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Background: This study continues surveillance of antimicrobial resistance associated with combat injuries in Ukraine., Aim: To compare species composition, antibiotic resistance profiles, and emergence of new resistance genes between 2014-2020 and 2022-2023., Methods: This was a retrospective multi-centre microbiological survey in Ukrainian hospitals. Antibiotic susceptibility, whole-genome sequencing and multi-locus sequence typing were conducted on 154 organisms obtained from 125 casualties between 2022 and 2023., Findings: The data revealed a predominance of Gram-negative bacteria, particularly Acinetobacter baumannii (35.7%), Pseudomonas aeruginosa (14.9%) and Klebsiella pneumoniae (20.7%). High levels of carbapenem resistance were observed among A. baumannii {meropenem 72.2% [39/54, 95% confidence interval (CI) 58.4-83.5]; imipenem 66.7% (36/54, 95% CI 52.5-78.9)}, K. pneumoniae [meropenem 90.6% (29/32, 95% CI 75.0-98.0); imipenem 81.2% (26/32, 95% CI 63.6-92.8)] and P. aeruginosa [meropenem 47.8% (11/23, 95% CI 26.8-69.4); imipenem 60.8% (14/23, 95% CI 38.5-80.3)] strains. A. baumannii sequence type (ST)-78 and ST-400 were prevalent from 2014 to 2020, while five strains of ST-1077 were newly identified in 2022-2023. P. aeruginosa strains showed diversity across 16 STs, with ST-773 increasing in frequency and new STs emerging, but lacking carbapenemase genes. K. pneumoniae exhibited increased genetic diversity over time, with three STs from 2014 to 2020 and six new STs, including bla NDM-1 , bla OXA-48 and bla KPC2 carriers, in 2022-2023., Conclusion: The prevalence of multi-drug-resistant isolates with STs associated with a high risk of global dissemination is increasing., (Copyright © 2024 The Healthcare Infection Society. All rights reserved.)

Introduction: Lebanon, a country located on the eastern shore of the Mediterranean Sea, is one of the world's smaller sovereign states. In the past few decades, Lebanon endured a perpetual political turmoil and several armed conflicts. July 12, 2006, marked the start of a one-month war in Lebanon, which resulted in thousands of casualties. Little is known about the long-term consequences of war injuries inflicted on civilians during the July 2006 war., Methods: The objectives of this paper were to identify and evaluate: 1- civilians' access to healthcare and medicine under conditions of war; 2- the long-term socioeconomic burden on injured civilians; and 3- their quality of life more than a decade post-war. We adopted a mixed-method research design with an emphasis on the qualitative component. We conducted interviews with patients, collected clinical and financial data from hospital medical records, and administered a self-rated health questionnaire, the EQ-5D-5L. Simple descriptive statistics were calculated using Excel. NVivo 12® was used for data management and thematic analysis., Results: We conducted 25 interviews. Injured civilians were mostly males, average age of 27. The most common mechanism of injury was blast injury. Most patients underwent multiple surgeries as well as revision surgeries. The thematic analysis revealed three themes: 1- recall of the time of the incident, the thousand miles journey, and patients' access to services; 2- post-trauma sequelae and services; and 3- long-term impact. Patients described the long-term burden including chronic pain, poor mobility, anxiety or depression, and limited activities of daily living., Discussion: Civilians injured during the July 2006 war described the traumatising events they endured during the war and the limited access to medical care during and post-war. Up until this study was conducted, affected civilians were still experiencing physical, psychological, and financial sequelae. Acknowledging the limitations of this study, which include a small sample size and recall bias, the findings underscore the necessity for the expansion of services catering to civilians injured during wartime., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Kobeissi, Menassa, Honein-AbouHaidar, El Achi, Abdul-Sater, Farhat, Al Mohtar, Hajjar, Abdul-Khalek, Chaya, Elamine, Hettiaratchy and Abu-Sittah.)

Background: Afghanistan has been plagued by war for more than 30 years, but little is known about the civilian cost of such a long-lasting conflict. In particular, the incidence of war injuries among civilians has largely been under-reported. EMERGENCY NGO's Surgical Centre for War Victims has been operating in Kabul since 2001, providing care free of charge to anyone injured in war. The primary aim of our study is to describe the population of patients admitted to our hospital in Kabul., Methods: This is a 5-year retrospective analysis of all recorded hospital admissions at EMERGENCY NGO's hospital in Kabul, Afghanistan, from 1 January 2017 to 31 December 2021., Results: During the study period, 16,053 patients were admitted. Of these, 85.7% were male and 17.5% were under 14 years old. The proportion of male patients increased progressively with the age ranges (from 63.4 to 89.0%). Bullet wounds were the most frequent kind of injury (55.6%), followed by shell, stab and mine wounds (32.2%, 8.3% and 3.9% respectively). Only 5.8% of patients arrived at our hospital within the "golden hour" following injury. No significant reduction in the hospitalization trend was observed over the study period. The overall in-hospital mortality rate was 4.41%, which bore no correlation to the number of admissions., Conclusions: This study provides for the first time epidemiology of war-related injuries in a hospital located in a place of long-standing conflict., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Introduction: Examinations of risk factors for suicide attempt in United States service members at high risk of mental health diagnoses, such as those with combat injuries, are essential to guiding prevention and intervention efforts., Methods: Retrospective cohort study of 8727 combat-injured patients matched to deployed, non-injured patients utilizing Department of Defense and Veterans Affairs administrative records., Results: Combat injury was positively associated with suicide attempt in the univariate model (HR = 1.75, 95% CI 1.5-2.1), but lost significance after adjustment for mental health diagnoses. Utilizing Latent Transition Analysis in the combat-injured group, we identified five mental/behavioral health profiles: (1) Few mental health diagnoses, (2) PTSD and depressive disorders, (3) Adjustment disorder, (4) Multiple mental health comorbidities, and (5) Multiple mental health comorbidities with alcohol use disorder (AUD). Multiple mental health comorbidities with AUD had the highest suicide attempt rate throughout the study and more than four times that of Multiple mental health comorbidities in the first study year (23.4 vs. 5.1 per 1000 person years, respectively)., Conclusion: Findings indicate that (1) combat injury's impact on suicide attempt is attenuated by mental health and (2) AUD with multiple mental health comorbidities confers heightened suicide attempt risk in combat-injured service members., (© 2022 American Association of Suicidology. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: The decade-long Syrian armed conflict killed or injured more than 11% of the Syrian population. Head and neck injuries are the most frequent cause of war-related trauma, about half of which are brain injuries. Reports about Syrian brain trauma victims were published from neighboring countries; However, none are available from Syrian hospitals. This study aims to report war-related traumatic brain injuries from the Syrian capital., Methods: We conducted a retrospective cohort study between 2014 and 2017 at Damascus Hospital, the largest public hospital in Damascus, Syria. Target patients were the victims of combat-related traumatic brain injuries who arrived alive and were admitted to the neurosurgery department or to another department but followed by the neurosurgery team. The collected data included the mechanism, type, and site of injury based on imaging findings; types of invasive interventions; intensive-care unit (ICU) admissions; as well as neurological status at admission and discharge including several severity scales., Results: Our sample consisted of 195 patients; Ninety-six of them were male young adults, in addition to 40 females and 61 children. Injuries were caused by shrapnel in 127 (65%) cases, and by gunshots in the rest, and most of them (91%) were penetrating. Sixty-eight patients (35%) were admitted to the ICU, and 56 (29%) underwent surgery. Neurological impairment was reported in 49 patients (25%) at discharge, and the mortality rate during hospitalization was 33%. Mortality and neurological impairment associated significantly with higher values on clinical and imaging severity scores., Conclusions: This study captured the full spectrum of war-related brain injuries of civilians and armed personnel in Syria without the delay required to transport patients to neighboring countries. Although the clinical presentation of injuries at admission was not as severe as that in previous reports, the inadequate resources (i.e., ventilators and operation rooms) and the lack of previous experience with similar injuries might have resulted in the higher mortality rate. Clinical and imaging severity scales can provide a handy tool in identifying cases with low probability of survival especially with the shortage of personal and physical resources., (© 2023. The Author(s).)

A modest but significant number of military personnel sustained injuries during deployments resulting in an altered-appearance (e.g., limb loss and/or scarring). Civilian research indicates that appearance-altering injuries can affect psychosocial wellbeing, yet little is known about the impact of such injuries among injured personnel. This study aimed to understand the psychosocial impact of appearance-altering injuries and possible support needs among UK military personnel and veterans. Semi-structured interviews with 23 military participants who sustained appearance-altering injuries during deployments or training since 1969 were conducted. The interviews were analyzed using reflexive thematic analysis, identifying six master themes. These themes indicate that in the context of broader recovery experiences, military personnel and veterans experience a variety of psychosocial difficulties related to their changed appearance. While some of these are consistent with evidence from civilians, military-related nuances in the challenges, protective experiences, coping approaches, and preferences for support are evident. Personnel and veterans with appearance-altering injuries may require specific support for adjusting to their changed appearance and related difficulties. However, barriers to acknowledging appearance concerns were identified. Implications for support provision and future research are discussed.

