Characteristics of injuries during the 2006 Lebanon conflict: a three-center retrospective study of survivors, 16 years after the conflict.

Background: Armed conflict injury is a growing public health concern, particularly in regions like the Middle East and North Africa (MENA). The protracted conflicts and political unrest in this region have led to a substantial number of injuries. Despite this, there is still limited understanding of the specific injury patterns stemming from conflicts, such as the 2006 Lebanon conflict. This study aimed to assess the characteristics and burdens of injuries resulting from this conflict, which occurred 16 years prior to this research. Methods: This retrospective study analyzed data of individuals affected by the 2006 Lebanon conflict, across three tertiary care centers. Demographics, injuries, complications, injury management, and hospitalization expenses were extracted from medical records and analyzed using SPSS version 29.0. Categorical variables were presented as counts and proportions, and continuous variables as mean ± standard deviation (SD). Hospital comparisons utilized chi-square or Fisher's exact tests for categorical variables, and one-way ANOVAs for continuous variables. Analysis was conducted from September to November 2023. Results: Across three hospitals, 341 patients were studied, comprising 73.6% males and 26.4% females. Among them, a notable proportion (57.3% males and 34.1% females) fell within the 18-39 age range. Children and adolescents under 18 years accounted for 15.9% of males and 25.9% of females. Blast-related injuries predominated, with 24.5% resulting from direct damage caused by explosive parts and 33.3% from blast wave forces. Extremity trauma occurred in 49.0% of patients, and head/neck trauma in 24.9%. Common injuries, including penetrating, musculoskeletal, and traumatic brain injuries affected 34.9%, 31.1, and 10.0% of patients, respectively. Wound repair, fracture treatment, and debridement were the most performed procedures on 15.5, 13.5 and 9.7% of the patients, respectively. The total cost of care was USD 692,711, largely covered by the Ministry of Public Health (95.9%). Conclusion: Conflict-related injuries significantly contribute to the global burden of disease. Therefore, there is a pressing need to improve national guidelines to prioritize life-threatening cases and potential long-term disabilities. Furthermore, enhancing electronic registry systems to collect clinical data on injured patients is essential for conducting research and better understanding the needs of conflict casualties.

[Current mortality from war injuries-A narrative review]. / Aktuelle Mortalität von Kriegsverletzungen ­ eine narrative Übersichtsarbeit.

BACKGROUND: The war in Ukraine has led to a strategic reorientation of the German Armed Forces towards national and alliance defense. This has also raised the need for medical and surgical adaptation to scenarios of conventional warfare. In order to develop appropriate and effective concepts it is necessary to identify those war injuries that are associated with a relevant primary and secondary mortality and that can be influenced by medical measures (potentially survivable injuries). OBJECTIVE: The aim of this selective literature review was to identify war injuries with high primary and secondary mortality. METHODS: A selective literature review was performed in the PubMed® database with the search terms war OR combat AND injury AND mortality from 2001 to 2023. Studies including data of war injuries and associated mortality were included. RESULTS: A total of 33 studies were included in the analysis. Severe traumatic brain injury and thoracoabdominal hemorrhage were the main contributors to primary mortality. Injuries to the trunk, neck, traumatic brain injury, and burns were associated with relevant secondary mortality. Among potentially survivable injuries, thoracoabdominal hemorrhage accounted for the largest proportion. Prehospital blood transfusions and short transport times significantly reduced war-associated mortality. CONCLUSION: Control of thoracoabdominal hemorrhage has the highest potential to reduce mortality in modern warfare. Besides that, treatment of traumatic brain injury, burns and neck injuries has a high relevance in reducing mortality. Hospitals of the German Armed Forces need to focus on these requirements.

Modified intermittent low negative pressure wound therapy for complex injuries: A case series.

