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Introduction: With a rise in gun violence across the United States, facial gunshot wounds (GSWs) present a challenging reconstructive problem that was once seldom encountered in civilian populations. Reconstruction of facial GSW injuries requires a combination of both microvascular and craniofacial surgical techniques. The aim of this study is to explore our experience with facial GSW injuries through an anatomic classification scheme and investigate the surgical techniques necessary to complete such reconstructions. Methods: A retrospective review was conducted at a tertiary academic center. All subjects who suffered facial GSWs and underwent definitive reconstruction at our institution were included. Facial GSWs were classified into 4 distinct anatomical zones of injury: lower (mandible), middle (maxilla and orbit), upper (above the orbit), and multi-zone injury. Microvascular reconstruction was further investigated based on the types of flaps used and the location of flap inset. Surgical outcomes, numbers of procedures, and complications were assessed, and statistical comparisons were made. Results: Thirty-six subjects underwent a total of 322 surgeries. Twenty subjects had multi-zone injury; 16 had single zone injury. Eighteen of the 36 subjects (50%) required microvascular reconstruction. These 18 subjects underwent a significantly increased number of reconstructive procedures ( P = .023). Twenty-six flaps were used, as multiple subjects required >1 flap. Fourteen of the 26 flaps were used in the middle third (54%), 7 in the lower third (27%), and 5 in the upper third (19%). Six flap complications required further surgical revision. On average, multi-zone injuries required more surgical procedures to complete reconstruction ( P = .018). Conclusion: Composite multi-zone facial GSW injuries present a higher degree of reconstructive complexity, and thus often require more surgical procedures, especially when the midface is involved. In our experience, microvascular reconstruction is more often used in multizone injury, and in our series was associated with an increased number of reconstructive procedures.

The aim of the study is to improve the organization and provision of surgical care to civilians with gunshot wounds to the chest in the context of armed conflict on the example of the Chechen campaign.Materials and methods. The work is based on the analysis of medical care provided to 106 wounded with gunshot wounds to the chest from the civilian population in the period from 1991 to 2000. Medical care was provided on the basis of the surgical hospital of the city hospital No. 9 in Grozny.Results and discussion. Found that providing medical care to wounded with gunshot wounds of the chest when massive flow in terms of actual hostilities rendered by the forces and means of civil hospitals, has a certain specificity. It is due to the fact that in such conditions, in contrast to military medical organizations, there are no stages of evacuation, often the wounded are delivered by non-specialized and unsuitable vehicles on destroyed roads, while they are not given or given insufficient pre-medical care. In such conditions, the workload of medical personnel of civil medical institutions associated with the provision of medical care increases. In this regard, in our opinion, it is necessary to develop measures aimed at improving the algorithm aimed at minimizing various errors that occur in civilian medical institutions during the mass admission of wounded.

Background Hemorrhage accounts for >30% of trauma-related mortalities. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemostasis in the civilian population remains controversial. We aim to investigate REBOA practices through analysis of surgeon and trauma center characteristics, implementation, patient characteristics, and overall opinions. Methods An anonymous 30-question standardized online survey on REBOA use was administered to active trauma surgeon members of the Eastern Association for the Surgery of Trauma. Results A total of 345 responses were received, and 130/345 (37.7%) reported REBOA being favorable, 42 (12.2%) reported REBOA unfavorably, and 173 (50.1%) were undecided. The majority of respondents (87.6%) reported REBOA performance in the trauma bay. 170 (49.3%) of respondents reported having deployed REBOA at least once over the past 2 years. 80.0% reported blunt trauma being the most common mechanism of injury in REBOA patients. Resuscitative endovascular balloon occlusion of the aorta deployment in zone 3 of the aorta was significantly higher in patients reported to suffer a pelvic fracture or pelvic hemorrhage, whereas REBOA deployment in zone 1 was significantly higher among patients reported to suffer hepatic, splenic, or other intra-abdominal hemorrhage ( P < .05). Conclusion Among survey respondents, frequency of REBOA use was low along with knowledge of clear indications for use. While current REBOA usage among respondents appeared to model current guidelines, additional research regarding REBOA indications, ideal patient populations, and outcomes is needed in order to improve REBOA perception in trauma surgeons and increase frequency of use.

To evaluate the pattern of sensorineural hearing loss (SNHL) in patients attending ENT OPD in a military setup as well as to compare the incidence of hearing loss in Military Personnel with civilian population. This observational cross sectional comparative study was conducted over a period of April 2018 to July 2019. A total of 300 patients with hearing loss (HL) were included. Demographic characteristics along with laterality of sensorineural hearing impairment were compared between military personnel and civilians. Data was statistically compared between civilians and military personnel. A P-value of

Мета роботи – дослідження місця та ролі Національної академії медичних наук (НАМН) України та підпорядкованих їй науково-дослідних установ, в структурі яких є клінічні підрозділи, в системі надання медичної допомоги пораненим, ураженим, травмованим і хворим військовослужбовцям під час антитерористичної операції та операції Об’єднаних сил (АТО/ООС). Матеріали та методи. Використано нормативно-правові акти з питань національної безпеки держави та охорони здоров’я в Україні, публікації у відкритих наукових джерелах стосовно діяльності Національної академії медичних наук України в цілях надання медичної допомоги військовослужбовцям під час АТО/ООС. Методи дослідження – бібліографічний, статистичний, аналітичний, системного підходу. Результати. НАМН України та підпорядковані їй науково-дослідні установи, в структурі яких є клінічні підрозділи, під час АТО/ООС взяли активну участь у наданні медичної допомоги пораненим, ураженим, травмованим і хворим військовослужбовцям ЗС України та інших військових формувань. Робота НАМН України щодо надання медичної допомоги військовослужбовцям була багатовекторною і велася за декількома напрямами: організаційний, безпосереднього надання медичної допомоги та наукового супроводу. Клінічні установи НАМН України під час АТО/ООС не припиняли надання високоспеціалізованої медичної допомоги цивільному населенню України, зокрема й вимушеним переселенцям з районів проведення АТО/ООС. Висновки. Завдяки злагодженій діяльності Президії НАМН України та підпорядкованих їй науково-дослідних установ зроблено вагомий внесок у надання високоспеціалізованої медичної допомоги пораненим, ураженим травмованим і хворим військовослужбовцям під час АТО/ООС, а також сформовано основні напрями розвитку вітчизняної військово-медичної науки: організаційний, лікувально-профілактичний та логістично-технологічний.

