Fig. 1
PRISMA flow diagram.
Fig. 2
Frequency of thoracic gunshot injuries per month and percentage of fatalities from thoracic GSW for studies with a low risk of bias.
Fig. 3
Frequency of thoracic gunshot injuries per month and percentage of fatalities from thoracic GSW for studies with a low and unclear risk of bias.
Tab. 1
Details of studies identified, thoracic GSW and fatalities
| Reference | Quality rating/Risk of bias | Operational theatre | Period | Population | No of thoracic GSW | % of thoracic wounds that GSW accounted for | % of GSW that thorax accounted for | Number/% of fatalities from thoracic GSW | % of fatalities from thoracic GSW | Remarks |
|---|---|---|---|---|---|---|---|---|---|---|
| (Oughterson et al. 1962) | Fair/Unclear | Bougainville | 15 Feb–21 Apr 1944 | US Army Ground forces | 85 | 40 | Accounted for 59.7% of deaths. | |||
| (Hopkins 1962) | Good/Low | New Georgia – Burma | Feb–June 1944 | 1st and 3rd battalion, 5307th Composite unit | 63 | 17 | 32 | 50.7 | ||
| (Tribby 1962) | Good/Unclear | Italy | 1944 | 1000 American Casualties KIA | 32 | Thoracic GSW accounted for 9% of all deaths | ||||
| (Herget et al. 1962) | Fair/Unclear | Korea | 15 Nov 1950–5 May 1951 | US Army | 37 | 6 | ||||
| (Brady 2003) | Good/Unclear | Vietnam | July 1967 – June 1969 | US Army | 51% | |||||
| (McNamara et al. 1970) | Fair/Unclear | Vietnam | Sept 1968–Nov 1969 | All Nationalities | 76 | 14 | ||||
| (Boyd 1975) | Good/Low | Belfast | 1972–1974 | Not detailed | 91 | 43 | 47.3 | |||
| (Moffat 1976) | Good/Low | Northern Ireland | 1971–1974 | British Serviceman | 118 | 17 | 48 | 40.7 | ||
| (Mabry et al. 2000) | Fair/Unclear | Somalia | 3–4 Oct 1993 | United States Army Ranger | 2 | 5 | ||||
| (Kosashvili et al. 2005) | Fair/Unclear | Israel | Mar 2002–Apr 2002 | Israeli defence force | 32 | 44 | Kevlar body armour | |||
| (Hinsley et al. 2005) | Poor/High | Iraq | 21 March and 4 April 2003, | Casualties treated at 202 field hospital | 3 | 10 | May include civilians | |||
| (Zouris et al. 2006) | Fair/Unclear | Iraq | Mar 23–Apr 30 2003 | US marines and sailors | 8.5 | |||||
| (Owens et al. 2008) | Fair/Unclear | Iraq and Afghanistan | Oct 2001–Jan 2005 | US service members | 19 | |||||
| (Ramasamy et al. 2009) | Fair/Unclear | Iraq | Jan–Oct 2006 | Iraq | 3 | |||||
| (Lewis 2006) | Good/Unclear | Iraq | Operation Telic–2006 | UK Military | 7 | |||||
| (Martin 2015)1 | Poor/Unclear | All theatres | 2001–2009 | Casualties in JTTR | ||||||
| (Popivanov et al. 2014) | Poor/High | Afghanistan | 2010 | Casualties presenting to Bulgarian Military hospital | 16 | 29 | May include civilians | |||
| (Belmont et al. 2010) | Fair/Unclear | Iraq | Iraq surge phase | US Army Brigade Combat Team, | 1.3 | |||||
| (Poon et al. 2013) | Fair/Unclear | Iraq and Afghanistan | Mar 2003–Mar 2011 | UK Military | 320 | 38.7 | 49 | 15.3 | ||
| (Penn-Barwell et al. 2016) | Good/Unclear | All Active theatres | Jan 2009–31 Dec 2013 | UK Military | 402 | 23 | 269 | 31 | ||
| (Stevenson et al. 2018) | Good/Low | Iraq and Afghanistan | 2003–2014 | UK military | 106 | 15 | 22 | 48 | 27 | |
| (Schauer et al. 2019) | Poor/Unclear | Iraq and Afghanistan | January 2007 to August 2016. | Casualties presenting to military emergency departments | 1087 | 16.3 | May include civilians | |||
| (Lesquen et al. 2016) | Poor/High | Afghanistan | 2009–2016 | Casualties admitted to French NATO combat support hospital | 47 | 53 | May include civilians |
Tab. A1
