Dena H. Jaffe

Bicycle injuries: A matter of mechanism and age

Bicycle riding is a popular form of recreation with positive health and environmental effects. These road users are vulnerable to serious injuries, especially when motor vehicles are involved. The goal of this study was to characterize cyclist-related injuries according to motor vehicle involvement for adults versus children. A retrospective study was carried out using data from 11 trauma centers in the Israeli National Trauma Registry (2001-2007). Injuries were classified according to whether a motor vehicle was involved, and differences in injury characteristics were assessed for adults (18+ years) versus children (1-17 years). A total of 5529 patients were hospitalized for bicycle injuries, of whom 1765 were adults and 3764 were children. Thirty percent (n=1662) of all bicycle injuries involved motor vehicles, although the rate of injuries resulting in hospitalization was 37% among adults and 27% among children. Injury characteristics and hospital resource utilization differed substantially by age group. Cyclists struck by a motor vehicle presented with more severe injuries requiring more hospital resources and resulting in poorer outcomes than those not involved with motor vehicles. The interaction effect between motor vehicle involvement and age was significant for torso injuries and need for medical imaging. We found that injury characteristics, hospital resource utilization and health-related outcomes for bicycle injuries are highly dependent on patients age and mechanism of injury. Effect modification of motor vehicle involvement by age may in part reflect physicians attitudes toward pediatric imaging. The risks identified in this study should be used for preparedness and management of trauma hospitalizations from bicycle injuries.

Management of patients with traumatic intracranial injury in hospitals without neurosurgical service.

BACKGROUNDnMany patients with intracranial bleeding (ICB) are being evaluated in hospitals with no neurosurgical service. Some of the patients may be safely managed in the primary hospital without transferring them to a designated neurosurgical center. In Israel, there are three approaches to alert patients with ICB: mandatory transfer, remote telemedicine neurosurgical consultation, and clinical-radiologic guidelines. We evaluated the outcome of alert patients with low-risk ICB who were managed in centers without neurosurgical service.nnnMETHODSnA retrospective cohort comparative study. Patients with ICB and a Glasgow Coma Score >12 were included. Low-risk ICB was defined as solitary brain contusion of <1 cm in diameter, limited small subarachnoid hemorrhage, or subdural hematoma of <5 mm in maximal width and length. The decision to transfer the patients to a neurosurgical center was based on one of the three models. Hospital A: mandatory transfer. Hospital B: telemedicine-based consultation with a remote neurosurgeon. Hospital C: clinical-radiologic algorithm-based guidelines. Primary endpoint was the neurologic outcome of patients at discharge.nnnRESULTSnThere were 152 patients in group A, 98 patients in group B, and 73 patients in group C. All patients of group A were transferred to a neurosurgical center. Fifty-eight percent of patients from hospital B and 26% of patients from hospital C were hospitalized in the primary center despite a proven ICB. These patients were discharged without any neurologic sequel of their injury. Two patients from group B and one patient from group C needed a delayed transfer to a neurosurgical center. None of the patient needed delayed neurosurgical intervention.nnnCONCLUSIONSnDespite the small sample size of this study, the presented data suggest that some patients with ICB can be safely and definitively managed in centers with no on-site neurosurgical service. The need for transfer may be based on telemedicine consultation or clinical -radiologic guidelines. Further larger scale studies are warranted.

Terror explosive injuries: a comparison of children, adolescents, and adults.

Objective:We sought to characterize injuries and outcomes from terror explosions with specific attention to children (0–10 years) and adolescents (11–15 years) compared to adults (16–45 years). Summary Background Data:Terror explosions target vulnerable populations and result in multidimensional injuries that may vary according to age group. The relative dearth of information regarding terror-related injuries among children inhibits proper preparedness and optimum management during such an event. Methods:A retrospective study was performed using data from the national Israel Trauma Registry (October 2000 to December 2005). Included were civilians and nonactive military personnel hospitalized as a result of a terror explosion. Results:During the 5.3-year study period, 49 children (0–10 years), 65 adolescents (11–15 years), and 723 adults (16–45 years) were hospitalized from terror explosions. Children were more likely than adults to sustain severe injuries (27% vs. 12%) and traumatic brain injury (35% vs. 20%) and less likely to sustain injuries to their extremities (35% vs. 57%) or open wounds (39% vs. 59%) (P ≤ 0.05). The adolescent injury profile was similar to that of adults, however, adolescents presented with less internal injuries, more contusions, and superficial wounds to extremities and were more likely to require surgery for mild to moderate wounds. Differences in hospital utilization and outcomes by age groups were observed when data were stratified by injury severity. Conclusions:Compared to adults, children, and adolescents exposed to terror explosions present with different injuries and hospital utilization and outcomes. These results further confirm that preparedness of a pediatric healthcare system is essential for effective management in the event of a future mass casualty incident.