The proportions of evacuations out of USCENTCOM that were due to battle injuries declined substantially in 2021. For USCENTCOM, evacuations for mental health disorders were the most common, followed by non-battle injury and poisoning, and signs, symptoms, and ill-defined conditions. For USAFRICOM, evacuations for non-battle injury and poisoning were most common, followed by disorders of the digestive system and mental health disorders.

Background/purpose: To characterize the nature of posterior segment ocular injuries in combat trauma., Methods: Eyes in the Walter Reed Ocular Trauma Database were evaluated for the presence of posterior segment injury. Final visual outcomes in open-globe versus closed-globe injuries and by zone of injury and the types of posterior segment injuries in open-globe versus closed-globe injuries were assessed., Results: Four hundred fifty-two of 890 eyes (50.8%) had at least one posterior segment injury. The mechanism of injury was most commonly an improvised explosive device in 280 (62.0%) eyes. Sixty-one patients (13.5%) had a Zone I injury, 50 (11.1%) a Zone II injury, and 341 (75.4%) a Zone III injury. Patients with Zone I injuries were more likely to have a final visual acuity of 20/200 or better compared with patients with either a Zone II (P < 0.001) or Zone III injury (P = 0.007). Eyes with a closed-globe injury were more likely to have a final visual acuity of 20/200 or better compared with those with an open-globe injury (P < 0.001). Furthermore, closed-globe injury compared with open-globe injury had a lower risk of vitreous hemorrhage (odds ratio 0.32, P < 0.001), proliferative vitreoretinopathy (odds ratio 0.14, P < 0.001), and retinal detachment (odds ratio 0.18, P < 0.001) but a higher risk of chorioretinal rupture (odds ratio 2.82, P < 0.001) and macular hole (odds ratio 3.46, P = 0.004)., Conclusion: Patients with combat ophthalmic trauma had similar posterior segment injury patterns to civilian trauma in open-globe versus closed-globe injuries. Zone II and III injuries were associated with a worse visual prognosis.

Recent reclassification of the Klebsiella genus to include Klebsiella variicola, and its association with bacteremia and mortality, has raised concerns. We examined Klebsiella spp. infections among battlefield trauma patients, including occurrence of invasive K. variicola disease. Klebsiella isolates collected from 51 wounded military personnel (2009-2014) through the Trauma Infectious Disease Outcomes Study were examined using polymerase chain reaction (PCR) and pulsed-field gel electrophoresis. K. variicola isolates were evaluated for hypermucoviscosity phenotype by the string test. Patients were severely injured, largely from blast injuries, and all received antibiotics prior to Klebsiella isolation. Multidrug-resistant Klebsiella isolates were identified in 23 (45%) patients; however, there were no significant differences when patients with and without multidrug-resistant Klebsiella were compared. A total of 237 isolates initially identified as K. pneumoniae were analyzed, with 141 clinical isolates associated with infections (remaining were colonizing isolates collected through surveillance groin swabs). Using PCR sequencing, 221 (93%) isolates were confirmed as K. pneumoniae, 10 (4%) were K. variicola, and 6 (3%) were K. quasipneumoniae. Five K. variicola isolates were associated with infections. Compared to K. pneumoniae, infecting K. variicola isolates were more likely to be from blood (4/5 versus 24/134, p = 0.04), and less likely to be multidrug-resistant (0/5 versus 99/134, p<0.01). No K. variicola isolates demonstrated the hypermucoviscosity phenotype. Although K. variicola isolates were frequently isolated from bloodstream infections, they were less likely to be multidrug-resistant. Further work is needed to facilitate diagnosis of K. variicola and clarify its clinical significance in larger prospective studies., Competing Interests: KM, SJK, MLC, and DL are employees of the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), a not-for-profit Foundation authorized by Congress to support research at the Uniformed Services University of the Health Sciences (USU) and throughout military medicine. This does not alter our adherence to PLOS ONE policies on sharing data and materials. Please see Data Availability Statement.

Background: Role 2 medical treatment facilities (MTFs) are frequently located in austere settings and have limited resources. A dedicated assessment of burn casualties treated at this level of care has not been performed. Therefore, the objective of this study was to characterize burn casualties presenting to role 2 MTFs in Afghanistan, along with the procedures they required, complications, and mortality to begin understanding the resources consumed by their care., Methods: We identified burn casualties from the Department of Defense Trauma Registry (DODTR). The inclusion criteria were (1) experienced burn injuries in Afghanistan between October 2005 and April 2018 and (2) had documentation of treatment at role 2 in the DODTR. We excluded casualties with only first-degree burns, not otherwise specified burns, or only corneal burns. Casualty demographics, injury characteristics, procedures, and outcomes were reported., Results: We identified 453 burn casualties with a median (interquartile range) Injury Severity Score of 10 (4-22) and percent total body surface area burned of 11 (5-30). There were 123 casualties (27.2%) with inhalation injury, and the casualties experienced 3,343 additional traumatic injuries and needed 2,530 procedures. Casualties with documentation of resuscitation information received a median (interquartile range) of 1.9 (0.7-3.7) L of crystalloid fluids. Complications were documented in 53 casualties (11.7%). Final mortality was reported in 36 casualties (8.0%), and mortality at role 2 MTFs was reported in 7 casualties (1.5%)., Conclusion: Burn casualties had many injuries and needed many procedures, including those related to airway management, resuscitation, and wound care. Given the urgency of these procedures, ensuring that there is enough equipment and supplies will be important in the future. Although infrequent, some casualties experienced complications. Factors that may influence resuscitation include injury severity, concomitant traumatic injuries, and available supplies. Obtaining more contextual information on the patient care environment will be useful going forward., Level of Evidence: Epidemiological, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Ocular injuries account for up to 13% of battle injuries, despite the implementation of advanced protective eyewear (PE). The aim of this study was to describe the extent of ocular injuries over the last years among Israel Defense Forces soldiers and to examine the change in PE policy introduced in 2013 and the effect of a high-intensity conflict on ocular injury characteristics., Methods: This retrospective registry-based analysis derived data from the Israel Defense Forces Trauma Registry and included soldiers who sustained combat-related ocular injuries between the years 2013 and 2019. Demographic data and injury characteristics of casualties, as well as information regarding the use of PE, were collected and analyzed., Results: A total of 2,312 military casualties were available for this study; the incidence of combat-related ocular injuries was 8.9% (n = 113). Ocular injuries occurred among male soldiers (98.2%) with a mean ± SD age of 22.7 ± 4.6 years; mechanism of injury was penetrating in 59.3% of the casualties and blunt in 22.1% of the casualties, ocular injury was isolated in 51.3% of the casualties, and others sustained concomitant injuries including head (32.7%), upper extremity injury (17.7%), lower extremity (15.9%), torso (8.0%), neck (6.2%), and other (5.9%) injuries. Ocular injuries rate was similar among casualties who used PE (11.2%) and those who did not use PE (13.0%) while injured (p = 0.596). Rate of open globe injuries was 9.1% in casualties who used PE and 39.5% (p = 0.002) in casualties who did not., Conclusion: Eye protection may significantly reduce ocular injuries severity. Education of the combatants on the use of PE and guidance of medical teams on proper assessment, initial treatment, and rapid evacuation of casualties are needed to improve visual outcomes of the casualties further., Level of Evidence: Epidemiological study, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Posttraumatic stress disorder (PTSD) is highly prevalent among refugees surviving mass atrocities, especially among women. Longitudinal studies investigating factors associated with PTSD course are essential to enable adequate treatment yet widely lacking., Objective: To identify longitudinal changes in PTSD severity and posttraumatic coping among severely traumatized female refugees as well as risk and protective factors for PTSD course., Design, Setting, and Participants: This prospective cohort study took place in 14 German cities in the context of a humanitarian admission program that resettled 1000 especially vulnerable women and children from northern Iraq to Germany. Approximately 400 adult beneficiaries of the humanitarian admission program were eligible for the study. At baseline, a total of 116 of the 400 beneficiaries (29.0%) participated, with 96 (82.8%) of these women participating in the follow-up assessment. The study included a baseline assessment conducted 2 years after resettlement (September 1, 2017, to January 12, 2018) and a 1-year follow-up (August 29, 2018, to January 15, 2019)., Exposures: Violence and/or captivity during the 2014 genocide in northern Iraq by the so-called Islamic State., Main Outcomes and Measures: Posttraumatic stress disorder severity and coping strategies were assessed in interpreter-aided interviews using the Impact of Event Scale-Revised., Results: A total of 116 women (mean [SD] age, 32.2 [8.2] years; 115 [99.1%] Yazidi; 1 [0.9%] Christian) participated at baseline. According to the Impact of Event Scale-Revised, a high PTSD severity was found (mean [SD] raw sum score, 60.88 [15.75] of 88, with higher scores indicating greater distress), with no significant change over time. Helpful coping strategies included prayer, belief in collective strength, and belief in personal strength. Earlier symptoms of intrusions (β = 0.389, P = .007) and longer captivity (β = 0.218, P = .02) were identified as being associated with PTSD severity 1 year later. Longer captivity was associated with PTSD aggravation over time (β = 0.227, P = .04). Posttraumatic strengthening in faith (β = -0.206, P = .05) and in social relationships (β = -0.221, P = .03) were associated with a reduction in PTSD symptoms., Conclusions and Relevance: These findings suggest that female refugee survivors of genocide are at high risk for severe and chronic PTSD beyond the initial years of resettlement. The findings provide suggestions for mental health care specialized for particularly vulnerable populations.