INTRODUCTION AND IMPORTANCE: Combat wounds can be difficult to manage and can lead to disfigurement and infection. The closure of these wounds is crucial, as delayed closure also increases the risk of further complications. Military medicine has introduced negative pressure wound therapy, which modulates wounds perfectly through the microscopic and macroscopic configurations of the wound environment. It is expensive and not available worldwide, and several modifications using low cast materials were mentioned in literature. METHODS: We present a case series of four patients using the previously mentioned modified technique in combat wound management, and discuss the results, outcome, and justification for choosing this modality of treatment. All patients underwent a thorough debridement, followed by a modified negative pressure wound treatment for three weeks, employing readily available medical devices. RESULTS: All wounds healed successfully without complication and a simple closure was used to cover the resultant wound. CONCLUSION: Modified NPWT with limited resources is capable of promoting healing in conflict-related wounds through multifactorial properties and transforming reconstructive methods from complex to simple procedures in areas with a shortage of medical supplies and surgeons in addition to busy operating rooms.

[Current role of the latissimus dorsi flap in traumatology: Analysis of the activity of a plastic surgery department in a military hospital]. / Place actuelle du lambeau de grand dorsal en traumatologie : analyse de l'activité d'un service de chirurgie plastique en hôpital militaire.

Reconstructive surgery's workhorse, the latissimus dorsi flap is increasingly abandoned in favour of fasciocutaneous flaps. The purpose of this study was to analyse the methods used to perform this flap and the evolution of its indications in order to define its current place in traumatology. Forty-four cases were recorded retrospectively from January 2000 to December 2020 at HIA Percy, including 37 cases of free flaps, mainly performed for reconstruction of extensive loss of substance with bone and/or joint exposure. It was also performed in 10.8% of cases for salvage after failure of an alternative reconstruction solution. This analysis confirms the value of the latissimus dorsi flap in cases of significant substance loss in the lower limb, but also in burn patients for functional rehabilitation or to allow early rehabilitation.

[Treatment of the wounded from the war in Ukraine in the trauma networks of the DGU-Requirement, reality and motivation over the course of 18 months ]. / Versorgung von Kriegsverletzten aus der Ukraine in den Traumanetzwerken der DGU ­ Anspruch, Wirklichkeit und Motivation im Verlauf von 18 Monaten .

BACKGROUND: The war in Ukraine and the medical treatment of the wounded in hospitals in Germany has now represented a challenge for more than 15 months. The majority of trauma patients were distributed via the general holding center (GMLZ) at the Federal Office of Civil Protection and Disaster Assistance (BBK) by the cloverleaf concept and the trauma networks. Initially, numerous offers of assistance were promoted with great solidarity. For documentation of the current motivation situation and also for identification of the potential for improvement, a 2-stage survey of senior physicians in the organized and certified hospitals in the trauma networks was carried out. MATERIAL AND METHODS: An online survey of senior physicians of the trauma network hospitals was carried out with a semistructured written questionnaire in December 2022 and a follow-up survey during the Trauma Network Meeting (TNT) Congress in September 2023 in Frankfurt. RESULTS: Of the questionnaires 113 could be evaluated in December 2022 and 70 completed questionnaires in September 2023. The answers came from national trauma centers (ÜTZ), regional trauma centers (RTZ) and local trauma centers (LTZ) each with approximately one third. On average 2.7 patients were treated in all participating hospitals up to December and up to September no more than 5 in more than half of the hospitals overall. The main challenges for all participants at both points in time were the long hospital stay, the demanding pathogen status and sometimes unclarified or not completely covered reimbursement of costs. Nevertheless, more than 80% of the specialist departments received backing from their hospital sponsors as well as their personnel for the continuing treatment of the wounded from Ukraine. CONCLUSION: The medical and professional challenges in the treatment of the wounded from Ukraine are, as expected, characterized by the demanding injury patterns of the musculoskeletal system and the colonization with multidrug-resistant pathogens. This results in a long course of treatment, where the remuneration does not always cover the costs. Despite these challenges the solidarity in the hospitals of the trauma networks is unbroken. Simultaneously, there are numerous possibilities for improvement in order to enhance the prerequisites for future comparable humanitarian assistance jointly with politics.

Neglected war injuries: Reconstruction versus amputation.

