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The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), exhibits high levels of mortality and morbidity and has dramatic consequences on human life, sociality and global economy. Neutralizing antibodies constitute a highly promising approach for treating and preventing infection by this novel pathogen. In the present study, we characterize and further evaluate the recently identified human monoclonal MD65 antibody for its ability to provide protection against a lethal SARS-CoV-2 infection of K18-hACE2 transgenic mice. Eighty percent of the untreated mice succumbed 6–9 days post-infection, while administration of the MD65 antibody as late as 3 days after exposure rescued all infected animals. In addition, the efficiency of the treatment is supported by prevention of morbidity and ablation of the load of infective virions in the lungs of treated animals. The data demonstrate the therapeutic value of human monoclonal antibodies as a life-saving treatment for severe COVID-19 infection., Here, using the K18-hACE2 transgenic mice model, the authors report the in vivo efficacy of a fully human neutralizing antibody against SARS-CoV-2 and show that when administered before or up to 3 days post infection, treated mice do not exhibit disease symptoms while 80% of control animals succumb to the infection.

The COVID-19 pandemic caused by SARS-CoV-2 imposes an urgent need for rapid development of an efficient and cost-effective vaccine, suitable for mass immunization. Here, we show the development of a replication competent recombinant VSV-∆G-spike vaccine, in which the glycoprotein of VSV is replaced by the spike protein of SARS-CoV-2. In-vitro characterization of this vaccine indicates the expression and presentation of the spike protein on the viral membrane with antigenic similarity to SARS-CoV-2. A golden Syrian hamster in-vivo model for COVID-19 is implemented. We show that a single-dose vaccination results in a rapid and potent induction of SARS-CoV-2 neutralizing antibodies. Importantly, vaccination protects hamsters against SARS-CoV-2 challenge, as demonstrated by the abrogation of body weight loss, and alleviation of the extensive tissue damage and viral loads in lungs and nasal turbinates. Taken together, we suggest the recombinant VSV-∆G-spike as a safe, efficacious and protective vaccine against SARS-CoV-2., Here, the authors generate a replication-competent VSV based vaccine expressing SARS-CoV-2 spike protein and show protection in the hamster model with one dose. Analysis of the antibody response in mice shows induction of neutralizing antibodies and suggests a desirable Th1-biased response to the vaccine.

The COVID-19 pandemic initiated a worldwide race toward the development of treatments and vaccines. Small animal models included the Syrian golden hamster and the K18-hACE2 mice infected with SARS-CoV-2 to display a disease state with some aspects of human COVID-19. A group activity of animals in their home cage continuously monitored by the HCMS100 (Home cage Monitoring System 100) was used as a sensitive marker of disease, successfully detecting morbidity symptoms of SARS-CoV-2 infection in hamsters and in K18-hACE2 mice. COVID-19 convalescent hamsters rechallenged with SARS-CoV-2 exhibited minor reduction in group activity compared to naive hamsters. To evaluate the rVSV-ΔG-spike vaccination efficacy against SARS-CoV-2, we used the HCMS100 to monitor the group activity of hamsters in their home cage. A single-dose rVSV-ΔG-spike vaccination of the immunized group showed a faster recovery than the nonimmunized infected hamsters, substantiating the efficacy of rVSV-ΔG-spike vaccine. HCMS100 offers nonintrusive, hands-free monitoring of a number of home cages of hamsters or mice modeling COVID-19.

Identification and characterization of novel unknown viruses is of great importance. The introduction of high-throughput sequencing (HTS)-based methods has paved the way for genomics-based detection of pathogens without any prior assumptions about the characteristics of the organisms. However, the use of HTS for the characterization of viral pathogens from clinical samples remains limited. Here, we report the identification of a novel Orthobunyavirus species isolated from horse plasma. The identification was based on a straightforward HTS approach. Following enrichment in cell culture, RNA was extracted from the growth medium and rapid library preparation, HTS and primary bioinformatic analyses were performed in less than 12 hours. Taxonomical profiling of the sequencing reads did not reveal sequence similarities to any known virus. Subsequent application of de novo assembly tools to the sequencing reads produced contigs, of which three showed some similarity to the L, M, and S segments of viruses belonging to the Orthobunyavirus genus. Further refinement of these contigs resulted in high-quality, full-length genomic sequences of the three genomic segments (L, M and S) of a novel Orthobunyavirus. Characterization of the genomic sequence, including the prediction of open reading frames and the inspection of consensus genomic termini and phylogenetic analysis, further confirmed that the novel virus is indeed a new species, which we named Ness Ziona virus.

