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Public Transport (PT) provides passenger mobility and contributes to sustainable transportation. To achieve this a PT system must provide continuous accessible service and connections for passengers. PT reliability is considered a major obstacle to growing its market share. Current solutions primarily address travel time reliability through methods like priority lanes and traffic signal priority. Dwell time reliability improvement, in turn, can be achieved by the use of smart cards which reduce the variability in boarding and alighting times. Another factor affecting reliability is in-vehicle crowdedness which causes delays and increases dwell time variability. To mitigate crowdedness, we propose a monetary approach that dynamically changes the fare based on the in-vehicle crowdedness level in a manner similar to congestion pricing. This approach would shift some passengers from boarding the over-crowded vehicle to waiting for the next, less crowded vehicle, while compensating them for the additional waiting. Passengers unwilling to wait might pay a penalty if the additional waiting time is reasonable. To assess the attitude of passengers towards a dynamic fare model, a stated preference questionnaire was developed to assess the factors that affect the choice of whether or not to board an over-crowded vehicle. Based on panel data and the fixed effect logit model it was revealed that the higher the waiting time, the lower the willingness to board the next vehicle. However, monetary schemes (penalties or discounts) increased the willingness to wait and board the next vehicle. Moreover, the willingness to wait was higher when a penalty was introduced compared to a discount, which is in line with the prospect theory. The results suggest that it is possible to construct a dynamic fare model that using data on vehicle crowdedness levels and waiting times obtained from advanced data collection systems, which is integrated within a mobile payment application. This approach could reduce crowdedness and increase reliability.

The mechanism of hepatitis C virus (HCV) -induced hepatotocellular carcinoma (HCC) is still unknown, but in vitro studies clearly suggest that HCV proteins exert a direct effect on liver carcinogenesis. HCV NS3 serine protease is known to play a key role in the life cycle of the virus and may interact with the host cellular regulatory proteins. The aim of the present study was to conduct a genetic analysis of the HCV NS3 gene coding for the serine protease isolated from serum, tumor, and nontumor tissue of HCC patients. RNA was extracted and HCV cDNA was amplified by nested reverse transcriptase-polymerase chain reaction (RT-PCR). Sequence comparison yielded unique changes at the vicinity of the catalytic sites of the NS3 clones isolated only from HCC tissue. These changes included the insertion of a "large" and charged amino acid, substitution of a polar with a hydrophobic amino acid, and substitution of a charged with a polar amino acid. Those changes affect the electrostatic charge around the active site, and thus the activity and substrate specificity of the serine protease. This is the first study to define significant amino acid changes at the catalytic domain of the NS3 serine protease gene isolated from HCC tissue. [ABSTRACT FROM AUTHOR]

Introduction: Intraosseous devices have become an alternative to peripheral intravenous (PIV) access. Despite the established success of intraosseous devices in laboratory and simulator studies, there is a lack of data regarding their real-world utilisation in prehospital settings. Therefore, this study aims to evaluate the success rates of intraosseous access in a prehospital military context and identify factors associated with failure., Methods: Using the Israel Defense Forces (IDF) Trauma Registry, we retrospectively collected data from 2010 to 2023. The primary outcome was the first pass success rate of intraosseous access, and logistic regression models were applied to identify variables associated with first pass failure., Results: The study included 172 trauma patients who underwent attempted intraosseous access with 46.5% cases which were classified as military events. The median age was 22 years, and 17.3% were paediatric patients. First pass success was achieved in 67.4% of cases, with a cumulative success rate of 80.8% after multiple attempts. Moreover, significant differences were noted when examining the success rate of the three intraosseous devices used by the IDF teams, with the highest success rate being documented for the NIO Adult versus the EZ-IO or the BIG (81.4%; 76.7%; 62.4%). However, logistic regression analysis revealed that the number of PIV access attempts was the only variable significantly associated