Criteria for the modified Newcastle-Ottawa Scale regarding star allocation to assess quality of studies
| Criteria | Acceptable (star awarded) | Unacceptable (star not awarded) |
|---|---|---|
| Representativeness of exposed cohort (*) | Population based | Hospital based |
| Civilians included | ||
| Ascertainment of exposure (*) | Trauma records | Anecdotal evidence |
| Comparability (**) | ** awarded for both number of casualties and number of fatalities comparable | No metrics comparable |
| * awarded for only one metric comparable | ||
| Assessment of outcome (*) | Trauma records | No outcome data |
Tab. A2
Quality assessment of studies using a modified Newcastle Ottawa Scale for assessing studies in the systematic review of military thoracic gunshot injuries
| Study ID | Selection | Comparability | Outcome | Total score (5*) | |
|---|---|---|---|---|---|
| Representativeness of exposed cohort (*) | Ascertainment of exposure (*) | (**) | Assessment of outcome(*) | ||
| (Herget et al. 1962) | * | * | * | 3 | |
| (Hopkins 1962) | * | * | ** | * | 5 |
| (Oughterson et al. 1962) | * | * | * | 3 | |
| (Tribby 1962) | * | * | ** | * | 5 |
| (McNamara et al. 1970) | * | * | * | 3 | |
| (Boyd 1975) | * | * | ** | * | 5 |
| (Moffat 1976) | * | * | ** | * | 5 |
| (Mabry et al. 2000) | * | * | * | 3 | |
| (Brady 2003) | * | * | * | * | 4 |
| (Kosashvili et al. 2005) | * | * | * | 3 | |
| (Hinsley et al. 2005) | * | * | 2 | ||
| (Lewis 2006) | * | * | ** | * | 5 |
| (Zouris et al. 2006) | * | * | * | 3 | |
| (Owens et al. 2008) | * | * | * | 3 | |
| (Ramasamy et al. 2009) | * | * | * | 3 | |
| (Belmont Jr et al. 2010) | * | * | * | 3 | |
| (Poon et al. 2013) | * | * | * | 3 | |
| (Popivanov et al. 2014) | * | * | 2 | ||
| (Martin 2015) | * | * | 2 | ||
| (Lesquen et al. 2016) | * | * | 2 | ||
| (Penn-Barwell et al. 2016) | * | * | ** | * | 5 |
| (Stevenson et al. 2018) | * | * | ** | * | 5 |
| (Schauer et al. 2019) | * | * | 2 |
[i] Total score:
,
,
Tab. A3
Risk of bias assessment using a modified Cochrane Tool
| Study ID | Allocation concealment (Selection bias) | Assessment of exposure (Performance bias) | Outcome of interest present at beginning (detection bias) | Incomplete data (attrition bias) | Selective reporting (reporting bias) | Total score* |
|---|---|---|---|---|---|---|
| (Herget et al. 1962) | + | + | + | ? | ? | 3 |
| (Hopkins 1962) | + | + | + | + | ? | 4 |
| (Oughterson et al. 1962) | + | + | + | ? | ? | 3 |
| (Tribby 1962) | + | + | + | ? | ? | 3 |
| (McNamara et al. 1970) | + | + | + | ? | ? | 3 |
| (Boyd 1975) | + | + | + | + | ? | 4 |
| (Moffat 1976) | + | + | + | + | ? | 4 |
| (Mabry et al. 2000) | + | + | + | ? | ? | 3 |
| (Brady 2003) | + | + | + | ? | ? | 3 |
| (Kosashvili et al. 2005) | + | + | + | ? | ? | 3 |
| (Hinsley et al. 2005) | − | + | + | ? | ? | 2 |
| (Lewis 2006) | + | + | + | ? | ? | 3 |
| (Zouris et al. 2006) | + | + | + | ? | ? | 3 |
| (Owens et al. 2008) | + | + | + | ? | ? | 3 |
| (Ramasamy et al. 2009) | + | + | + | ? | ? | 3 |
| (Belmont Jr et al. 2010) | + | + | + | ? | ? | 3 |
| (Poon et al. 2013) | + | + | + | ? | ? | 3 |
| (Popivanov et al. 2014) | − | + | + | ? | ? | 2 |
| (Martin 2015) | + | + | + | ? | ? | 3 |
| (Lesquen et al. 2016) | − | + | + | ? | ? | 2 |
| (Penn-Barwell et al. 2016) | − | + | + | + | ? | 3 |
| (Stevenson et al. 2018) | + | + | + | + | ? | 4 |
| (Schauer et al. 2019) | + | + | + | ? | ? | 3 |
= Low risk of bias,
= Unclear risk of bias,
= High risk of bias.