BackgroundMore than 17.000 Palestinians were injured during different Israeli military incursions on the Gaza Strip from 2006 to 2014. Many suffered traumatic extremity amputations. We describe the injuries, complications, living conditions and health among a selection of traumatic amputees in the Gaza Strip.MethodsWe included 254 civilian Palestinians who had survived, but lost one or more limb(s) during military incursions from 2006 to 2016. All patients were receiving follow-up treatment at a physical rehabilitation center in Gaza at the time of inclusion. We measured and photographed anatomical location and length of extremity amputations and interviewed the amputees using standard questionnaires on self-reported health, socioeconomic status, mechanism of injury, physical status and medical history.ResultsThe amputees were young (median age 25,6 years at the time of trauma), well educated (37% above graduate level), males (92%), but also 43 children (17% ≤ 18 years). The greater part suffered major amputations (85% above wrist or ankle). Limb losses were unilateral (35% above-, 29·5% below knee), and bilateral (17%) lower extremity amputations. Pain was the most frequent long-term complaint (in joints; 34%, back; 33% or phantom pain; 40·6%). Sixty-three percent of amputees were their family’s sole breadwinner, 75·2% were unemployed and 46% had lost their home. Only one in ten (11·6%) of the destroyed homes had been rebuilt.ConclusionsThe most frequently observed amputees in our study were young, well-educated male breadwinners and almost one in five were children. Conflict-related traumatic amputations have wide-ranging, serious consequences for the amputees and their families.

Background Little data exist to describe the use and medical consequences of drone strikes on civilian populations in war and conflict zones. Gaza is a landstrip within the Palestinian territories and the home of 2 million people. The median age in Gaza is 17•2 years and almost half of the population is below the age of 14 years. We studied the prevalence and severity of extremity amputation injuries caused by drone strikes compared with those caused by other explosive weapons among patients with amputations attending the main physical prosthesis and rehabilitation centre in Gaza.Methods In this retrospective cross-sectional study, we recruited patients from the Artificial Limb and Polio Centre (ALPC) in Gaza city in the Gaza strip with conflict-related traumatic extremity amputations. Patients were eligible if they had one or more amputations sustained during a military incursion in Gaza during 2006-16 and had an available patient record. Each patient completed a self-reporting questionnaire of the time and mechanism of injury, subsequent surgeries, comorbidities, and their socioeconomic status, and we collected each patient's medical history, recorded the anatomical location of their amputation or amputations, and interviewed each patient to obtain a detailed description of the incursion or incursions that led to their amputation injury. We classified the severity of amputations and number of subsequent surgeries on ordinal scales and then we determined the associations between these outcomes and the mechanism of explosive weapon delivery (drone strike vs other) using ordinal logistical regression.Findings We collected data on 254 patients from APLC who had sustained an amputation injury. Of these patients, 234 (92%) were male and 43 (17%) were aged 18 years or younger at the time of injury. The age of participants was representative of the Gaza population, with a median age at inclusion was 28 years (IQR 23-33), and the median age at the time of injury was 23 years (IQR 20-29). 136 (54%) amputation injuries were caused by explosive weapons delivered by drone strikes, with explosives delivered by tanks being the next most common source of amputation injury (28 [11%]). Adjusted for age and sex, drone-delivered weapons caused significantly more severe injuries than explosives delivered by other mechanisms (eg, military jet airplanes, helicopters, tank shelling, and naval artillery; odds ratio [OR] 2•50, 95% CI 1•52-4•11; p=0•0003). Compared with all other types of weapons, the patients whose injuries were caused by drone strikes needed significantly more subsequent surgical operations to treat their amputation injuries than those injured by other weapons (OR 1•93, 1•19-3•14; p=0•008).Interpretation Drone strikes were the most commonly reported cause of amputation injury in our study population and were associated with more severe injuries and more additional surgeries than injuries caused by other explosive weapons. Limitations of our study include the self-reported nature of the mechanism of injury and number of...

ObjectivesThe aim of this study was to explore possible long-term negative health effects of injuries sustained by modern weaponry.SettingThe study was conducted in Gaza’s main hospital, Al-Shifa Hospital.ParticipantsDuring the last 10 to 15 years, thousands of civilian Palestinians in Gaza have survived numerous military incursions, but with war-related traumatic injuries caused by explosive weapons. It is unclear to which extent the injuries sustained by such modern weaponry may increase survivors’ risks of negative long-term health effects and serious illness. We have reported mechanisms and severity of injury, demographics and psychosocial status among 254 Palestinian patients in Gaza with war-related extremity amputations. Among the same amputees, subgroups of patients presented a variety of alarming symptoms and findings. 94 patients received further diagnostic clinical exploration, radiology imaging and clinical chemistry laboratory tests at the main clinical centre in Gaza, the Al-Shifa Hospital.ResultsNine out of ten of the referred patients were young (median 31.5 years) males (88/94, 92.6%). Ultrasound imaging revealed that 19 of 90 patients (20%) had fatty liver infiltration, 3 patients had lung nodules and 10 patients had lung atelectasis on chest CT. Twelve had remaining shrapnel(s) in the chest, five patients had shrapnel(s) in the abdomen and one in the scrotum. We found shrapnel(s) in the amputation stumps of 26 patient’s amputated limbs, while 8 patients had shrapnel in the non-amputated limb. Three patients had liver lesions. Nineteen patients had elevated liver enzymes, 32 patients had elevated erythrocyte sedimentation rate and 12 were anaemic. Two patients tested positive for hepatitis C virus and three were positive for hepatitis B virus (HBV). One of the 19 patients with fatty liver tested positive for HBV. Two of the patients with fatty liver infiltration had elevated glycatedhaemoglobin levels and confirmed diabetes mellitus type II.ConclusionNearly half (44, 8%) had remaining metal fragments from explosives of unknown composition harboured in various parts of their bodies. All patients identified with lesions and nodules are being followed up locally. As of now, we cannot anticipate the long-term health consequences of living with metal residuals from modern explosive weapons embedded in body organs and tissue.