SummaryA wide range of SARS-CoV-2 neutralizing monoclonal antibodies (mAbs) were reported to date, most of which target the spike glycoprotein and in particular its receptor binding domain (RBD) and N-terminal domain (NTD) of the S1 subunit. The therapeutic implementation of these antibodies has been recently challenged by emerging SARS-CoV-2 variants that harbor extensively mutated spike versions. Consequently, the re-assessment of mAbs, previously reported to neutralize the original early-version of the virus, is of high priority.Four previously selected mAbs targeting non-overlapping epitopes, were evaluated for their binding potency to RBD versions harboring individual mutations at spike positions 417, 439, 453, 477, 484 and 501. Mutations at these positions represent the prevailing worldwide distributed modifications of the RBD, previously reported to mediate escape from antibody neutralization. Additionally, the in vitro neutralization potencies of the four RBD-specific mAbs, as well as two NTD-specific mAbs, were evaluated against two frequent SARS-CoV-2 variants of concern (VOCs): (i) the B.1.1.7 variant, emerged in the UK and (ii) the B.1.351 variant, emerged in South Africa. Variant B.1.351 was previously suggested to escape many therapeutic mAbs, including those authorized for clinical use. The possible impact of RBD mutations on recognition by mAbs is addressed by comparative structural modelling. Finally, we demonstrate the therapeutic potential of three selected mAbs by treatment of K18-hACE2 transgenic mice two days post infection with each of the virus strains.Our results clearly indicate that despite the accumulation of spike mutations, some neutralizing mAbs preserve their potency against SARS-CoV-2. In particular, the highly potent MD65 and BL6 mAbs are shown to retain their ability to bind the prevalent novel viral mutations and to effectively protect against B.1.1.7 and B.1.351 variants of high clinical concern.

We announce the genome sequences of two strains of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolated in Israel, one imported by a traveler who returned from Japan and the second strain collected from a patient infected by a traveler returning from Italy. The sequences obtained are valuable as early manifestations for future follow-up of the local spread of the virus in Israel.

The COVID-19 pandemic caused by SARS-CoV-2 that emerged in December 2019 in China resulted in over 7.8 million infections and over 430,000 deaths worldwide, imposing an urgent need for rapid development of an efficient and cost-effective vaccine, suitable for mass immunization. Here, we generated a replication competent recombinant VSV-ΔG-spike vaccine, in which the glycoprotein of VSV was replaced by the spike protein of the SARS-CoV-2. In vitro characterization of the recombinant VSV-ΔG-spike indicated expression and presentation of the spike protein on the viral membrane with antigenic similarity to SARS-CoV-2. A golden Syrian hamster in vivo model for COVID-19 was implemented. We show that vaccination of hamsters with recombinant VSV-ΔG-spike results in rapid and potent induction of neutralizing antibodies against SARS-CoV-2. Importantly, single-dose vaccination was able to protect hamsters against SARS-CoV-2 challenge, as demonstrated by the abrogation of body weight loss of the immunized hamsters compared to unvaccinated hamsters. Furthermore, whereas lungs of infected hamsters displayed extensive tissue damage and high viral titers, immunized hamsters’ lungs showed only minor lung pathology, and no viral load. Taken together, we suggest recombinant VSV-ΔG-spike as a safe, efficacious and protective vaccine against SARS-CoV-2 infection.

The novel highly transmissible human coronavirus SARS-CoV-2 is the causative agent of the COVID-19 pandemic. Thus far, there is no approved therapeutic drug, specifically targeting this emerging virus. Here we report the isolation and characterization of a panel of human neutralizing monoclonal antibodies targeting the SARS-CoV-2 receptor binding domain (RBD). These antibodies were selected from a phage display library constructed using peripheral circulatory lymphocytes collected from patients at the acute phase of the disease. These neutralizing antibodies are shown to recognize distinct epitopes on the viral spike RBD, therefore they represent a promising basis for the design of efficient combined post-exposure therapy for SARS-CoV-2 infection.