with decreased odds of achieving first pass intraosseous access., Conclusion: These findings suggest that intraosseous devices are a viable alternative for establishing vascular access in prehospital military settings. However, success rates were slightly lower than previous reports, potentially due to the severity of injuries in the study cohort. Our analyses revealed a higher number of PIV access attempts correlated with reduced first pass intraosseous success, possibly stemming from caregiver proficiency in obtaining vascular access. Further research is needed to explore additional factors affecting intraosseous access success rates., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Traumatic spinal injuries (TSI) pose a significant life-long burden, impacting both military and civilian populations. Assessing long-term outcomes is crucial for comprehending the enduring consequences of the initial insult and informing effective prevention and management strategies. Most existing studies have narrowly focused on subsets of traumatic cord injuries, leaving a gap in understanding the broader impact of severe spinal trauma. This study aims to examine severe TSIs in military personnel, who may face unique risk factors and injury patterns, and its association with long-term disability., Methods: A retrospective cohort study was conducted on all military personnel who suffered traumatic injuries (Injury Severity Score ≥ 9) from 1997 to 2020. Severe spinal injuries were defined using the spinal Abbreviated Injury Scale ≥ 3 (n = 95), and compared to all other injuries as a reference group (n = 1,394). Data were extracted and cross-referenced from three distinct nationwide registries-pre-hospital, admission, and rehabilitation. Logistic regression analysis was used to evaluate the impact of spinal injuries on long-term disabilities (defined as the highest possible disability tier). The study received approval from the institutional review board of the Israel Defense Forces Medical Corps., Results: Motor vehicle accidents and falls were the primary causes of spinal injuries (50.5% and 15.8%, respectively). The median age at injury was 20 years (interquartile range 19-22). Personnel with spinal trauma had a significantly higher prevalence of Injury Severity Score  ≥ 25 (46.3% vs. 19.9%, P < .001), longer median hospital stays (11 vs. 8 days, P = .036), and increased intensive care unit admissions (55% vs. 40%, P = .05). The median follow-up duration was 10.9 years (interquartile range 6.7-14.3). Spinal injuries were associated with a more than 10-fold increase in the adjusted odds ratio for severe permanent disability (11.92, 95% CI, 5.95-23.72)., Conclusion: Upon long-term follow-up, military personnel with severe TSI exhibit a significantly higher prevalence of debilitating disability compared to those with significant non-spinal traumatic injuries. These findings highlight the critical need for targeted prevention strategies and improved management of spinal injuries to reduce long-term disability. Strengths of this study include its extensive follow-up period and the use of multiple nationwide registries. However, the study may be limited by potential discrepancies in identity matching across databases and the reliance on disability claims, which may underrepresent the true prevalence of long-term disability. Future research should explore the efficacy of early interventions and rehabilitation strategies in mitigating long-term disability following spinal injuries. This study underscores the importance of developing evidence-based policies to enhance care for individuals with TSIs., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Background: On Saturday, October 7th, approximately 3000 Hamas-led terrorists infiltrated Israel's southern border and attacked civilians and soldiers. Terrorists murdered close to 1200 people, abducted hundreds, and injured thousands. This surprise attack involved an unprecedented number of casualties. This article describes the injuries and outcomes of the hospitalized casualties., Methods: Hospitalized trauma casualties with an injury date of October 7 to 8, 2023, and with ICD9 E-codes E979 and E990 through E999, were extracted from the Israel National Trauma Registry. Demographic, injury, and hospital resource-use data were analyzed., Results: A total of 630 hospitalized casualties (277 civilians and 353 soldiers) suffered from gunshot wounds (90%), explosion-related wounds (19%), and multiple injury mechanisms (16%). The median age for civilians was 33 years (ages <1-88) and 21 years for soldiers. The most frequently injured body regions were lower (49%) and upper (42%) extremities, abdominal (28%), and thoracic (23%) injuries. Four hundred thirty-one (68%) patients underwent surgery, of which 240 within 