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Multivariable calculus is a subject undertaken by engineering students as a core module at the freshman level. One of the intended learning outcomes (ILOs) in multivariable calculus is to gain an intuition for visualizing three-dimensional surfaces and deducing their properties. For students to visualize more complex multivariable calculus concepts, a virtual reality (VR) application has been created. Tapping on existing infrastructures, we investigate the effectiveness of visualization through VR usage vis-à-vis a two-dimensional digital screen. We have conducted a controlled trial on a group of N = 119 students across two groups. The first group (control group) comprises students who participated in an online quiz (as a baseline test). The second group (treatment group) is given two sets of tests, the first is the same baseline test that the control group participated in, before administering the test questions on the VR platform (termed the treatment test) to the same group of students. Our analysis reveals that students, in general, perform better on questions pertaining to the identification of the sign of partial derivatives in the treatment test, but for other intended learning outcomes linked to other questions, students have performance similar to the baseline test. Furthermore, low-progress students in the treatment group exhibited improvement after the treatment. Our work here has the potential to be developed into a future-ready smart classroom through VR usage. [ABSTRACT FROM AUTHOR]

Background: Data regarding the effect of prehospital blood administration to trauma patients during short-to-moderate time evacuations is scarce. The Israel Air Force Airborne Combat Search and Rescue is the only organization that deals with aeromedical evacuation for both military and civilian casualties in Israel and the only one with the ability to give blood in the prehospital setting.Methods: Data on packed red blood cells (PRBCs) administration in the evacuation missions from January 2003 to June 2010 were analyzed and actual transfusion practice was compared to clinical practice guidelines (CPGs).Results: Over the studied 101 months, a total of 1,721 patients were evacuated by Combat Search and Rescue. Of these, 87 (5.1%) trauma patients were transfused with PRBC. Demographics included 83% male and 17% female with a median age of 23 years. Main mechanisms of injury included gunshot wounds (36%), motor vehicle accidents (28%), and blast injuries (24%) with an average of 2.6 injured regions per casualty. The most commonly injured body regions included lower extremities (52%), chest (45%), and abdomen (38%). Overall, 10 (11%) casualties died. Lifesaving intervention included tourniquets (27%), endotracheal intubation (24%), tube thoracostomy (24%), and needle thoracostomy (21%) times. For 98% of the patients, clinical judgment led to administration of red blood cells before indicated by the CPG. The heart rate tended to decrease during the evacuation, whereas there was no clear trend in systolic or diastolic blood pressure or shock index.Conclusions: In our aeromedical experience, transfusion of PRBCs for trauma patients was safe, feasible, and most likely beneficial. PRBCs were administered according to the flight surgeons' clinical judgment and not in complete adherence to CPGs in most cases. Data collected from this and similar studies worldwide have led to change in CPGs with the shift from hypertensive resuscitation to hypotensive-hemostatic Remote Damage Control Resuscitation. [ABSTRACT FROM AUTHOR]

Background: Point of injury needle thoracostomy (NT) for tension pneumothorax is potentially lifesaving. Recent data raised concerns regarding the efficacy of conventional NT devices. Owing to these considerations, the Israeli Defense Forces Medical Corps (IDF-MC) recently introduced a longer, wider, more durable catheter for the performance of rapid chest decompression. The present series represents the IDFMC experience with chest decompression by NT. Methods: We reviewed the IDF trauma registry from January 1997 to October 2012 to identify all cases in which NT was attempted. Results: During the study period a total of 111 patients underwent chest decompression by NT. Most casualties (54%) were wounded as a result of gunshot wounds (GSW); motor vehicle accidents (MVAs) were the second leading cause (16%). Most (79%) NTs were performed at the point of injury, while the rest were performed during evacuation by ambulance or helicopter (13% and 4%, respectively). Decreased breath sounds on the affected side were one of the most frequent clinical indications for NT, recorded in 28% of cases. Decreased breath sounds were more common in surviving than in nonsurviving patients. (37% v. 19%, p < 0.001). A chest tube was installed on the field in 35 patients (32%), all after NT. Conclusion: Standard NT has a high failure rate on the battlefield. Alternative measures for chest decompression, such as the Vygon catheter, appear to be a feasible alternative to conventional NT. [ABSTRACT FROM AUTHOR]

An artificial-neural-networks-based in-process tool wear prediction (ANN-ITWP) system has been proposed and evaluated in this study. A total of 100 experimental data have been received for training through a back-propagation ANN model. The input variables for the proposed ANN-ITWP system were feed rate, depth of cut from the cutting parameters, and the average peak force in the y-direction collected online using a dynamometer. After the proposed ANN-ITWP system had been established, nine experimental testing cuts were conducted to evaluate the performance of the system. From the test results, it was evident that the system could predict the tool wear online with an average error of ±0.037 mm. Experiments have shown that the ANN-ITWP system is able to detect tool wear in 3-insert milling operations online, approaching a real-time basis . [ABSTRACT FROM AUTHOR]

The article proposes a study to develop an in-process tool wear monitoring (ITWM) system using cutting force as a sensing signal and integrating the multiple regression approach as the decision mechanism. In order to accomplish this goal, this ITWM system requires an integration of sensing and decision-making techniques. For any in-process machining monitoring system, the sensing techniques are used to give the machine the capability of seeing that is equivalent to the human's eyes. In this study, the ITWM system that integrated multiple-linear regression can be named the multiple-linear-regression-based in-process tool wear prediction system. The multiple-linear-regression model of tool wear, the MLR-ITWP system was built with the help of the statistical software package JMP. Once the regression model was formed, the MLR-ITWP system was built. To evaluate the performance of the developed system, nine sets of data were used for testing. A new in-process tool wear prediction system in milling operations had been set up, developed, and examined. The system showed the capability of predicting tool wear during the machining process. This study provides the authors with a better position in continuing the tool monitoring system to enable an automated machining process for more efficient manufacturing in the future.