Introduction The incidence of carpal tunnel syndrome (CTS) is increased in occupations exposed to repetitive motion, poor wrist posture, and vibration exposure. While all pilots are exposed to these factors, helicopter pilots are especially exposed to vibration. The study is to identify the incidence and risk factors for CTS in military aviators. Materials and Methods Clearance was obtained from Tripler Army Medical Center IRB. The Defense Medical Epidemiological Database was queried for all new cases of CTS from 2006 to 2015. Incidence rates (IRs) were determined for helicopter pilots, fixed-wing pilots, and nonpilot officers. Poisson regression analysis was used to calculate adjusted IR in order to control for demographic factors. Race was also taken into account, where pilots would classify themselves into a white or non-white race, defined by each individual. Race was assessed in the study to see if there were any differences in IR of CTS between white and non-white pilots. Results We identified 7,398 new cases of CTS among 2,319,352 person-years within the study period. Increasing age, female gender, and non-white race were significantly correlated with higher IR. Fixed-wing pilots demonstrated significantly lower adjusted IR than nonpilot officers in each age group. Helicopter pilots demonstrated higher IR than fixed-wing pilots in each age group. Helicopter pilots had lower incidence of CTS early in their career compared to nonpilot officers, but by age 40+, their IR ratio was significantly higher (1.21). Conclusion Analysis of the database indicates that fixed-wing pilot status is a protective factor against development of CTS among U.S. military officers. In contrast, helicopter pilots were found to be at an increased rate of CTS than their fixed-wing counterparts. Their incidence is comparable to their nonpilot officer peers early in their career, but is significantly increased at the senior level. Increasing age and female gender are risk factors in the military officer population as expected. Non-white race was found to increase risk in the military population, in contrast to reports of the civilian population.

Smart City is an emerging concept in global urban development. A Smart City applies ICT technologies to provide greater efficiencies for its urban areas and civilian population. One of the key requ...

BACKGROUND: A single 2-year National Health and Nutrition Examination Survey (NHANES) cycle is designed to provide accurate and stable estimates of conditions with prevalence of at least 10%. Recent NHANES-based estimates of a tuberculin skin test ≥10 mm in the noninstitutionalized U.S. civilian population are at most 6.3%. METHODS: NHANES included a tuberculin skin test in 1971–1972, 1999–2000, and 2011–2012. We examined the robustness of NHANES-based estimates of the U.S. population prevalence of a skin test ≥10 mm with a bias analysis that considered the influence of non-U.S. birth distributions and within-household skin test results, reclassified borderline-positive results, and adjusted for tuberculin skin test item nonresponse. RESULTS: The weighted non-U.S. birth distribution among NHANES participants was similar to that in the overall U.S. population; further adjustment was unnecessary. We found no evidence of bias due to sampling multiple participants per household. Prevalence estimates changed 0.3% with reclassification of borderline-positive tuberculin skin test results and 0.2%–0.3% with adjustment for item nonresponse. CONCLUSIONS: For estimating the national prevalence of a tuberculin skin test ≥10 mm during these three survey cycles, a conventional NHANES analysis using the standard participant weights and masked design parameters that are provided in the public-use datasets appears robust.

ZusammenfassungHäufiger als vielfach angenommen tritt – nach Berechnungen von 2 Metaanalysen – im Mittel bei ca. 25% der PTBS-Fälle das Vollbild der Posttraumatischen Belastungsstörung (PTBS) erst nach mehr als 6 Monaten auf. Die Prävalenzzahlen variieren stark je nach untersuchter Population. Im militärischen Bereich tritt eine PTBS mit verzögertem Beginn deutlich häufiger auf als im zivilen (38,2 vs. 15,3%). Für das Spektrum an Prävalenzzahlen werden Unterschiede in der Definition, der Methodik, den Untersuchungskollektiven wie auch den Traumaformen selbst verantwortlich gemacht. Je länger die Beobachtungszeit, um so eher die Erfassung von verzögertem Beginn einer PTBS. Für die Entstehung und Aufrechterhaltung wurden einige Einflußfaktoren identifiziert. In der Begutachtung wird bei verzögertem Beginn die Forderung nach „Brückensymptomen“ gestellt. Diese sind zwar häufig, jedoch nicht zwingend erforderlich. Am Beispiel von politischer Inhaftierung in der DDR werden Verlaufsformen der PTBS wie auch des Subtyps des „verzögerten Beginns“ dargestellt.

With the increased number of mass shootings in recent years, this paper seeks to review recent literature on the management of active shooter settings and the care for pediatric victims. Tactical Combat Casualty Care (TCCC) functions on the principal of expeditious recognition and aggressive treatment of preventable death on the battlefield. The Committee for Tactical Emergency Casualty Care (C-TECC) was formulated to translate the TCCC guidelines to the civilian population. The adaptation of C-TECC’s guidelines have also considered the importance of real-world demographics, including the pediatric population. Pediatric C-TECC guidelines advise, if possible, that the patient should move to a position of safety. If not possible, risks and benefits should be weighed for rescue attempts in terms of the activity and safety of the situation. The practitioner should realize that time may be more limited for pediatric patients in terms of rescue and medical salvage. Prompt placement of tourniquets, hemostatic agents, and wound packing for hemorrhage control, especially in ongoing active threat scenarios, is recommended. However, guidelines like C-TECC are reactionary. The prevention of traumatic injury is still paramount and the goal will always be minimizing the chance of harm to the public prior to the injury occurring.

The incidence of self-inflicted gunshot wounds has increased significantly in the civilian population. In this case, we present a 25-year-old male with a self-inflicted gunshot wound to the neck exiting to the left shoulder. Penetrating injuries to the neck carry a high likelihood of severe injury and death. Exsanguination due to damage to the carotid or vertebral arteries is the most common cause of immediate death. Traumas caused by gunshot wounds can be complicated by an unusual path and can be devastating, depending on the extent of the injury. Our patient presents with a unique singular outcome of a spinal cord injury from anterior penetrating neck trauma. The aim of this case report is to raise awareness of a unique outcome from a self-inflicted gunshot wound, as it is vital to be aware of all possible outcomes because these injuries become more prevalent in our communities.

The article presents, on the basis of archival documents and literature sources, the distribution and placement of hospital staff, staffing of physicians and nurses, support of population with medical personnel and medications, changes in beds stock, equipment of hospital institutions on the unoccupied territories of the USSR. An increase of workload, volume and intensity of labor of personnel of civil health care during the first two years of the Great Patriotic War was established. The unreadiness of the Narkomzdrav (the USSR People's Commissariat of Health Care) for making optimal decisions concerning the rational application of human resources in the beginning of the war is proved.

Objective Firearm violence has a high economic impact, representing the third most expensive injury and associated with the fourth highest hospitalisation cost. This study was performed to determine the clinical and epidemiological characteristics of patients with injuries due to firearm projectile during a period of increased violence related to organised crime in our country. Methods A retrospective study (2010–2017) was conducted to analyse the clinical data of patients admitted due to firearm projectile injury. Clinical and epidemiological characteristics of each patient were recorded, and patients were stratified by sex and age. Compared low-energy versus high-energy gunshot injuries, complications and treatment. Results A total of 1309 gunshot wounds in appendicular skeleton and spine fractures. The mean age of the patients was 29 ± 11.5 years. Upper extremities wounds in 358 cases, lower extremities wounds in 727 cases and 224 fractures in spine region. There were no significant differences between low-velocity and high-velocity projectiles in anatomic affected region, complications and treatment. Conclusions We concluded that firearm projectiles cause a variety of injuries both in soft and bone tissues and caused a major rate of complications in our patients even with low- or high-energy weapons. The majority of patients affected were the civilian population. Most patients with gunshot wounds were young males. We observed a low mortality rate in our patients. Level of evidence III; retrospective cohort study.

