{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T06:13:58Z","timestamp":1788329638736,"version":"build-2803163510"},"reference-count":17,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T00:00:00Z","timestamp":1788307200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Prolonged missile-related conflicts may generate evolving civilian injury patterns and continuing war-related presentations to emergency departments. Although mass casualty incidents receive substantial attention in the disaster medicine literature, less is known regarding how civilian injury profiles and war-related emergency department presentations evolve during recurrent and prolonged conflict conditions. Understanding these changes is important for healthcare preparedness and continuity of emergency services.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Materials and Methods<\/jats:title>\n                    <jats:p>We conducted a retrospective observational study of civilian presentations to a large urban emergency department documented as occurring in the context of 2 conflicts involving attacks by the same regional adversary: June 13-25, 2025, and February 28-April 19, 2026. Demographic characteristics, injury severity, patient disposition, and diagnosis categories were analyzed. Because 4 nearby mass casualty incidents occurred during the first conflict period, an adjusted analysis excluding casualties presenting on mass casualty incident dates was performed to evaluate underlying wartime injury patterns. The second conflict period was additionally divided into early and later phases to assess temporal changes during prolonged conflict exposure. Daily presentation rates were calculated to account for differences in conflict duration. The study was approved by the Institutional Review Board of Edith Wolfson Medical Center (approval no. 0084-26-WOMC, 2026). The requirement for informed consent was waived due to the retrospective nature of the study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>A total of 1,018 war-related civilian ED presentations were included. Period 1 included 418 presentations over 13 days, corresponding to 32.2 presentations per day. After excluding the 4 mass casualty incident dates, 127 presentations occurred over 9 days, corresponding to 14.1 presentations per day. Period 2 included 600 presentations over 51 days, corresponding to 11.8 presentations per day. Initial analyses demonstrated lower injury severity during Period 2; however, after exclusion of mass casualty incident-associated casualties, severity distributions were similar, with mild injuries accounting for 96.1% and 97.0% of presentations, respectively. Diagnosis distributions differed significantly between periods (P\u2009&amp;lt;\u2009.001). Extremity injuries increased from 31.9% to 44.2% and peaked during the early phase of Period 2 at 48.2%, before declining to 34.8% during the later phase. Psychological\/anxiety-related presentations decreased from 11.8% to 0.8%, while multiregion trauma reached 9.9% during the later phase of Period 2. War-related presentations continued throughout the prolonged second conflict period despite the absence of nearby missile impacts or formal mass casualty incident activation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Civilian wartime injury profiles evolved across recurrent missile-related conflicts despite relatively stable injury severity after adjustment for local mass casualty incidents. Preparedness strategies should consider both acute mass casualty events and the continuing occurrence of predominantly low-acuity war-related emergency department presentations during prolonged conflict conditions.