12 hours. Over half of the severe and critical (Injury Severity Score 16+) casualties were discharged to a rehabilitation center. In-hospital mortality rate was 2.5%., Conclusion: Israel's hospitals faced many challenges following the mega mass casualty incident, including the absorption, diagnosis, treatment, and rehabilitation of a massive number of casualties. Hospitals needed to immediately repurpose to provide additional imaging equipment and operating rooms. Additionally, the huge demand for rehabilitation resources necessitated immediate reorganization and transformation of existing medical facilities to accommodate the many casualties requiring rehabilitation. The injury details and outcomes from this mega mass casualty incident provide important information for planning and preparedness at local, regional, and national levels., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Emergency airway management is critical in trauma care. Cricothyroidotomy (CRIC) is a salvage procedure commonly used in failed endotracheal intubation (ETI) or difficult airway cases. However, more data is needed regarding the short and long-term complications associated with CRIC. This study aimed to evaluate the Israel Defense Forces experience with CRIC over the past 2 decades and compare the short-term and long-term sequelae of prehospital CRIC and ETI., Methods: Data on patients undergoing either CRIC or ETI in the prehospital setting between 1997 and 2021 were extracted from the Israel Defense Forces trauma registry. Patient data was then cross-referenced with the Israel national trauma registry, documenting in-hospital care, and the Israel Ministry of Defense rehabilitation department registry, containing long-term disability files of military personnel., Results: Of the 122 patients with short-term follow-up through initial hospitalization, 81% underwent prehospital ETI, while 19% underwent CRIC. There was a higher prevalence of military-related and explosion injuries among the CRIC patients (96% versus 65%, P = 0.02). Patients who underwent CRIC more frequently exhibited oxygen saturations below 90% (52% versus 29%, P = 0.002). Injury Severity Score was comparable between groups.No significant difference was found in intensive care unit length of stay and need for tracheostomy. Regarding long-term complications, with a median follow-up time of 15 y, CRIC patients had more upper airway impairment, with most suffering from hoarseness alone. One patient in the CRIC group suffered from esophageal stricture., Conclusions: This retrospective comparative analysis did not reveal significant short or long-term sequelae among military personnel who underwent prehospital CRIC. The long-term follow-up did not indicate severe aerodigestive impairments, thus suggesting that this technique is safe. Along with the high success rates attributed to this procedure, we recommend that CRIC remains in the armamentarium of trauma care providers. The findings of this study could provide valuable insights into managing difficult airway in trauma care and inform clinical decision-making in emergency settings., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The effectiveness of psychological interventions (PI) for malignant diseases is controversial. We aimed to investigate the effect of PI on survival and quality of life (QoL) in patients with cancer. We performed a systematic search of MEDLINE, Cochrane, and Embase databases to identify randomized controlled trials comparing PI to standard care (PROSPERO registration number CRD42021282327). Outcomes were overall survival (OS), recurrence-free survival (RFS), and different domains of QoL. Subgroup analysis was performed based on the provider-, type-, environment-, duration of intervention; cancer stage, and type. Pooled hazard ratios (HR) and standardized mean difference (SMD) with 95% confidence intervals (CI) were calculated using a random-effects model. The OS and RFS did not differ significantly between the two groups (OS:HR = 0.97; CI 0.87-1.08; RFS:HR = 0.99; CI 0.84-1.16). However, there was significant improvement in the intervention group in all the analyzed domains of QoL; in the global (SMD = 0.65; CI 0.35-0.94), emotional (SMD = 0.64; CI 0.33-0.95), social (SMD = 0.32; CI 0.13-0.51) and physical (SMD = 0.33; CI 0.05-0.60) domains. The effect of PI on QoL was generally positive immediately, 12 and 24 weeks after intervention, but the effect decreased over time and was no longer found significant at 48 weeks. The results were better in the breast cancer group and early stages of cancer. PIs do not prolong survival, but they significantly improve the QoL of cancer patients. PI should be added as standard of care 3-4 times a year, at least for patients with early-stage cancer., (© 2024. The Author(s).)