The possibility that a simple model of interaction between a localized vortical disturbance and laminar uniform unbounded shear flow is capable of reproducing the generation mechanism and characteristics of coherent structures naturally occurring in wall bounded turbulent flows is examined numerically. Gaussian and toroidal vortices are used as the initial disturbances. The concentrated vorticity field of the Gaussian vortex is defined by a single length scale δ, which is assumed to be much smaller than the characteristic scale of the base flow. The toroidal disturbance is defined by two length scales r0 and δ, corresponding to the radius and thickness of the torus, respectively. For a small-amplitude Gaussian disturbance, the numerical solution of the full Navier-Stokes equations agrees well with the analytical solution of the linearized vorticity equation. Accordingly, the disturbance, independent of its initial geometry, eventually evolves into a pair of counter-rotating quasi-streamwise vortices and an associated low-speed streak. Moreover, an optimal range of r0/δ is found for which the spanwise separation of the two elongated vortical regions, expressed in wall units, corresponds well to the spacing of streaks and hairpin vortex legs observed in turbulent flows. Preliminary results show that a large-amplitude disturbance, independent of its initial geometrical shape, eventually evolves into a hairpin vortex. [ABSTRACT FROM AUTHOR]

Background: Many scoring systems, algorithms, and guidelines have been developed to aid in the evaluation and diagnosis of acute appendicitis (AA). Many of these algorithms advocate against the routine use of radiological investigations when there is a high clinical suspicion of AA. However, there has been a significant rise in the use of imaging techniques for diagnosing AA in the past two decades. This is a national study aimed at assessing the adherence of residents assigned to the emergency department to the clinical guidelines for diagnosing AA. Methods: We introduced a case study of a male patient with highly suspicious clinical findings of AA to all surgical and emergency medicine residents assigned to the emergency department with the autonomy to make critical decisions to determine the preferred way of diagnosing AA. Results: A total of 62.4% of all relevant residents participated in this survey; 69.6% reported that the Alvarado score was eight or higher, and 82.1% estimated that the next step recommended by most clinical guidelines was appendectomy without further abdominal imaging tests. However, 83.4% chose to perform an imaging test to establish the diagnosis of AA. Conclusions: Our study revealed a notable non-adherence to clinical guidelines in diagnosing AA. Given the significance of these guidelines, we assert that adopting medical recommendations should not solely depend on individual education but should also be incorporated as a departmental policy. [ABSTRACT FROM AUTHOR]

Introduction: Combat ground maneuvers consist of various platforms and have several environmental characteristics, influenced by the terrain, the operational mission, and the force's capabilities. This study assesses data on injuries sustained during urban warfare, aiming to evaluate the relationship between injury characteristics, maneuver platform, and personal protective gear on the battlefield.Materials and Methods: IDF soldiers injured infantry soldiers from the "Cast Lead" and the "Protective Edge" operations in the Gaza Strip (2008-2009 and 2014, respectively) were divided into four groups according to the maneuver platform and the environment: mounted infantry (armored and unarmored vehicle) and dismounted infantry (urban and open area). The primary outcome was the severity of the injury, and the secondary outcome was the injured body part.Results: Overall, 588 casualties were included in the final analysis, of whom 507 were dismounted infantry soldiers (265 in open terrain and 242 in urban area) and 81 were mounted infantry soldiers (20 in unarmored and 61 were injured in armored vehicles). The Injury Severity Score was similar in all subgroups. Open terrain subgroups were found to have fewer head injuries and higher levels of lower extremity injuries, similar to the unarmored vehicle group. More facial injuries were documented in the urban area group.Conclusions: The Injury Severity Score was not influenced by environmental protection. Although we found differences in the injured body parts, further studies on the exact mechanism of injury are needed to elucidate further the relationship and differences between the various platforms used and injuries seen in urban warfare, aiming for tailor-made protection. [ABSTRACT FROM AUTHOR]

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

Background: Point of injury needle thoracostomy (NT) for tension pneumothorax is potentially lifesaving. Recent data raised concerns regarding the efficacy of conventional NT devices. Owing to these considerations, the Israeli Defense Forces Medical Corps (IDF-MC) recently introduced a longer, wider, more durable catheter for the performance of rapid chest decompression. The present series represents the IDF-MC experience with chest decompression by NT.Methods: We reviewed the IDF trauma registry from January 1997 to October 2012 to identify all cases in which NT was attempted.Results: During the study period a total of 111 patients underwent chest decompression by NT. Most casualties (54%) were wounded as a result of gunshot wounds (GSW); motor vehicle accidents (MVAs) were the second leading cause (16%). Most (79%) NTs were performed at the point of injury, while the rest were performed during evacuation by ambulance or helicopter (13% and 4%, respectively). Decreased breath sounds on the affected side were one of the most frequent clinical indications for NT, recorded in 28% of cases. Decreased breath sounds were more common in surviving than in nonsurviving patients. (37% v. 19%, p < 0.001). A chest tube was installed on the field in 35 patients (32%), all after NT.Conclusion: Standard NT has a high failure rate on the battlefield. Alternative measures for chest decompression, such as the Vygon catheter, appear to be a feasible alternative to conventional NT. [ABSTRACT FROM AUTHOR]

Introduction: Musculoskeletal injuries dominate warfare-related trauma and differ from civilian settings in higher hospitalization costs, morbidity, and mortality. Partly due to introduction of personal protective equipment in the Israel Defence Force (IDF) to minimize head and torso injuries while the extremities remained unprotected. This study describes military extremity injury patterns, prehospital treatment and injury sequela regarding return-to-duty and disability compensation.Methods: This retrospective study examined cases of battle and non-battle trauma casualties treated by the IDF Medical Corps from 2013 to 2020. Data from the IDF Trauma Registry (IDF-TR) was merged with The Israeli National Trauma Registry (INTR). Cases with high morbidity discharged from military service were compared with lower morbidity patients who returned to active duty service.Results: Out of 1360 injured soldiers, 280 (20.6%) were found to have isolated limb fractures (ILFs). High morbidity casualties had more open fractures (63% vs. 42%) and higher involvement of lower extremities (79% vs. 58%) (p < 0.001), higher rates of tourniquets use (28% compared to 9%, p < 0.001), external fixation (34% vs. 19%, p < 0.001) and amputations (9% vs. 1%, p = 0.003), required more rehabilitation (34% vs. 7%, p < 0.001), and had 46% medical disabilities compared to 24% with low morbidity (p < 0.001).Conclusions: ILFs are associated with significant morbidity and disability. High morbidity is associated with high energy, scar-producing, lower-extremity open fractured limbs treated by tourniquets. Future studies should evaluate whether junctional or extremity protective gear is combat feasible and whether introducing Clinical Practice Guidelines to manage suspected limb fractures can decrease morbidity rates and improve return to duty. [ABSTRACT FROM AUTHOR]