Objective Firearm violence has a high economic impact, representing the third most expensive injury and associated with the fourth highest hospitalization cost. This study was performed to determine the clinical and epidemiological characteristics of patients with injuries due to firearm projectile during a period of increased violence related to organized crime in our country. Methods A retrospective study (2010–2017) was conducted to analyze the clinical data of patients admitted due to firearm projectile injury. Clinical and epidemiological characteristics of each patient were recorded, and patients were stratified by sex and age. Compared low-energy versus high-energy gunshot injuries, complications and treatment. Results A total of 1309 gunshot wounds in appendicular skeleton and spine fractures. The mean age of the patients was 29 ± 11.5 years. Upper extremities wounds in 358 cases, lower extremities wounds in 727 cases and 224 fractures in spine region. There were no significant differences between low-velocity and high-velocity projectiles in anatomic affected region, complications and treatment. Conclusions We concluded that firearm projectiles cause a variety of injuries both in soft and bone tissues and caused a major rate of complications in our patients even with low- or high-energy weapons. The majority of patients affected was the civilian population. Most patients with gunshot wounds were young males. We observed a low mortality rate in our patients. Level of evidence III; Retrospective cohort study.

Bodily injuries, caused by firearms and special non-lethal means, which are provided for law enforcementagencies and special services and they are available to the civilian population as well (pistols for firingammunition equipped with elastic bullets, stun guns, etc.,) and the consequences of torture using variousmethods and the traumatic factors that caused by them have to get expert objective assessment. Among otherlaboratory studies, it is important to determine the characteristics of the composition of chemical elementsin objects of biological and non-biological origin by performing X-ray fluorescence spectral analysis usingmodern spectrometers. The object: to determine the characteristics of the elemental composition of metalsand their topography in injuries caused by gunshots and stun gun by conducting X-ray fluorescence spectralanalysis using spectrometers “ElvaX CEP-01” and “M4 TORNADO”. Conclusions: the use of spectrometersincreases the accuracy and objectivity of expert examinations of injuries caused by firearms and electricshock device as they have a wide range of chemical elements detection in the composition of the products ofthe shot and the electro tag from sodium to uranium. Using X-ray fluorescence spectral analysis, it is possiblenot only to detect metals in the layers of soot on injuries, but also to conduct a targeted “microscopic” studyof their topography for partial group identification of firearms and the installation of electrode metal, whichacted as a contact body conductor. X-ray fluorescence spectral analysis is a non-destructive research method.

The prevalence of tuberculosis among military health system (MHS) and Veterans Affairs (VA) beneficiaries in Hawaii and the Pacific Islands has not been previously reported. Our analysis evaluates the prevalence of M. tuberculosis (MTB) among acid fast bacilli culture(s) (AFB) tested at Tripler Army Medical Center (TAMC) on Oahu, HI and describes demographic factors associated with positive samples. We analyzed 9,768 AFBs from 4,129 individuals with AFB specimens processed at TAMC from January 2002 to November 2019: of those who were tested 3,178 were MHS beneficiaries and 951 were VA beneficiaries. There were a total of 40 individuals with MTB-positive cultures over the period of study: 31 MHS beneficiaries and 9 VA beneficiaries. Of the MTB-positive specimens, 93% were from pulmonary samples while the remainder were from lymph node aspirates (5%) and peritoneal samples (2%). Cumulative incidence rates of MTB-isolation were 1.8 per 100,000 MHS beneficiaries and 1.2 per 100,000 VA beneficiaries, both of which were lower than reported incidence rates in Hawaii, the U.S.-affiliated Pacific Islands and the United States for the study period. MHS beneficiaries of Asian-Pacific Islander race or ethnicity had nearly 20 times higher odds of positive AFB than white MHS beneficiaries (OR = 19.56, 95% CI 5.52, 69.29, p = < 0.001). This study demonstrated a higher odds of MTB-positivity associated with Asian-Pacific Islander race or ethnicity and low incidence rates of TB among MHS and VA beneficiaries in Hawaii and the Pacific Islands when compared with the civilian population.

Opiates are addicting and have a high potential for dependency. In the past decades, opiates remained the first-line pharmaceutical option of prehospital treatment for acute traumatic pain in the civilian population. Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist that has analgesic properties and may serve as an alternative agent for the treatment of acute traumatic pain in prehospital settings. This study aims to assess the safety and efficacy of ketamine administration by paramedics in civilian prehospital settings for the treatment of acute traumatic pain. This was a prospective observational study in San Bernardino, Riverside and Stanislaus counties. Patients were included if they were > 15 years of age with complaints of traumatic or burn-related pain. Patients were excluded if they received opiates up to six hours prior to or concurrently with ketamine administration. The dose administered was 0.3 mg/kg intravenously over five minutes with a maximum dose of 30 mg. The option to administer a second dose was available to paramedics if the patient continued to have pain after 15 minutes following the first administration. Paired-T tests were conducted to assess the change in the primary outcome (pain score) and secondary outcomes (e.g. systolic blood pressure, pulse, and respiratory rate). P-value

Canadian Blood Services (CBS) operates a national rare blood program to meet the needs of a highly diverse Canadian civilian population. This program manages the frozen inventory of red blood cell products maintaining upwards of 800 units of strategically identified phenotypes for patient use. Red cell concentrates (RCCs) are collected from identified donors with rare blood types as whole blood and are further processed into leukocyte reduced red cell concentrates in SAGM. These units can be stored for up to 21 days prior to glycerolization and frozen storage. The use of the ACP 215, a closed system cell processor, for cryopreservation using the high glycerol method allows for an extended expiry date of 14 days post deglycerolization when RBCs are suspended in AS-3 and stored hypothermically prior to transfusion. This method produces units that meet all Canadian regulatory standards. Introduction of extended outdates has allowed CBS to decrease operational costs and improve cryopreserved RCC product quality.