The novel highly transmissible human coronavirus SARS-CoV-2 is the causative agent of the COVID-19 pandemic. Thus far, there is no approved therapeutic drug specifically targeting this emerging virus. Here we report the isolation and characterization of a panel of human neutralizing monoclonal antibodies targeting the SARS-CoV-2 receptor binding domain (RBD). These antibodies were selected from a phage display library constructed using peripheral circulatory lymphocytes collected from patients at the acute phase of the disease. These neutralizing antibodies are shown to recognize distinct epitopes on the viral spike RBD. A subset of the antibodies exert their inhibitory activity by abrogating binding of the RBD to the human ACE2 receptor. The human monoclonal antibodies described here represent a promising basis for the design of efficient combined post-exposure therapy for SARS-CoV-2 infection., Here, Noy-Porat, Makdasi et al. report the isolation of a panel of neutralizing mAbs selected against SARS-CoV-2 receptor-binding domain (RBD) from a phage display library constructed based on patient samples collected in the acute phase of the disease, which show efficient neutralizing activities against authentic virus in vitro.

We report a case of monkeypox in a man who returned from Nigeria to Israel in 2018. Virus was detected in pustule swabs by transmission electron microscopy and PCR and confirmed by immunofluorescence assay, tissue culture, and ELISA. The West Africa monkeypox outbreak calls for increased awareness by public health authorities worldwide.

Large numbers of rodents are often used in the study of disease progression and in the evaluation of its potential treatments. To avoid subjective observation and to minimize home cage interference, we developed a computerized home cage monitoring system (HCMS100) based on a standard cage rack adapted with a single laser beam and a detector mounted on each cage, enabling to monitor mice movements based on laser beam interruptions. This retrofit system provided continuous and uninterrupted monitoring of spontaneous movement of a group of mice in a home cage. Validity was evaluated using disease state induced by LPS modelling bacterial infection and by influenza virus. RESULTS: Spontaneous activity of different number of mice (2-8) per cage showed the expected circadian rhythm with increased activity during the night, and its extent dependent on the number of mice in the cage. Females and males show similar circadian rhythm. Intranasal LPS administration and pulmonary infection with live influenza virus resulted in major reduction of mice activity along disease progression. Increase in activity over time was a good indicator of the recovery process from both LPS exposure and the flu infection. CONCLUSIONS: HCMS100 was shown to be a reliable, inexpensive, easy to use system that requires no changes in the common housing of various experimental animals (mice, hamsters, rats etc.). With minimal intervention, HCMS100 provides a continuous record of group activity with clear pattern of circadian rhythm, allowing long term recording of home cage activity even in restricted access environments.

The surge in mass casualty terror attacks during the first decade of the 21st century presented a special challenge for health organizations. Unique types of injury resulting from these Mass Casualty Events called for special capabilities to restore the balance between immediate demands and scarce resources. Post Traumatic Stress Disorder (PTSD), to both victims and healthcare providers and first responders required extra knowledge and early intervention. All these and the concerns of the possibilities of non-conventional weapons terror attacks, led to the defining of “Terror Medicine”, a new medical field. This field evolves the medical macro management of terror attacks, the focused clinical management of the specific injuries and coping with the aftermath consequences. The scope of Terror Medicine is: Prevention, Preparedness, Response and Recovery. The evolution and trends of Terror Medicine is discussed in this article.

Mass casualty events due to terror attacks have escalated throughout Israel since September 2000, with a high proportion of these events occurring in the Jerusalem area. Immediately after news of a large-scale terror attack is received, family/public information centers are set up in all local hospitals to meet the needs of members of the public who call or arrive at hospitals anxious to obtain information about relatives who may have been at the site of the attack. The most urgent task facing these centers is the quick and accurate identification of victims whose identity is in question. To date, some 3000 casualties have been treated at Hadassah Hebrew University Medical Center (Hadassah), a level I trauma center. This number accounts for nearly half of Israel’s total number of casualties from terror attacks during this period. Extensive experience has led the hospital to develop a unique organizational model for its family/public information center; in this model, members of the nursing staff identify casualties. The experience and knowledge gained in dealing with terror events also can be applied to other types of mass casualty events, such as major road or work accidents.