Background and Aims: Solid pancreatic masses are sampled through tissue acquisition by endoscopic ultrasound (EUS). Inadequate samples may significantly delay diagnosis, increasing costs and carrying risks to the patients., Aim: assess the diagnostic adequacy of tissue acquisition using contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) compared to conventional EUS., Methods: Five databases (PubMed, Embase, CENTRAL, Scopus and Web of Science) were searched in November 2023. Studies comparing diagnostic adequacy, accuracy and safety using CEH-EUS versus conventional EUS for tissue acquisition of solid pancreatic masses were included. Risk of bias was assessed using the Risk of Bias tool for randomized controlled trials (RoB2) and the Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) tool for non-randomized studies, level of evidence using the GRADE approach, Odds Ratios (RR) with 95 % Confidence Intervals (CI) calculated and pooled using a random-effects model. I 2 quantified heterogeneity., Results: The search identified 3858 records; nine studies (1160 patients) were included. OR for achieving an adequate sample was 1.467 (CI: 0.850-2.533), for randomized trials 0.902 (CI: 0.541-1.505), for non-randomized 2.396 (CI: 0.916-6.264), with significant subgroup difference. OR for diagnostic accuracy was 1.326 (CI: 0.890-1977), for randomized trials 0.997 (CI: 0.593-1.977) and for non-randomized studies 1.928 (CI: 1.096-3.393), significant subgroup difference (p = 0.0467). No differences were observed for technical failures or adverse events. Heterogeneity was low, risk of bias "low" to "some concerns" for most outcomes, mostly moderate for non-randomized studies., Conclusion: Non-randomized studies indicated differences in favor of contrast-enhanced EUS, randomized studies showed no difference in diagnostic adequacy, accuracy or sensitivity when using CEH-EUS., Competing Interests: Declaration of competing interest None to declare., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To examine the association between late adolescence ADHD and the risk of serious injury in early adulthood., Method: A nationwide cohort study utilizing data from the Military Health Examinations Database for potential military recruits (age 16.5-18 years), cross-referenced with the Israeli National Trauma Registry (2008-2020). Individuals with and without ADHD (mild/severe) were compared for early adulthood injury risk using Cox models., Results: This study compared 76,403 participants with mild ADHD (18.76%) and 330,792 without (81.24%), alongside 2,835 severe ADHD participants (1.11%) versus 252,626 without (98.89%). Adjusted hazard ratios for injury-related hospitalization were 1.27 (95% CI [1.17, 1.37]) for mild ADHD and 1.40 (95% CI [1.09, 1.79]) for severe ADHD, compared to non-ADHD., Conclusions: Adolescents with ADHD, regardless of severity, had a significantly higher risk of hospitalization due to injury that persists into early adulthood, underscoring the importance of recognizing ADHD as an injury risk and incorporating it into injury prevention strategies., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Military and prehospital medical organizations invest significant resources to advance the treatment of trauma patients aiming to reduce preventable deaths. Focus is on hemorrhage control and volume resuscitation with blood products, with adoption of Remote Damage Control Resuscitation (RDCR) guidelines. The Israel Defense Forces Medical Corps (IDF-MC) has been using tranexamic acid and freeze-dried plasma (FDP) as part of its RDCR protocol for more than a decade. In recent years, low-titer group O whole blood (LTOWB) has been integrated, on IDF evacuation helicopters and expanded to mobile ambulances, complementing FDP use in treating trauma patients in state of profound shock., Study Design and Methods: During the war that erupted in October 2023, the IDF-MC made a decision to bring LTOWB forward, and to equip every combat brigade level mobile intensive care units with LTOWB, onboard armored vehicles. The goal was to make whole blood available as close as possible to the point of injury and within minutes from time of injury., Results and Discussion: We describe the IDF-MCs' efforts to bring LTOWB to the front lines and present four cases in which LTOWB was administered. All patients were young male, with significant blood loss following penetrating injuries. One patient died in the operating room, following hospital arrival and emergency thoracotomy. The others survived. Our initial experience with bringing LTOWB as close as possible to the point of injury during high intensity fighting is encouraging, showing patient benefit along with logistic feasibility. After action reports and data collection will continue., (© 2024 The Authors. Transfusion published by Wiley Periodicals LLC on behalf of AABB.)

Background : Trauma laparotomy (TL) remains a cornerstone of trauma care. We aimed to investigate prehospital measures associated with in-hospital mortality among casualties subsequently undergoing TLs in civilian hospitals. Methods : This retrospective cohort study cross-referenced the prehospital and hospitalization data of casualties treated by Israel Defense Forces-Medical Corps teams who later underwent TLs in civilian hospitals between 1997 and 2020. Results : Overall, we identified 217 casualties treated by IDF-MC teams that subsequently underwent a TL, with a mortality rate of 15.2% (33/217). The main mechanism of injury was documented as penetrating for 121/217 (55.8%). The median heart rate and blood pressure were within the normal limit for the entire cohort, with a low blood pressure predicting mortality (65 vs. 127, p < 0.001). In a multivariate analysis, prehospital endotracheal intubation (ETI), emergency department Glasgow coma scores of 3-8, and the need for a thoracotomy or bowel-related procedures were significantly associated with mortality (OR 6.8, p < 0.001, OR = 48.5, p < 0.001, and OR = 4.61, p = 0.002, respectively). Conclusions : Prehospital interventions introduced throughout the study period did not lead to an improvement in survival. Survival was negatively influenced by prehospital ETI, reinforcing previous observations of the potential deleterious effects of definitive airways on hemorrhaging trauma casualties. While a low blood pressure was a predictor of mortality, the median systolic blood pressure for even the sickest patients (ISS > 16) was within normal limits, highlighting the challenges in triage and risk stratification for trauma casualties.

