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

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

Dog bites are a substantial public health concern. Rarely has hospitalizations resulting from dog bites been examined. We examined, at a national level, demographic and injury characteristics of dog-bites injuries requiring hospitalization to target prevention programs and policies for those who are at higher risk.Data on hospitalizations due to dog-bite injuries with an ICD9-CM E906.0 coding were extracted from the Israeli National Trauma Registry between 2009-2016. We calculated the annual incidence of hospitalized dog-bite injuries and compared rates by Chi-squared test. Mantel Haenszel chi-squared test and Dickey-Fuller time-series analysis were used to test linear age and temporal trends, respectively.Overall 986 persons were hospitalized for dog-bite injuries between 2009-2016. An increasing significant trend over the 8-year-period in the proportion of hospitalized dog-bite injuries among all trauma hospitalizations was revealed among children between 0 and 14 years old (p = 0.01). Children had also approximately twice the risk for dog-bite injuries compared to persons aged between 15 and 94 years old (relative risk [RR] = 1.89, 95% confidence interval [CI] = 1.35-2.66, p 0.0001); the 2016 (latest year) rate per 100,000 was significantly higher for boys than for girls (RR = 2.85, 95%CI = 1.57-5.19, p 0.0001); no gender differences were detected in the other age groups. Injury in the face/head/neck was most common in children between 0 and 14 years old (49.7%), specifically among the youngers (1, 1-3 and 4-5 year olds) compared with the 6-11 and 12-14 age groups (p 0.0001), with 4-fold-risk compared with persons aged between 15 and 94 years old (RR = 3.78, 95%CI, 3.01-4.75). There was no overall significant temporal trend in the annual incidence rates (from 1.84 (95%CI = 1.54-2.15) in 2009 to 1.54 (95%CI = 1.28-1.81) in 2016 per 100,000 population.Children younger than 15 years, with greater extent in boys than girls, represent the high-risk demographic group for dog bites. Prevention programs targeting at this group should be implemented and translated into an actual reduction in the incidence of dog-bites. In addition, an ongoing monitoring and reporting system specific for all dog-bites should be established in Israel, in order to better understand how to minimize the incidence of dog-bites and evaluate prevention efforts.

The use of electric bicycles (E-bike) has dramatically increased. E-bikes offer convenient, environmental-friendly, and less expensive alternative to other forms of transport. However, E-bikes provide a new public health challenge in terms of safety and injury prevention. This study is the first to specifically investigate the E-bike related orthopaedic injuries, based on a national trauma registry.Data from a National Trauma Registry were reviewed for patients hospitalized following E-bike related injuries. Between Jan 2014 to Dec 2015, a total of 549 patients were reviewed. Data were analyzed according to demography, type of orthopaedic injury, associated injuries and severity, injury mechanism and treatment in the operating room.A total of 360 (65%) patients sustained orthopaedic injuries, out of them 230 (63.8%) sustained limb/pelvis/spine fractures. Lower extremity fractures were more prevalent than upper extremity fractures (p0.001). The tibia was the most fractured bone (19.2%). Patients over the age of 50 years were at the highest risk for spine (20. 5%, p=0.0001), pelvis (15.9%, p=0.0001) and femoral neck (15.9%, p=0.0172) fractures relative to other age groups. Approximately 42% of patients sustained associated injuries, with head/neck/face injuries being the most prevalent (30.3%). followed by chest (11.9%) and abdominal injury (13.3%). A collision between E-bike and a motorized vehicle was the mechanism of injury in 35% of cases. In this mechanism of injury, patients had 1.7 times the risk for associated injuries (p0.0001) and the risk for major trauma (ISS score ≥16) was more than the double (p=0.03). One third of patients with orthopaedic injuries required treatment in the operating room. Treatment varied depending on the type of fracture.This study provides unique information on epidemiological characteristics of orthpaedic injuries caused be E-bikes, pertinent both to medical care providers, as well as to health policy-makers allocating resources and formulating prevention strategies.

Background When treating patients with stab injuries of the torso, clinicians often lack timely information about the degree and nature of internal organ damage. An externally observable sign significantly associated with characteristics of torso injuries may therefore be useful for practitioners. One such potential sign is the presence of wounds to the hands, sometimes sustained during victims' attempt to defend themselves during the violent altercation. Thus, the primary aim of this study was to evaluate the association between presence of upper extremity wounds and the severity of the thoracic and intra-abdominal injuries due to stabbing. Methods This study was carried out retrospectively using data on 8714 patients with stabbing-related injuries from 19 trauma centers that participated in the Israeli National Trauma Registry (INTR) between January 1st1997 and December 31st 2013. Patients with wounds of upper extremities in addition to torso injuries (UE group) were compared to other patients with torso injuries (TO group) in terms of demographics, injury characteristics and clinical outcome. Results The compared groups were found to be homogeneous in terms of age and systolic blood pressure; the number of sustained torso injuries was also identical. The UE group comprised a slightly greater percentage of females, however both groups were predominantly male. Patients with upper extremity injuries had a lower proportion of internal organ damage (36% vs. 38.5%) and lower mortality (0.9% vs. 2%). The higher mortality of patients without upper extremity wounds remained significantly different even when adjusted by other epidemiological parameters (OR 2.46, 95% CI 1.33–5.08).The number of sustained upper extremity injuries was positively associated with deeper penetration of the torso by the stabbing instrument. Conclusions Patients with stabbing-related upper extremity wounds had a significant survival advantage over patients without such injuries. However, a greater number of sustained upper extremity wounds may be an external sign of greater severity of thoracic and intraabdominal stabbing injuries.