During recent months, the Centers for Disease Control and Prevention (CDC) announced the occurrence of three major biosafety incidents, raising serious concern about biosafety and biosecurity guideline implementation in the most prestigious agencies in the United States: the CDC, the National Institutes of Health (NIH) and the Federal Drug Administration (FDA). These lapses included: a) the mishandling of Bacillus anthracis spores potentially exposing dozens of employees to anthrax; b) the shipment of low pathogenic influenza virus unknowingly cross-contaminated with a highly pathogenic strain; and c) an inventory lapse of hundreds of samples of biological agents, including six vials of variola virus kept in a cold storage room for decades, unnoticed. In this review we present the published data on these events, report the CDC inquiry's main findings, and discuss the key lessons to be learnt to ensure safer scientific practice in biomedical and microbiological service and research laboratories.

Terror-related injuries caused by secondary fragments (SF) from explosive devices show a distinctive pattern in severity, distribution, outcomes of assault, and health-system resource use as compared with terror-related penetrating injuries caused by gunshot wounds.A case-comparison study conducted in a tertiary university hospital and the only Level I trauma center in the Jerusalem vicinity. During a period of 4 years, over 1,500 casualties of terror-related injuries were treated in one Level I trauma center. The study included 533 patients who were admitted for hospitalization. Excluded from the study were victims who were dead on arrival or who succumbed to their injuries within 30 minutes of arrival at the emergency department. Data were collected from trauma registry records.Gunshot-wound victims were mostly men, aged 19 to 30, and SF victims were more evenly distributed between the genders and across the age spectrum. Injury Severity Score (ISS) was considerably higher in SF victims, although critical mortality rates were higher in gunshot-wound victims. More than 40% of SF victims were injured in three or more body regions, as opposed to10% in gunshot-wound victims. Use of imaging modalities and ICUs was considerably higher for SF victims.Terror victims suffering from SF wounds have more complex, widespread, and severe injuries than victims suffering from gunshot wounds. They tend to involve multiple body regions and use more in-hospital resources. Attenuation of bus seats and protective vests can lead to a reduction in severity of these injuries.

Terror-related multiple casualty incidents (MCI) in Israel since September 2000 have resulted in a new pattern of injury as a result of the mechanisms of trauma. The objective of this study was to asses the temporal death distribution among the civilian casualties in the Jerusalem vicinity during a 3-year period. All terrorist attacks in the Jerusalem district from September 2000 to September 2003 were included in this study. The data of all deaths were processed including the time of the attack, the evacuation time to the hospitals, and the time of death. During the study period 28 terror-related MCI occurred. A total of 2328 victims were injured and 273 died, for an overall fatality rate of 11.7%. A unique temporal death distribution was identified; 82.8% of the deaths occurred immediately, at the scene of the attack (scene death); of the remaining 17.2% of patients who died in the hospital, half died within 4 hours of arrival (immediate death), one quarter within 5–24 hours (early death), and one quarter later than that (late death). The temporal death distribution was significantly different when classifying the mechanism of trauma to suicide bombings versus shooting. The scene mortality was higher in the suicide bombings than in shooting attacks (86.7% versus 77%, P = 0.039 ). In contrast, the mortality within 1–24 hours was higher in the shooting attacks (17% versus 6.3%, P = 0.05). Terror-related MCI occurring in civilian settings have a unique temporal death distribution. A very high scene mortality is seen compared to the classical description of Donald Trunkey1 in 1983. The late deaths, which composed 30% of the mortality in civilian settings, comprise only 4.4% of the total mortality in MCIs. A rough estimate of the in-hospital mortality could be achieved after the first 4 hours, allowing the assessment and distribution of hospital resources. Futile care should be identified early and availability of ICU beds can be calculated according to the immediate mortality.

Bioterrorism has global implications, especially with regard to the use of contagious bio agents or “epidemic generators” with a high potential for causing epidemics. The grave medical implications of a bioterror attack are obvious, but some of the related ethical issues are often overlooked. Moral issues associated with the threat and with the attack may carry long-term consequences, which may shake the rudiments of democratic societies. Some of these efforts may be aided by regulations, laws, and enforcement. The best results will be achieved by a sense of responsibility and understandings of the public.

On September 11, 2001, the world changed. The vicious giant of terrorism that was dormant until that date had arisen. After the horrific mass-casualty terror attack on the United States, any and all forms of assault seem possible. Owing to the complexity of injuries encountered in terror attack victims, fast and accurate imaging plays an essential role in triage and identification of abnormalities associated with injuries. The radiologist becomes a crucial part of the first-line team of doctors treating these patients. Knowledge that the best available treatment is given to terror attack victims can enhance the strength and endurance of society against terror. On the basis of the authors' experience with terror events in Israel, the steps involved in imaging of terror attack patients include conventional radiography, focused abdominal sonography in trauma, computed tomography, and angiography, with the judicious use of supplemental imaging.