Several options to treat hospitalized severe COVID-19 patients have been suggested. The study aimed to describe survival in patients treated with convalescent COVID plasma (CCP) and to identify in-hospital mortality predictors. This prospective cohort study examined data from 112 severe COVID-19 patients hospitalized in the Corona Departments in an acute care hospital who received two units of CCP (at least one of them high-titer). Demographic and medical data was retrieved from the patients' electronic health records (EHR). Possible predictors for in-hospital mortality were analyzed in a univariate analysis and those found to be clinically significant were further analyzed in a multivariable analysis. Median age was 67 years (IQR 55–74) and 66 (58.9%) of them were males. Of them, 20 (17.9%) died in hospital. On multivariable analysis diabetes mellitus (p = 0.004, OR 91.54), mechanical ventilation (p = 0.001, OR 59.07) and lower albumin levels at treatment (p = 0.027, OR 0.74) were significantly associated with increased in-hospital mortality. In our study, in-hospital mortality in patients receiving CCP is similar to that reported for the general population, however certain variables mentioned above were associated with increased in-hospital mortality. In the literature, these variables were also associated with a worse outcome in patients with COVID-19 who did not receive CCP. As evidence points toward a benefit from CCP treatment in immunocompromised patients, we believe the above risk factors can further define COVID-19 patients at increased risk for mortality, enabling the selection of candidates for early treatment in an outpatient setting if possible. [ABSTRACT FROM AUTHOR]

1-Aminobenzotriazole (ABT) is a non-isoform specific, time-dependent inhibitor of cytochrome P450 (CYP) enzymes used extensively in preclinical studies to determine the relative contribution of oxidative metabolism. Although ABT has been widely used, the extent and duration of its inhibitory effect is not well understood. The purpose of this study is to characterize ABT inhibition of CYP in rats at both the hepatic and intestinal levels. In vivo studies using midazolam (p.o. and i.v.), as a probe for CYP activity, demonstrated that CYP inhibition was not complete even at the highest dose (300 mg/kg). Additional in vivo studies demonstrated that even at 26 h following ABT administration, there was significant CYP inhibition remaining. In vitro studies, conducted in both rat liver microsomes and rat hepatocytes, confirm that ABT is a time-dependent inhibitor of rat CYP orthologs. However, in rat liver microsomes, there was more than 15% CYP activity remaining following a 60 min preincubation at 2 m m ABT and 5-10% of CYP activity was remaining in rat hepatocytes suspended in rat plasma following a 60 min preincubation at 2 m m ABT. 1-Aminobenzotriazole is a useful tool in elucidating the oxidative component of metabolism in preclinical species; however, conclusions made from the preclinical use of ABT should not operate under the assumption that CYP enzymatic activity is completely inhibited. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Introduction: Obtaining vascular access is of paramount importance in trauma care. When peripheral venous access is indicated but cannot be obtained, the intraosseous route represents an alternative. The Bone Injection Gun (BIG) is the device used for intraosseous access by the Israeli Defense Force (IDF). The purpose of this study is to assess the success rate of intraosseous access using this device.Method: The IDF Trauma Registry from 1999 to 2012 was searched for patients for whom at least 1 attempt at intraosseous access was made.Results: 37 attempts at intraosseous access were identified in 30 patients. Overall success rate was 50%. No differences in success rates were identified between different care givers. Overall mortality was 87%.Conclusion: The use of BIG in the IDF was associated with a low success rate at obtaining intraosseous access. Although inability to achieve peripheral venous access can be considered an indicator for poor prognosis, the high mortality rate for patients treated with BIG can also stand for the provider's low confidence in using this tool, making its use a last resort. This study serves as an example to ongoing learning process that includes data collection, analysis, and improvement, constantly taking place in the IDF. [ABSTRACT FROM AUTHOR]

Background and Objectives: Passive immunization using investigational COVID‐19 convalescent plasma (CCP) is a promising therapeutic strategy and could improve outcome if transfused early and contain high levels of anti‐SARS‐CoV‐2 antibodies. We report the management of a national CCP collection and distribution program in Israel. Materials and Methods: From 1 April 2020 to 15 January 2021, 4020 volunteer donors donated 5221 CCP units and 837 (20.8%) donors donated more than once. Anti‐nucleocapsid IgG antibodies were determined using chemiluminescent immunoassay method (Abbott). A statistical model based on repeated IgG tests in sequential donations was created to predict the time of antibody decline below sample/cut‐off (S/CO) level of 4.0. Results: Ninety‐six percent of CCP donors suffered a mild disease or were asymptomatic. Older donors had higher antibody levels. Higher antibody levels (S/CO ≥4) were detected in 35.2% of the donors. Low positive (S/CO ≥1.4–3.99) were found in 37%, and 27.8% had undetectable antibodies (S/CO ≤1.4). The model predicted decrease antibody thresholds of 0.55%/day since the first CCP donation, providing guidance for the effective timing of future collections from donors with high antibody levels. Conclusions: An efficient CCP collection and distribution program was achieved, based on performing initial and repeated plasma collections, preferably from donors with higher antibody levels, and only antibody‐rich units were supplied for therapeutic use. The inventory met the quantity and quality standards of the authorities, enabled to respond to the growing demand of the medical system and provide a product that may contribute to improve prognosis in patients with COVID‐19. [ABSTRACT FROM AUTHOR]