Cold traumas (CT) were once primarily military problems, but are becoming increasingly prevalent among the civilian population. It is associated with a growing interest in outdoor activities such as skiing, hiking, mountaineering and increase in the numbers of homeless. Occurrence of CT grows up in winter, when number of injured reaches more then 12 000 people. Most of the injured need hospital treatment, mortality is excess 10 % of cases. Research as to the pathophysiology of frostbite has revealed notable similarities with the inflammatory processes seen in burn injuries and ischaemia/reperfusion injury. Evidence for the role of tromboxanes and prostaglandins has resulted in a more active approach to the medical treatment of frostbite. Considering the role of eicosanoids in the development of CT we can assume positive influence of arachidonic acid cascade inhibitors for such pathology. The aim of the work is to compare the power of frigoprotective effect of NSAIDs with different selectivity and paracetamol using the model of acute general cooling. The experiment was carried out using healthy white male mice weighing 20–24 g during single day from 12.00 till 18.00. Mice were put into individual 500 cm3 plastic cages with free access to air and without movement restriction. Cages were situated inside the freezer «Nord Inter-300» with transparent top and at a temperature of –18 °C. An integral index of frigoprotective effect was chosen the duration of life. Drugs and substances that were used in the experiment: nonselective inhibitors of COX – acetylsalicylic acid (Aspirin, tablets, «Bayer», Germany), diclofenac sodium (Voltaren, tablets, «Novartis», Switzerland); highly selective inhibitor of COX-2 – celecoxib (Celebrex, tablets, «Pfizer», USA), etoricoxib (Arcoxia, tablets, «Merck Sharp & Dohme Idea Inc», USA); inhibitor of COX-3: paracetamol (Panadol, tablets, «Glaxo Smith Kline plc», Ireland); double inhibitor of COX-2/5-LOX – darbufelone, darbufelone mesylate, 5-(3,5-di-tret-butyl-4-hydroxybenziliden)-2-(thiazol-2-ilimino)-thiazolidin-4-on (substances). The results of the present study show that paracetamol doesn’t demonstrate frigoprotective activity. Etoricoxib render the highest frigoprotective effect among traditional NSAIDs. Darbufelone mesylate shows the highest frigoprotective activity among all used inhibitors of arachidonic acid cascade. Considering that we can suppose important role of 5-LOX and leukotrienes in pathogenesis of cold trauma.

Background: The mortality rate of US Veterans is greater than that of civilians, and US Veterans experience disproportionately higher burden of medical comorbidities. Disparities in coronary artery disease (CAD) incidence and its risk factors between US veterans and civilians has not previously been reported. This study seeks to identify disparities in the incidence of CAD and CAD risk factors in US veterans and the general population. Methods: A total of 1535 consecutive US Veterans presenting for left heart catheterization (LHC) were reviewed. We present risk factor burden, LHC outcome, and mortality with mean follow-up time of 112 ± 65.2 months. Results: At mean follow-up of 112 months (9.3 years), all-cause mortality was 68.3%. 12.7% had normal coronaries (NC), 14.9% had non-obstructive coronary artery disease and 72.3% had obstructive coronary artery disease (ObCAD). Mean BMI was 30.0; 87.8% had hypertension (HTN), 78.1% had hyperlipidemia (HLD), 52.2% has reduced ejection fraction (rEF), 45.5% had diabetes (DM), and 17.5% had chronic kidney disease (CKD). In order of decreasing Cox hazard, six risk factors (CKD, rEF, PVD, HTN, obesity and DM) were independent predictors of mortality. Conclusion: Mortality and incidence of ObCAD in US veterans are notably greater than in the American general population (per the CDC National Health Report) and other developed countries (per the WHO NCD Report). Compared to the general population, there is greater burden of HTN, HLD, DM and CKD in US Veterans. Among US Veterans, CKD carried a greater HR compared to HTN and DM, with no significant HR for HLD. This differs markedly from the general population studied in the REACH registry which established HTN, HLD and DM as the greatest predictors of cardiovascular mortality. The low hazard of HLD was likely secondary to its ubiquity in most patients in the cohort, regardless of CAD status. US Veterans have unique healthcare needs and our study guides which risk factors need to be managed to improve disparities in US Veteran health.

POSSIBILITIES OF SOCIAL MEDIA IN INFORMATION OPERATIONS Current conflicts are characterized by the changing environment having a considerable influence on military operations. The armed forces must calculate with civilian factors that are increasingly coming to the forefront in conducting operations. It is no longer enough to defeat the enemy using military power, but necessary to stabilize the area of responsibility and incline thelocal population to be on our side. Influencing the civilian population is conducted mainly by providing information that is disseminated by traditional methods such as radio, television, and print. Dissemination of information is no longer just the domain of the media but comes to the fore via internet communication. Thanks to the development of technologies and especially the availability of Smartphones, social networks are becoming the new phenomena.

BACKGROUND AND PURPOSE: Cerebral microhemorrhages are a known marker of mild traumatic brain injury. Blast-related mild traumatic brain injury relates to a propagating pressure wave, and there is evidence that the mechanism of injury in blast-related mild traumatic brain injury may be different from that in blunt head trauma. Two recent reports in mixed cohorts of blunt and blast-related traumatic brain injury in military personnel suggest that the prevalence of cerebral microhemorrhages is lower than in civilian head injury. In this study, we aimed to characterize the prevalence of cerebral microhemorrhages in military service members specifically with chronic blast-related mild traumatic brain injury. MATERIALS AND METHODS: Participants were prospectively recruited and underwent 3T MR imaging. Susceptibility-weighted images were assessed by 2 neuroradiologists independently for the presence of cerebral microhemorrhages. RESULTS: Our cohort included 146 veterans (132 men) who experienced remote blast-related mild traumatic brain injury (mean, 9.4 years; median, 9 years after injury). Twenty-one (14.4%) reported loss of consciousness for 2 episodes. No cerebral microhemorrhages were identified in any subject, as opposed to the frequency of SWI-detectable cerebral microhemorrhages following blunt-related mild traumatic brain injury in the civilian population, which has been reported to be as high as 28% in the acute and subacute stages. CONCLUSIONS: Our results may reflect differences in pathophysiology and the mechanism of injury between blast- and blunt-related mild traumatic brain injury. Additionally, the chronicity of injury may play a role in the detection of cerebral microhemorrhages.

В статті на основі аналізу сучасного стану та тенденцій розвитку інформаційних і інших високих оборонних технологій та їх впливу на забезпечення національної безпеки і оборони, з врахуванням особливостей високотехнологічного розвитку людства, виявлені основні проблемні питання їх впровадження, ефективного застосування у воєнній сфері та визначені шляхи їх вирішення. З єдиних позицій розглянуті системи оперативного управління військами (силами) та зброєю, їх роль і місце у формуванні єдиного бойового простору та практичній реалізації мережецентричних концепцій організації та ведення бойових дій, а також системо-утворююча та інтегруюча роль інформаційних технологій у вирішенні цих питань. Досліджено фактори, які впливають на зростання кількості загроз і ризиків інформаційних, кібер та когнітивних деструктивних впливів на високотехнологічні системи (комплекси, засоби), особовий склад Збройних Сил та населення через кіберпростір в сучасних умовах і їх трансформації. Запропоновані можливі шляхи щодо удосконалення системи інформаційної і кібербезпеки та кібероборони держави у воєнній сфері. Розглянуті проблемні питання наукового супроводження створення, впровадження та забезпечення ефективного застосування високотехнологічних розробок у сфері оборони, а також підготовки фахівців за високотехнологічними напрямами в інтересах забезпечення національної безпеки і оборони та запропоновані шляхи їх вирішення.