INTRODUCTION: War injuries are remarkably different situations with profound severity and significant contamination compared to civilian injuries. Delayed definitive management makes the situation much more complicated. This study aimed to report the outcomes of limb reconstruction of neglected war injuries with a previous decision of amputation. PATIENTS AND METHODS: From 2010 to 2021, 1104 patients with war-related fractures from conflict-zone countries were referred to our center including 589 open tibial fractures. Of these tibial fractures, amputation had already been decided in 54 cases, and the patients were looking for a trial of reconstruction and avoiding amputation. These cases were included in the current study. The treatment approach was a single-stage procedure with bone and soft tissue reconstruction. RESULTS: This study included 54 male patients with a mean age of 26.3 years. Infection was the predominant feature in 43 cases (79.6 %). CT angiography revealed a one-vessel limb in 17 patients. Peripheral nerve injuries affected 15 patients. The mean time from injury to presentation was 8.5 weeks. The bone gap (2-13 cm) was evident in 44 cases. In four cases, the contralateral limb was amputated below the knee. There were associated injuries in nine cases. Rotational flap coverage was done in the same setting for 19 legs. Gastrocnemius flap was done in two cases. The mean follow-up duration was 45.1 months. The treatment methods included bifocal management (33 cases), trifocal management (17 cases), fibular transfer (two cases), and a mono-focal approach in two cases. All fractures healed successfully. The mean external fixation period was 7.6 months. Recurrence of infection occurred in three patients. A non-displaced refracture developed in one case. Five cases had a residual angular deformity. Eventually, the ASAMI bone and functional results were good in all cases. CONCLUSIONS: Neglected war injuries constitute a complex problem where amputation may be indicated. Our approach includes one-stage limb reconstruction with the corticotomy-first technique, conservative debridement of the docking site, concomitant osteoplastic procedure, and gradual distraction to tackle all the aspects of the problem. The good results obtained in the presented series make it a valid approach to avoid amputation in neglected war injuries.

Implications for future humanitarian aid missions: Lessons from point-of injury and hospital care for Syrian refugees.

BACKGROUND: Warzone humanitarian medical aid missions are infrequent and applying lessons from these missions is vital to ensuring preparedness for future crises. Between 2013-2018, the Israel Defense Forces Medical Corps (IDF-MC) provided humanitarian medical aid to individuals injured in the Syrian Civil War who chose to seek medical assistance at the Israeli-Syrian border. Patients requiring care surgical or advanced care were transferred to civilian medical centers within Israel. This study aims to describe the injury characteristics and management of hospitalized Syrian Civil War trauma patients over a five-year period. METHODS: Retrospective cohort analysis cross-referencing data from the IDF trauma registry, documenting prehospital care, and the Israel National Trauma Registry, documenting in-hospital care, between 2013 and 2018. Syrian trauma patients hospitalized in Israeli hospitals were cross-referenced between the two registries. Multivariable logistic regression was applied to identify independent factors associated with in-hospital mortality. RESULTS: Overall, 856 hospitalized trauma patients were included following definitive cross-matching. The median age was 23 years, and 93.3% were males. Blast (n = 532; 62.1%) and gunshot (n = 241; 28.2%) were the most common injury mechanisms. Injury Severity Score was ≥25 for 28.8% of patients and most common body regions with severe injury (Abbreviated Injury Scale≥3) were the head (30.7%) and thorax (25.0%). Intensive care unit admission was required for 40.1% of patients, and the median hospital stay was 13 days. In-hospital mortality was recorded for 73 (8.5%). Signs of shock upon emergency department admission and severe head injury were significantly associated with mortality in the adjusted model whereas age of <18 years was associated with decreased odds for in-hospital mortality. CONCLUSIONS: Trauma patients hospitalized in Israel following injuries sustained in the Syrian Civil War were characterized by a high prevalence of blast injuries with concomitant involvement of several body regions. Future missions should ensure preparedness for complex multi-trauma, often involving the head, and ensure high intensive care and surgical capacities.

Civilian war victims in Afghanistan: five-year report from the Kabul EMERGENCY NGO hospital.

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

New surgical technique in restoring the chin lost due to trauma by using a subperiosteal problast implant.