Background: . Ocular injuries constitute a major cause of visual morbidity, and they have a significant socioeconomic impact worldwide. We aimed to document the types and causes of Syrian War related ocular injuries in Damascus, Syria., Methods: . Medical records were retrospectively reviewed to evaluate all patients in Al-Mouwasat University Hospital and Damascus Hospital, whose ocular injuries were caused by war-related activities during the period extending between January of 2016 and December 2017., Results: . 150 eye injuries in 127 patients were reviewed, in which 46 (31%) were bilateral and 87 (58%) were open globe injuries. The leading cause of the observed ocular injuries was improvised explosive devices (IED) [37 eyes (41%)]. The majority of patients presented with an initial best corrected visual acuity (BCVA) of "light perception" (LP) to "hand movement" (HM) [51 eyes (34%)]. Information on the final BCVA was available for 69 injured eyes only, and it was "no light perception" (NLP) in 20 eyes (29%)., Conclusion: . Explosive weaponry is the main culprit in most war-related ocular injuries in Syria. The high incidence of open globe injuries caused many of the cases to be severe in nature. Education on the precautionary measures that protect the eyes such as the use of combat eye protection during wartimes ought to be enforced, so that future ocular injuries can be prevented., Competing Interests: Declaration of Competing Interest None, (Copyright © 2020. Published by Elsevier Ltd.)

Importance: There is uncertainty about the role that military deployment experiences play in suicide-related outcomes. Most previous research has defined combat experiences broadly, and a limited number of cross-sectional studies have examined the association between specific combat exposure (eg, killing) and suicide-related outcomes., Objective: To prospectively examine combat exposures associated with suicide attempts among active-duty US service members while accounting for demographic, military-specific, and mental health factors., Design, Setting, and Participants: This cohort study analyzed data from the Millennium Cohort Study, an ongoing prospective longitudinal study of US service members from all military branches. Participants were enrolled in 4 phases from July 1, 2001, to April 4, 2013, and completed a self-administered survey at enrollment and every 3 to 5 years thereafter. The population for the present study was restricted to active-duty service members from the first 4 enrollment phases who deployed in support of the wars in Iraq and Afghanistan. Questionnaire data were linked with medical encounter data through September 30, 2015. Data analyses were conducted from January 10, 2017, to December 14, 2020., Exposures: Combat exposure was examined in 3 ways (any combat experience, overall combat severity, and 13 individual combat experiences) using a 13-item self-reported combat measure., Main Outcomes and Measures: Suicide attempts were identified from military electronic hospitalization and ambulatory medical encounter data using the International Classification of Diseases, Ninth Revision codes., Results: Among 57 841 participants, 44 062 were men (76.2%) and 42 095 were non-Hispanic White individuals (72.8%), and the mean (SD) age was 26.9 (5.3) years. During a mean (SD) follow-up period of 5.6 (4.0) years, 235 participants had a suicide attempt (0.4%). Combat exposure, defined broadly, was not associated with suicide attempts in Cox proportional hazards time-to-event regression models after adjustments for demographic and military-specific factors; high combat severity and certain individual combat experiences were associated with an increased risk for suicide attempts. However, these associations were mostly accounted for by mental disorders, especially posttraumatic stress disorder. After adjustment for mental disorders, combat experiences with significant association with suicide attempts included being attacked or ambushed (hazard ratio [HR], 1.55; 95% CI, 1.16-2.06), seeing dead bodies or human remains (HR, 1.34; 95% CI, 1.01-1.78), and being directly responsible for the death of a noncombatant (HR, 1.81; 95% CI, 1.04-3.16)., Conclusions and Relevance: This study suggests that deployed service members who experience high levels of combat or are exposed to certain types of combat experiences (involving unexpected events or those that challenge moral or ethical norms) may be at an increased risk of a suicide attempt, either directly or mediated through a mental disorder.

Background: Modern conflicts take a disproportionate and increasing toll on civilians and children. Since 2013, hundreds of Syrian children have fled to the Israeli border. Severely injured children were triaged for military airborne transport and brought to civilian trauma centers in Israel. After recovery, these patients returned to their homes in Syria.We sought to describe a unique model of a coordinated military-civilian response for the stabilization, transport, and in-hospital management of severe pediatric warzone trauma., Methods: Prehospital and in-hospital data of all severe pediatric trauma casualties transported by military helicopters from the Syrian border were extracted. Data were abstracted from the electronic medical records of military and civilian medical centers' trauma registries., Results: Sixteen critically injured children with a median age of 9.5 years (interquartile range [IQR], 6.5-11.5) were transported from the Syrian border to Level I and Level II trauma centers within Israel. All patients were admitted to intensive care units. Eight patients underwent lifesaving procedures during flight, 7 required airway management, and 5 required thoracostomy. The median injury severity score was 35 (IQR, 13-49). Seven laparotomies, 5 craniotomies, 3 orthopedic surgeries, and 1 skin graft surgery were performed. The median intensive care unit and hospital length of stay were 6 days (IQR, 3-16) and 34 days (IQR, 14-46), respectively. Fifteen patients survived to hospital discharge and returned to their families., Conclusion: The findings of this small cohort suggest the benefits of a coordinated military-civilian retrieval of severe pediatric warzone trauma., Level of Evidence: Therapeutic, Level V., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The cause of amyotrophic lateral sclerosis (ALS) is unknown, but occupations have been explored as a potential proxy measure of risk. There is a substantial body of literature connecting military service to ALS. We aimed to summarize and assess the quality of this evidence., Methods: Systematic review of the literature, including observational studies which explored one of the following exposures: general military service (army, air force, marines, or navy); or specific exposures associated with military service measured among military personnel. The outcome of interest was ALS incidence, which could include onset, diagnosis, or death from ALS., Results: A total of 2642 articles were screened. Following exclusion, 19 articles remained for inclusion in the systematic review, including 1 meta-analysis and 18 original observational studies. Most studies were of moderate quality. In general, the relationship between military service was suggestive of an increased risk, particularly among Gulf War and WWII veterans. Exposure to pesticides (including Agent Orange) certain chemicals (exhaust, burning agents), heavy metals, and head trauma appeared to increase the risk of ALS among military personnel., Conclusions: There is a possible association between military service and the subsequent development of ALS; however, the evidence was limited. Studies were generally hindered by small sample sizes and inadequate follow-up time. Future studies should endeavor to objectively measure specific exposures, or combinations thereof, associated with military service, as this will be of vital importance in implementing preventative strategies into military organizations., (© 2020 The Authors. Acta Neurologica Scandinavica published by John Wiley & Sons Ltd.)

The establishment of the United Nations after World War II raised hopes of a new era of peace. This was over-optimistic. Between 1945 and 1992, there were 149 major wars, killing more than 23 million people. Recent developments in warfare have significantly heightened the dangers for children. During the last decade child war victims have included: 2 million killed; 4-5 million disabled; 12 million left homeless; more than 1 million orphaned or separated from their parents; some 10 million psychologically traumatized. Researches indicate that children do develop PTSD after experiencing very stressful, life-threatening events such as happen in war. Wars of 21 st century are often guerrilla-type civil wars in which women and children are not only the main victims, but are deliberately targeted. Thousands are displaced both internally and across borders. Wars at the end of nineties of 20 th century in the region of ex Yugoslavian countries brought all the cruelty of war vivid again on European ground. Population were exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. During the War in Bosnia and Herzegovina 1992-1995 there were about 100 000 people killed (20% woman and 3.5% children) and about 18 000 children were orphaned because of war. Children are not capable to regulate their emotions and hyper-arousal on their own. It depends of the way how their parents (caretaker) regulate her/his own emotions. During the war weak child's ego is paralyzed with intensive stimuli and floating anxiety, it does not manage to make constructive solution for traumatic experiences in such a short time. Mothers with small children are especially vulnerable group during the war time: they are supposed to take care about children and feel happiness, what is almost impossible Severe war experiences could cause depressive symptoms in mothers, what reduce their emotional disposability and could lead in different form of the child's neglecting. PTSD symptoms were lasting longer in children if their mothers have had functioning problems. Traumatization of mothers is connected with different behavior problems in their children. Wars are continuing all over the world and there is a continuity of researches about their consequences on children. Any programs that intend to mitigate the psychological effects of such trauma need to adopt a public health approach aimed at reaching many thousands.