Traditionally, auditors are apprehensive when it comes to auditing clinical decisions. A novel model might lead to better integration of auditors into the core activities of health system medical care, while creating common interests among all participants in the process.

The ongoing intensive wave of terror assaults against Israel is already approaching its fourth year. The endurance of the Israeli population to this hardship can be attributed, to a certain extent, to proficient leadership. Directing a tertiary university hospital, such as Hadassah, throughout this dire period has required distinctive leadership capabilities. Problems such as staff management during crisis, security, provision of information to the public and media, coping with the clinical routine, teaching and research activities and handling the economic burden, were all aspects of hospital administration that had to be taken care of. We believe that the core issue of medical management in time of terror attacks is establishing the right balance between the specific and peacetime routine. The measures taken to deal with these difficulties can serve as a model of contingency management in the field of medicine as well as other areas.‐

Despite the findings that pain and depression are not always directly linked, enough evidence suggest that a complex relationship between pain and depression exists. Using an electronic pressure algometer placed on the sternum, the changes in pressure pain threshold (PPThr) and pressure pain tolerance (PPTol) were evaluated in 19 patients affected by refractory major depression without psychotic features, throughout a full course of electroconvulsive therapy (ECT) treatment. Measurements were done before the first treatment, after the 6th treatment and after the last treatment. After the 6th treatment, mean (+/- SD) PPThr increased significantly from 11.48 (+/- 4.81) kg/cm2 at baseline, to 13.7 (+/- 5.59) kg/cm2 (p=0.0076) while PPTol did not change significantly (from 18.46 (+/- 6.75)kg/cm2 to 17.4 (+/- 8.1)kg/cm2). At the end of the treatment course, mean (+/- SD) PPThr did not increase further significantly (15.06 (+/- 5.21)kg/cm2 (p=0.0234)) while PPTol increased significantly to 21.34 (+/- 7.8)kg/cm2 (p=0.0047). ECT's efficacy was measured with the 21-item Hamilton Rating Scale for Depression (21-HAM-D). Mean (+/- SD) 21-HAM-D scores decreased significantly from 30.9 (+/- 4.15) at baseline, to 10.47 (+/- 5.78) (p=0.0001) after the 6th treatment, with no further significant change at the end of the treatment course (9.94 +/- 3.07; p=0.0254). Both pain threshold and pain tolerance increased following the alleviation of the depressive disorder and a possible usefulness of ECT may be postulated for treating severe, chronic pain syndromes. However, a more significant conclusion is that the increase of the PPThr noted early during ECT treatment may serve as an early outcome possible detector of ECT efficacy in depressed patients.

This article aims to summarize the accumulating experience of Hadassah University Hospitals in Jerusalem, Israel with ongoing terror attacks. The authors review their ongoing documented data from the first two years of the last wave of Palestinian terror attacks. Injury patterns and epidemiology of 1,916 terror victims are analyzed. The main finding is that terror is associated with significantly more severe and resource-demanding injuries than other forms of trauma. Main lessons and con­clusions from managing this terror wave are presented. The authors believe that preparedness and application of lessons learned from conventional terror will enhance the durability of society against terror associated with weapons of mass destruction.­

The organizational and medical conduct in disaster situations is complex and presents a challenge to every manager in the prehospital setting. The handling of such situations is characterized by the need to make decisions under uncertainty in real time, with deficient medical and support forces. The approach used in mass casualty incident situations is cycles of treatment, commonly known as the "butterfly system." There are serious logistic problems involved, both industrial and structural, physical obstacles that may interfere with rescue treatment and evacuation, disruption in communications, and many other difficulties. On top of these, there are other obstacles such as interruption with the cooperation and coordination of different force, enforcement and rescue teams, the press, inquisitive people, and others. However, the most serious problem of all is the tendency in complex situations to attempt to work with fixed preformed guidelines or protocols for operation. One disaster differs from another, regarding location, number of casualties, distribution, severity, type of injury and the nature of injury, size of available rescue teams, time and equipment needs, damage to roads, distance from hospital, and other variables. One of the most important lessons learned from the management of such incidents is do not set fixed protocols but rather principles only. By applying principles adapted to the situation, managers will be able to perform better.