Bone grafts are the most common techniques used in maxillofacial surgery in restoring any lost or defective bone. This novel surgical technique utilizes a new modified problast to restore the contour of the defected chin.

Innovation of new surgical technique to contour the missing bone in the face of survivors of traffic and war injuries by new modified Problast painted with a mixture of biocompatible materials.

The bone grafts taken from the patient himself (Auto genius graft) to restore the contour of the lost facial bone lost is the ideal technique on the road to recovery from injuries of war or traffic accidents. This novel surgical procedure utilizes a new modified Problast painted with a mixture of a biocompatible materials to restore the lost parts of the zygomatic bones, due to traffic accidents, shell injuries, or bullet injuries.

Challenges in abdominal re-exploration for war casualties following on-site abdominal trauma surgery and subsequent delayed arrival to definitive medical care abroad - an unusual scenario.

BACKGROUND: During the Syrian civil war, patients were initially treated on-site in Syria and later transferred to medical centers in Israel. Relevant details concerning the exact nature of injury and medical/surgical care received in Syria were unavailable to clinicians in Israel. Many of these patients required abdominal re-exploration for obvious or suspected problems related to their injury. Our aim is to present our approach to abdominal trauma patients who survived initial on-site surgery and needed subsequent abdominal re-exploration abroad, in our medical center. METHODS: Clinical data from all medical records were retrospectively analyzed. Each patient underwent total body computerized tomography on arrival, revealing diverse multi-organ trauma. We divided the patient population who had abdominal trauma into 4 sub-groups according to the location in which abdominal surgical intervention was performed (abdominal surgery performed only in Syria, surgery in Syria and subsequent re-laparotomy in Israel, abdominal surgery only in Israel, and management of patients without abdominal surgical intervention). We focused on missed injuries and post-operative complications in the re-laparotomy sub-group. RESULTS: By July 2018, 1331 trauma patients had been admitted to our hospital, of whom 236 had suffered abdominal trauma. Life-saving abdominal intervention was performed in 138 patients in Syria before arrival to our medical center. A total of 79 patients underwent abdominal surgery in Israel, of whom 46 (33%) required re-laparotomy. The absence of any communication between the surgical teams across the border markedly affected our medical approach. Indications for re-exploration included severe peritoneal inflammation, neglected or overlooked abdominal foreign bodies, hemodynamic instability and intestinal fistula. Mortality occurred in 37/236 patients, with severe abdominal trauma as the main cause of fatality in 10 of them (4.2%), usually following urgent re-laparotomy. CONCLUSIONS: Lack of information about the circumstances of injury in an environment of catastrophe in Syria at the time and the absence of professional communication between the surgical teams across the border markedly dictated our medical approach. Our concerns were that some patients looked deceptively stable while others had potentially hidden injuries. We had no information on who had had definitive versus damage control surgery in Syria. The fact that re-operation was not performed by the same team responsible for initial abdominal intervention also posed major diagnostic challenges and warranted increased clinical suspicion and a change in our standard medical approach.

Better be prepared: the spectrum of neuropsychiatric impairment among Libyan war victims transferred to Germany for trauma rehabilitation.

BACKGROUND: The current Libyan civil war has originated many casualties, imposing medical challenges. War injuries are complex, requiring specialized knowledge and interdisciplinary assessment for adequate patient and intercultural management. METHODS: This retrospective study analyzed records of 78 Libyan patients admitted from July 2016 to November 2017 to neurological and trauma surgical departments of Krankenhaus Nordwest, Frankfurt, Germany. Issues of system preparation of the hospital, demographics, injury patterns and therapies were analyzed. The chi-squared test was used to analyze differences in injury patterns in explosion and gunshot injuries. RESULTS: Seventy-seven of seventy-eight patients were male (mean age 30.6 years). The patients received primary and secondary treatment in Tunisia (n = 39), Libya (n = 36) and Turkey (n = 23). Forty-eight patients had gunshot injuries, 37 explosion injuries, 11 both. Preparation for management of injuries included hygienic and isolation protocols, organization of interpreters and intercultural training. Patients presented with a broad variety of neurological, psychiatric and trauma surgical injuries. Fifty-six patients had sensory, 47 motor deficits. Nine reported headache, 5 vertigo, 13 visual impairment, 28 psychiatric symptoms. Eighteen patients had central nervous damage, 50 peripheral nervous damage. Central nervous damage was significantly more common in gunshot than explosion injuries (p = 0.015). Peripheral nervous damage was more common in explosion than gunshot injuries (p < 0.1). Fifty-one patients had polytrauma and 49 suffered from fractures. Therapy included surgical interventions (n = 56) and physiotherapy. Structured rehabilitation programs were often indicated. CONCLUSION: Specialized knowledge about war injuries and their management including hospital preparation and planning regarding infrastructure may be required anytime. Injuries include a broad variety of neurological, psychiatric and trauma surgical injuries. Therefore, an interdisciplinary approach is crucial.