Importance: Yazidi women in northern Iraq have experienced severe human rights violations through attacks by the so-called Islamic State group, with severe consequences for their health. However, no studies to date have investigated how war-related and gender-based violence, including partner violence, are associated with mental health disorders in this population., Objective: To evaluate the associations between Yazidi women's experiences of violence (ie, war violence, partner violence, enslavement) and their mental health., Design, Setting, and Participants: This cross-sectional study of 326 women was conducted in camps for displaced persons in the Kurdistan region of Iraq between January and July 2017. Participants were married women from the Yazidi population in northern Iraq who were affected by Islamic State attacks. Participants were selected via household-randomized sampling. Data analysis was conducted from December 2018 to September 2019., Exposures: Experiences of enslavement, war-related events, and intimate partner violence were measured with event checklists., Main Outcomes and Measures: Posttraumatic stress disorder (PTSD) and depression levels were measured using culturally validated instruments., Results: A total of 326 women (mean [SD] age, 34.3 [12.9] years) participated in the study. Almost all participants reported the experience of at least 1 war-related violent event (325 [99.7%]), 54 (16.6%) reported a history of abduction and sexual slavery, and 215 (66.0%) reported the experience of at least 1 type of intimate partner violence in the past year. There were no significant differences between women who did and did not experience abduction regarding exposure to intimate partner violence. Rates of PTSD and depression symptoms were high among the whole sample, and women who experienced abduction reported significantly higher levels of psychopathology than those who did not (mean [SD] PTSD score: 61.48 [12.38] vs 47.61 [14.42]; t324 = -6.91; P < .001; mean [SD] depression score: 3.07 [0.68] vs 2.43 [0.68]; t324 = -6.78; P < .001). Multivariate hierarchical regressions revealed that psychopathology was associated with exposure to war-related events (PTSD: β = 0.29; P < .001; depression: β = 0.27; P < .001) as well as with exposure to gender-based violence in Islamic State captivity (PTSD: β = 0.19; P = .001; depression: β = 0.28, P < .001) and in their marriage (PTSD: β = 0.13; P = .008; depression: β = 0.18; P < .001)., Conclusions and Relevance: In this study, interviewed Yazidi women often experienced intimate partner violence as well as war-related and gender-based violence under Islamic State attacks and enslavement, experiences that were associated with mental health impairment. The findings underline the importance of also addressing gender-based violence within health care approaches for war-affected populations.

Background: Role 2 forward surgical teams provide damage-control resuscitation and surgery for life- and limb-threatening injuries. These teams have limited resources and personnel, so understanding the anatomic injury patterns seen by these teams is vital for providing adequate training and preparation prior to deployment. The objective of this study was to describe the spectrum of injuries treated at Role 2 facilities in Afghanistan., Methods: Using Department of Defense Trauma Registry data, a retrospective, secondary data analysis was conducted. Eligible patients were all battle or non-battle-injured casualties treated by Role 2 forward surgical teams in Afghanistan from October 2005 to June 2018. Abbreviated Injury Scale (AIS) 2005 codes were used to classify each injury and Injury Severity Score (ISS) was calculated for each patient. Patients with multiple trauma were defined as patients with an AIS severity code >2 in at least two ISS body regions., Results: The data set included 10,383 eligible patients with 45,225 diagnosis entries (range, 1-27 diagnoses per patient). The largest number of injuries occurred in the lower extremity/pelvis/buttocks (23.9%). Most injuries were categorized as minor (39.4%) or moderate (38.8%) in AIS severity, while the largest number of injuries categorized as severe or worse occurred in the head (13.5%). Among head injuries, 1,872 injuries were associated with a cerebral concussion or diffuse axonal injury, including 50.6% of those injuries being associated with a loss of consciousness. There were 1,224 patients with multiple trauma, and the majority had an injury to the extremities/pelvic girdle (58.2%). Additionally, 3.7% of all eligible patients and 10.5% of all patients with multiple trauma did not survive to Role 2 discharge., Conclusion: The injury patterns seen in recent conflicts and demonstrated by this study may assist military medical leaders and planners to optimize forward surgical care in future environments, on a larger scale, and utilizing less resources., Level of Evidence: Epidemiological, Level III.

Background: Trauma is the leading cause of death among casualties between 1 and 44 years. A large proportion of trauma deaths occurs even before arriving at a medical facility. The paucity of prehospital data is a major reason for the lagging development of prehospital trauma care research. This study aims to describe the Israel Defense Forces Prehopistal Trauma Registry, the steps taken to improve data collection and quality, the resulting trends, and the registry's contribution to policymaking., Methods: This study explores the quantity and quality of point of injury and prehospital data in the registry between the years 1997 and 2018. We assessed the number of recorded casualties per year, casualties characteristics, and documentation variables in the registry, with a specific focus on documentation of vital signs throughout the years., Results: Overall, 17,905 casualties were recorded. Most casualties were young males (88.6%)-military personnel (52.7%), Syrian refugees (16.2%), Israeli civilians (11.5%), and Palestinians (9.0%). The median number of annual records from 2006 onward was significantly higher compared with before 2006 (1,000 [IQR, 792-1,470] vs. 142 [IQR, 129-156]). Between 2010 and 2018, documentation rate increased in all vital signs investigated including heart rate (56.3% vs. 1.0%), level of consciousness (55.1% vs. 0.3%), respiratory rate (51.8% vs. 0.3%), blood oxygen saturation (50.0% vs. 1.0%), Glasgow Coma Scale (48.2% vs. 0.4%), systolic blood pressure (45.7% vs. 0.8%), and pain (19.1% vs. 0.5%)., Conclusion: Point of injury and prehospital documentation are rare yet essential for ongoing improvement of combat casualty care. The Israel Defense Forces Trauma Registry is one of the largest and oldest prehospital computerized military trauma registries in the world. This study shows a major improvement in the quantity and then in the quality of prehospital documentation throughout the years that affected guidelines and policy. Further work will focus on improving data completeness and accuracy., Level of Evidence: Retrospective study, level III.

Many factors govern the nature, severity, and outcome of missile war injuries and associated soft tissue damages. Managements of primary phase and trauma care have improved significantly. Many of these injured victims survived and require immediate care for primary phase management. Secondary phase was achieved by reconstruction of soft tissue by local, regional flaps, and bony defect by bone grafting.There is no consensus on timing of treatment of bone and soft tissue of missile war injuries.Currently, in Iraq, anti-government's protestors' movement for the last 3 months mainly unemployed young people demanding for human rights has resettled in 22,000 people being injured. This includes more than 600 young men who were assassinated by unknown killers through confrontation with security and police men using tear gas canisters and sound bombs. The demonstrators used mini cars (Tuck Tuck) for attacking policemen and security people and used them for transferring injured demonstrators as ambulance to a special tent in the Tahrir Square for receiving first aid.

Background: Perforating and cutting injuries to the head and neck due to shrapnels are largely life-threatening and require immediate medical attention. In the present article, the surgical conditions in the war-related head and neck injuries were presented in terms of war surgery with mortality rates., Materials and Methods: The study was designed as a retrospective clinical case-control study including primarily 179 head and neck injuries that occurred due to shrapnels in the Syrian Civil War. The records of 2015-2019 years were analyzed according to demographics, injury types, injury location, plastic surgery approaches and postoperative outcomes., Results: Injury mechanism of all wounds was penetrating type, which was commonly secondary to an explosive device, collapse due to shrapnels of the explosion, gunshot or grenade. While 43(24%) of the wounded were soldiers, 136 (76%) were civilians. Considering the reason for the shrapnel injury, 83% was due to the explosion and 17% was due to gunshot injuries. The 32% showed facial fractures. As the most common fractures of the face were around the maxilla-zygoma (28.4%), orbita (22%), and teeths (18.5%). Considering neck injury zones, region-2 was mostly affected by the region. The third zone had the lowest rate of injury with 10%. In 89 (49%) patients, the authors preferred primary, while 15 gained secondary reconstruction (8%). The authors used Limberg flap for 24 (32%) patients, rotation flap for 39 (52%) patients, and bilobe flap for 12 (16%) patients., Conclusion: The most important cause of mortality was not the destruction, tissue loss caused by shrapnel injury, or experience of the surgeon, but the severe states of sepsis or multiple different trauma when brought for treatment from long range from the war zone.