ObjectivesThe aim of this study was to explore determinants of psychosocial distress and pain in patients who have survived severe extremity amputation in Gaza.SettingThis study was conducted in a secondary care rehabilitation centre in Gaza, Palestine. The clinic is Gaza’s sole provider of artificial limbs.ParticipantsWe included 254 civilian Palestinians who had survived but lost one or more limb(s) during military incursions from 2006 to 2016. We included patients with surgically treated amputation injuries who attended physical rehabilitation at a specialist prosthesis centre in Gaza. Amputees with injuries prior to 2006 or non-military related injuries were excluded.We assessed their pain and psychological stress using the General Health Questionnaire (GHQ-12). We used income, amputation severity scored by proximity to torso, current employment status, loss of family members and loss of home as independent variables.ResultsThe amputees median age was 23 years at the time of trauma, while a median of 4.3 years had passed from trauma to study inclusion. Nine of 10 were male, while 43 were children when they were amputated (17%≤18 years). One hundred and ninety-one (75%) were unemployed and 112 (44%) reported unemployment caused by being amputated. Pain was the most frequent problem, and 80 amputees (32%) reported to suffer from daily pain. Family income was significantly correlated with the physical pain (OR=0.54, CI 0.36 to 0.80, p=0.002). Psychological distress was higher among unemployed amputees (OR=1.36, CI 1.07 to 1.72, p=0.011). We found no association between psychological distress (GHQ-scores) and the extent of the initial amputation.ConclusionPain and psychological distress following war-related extremity amputation of one or more limbs correlated stronger with deteriorated family economy and being unemployed than with the anatomical and medical severity of extremity amputations.

Background In the past 10-15 years, thousands of civilians in Gaza have experienced conflict-related traumatic injuries. How injuries affect survivors' risks of negative long-term health effects and serious illness is unclear. We report follow-up findings in a group of patients with traumatic amputations.Methods Eligible patients had traumatically amputated limbs and showed signs and symptoms of possible serious illness on standardised clinical examination. The patients were all receiving rehabilitation treatment at the Artificial Limbs and Polio Centre, Gaza, which is the main provider of rehabilitation and protheses. All patients had suffered from at least one amputation during Israeli military incursions between 2006 and 2016. All were offered referral to the Al-Shifa Hospital, Gaza, for further diagnostic clinical, radiological, and laboratory tests. Each patient was examined by CT of the abdomen (or ultrasonography if CT could not be performed) and chest and MRI of the amputation stump or stumps. Laboratory analyses included ESR, complete blood count, kidney and liver function tests, serum glucose, creatine kinase, lactate dehydrogenase, and hepatitis B and hepatitis C virus infections.Findings Of 254 traumatically amputated patients assessed, 105 had signs and symptoms of possible serious illness, among whom 94 accepted referrals. 88 (93%) of 94 were men and the median age was 31.5 years, mean age 34 years (SD 9•6). Of 90 patients who had imaging, 19 (21%) patients had fatty liver infiltration, three (<1%) had lung nodules, and ten had lung atelectasis. Shrapnel was found in the chest of 12 patients (13%), the abdomen of five patients (6%), the scrotum of one patient (<1%), in the amputation stumps of 26 patients (29%), and the non-amputated limbs of eight patients (1%). Three (<1%) of 90 patients had liver lesions. 32 (34%) of 94 patients had elevated ESR, 19 (20%) had elevated liver enzyme concentrations, and 12 (13%) were anaemic. Two patients tested positive for hepatitis C virus and three were positive for hepatitis B virus (one with fatty liver changes). Two of the 19 patients with fatty liver infiltration were diagnosed as having type 2 diabetes. A limitation of this study is that, owing to conflict-related supply-chain issues in Gaza, we were unable to collect complete data in four (5%) of patients.Interpretation As well as residual shrapnel in more than half of patients, a notable proportion of patients had fatty liver infiltration, for which we have no clear hypothesis. We recommend close medical follow-up for trauma patients in injured by explosives.Funding The Norwegian street-artist AFK provided €1,500 to this project, which was used to cover patients' transportation costs. ContributorsAll authors contributed to the design of the methodology, project administration, investigation and data collection. MG supervised the research project. HH-L and AI did the data analysis. HH