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/milmed\/usag412","type":"journal-article","created":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T11:52:43Z","timestamp":1787140363000},"source":"Crossref","is-referenced-by-count":0,"title":["Sustained War-Related Emergency Department Presentations and Evolving Civilian Injury Patterns During Recurrent Missile-Related Conflict"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-0556-335X","authenticated-orcid":false,"given":"Yuval","family":"Dadon","sequence":"first","affiliation":[{"name":"Hospital Management, Edith Wolfson Medical Center , Holon,","place":["Israel"]},{"name":"Gray Faculty of Medical and Health Sciences, Tel Aviv University , Tel Aviv,","place":["Israel"]},{"name":"IMPACT Institute for Health Policy and Care Transformation Research, Edith Wolfson Medical Center , Holon,","place":["Israel"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1599-2618","authenticated-orcid":false,"given":"Amir","family":"Nutman","sequence":"additional","affiliation":[{"name":"Hospital Management, Edith Wolfson Medical Center , Holon,","place":["Israel"]},{"name":"Gray Faculty of Medical and Health Sciences, Tel Aviv University , Tel Aviv,","place":["Israel"]},{"name":"IMPACT Institute for Health Policy and Care Transformation Research, Edith Wolfson Medical Center , Holon,","place":["Israel"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3152-4101","authenticated-orcid":false,"given":"Orit","family":"Mazza","sequence":"additional","affiliation":[{"name":"Hospital Management, Edith Wolfson Medical Center , Holon,","place":["Israel"]},{"name":"Gray Faculty of Medical and Health Sciences, Tel Aviv University , Tel Aviv,","place":["Israel"]},{"name":"IMPACT Institute for Health Policy and Care Transformation Research, Edith Wolfson Medical Center , Holon,","place":["Israel"]},{"name":"Loewenstein Rehabilitation Hospital , Raanana,","place":["Israel"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-9205-9713","authenticated-orcid":false,"given":"Uri","family":"Feinstein","sequence":"additional","affiliation":[{"name":"Hospital Management, Edith Wolfson Medical Center , Holon,","place":["Israel"]},{"name":"IMPACT Institute for Health Policy and Care Transformation Research, Edith Wolfson Medical Center , Holon,","place":["Israel"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2853-7227","authenticated-orcid":false,"given":"Linoy","family":"Gabay","sequence":"additional","affiliation":[{"name":"Hospital Management, Edith Wolfson Medical Center , Holon,","place":["Israel"]},{"name":"IMPACT Institute for Health Policy and Care Transformation Research, Edith Wolfson Medical Center , Holon,","place":["Israel"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6127-0213","authenticated-orcid":false,"given":"Anat","family":"Engel","sequence":"additional","affiliation":[{"name":"Hospital Management, Edith Wolfson Medical Center , Holon,","place":["Israel"]},{"name":"Gray Faculty of Medical and Health Sciences, Tel Aviv University , Tel Aviv,","place":["Israel"]},{"name":"IMPACT Institute for Health Policy and Care Transformation Research, Edith Wolfson Medical Center , Holon,","place":["Israel"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,9,2]]},"reference":[{"key":"2026090201312794900_usag412-B1","doi-asserted-by":"publisher","first-page":"1468","DOI":"10.1097\/TA.0b013e3181a27e7f","article-title":"Injuries from explosions: physics, biophysics, pathology, and required research focus","volume":"66","author":"Champion","year":"2009","journal-title":"J Trauma"},{"key":"2026090201312794900_usag412-B2","doi-asserted-by":"publisher","first-page":"265","DOI":"10.1136\/jramc-155-04-05","article-title":"Improvised explosive devices: pathophysiology, injury profiles and current medical management","volume":"155","author":"Ramasamy","year":"2009","journal-title":"J R Army Med Corps"},{"key":"2026090201312794900_usag412-B3","doi-asserted-by":"publisher","first-page":"303","DOI":"10.1097\/SLA.0b013e318180a3f7","article-title":"Abdominal trauma after terrorist bombing attacks exhibits a unique pattern of injury","volume":"248","author":"Bala","year":"2008","journal-title":"Ann Surg"},{"key":"2026090201312794900_usag412-B4","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1016\/j.ajem.2023.05.003","article-title":"High risk and low prevalence diseases: blast injuries","volume":"70","author":"Bukowski","year":"2023","journal-title":"Am J Emerg Med"},{"key":"2026090201312794900_usag412-B5","volume-title":"StatPearls","author":"Jorolemon","year":"2026"},{"key":"2026090201312794900_usag412-B6","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1186\/s13049-024-01299-7","article-title":"Civilian pattern of injuries in armed conflicts: a systematic review","volume":"32","author":"Chevalley","year":"2024","journal-title":"Scand