Objectives: The aim of this study was to explore possible long-term negative health effects of injuries sustained by modern weaponry., Setting: The study was conducted in Gaza's main hospital, Al-Shifa Hospital., Participants: During the last 10 to 15 years, thousands of civilian Palestinians in Gaza have survived numerous military incursions, but with war-related traumatic injuries caused by explosive weapons. It is unclear to which extent the injuries sustained by such modern weaponry may increase survivors' risks of negative long-term health effects and serious illness. We have reported mechanisms and severity of injury, demographics and psychosocial status among 254 Palestinian patients in Gaza with war-related extremity amputations. Among the same amputees, subgroups of patients presented a variety of alarming symptoms and findings. 94 patients received further diagnostic clinical exploration, radiology imaging and clinical chemistry laboratory tests at the main clinical centre in Gaza, the Al-Shifa Hospital., Results: Nine out of ten of the referred patients were young (median 31.5 years) males (88/94, 92.6%). Ultrasound imaging revealed that 19 of 90 patients (20%) had fatty liver infiltration, 3 patients had lung nodules and 10 patients had lung atelectasis on chest CT. Twelve had remaining shrapnel(s) in the chest, five patients had shrapnel(s) in the abdomen and one in the scrotum. We found shrapnel(s) in the amputation stumps of 26 patient's amputated limbs, while 8 patients had shrapnel in the non-amputated limb. Three patients had liver lesions. Nineteen patients had elevated liver enzymes, 32 patients had elevated erythrocyte sedimentation rate and 12 were anaemic. Two patients tested positive for hepatitis C virus and three were positive for hepatitis B virus (HBV). One of the 19 patients with fatty liver tested positive for HBV. Two of the patients with fatty liver infiltration had elevated glycatedhaemoglobin levels and confirmed diabetes mellitus type II., Conclusion: Nearly half (44, 8%) had remaining metal fragments from explosives of unknown composition harboured in various parts of their bodies. All patients identified with lesions and nodules are being followed up locally. As of now, we cannot anticipate the long-term health consequences of living with metal residuals from modern explosive weapons embedded in body organs and tissue., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: War causes more death and disability than many major diseases. There are few studies in the context of the deleterious impact of war on fertility potential; therefore, in this study, we tried to review articles about the adverse effects of war on male/ female fertility potential., Methods: In this study, a total of 183 articles related to the effects of war on fertility potential were examined by a systematic search using known international medical databases., Results: Among these studies, there were limited studies on the effects of war on female infertility and most studies examined the effects of war on sperm parameters and male infertility. The physical and psychological trauma of war can increase the risk of infertility in men and women. Presence of reproductive system toxins in weapons, stressful periods of war and direct damage to the reproductive system can impair the fertility of men and women. The way war affects male fertility is not clear, but the higher degree of stress during wartime seems to play an important role. Using reproductive toxicants during the war also increases the risk of impairment in reproductive function in men. Some studies have shown the harmful effects of Sulfur mustard as a war chemical toxin especially on sperm quality and male infertility. Oxidative stress induced by free radicals is a major mechanism for the direct effects of Sulfur mustard on male infertility., Conclusion: The study of past research suggests that exposure to war may be an independent risk factor for reproductive disorders and infertility in men. For female infertility, war leads to menstrual dysfunction., (© 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Epidemiology can be considered as a responsible public health science the aim of which is to control health problems. One of the most important public health problems is "war". The aim of the present paper, therefore, is threefold: firstly, to determine to what extent war has been investigated from an epidemiological point of view; secondly, what the definition and scope of "war epidemiology" would be; and thirdly, if it would be possible to introduce a new branch of epidemiology entitled "peace epidemiology". In the present study, I have tried to fulfill the aims of the study based on my experiences in war and peace epidemiology and also by reviewing the most relevant websites, documents and papers. Evidence suggests that enough epidemiological studies have not been carried out to determine the sheer public health consequences of war. "War epidemiology" can be defined as "the study of the distribution and determinants of war-related events in specified populations, and the application of this study to the control of war". "Peace epidemiology" is a new branch of epidemiology which "highlights how peace could positively shape our world". Epidemiologists need to produce more scientific evidence about the negative public health consequences of wars and also the positive public health consequences of peace. The ultimate aim of "war epidemiology" is to control war, usually by secondary and tertiary prevention activities. However, the ultimate aim of "peace epidemiology" is to reinforce peace by primary and/or primordial prevention activities., (© 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Limited studies have reported epidemiologic data on the impact of Iran-Iraq war. This study examines the war casualties for both combatants and civilians on Iranians at national level., Methods: Databases of Veterans and Martyrs Affair Foundation (VMAF), Janbazan Medical and Engineering Research Center (JMERC) and Ministry of Health were used to collect the data. The prevalence of injuries for both civilians and combatants was presented. Casualties were studied based on conventional and unconventional weapons attacks (1980-2018), separately., Results: The Iran-Iraq war led to 183623 lost lives, 554990 injured and 40240 captured. The mean length of captivity was 45.7 months (1 month-19 years) and 2.7% (n = 575) died in captivity. There were 1439180 war related injuries recorded in databanks, mostly affecting men (98.4%). About 1439180 injuries were recorded, most of them related to conventional weapons (938928 [65.24%]). Remaining artillery and mortar fragmentation in the body (39.5%, n = 371236), psychological disorders (15.9%, n = 228944), and exposure to chemical weapons (11%, n = 158817) were the most prevalent war-related injuries., Conclusion: Human casualties of the Iran-Iraq war on the Iranian side and the health care system are huge even after more than three decades., (© 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Damage control resuscitation (DCR) and damage control surgery (DCS) has now been developed as a well-established standard of care for severely injured civilian patients worldwide. On the other hand, the application of combat DCR/DCS has saved the lives of thousands of severely injured casualties in several wars during the last two decades. This article describes the great progress on DCR/DCS in the last two decades and its application in the Chinese People's Liberation Army (PLA). The main development of the advanced theories of combat DCR/DCS including the global integration of DCR/DCS, application of remote battlefield DCR, balanced hemostatic resuscitation in combat hospitals and enhancement of en route DCR. There are two key factors that determine the feasibility of combat DCR: one is the availability of resources and supplies to implement the advanced theories of combat DCR/DCS, the other is the availability of qualified personnel who master the skills needed for the implementation of DCR/DCS. In the PLA, the advanced theories of combat DCR/DCS have now been widely accepted, and some of related advanced products, such as fresh-frozen plasma, packed red blood cells, and platelets, have been available in Level III medical facilities. In conclusion, great progress in combat DCR/DCS has been achieved in recent years, and the Chinese PLA is keeping good pace with this development, although there is still room for improvement.

Musculoskeletal Injuries (MSKI) are exceedingly common in the US Military, resulting in compromised military medical readiness and a substantial burden on both health care and financial resources. Severe combat-related MSKI sustained during nearly 2 decades of conflict in Iraq and Afghanistan have resulted in frequently devastating injuries that challenge acute care capabilities, require extensive rehabilitation, and often result in long-term disability. Non-combat-related MSKI, while often less severe, are far more common than combat-related MSKI and overall cause a substantially greater number of lost duty days and nondeployable Service Members. Given the strain placed on health care and financial resources by MSKI, further efforts must be directed towards prevention, treatment, and rehabilitative strategies in order to mitigate the burden of MSKI in the US Military.