Foram estudados 417 casos de ferimentos craniencefálicos por projétil de arma de fogo ocorridos em população civil, com o objetivo de determinar os fatores que influenciam a mortalidade. Foram selecionados pacientes com ferimento único, que chegaram com vida ao hospital em um período de até seis horas após o trauma e que evoluíram para o óbito após a internação ou permaneceram internados por pelo menos 48 horas. A mortalidade global foi de 63,1% – 263 casos que foram analisados separadamente. Constatou-se que mortalidade não foi influenciada, significativamente, por variáveis como idade ou sexo do paciente, causa da ocorrência, calibre do projétil, local de entrada no crânio, presença de hematoma intracraniano ou pelo tratamento instituído. Foram considerados como fatores prognósticos significativos o estado neurológico do paciente, quando de sua internação, e a trajetória do projétil – morreram 93,2% dos pacientes comatosos com ECG < 6 e 91,4% entre os que apresentaram ferimentos em que o projétil cruzou tanto o plano coronal como o sagital. Por outro lado, apenas 1,9% dos pacientes acordados sem sinais neurológicos focais e 3,8% entre os que o projétil não atravessou nenhum dos planos evoluíram para óbito. Levando-se em consideração que o prognóstico quanto à mortalidade é considerado um dos critérios mais importantes a influir sobre a decisão cirúrgica, concluiu-se que pacientes em coma profundo, com lesões bi-hemisféricas e de vários lobos cerebrais, apresentam muito mau prognóstico, com elevada taxa de mortalidade e que, provavelmente, devam ser considerados como fora de possibilidades terapêuticas.

Many healthcare providers are not familiar with the Food and Drug Administration (FDA) vaccine licensure process, the Advisory Committee on Immunization Practices (ACIP) vaccine recommendation process, and how FDA vaccine licensure and ACIP recommendations are related. Vaccines for use in the United States military and civilian populations are licensed by the FDA by several potential pathways but use of licensed vaccines in the civilian population should be based on recommendations made by the ACIP. In performing these distinct activities, FDA and ACIP function under different mandates. In this article, we discuss whether the FDA licensure pathways used to approve a vaccine impacts ACIP recommendation categories for vaccines licensed from 2006 to 2016.

Purpose Injured Syrian patients are commonly transferred to local hospitals and field clinics immediately after being injured. Since February 2011, more than 2,000 injured Syrian patients have been transferred to and treated in northern Israeli medical centers. The aim of the present study was to evaluate the epidemiology and general nature of the injuries, with special attention to maxillofacial (MF) injuries. Patients and Methods The medical files of all injured Syrian patients who were treated in 2 major medical centers in northern Israel from December 2012 through December 2015 were reviewed. Computerized data were collected and analyzed based on the cause of injury, anatomic location, Injury Severity Score (ISS) at admission, hospitalization duration, and duration in the intensive care unit. Results The study cohort included 227 patients (204 male [90%], 23 female [10%]; mean age, 24.5 ± 11 yr). The median calculated ISS was 20.6 ± 13.9. The mean interval from injury to recorded admission time was 86.37 hours. Fifty patients had MF injuries (22%). Of these, 45 were adults (44 men, 6 women). Patients' age ranged from 16 to 27.3 years. The mean interval from injury to time of admission was 24 hours and the mean ISS on admission was 24.5 ± 12.7, which was significantly higher than the overall ISS (median, 24.5 vs 16; P = .005). Conclusion Several features observed in the present study had a direct effect on treatment quality and success. Those features included delay from injury to hospital admission; lack of body armor protection, including helmets, which explained the high prevalence of MF injuries; and the multiple sites of injury.

Nonfreezing cold injury has been primarily described in military populations as a result of prolonged exposure to wet environments and cold, but not freezing, temperatures. This type of injury occurs less commonly in the civilian population and in children, but poses a risk for short-term debilitating extremity pain, tissue damage, and infection and for long-term chronic neuropathic pain and temperature intolerance. We describe a case of nonfreezing cold injury in a pediatric hiker.

Mortality secondary to trauma related hemorrhagic shock has not improved for several decades. Underlying the stall in progress is the conundrum of effective pre-hospital interventions for hemorrhage control. As we know, neither pressing hard on the gas nor "Stay and play" have changed mortality over the last 20 years. For this reason, when dealing with effective changes that will improve severe hemorrhage mortality outcomes, there is a need for the creation of a hybrid pre-hospital model.Improvements in mortality outcomes for patients with severe hemorrhage based on evidence for common civilian prehospital procedures such as in-field intubation and immediate fluid resuscitation with crystalloid solution is weak at best. The use of tourniquets, once considered too risky to use, however, has risen dramatically in large part due success seen during their use in the military. Their use in the civilian setting shows promising results. Recently updated military Advanced Resuscitative Care (ARC) guidelines propose the use of prehospital whole blood transfusion as well as in-field use of Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Several case studies from Europe suggest these strategies are feasible for use in the civilian population, but could they be implemented in the U.S.?

More than 180 pathogens have been explored or employed as biological weapons that pose a potential threat to military, civilian population, and crops. Biological warfare (BW) agents include bacteria, fungi, viruses, and toxins that affect human beings, animals, and plants, and can be used in bioterrorist activity and biological warfare attacks. They are characterized by low detectable quality, high effectiveness, adequate reach ability, and comparative ease of delivery. It can be delivered by unconventional methods like aerosol sprays, water and food contamination, or by covert injection. In perspective on their hidden movement, easy transportation, and complicated detection, they are readily adaptable for terrorist operations or to gain political advantage. BW agents are a serious concern nowadays due to emerging bioterrorist incidents all over the world. Although various treatment strategies have been developed in recent years to treat or neutralize such kinds of biological warfare agents, these are not enough for a complete cure. In this chapter, we review the various biological warfare agents, their possible mode of transmission, and treatment strategies that be adopted during biological and bioterrorist activity. The present chapter also highlights specific antibiotics, antivirals, vaccines, and monoclonal antibodies that may be effective against the particular disease-causing organisms.

The protection of civilians, military professionals, including specialists of the Czech Armed Forces chemical corps, specialists of the Czech Republic Fire Rescue Service chemical service and, last but not least, employees of industrial enterprises against toxic substances is a long-term priority of the responsible state administration bodies. The priorities of these state bodies are focused on protection of the civilian population and industrial workers against the effects of toxic substances and related material equipment. The current security environment is characterized by a range of threats, including the proliferation of weapons of mass destruction and the possibility of releasing industrial hazardous substances such as toxic industrial materials into the environment. It is therefore possible to talk about the phenomenon of CBRN (C-chemical, B-biological, R-radiological, N-nuclear) threats that are expressed by the existence or use of nuclear, biological or chemical means against the civilian population. Critical Infrastructure means both production and non-production systems, the malfunctioning of which would have serious implications for security, economy and the preservation of the essential scope of other essential functions of the state in crisis situations. The risk of the CBRN threat is determined by the degree of severity expressed by the constantly expanding range of entities that have or are seeking to obtain them. The aim of the chapter is to notice that barrier materials used in the branch of individual protection must be assessed in accordance with those characteristics which are connected with resistivity against the permeation of toxic compounds.