J Trauma Resusc Emerg Med"},{"key":"2026090201312794900_usag412-B7","doi-asserted-by":"publisher","first-page":"233","DOI":"10.14744\/tjtes.2024.40088","article-title":"Evaluation of the effects of explosions: a ten-year retrospective study","volume":"31","author":"Kaya","year":"2025","journal-title":"Ulus Travma Acil Cerrahi Derg"},{"key":"2026090201312794900_usag412-B8","doi-asserted-by":"publisher","first-page":"311","DOI":"10.1097\/01.sla.0000114012.84732.be","article-title":"Gunshot and explosion injuries: characteristics, outcomes, and implications for care of terror-related injuries in Israel","volume":"239","author":"Peleg","year":"2004","journal-title":"Ann Surg"},{"key":"2026090201312794900_usag412-B9","doi-asserted-by":"publisher","first-page":"258","DOI":"10.1016\/S0735-6757(03)00043-3","article-title":"Patterns of injury in hospitalized terrorist victims","volume":"21","author":"Peleg","year":"2003","journal-title":"Am J Emerg Med"},{"key":"2026090201312794900_usag412-B10","doi-asserted-by":"publisher","first-page":"71","DOI":"10.22141\/1608-1706.1.27.2026.1068","article-title":"Analysis of traumatic injuries among civilian casualties as a result of modern hostilities","volume":"27","author":"Tanasiienko","year":"2026","journal-title":"Trauma"},{"key":"2026090201312794900_usag412-B11","doi-asserted-by":"publisher","first-page":"70","DOI":"10.46847\/ujmm.2023.3(4)-070","article-title":"Severity of injuries in case of mine-blast trauma depending on the location of the person at the time of the explosion","volume":"4","author":"Chorna","year":"2023","journal-title":"Ukr J Mil Med"},{"key":"2026090201312794900_usag412-B12","doi-asserted-by":"publisher","first-page":"e2896","DOI":"10.1093\/milmed\/usac343","article-title":"Physical trauma following rocket warning sirens in Israel","volume":"188","author":"Manor","year":"2023","journal-title":"Mil Med"},{"key":"2026090201312794900_usag412-B13","doi-asserted-by":"publisher","first-page":"112937","DOI":"10.1016\/j.injury.2025.112937","article-title":"Injuries while seeking shelter during air-raid sirens: a retrospective comparative study from two armed conflicts in Israel","volume":"57","author":"Alpert","year":"2026","journal-title":"Injury"},{"key":"2026090201312794900_usag412-B14","doi-asserted-by":"publisher","first-page":"38","DOI":"10.1186\/s13584-024-00625-9","article-title":"Civilians under missile attack: post-traumatic stress disorder among the jewish and bedouin population of Southern Israel","volume":"13","author":"Shvartsur","year":"2024","journal-title":"Isr J Health Policy Res"},{"key":"2026090201312794900_usag412-B15","doi-asserted-by":"publisher","first-page":"201","DOI":"10.1097\/00005373-200208000-00001","article-title":"Medical management of disasters and mass casualties from terrorist bombings: how can we cope?","volume":"53","author":"Frykberg","year":"2002","journal-title":"J Trauma"},{"key":"2026090201312794900_usag412-B16","doi-asserted-by":"publisher","first-page":"1606907","DOI":"10.3389\/ijph.2024.1606907","article-title":"Managing a mega mass casualty event by a civilian emergency medical services agency: lessons from the first day of the 2023 Hamas-Israel war","volume":"69","author":"Jaffe","year":"2024","journal-title":"Int J Public Health"},{"key":"2026090201312794900_usag412-B17","doi-asserted-by":"publisher","first-page":"47","DOI":"10.1186\/s13031-024-00603-7","article-title":"Treating wartime injuries amidst attack: insights from a medical facility on the edge of combat","volume":"18","author":"Levy","year":"2024","journal-title":"Confl Health"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article-pdf\/doi\/10.1093\/milmed\/usag412\/70903772\/usag412.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article-pdf\/doi\/10.1093\/milmed\/usag412\/70903772\/usag412.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T05:31:35Z","timestamp":1788327095000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article\/doi\/10.1093\/milmed\/usag412\/8779476"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,2]]},"references-count":17,"URL":"https:\/\/doi.org\/10.1093\/milmed\/usag412","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,2]]},"article-number":"usag412"}}