Objective: Confirmatory factor analysis (CFA) has previously been employed to examine the latent factor structure of posttraumatic stress disorder (PTSD) symptoms with mixed results. A limited number of studies examined PTSD factor structure among veterans of recent military conflicts. This study examined the relationship between PTSD factor structure and the hallmark conditions of these conflicts, mild traumatic brain injury (mTBI) and close-range blast exposure (CBE)., Method: The fit of previously proposed PTSD factor models was compared in a cohort of 387 combat-exposed veterans, with stratified analyses comparing factor structure models between those with a history of military-related mTBI and CBE (n = 106) and those without either of these antecedents (n = 151). CFAs were conducted using criteria from the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994)., Results: The 4-factor emotional numbing (EN) model yielded the best fit when using a clinician-administered assessment of PTSD symptoms regardless of mTBI/CBE exposure status. However, when using a self-report measure of PTSD symptom severity, the EN model yielded best fit for those with mTBI/CBE exposure history while the 5-factor dysphoric arousal (DA) model was preferable among combat-exposed veterans with no history of mTBI/CBE exposure., Conclusions: Factors including mTBI and blast exposure and type of assessment tools must be considered when determining preferable PTSD latent factor structure models. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Introduction: Once injured in the battlefield in Iraq and Afghanistan, U.S. and NATO troops receive medical treatment through tiered echelons of care with varying resources, from austere to state-of-the-art. Similar to civilian trauma systems, the aim is to provide rapid and safe patient movement toward definitive management. A consequence of the rapid transfer of patients is the possibility of missed or delayed diagnosis of injuries. With the new injury patterns seen during these conflicts, we aimed to identify and characterize which injuries are missed and what consequences do they have on our troops' road to recovery., Patients and Methods: A retrospective review of a PI database (established 2007) for consecutively admitted combat casualties was performed between 2007-2013. Baseline patient characteristics, injury year, admitting service, injury type, and subsequent management decisions were categorized and analyzed., Results: There were 301 missed injuries (MI) identified in 248 patients. The annual missed injury rate was 25 per 1000 admissions. Missed injuries were associated with a penetrating mechanism (82.7% vs 58.5%, p < 0.001), ICU admission (58.5% vs 27.4%, p < 0.001), higher ISS (median 14 vs 8, p < 0.001), and a longer length of stay (median 3 versus 2 days, p < 0.001). 194 (64.5%) missed injuries led to a change in management, with 68 (22.6%) requiring a surgical procedure. 1.3% of missed injuries were life threatening, 28.2% major and 65.4% minor. The most common injuries were distal extremity fractures (23.9%), followed by spine fractures (13.3%) and traumatic tympanic membrane rupture (12.6%), There were no deaths attributed to a missed injury., Discussion: Missed injuries during combat operations occur on a low but consistent basis. Most injuries are orthopedic in nature and typically occur in critically ill patients admitted to the ICU. It is rare that a missed injury results in a life-threatening condition., Conclusion: As healthcare practitioners prepare for future deployments, this analysis may serve as a resource to focus on frequently missed injuries and possibly improve their detection., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Military veterans wounded in combat are a high-risk group for emotional and physical distress, which may be exacerbated by misuse of prescription opioids and sedatives. The goal of the current study was to examine the prevalence and correlates of prescription opioid and sedative misuse among veterans wounded in combat., Method: We recruited veterans from the Combat Wounded Coalition (n = 212; 84% non-Hispanic White; 97.6% male) to complete an online survey of mental health and substance use disorder symptoms, assessed via the DSM-5 Self-Rated Level 1 Cross-Cutting Symptoms Measure, the Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5, the Pain Enjoyment General Activity Scale, and the Alcohol Use Disorders Identification Test (AUDIT). Prescription opioid and sedative misuse was assessed by frequency of use in the past year that was not currently prescribed or using more than prescribed., Results: Participants reported high rates of past year prescription opioid misuse (46.2%) and sedative misuse (21.7%). Misuse of both opioids and sedatives was associated with the most distress, including greater depression, anger, sleep disturbance, AUDIT scores, PTSD symptoms, suicidality, and pain interference. In multivariable multinomial logistic regression analyses, greater sleep disturbance (OR = 1.73) was associated with greater odds of sedative misuse versus no misuse. Higher AUDIT scores were associated with greater risk of sedative misuse (OR = 1.16) versus opioid misuse only., Conclusions: Military veterans wounded in combat have high rates of prescription opioid misuse and sedative misuse. Sleep problems and AUDIT scores might help identify veterans who are at most risk for opioid and sedative misuse., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Surviving the first episode of bacteremia predisposes burn casualties to its recurrence. Herein, we investigate the incidence, mortality, bacteriology, and source of infection of recurrent bacteremia in military burn casualties admitted to the U.S. Army Institute of Surgical Research Burn Center over a 10year period., Methods: Bacteremia was defined as the growth of Gram-positive or Gram-negative organisms in a blood culture that excluded probable skin contaminants. Recurrent bacteremia was defined as a subsequent episode of bacteremia ≥7 days after the first episode. Polymicrobial bacteremia was the presence of more than one pathogen in the same blood culture. Bacteremia was attributed to UTI, pneumonia, or wound sepsis. All other bacteremias were considered non-attributable bloodstream infections. Univariate and multivariate analyses determined factors predictive of clinical outcome., Results: Out of 952 combat-related burn casualties screened, 166 cases were identified; 63% (non-recurrent) and 37% (recurrent) with median time to recurrence of 20 days. Univariate and multivariate analysis showed that the mortality rate was two and nine-fold, respectively, higher with recurrent bacteremia. Univariate analysis found that except for urinary tract infection, large burn size (>20%), 3rd degree burns, increased injuiry severity, perineal burns, and mechanical ventilator days were independent factors predictive of recurrence of bacteremia as well as increased mortality in the recurrent bacteremia cohort. Acinetobacter baumannii complex (63%) was prevalent in the non-recurrent group, while Klebsiella pneumoniae (46% vs. 30%) and Pseudomonas aeruginosa (35% vs. 26%) were prevalent in recurrent bacteremia. Half of the recurrent bacteremia cases were polymicrobial, compared to 9% in non-recurrent bacteremia. Pneumonia was prevalent in non-recurrent bacteremia (38%) and a combination of pneumonia and wound sepsis (29%) in recurrent bacteremia casualties., Conclusions: Recurrent bacteremia increases mortality in military burn casualties. Additional research is needed to address and mitigate the underlying causes, thereby improving survival., (Copyright © 2018 Elsevier Ltd and ISBI. All rights reserved.)

Objective: The current conflicts in Iraq and Afghanistan resulted in an increased incidence of burn injury in the military population. We sought to compare the characteristics and outcomes of this population to a civilian cohort cared for at the same burn center over the same time-period., Methods: A retrospective review was performed to examine differences in the demographics, etiology, mortality, and functional status over a 12-year period. Descriptive analyses were performed. Logistic regression was used to calculate the likelihood of mortality., Results: A total of 3814 patients were included in this analysis; 1069 were military casualties. When compared to civilians, military patients were younger, had a higher incidence of flame-induced burn injury, mean total body surface area burned (% TBSA), rate of inhalation injury, and lower mortality. Civilian patients presented with a higher Baux score. Although most military patients had a full functional recovery, they had a greater incidence of severe disability. In a univariate model, likelihood of mortality was higher in civilians. No difference in mortality between the two cohorts was found after adjusting for age, inhalation injury, gender, % TBSA and percent full-thickness burn., Conclusions: Military patients exhibited improved survival and functional recovery over their civilian counterparts. However, mortality did not differ between civilian and military patients after controlling for known covariates. Further studies are needed to improve functional outcomes in civilian patients, who may not have the inherent advantages of younger age and healthier physical status found in military patients., (Published by Elsevier Ltd.)

Background: During the past 17 years of conflict the deployed US military health care system has found new and innovative ways to reduce combat mortality down to the lowest case fatality rate in US history. There is currently a data dearth of emergency department (ED) care delivered in this setting. We seek to describe ED interventions in this setting., Methods: We used a series of ED procedure codes to identify subjects within the Department of Defense Trauma Registry from January 2007 to August 2016., Results: During this time, 28,222 met inclusion criteria. The median age of causalities in this dataset was 25 years and most (96.9%) were male, US military (41.3%), and part of Operation Enduring Freedom (66.9%). The majority survived to hospital discharge (95.5%). Most subjects sustained injuries by explosives (55.3%) and gunshot wound (GSW). The majority of subjects had an injury severity score that was considered minor (74.1%), while the preponderance of critically injured casualties sustained injuries by explosive (0.7%). Based on AIS, the most frequently seriously injured body region was the extremities (23.9%). The bulk of administered blood products were packed red blood cells (PRBC, 26.4%). Endotracheal intubation was the most commonly performed critical procedure (11.9%). X-ray (79.9%) was the most frequently performed imaging study., Conclusions: US military personnel comprised the largest proportion of combat casualties and most were injured by explosive. Within this dataset, ED providers most frequently performed endotracheal intubation, administered blood products, and obtained diagnostic imaging studies., (Published by Elsevier Inc.)

Background: We have previously reported a higher than expected rate of upper-extremity amputation (UEA) in victims of an antipersonnel improvised explosive device (AP-IED) compared with a similar cohort injured by antipersonnel mines (APM). The goal of this study was to describe the rate, severity and impact of UAE caused by an AP-IED., Methods: We analyzed a prospective database of 100 consecutive dismounted AP-IED victims with pattern 1 injuries to compare the outcomes of the cohort with UEA to that without., Results: We found that UEA (8 above elbow, 19 below elbow, 1 through elbow, 3 hand, 15 digit(s)) was much more prevalent with AP-IED than with APM (40% v. 6%, p < 0.001). In addition, UEA was associated with a higher rate of multiple amputations (39 [98%] v. 32 [53%], p < 0.001), bilateral lower-extremity amputation (LEA; 33 [82.5%] v. 30 [53.3%], p = 0.003) and facial injury (8 [20%] v. 4 [6.4%], p = 0.044), but not with pelvic disruption (10 [25%]), genitoperineal mutilation (19 [48%]), eye injury (6 [15%]), or skull fracture (6 [15%]). The fatality rate was higher in patients with UEA than in those without (12 [30%] v. 7 [12%], p = 0.022)., Conclusion: Upper-extremity amputation is more prevalent with AP-IED than APM. Presence of UEA is associated with more severe injury and increased risk of death in AP-IED victims. Upper-limb injury has significant consequences for rehabilitation from LEA, which universally accompanies UEA in AP-IED victims. Upper-extremity injury should be amenable to prevention by innovative personal protective equipment designed to protect the flexed elbow., Competing Interests: None declared., (© 2018 Joule Inc. or its licensors)