BackgroundIn the United States (U.S.), the overall death rate in 1-4 year-olds had been steadily declining until 2011, after which it ceased to improve. To understand this trend reversal, we investigated trends in the causes of their deaths.MethodsMortality data were obtained from the U.S. Centers for Disease Control and Institute for Health Metrics and Evaluation, firearm background check data from the National Instant Criminal Background Check System, and civilian firearm prevalence from the Small Arms Survey.FindingsIn 1-4 year-olds, the rate of fatal firearm accidents during 2002-2017 increased exponentially at an average rate of 6.0%/year (p=0.0003). The rate of increase was the greatest of all evaluable causes of death in the age group. Both the rate increase and most recent absolute rate in firearm accidental deaths in young children were correlated with the concurrent corresponding rate of firearm background checks (p = 0.0002 and 0.003, respectively). Also, the firearm accidental death rate in countries with high civilian firearm prevalence was correlated with the number of guns per civilian population (p=0.002).InterpretationPrior to 2004, the childhood firearm death rate did not increase during the Federal Assault Weapons Ban. Since 2004 when the Ban ended, the steadily increasing rate of sales and concomitant availability of, and access to, firearms in the U.S. has been associated with an increase in fatal firearm accidents in its youngest children. The acceleration of firearm deaths and injuries among young Americans requires urgent, definitive solutions that address firearm prevalence.FundingNo external funding.KEY POINTSQuestionIn the U.S., how has the escalation of both firearm sales and firearm death rates affected the country’s youngest population?FindingsWhile the steadily increasing rate of sales and concomitant availability of, and access to, firearms in the U.S. has increased since 2004, fatal firearm accidents in 1 to 4 year-olds increased exponentially and at a rate greater than all other evaluable causes of death in the age group.InterpretationThe ominous acceleration of firearm deaths and injuries among young Americans requires urgent, definitive solutions from multiple stakeholders to effectively reduce firearm access.

The authors study the connections between salt resources, salt exploitation and Roman army in Dacia. Even though salt resources are attested almost across the entire province of Dacia (excepting perhaps the western part), the eastern part is the richest not only in salt deposits, but also salt springs. Salt was important not only for the troops (food — nutrition and preservation, hide and leather processing, horses’ and other animals’ alimentation), but also for the civilian population. The army needed salt not only for its own purposes, but for distributing it in the rest of the province. However, despite the important role of the army concerning the salt resources’ protection, we have to pay attention also at he other missions the troops were charged with.

Category: Ankle Arthritis, Orthosis Introduction/Purpose: When it comes to ambulation, the dynamic interplay of anatomy at the foot and ankle affords weight acceptance, stability and force production. The outcome is gait efficiency. Various musculoskeletal injuries challenge gait biomechanics. While surgical management may address the fault in kinetic chain, it may not fully address the problem of pain, functional outcome and patient satisfaction. Non-surgical interventions such as bracing using ankle foot orthoses (AFO) aim to assist, restore and redirect weightbearing forces with immobility in mind. As an energy-storing AFO, however, the IDEO was created to improve functional performance in veterans after limb salvage procedures. The goal of the study was to evaluate outcomes following use of Exosym (or IDEO) bracing for foot and ankle pathologies in the civilian population. Methods: Through review of one institution’s electronic medical record, 29 patients ages 18 years or older who were prescribed the Exosym brace by a single foot and ankle surgeon over a 5-year period were identified. A composite questionnaire including patient-reported outcomes of PROMIS SF Physical Function, PROMIS SF Pain Interference, Brace Use, and EQ-5D was obtained over the phone or by email. Results: A total of 29 patients were prescribed the brace over a 5-year period with only 18 patients receiving the brace. Insurance denying coverage was the most common reason (n=7) for patients not receiving the brace. Of the 18 patients that received the brace, 17 of them were willing to answer the questionnaire. The average age of patients with the Exosym brace was 42.3 (sd=13.8) years old with 6 (35%) being female. Patients with the Exosym brace reported an average score of 47.2 (sd=6.0) for the PROMIS Physical Function and 53.6 (sd=8.4) for the PROMIS Pain Interference. The average satisfaction with the Exosym brace was 65.5 (sd=17.6) out of a possible 100. Conclusion: Exosym bracing in various foot and ankle pathologies provides functionality and pain modulation in the civilian population that rivals respective subpopulation norms. One of the acknowledged limitations of the study is that not obtaining pre- bracing patient reported outcomes precluded evaluation of a minimum clinically important difference. However, the study was not designed to provide such data. It did, however, provide impetus to pursue a follow-up study evaluating plantar pressure changes with and without brace use, which is currently ongoing. Such knowledge may help identify which injuries would be best suited for Exosym bracing.

This study presents a cellular automata (CA) model to assist decision-makers in understanding the effects of infrastructure development projects on adverse events in an active war theater. The adverse events are caused by terrorist activities that primarily target the civilian population in countries such as Afghanistan. In the CA-based model, cells in the same neighborhood synchronously interact with one another to determine their next states, and small changes in iteration yield to complex formations of adverse event risks. The results demonstrate that the proposed model can help in the evaluation of infrastructure development projects in relation to changes in the reported adverse events, as well as in the identification of the geographical locations, times, and impacts of such developments. The results also show that infrastructure development projects have different impacts on the reported adverse events. The CA modeling approach can be used to support decision-makers in allocating infrastructure development funds to stabilize active war regions with higher adverse event risks. Such models can also improve the understanding of the complex interactions between infrastructure development projects and adverse events.

