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The Syrian Civil War has now raged on for 6 years, has claimed the lives of more than 470 000 people (mostly civilians), and the death toll rises by the day.1,2 Indeed, as a result of this conflict, the average life expectancy (at birth) in Syria has dropped from 70 years to 55 years.3 Millions of people have become refugees, both within and outside their own country, in what has been described as one of the greatest humanitarian crises of our times.4 The medical system of care in Syria has been destroyed and aid is not reaching those civilians most in need.5,6 The war's knock-on effects include inadequate health care, the spread of disease, and absence of access to food or clean water, not to speak of the genesis of a stream of refugees seeking a safe haven in neighbouring countries and further afield, especially in Europe.

[...]this technique may significantly increase the procedure time, patients' discomfort, and potential for complications. Besides battery-powered IO infusion drills (EZIO), several semi-automatic spring devices (e.g., Bone Injection Gun [BIG] and New Intraosseous [NIO]) are available for IO access. [...]we evaluated only one aspect of a successful IO access establishment. The use of longer needles or alternate insertion sites is warranted in this population.Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Data statement The data that support the findings of this study are available from the corresponding author, upon reasonable request.Source of support and sponsorship None.Conflicts of Interest and Source of Funding Aeyal Raz reports receiving consultant fees and research support from Medtronic and consultant fees from Neuroindex (none related to this work).

Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason. Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma. In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0–57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13–0.51, p < 0.001) and 0.16 (95% CI 0.06–0.46, p < 0.001), respectively. Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.

A 46-year-old male was admitted to the trauma department after a motor vehicle accident. He presented with severe abdominal pain and a distended abdomen with peritonitis. His past surgical history included total proctocolectomy with ileal J-pouch anal anastomosis for ulcerative colitis 20 years previously. Computed tomography showed free peritoneal air and fluid in the abdomen mandating an exploratory laparotomy. A perforation at the ileal J-pouch blind end was found. Primary closure with diverting loop ileostomy was performed. The patient had an uneventful recovery and underwent closure of the ileostomy two months later. The case and management are discussed after reviewing the literature.

Gastrointestinal stromal tumor (GIST) is a rare stromal neoplasm, which represents the most common mesenchymal tumor of the gastrointestinal tract. It is characterized by indolent clinical symptoms, although it can present as a life-threatening emergency. Herein, we present two cases of primary small bowel GIST treated at our department. A 68-year-old female patient presented to our emergency department with a diffuse abdominal pain of acute onset. Imaging studies revealed a mass at proximal jejunum, with a nearby free air and fluid. At surgery, a mass of 9 cm was found at proximal jejunum, 3 cm distal to the treitz ligament, with perforation on the lateral wall of the mass. En bloc resection was performed. Pathology report was positive for gastrointestinal stromal tumor. A 70-year-old male patient presented to our emergency department with 3 days of dark tarry stool and few hours of hematochezia. Computed tomography angiography revealed a mass at the pelvis, with calcifications, attached to the distal ileum, with intraluminal blush of intravenous iodine. At surgery, a mass of 8 cm at the distal ileum was found. Resection of the mass along with a 20 cm of ileum was completed. Histopathology report was positive for malignant gastrointestinal stromal tumor.

The American College of Surgeons Committee on Trauma in its Advanced Trauma Life Support course recommends using intraosseous (IO) infusion in children in whom intravenous access is difficult. After repeated attempts for peripheral and central vascular access failed, the patient deteriorated hemodynamically, and a 15 gauge intraosseous (IO) needle was inserted in her proximal tibia using a battery-powered IO driver [1].