INTRODUCTION Tactical emergency medical support (TEMS) is a specialized area of emergency medical services (EMS). Its primary goal is to provide medical care under tactical environments to help save lives and accomplish the team’s mission. It may reduce the likelihood of death, injury, permanent disability, and illness among tactical operators, civilians, and suspects; reduce lost work time; decrease liability for the law enforcement agency; and enhance team morale. In addition, TEMS providers can train officers to treat themselves and others, a valuable capability if medical personnel are not immediately available. Much of the medical care administered by TEMS providers is based on local or regional EMS protocols and on a number of tactical medical curricula, including Tactical Combat Casualty Care (TCCC), the STORM (Specialized Tactics for Operational Rescue and Medicine) family of courses, and CONTOMS (Counter Narcotics and Terrorism Operational Medical Support). The primary objectives of these curricula are to treat the casualty, prevent further casualties, and complete the mission. The TCCC curriculum addresses rapid hemorrhage control, including early tourniquet application; airway management; fluid resuscitation; field analgesia, antibiotic administration; and hypothermia prevention. Efforts are ongoing to expand the role of, and standardize the care administered by, TEMS providers. How to incorporate a military-based TEMS component into civilian Special Weapons and Tactics (SWAT) teams and how tactical commanders can use this potentially valuable asset receive less attention. Medical personnel can be an important addition to a SWAT team, but they can also be a liability. Tactical leaders tasked with integrating a medical component in their team must learn to utilize providers in a safe and effective fashion. They should have an appreciation for the potential benefits and limitations of on-scene medical care, how to manage victim evacuation and the timing for that evacuation, and how to balance the needs of the patient with the success of the mission. Although law enforcement and medical providers focus on different aspects of a mission, either addressing the threat or caring for the injured, the joint mission in scenarios such as an active shooter is to save lives. The medical and tactical efforts should be complementary and by this synergistic to the mission. Based on our experience in the Israeli Special Forces and in civilian EMS, TEMS, and SWAT teams in the United States, we propose a joint forces field algorithm that addresses the medical and tactical considerations of patient care in a hostile environment. It can be followed by medical providers and tactical operators to better coordinate their efforts. It may assist civilian SWAT leaders working with TEMS personnel to incorporate medical providers into their teams and medical considerations into their tactics. The aim is to narrow the gap that may exist between law enforcement and medical priorities in the field and provide higher-quality patient care so SWAT teams can better accomplish their mission.

Study Objectives: To determine whether isolated eardrum perforation is a marker for concealed blast lung injury in survivors of terrorist bombings. Methods: Survivors who arrived at hospitals after 11 terrorist bombings in Israel between April 6, 1994, and March 4, 1996, were examined otoscopically by ear, nose, and throat specialists. All patients with eardrum perforation underwent chest radiography and were hospitalized for at least 24 hours for observation. The clinical course and final outcome of patients with isolated perforation of the eardrums and of those with other blast injuries were surveyed. Results: A total of 647 survivors were examined; 193 (29.8%) of them sustained primary blast injuries, including 142 with isolated eardrum perforation and 51 with other forms of blast injuries (18 with isolated pulmonary blast injury, 31 with combined otic and pulmonary injuries, and 2 with intestinal blast injury). Blast lung injury was promptly diagnosed on admission by physical examination and chest radiography. No patient presenting with isolated eardrum perforation developed later signs of pulmonary or intestinal blast injury (mean 0%; 95% confidence interval, 0% to 2.7%). Conclusion: Isolated eardrum perforation in survivors of explosions does not appear to be a marker of concealed pulmonary blast injury nor of a poor prognosis. Therefore, in a mass casualty event, persons who have sustained isolated eardrum perforation from explosions may safely be discharged from the emergency department after chest radiography and a brief observation period. [Leibovici D, Gofrit ON, Shapira SC: Eardrum perforation in explosion survivors: Is it a marker of pulmonary blast injury? Ann Emerg Med August 1999;34:168-172.]