[Terror awareness of 5th year medical students in the Mannheim reformed curriculum medicine plus]. / "Terror awareness" bei Humanmedizinstudierenden im 5. Jahr des Mannheimer Reformierten Curriculums Medizin plus.

BACKGROUND: The treatment of gunshot wounds and wounds caused by explosive devices as used in terrorist attacks is not currently an issue for education in most medical faculties; however, because of the increasing number of terrorist attacks in Germany and Europe this is becoming more important. The aim of this study was to evaluate the knowledge of dealing with and treatment of patients as victims of terrorist attacks of 5th year medical students at the Mannheim Medical Faculty of Heidelberg University prior to and after a specific seminar. METHODS: All students offered to participate voluntarily. Before the seminar a questionnaire with six questions about previous knowledge on terror awareness was distributed. After the seminar another almost identical questionnaire with six questions was distributed and completed by the students. RESULTS: A total of 97 medical students agreed to take part in the study of whom 53 were female. The mean age was 25.4 years (SD 2.75 years). After the seminar the students wanted to statistically significantly intensify the topic and believed that hospitals should be prepared for the treatment of victims of terrorism. CONCLUSION: With the seminar "Military Medicine", which was held as part of the Mannheim reformed curriculum of medicine (MaReCuM plus) in the 5th year, the interest of medical students could be significantly increased. This study could show for the first time that terrorist attacks and the resulting injuries have significant relevance for medical students. Consideration of this topic in all medical school curricula would be justified.

Injury patterns and causes of death in 953 patients with penetrating abdominal war wounds in a civilian independent non-governmental organization hospital in Lashkargah, Afghanistan.

Background: Management of penetrating abdominal war injuries centers upon triage, echeloned care, and damage control. A civilian hospital based in a war zone can rarely rely upon these principles because it normally has limited resources and lacks rapid medical evacuation. We designed this study to describe organ injury patterns and factors related to mortality in patients with penetrating abdominal war injuries in a civilian hospital in an active war zone in Afghanistan, examine how these findings differ from those in a typical military setting, and evaluate how they might improve patients' care. Methods: We reviewed the records of all patients admitted at the Lashkargah "Emergency" hospital with penetrating abdominal injuries treated from January 2006 to December 2016. Demographic and clinical data were recorded; univariate and multivariate analyses were used to identify variables significantly associated with death. Results: We treated 953 patients for penetrating abdominal injury. The population was mainly civilian (12.1% women and 21% under 14). Mean age was 23 years, and patients with blast injuries were younger than in the other groups. The mechanism of injury was bullet injury in 589 patients, shell injury in 246, stab wound in 97, and mine injury in 21. The most frequent abdominal lesion was small bowel injury (46.3%). Small and large bowel injuries were the most frequent in the blast groups, stomach injury in stab wounds. Overall mortality was 12.8%. Variables significantly associated with death were age > 34 years, mine and bullet injury, length of stay, time since injury > 5 h, injury severity score > 17, and associated injuries. Conclusions: Epidemiology and patterns of injury in a civilian hospital differ from those reported in a typical military setting. Our population is mainly civilian with a significant number of women and patients under 14 years. BI are more frequent than blast injuries, and gastrointestinal injuries are more common than injuries to solid organs. In this austere setting, surgeons need to acquire a wide range of skills from multiple surgical specialties. These findings might guide trauma and general surgeons treating penetrating abdominal war wounds to achieve better care and outcome.