Background: Organisms from many distinct evolutionary lineages acquired the capacity to enter a dormant state in response to environmental conditions incompatible with maintaining normal life activities. Most studied organisms exhibit seasonal or annual episodes of dormancy, but numerous less studied organisms enter long-term dormancy, lasting decades or even centuries. Intriguingly, many planktonic animals produce encased embryos known as resting eggs or cysts that, like plant seeds, may remain dormant for decades. Herein, we studied a rotifer Brachionus plicatilis as a model planktonic species that forms encased dormant embryos via sexual reproduction and non-dormant embryos via asexual reproduction and raised the following questions: Which genes are expressed at which time points during embryogenesis? How do temporal transcript abundance profiles differ between the two types of embryos? When does the cell cycle arrest? How do dormant embryos manage energy?, Results: As the molecular developmental kinetics of encased embryos remain unknown, we employed single embryo RNA sequencing (CEL-seq) of samples collected during dormant and non-dormant embryogenesis. We identified comprehensive and temporal transcript abundance patterns of genes and their associated enriched functional pathways. Striking differences were uncovered between dormant and non-dormant embryos. In early development, the cell cycle-associated pathways were enriched in both embryo types but terminated with fewer nuclei in dormant embryos. As development progressed, the gene transcript abundance profiles became increasingly divergent between dormant and non-dormant embryos. Organogenesis was suspended in dormant embryos, concomitant with low transcript abundance of homeobox genes, and was replaced with an ATP-poor preparatory phase characterized by very high transcript abundance of genes encoding for hallmark dormancy proteins (e.g., LEA proteins, sHSP, and anti-ROS proteins, also found in plant seeds) and proteins involved in dormancy exit. Surprisingly, this period appeared analogous to the late maturation phase of plant seeds., Conclusions: The study highlights novel divergent temporal transcript abundance patterns between dormant and non-dormant embryos. Remarkably, several convergent functional solutions appear during the development of resting eggs and plant seeds, suggesting a similar preparatory phase for long-term dormancy. This study accentuated the broad novel molecular features of long-term dormancy in encased animal embryos that behave like "animal seeds"., (© 2024. The Author(s).)

Behind armor blunt trauma (BABT) is a non-penetrating injury caused by energy transfer and rapid deformation of protective body armor. Although modern military body armor is designed to prevent penetrating trunk injuries, high-energy projectiles can produce a significant energy transfer to tissues behind the armor and inflict injuries such as fractures or organ contusions. However, knowledge of BABT is limited to biomechanical and cadaver modeling studies and rare case reports. We report two cases of BABT resulting from close-range fire and discuss the potential implications for triaging patients with BABT in battlefield scenarios. In the first case, a 19-year-old male soldier sustained a single close-range 5.56-mm assault rifle gunshot to his chest body armor. The soldier initially reported mild pain in the parasternal region and assessment revealed a 4 cm × 3 cm skin abrasion. Following emergency department evaluation, the soldier was diagnosed with a non-displaced transverse fracture of the sternal body. In the second case, a 20-year-old male sustained five machine gun bullets (7.62 mm) to his body armor. Computed tomography of the chest revealed pulmonary contusions in the right lower and middle lobes. Both soldiers achieved full recovery and returned to combat duty within several weeks. These cases highlight the potential risks of energy transfer from high-velocity projectiles impacting body armor and the need for frontline providers to be aware of the risk of underlying blunt injuries. Further reporting of clinical cases and modeling studies using high-velocity projectiles could inform recommendations for triaging, evacuating, and assessing individuals with BABT., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Prehospital traumatic cardiac arrest (TCA) is associated with a poor prognosis and requires urgent interventions to address its potentially reversible causes. Resuscitative efforts of TCA in the prehospital setting may entail significant resource allocation and impose added tolls on caregivers. The Israel Defense Forces Medical Corps (IDF-MC) instructs clinicians to perform a set protocol in the case of TCA, providing prompt oxygenation, chest decompression and volume resuscitation. This study investigates the settings, interventions, and outcomes of TCA resuscitation by IDF-MC teams over 25 years in both combat and civilian settings., Methods: Retrospective study of the IDF-MC Trauma Registry between 1997-2022. Search criteria were applied to identify cases where the TCA protocol was initiated. A manual review of cases matching the search criteria was performed by two curators to determine the indications, interventions, and outcomes of casualties with prehospital TCA. Patients for whom interventions were performed outside of the TCA protocol, such as with measurable vital signs, were excluded. The primary outcome was survival to hospital admission, with the secondary outcome being return of vital signs in the prehospital setting., Results: Following case review, 149 patients with prehospital TCA were included, with a median age of 21 (interquartile range 19-27). Eighty-four (56.4%) presented with TCA in military or combat settings, with gunshot wounds and blast injuries being the most common mechanisms in this group. For 56 casualties (37.8%), all components of the protocol were performed (oxygenation, chest decompression, and volume resuscitation). Five (3.4%) casualties had return of vital signs in the prehospital setting, but none survived to hospital admission., Conclusion: The prognosis of prehospital TCA is poor, and efforts to address its potentially reversible causes may often be futile. These notions may be further emphasized in military settings, where resources are limited, and extensive penetrating injuries are more common.