Introduction Non-operative management has become the standard approach for treating stable patients sustaining blunt hepatic or splenic injuries in the absence of other indications for laparotomy. The liberal use of computed tomography (CT) has reduced the rate of unnecessary immediate laparotomies; however, due to its limited sensitivity in the diagnosis of hollow viscus injuries (HVI), this may be at the expense of a rise in the incidence of missed HVI. The aim of this study was to assess the incidence of concomitant HVI in blunt trauma patients diagnosed with hepatic and/or splenic injuries, and to evaluate whether a correlation exists between this incidence and the severity of hepatic or splenic injuries. Methods A retrospective cohort study involving blunt trauma patients with splenic and/or liver injuries, between the years 1998 and 2012 registered in the Israel National Trauma Registry. The association between the presence and severity of splenic and/or liver injuries and the incidence of HVI was examined. Results Of the 57,130 trauma victims identified as suffering from blunt torso injuries, 2335 (4%) sustained hepatic injuries without splenic injuries (H group), 3127 (5.4%) had splenic injuries without hepatic injuries (S group), and 564 (1%) suffered from both hepatic and splenic injuries (H + S group). Overall, 957 patients sustained 1063 HVI. The incidence of HVI among blunt torso trauma victims who sustained neither splenic nor hepatic injuries was 1.5% which is significantly lower than in the S (3.1%), H (3.1%), and H + S (6.7%) groups. In the S group, there was a clear correlation between the severity of the splenic injury and the incidence of HVI. This correlation was not found in the H group. Conclusions The presence of blunt splenic and/or hepatic injuries predicts a higher incidence of HVI, especially if combined. While in blunt splenic injury patients there is a clear correlation between the incidence of HVI and the severity of splenic injury, such a correlation does not exist in patients with blunt hepatic injury.

Background In April 2004 the Israeli Ministry of Health decided to condition DRG payment for hip surgery by time between hospitalisation and operation, giving a fine for every day's delay beyond 48 h. An evaluation study performed 2 years after the reform has shown the positive influence of the reform on patient's survival in the hospital. This study evaluates the impact of the reform on the longer-term mortality of patients. Methods A retrospective study based on data from nine hospitals of the national trauma registry available for the years 2001–2007, with surveillance on 2-year survival through data of Ministry of the Interior. The study population includes patients aged 65 and above with an isolated hip fracture following trauma. Mortality curves and Cox regression were utilised to compare the influence of different parameters on long-term mortality. Results Earlier surgery had a significant positive impact on survival through the whole length of the study period. In the period after the introduction of the new reimbursement system for hip fracture surgeries, a significant decrease in the longer-term mortality was observed up to 6 months of follow-up, even when adjusted by patients’ age, gender and the receiving hospital. After 6 months there was no further decrease in relative risk, though the survival advantage remained with patients hospitalised after the reform. Conclusions The reform appears successful in decreasing the longer-term patient mortality after hip fracture through influencing surgical practice.

Objectives Research has shown that early surgical intervention for hip fractures serves to decrease mortality. In 2004 the Ministry of Health decided to condition the reimbursement regime at the time of operation. The objectives of this study were to examine whether the reform succeeded to decrease inpatient mortality of hip fracture casualties. Method The study utilised data drawn from the Israeli Trauma Registry (ITR) for the years 1999–2006. The study population included patients aged 65 and older with an isolated diagnosis of hip fracture following trauma. Results Two years after the reform, the inpatient mortality decreased by 34% amongst patients undergoing fixation surgery, and by 30% amongst all operated patients. Median LOS decreased by 2 days. The proportion of patients undergoing hip fracture fixation surgery within 48 h increased by 35%. Conclusions The implementation of a payment limited by time for hip fracture fixation surgery increased the number of patients being operated within 48 h, shortened patient LOS, and decreased inpatient mortality.

Background The increase in the incidence of suicide bombings on urban civilian populations in the recent years necessitates a better understanding of the related epidemiology in order to improve the outcome of future casualties. Objective To characterise the epidemiology of mass casualty incidents following suicide explosions in relation to the surrounding settings. Methods This study presents an analysis of the immediate medical consequences of 12 consecutive multiple casualty incidents (MCI's). Both pre-hospital and in-hospital data was assessed for each event including EMS evacuation times, types of injuries, body regions involved, Emergency Department (ED) triage, ED interventions and surgical procedures performed. Results The average arrival time of the first ambulance to the scene was 6.8 ± 2.3 min. The first “urgent” patient was evacuated in average of 7.6 ± 5.3 min later, while the last “urgent” patient was evacuated 27.8 ± 7.9 min after the explosion. Explosions that occurred in buses had the worst rates of overall mortality (21.2%). However, those who survived closed space explosions suffered from the highest number of severe and moderate (ISS > 8) injuries (22.9%). Casualties in this group underwent the largest number of both Emergency Room and Surgical interventions. Of the three settings, open space explosions resulted in the largest numbers of casualties with the smallest percentage of severe injuries or death. Conclusions MCIs resulting from suicide explosions can be classified according to the setting of the event since each group was found to have distinct epidemiological characteristics.

Corrigendum to ‘‘Israeli hospital preparedness for terrorism-related multiple casualty incidents: Can the surge capacity and injury severity distribution be better predicted?’’ [Injury 40 (7) (2009) 727–731] Yona Kosashvili *, L. Aharonson-Daniel , Kobi Peleg , Ariel Horowitz , Danny Laor , Amir Blumenfeld e Orthopedic Department, Assaf Harofeh Medical Center, Zerrifin, Israel b Israeli National Center for Trauma and Emergency Medicine Research, at the Gertner Institute for Epidemiology and Health Policy, Israel c Israeli Defense Force, Medical Corps, Homeland Security Division, Israel d Emergency and Disaster Medicine Division of the Israeli Ministry of Health, Tel Aviv, Israel e Israeli Defense Force, Medical Corps, Trauma Division, Tel Hashomer, Israel