The normalisation of terror: the response of Israel's stock market to long periods of terrorism

Man-made disasters such as acts of terrorism may affect a societys resiliency and sensitivity to prolonged physical and psychological stress. The Israeli Tel Aviv stock market TA-100 Index was used as an indicator of reactivity to suicide terror bombings. After accounting for factors such as world market changes and attack severity and intensity, the analysis reveals that although Israels financial base remained sensitive to each act of terror across the entire period of the Second Intifada (2000-06), sustained psychological resilience was indicated with no apparent overall market shift. In other words, we saw a normalisation of terror following an extended period of continued suicide bombings. The results suggest that investors responded to less transitory global market forces, indicating sustained resilience and long-term market confidence. Future studies directly measuring investor expectations and reactions to man-made disasters, such as terrorism, are warranted.

Are injuries from terror and war similar? A comparison study of civilians and soldiers.

Objective:To compare injuries and hospital utilization and outcomes from terror and war for civilians and soldiers. Summary Background Data:Injuries from terror and war are not necessarily comparable, especially among civilians and soldiers. For example, civilians have less direct exposure to conflict and are unprepared for injury, whereas soldiers are psychologically and physically prepared for combat on battlefields that are often far from trauma centers. Evidence-based studies distinguishing and characterizing differences in injuries according to conflict type and population group are lacking. Methods:A retrospective study was performed using hospitalization data from the Israel National Trauma Registry (10/2000–12/2006). Results:Terror and war accounted for trauma hospitalizations among 1784 civilians and 802 soldiers. Most civilians (93%) were injured in terror and transferred to trauma centers by land, whereas soldiers were transferred by land and air. Critical injuries and injuries to multiple body regions were more likely in terror than war. Soldiers tended to present with less severe injuries from war than from terror. Rates of first admission to orthopedic surgery were greater for all casualties with the exception of civilians injured in terror who were equally likely to be admitted to the intensive care unit. In-hospital mortality was higher among terror (7%) than war (2%) casualties, and particularly among civilians. Conclusions:This study provides evidence that substantial differences exist in injury characteristics and hospital resources required to treat civilians and soldiers injured in terror and war. Hospital preparedness and management should focus on treating combat injuries that result from specific causes—terror or war.

The Role of Community in Pediatric Injury

Cultural variations between communities may impact injury rates, especially among children. We conducted a retrospective study of three communities in Israel using data from the Israel National Trauma Registry (1998–2007). Pediatric injury hospitalization rates in urban communities with varied levels of socio-economic status (low, medium, and high) were compared for all injuries and cause-specific injuries. Age-standardized and age-specific rates were calculated. Age-standardized injury hospitalization rates were lowest for the low socio-economic status (SES) community (299.7, 95% confidence interval [CI] 289.8–309.6) compared to the medium SES (658.2, 95% CI 629.1–687.3) and high SES (443.7, 95% CI 422.2–465.3) communities. Similar rates were observed for injuries from falls, transportation, accidental striking and intentional causes. For example, rate ratios for falls were 149.1 (95% CI 142.0–156.2), 340.8 (95% CI 319.5–362.1) and 245.7 (229.9–261.5) in the low, medium and high SES communities, respectively. Deviations from these overall trends were noted, however, for pedestrian injuries and burns that were relatively higher in the low SES community and injuries from motorized vehicles that were greater among children living in the high SES community. These results suggest that strong social capital is associated with reduced pediatric injury risks regardless of community wealth. However, targeted interventions for reducing injuries in at-risk populations that rely solely on injury rates may omit culturally distinct communities and overlook their uneven burden to the trauma care system.