Introduction:Full-scale disaster drills are complex, expensive, and may involve hundreds or thousands of people. However, even when carefully planned, they often fail to manifest the details of medical care given to the casualties during the drill.Objective:To assess the feasibility of integrating physicians among the simulated casualties of a hospital disaster drill.Methods:A total of 178 physicians graduating an Advanced Trauma Life Support (ATLS) course participated in eight hospital disaster drills during 1994 as “Smart Victims.” The participants were given cards with descriptions of their injury and detailed instructions on how to manipulate their medical condition according to the medical care provided in the hospital. They also were given coded questionnaires to fill out during the process of the drill. Conclusions were drawn from analysis of the questionnaires and from a roundtable discussion following each drill.Results:The “smart casualties” made comments on the following topics: 1) triage (over-triage in 9%, and under-triage in 4%); 2) treatment sites; 3) medical equipment usage (i.e., shortage of ventilators and splinting devices); 4) medical knowledge and care rendered by the hospital staff; 5) evacuation and escorting of the wounded; 6) management of patients with post-traumatic stress disorder; and 7) medical documentation. Their comments contributed valuable information on the quality of medical care and organization, and identified obstacles that otherwise would have been overlooked. The “smart casualties” were very cooperative and indicated that their participation in the drill contributed to their understanding of disaster situations in hospitals.Conclusion:Integrating physicians among the simulated casualties in a hospital disaster drill may contribute to achieving the objectives of hospital disaster drills and add to disaster management education of the simulated casualty physicians.

To compare injury patterns resulting from explosions in the open air versus within confined spaces.Medical charts of 297 victims of four bombing events were analyzed. Two explosions occurred in the open air and two inside buses. Similar explosive devices were applied in all four incidents. The incidence of primary blast injuries, significant penetrating trauma (Abbreviated Injury Scale scoreor = 2), burns, Injury Severity Score, Revised Trauma Score, and mortality were compared between the two populations.A total of 204 casualties were involved in open-air bombings, 15 of whom died (7.8%). Ninety-three victims were involved in bus bombings, 46 of whom died (49%). The difference in mortality rate was highly significant, p0.00001. Primary blast injuries were observed in 25 and 31 victims (34.2% and 77.5% of admitted victims), respectively (p = 0.00003). Median Injury Severity Score was 4 versus 18, respectively (p0.0001).Explosions in confined spaces are associated with a higher incidence of primary blast injuries, with more severe injuries and with a higher mortality rate in comparison with explosions in the open air.

Study Objectives: To determine alfentanil levels with a specific radioimmunoassay in serum and ovarian follicular fluid. Design: Observational study. Setting: University hospital. Patients: 14 ASA status I women undergoing oocyte retrieval for in vitro fertilization. Interventions: General anesthesia was induced with alfentanil 15 μg/kg and midazolam 2 mg and maintained with alfentanil 0.5 mg, 60% nitrous oxide (N 2 O) in oxygen (O 2 ) and midazolam up to a total of 4 mg. Oocyte retrieval was performed using a transvaginal ultrasound guided technique, 34 to 36 hours after human chorionic gonadotrophin administration. Measurements and Main Results: Mean procedure time for oocyte retrieval was 18 ± 2.4 (SEM) minutes. All patients were fully awake within 5 minutes and all patients except one were able to move from the operating table to the stretcher with minimal help. Mean total protein concentration in the follicular fluid was 3.8 ± 0.4 mg%. Maximal serum alfentanil concentrations (Cmax) were attained 5 minutes after start of the procedure (tmax) and were 92 ± 20 ng/ml. In contrast, alfentanil concentrations in the follicular fluid increased constantly throughout the procedure up to 8.9 ± 0.8 ng/ml at 15 minutes. Clinical pregnancy rate was 3 of 14 patients. Conclusion: It is evident that during the oocyte retrieval procedure, the alfentanil concentrations in the follicular fluid are about ten-fold smaller than the serum alfentanil concentrations at the same time points. Similar pharmacokinetics have been shown when propofol was used as anesthetic. The low accumulation of alfentanil in the follicular fluid increases the attractiveness of alfentanil for anesthesia during oocyte retrieval for in vitro fertilization.

Limited conflicts and the war against terrorism, in particular, have changed the emphasis in the present trend from preparing to cope with full-scale wars to the need to combat in limited conflicts. This shift has affected significantly medical units’ preparations. Law enforcement organizations have come together with medical first responders in a combined new model. This model is supposed to be adopted and utilized in combat and evolved from the civilian model toward a modus operandi that combines the tactical and medical protocols into a single algorithm, the “Tactical Combat Casualty Care” (TCCC). This TCCC model is believed to enhance the mutual understanding and cooperation of tactical and medical forces in combat and especially amongst special military units. Utilizing the model will be achieved by the development of well-matched standard operating procedures and sharing drills. All these acts are hoped to improve safety of the participating units and hopefully also the medical outcomes.