Key Points Question Is enactment of medical marijuana laws in the United States associated with changes in nonmedical prescription opioid use and prescription opioid use disorder among prescription opioid users overall and by age and racial/ethnic group? Findings This cross-sectional study using individual-level restricted data from the 2004 to 2014 US National Survey on Drug Use and Health showed small increases in nonmedical prescription opioid use and no significant change in prescription opioid use disorder among users after medical marijuana law enactment. Similar patterns were observed across age and racial/ethnic groups. Meaning Medical marijuana law enactment was not associated with a reduction in individual-level nonmedical prescription opioid use, contradicting the hypothesis that people would substitute marijuana for prescription opioids., This cross-sectional study uses data from the US National Survey on Drug Use and Health to estimate changes in nonmedical prescription opioid use and prescription opioid use disorder in states that have legalized the use of medical marijuana., Importance Between 1997 and 2017, the United States saw increases in nonmedical prescription opioid use and its consequences, as well as changes in marijuana policies. Ecological-level research hypothesized that medical marijuana legalization may reduce prescription opioid use by allowing medical marijuana as an alternative. Objectives To investigate the association of state-level medical marijuana law enactment with individual-level nonmedical prescription opioid use and prescription opioid use disorder among prescription opioid users and to determine whether these outcomes varied by age and racial/ethnic groups. Design, Setting, and Participants This cross-sectional study used restricted data on 627 000 individuals aged 12 years and older from the 2004 to 2014 National Survey on Drug Use and Health, a population-based survey representative of the civilian population of the United States. Analyses were completed from March 2018 to May 2018. Exposures Time-varying indicator of state-level medical marijuana law enactment (0 = never law enactment, 1 = before law enactment, and 2 = after law enactment). Main Outcomes and Measures Past-year nonmedical prescription opioid use and prescription opioid use disorder among prescription opioid users. Odds ratios of nonmedical prescription opioid use and prescription opioid use disorder comparing the period before and after law enactment were presented overall, by age and racial/ethnic group, and adjusted for individual- and state-level confounders. Results The study sample included 627 000 participants (51.51% female; 9.88% aged 12-17 years, 13.30% aged 18-25 years, 14.30% aged 26-34 years, 25.02% aged 35-49 years, and 37.50% aged ≥50 years; the racial/ethnic distribution was 66.97% non-Hispanic white, 11.83% non-Hispanic black, 14.47% Hispanic, and 6.73% other). Screening and interview response rates were 82% to 91% and 71% to 77%, respectively. Overall, there were small changes in nonmedical prescription opioid use prevalence after medical marijuana law enactment (4.32% to 4.86%; adjusted odds ratio, 1.13; 95% CI, 1.06-1.20). Prescription opioid use disorder prevalence among prescription opioid users decreased slightly after law enactment, but the change was not statistically significant (15.41% to 14.76%; adjusted odds ratio, 0.95; 95% CI, 0.81-1.11). Outcomes were similar when stratified by age and race/ethnicity. Conclusions and Relevance This study found little evidence of an association between medical marijuana law enactment and nonmedical prescription opioid use or prescription opioid use disorder among prescription opioid users. Further research should disentangle the potential mechanisms through which medical marijuana laws may reduce opioid-related harm.

The effects of a period without physical training on the civilian population are well established. However, no studies show the effects of a period without mandatory physical training on maximum oxygen uptake (VO2 max) and anthropometric parameters in naval cadets. This study aimed to investigate changes in VO2 max and anthropometric parameters after 12 weeks without mandatory physical training in naval cadets. The sample was 38 healthy and physically active naval cadets. The measured variables, including VO2 max and anthropometric parameters, were evaluated through the 12-minute race test (12MRT) and the somatotype. Both variables had a separation of 12 weeks without mandatory physical training. A t-test for related samples was used to evidence changes between the test and post-test; effect size was calculated through Cohen’s d-test. Distance in 12MRT and VO2 max showed significant decreases at the end of 12 weeks without mandatory physical training (p < 0.001). Likewise, the tricipital skinfold thickness and the endomorphic component showed significant increases (p < 0.05). 12 weeks without mandatory physical training significantly reduces the VO2 max in naval cadets. Simultaneously, the same period without physical training increases both the tricipital skinfold thickness and the endomorphic component in this population.

PURPOSEY: The majority of research efforts centering on injury among older adults focus on fall-related injuries and short-term consequences of injury. Little is known about the long-term consequences of all-cause nonfatal injuries, including minor injuries. Using a recent, large, and nationally representative sample of the U.S. non-institutionalized civilian population, the current study examines whether older adults who sustained a nonfatal injury (serious and minor) have higher risk of long-term morbidity and mortality outcomes compared with noninjured seniors. METHODS: Linked National Health Interview Survey-Medical Expenditure Panel Survey (NHIS-MEPS) data were used to fit logistic and 2-part models to estimate associations between injury incidence and later injury, hospitalization incidence, and length of hospital stay during the 2.5 years following the NHIS interview among 16,109 older adults. Data from the linked National Health Interview Survey-National Death Index (NHIS-NDI) files were used to estimate a Cox proportional hazards model to examine the association between injury incidence and mortality for up to 11 years after the initial interview among 79,504 older adults. RESULTS: Relative to no injury, serious nonfatal injury was significantly associated with increased risk of another injury, hospitalization, and mortality. Minor injuries were significantly related to higher risk of later injury and mortality. IMPLICATIONS: Because even minor injuries are strongly associated with increased risks of later injury and mortality, preventing injury among seniors may be an effective way to improve quality of life and reduce declines in functional capacity.

In their writing war, Irene Nemirovsky (Suite francaise, 2004), Sarah Kofman (Rue Ordener, Rue Labat, 1994), and Marguerite Duras (La douleur, 1985), each articulate an alimentary ethics, through a novel, an autobiographical memoir, and an auto-fictional memoir, all published four to six decades after the Occupation. An alimentary ethics is constituted variably in the texts, taking form in food collaborations and complicities; ideological affiliations, of Resister or collaborator; moral meanings of food; and motivations for and the manifestation of individual virtue. The principle of hospitality, offered or refused to the guest/foreigner, intersects with a critique of gender, of the maternal function of feeding and nourishing. Read together, the texts of these three authors provide a micro-history and social analysis of the relationships of the civilian population to food in wartime through a praxis of the everyday, namely women’s strategies in procuring and distributing food; struggles over the definitio...

Prevalence and patterns of dietary supplement (DS) use by U.S. Army soldiers differ from the civilian population. Longitudinal trends in use of DSs by civilians have been examined, but are unavailable in subpopulations such as military service members. The present study examined longitudinal changes in DS use by soldiers. A standardized questionnaire on DS use was administered in 2006–2007 (N = 989) and 2010–2011 (N = 1196) to convenience samples of active duty soldiers. Data were weighted for total population demographics of age, sex, and rank. Regular use of DSs by soldiers increased significantly (56% ± 1.6% vs. 64% ± 1.7%; p ≤ 0.001) over the 4 years primarily because of an increase of DS use among the youngest 18- to 24-year-old soldiers (43.0% ± 2.5% vs 62.3% ± 2.4%; p ≤ 0.01). Protein (22% ± 1.4% vs. 26% ± 1.5%; p ≤ 0.001) and combination (10.0% ± 1.0% vs. 24% ± 1.4%; p ≤ 0.001) product consumption also increased over the 4 years. Individual vitamin and mineral use — including iron, magnesium, selenium, and vitamins A, B6, B12, and D — significantly increased as well (p ≤ 0.05). In addition, expenditures on DSs by soldiers increased over time (p < 0.01). Reasons reported by soldiers for DS use suggest use increased to meet the occupational demands of military service. Educational interventions to minimize inappropriate use of DSs by soldiers are necessary to reduce adverse events resulting from unnecessary use of DSs and the financial burden associated with their use.

This year, 2016, marks the centenary of some of the worst battles of World War I. It Is timely to reflect on the experiences of those who lived through those events, and the significant effects on the development of that occurred as a result. War has been a catalyst that has accelerated the development of medicine and surgery throughout history. The challenges of the Western Front, with its massive numbers of injured, saw progress In the understanding and management of trauma and shock, and significant Improvement in the provision of anaesthesia and the training of anaesthesia providers. The result was Increased anaesthetic safety for the civilian population after the war and further development of anaesthesia and resuscitation as a specialised area of medicine.