Introduction: The Israeli Defense Forces Medical Corps (IDF-MC) implemented the use of low-titer group O whole blood (LTOWB) as the first-choice resuscitation fluid in the IDF airborne Combat Search and Rescue Unit (IDF-CSAR) for aerial evacuation of both military and civilian casualties in June 2018 for injured patients with hemorrhagic shock and at least one of the following: systolic blood pressure <90 mm Hg, heart rate >130 beats/min, deterioration of consciousness without head injury or hemoglobin concentration ≤7 g/dL. Method: All casualties treated with LTOWB by IDF-CSAR providers from June 2018 to January 2021 were included. Demographic and prehospital treatment data were collected in order to check compliance and adherence to the IDF-MC guidelines. This is a follow-up retrospective report. Results: Overall, 1,608 LTOWB units were supplied to the IDF-CSAR during the study period. Of these, 33 were transfused to 27 casualties; 17 (69%) with blunt injury, 8 (29.6%) with penetrating injuries, and 1 (3.7%) with gastrointestinal bleeding without trauma. The leading cause of injury was motor vehicle accidents. A total of 23 casualties received 1 unit of LTOWB, 3 received 2 units and 1 patient received 4 units. Two casualties were children. The median heart rate was 120 beats/min, 8 (29.6%) casualties had heart rates >130 beats/min. Median systolic blood pressure was 95 mm Hg, 7 (26%) casualties had blood pressure <90 mm Hg. The median Glasgow Coma Score was 14. No adverse reactions were documented following the administration of LTOWB. 77.8% of patients received LTOWB in adherence to the guidelines. Conclusion: Appropriate administration of LTOWB has improved over time in IDF-CSAR. Using LTOWB is feasible and simpler than administering packed red blood cells and plasma concurrently. Further efforts are needed to introduce LTOWB in other prehospital and in-hospital scenarios, with an increase in the maximum antibody titer threshold, to meet the expected increase in demand. [ABSTRACT FROM AUTHOR]

Abstract: Background: In Israel, the Airborne Rescue and Evacuation Unit (AREU) provides prehospital trauma care in times of peace and during times of armed conflict. In peacetime, the AREU transports children who were involved in motor vehicle collisions (MVC) and those who fall off cliffs (FOC). During armed conflict, the AREU evacuates children who sustain firearm injuries (FI) from the fighting zones. Objective: To report on prehospital injury severity of children who were evacuated by the AREU from combat zones. Methods: A retrospective comparative analysis was conducted on indicators of prehospital injury severity for patients who had MVC, FOC, and FI. It included the National Advisory Committee for Aeronautics (NACA) score, the Glasgow Coma Scale (GCS) score on scene, and the number of procedures performed by emergency medical personnel and by the AREU air-crew. Results: From January 2003 to December 2009, 36 MVC, 25 FOC, and 17 FI children were transported from the scene by the AREU. Five patients were dead at the scene: 1 (2.8%) MVC, 1 (4%) FOC, and 3 (17.6%) FI. Two (11.7%) FI patients were dead on arrival at the hospital. MVC, FOC, and FI patients had mean (±SD) NACA scores of 4.4 ± 1.2, 3.6 ± 1.2, and 5 ± 0.7, respectively. Mean (±SD) GCS scores were 8.9 ± 5.6, 13.6 ± 4, and 6.9 ± 5.3, respectively. Life support interventions were required by 29 (80.6%) MVC, 3 (12%) FOC, and 15 (88.2%) FI patients. Conclusions: In the prehospital setting, children evacuated from combat zones were more severely injured than children who were transported from the scene during peacetime. [Copyright &y& Elsevier]

Background. Hydatid cyst disease is a zoonosis caused by Echinococcus genera. The disease is endemic to certain rural areas in the world. Operative treatment is the main component in curing hydatid cysts of the liver. Objective. Describing the unique characteristics of the hydatid cyst patients in Israel, a nonendemic country. Methods. Data was collected form 29 patients treated operatively in Rabin Medical Center from 1994 to 2007. Results. The study included 18 females and 11 males with an average age of 54.9 years. Fifty-two% of the patients immigrated as children from Arab countries to Israel, 21% were Arab-Israelis leaving in the north and center of Israel, and 24%immigrated from the former Communist Bloc. Pericystectomy was performed in 20/29, and cyst unroofing was performed in 9/29. Hydatid cysts average size was 10.7 cm, and the cysts were located in the right or left or involved both lobes in 62%, 28%, and 10% of the lesions, respectively. Postoperative mortality occurred in one case, and severe morbidity occurred in 4 patients. Conclusions. Hydatid cyst disease in Israel is uncommon and is mostly seen in distinct 3 demographic groups. Despite the relatively low patient volume, good results in terms of morbidity, mortality, and recurrence were achieved. [ABSTRACT FROM AUTHOR]

Background: Several tools have been proven to predict the need for massive transfusion in trauma casualties, yet tools that are easily applicable in the prehospital setting for predicting the need for any blood product transfusion in the emergency department (ED) are lacking.Methods: A retrospective analysis of the cross-referenced Israeli Defense Forces Trauma Registry and the Israeli National Trauma Registry databases was performed to identify predictors for any blood product transfusion in the ED. A scoring system was developed after internally validating the prediction model. Division to risk groups was performed.Results: Seven variables (systolic blood pressure, heart rate, arterial oxygen saturation, trunk involvement, mechanism of injury, chest decompression, and tourniquet application) were included in the scoring system, ranging from 0 to 11.5. Risk groups for ED transfusion included very low (0.8%), low (3.2%), intermediate (8.5%), and high (31.2%) risk.Conclusion: A scoring system for predicting the need for any blood product transfusion in the ED was developed, based on information readily available in the early stages of prehospital resuscitation, allowing the receiving medical facility to prepare for that need. [ABSTRACT FROM AUTHOR]

In this paper, a quasistatic model is extended to describe the double ionization of Helium in intense linearly polarized field. Our numerical calculations reproduce the excessive double ionization and the photoelectron spectra observed experimentally both quantitatively and qualitatively. Moreover, the correlation between magnitude and direction of momentum in the polarization axis of two emission electrons has been studied. [ABSTRACT FROM AUTHOR]