Background: Pelvic fractures resulting from high-energy trauma can frequently present with life-threatening hemodynamic instability that is associated with high mortality rates. The role of pelvic exsanguination in causing hemorrhagic shock is unclear, as associated injuries frequently accompany pelvic fractures. This study aims to compare the incidence of hemorrhagic shock and in-hospital outcomes in patients with isolated and non-isolated pelvic fractures., Methods: Registries-based study of trauma patients hospitalized following pelvic fractures. Data from 1997 to 2021 were cross-referenced between the Israel Defense Forces Trauma Registry (IDF-TR), documenting prehospital care, and Israel National Trauma Registry (INTR) recording hospitalization data. Patients with isolated pelvic fractures were defined as having an Abbreviated Injury Scale (AIS) <3 in other anatomical regions, and compared with patients sustaining pelvic fracture and at least one associated injury (AIS ≥ 3). Signs of profound shock upon emergency department (ED) arrival were defined as either a systolic blood pressure <90 mmHg and/or a heart rate >130 beats per min., Results: Overall, 244 hospitalized trauma patients with pelvic fractures were included, most of whom were males (84.4%) with a median age of 21 years. The most common injury mechanisms were motor vehicle collisions (64.8%), falls from height (13.1%) and gunshot wounds (11.5%). Of these, 68 (27.9%) patients sustained isolated pelvic fractures. In patients with non-isolated fractures, the most common regions with a severe associated injury were the thorax and abdomen. Signs of shock were recorded for 50 (20.5%) patients upon ED arrival, but only four of these had isolated pelvic fractures. In-hospital mortality occurred among 18 (7.4%) patients, all with non-isolated fractures., Conclusion: In young patients with pelvic fractures, severe associated injuries were common, but isolated pelvic fractures rarely presented with profound shock upon arrival. Prehospital management protocols for pelvic fractures should prioritize prompt evacuation and resuscitative measures aimed at addressing associated injuries.

Background: Cold-stored low-titer group O whole blood (LTOWB) has become increasingly utilised in both prehospital and in-hospital settings for resuscitation of traumatic haemorrhage. However, implementing the use of LTOWB to ground medical teams has been limited due to logistic challenges., Methods: In 2022, the Israel Defense Forces (IDF) started using LTOWB in ambulances for the first time in Israel. This report details the initial experience of this rollout and presents a case-series of the first patients treated with LTOWB., Results: Between January-December 2022, seven trauma patients received LTOWB administered by ground IDF intensive care ambulances after presenting with profound shock. Median time from injury to administration of LTOWB was 35 min. All patients had evidence of severe bleeding upon hospital arrival with six undergoing damage control laparotomy and all but one surviving to discharge., Conclusions: The implementation of LTOWB in ground medical units is in its early stages, but continued experience may demonstrate its feasibility, safety, and effectiveness in the prehospital setting. Further research is necessary to fully understand the indications, methodology, and benefits of LTOWB in resuscitating severely injured trauma patients in this setting., (© 2023 The Authors. Transfusion Medicine published by John Wiley & Sons Ltd on behalf of British Blood Transfusion Society.)