Purpose: We update the incidence of intraocular foreign bodies (IOFB) in soldiers admitted to Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom., Design: This consecutive retrospective case series included 890 eyes of 652 patients., Methods: Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any American soldier or Department of Defense civilian with an IOFB injured in Operation Iraqi Freedom/Operation Enduring Freedom. Closed globe injuries with orbital foreign bodies, injury outside of a combat zone, or non-Department of Defense civilian trauma were the exclusion criteria., Main Outcome Measures: Primary outcome measures were final visual outcome and the number, size, and location of IOFBs. Secondary outcome measures included surgical procedures, use of eye protection, associated complications, source of injury and Ocular Trauma Score., Results: There were 890 eye injuries in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. IOFBs were found in 166 eyes of 149 patients (18.6%; 95% confidence interval [CI], 16.2%-21.3%). Most patients had a single IOFB (80.7%). An IOFB was positively associated with Ocular Trauma Score grade 1 or 2 (0-65) injuries (odds ratio [OR], 1.58; 95% CI, 1.07-2.38; P = 0.01). There were 130 eyes (78.33%) that had recorded time from initial visual acuity to final visual acuity and it ranged from 8 to 2421 days (mean, 433.24 days). Thirty-eight (25.16%; 95% CI, 18.89%-32.67%) eyes had no change in visual acuity, 98 (64.90%; 95% CI, 57.00%-72.07%) had improved visual acuity, and 15 (9.93%; 95% CI, 6.01%-15.84%) had decreased visual acuity. IOFB was not found to predict final visual acuity of <20/200 in multivariate analysis when other injury features were known (P = 0.1). Pars plana vitrectomy was completed on 124 eyes (74.70%). Removal of IOFB was performed in 118 eyes (71.08%; average of 31.67 days after initial injury) with a delayed procedure occurring after primary closure and antibiotics owing to a lack of surgical capacity in Iraq and Afghanistan. Retinal detachment occurred in 48 eyes (28.92%) and proliferative vitreoretinopathy in 44 eyes (26.5%)., Conclusions: IOFBs occur frequently in combat ocular trauma and are significantly associated with more severe injuries. However, IOFBs were not found to be a significant risk factor for visual acuity of <20/200., (Published by Elsevier Inc.)

Backgrounds: The NATO KAIA Hospital (Kabul International Airport), under French command, provided medical support for NATO forces in the Kabul region from 2009 to 2014. Medical assistance to civilians was an additional mission which included support for children who were war injured. The objective of this study was to analyze characteristics of cephalic injuries in children victims of war trauma., Methods: A retrospective study was conducted and commenced with the hospital opening (July 2009) to March 2012 on all children (<15years) with war trauma. We distinguished cephalic lesions in cranial (neuro-surgical), ophthalmological and neck regions. We analyzed mechanism, region, severity score, surgeries and resuscitation efforts., Results: 217 children were operated on with 81 war traumas (mean age 10.2years). 36 children (44.4%) had a cephalic injury. 52.9% of the injured had an ophthalmological injury, 38.2% a cranial region injury and 29.4% a neck lesion. Mortality rate was 5.6% (1 hemorrhagic shock and 1 cerebral wound) in this cephalic lesion group. Ophthalmic injuries were the most common of cephalic injuries; 19 children of which 7 had a bilateral injury (26 eyes). In this group, fragmentary injuries were the most frequent (64% of eyes). In cerebral lesion group, the lesions were linked to a bullet or a shrapnel in 9 of 13 children. This mechanism systematically caused a crania-cerebral wound. Explosion (fragmentary and shrapnel) was the most important in the neck lesions (7 children of 10)., Conclusions: The cephalic lesions were the second most common region in children during our experience in Afghanistan. Lack of protection (helmet) in children may explain the frequency of cephalic wounds., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

In February 2016, the camp of the United Nations Multidimensional Integrated Stabilization Mission in Mali (MINUSMA), in Kidal, was attacked and many people were wounded and killed. This study aims to determine the nature of extremity traumas and to describe their treatment. We conducted a descriptive cross-sectional study of extremity traumas in the victims of the attack on the camp of MINIUSMA in Kidal. The parameters studied were age, sex, admission delay, seat of the lesions and type of emergency surgical treatment performed. The study involved 60 wounded patients: 57(95%) men and 3(5%) women. The average age of patients was 28.9 years; 127 lesions were identified, of which 109 (85.8%) on the limbs. Clinical and radiological examinations revealed 32 (29.3%) musculocutaneous disruptions, 11 (10.1%) open fractures, 15 (13.7%) burns, 8 (7.3%) vascular and nervous injuries and 7 sprains. Severely wounded patients underwent resuscitation upon admission. Four of them underwent emergency surgery. The remaining wounded patients underwent surgery after restoration of hemodynamic stability with resuscitation. Six patients (10%) were transferred to a Level 3 Hospital for further treatment. Four wounded patients (6.7%) died. Extremity traumas are frequent but not life-threatening when isolated. They have a higher risk of infection and gangrene which can result in amputation.

In 2017, a total of 626 medical evacuations of service members from the U.S. Central Command area of responsibility were followed by at least one medical encounter in a fixed medical facility outside the operational theater. There were more medical evacuations for mental health disorders than for any other category of illnesses or injuries. Annual rates of medical evacuations attributable to battle injuries decreased from 3.5 per 1,000 deployed personyears [dp-yrs] (n=317) in 2013 to a low of 0.73 per 1,000 dp-yrs (n=28) in 2016, and then increased to 1.4 per 1,000 dp-yrs (n=53) in 2017. Annual rates of medical evacuations attributable to non-battle injuries and illnesses were relatively stable from 2015 through 2017. Compared to their respective counterparts, medical evacuation rates were highest among non-Hispanic black service members, among those aged 19 years or younger or aged 45 years or older, among Army members, and among those in combat-specific occupations. Most service members who were evacuated were returned to normal duty status following their post-evacuation hospitalizations or outpatient encounters.

Background: Approximately 4.5% of surgical procedures performed at Role 2 (R2) (forward surgical) and Role 3 (R3) (theater) medical treatment facilities can be classified as neurosurgical. These procedures are foreign to the routine daily practice of the military general surgeon. The purpose of this study was to examine the neurosurgical workload in Iraq and Afghanistan in order to inform the future predeployment neurosurgical training needs of nonneurosurgical providers., Methods: Retrospective analysis of the Department of Defense Trauma Registry for all R2 and R3 medical facilities, from January 2002 to May 2016. The 103 neurosurgical International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes identified were grouped by anatomic location. Select groups were further subdivided. Data analysis used Stata version 14 (College Station, TX)., Results: A total of 7,509 neurosurgical procedures were identified. The majority (7,244 [96.5%]) occurred at R3 theater hospitals. Cranial procedures were the most common at both R2 (120, 45.3%) and R3 (4,483 [61.9%]), with craniotomy/craniectomy the most frequent procedure. Spine procedures were performed almost exclusively at R3, with 61.1% being fusions/stabilizations and 26.9% being spinal decompression alone. Neurosurgical caseload was variable over the 15-year study period, dropping to almost zero in 2016., Conclusions: Neurosurgical procedures were performed primarily at larger R3 theater hospitals where neurosurgeons were assigned if present in theater; however, more than 100 cranial procedures were performed at forward R2 where neurosurgeons were not deployed. Considering that neurosurgeons are not everywhere available within the war zone, deploying general surgeons should have familiarity with trauma neurosurgery., Level of Evidence: Epidemiologic study, level III; Care Management, level IV.

Background: Abdominal surgery constitutes approximately 13% of surgical procedures performed for combat injuries. This study examines the frequencies and type of abdominal surgical procedures performed during recent US Military operations., Methods: A retrospective analysis of the Department of Defense Trauma Registry was performed for all Role 2 (R2) and Role 3 (R3) medical treatment facilities (MTFs), from January 2002 to May 2016. The 273 International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes that were identified as abdominal surgical procedures were stratified into 24 groups based on anatomic and functional classifications and then grouped by whether they were laparoscopic. Procedure grouping and categorization were determined, and adjudicated if necessary, by subject matter experts. Data analysis used Stata version 14 (College Station, TX)., Results: A total of 26,548 abdominal surgical procedures were identified at R2 and R3 MTFs. The majority of abdominal surgical procedures were reported at R3 facilities. The largest procedure group at both R2 and R3 MTFs were procedures involving the bowel. There were 18 laparoscopic procedures reported (R2: 4 procedures, R3: 14 procedures). Laparotomy not otherwise specified was the second largest procedure group at both R2 (1,060 [24.55%]) and R3 (4,935 [22.2%]) MTFs. Abdominal caseload was variable over the 15-year study period., Conclusions: Surgical skills such as open laparotomy and procedures involving the bowel are crucial in war surgery. The abundance of laparotomy not otherwise specified may reflect inadequate documentation, or the plethora of second- and third-look operations and washouts performed for complex abdominal injuries. Traditional elective general surgical cases (gallbladder, hernia) were relatively infrequent. Laparoscopy was almost nonexistent. Open abdominal surgical skills therefore remain a necessity for the deployed US Military General Surgeons; this is at odds with the shifting paradigm from open to laparoscopic skills in stateside civilian and military hospitals., Level of Evidence: Epidemiologic study, level III.

