and neck injuries. IPS patients had more abdomen injuries; however, respective injuries in the TRS group were more severe. Greater injury severity of the TRS patients reflected on their higher hospital resources utilization and greater in-hospital mortality.Victims of terror stabbings are profoundly different in their characteristics, sustain injuries of a different profile and greater severity, require more hospital resources, and have worse off clinical outcomes, emphasizing the need of the healthcare systems to adjust itself appropriately to deal successfully with future terror attacks.

Background A considerable proportion of hospitalized trauma patients are due to motor vehicle crashes. While the safety implications of seatbelt use in reducing severe injuries and fatalities are well established, and while it is argued that females are underrepresented in safety vehicle tests, it is unclear whether seatbelts have equally benefitted drivers of either gender. Previous studies have not, to the best of our knowledge, tested moderation effect of seatbelt use on the association between gender and crash-related injury. Methods We performed a retrospective cohort study using data drawn from the National Trauma Registry database, 2008–2018, to determine the role of car driver's gender as a predictor of injury outcome following a road traffic crash resulting in hospitalization. Modified Poisson regression models were applied controlling for age, ethnicity, seatbelt use, impact type, road type, and year of hospitalization. Effect modification of the gender-injury outcome associations was tested for belt-restraint status using multiplicative interaction terms. Results There was no evidence for a modification effect of the gender-seatbelt and injury associations, indicating that males are at greater risk for injury, independent of seatbelt use. The relative risk (RR) for a male driver to sustain severe injuries was approximately two fold the injury risk of female drivers (RR = 1.9, 95%CI: 1.6–21). The corresponding RRs for severe head and torso injuries were 2.5 (95%CI: 2.0–3.2) and 1.8 (95%CI: 1.5–2.2), respectively. Conclusions The results suggest that seatbelts provide equal injury protection for drivers of both genders; yet, males are at a greater risk to sustain severe injuries regardless of seatbelt use. This finding points to the possibility that risk-taking behaviors contribute to gender specific disparities and should be the focus of targeted interventions by health professionals and policymakers.

AIM To measure individual and environmental risk factors predicting reported child injuries. METHODS A prospective, follow-up study was performed including 380 parents of children aged 1-6 years, living in various communities throughout Israel. Parents were interviewed three times, 3 months apart. Injuries were defined as including minor injuries that required parental attention and medically attended injuries: doctor or nurse visit, emergency medical services or hospitalisation. Parents reported the level of safety for both indoor and outdoor environments, covering 11 items pertaining to safety elements dedicated to prevent child injury. Socio-demographic and parents' attitudes towards child injury were also measured. RESULTS During the 6-month follow-up period, 37% of parents reported that their child was injured, and 29% of them received medical attention. Reported outdoor safety environment was found to be a predictor of child injury, suggesting that the risk of child injury is higher among children living in unsafe outdoor environments. However, this depended on levels of religiosity (with an odds ratio of 2.48 and 95% confidence interval of 1.09-5.64 for traditional families and an odds ratio of 3.65 and 95% confidence interval of 1.58-8.46 for religious families). CONCLUSIONS Safe environments play a major role in decreasing the risk of injury among children. In order to decrease injury rates among young children, attention should be given to the immediate outdoor environment in which children grow up and play. Decision makers might particularly want to pay closer attention to the influence of religious backgrounds on child safety through safe environments.

