IntroductionThe Israel Defense Forces (IDF) has strict protocols for the diagnosis and treatment of stress fractures wherein diagnosis is clinical with imaging used for persistent symptoms only. The purpose of this study was to examine the incidence of clinical and radiological stress fractures during IDF combat training.MethodsMedical records of all soldiers enlisted to combat training between 2014 and 2017 were scanned for the diagnosis of stress fractures. We examined the imaging tests ordered (plain radiographs and bone scans) and their results and the time between the clinical diagnosis to imaging tests.ResultsDuring 4 years, 62 371 soldiers (10.1% women) had started combat training, and 3672 of them (5.9%) were diagnosed with clinical stress fractures. Radiographs were ordered for 53.5% of those diagnosed, of whom 29.7% also had a bone scan. Some 42% of radiographs were taken within 21 days. Radiographs were positive for stress fractures in 11.1% of tests. Bone scans showed evidence of stress fractures in 49.7%, of which 49.2% diagnosed stress fractures in multiple bones.ConclusionThe high percentage of negative radiographs may indicate towards alternative causes for symptoms. Performing the radiograph before or after 21 days did not affect workup results diverting from current belief that later radiographs will be more sensitive. Multiple stress fractures are a common finding, indicating that the increased training load puts the whole musculoskeletal system at increased risk for injury. Research results may necessitate a revision of clinical guidelines for the diagnosis of stress fractures in military trainees.

Background Attrition from combat service carries significant organizational and personal ramifications, but predicting factors associated with attrition remains challenging. Aims To evaluate medical and psychosocial factors associated with attrition from basic combat training (BCT) in the Israel Defense Forces (IDF). In addition, we identify subsets of the recruit population which exhibit certain trends in terms of medical corresponding with a high risk of attrition. Methods A cross-sectional study of IDF combat trainees undergoing infantry BCT between 2012 and 2017. Data were collected from the soldiers’ electronic medical and administrative records. We used multivariable logistic regression and the SAS® decision-tree tool to analyse key predictive factors for attrition. Results A total of 46 472 soldiers enlisted to BCT during the research period. The mean body mass index (BMI) was 21.8 (SD 3.54). The overall attrition rate was 10%. The following factors were associated with attrition from BCT: ethnicity (P < 0.01), BMI (P < 0.01), pre-enlisting motivation score (P < 0.01) and the number of mental health officer visits (P < 0.01). Using a decision-tree model, we found a high attrition rate among soldiers who had >5.2 to primary care physician visits (11% attrition rate versus 3%) or more than 11 sick leave days (59% versus 19%). Conclusions This study sheds light on unique measures relating to attrition. Attrition is associated with several demographic and psychosocial factors. Early prediction of motivation and monitoring of healthcare utilization may enable early identification and focused interventions targeting soldiers at high risk for attrition. These findings need to be further translated into actionable directives and further investigations.

<b><i>Background:</i></b> The effects of high-risk environment on young adults with mild asthma were never fully tested in practice, as most high-risk occupations do not welcome them. This study examines the effect of combat training on asthma worsening in the Israeli Defense Forces. <b><i>Methods:</i></b> Persons with asthma in remission and mild intermittent asthma who underwent combat training between 2014 and 2017 were compared in terms of disease worsening to their counterparts performing clerical duties during a follow-up of 8 months. Among combat trainees, exposure to known triggers for asthma exacerbation and health status on enlistment were assessed as risk factors for asthma exacerbation. <b><i>Results:</i></b> Asthma worsening among persons with asthma in remission was twice as common among those who are undergoing training compared to persons performing clerical duties. This difference was smaller among mild intermittent asthmatics. For both asthma severities, rates of asthma exacerbation requiring emergency room treatment were several times higher among the training group. Among individuals undergoing training, mild intermittent asthma was a significant risk factor for asthma worsening compared to asthma in remission (OR 1.99 [1.44–2.75]) while age (OR 0.67 [0.53–0.85]) and immigration to Israel (OR 0.55 [0.31–0.95]) were significant protective factors. <b><i>Interpretation:</i></b> Young adults with mild asthma are at significant risk for severe exacerbations when exposed to high-risk environment even among individuals who have long been symptom free. No single risk factor was found to have an independent effect suggesting a synergistic mechanism that is harder to mitigate.