Background: Neck injuries are an important cause of combat mortality and morbidity. This study's objective was to examine the characteristics and causes of neck injuries among Israel Defense Forces (IDF) and emphasize the best treatment protocols for the advanced life support providers in the prehospital combat environment.Methods: The IDF Trauma Registry (IDF-TR) includes prehospital data regarding casualties treated by the IDF's medical forces. This study was a retrospective, observational study that included all casualties who were injured between January 2006 and December 2018.Results: Between January 2016 and December 2018, 3294 casualties were recorded. During the study period, 1% (41/3,394) of all injury casualties in the registry were isolated neck injuries compared to 94% (3185/3,394) without neck injury. 42% (14/41) percent of the neck casualties were classified as urgent compared to 26% (830/3185, P = 0.09) in the no neck group. The most frequent type of injury mechanism in the neck casualties was penetrating injury (54% 22/41), mostly due to shrapnel (68% 15/22). 60% of neck injured personnel were injured during the 2nd Lebanon War and Operation Protective Edge in high-intensity conflicts. As for life-saving interventions, advanced airway interventions were performed in 12% of neck injured group (5/41) compared to 3% (104/3185, P = 0.02) in the no neck group. We revealed that cricothyroidotomy was performed in almost 10% (4/41) of neck injured casualties compared to only 1% (19/3185, P<0.0001) in no neck casualties. As for damage control resuscitation, neck injury casualties received higher amounts of Fresh Dried Plasma 7% (3/41) Vs. 1% (32/3185, P = 0.02) and Tranexamic acid 15% (6/41) Vs. 4% (124/3185, P = 0.01) compared to non-neck casualties.Conclusions: Military neck injuries are a significant cause of substantial disability and result in incompatibility with combat duties in previously healthy soldiers. Prompt medical care, especially urgent hemodynamic and airway management, is paramount in these injuries. Routine use of designated neck protection might lower the number of neck injuries, mitigate their severity, and even decrease mortality.Level Of Evidence: Level III (Retrospective study with up to two negative criteria). [ABSTRACT FROM AUTHOR]

Background: To describe ocular injuries sustained by Israeli Defense Forces (IDF) soldiers during low-intensity conflicts from 1998 to 2017, and to evaluate the use of protective eyewear.Methods: Retrospective analysis of data retrieved from two tertiary Israeli medical centers and the military trauma registry. The analysis included all IDF soldiers with ocular injuries who were referred to these centers between 1998 and 2017. Data on injury type, the use of protective eyewear, and interventions were retrieved and analyzed. Additional data regarding the use of protective eyewear and ocular injuries in 108 patients with head and neck injuries in one operation was analyzed.Results: A total of 126 soldiers, all males, mean age 22 (SD 5.3) years, sustained ocular injuries during low-intensity conflicts and treated at one of the two participating medical centers. Blast was the most common type of injury (n = 70/126, 56%), followed by shrapnel (n = 37/126, 29%) and gunshot wound (n = 12/126, 9%). The Birmingham Eye Trauma Terminology System (BETTS) injury pattern disclosed lamellar laceration (n = 34/126, 27%), intraocular foreign body (n = 27/126, 21%), penetrating (n = 10/126, 8%), and perforating (n = 7/126, 6%) injuries. Average VA improved from 20/140 at presentation to 20/60 after surgical or conservative intervention, the median VA improved from 20/40 to 20/30 (P < 0.001). Forty-nine patients (49/126, 39%) had poor visual outcome. The mean follow-up lasted 22 (SD 31) months. The use of protective eyewear was correlated with better initial VA(20/30 vs 20/217, P = 0.07). Among 108 patients with head and neck injuries, there was a higher rate of ocular injuries in the group of patients who did not use protective eyewear (n = 26/73, 36% vs n = 4/35, 11%, P = 0.016).Conclusions: Ocular injuries are common occurrences in low-intensity conflicts. The use of protective eyewear significantly reduces these injuries and should be mandatory.Level Of Evidence: III, prognostic. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to assess the current experience of Israel Defense Forces' (IDF) advanced life support (ALS) providers in performing life-saving interventions (LSIs), the rate of doctors and paramedics achieving the Trauma and Combat Medicine Branch benchmarks, and the rate of providers feeling confident in performing the interventions although not achieving the benchmarks.Methods: This study was based on an online survey delivered to IDF ALS providers. The survey investigated demographics; experience in performing endotracheal intubation, cricothyroidotomy, tube thoracostomy, and intraosseous access on human patients; and confidence in performing these LSIs. All benchmarks chosen referred to the number of times performed in the previous year. The benchmarks were 20 for intubation, 3 for cricothyroidotomy, 4 for tube thoracostomy, and 3 for intraosseous access.Results: During the survey period, 175 IDF ALS providers started the survey, but only 138 (79%) completed it, 93 (67%) of them were paramedics. Doctors had higher rates than paramedics of failing to achieve the benchmarks for intubation (96 vs. 57%, P < .001) and intraosseous access (100 vs. 66%, P < .001). All respondents failed to achieve the benchmark for cricothyroidotomy, and all but one paramedic failed to achieve the tube thoracostomy benchmark. Doctors had lower rates of high confidence when failing to achieve the benchmark for intubation (35 vs. 64%, P = .008) and intraosseous access (7 vs. 31%, P = .005) compared to paramedics.Conclusion: IDF ALS providers have alarmingly limited experience in performing LSIs. Many of them are confident in their ability despite not achieving evidence-based benchmarks. Additional training is required, maybe as a part of an annual medical fitness test. [ABSTRACT FROM AUTHOR]

Introduction: Throughout history, underground systems have served military purposes in both offensive and defensive tactical settings. With the advance of underground mining, combat tactics, and weapon systems, providing medical support in the subterranean battlefield is a constantly growing challenge. This retrospective cohort study describes the Israeli Defense Force (IDF) Medical Corps experience with treating casualties from underground warfare, as recorded in the IDF Trauma Registry.Methods: A retrospective cohort study of all casualties engaged in underground warfare, between the years 2004-2018. Medical data were extracted from the IDF Trauma Registry and tactical data were obtained from operational reports. An expert committee characterized the most prevalent challenges. Recommendations were based on a literature review and the lessons learned by the IDF experience.Results: During the study period, 26 casualties were injured in the underground terrain. Of casualties, 12 (46%) due to blast injuries, 9 (35%) were due to smoke inhalation, and 5 (19%) due to crushing injuries. All were males, and the average age was 21.6 years. Ten (38%) were killed in action (died before reaching a medical facility). All 16 casualties reaching the hospital survived (Table I). The expert committee divided the most common challenges into three categories-tactical, environmental, and medical. An overview of medical response planning, common injuries, and designated combat casualty care are discussed below. As in all combat casualty care, the focus should be on safety, bleeding control, and rapid evacuation.Conclusion: To plan and provide medical support, a thorough understanding of operational planning is essential. This manuscript presents the evolution of underground warfare, tactical and medical implications, environmental hazards, and common casualty care challenges. [ABSTRACT FROM AUTHOR]