Hemorrhage is the leading cause of possible preventable death in the battlefield. There is an increasing evidence for the effectiveness of blood component therapy in general, and plasma infusion in particular but their use is less applicable in the prehospital setting due to logistic difficulties. Israeli Defense Force has implemented the use of freeze-dried plasma (FDP) at the point of injury (POI), this adoption of FDP use entailed doubts regarding the feasibility and effectiveness of this practice. In this article, we present our experience with the use of FDP at the POI and prehospital setting regarding the feasibility, safety, adverse reactions, and adherence to clinical practice guidelines.This is a descriptive retrospective cohort study based on all casualties receiving FDP during January 2013 to June 2016. The study describes the injury, treatment, and outcome characteristics from POI until hospital discharge.During the study period, 109 casualties received FDP. The majority were men, aged 18 years to 35 years. Multiple severe injuries were found in almost half of the casualties, 78% had penetrating injury, and more than half were involved in a multicasualty event. Eighty-three percent were treated with one unit of FDP, 13% with two units, and 4% casualties with three units, nine patients (8.2%) were also treated in the prehospital setting with packed red blood cells. Fifty-seven percent fulfilled at least one criterion for the administration of FDP. Lifesaving interventions were required in 64%. In five (4.6%) cases, there were difficulties with FDP administration. Side effects were reported in one female patient.This study supports the usage feasibility of FDP at the POI and in the prehospital setting. Further adjustment of the clinical practice guidelines is required basing it not only on pathophysiologic parameters but also on clinical judgment. Further investigation of the available data is required to learn about the effectiveness of FDP at POI.Retrospective case series study, level IV.

ObjectiveWe aimed to identify and seek agreement on factors that may influence decision-making related to the distribution of patients during a mass casualty incident.MethodsA qualitative thematic analysis of a literature review identified 56 unique factors related to the distribution of patients in a mass casualty incident. A modified Delphi study was conducted and used purposive sampling to identify peer reviewers that had either (1) a peer-reviewed publication within the area of disaster management or (2) disaster management experience. In round one, peer reviewers ranked the 56 factors and identified an additional 8 factors that resulted in 64 factors being ranked during the two-round Delphi study. The criteria for agreement were defined as a median score greater than or equal to 7 (on a 9-point Likert scale) and a percentage distribution of 75% or greater of ratings being in the highest tertile.ResultsFifty-four disaster management peer reviewers, with hospital and prehospital practice settings most represented, assessed a total of 64 factors, of which 29 factors (45%) met the criteria for agreement.ConclusionsAgreement from this formative study suggests that certain factors are influential to decision-making related to the distribution of patients during a mass casualty incident. (Disaster Med Public Health Preparedness. 2018;12:101–108)

Introduction Diverse decision-making is needed in managing mass casualty incidents (MCIs), by emergency medical services (EMS). The aim of the study was to review consensus among international experts concerning policies of EMS management during MCIs. Methods Applicability of 21 EMS policies was tested through a 2-cycle modified e-Delphi process, in which 38 multi-disciplinary experts from 10 countries participated. Threshold for approving proposed solutions was defined as consensus of >80%. Policies that did not achieve the targeted consensus were reviewed to detect variability according to respondents' origin country. Results 16 policies were endorsed in the first cycle including collaboration between ambulance service providers; implementing a unified mode of operation; preparing criteria for ground versus aerial evacuation; and, developing support systems for caregivers exposed to violence. An additional policy which proposed that senior EMS officers should not necessarily act as on-site MCI commanders was endorsed in the second cycle. Demographic breakdown of views concerning non-consensual policies revealed differences according to countries of origin. Assigning ambulances to off-duty team members was highly endorsed by experts from Israel and South Africa and strongly rejected by European respondents. Avoiding entry to risk areas until declared safe was endorsed by European, Asian and Oceanic experts, but rejected by Israeli, South African and North American experts. Conclusions Despite uniqueness of countries and EMS agencies, solutions to most dilemmas were applicable to all organizations, regardless of location or affiliation. Cultural diversity was found concerning readiness to implement military-civilian collaboration in MCIs and a rigid separation between work-leisure responsibilities.