The low percentage of men in nursing is not a problem outside of the United States or in the U.S. military, which, at 35%, has substantially more men in nursing than the civilian population. 1 In other countries—such as Jordan, New Zealand, the Philippines, and the United Kingdom—the percentage of men in nursing ranges from a high of 38% (in Jordan) to about 9% (in New Zealand). 2,3 In fact, because of the unprecedented surplus of male nurses in Jordan, that country restricted men's admissions into nursing schools to 30%. 2

The conduct of hostilities in urban areas is inherently difficult, particularly with respect to the protection of civilians. International humanitarian law places restraints on both attackers and defenders. While much is written about the obligations of attackers with respect to protecting civilians, much less attention has been paid to the defender's obligations. These obligations are routinely referred to as “passive precautions” or “precautions against the effects of attacks” and are codified in Article 58 of Additional Protocol I to the 1949 Geneva Conventions. Article 58 requires parties, “to the maximum extent feasible”, to remove civilians and civilian objects from the vicinity of military objectives, to avoid locating military objectives within or near densely populated areas, and to take other necessary precautions to protect civilians and civilian objects from the dangers resulting from military operations.Even though they are limited by only requiring those actions which are feasible, the obligations placed on the defender are far from trivial and, if applied in good faith, would certainly provide much needed protections to civilians in armed conflict, particularly in times of urban conflict. However, this ever-increasing urbanization is creating significant pressure on the doctrine of precautions in defence, stretching the “feasibility” standard beyond its capacity to adequately protect civilians. On the other hand, the emergence of advanced technology provides a mechanism for defenders to more easily and more fully comply with their obligations to segregate or protect the civilian population.For the customary obligation of “precautions against the effects of attacks” to maintain its effectiveness, particularly in urban areas of conflict, the understanding of feasibility and what is “practicable” in current urbanized armed conflicts will have to expand, increasing the practical responsibilities on the defender, including through the use of modern technology. Moreover, imposing criminal responsibility when appropriate and feasible precautions are not taken will rectify the perceived imbalance between the responsibilities of the attacker and those of the defender.

Background Invasive fungal infections (IFI) following traumatic injury are devastating complications that threaten life and limb. In military combat wounds, post-traumatic IFI patients have up to 6 times higher mortality rates and 2.6-5.1 times higher rate of high-level amputations compared to non-IFI patients, though no such data exists for the civilian population. This study is the first cohort to analyze a post-traumatic civilian population for IFI, its epidemiology and outcomes. Methods We conducted a single-center retrospective cohort study of all trauma patients over the age of 18 years admitted to a large tertiary referral hospital between 2004 to 2015 who required surgery for their injury and had operative cultures submitted from their wounds. Patient demographics, comorbid conditions, mechanisms of trauma, environmental exposures, and laboratory data were included for analysis. Patients with positive culture for fungus from a site compatible with IFI were considered IFI patients. Data was analyzed using descriptive statistics with p≤0.05 considered significant. Results Our cohort includes 1,107 patients that met inclusion criteria. Of these, 120 patients had a positive culture for fungus, 454 patients had a positive culture for bacteria and 533 patients had no positive culture from a site of interest. Basic patient demographics, geographical setting of the trauma, and anatomical site of injury were not significantly associated with having a positive fungal culture. Necrosis was present in 19 (15.8%) IFI vs. 74 (7.5%) non-IFI patients (p=0.002). Soil contamination of a wound was present in 6 (5.0%) IFI vs. 11 (1.1%) non-IFI patients (p=0.001). 55.8% of 120 IFI wounds penetrated below fascial layers compared to 26.7% of 987 non-IFI wounds (p< 0.001). Presence of IFI increased likelihood of requiring amputation (6.7% vs. 2.7%, p=0.02) and prolonged hospitalization >14 days (77.5% vs. 57.4%, p< 0.001) compared to those without. Conclusion IFI significantly increased patient risk for amputation and prolonged hospital length of stay following traumatic injury in a civilian population. Presence of IFI was associated with wounds penetrating below the fascial layer, presence of wound necrosis, and soil contamination of a wound. Disclosures Andrej Spec, MD, MSCI, Astellas (Grant/Research Support)Mayne (Consultant)Scynexis (Consultant)

Background: In the U.S. civilian population, sex differences have been identified in cardiovascular health; these differences have been used to inform care. Our objective is to determine i...

Background: Cranial firearm injuries (CFAIs) are expected to be frequent during warfare; however, it is becoming increasingly common among civilian population in our part of the world. These injuries are associated with significant morbidity and mortality in addition to financial loss. The objective of our study is to evaluate the pattern of gunshot injuries to cranium and their outcome. Methods: The study was conducted on 114 patients presenting with CFAIs to Jinnah Postgraduate Medical Centre, Karachi, Pakistan, between June 2015 and January 2019. Patients were evaluated with respect to age, gender, pattern of injury, Glasgow coma scale on arrival, radiological and clinical assessment, surgical intervention, and Glasgow outcome score measured at 6 months follow-up. Results: Among patients with cranial gunshot, injuries most were males (76.3%). More than 50% patients aged between 18 and 35 years. About 46.5% of patients presented with moderate traumatic brain injury commonly involving the temporal lobe (36.8%). Of total 114 patients, 84.2% were managed conservatively but wound debridement was done in all patients. At 6 months, the overall mortality in our patients was 33.3%. Patients with good outcome (GOS 4 and 5) were 30.7% and 35.9% patients had bad outcome (GOS 2 and 3). Complication rate was 14.9% and the most common complication was disseminated intravascular coagulation in 5.2%. Conclusion: Surgical intervention has no significant benefit over conservative management on long-term mortality and should be limited to patients with large intracranial hematomas and intraventricular hematomas causing hydrocephalus.

Studies have shown stress may lead to diabetes-related morbidities. In recent years during enhanced hostility periods, the population of Southern Israel experienced alert sirens and rocket fire on a daily basis. We investigated whether the exposure to these stressful circumstances, which peaked during three large military operations (MO), was associated with increased glucose levels among the civilian population. We included all fasting serum glucose tests taken between 2007–2014, of Clalit Health Services members in Southern Israel who had at least one fasting glucose test during an MO period and at least one test drawn at other times. We analyzed the association between MO periods and glucose using linear mixed-effects models. We included 408,706 glucose tests (10% during MO periods). Among subjects who reside in proximity to Gaza, glucose levels were 2.10% (95% CI 1.24%; 2.97%) higher in MO days compared to other times. A weaker effect was observed among subjects in more remote locations. In conclusion, we found stress to be associated with increased fasting glucose levels, especially among those who reside in locations in which the intensity of the threat is higher. Since glucose may be a marker of the population at cardiovascular risk, further studies are required.