Major amputations of the lower and upper limbs are among the most life-altering and debilitating combat injuries. From 1 January 2001 through 31 October 2017, a total of 1,705 service members sustained major deployment-related lower and upper limb amputations. Lower limb amputations were far more common than upper limb amputations, with a total of 1,914 lower limb amputations, compared to 302 upper limb amputations. The greatest single-year number of amputations occurred in 2011, with a reported total of 273 service members who sustained 403 major limb amputations. The injured cohort mostly comprised non-Hispanic white male service members aged 21-29 years. Furthermore, the majority of the injured cohort included active component, mid-level or junior enlisted members of the Army or Marine Corps in combat-specific occupations. These findings reiterate and extend previous reports of the annual numbers, types, and anatomic locations of deployment-related limb amputations, along with the demographics and military characteristics of the injured cohort from the Iraq and Afghanistan conflicts.

Injuries have consistently ranked among the top morbidity burdens among U.S. military service members. This report describes the incidence, trends, types, causes, and dispositions of acute injuries among active component service members by anatomic region. From 2008 through 2017, there were more than 3.6 million acute incident injuries among more than 1.6 million individuals. The highest rates were for injuries to the foot/ankle, head/neck, and hand/wrist. Injury incidence decreased during the surveillance period for all anatomic sites except for the leg and knee. In addition, incidence varied by military/demographic characteristics and anatomic site. Overall, service members in the Army and service members in motor transport and/or combat-related occupations tended to have higher incidence rates than their respective counterparts. "Sprains and strains" was the most common type of injury (48.5%), and most injuries were due to undocumented or undetermined causes (69.7%). The most common disposition was "returned to duty with no limitations" (69.8%). Findings suggest that injury prevention strategies should be tailored to different populations with different risk factors. Future analyses will describe the epidemiology of cumulative traumatic injuries.

Background: Measurement of mortality and injury in conflict situations presents many challenges compared with stable situations. However, providing information is important to assess the impact of conflict on populations and to estimate humanitarian needs, both in the immediate and longer term. Mosul, Iraq's second largest city, was overrun by fighters of the Islamic State of Iraq and Syria (ISIS) on June 4, 2014. In this study, we conducted household surveys to measure reported deaths, injuries, and kidnappings in Mosul, Iraq, both during the occupation of the city by fighters of ISIS and the months of Iraqi military action known as the liberation., Methods and Findings: Mosul was overrun by ISIS forces on June 4, 2014, and was under exclusive ISIS control for 29 months. The military offensive by Iraqi forces, supported by coalition artillery and airstrikes, began on October 17, 2016, in east Mosul and concluded in west Mosul with the defeat of ISIS on June 29, 2017. We conducted a 40-cluster population-based survey as soon as the security forces permitted access for the survey team. The objective of the survey was to measure reported deaths, injuries, and kidnappings in Mosul households during 29 months of ISIS-exclusive control (June 2014-October 2016) and the nine months of Iraqi military action known as the liberation (October 2016-June 2017). In east Mosul, the survey was conducted from March 23 to March 31, 2017, and in west Mosul from July 18 to July 31, 2017. Sampling was based on pre-ISIS population distribution, with revisions made following the extensive destruction in west Mosul. The 1,202 sampled households included 7,559 persons: 4,867 in east Mosul and 2,692 in west Mosul. No households declined to participate. During the time from June 4, 2014, to the time of the survey, there were 628 deaths reported from the sampled households, of which 505 were due to intentional violence, a mortality rate of 2.09 deaths per 1,000 person-months. Over the entire time period, the group with the highest mortality rates from intentional violence was adults aged 20 to 39: 1.69 deaths per 1,000 person-months among women and 3.55 among men. In the 29 months of ISIS-exclusive control, mortality rates among all males were 0.71 reported deaths per 1,000 person-months and for all females were 0.50 deaths per 1,000 person-months. During the nine months of the military liberation, the mortality rates jumped to 13.36 deaths per 1,000 person-months for males and 8.33 for females. The increase was particularly dramatic in west Mosul. The leading cause of reported deaths from intentional violence was airstrikes-accounting for 201 civilian deaths-followed by 172 deaths from explosions. Reported deaths from airstrikes were most common in west Mosul, while reported deaths from explosions were similar on both sides of Mosul. Gunshots accounted for 86 cases, predominantly in west Mosul where ISIS snipers were particularly active. There were 35 persons who were reported to have been kidnapped, almost entirely prior to the military offensive. By the time of the survey, 20 had been released, 8 were dead, and 7 still missing, according to household reports. Almost all of the 223 injuries reported were due to intentional violence. Limitations to population-based surveys include a probable large survivor bias, the reliance on preconflict population distribution figures for sampling, and potential recall bias among respondents., Conclusions: Death and injuries during the military offensive to liberate Mosul considerably exceeded those during ISIS occupation. Airstrikes were the major reported cause of deaths, with the majority occurring in west Mosul. The extensive use of airstrikes and heavy artillery risks an extensive loss of life in densely populated urban areas. The high probability of survivor bias in this survey suggests that the actual number of injuries, kidnappings, and deaths in the neighborhoods sampled is likely to be higher than we report here.

Objectives: The military uses "just-in-time" training to refresh deploying medical personnel on skills necessary for medical and surgical care in the theater of operations. The burden of pediatric care at Role 2 facilities has yet to be characterized; pediatric predeployment training has been extremely limited and primarily informed by anecdotal experience. The goal of this analysis was to describe pediatric care at Role 2 facilities to enable data-driven development of high-fidelity simulation training and core knowledge concepts specific to the combat zone., Setting and Patients: A retrospective review of the Role 2 Database was conducted on all pediatric patients (< 18 yr) admitted to Role 2 in Afghanistan from 2008-2014., Interventions: Three cohorts were determined based on commercially available simulation models: Group 1: less than 1 year, Group 2: 1-8 years, Group 3: more than 8 years. The groups were sub-stratified by point of injury care, pre-hospital management, and Role 2 facility medical/surgical management., Measurements and Main Results: Appropriate descriptive statistics (chi square and Student t test) were utilized to define demographic and epidemiologic characteristics of this population. Of 15,404 patients in the Role 2 Database, 1,318 pediatric subjects (8.5%) were identified. The majority of patients were male (80.0%) with a mean age of 9.5 years (± SD, 4.5). Injury types included: penetrating (56%), blunt (33%), and burns (7%). Mean transport time from point of injury to Role 2 was 198 minutes (±24.5 min). Mean Glasgow Coma Scale and Revised Trauma Score were 14 (± 0.1) and 7.0 (± 1.4), respectively. Role 2 surgical procedures occurred for 424 patients (32%). Overall mortality was 4% (n = 58)., Conclusions: We have described the epidemiology of pediatric trauma admitted to Role 2 facilities, characterizing the spectrum of pediatric injuries that deploying providers should be equipped to manage. This analysis will function as a needs assessment to facilitate high-fidelity simulation training and the development of "pediatric trauma core knowledge concepts" for deploying providers.

Few data are available to evaluate the impact of Syrian war on civilian population; to describe this impact on child health, this article uses data from Médecins Sans Frontières-Operational Centre Amsterdam's activities in Tal-Abyad and Kobane cities, northern Syria (2013-2016). Data were obtained from routine medical datasets and narrative reports, for out-patient clinics, immunisation, nutritional monitoring and assessments, and in-patient care, and were analysed quantitatively and qualitatively. Infections were the largest contributor to morbidity. The proportion of < 5 year out-patient consultations of infectious diseases that are listed for outbreak monitoring in emergencies was 15% in 2013, 51% in 2014, 75% in 2015 and 70% in 2016. Thalassemia was recorded in 0.5% of 2014 < 5 year out-patient consultations and 3.4% of 2013-2014 < 18-year in-patient admissions. Measles immunisation activities and routine Extended Programme for Immunisation were re-activated across northern Syria; however, immunisation coverage could not be calculated. Results from our routine data must be compared cautiously, due to differences in settings and disease categories., Conclusion: With such scattered interventions, routine data are limited in providing a quantified evidence of emergency's health impact; however, they help in drawing a picture of children's health status and highlighting difficulties in providing curative and preventive services, in order to reflect part of population's plight. What is Known • Few data exist to evaluate the impact of the Syrian war on the health of children; • Médecins Sans Frontières (MSF-OCA) has worked in northern Syria during different times since 2013. What is New • Quantitative and qualitative analysis of MSF's routine medical data and situtation reports show that one fifth of all consultations in children < 5 years in MSF health facilities in northern Syria 2013-2016 were due to communicable diseases; • The analysis also highlights the burden of chronic conditions that were prevalent in Syria before the war, e.g. thalassemia.