Pelvic fractures are a marker of severe injury, mandating a thorough investigation for the presence of associated injuries. Anatomical and physiological differences between adults and children may lead to a different impact of pelvic fractures on these populations. The purpose of this study is to compare pelvic fractures between pediatric and adult blunt trauma victims, mainly regarding their severity and associated intraabdominal injuries.A retrospective study involving blunt trauma patients suffering pelvic fractures, according to the records of the Israeli National Trauma Registry. Patients included children, aged 0-14years, and adults between 15 and 64years. The presence and severity of associated injuries were assessed.Overall, 7621 patients aged 0-64years were identified with pelvic fractures following blunt trauma. The incidence of pelvic fractures in children was (0.8%), as compared to 4.3% in adults, p0.0001. The most common mechanism of injury was motor vehicle accident (MVA) in adults, and pedestrian hit by car (PHBC) in children. About a quarter of the patients in both groups had an ISS25. Adults sustained significantly more moderate to severe pelvic fractures (AIS≥3) than children (26.7% vs. 17.4%, p0.0001). The overall mortality rate was similar among the two groups (5.4% in adults, 5.2% in children, p=0.7554). The only associated injury with statistically significant difference in incidence among the two groups was rectal injury (1.2% among children, 0.2% among adults, p0.0001). Among adult patients, there was a clear correlation between the severity of pelvic fractures and the severity of concomitant splenic and hepatic injuries (p=0.026, p=0.0004, respectively). Among children, a similar correlation was not demonstrated.Adults involved in blunt trauma are more likely to sustain pelvic fractures, and these are generally more severe fractures, as compared to children suffering from blunt trauma. Nonetheless, mortality rates were found similar in both groups. The only associated injury with statistically significant difference in incidence among the two groups was rectal injury. In adults, but not in children, higher grade pelvic fractures correlated with more severe concomitant splenic or hepatic injuries.The level of evidence for this study is III (3).

Traumatic vertebral fracture accounts for 10-15% of trauma related admissions. While the correlation between lumbar vertebral fractures and abdominal injuries is well established, the relationship between thoracic vertebral fractures (TVF) and abdominal injuries is comparatively less well elucidated. Using a large national trauma database, we aimed to examine the incidence and severity of associated abdominal injuries in blunt trauma patients suffering from TVF.A retrospective cohort study using the Israeli National Trauma Registry was conducted. Patients with thoracic vertebrae spine fractures following blunt mechanisms of trauma between 1997 and 2018 were examined, comparing the incidence and severity of associated intraabdominal organs injuries with and without TVF. Demographics and outcomes between the two cohorts were compared.From 362,924 blunt trauma patients, 4967 (1.37%) had isolated TVF. Mean age was 49.8 years and 61.9% were males. The most common mechanism of injury was fall following by MVC. The patients with TVF had significantly higher rates of increased ISS score (ISS 16, 28.45% vs. 10.42%, p 0.001) and higher mortality rate (3.5% vs. 2%, p 0.0001). Patients with TVF had 2-3 times more intraabdominal organ injuries (p 0.001). The most commonly injured organ was spleen (3.28%); followed by liver (2.64%) and kidney (1.47%). An analysis of non-isolated thoracic spine fractures showed same distribution in age, ISS, mechanisms, patterns of intra-abdominal injury, mortality rate and laparotomy rate.Clinicians should have an elevated suspicion for intra-abdominal injuries when a thoracic spine fracture is identified, which may necessitate further evaluation.

The unique characteristics of terror-related explosion events necessitate a thorough reevaluation process to prepare all levels of medical treatment for casualties of such incidents, from the prehospital setting, through the hospitals, and all the way to rehabilitation and mental health. This chapter discusses the main operational considerations stemming from the modern trends of terror explosion injuries noted in recent evidence-based research. In particular, the chapter describes how explosive device characteristics interact with physical location of the explosion to define the patterns of injury and required clinical resources, as well as the influence of the general setting of the event (military/civilian, urban/rural) on scene and medical management.