Introduction: The most common cause of preventable death on the battlefield is significant blood loss, eventually causing decrease in tissue oxygen delivery. Pulse oximeters (POs) are widely used by the Israeli Defense Forces to obtain fast and noninvasive information about peripheral oxygen saturation (SpO2). However, POs are produced by different manufacturers and therefore include different sensors and are based on distinctive algorithms. This makes them susceptible to different errors caused by factors varying from environmental conditions to the severity of injury. The objectives of this study were to compare the reliability of different devices and their accuracy under various conditions.Material and Methods: Six POs underwent performance analysis. The finger-based category included: MightySat by Masimo, Onyx II by Nonin, and CMS50D by Contec. The handheld category comprised: RAD5 by Masimo, 9847 model by Nonin, and 3301 model by BCI. Several environmental and physiological parameters were altered using the ProSim8 simulator by Fluke biomedical, forming unique test cases under which the devices were tested in stationary and motion conditions.Results: All finger-based POs showed higher error rates of PO SpO2 and heart rate measurements in motion conditions, regardless of the manufacturer. However, newer devices in the handheld category were not affected. Results presented in Phase II showed that the SpO2 measurement error in all the devices was affected by pigmentation. However, the CMS50D, considered a low-cost device, had a significantly higher error size than other devices. In the devices that were influenced both by pigmentation and the finger cleanliness factors, the combined detected error size was clinically significant. The pigmentation, ambient light, and finger cleanliness also had a significant effect on the heart rate measurement in the CMS50D model, unlike the handheld devices, which were not affected. During Phase II, neither the Nonin nor the Masimo devices were deemed to have a significant advantage.Conclusion: Considering measurement limitations of POs used is extremely important. Use of handheld devices should be favored for use in motion conditions. Technologically advanced and/or recently developed devices should be preferred because of evolving algorithms, which decrease or eliminate the error factors. The "dirty finger" effect on the measurement error cannot be neglected and therefore the action of finger cleaning should be considered part of the treatment protocol. [ABSTRACT FROM AUTHOR]

Introduction: A variety of factors influence the motivation to choose a medical career; however, the influence of premedical experiences on health professional trainees' choices is a neglected one. We hypothesize that medical exposure during service in the Israeli Air Force special operations forces (SOFs) has an impact on motivation for medical studies. The Israeli scenario, in which career choice is anteceded by substantial military experience, allows us to examine this hypothesis.Materials and Methods: We conducted a retrospective cohort study among physicians and medical students who served as operators in the Israeli Air Force SOF; Unit 669 (an airborne combat search and rescue unit), and Shaldag (an airborne SOF unit). All medical students and physicians enlisted between January 2001 and December 2010 were eligible for enrollment.Results: Of over 700 operators screened, 3.7% of Shaldag veterans and 11.1% of Unit 669 veterans had started or finished medical school (P-value < 0.001). Overall, 49 veterans answered the questionnaire and enrolled in the study, of whom 17 (34.7%) were Shaldag veterans and 32 (65.3%) were Unit 669 veterans. Subjective questions implied a significant effect of the service in Unit 669 on career choice. Paramedics had a relative risk of becoming physicians of 7.37 when compared to nonparamedic operators, irrespective of their original unit.Conclusions: Medical exposure of Unit 669 operators during military service significantly contributed to their motivation for becoming physicians. Thus, military service in this setting acts de facto as an effective medical immersion program. This adds another factor to the myriad of factors that motivate young adults in their choice of a medical career. [ABSTRACT FROM AUTHOR]

Background Routine assessments of lower urinary tract symptoms (LUTS) include standard uroflowmetry (UF), which is labour and equipment intensive to perform, and stressful and unnatural for patients. An ideal test should be accurate, repeatable, affordable and portable. Objective To evaluate the accuracy of a machine-learning (ML) augmented audio-uroflowmetry (AF) algorithm in predicting urinary flows. Subjects and methods This pilot study enrolled 25 healthy men without LUTS, who were asked to void into a gravimetric uroflowmeter. A smartphone recorded the voiding sounds simultaneously. Paired uroflow and audio parameters were used to train an ensemble ML model to predict urinary flows from voiding sounds. Pearson's correlation coefficient was used to compare UF with AF values. Statistical significance was defined as p<0.05. Results A total of 52 voiding session were captured, of which n=35 were used for training and n=17 for testing the algorithm. Each voiding session was divided into 0.1 s frames, resulting in >300 analysable datapoints per session. Pearson's coefficients showed strong correlations for flowtimes (r=0.96, p<0.0001), voided volumes (r=0.83, p<0.0001) and average flowrates (r=0.70, p=0.0019), and moderate correlation for maximal flowrate (r=0.69, p=0.0022). AF predicted flow patterns showed good agreement with UF tracings. The main limitations were the small participants sample size and use of a single smartphone type. Conclusions ML augmented AF can predict uroflow parameters with a good accuracy, and can be a viable alternative to standard UF. Further work is needed to develop this platform for use in real-life conditions and across genders. [ABSTRACT FROM AUTHOR]

Oral administration is the preferred route for drug delivery and its success is highly dependent on a compound's ADME properties, of which, permeability plays a major role. Therefore, permeability enhancers are an attractive area of research in the pharmaceutical industry. Recent data suggest that sodium N-[8-(2-hydroxybenzoyl) amino] caprylate (SNAC) is an effective permeability enhancer, yet the pharmacokinetic (PK) and systemic effects of SNAC are poorly understood, specifically its oral bioavailability and systemic effects on distribution, which could influence the safety of certain drugs. To answer these questions, both in vitro and in vivo studies were conducted. Of 3 permeability enhancers (SNAC, 4-CNAB, and 5-CNAC), SNAC was found to have the greatest effect on the absorption of cyanocobalamin in rats. It was also found that SNAC is orally bioavailable (almost 40%) when dosed to rats. Based on these findings, tool compounds were co-dosed in rats to further evaluate the systemic effects of SNAC. Oral co-dosing of SNAC with an intravenous infusion of 2 poorly brain penetrant compounds, quinidine, and gabapentin, did not increase brain ISF: plasma ratio or total brain:plasma ratio for either of these compounds, implying that SNAC is effective only in the intestine at pharmacologically relevant concentrations. [ABSTRACT FROM AUTHOR]