Establishing the Military Tract in the Hebrew University School of Medicine is an opportunity to enrich the medical curriculum with contents relevant to better training of military physicians. Subjects such as hyperbaric medicine, hypobaric physiology, terror medicine, mass casualty event (MCE) and management of non-conventional injuries will be added to the regular M.D. curriculum. Medical education based on the elements of excellence: Judaism, Zionism, humanism and leadership, will be the foundations for the future generation of medical leaders in Israel for both the military and civilian systems. This leadership will be articulated in the clinical, research and administrative fields.

Essentials of terror medicine / , Essentials of terror medicine / , کتابخانه دیجیتال جندی شاپور اهواز

Increased global terrorism has given rise to unique medical requirements that may be described as terror medicine. Using Israeli experience as a reference base, this paper notes four broad areas of terror medicine: preparedness, incident management, mechanisms of injuries and responses, and psychological consequences. Whether terror medicine is treated as a stand-alone discipline or part of disaster medicine, or of a larger enterprise like public health, its parameters should be understood and taught. Efforts to discourage and prevent terrorist attacks should be among a society’s highest priorities. No less important are the requirements to prepare for, respond to, and recover from these events. The more that individuals and institutions become familiar with the essentials of terror medicine, the greater the protection they can provide to the public.

Background. Improving the appropriateness of testing behavior and reducing the number of laboratory tests have been recognized as essential parts of quality improvement. Objective. To assess the effectiveness of an administrative and a short-term educational intervention aimed at reducing clinical biochemistry laboratory utilization. Design. An analysis comparing utilization of laboratory tests performed on in-patients before and after the intervention. Setting. Computerized database of all laboratory tests performed in Hadassah Ein Kerem Medical Center, Jerusalem, Israel during 1999–2003. Intervention. The administrative intervention included restricting available emergency laboratory tests and frequency of repeated orders. The educational measures included: discussion of the misuse of laboratory tests and its consequences with the hospital medical staff, and presentation of the new restrictive policy. A feedback of the intervention’s results was sent to the wards and reviewed with senior medical staff. Main outcome measures. Change in utilization (measured as rates per 100 hospital days) of clinical biochemistry tests by hospital division and by selected laboratory tests. Results. An overall reduction of 19% in laboratory tests (95% CI: 18.8–19.2%) was observed in the year after the intervention. Utilization decreased significantly in all the hospital’s medical divisions, within a range of 14.9–43.8%. During the intervention period, utilization of hematology tests was reduced by 7.6% ( P = 0.009). Statistically significant reductions were noted in the ordering of all 12 selected clinical biochemistry tests. Although the orders of total cholesterol decreased by 72.2%, the utilization of ‘high-volume’ tests, such as glucose and electrolytes, showed only a modest decrease (7.9% and 6.9%, respectively). Conclusions. The present study included all hospital medical staff and covered all the available clinical biochemistry tests. This rather simple and low-cost intervention resulted in significant reductions in clinical biochemistry test orders as well as in the ordering of hematological blood tests.

During a period of 13 months--1 October 2000 to 31 October 2001--586 terror assault casualties were treated in the trauma unit and emergency department of Hadassah University Hospital (Ein Kerem campus); 27% (n = 158) were hospitalized and the rest were discharged within 24 hours.To analyze the special requirements of a large number of victims who received treatment during a short period.Data were attained from the main admitting office and the trauma registry records. Factors analyzed included age, gender, mechanism of injury, anatomic site of injury, Injury Severity Score, and length of stay.Males comprised 81% of the hospitalized patients. The majority of the injuries (70%) were due to gunshot wounds and 31% of the hospitalized patients were severely injured (ISSor = 16). Twelve patients died, yielding a mortality rate of 7.5%.The nature of the injuries was more complex and severe than trauma of other etiologies, as noted by the mean length of stay (10.2 vs. 7.2 days), mean intensive care unit stay (2.8 vs. 0.9 days), and mean operations per patient (0.7 vs. 0.5). The mean insurance cost for each hospitalized terror casualty was also higher than for other trauma etiologies (US$ 3,200 vs. 2,500).