BACKGROUND Most of the trauma patients who die in the first 24 h from arrival to the hospital do so as a result of haemorrhagic shock. Resuscitative endovascular balloon occlusion of the aorta (REBOA) facilitates expedient proximal aortic control, potentially bridging a needed gap for partial or non-responders to traditional resuscitation en route to emergent definitive haemostasis. This resuscitation tool continues to evolve and has recently achieved some consensus defined indications for its use. The aim of this study is designed to examine the potential utility of REBOA among trauma victims who die within 24 h of arrival. METHODS Data of all trauma patients who died in the first 24 h, from 2012 to 2017 were extracted from the National Trauma Registry in the Gertner Institute for Epidemiology and Health Policy Research. Patients who died in the first half an hour, and those with neck and thorax injuries were excluded. Demographics, clinical and injury data were collected. RESULTS Overall, 129 patients were included; 74% male and 26% female with the mean age of 46.4 years. A total of 76% suffered blunt trauma and 24% penetrating trauma. Mean survival time was 5.87 h. The cause of death was major abdominal organ injury in 47.2%, injury to major abdominal vessel in 23.3% and pelvic fractures in 21.7%. A total of 69 patients (53.5%) ultimately required delayed resuscitative thoracotomy in the operation room. CONCLUSION Registry data suggest that there is a subset of patients presenting to modern trauma centres who might benefit from REBOA in order to avoid death.

Objective: To compare demographic, injury and hospitalization characteristics and mortality between Isolated and Non-Isolated traumatic brain injury.Methods: A retrospective study based on the Isra...

BackgroundThe use of off-road vehicles such as all-terrain vehicles (ATVs) and recreational off-highway vehicles has increased in recent years. A higher percentage of patients hospitalised following ATV crashes suffered severe injuries, compared with those hospitalised following other MVCs.ObjectiveTo identify incidence of ATV-related injury and characterise groups with higher prevalence.MethodsA retrospective study of the Israel National Trauma Registry data between years 2008 and 2016. ATV crash victims were compared with other types of MVC casualties according to demographics, injuries and hospital resource utilisation. Identifying groups with greater prevalence for severe injuries caused by ATV crashes was conducted using logistic regressions.ResultsAn increase of 49% in the number of casualties hospitalised following an ATV crash was observed between 2013 and 2016. Non-Jews, males and users 15–29 years old were hospitalised at a higher rate compared with their proportion in the population. ATV crash casualties were more severely injured compared with other MVC casualties (22% vs 14%), had longer hospital length of stay (8+ days) (25% vs 18%), more admissions to intensive care units (16% vs 10%) and underwent more surgery (39% vs 26%, respectively). Males, non-Jews and casualties who did not wear a helmet were about two times more likely to suffer from severe head injury (95% CI 1.20 to 3.60, 1.41 to 2.75 and 1.27 to 4.73, respectively).ConclusionsAn increase in ATV-related casualties was observed. A customised safety intervention programme is needed that targets demographic groups identified with higher injury incidence. Awareness of legislated and common sense ATV safety practices, specifically helmet use, should be raised.

Background Wrist and hand injuries are common and constitute a major economic burden. General injury prevention programs have failed to demonstrate a decrease in injury rates. We hypothesized that there are differences in injury patterns in culturally diverse subpopulations of a metropolitan area treated within the same medical system, which may partly explain the difficulties associated with injury prevention. Methods We conducted a survey of patients admitted to emergency departments of two hospitals in Jerusalem for wrist and hand injuries during a 3 month period. Patients were asked to complete a questionnaire regarding demographic data, injury type and mechanism. Injury type and mechanism were then compared for age, gender, level of education and degree of religiosity. Results The questionnaire was completed by 799 patients (response rate 62%; 75% male; average age 27). Thirty-one percent reported they were injured at work, 33% at home and 36% during leisure activities. Data analysis showed that several subpopulations were found to be at risk as compared to their corresponding groups and relative proportion in the overall population of the city. These included contusions after falls in non-ultra-Orthodox Jewish women aged 65 years and over, crush injuries in ultra-Orthodox Jews under the age of 10 (53% vs. 14% for non ultra-Orthodox Jews, respectively) and Muslim teens. Muslims were injured more, especially at work, in comparison to their relative proportion in the population as a whole. Conclusion Different subpopulations at risk and different injury patterns of wrist and hand injuries were found in this culturally heterogeneous population. Awareness of these differences may be the first step when designing specific injury prevention programs in a culturally diverse population. A combined effort of community leaders and government agencies is needed to deal with the specific populations at risk, although legislation may be needed to limit some of the risks such as teens and specific work related hazards and exposures.