Maxillofacial surgery in wartime Middle-East: Paul Tessier's missions to Iran.

The Iraq-Iran war (1980-88) resulted in numerous maxillofacial injuries. More than 400,000 people were wounded and required specialist care. Paul Tessier, a leading French plastic surgeon and pioneering craniofacial surgeon, was involved in several missions to Iran and operated on a vast cohort of patients with complex war trauma sequelae. Our study included 322 files relating to patients with war injuries operated on by Paul Tessier in Iran from 1990 to 1993. The files were the property of the Association Française des Chirurgiens de la Face. Relevant epidemiological parameters and data on surgical indications and procedures were collected. Descriptive statistics were used in order to characterize the cohort, and a multivariate logistic model was developed in order to assess factors associated with severe eye injuries within all facial injuries. Age range at admission was 5-67 years (average: 27.15 ± 6.97). The most common trauma mechanisms were shell fragments (161 patients; 50 %) and bullets (27 patients; 8.38 %). The bone and orbital contents in the upper third of the face were affected in 124 patients (38.50%); 72 patients (22.36%) had trauma of the middle third of the face; and 86 patients (26.71%) had trauma of the lower third. A total of 175 bone grafts were harvested by Tessier: 72 (41.14%) iliac grafts and 94 (53.71%) frontal and/or parietal grafts. Tessier managed 60 orbital fractures (18.63%) and 95 patients with uni- or bilateral enucleations (29.50%). A multivariate logistic model showed that patients injured by shells were 4.04 (1.32; 17.60) more likely (p = 0.03) than patients with gunshot wounds to have had uni- or bilateral enucleation, regardless of age and gender. Tessier's files provide first-hand information on the injury patterns that resulted from a regional war in the 1980s, and on the reconstruction challenges faced by a country during its post-war recovery period.

Perceptions of Healthcare-Associated Infection and Antibiotic Resistance among Physicians Treating Syrian Patients with War-Related Injuries.

Healthcare-associated infections (HAIs) constitute a major contributor to morbidity and mortality worldwide, with a greater burden on low- and middle-income countries. War-related injuries generally lead to large tissue defects, with a high risk of infection. The aim of this study was to explore how physicians in a middle-income country in an emergency setting perceive HAI and antibiotic resistance (ABR). Ten physicians at a Jordanian hospital supported by Médecins Sans Frontières were interviewed face-to-face. The recorded interviews were transcribed verbatim and analyzed by qualitative content analysis with an inductive and deductive approach. The participants acknowledged risk factors of HAI and ABR development, such as patient behavior, high numbers of injured patients, limited space, and non-compliance with hygiene protocols, but did not express a sense of urgency or any course of action. Overuse and misuse of antibiotics were reported as main contributors to ABR development, but participants expressed no direct interrelationship between ABR and HAI. We conclude that due to high patient load and limited resources, physicians do not see HAI as a problem they can prioritize. The knowledge gained by this study could provide insights for the allocation of resources and development of hygiene and wound treatment protocols in resource-limited settings.

Mandibular war injuries caused by bullets and shell fragments: a comparative study.

PURPOSE: Is to compare the patterns, severity, and management of the high- and low-velocity mandibular war injuries managed at Al Shaheed Gazi Al-Hariri Hospital in Baghdad Medical City, Iraq, during a 2-year period. METHODS: Forty-one patients with a history of mandibular war injuries treated by our maxillofacial team were reviewed during a period of 2 years (2015-2017). All patients were treated in the Maxillofacial Unit of the Hospital of Specialized Surgeries in Baghdad Medical City. RESULTS: A 2-year retrospective study evaluated 41 patients with mandibular war injuries with a total of 94 fractures (comminution represents 79.06% of the bullet injuries, while it is only 62.74% with IED injuries). Management of these injuries was varied according to the severity of the injuries and resources available. Close reduction was used in 72.72% of the linear fracture cases, whereas open technique was used in 56.6% of the comminuted fractures. CONCLUSIONS: Bullet injuries were associated with a higher number of mandibular comminuted fractures, in addition to more extensive bone loss. While shell injuries of IED (improvised explosive devices), on the other hand, were associated with higher infection rate and more postoperative complication.

