title: Systematic review of the prevalence and characteristics of battle casualties from NATO coalition forces in Iraq and Afghanistan.
abstract: BACKGROUND
  The North Atlantic Treaty Organization (NATO) coalition forces remain heavily committed on combat operations overseas. Understanding the prevalence and characteristics of battlefield injury of coalition partners is vital to combat casualty care performance improvement. The aim of this systematic review was to evaluate the prevalence and characteristics of battle casualties from NATO coalition partners in Iraq and Afghanistan. The primary outcome was mechanism of injury and the secondary outcome anatomical distribution of wounds.
  
  
  METHODS
  This systematic review was performed based on all cohort studies concerning prevalence and characteristics of battlefield injury of coalition forces from Iraq and Afghanistan up to December 20th 2013. Studies were rated on the level of evidence provided according to criteria by the Centre for Evidence Based Medicine in Oxford. The methodological quality of observational comparative studies was assessed by the modified Newcastle-Ottawa Scale.
  
  
  RESULTS
  Eight published articles, encompassing a total of n=19,750 battle casualties, were systematically analyzed to achieve a summated outcome. There was heterogeneity among the included studies and there were major differences in inclusion and exclusion criteria regarding the target population among the included trials, introducing bias. The overall distribution in mechanism of injury was 18% gunshot wounds, 72% explosions and other 10%. The overall anatomical distribution of wounds was head and neck 31%, truncal 27%, extremity 39% and other 3%.
  
  
  CONCLUSIONS
  The mechanism of injury and anatomical distribution of wounds observed in the published articles by NATO coalition partners regarding Iraq and Afghanistan differ from previous campaigns. There was a significant increase in the use of explosive mechanisms and a significant increase in the head and neck region compared with previous wars.
authors.affiliation: Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands. Electronic address: r.hoencamp@lumc.nl.
authors.forename: Rigo
authors.initials: R
authors.lastname: Hoencamp
authors.affiliation: Leiden University Medical Centre, Military Mental Health Research, Utrecht, The Netherlands. Electronic address: hgjm.vermetten@mindef.nl.
authors.forename: Eric
authors.initials: E
authors.lastname: Vermetten
authors.affiliation: Department of Surgery-Trauma Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands. Electronic address: edward.tan@radboudumc.nl.
authors.forename: Edward C T H
authors.initials: EC
authors.lastname: Tan
authors.affiliation: Department of Statistics and Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands. Electronic address: h.putter@lumc.nl.
authors.forename: Hein
authors.initials: H
authors.lastname: Putter
authors.affiliation: Department of Surgery, University Medical Centre, Utrecht, The Netherlands. Electronic address: l.p.h.leenen@umcutrecht.nl.
authors.forename: Luke P H
authors.initials: LP
authors.lastname: Leenen
authors.affiliation: Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands. Electronic address: j.f.hamming@lumc.nl.
authors.forename: Jaap F
authors.initials: JF
authors.lastname: Hamming
mesh_terms: D055826:Afghan Campaign 2001-; D001753:Blast Injuries / Q000453:epidemiology* / Q000473:pathology / Q000517:prevention & control; D006801:Humans; D015601:Injury Severity Score; D054542:Iraq War, 2003-2011; D008887:Military Medicine; D008889:Military Personnel; D015995:Prevalence; D011482:Protective Devices / Q000706:statistics & numerical data*; D014481:United States; D014948:Wounds, Gunshot / Q000453:epidemiology* / Q000473:pathology / Q000517:prevention & control
keywords: Battle; Combat; Explosive; Military; Systematic review; Wound