Background Populations of different ethnicity and country of origin living in the same country may possess particular features of violence-related injuries. This study aims to compare violence-related injury characteristics and circumstances, hospital resource utilization and in-hospital mortality among the major ethnic groups in Israel. Methods A study based on the Israeli National Trauma Registry database of patients hospitalized due to violence-related injuries between 2008 and 2017. Data included demographic, injury and hospitalization characteristics and in-hospital mortality. Statistical analysis included χ 2-test and multiple logistic regression. Results During the study period, 16,151 violence related-hospitalizations were reported, of which; 46.1% were Arab Israelis (AI), 3.2% were Israelis born in Ethiopia (IBE), 12.7% were Israelis born in the former Soviet Union (IBFSU) and 38.0% were all other Israelis (AOI). The proportion of violence-related hospitalizations among AI, IBE and IBFSU was greater than their respective proportion in the Israeli population. In comparison to the other groups, stab injuries were significantly greater among IBE (30% vs 39%); unarmed brawl-related injuries were greater among IBFSU (22–41% vs 49%) and firearm injuries were greatest among AI (2–8% vs 23%). These differences in violence mechanism persisted even after accounting for age, gender, injury place and time differences. The foreign born groups had higher rates for injuries sustained on the street/road (58% for IBE, 54% for IBFSU vs 46% for AI and AOI, each), with IBE also showing higher rates for weekend and weeknight injuries compared to the other groups (83% vs 71–75%). IBE were more likely to suffer from severe and critical injuries (19% vs 12–16%), to be admitted to the intensive care unit (17% vs 9–11%) and to have prolonged hospital stays of seven days or more (20% vs 16–17%), with no significant difference in in-hospital mortality between the comparison groups. Conclusions Characteristics of violence-related casualties differed significantly among diverse ethnic populations living in the same country. Each population group showed specific attributes regarding injury mechanism, circumstances, severity and hospital utilization. Violence prevention programs should be culturally adapted and take into account ethnicity and country of origin of the target population.

The current paradigm in disaster risk planning and reduction is the All-Hazards Approach (AHA) framework, which suggests that different hazards share commonalities allowing for the generalization of parts of the preparedness to all. A growing body of literature suggests that this approach has many flaws, rendering it suboptimal in promoting disaster readiness. The Novel Corona Virus Disease (COVID-19) outbreak is a major wake-up call in this regard. This perspective article uses the experience from the COVID-19 pandemic that disproves or at least undermines, many aspects of the AHA, including early warning, medical public health response, reliance on international assistance, lead agency, and politicization of the crisis. A pandemic is a unique disaster with little relationship to other disaster types and requires an entirely different way of planning. The COVID-19 pandemic is a call to action for a consolidated alternative framework called the Top-Hazards Approach (THA), arguing that inherently different events require different planning and mitigation tactics, and therefore should be prioritized according to likelihood and severity in each local context.

The objective of this study was to describe demographic and injury characteristics of hospitalized injured patients involved in e-bike and motorized scooter accidents at a national level in Israel divided by different road user groups: riders and pedestrians.This was a retrospective study based on data from the National Trauma Registry, between January 1, 2013, and December 31, 2015. All hospitalized casualties due to the involvement of an e-bike or motorized scooter were included. The type of hospitalized road user was further categorized and described by different variables.During the study period, the Israel Trauma Registry identified 795 hospitalized patients due to an e-bike or motorized scooter accident, with a dramatic 6-fold increase from 2013 to 2015. Although the majority of the injured patients were riders, 8% were pedestrians. Among the total casualties, 33% were children aged 0-14 years and among pedestrians 42% were children and 33% were seniors (ages 60+). Five persons died in hospital, 3 riders and 2 pedestrians.E-bike and motorized scooter riders represent the majority of patients hospitalized due to related traffic incident. This finding questions the social and economic advantages of electric-powered 2-wheeled vehicles.