The burden of war-injury in the Palestinian health care sector in Gaza Strip.

BACKGROUND: War-related injury is a major public health concern, and a leading cause of mortality, morbidity, and disability globally, particularly in low and middle-income countries such as Palestine. Little is known about the burden of war-related injury in the Palestinian context. The objective of this study was to characterize the incidence and pattern of injuries, associated with war in Gaza Strip, from July 8 to August 26, 2014. METHODS: This was a descriptive study based on an injury registry at hospital facilities in the Gaza Strip. A total of 420 victims records from 2014 Gaza war injuries were randomly selected, proportionate to the size of the study population estimated across five Gaza governorates. Simple descriptive statistics were calculated to explore the frequency and percentage distribution of study variables and injury data. A chi-square test (X2) was used. The significance level was derived at p < 0.05. The data were analyzed by IBM SPSS software, version 23. RESULTS: Males (75.5%) have experienced more war-related injuries than females (24.5%), constituting a male: female ratio of 3.1:1. Almost half (49.5%) of the injured victims were of the age group 20-39, followed by children and adolescents (< 20 years), accounting for 31.4%. More than half of victims were single (53.6%), 44.3% were married and the rest were widowed or divorced. The overall number of injuries was 6.4 per 1000 population, though it varied among regions. North Gaza reported the highest number of injuries (9.0) and Rafah the lowest (4.7) per 1000 population. Blast and explosion were found to be the most common causes of war injuries (72.9%). The highest proportion of injuries were reported in the upper body. Multiple body shrapnel wounds and burns (39.3%) were most frequent. Other types of injuries were multiple organ injury (24.3%), fractures (13.6%), internal organ injury and bleeding (9.8%), amputation (4.5%), abrasions/lacerations and contusions (4.8%), vision or hearing loss or both (1.9%) and respiratory problems (1.9%). The highest percentage of injuries were classified as mild (46.9%), and the rest ranged from moderate-to-severe. Almost 26% of individuals had sustained disability, and most of them had physical/motor impairment. CONCLUSION: War-related injuries constitute a major problem to public health discipline and clinical medicine as well. A better surveillance system using ICD codes, and development of a comprehensive electronic data network are necessary to make future research easier and more timely.

Cephalic region war injuries in children: Experience in French NATO hospital in Kabul Afghanistan.

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

Molecular Epidemiology of Multidrug-Resistant Bacteria Isolated from Libyan and Syrian Patients with War Injuries in Two Bundeswehr Hospitals in Germany.

INTRODUCTION: We assessed the molecular epidemiology of multidrug-resistant bacteria colonizing or infecting war-injured patients from Libya and Syria who were treated at the Bundeswehr hospitals Hamburg and Westerstede, Germany. METHODS: Enterobacteriaceae and Gram-negative rod-shaped nonfermentative bacteria with resistance against third-generation methoxyimino cephalosporins or carbapenems as well as methicillin-resistant Staphylococcus aureus (MRSA) from war-injured patients from Libya and Syria were assessed by molecular typing, i.e., spa typing for MRSA strains and rep-PCR and next-generation sequencing (NGS) for Gram-negative isolates. RESULTS: A total of 66 isolates were assessed - comprising 44 Enterobacteriaceae, 16 nonfermentative rod-shaped bacteria, and 6 MRSA from 22 patients - and 8 strains from an assessment of the patient environment comprising 5 Enterobacteriaceae and 3 nonfermentative rod-shaped bacteria. Although 24 out of 66 patient strains were isolated more than 3 days after hospital admission, molecular typing suggested only 7 likely transmission events in the hospitals. Identified clonal clusters primarily suggested transmission events in the country of origin or during the medical evacuation flights. CONCLUSIONS: Nosocomial transmissions in hospital can be efficiently prevented by hygiene precautions in spite of heavy colonization. Transmission prior to hospital admission like on evacuation flights or in crises zones needs further assessment.