Knowledge of the outcomes of critically ill patients is crucial for health and government officials who are planning how to address local outbreaks. The factors associated with outcomes of critically ill patients with coronavirus disease 2019 (Covid-19) who required treatment in an intensive care unit (ICU) are yet to be determined. Methods: This was a retrospective registry-based case series of patients with laboratory-confirmed SARS-CoV-2 who were referred for ICU admission and treated in the ICUs of the 13 participating centers in Israel between 5 March and 27 April 2020. Demographic and clinical data including clinical management were collected and subjected to a multivariable analysis; primary outcome was mortality. Results: This study included 156 patients (median age = 72 years (range = 22–97 years)); 69% (108 of 156) were male. Eighty-nine percent (139 of 156) of patients had at least one comorbidity. One hundred three patients (66%) required invasive mechanical ventilation. As of 8 May 2020, the median length of stay in the ICU was 10 days (range = 0–37 days). The overall mortality rate was 56%; a multivariable regression model revealed that increasing age (OR = 1.08 for each year of age, 95%CI = 1.03–1.13), the presence of sepsis (OR = 1.08 for each year of age, 95%CI = 1.03–1.13), and a shorter ICU stay(OR = 0.90 for each day, 95% CI = 0.84–0.96) were independent prognostic factors. Conclusions: In our case series, we found lower mortality rates than those in exhausted health systems. The results of our multivariable model suggest that further evaluation is needed of antiviral and antibacterial agents in the treatment of sepsis and secondary infection. [ABSTRACT FROM AUTHOR]

Background: A walking blood bank (WBB) refers to the use of fellow combatants for battlefield blood donation. This requires pretesting combatants for infectious diseases and blood type. A fundamental prerequisite for this technique is that the donating soldier will suffer minimal physiological and mental impact. The purpose of the current study is to assess the effect of blood shedding on battlefield performance.Methods: This is a double-blind randomized control trial. Forty Israel Defense Forces combatants volunteered for the study. Participants underwent baseline evaluation, including repeated measurement of vital signs, cognitive evaluation, physical evaluation, and a strenuous shooting test. Three weeks after the baseline evaluation, subjects were randomized to either blood donation or the control group. For blinding purposes, all subjects underwent venous catheterization for the duration of a blood donation. Repeated vital signs and function evaluation were then performed.Results: Thirty-six patients were available for randomization. Baseline measurements were similar for both groups. Mean strenuous shooting score was 80.5 ± 9.5 for the control group and 82 ± 6.6 for the test group (p = 0.58). No clinically or statistically significant differences were found in tests designed to evaluate cognitive performance or physical functions. Vital signs taken multiple times were also similar between the test and control groups.Conclusions: Executive, cognitive, and physical functions were well preserved after blood donation. This study supports the hypothesis that a WBB does not decrease donor combat performance. The categorical prohibition of physical exercise following blood donation might need to be reconsidered in both military and civilian populations. [ABSTRACT FROM AUTHOR]

Background: The Israeli Defense Force Medical Corps (IDF-MC) recently implemented the use of low titer group O whole blood (LTOWB) in the airborne combat search and rescue unit (CSAR) for both military and civilian patients during transport to definitive care. LTOWB is preferentially used by the CSAR instead of red blood cell units and freeze-dried plasma (FDP) for patients with signs of hemorrhagic shock. Ten percent of group O donors were eligible to donate LTOWB as they had anti-A and -B IgM titers of <50.Methods: All patients treated by CSAR providers with LTOWB between July 2018 and June 2019 were included.Results: Between July 2018 and June 2019, eight patients have received 10 units of LTOWB. All patients suffered blunt injuries, 6 out of 8 (75%) of whom were due to motor vehicle accidents. Four patients (4 out of 8, 50%) received a single LTOWB unit, two patients (2 out of 8, 25%) received two units. Two pediatric patients received fewer than one unit of LTOWB. Median (range) heart rate was 130 (30-150) bpm, median systolic blood pressure was 107 (80-124) mmHg, and median Glasgow coma scale was 8 (on a scale of 3-15). For four (4 out of 8, 50%) patients, LTOWB was the only blood product used for volume resuscitation. All six adult patients were treated with 1 g of tranexamic acid at the point of injury.Conclusions: The CSAR has successfully implemented a LTOWB program for the pre-hospital treatment of bleeding patients, and as its experience grows this product will be made available to other units and in civilian hospitals. [ABSTRACT FROM AUTHOR]

Background: Early application of tourniquets has reduced injury death rates. At the end of 2013, the Israel Defense Forces Medical Corps completed a military-wide introduction of the Combat Application Tourniquet as the standard-issued tourniquet. The accompanying clinical practice guideline encouraged combat soldiers and medical teams towards a liberal use of tourniquets for extremity injuries, even when in doubt.Objectives: This study aimed to assess the effects of the wide introduction of advanced tourniquets on the rate of tourniquet applications, the type of tourniquet applied, and the differences in hospitalisation outcomes following the introduction.Methods: The study population was composed of hospitalised military casualties with an extremity injury treated by military medical teams between 2006 and 2015. Prehospital data were extracted from the Israel Defense Forces Trauma Registry and matched to corresponding hospital data from the Israeli National Trauma Registry. Two periods were compared: 2006-2013 "pre-intervention period" and 2014-2015 "post-intervention period".Results: A total of 1,578 casualties were recorded during the study period. Of these, 320 (20.3%) occurred between 2014-2015. Characteristics of casualties in the post-intervention period were similar to those in the pre-intervention period including the rate of traumatic amputations (2.5% vs 2.2%, p = 0.93) and Injury Severity Score of 16 or above (12.8% vs 14.9%, p = 0.40). The rate of tourniquet application was more than four-fold in the post-intervention period compared to the pre-intervention period (22.8% vs 5.5%, p < 0.001). Nevertheless, rates of in-hospital amputations (1.6% vs 1.6%, p = 1.00) and death (0.9% vs 1.3%, p = 0.53) were similar in the two periods.Conclusion: Following the IDF military-wide introduction of advanced tourniquets, the tourniquet application rate rose sharply, the use of old tourniquets ceased over time, and in-hospital amputation rate did not increase. These findings suggest that the awareness for haemorrhage control using advanced tourniquets rose. [ABSTRACT FROM AUTHOR]