Patients with extensive burn injuries suffer from multisystem trauma, which affects their medical, psychological, and social well-being for many years. Monitoring those patients has revealed changes in the endocrine, cardiac, and respiratory systems years after the injury. Our study tries to examine whether changes manifest as a higher risk of death during their lifespan, compared with the general population. Data from the years 1998 to 2013 regarding two groups of patients was obtained from a national trauma registry: one group had suffered burns over 20% of their TBSA and survived the hospitalization period and the second group was a control group of patients admitted with minimal trauma (Injury Severity Score = 1-minor injury to a single body region). Mortality rates during the posthospitalization period were compared after adjusting for age and follow-up periods. The authors collected 1115 second- or third-degree burn victims with 20% TBSA and 81,688 trauma victims with an Injury Severity Score = 1. Follow-up periods ranged from 8 months to almost 17 years. When comparing the groups after correcting for age, sex, and follow-up period, no significant differences in mortality risk were found. Possible explanations for the lack of differences in mortality risk include the lack of an adequate follow-up period, a misguided research hypothesis (ie, despite existence of physiological changes in burn patients, these changes do not affect the lifespan), or a control group that does not optimally represent mortality in the general population.

TBI may be defined by different methods. Some may be most useful for immediate clinical purposes, however less optimal for epidemiologic research. Other methods, such as the Abbreviated Injury Score (AIS), may prove more beneficial for this task, if the cut-off-points for their categories are defined correctly.To reveal the optimal cut-off-points for AIS in definition of severity of TBI in order to ensure uniformity between future studies of TBI.Mortality of patients with TBI AIS 3, 4 was 1.9% and 2.9% respectively, comparing with 31.1% among TBI AIS 5+. Predictive discrimination ability of the model with cut-off-points of 5+ for TBI AIS (in comparison with other cut-off-points) was better. Patients with missing Glasgow Coma Scale (GCS) in the ED had an in-hospital mortality rate of 11.5%. In this group, 25% had critical TBI according to AIS. Normal GCS didn't indicate an absence of head injury, as, among patients with GCS 15 in the ED, 26% had serious/critical TBI injury. Moreover, 7% of patients with multiple injury and GCS 3-8 had another reason than head injury for unconsciousness.This study recommends the adoption of an AIS cut-off ≥ 5 as a valid definition of severe TBI in epidemiological studies, while AIS 3-4 may be defined as 'moderate' TBI and AIS 1-2 as 'mild'.

To examine whether characteristics and circumstances of injuries are related to ethnicity.The study was based on the Israeli National Trauma Registry data for patients hospitalized between 2008 and 2011. Data included demographics, injury, hospital resource utilization characteristics and outcome at discharge. Univariate analysis followed by logistic regression models were undertaken to examine the relationship between injury and ethnicity.The study included 116,946 subjects; 1% were Ethiopian Born Israelis (EBI), 11% Israelis born in the Former Soviet Union (FSUBI) and 88% the remaining Israelis (RI). EBI were injured more on street or at work place and had higher rates of penetrating and severe injuries. However, FSUBI were mostly injured at home, and had higher rates of fall injuries and hip fracture. Adjusted analysis showed that EBI and FSUBI were more likely to be hospitalized because of violence-related injuries compared with RI but less likely because of road traffic injuries. Undergoing surgery and referral for rehabilitation were greater among FSUBI, while admission to intensive care unit was greater among EBI.Targeted intervention programmes need to be developed for immigrants of different countries of origin in accordance with the identified characteristics.