Evacuation Patterns of Ethnic Groups Under Fire

Background: The north of Israel is inhabited by approximately one million people, of which 60% are Jews and 40% Non-Jews. During the 34-day Second Lebanon War (July 2006), approximately 4,000 rockets of various types were fired at the civilian population in the northern part of Israel. About 300,000 people decided to spontaneously evacuate the areas under attack. Objectives: The objective of this paper was to evaluate the differences between Jews and Non-Jews in their decision to evacuate from a threatened area and to identify the factors that influenced their decision. Method: We carried out a telephone survey one year after the end of the 2nd Lebanon war. A representative sample was constructed of civilians who had resided in the north prior to the start of the war and were over 18 years of age. Results: Significant differences were found between the Jews & Non-Jews in their evacuation behaviors and expose the main reasons for evacuating or not evacuating during the war. It exposes the two groups future plans for considering evacuation in a similar situation. 50% of Jews evacuated and only 9% of non-Jews evacuated, and this discrepancy is a difference that makes our study a worthwhile one in order to identify the different factors involved. Conclusions: The government policy-makers in Israel had chosen not to issue orders for the evacuation of the northern population during the 2nd Lebanon war, yet over 300,000 individuals evacuated. The main reasons for deciding to evacuate during the 2nd Lebanon War differed between Jews and non-Jews. This study found differences in personal decisions to evacuate; differences which may have an important influence on the future behavior of the Israeli population and particularly of the Non-Jewish population. What appears from our study was that the expected rate of future evacuation on the Non-Jewish group was expected to more than double (9% in 2006 as compared to 29.1% who would evacuate in the future). If decision makers in Israel have the intention for the Non-Jewish population to evacuate in similar future events, it is necessary to reduce barriers so that evacuation will be more likely.

Civilians under fire: evacuation behaviour in north Israel during the Second Lebanon War

This paper seeks to understand evacuation behaviour in a case of spontaneous evacuation. During the Second Lebanon War of 2006, more than one-third of residents in north Israel spontaneously evacuated--the remainder stayed in situ. Using a telephone survey of 665 respondents residing in north Israel, we were able to characterise the behaviour of evacuees and non-evacuees. The main reasons cited for evacuating were fear of injury to self or family, the effect on children, inability to remain in a protective space, and family pressure. The main reasons cited for remaining at home were no suitable alternative, did not perceive a high level of danger, had to go to work, and there is no place like home. There were no significant differences with regard to most socio-demographic characteristics of the population. These findings should aid emergency managers in preparing the population for a future emergency and in engaging in effective dialogue with the population during an emergency on the evacuation option.

Bicycle injuries: a matter of mechanism and age

Introduction Bicycle riding is a popular form of recreation with positive health and environmental consequences. These road users are vulnerable to serious injuries, especially when motor vehicles are involved. Objectives The goal of this study is to characterise cyclist-related injuries according to motor vehicle involvement for adults versus children. Methods A retrospective study was carried using data from 11 trauma centres in the Israeli National Trauma Registry (2001–2007). Injury mechanism was classified according to motor vehicle involvement and differences in injury characteristics were assessed for adults (18+ years) versus children (1–17 years). Results A total of 5529 patients were hospitalised for bicycle injuries, of which 1765 were adults and 3764 were children. Thirty percent (n=1662) of all bicycle injuries involved motor vehicle and adults were 1.3 times more likely to be involved in a motor vehicle-related bicycle accident than children (95% CI 1.16 to 1.49). Injury characteristics and hospital resource utilisation differed substantially by age group. Cyclists struck by a motor vehicle presented with multiple injuries, utilised more hospital resources and had worse outcomes than those not involved with motor vehicles. The interaction effect between motor vehicle involvement and age was significant for torso injuries and imaging tests. Conclusions Injury characteristics, hospital resource utilisation and health-related outcomes for bicycle injuries are highly dependent on patients age and mechanism of injury. Effect modification of motor vehicle involvement by age may reflect physicians attitudes towards paediatric imaging.