Whole blood is the preferred product for resuscitation of severe traumatic hemorrhage. It contains all the elements of blood that are necessary for oxygen delivery and hemostasis, in nearly physiologic ratios and concentrations. Group O whole blood that contains low titers of anti-A and anti-B antibodies (low titer group O whole blood) can be safely transfused as a universal blood product to patients of unknown blood group, facilitating rapid treatment of exsanguinating patients. Whole blood can be stored under refrigeration for up to 35 days, during which it retains acceptable hemostatic function, though supplementation with specific blood components, coagulation factors or other adjuncts may be necessary in some patients. Fresh whole blood can be collected from pre-screened donors in a walking blood bank to provide effective resuscitation when fully tested stored whole blood or blood components are unavailable and the need for transfusion is urgent. Available clinical data suggest that whole blood is at least equivalent if not superior to component therapy in the resuscitation of life-threatening hemorrhage. Low titer group O whole blood can be considered the standard of care in resuscitation of major hemorrhage. [ABSTRACT FROM AUTHOR]

The in vitro haemostatic functions of fresh whole blood (FWB) are well preserved after cold storage. This study aimed to determine whether platelets derived from FWB and stored whole blood (SWB) contribute to clot formation in tissue injury after transfusion into coagulopathic rats with polytrauma/haemorrhage (T/H). The rats were resuscitated 1 h after trauma with FWB or SWB collected from green fluorescence protein (GFP) transgenic rats. After transfusion, a liver incision was made and the tissue was collected 10 min after injury to identify GFP+ platelets by immunohistochemistry. In comparison to FWB, platelet aggregation to adenosine diphosphate and protease-activated receptor-4 was reduced by 35% and 20%, and clotting time was shortened by 25% in SWB. After transfusion, SWB led to a significant increase in platelet activation as measured by an elevation of CD62P and phosphatidylserine expression. The platelets from SWB were in a higher activation state, and showed higher clearance rate and formation of platelet-leucocyte aggregates than those from FWB after transfusion. Platelets from both FWB and SWB were equivalently incorporated into the clot at the incisional site, as determined by co-localization of CD61 and GFP. This study suggests that SWB contributes to haemostatic function and is an effective alternative resource to treat trauma patients. [ABSTRACT FROM AUTHOR]

We report here structure-guided optimization of a novel series of NF-κB inducing kinase (NIK) inhibitors. Starting from a modestly potent, low molecular weight lead, activity was improved by designing a type 11/2 binding mode that accessed a back pocket past the methionine-471 gatekeeper. Divergent binding modes in NIK and PI3K were exploited to dampen PI3K inhibition while maintaining NIK inhibition within these series. Potent compounds were discovered that selectively inhibit the nuclear translocation of NF-κB2 (p52/REL-B) but not canonical NF-κB1 (REL-A/p50). [ABSTRACT FROM AUTHOR]

Abstract: The advancement of a series of ligand efficient 2-amino-[1,2,4]triazolo[1,5-a]pyridines, initially identified from high-throughput screening, to a JAK2 inhibitor with pharmacodynamic activity in a mouse xenograft model is disclosed. Display Omitted [Copyright &y& Elsevier]

[Display omitted] Spray dried amorphous solid dispersions (ASDs) stand as one of the most effective formulation strategies to address issues of low aqueous solubility when developing new chemical entities. An emerging research topic focusing on the formation of amorphous nanoparticles or nanodroplets from ASD formulations has attracted attention recently. These ASD nanoparticles can be highly beneficial and able to further increase oral bioavailability. The incorporation of surfactants in ASD formulations has been shown to facilitate the formation of these nanoparticles. Therefore, understanding the mechanism of surfactant-promoted nanoparticle formation becomes critical for the rational design of ASD formulations. This work demonstrated the importance of inclusion of the surfactant within the ASD composition for nanoparticle formation. In contrast, when a surfactant is added externally (e.g., by inclusion in the dosing vehicle), only a limited degree of nanoparticle formation was observed even at the optimized surfactant-to-drug ratios. A variety of different surfactants were also assessed for understanding their impact on ASD nanoparticle formation. The spray drying systems containing nonionic surfactants, Tween 80 and Vitamin E TPGS, produced higher amounts of in situ ASD nanoparticles when compared to an anionic surfactant, sodium lauryl sulfate (SLS). The ASD nanoparticles produced by the Genentech developmental compound, GDC-0334, were highly stable and retained their original particle size and amorphous feature for at least 18 h under biorelevant conditions. The high degree of nanoparticle formation from spray dried GDC-0334 containing Tween 80 combined with the superior physical stability of the nanoparticles also translated to enhanced in vivo performance in a rat pharmacokinetics study. [ABSTRACT FROM AUTHOR]

This paper presents an application of the Taguchi parameter design method to optimizing the surface finish in a turning operation. The Taguchi parameter design method is an efficient experimental method in which a response variable can be optimized, given various control and noise factors, and using fewer experimental runs than a factorial design. The control parameters for this operation included: spindle speed, feed rate, depth of cut, and tool nose radius. Noise factors included varying room temperature, as well as the use of more than one insert of the same specification, which introduced tool dimension variability. A total of 36 experimental runs were conducted using an orthogonal array, and the ideal combination of control factor levels was determined for the optimal surface roughness and signal-to-noise ratio. A confirmation run was used to verify the results, which indicated that this method was both efficient and effective in determining the best turning parameters for the optimal surface roughness. [ABSTRACT FROM AUTHOR]