OBJECTIVE: Examine the impact of setting on the magnitude and pattern of civilian injuries from terrorist explosions. This may help surgical staffs anticipate the resources required to treat victims of terrorist attacks. METHODS: A retrospective study of 823 patients from 65 explosive events of the Second Intifada (2000-2005) in the National Trauma Registry. After verification all the events were divided into 5 categories: explosions inside buildings (CS), explosions near buildings (SO), explosions inside buses (IB), explosions near buses (AB), and explosions in an open space (OS). The categories were then compared in terms of sustained injuries, utilization of hospital resources and clinical outcomes. RESULTS: CS and IB scenarios were found to cause the most severe injuries, demanded the most hospital resources and had the worst outcomes, but had several important differences in injury profiles. AB setting proved to be a stand-alone scenario with the lowest severity, possibly due to protection provided to the passengers by the bus. The high volume of blast injuries in SO scenario supports the idea that the explosion wave could be reflected onto the people standing outside a building next to its wall. OS patients had the lowest proportion of blast trauma and burns. CONCLUSIONS: The existing taxonomy of terrorist bombings, which distinguishes explosions in open spaces from those occurring in closed environments, does not fully differentiate patterns of injury that follow blasts in intermediate environments. Expanding the framework from 2 categories to 5 appears to provide greater precision and may be clinically useful to health care providers. Language: en

BACKGROUND: Semi-rigid cervical collars (SRCC) are routinely applied to victims of explosions as part of the pre-hospital trauma protocols. Previous studies have shown that the use of SRCC in penetrating injuries is not justified due to the scarcity of unstable cervical spine injuries and the risk of obscuring other neck injuries. Explosion can inflict injuries by fragments penetration, blast injury, blunt force and burns. The study purpose was to determine the occurrence of cervical spine instability without irreversible neurological deficit and other potentially life threatening non-skeletal neck injuries among victims of explosions. The potential benefits and risks of SRCC application in explosion related injuries (ERI) was Evaluated. METHODS: a retrospective cohort study of all explosions civilian victims admitted to Israeli hospitals during the years 1998-2010. Data collection was based on the Israeli national trauma registry and the hospital records, and included demographic, clinical and radiological details of all patients with documented cervical spine injuries. RESULTS: the cohort included 2,267 patients. All of them were secondary to terrorist attacks. SRCC was applied to all the patients at the scene. Nineteen patients (0.83%) had cervical spine fractures. Nine patients (0.088%) had unstable cervical spine injury. All but one had irreversible neurological deficit on admission. 151 patients (6.6%) had potentially life threatening penetrating non-skeletal neck injuries. CONCLUSIONS: Unstable cervical spine injuries secondary to explosion are extremely rare. The majority of unstable cervical spine fractures were secondary to penetrating injuries, with irreversible neurological deficits on admission. The application of SRCC did not seem to be of any benefit in these patients and might pose a risk of obscuring other neck injuries. We recommend that SRCC will not be used in the pre-hospital management of victims of explosions. LEVEL OF EVIDENCE: Retrospective observational study, level III. Language: en

OBJECTIVES: To review hospitalised burn patients from 2004 to 2010 admitted to Israeli burn units and compare these result with data from 1997 to 2003. METHODS: Retrospectively, data was collected from the Israeli Trauma Registry (ITR) encompassing all burn admissions to Israeli burn units from 2004-2010 and compared to 1997-2003. RESULTS: Of the 5269 burn patients admitted from 2004 to 2010, 39.8% were non-Jewish. Infants under two years were the prominent age group (24.1%). Second to third degree burns 1-9% TBSA/first degree burns were 71%, second to third degree burns 10-19% TBSA were 16% and those 20%>TBSA consisted of 13%. Only 2.7% involved an inhalation injury. The average length of stay was 11.67 days and mortality rate 3.72%. All data was compared to the previous year's 1997-2003 and trends were identified. CONCLUSIONS: Within Israel, high risk populations remain infants under two years of age, males and those from non-Jewish populations. National prevention strategies and campaigns are warranted to inform and educated parents of young children and those at risk of burns. Of note, advances in burn care and procedures might have contributed to a decrease in the length of hospital stay (LOS). Language: en