Background Although the application of damage control surgery for trauma has been widely reported and defined, similar approach in non-trauma patients has not been well detailed. Methods A retrospective analysis of data from non-trauma patients who underwent emergency laparotomy between May 2006 and December 2008. Demographics, indications for surgery and outcome of patients who had definitive laparotomies (DL) and patients who had abbreviated laparotomies (AL) were compared. Appendectomies were excluded. Results and discussion Two-hundred ninety-one patients (55% males) were included. Thirty-one (10.7%) underwent AL (58% males). Mean age of patients who had DL and AL was 65 and 62.8 years respectively. Peritonitis and mesenteric ischemia were more common indications in patients with AL than DL: 48.4% vs. 30.4% (p = 0.04) and 32.3% vs. 3.5% (p < 0.0001) respectively. Only 29% of patients who had AL were hemodynamically unstable. Mortality rates were 54.8% and 16.5% in patients with AL and DL respectively (p < 0.0001). Patients who died after AL and DL were significantly older than patients who survived (75 vs. 47.3 and 74 vs. 63 years respectively, p < 0.0001). Median hospital stay was 21 and 9 days for patients with AL and DL respectively (p < 0.05). Patients who underwent AL had significantly more wound infections, sepsis and multi-organ failure. Conclusion The philosophy of damage control surgery is applied to non-trauma patients as some of the prerequisites for the decision to elect this strategy are the same. Peritonitis is the most common indication for AL in non-trauma patients.

Upper dorsal sympathectomy is the only successful therapeutic method for idiopathic palmar hyperhidrosis (IPHH). However, the techniques for sympathetic ablation are still debated. The aim of this study was to compare prospectively two accepted methods for endoscopic sympathetic ablation: resection of T2‐T3 ganglia versus transection of the chain over the second to fourth ribs. During the period September 2000 to June 2002, a total of 32 patients with IPHH were operated on. Operations were performed under general anesthesia through two 5‐mm trocars using electrocautery. Resection was done on one side and transection on the other, with both sides being addressed during the same operation. The sides of resection/transection were alternated at each operation. There were 14 men and 18 women aged 18.8 ± 4.7 years. The mean operating times for sympathectomy were 12.0 ± 3.1 minutes for resection and 6.6 ± 1.9 minutes for transection (p = 1.38). All patients were examined at 2 weeks postoperatively and again at 1 month. During November–December 2005, patients were approached by telephone questionnaire, the mean follow‐up period being 4.3 ± 0.9 years. Altogether, 26 of the 32 patients could be located (15 women, 11 men). There was no significant difference with regards to perioperative complications, immediate or long‐term pain. All but two hands were warm and dry 1 month after operation and remained so at follow‐up. The exceptions included one hand with recurrent hyperhidrosis after 1.5 years and one that became less dry and cold at 3 years. Both were on the transected sides. Our results suggest that sympathetic resection may achieve slightly better long‐term results than transection in patients with IPHH. Large‐scale prospective studies are needed to confirm these results.

[...]our study shows that in perforated PUD, older age, elevated lactate levels and diabetes might predict an unfavorable outcome even among patients operated in a timely manner.

Injury patterns are closely related to changes in behavior. Pandemics and measures undertaken against them may cause changes in behavior; therefore, changes in injury patterns during the coronavirus disease 2019 (COVID-19) outbreak can be expected when compared to the parallel period in previous years. The aim of this study was to compare injury-related hospitalization patterns during the overall national lockdown period with parallel periods of previous years. A retrospective study was completed of all patients hospitalized from March 15 through April 30, for years 2016-2020. Data were obtained from 21 hospitals included in the national trauma registry during the study years. Clinical, demographic, and circumstantial parameters were compared amongst the years of the study. The overall volume of injured patients significantly decreased during the lockdown period of the COVID-19 outbreak, with the greatest decrease registered for road traffic collisions (RTCs). Patients' sex and ethnic compositions did not change, but a smaller proportion of children were hospitalized during the outbreak. Many more injuries were sustained at home during the outbreak, with proportions of injuries in all other localities significantly decreased. Injuries sustained during the COVID-19 outbreak were more severe, specifically due to an increase in severe injuries in RTCs and falls. The proportion of intensive care unit (ICU) hospitalizations did not change, however more surgeries were performed; patients stayed less days in hospital. The lockdown period of the COVID-19 outbreak led to a significant decrease in number of patients hospitalized due to trauma as compared to parallel periods of previous years. Nevertheless, trauma remains a major health care concern even during periods of high-impact disease outbreaks, in particular due to increased proportion of severe injuries and surgeries.