The symmetry rule: a seven-year study of symptoms and explanatory labels among Gulf War veterans

Noticing medical symptoms can cause one to search for explanatory labels such as "ate bad food" or even "exposed to anthrax," and perhaps these labels may cause new symptom reports. The present study examined whether there is empirical support for this symptom-label "symmetry rule." We interviewed veterans (N= 362) from the Gulf War Registry in 1995 and 2002 about their medical symptoms and about their exposure to war-related hazards and stressors. Health symptom reports were strongly correlated between the two time periods and showed relatively stable mean levels, whereas recall of war-related exposures was notably unstable. Veterans starting with fewer medical symptoms recalled fewer war-related exposures seven years later. Initial recollection of chemical and biological warfare exposure (but not other exposures) longitudinally predicted novel medical symptoms. The findings generally support the symmetry rule hypotheses, although the evidence for the label to symptom link was less strong. The findings account for some variability in symptoms and exposure recall over time, but they do not, on their own, account for the Gulf War veterans' elevated number of unexplained medical symptoms.

Cutaneous and Ocular Late Complications of Sulfur Mustard in Iranian Veterans

Although sulfur mustard (SM) has been used as a chemical warfare agent since the early twentieth century, it has reemerged in the past decade as a major threat around the world. This agent injured over 100,000 Iranians and one-third is suffering from late effects until today. Mustard affects many organs such as the skin, eyes, and lungs, as well as the gastrointestinal, endocrine, and hematopoietic system. In this study we focused on review of the late Cutaneous and ocular complications caused by exposure to SM. All studies regarding long-term ocular and cutaneous effects, which have been done on Iranian population, were collected from domestic and international sources. Pruritus is the most common complain and a malignant change is the most important lesion, which has to be considered. Also this agent is causes of chronic and delayed destructive lesions in the ocular surface and cornea, leading to progressive visual deterioration and ocular irritation.

Chemical exposure preparedness for emergency departments in a Midwestern city

OBJECTIVE

To determine if each hospital in a large Midwestern city has the resources to treat 50 patients exposed to terrorist chemical agents and/or industrial chemicals.

DESIGN

Surveys specific to each department were sent to emergency department (ED) nursing supervisors, safety officers, and pharmacy directors of each hospital.

SETTING

The survey was performed in a large Midwestern city (metropolitan population of 1,500,000).

PARTICIPANTS

Nine hospitals.

MAIN OUTCOME MEASURES

The survey measured the presence of written materials, amount of equipment, quantities of pharmaceuticals, and number of staff available in each hospital. Hospital staff also rated the preparedness of their hospital.

RESULTS

Twelve of the 27 respondents returned the survey for a response rate of 44 percent. None of the EDs had a known cooperative written plan with the police or fire departments. Three safety officers reported limited numbers of hospital security personnel and a total of 35 ventilators for respiratory failure. The four pharmacy directors reported limited sum doses of atropine (315), cyanide antidote (10 complete kits), and succimer (100). Respondents who felt qualified to evaluate the ED gave a mean score of 5.4 on a scale of 1-10 when asked how prepared they felt their ED was to treat 50 chemical exposure patients.

CONCLUSIONS

Despite hospital staff rating chemical exposure preparedness as 5.4, it is unlikely that each hospital could handle 50 patients exposed to some chemicals due to lack of prearranged coordination, security, antidotes, and ventilators.

Terror Australis 2004: preparedness of Australian hospitals for disasters and incidents involving chemical, biological and radiological agents

OBJECTIVE

To assess the level of preparedness of Australian hospitals, as perceived by senior emergency department physicians, for chemical, biological and radiological (CBR) incidents, as well as the resources and training available to their departments.

METHODS

Detailed questionnaires were mailed to the directors of the 86 hospital emergency departments (EDs) in Australia accredited by the Australasian College for Emergency Medicine. Questions covered hospital planning, available resources and training, and perceived preparedness.

RESULTS

Responses were received from 76 departments (88%): 73 reported that their ED had a disaster plan, with 60 (79%) having a contingency plan for chemical, 57 (75%) for biological, and 53 (70%) for radiological incidents. Specific staff training for managing patients from a conventional mass casualty incident was given in 83% of EDs, falling to 66% for a CBR incident. Forty-three per cent reported that their plan involved staff managing contaminated patients, but availability of personal protective equipment and decontamination facilities varied widely. Although 41% believed their ED could cope with a maximum of 20 patients in the first 2 hours after a conventional incident, this increased to 71% for a CBR incident. Staff training was considered the main funding priority (59%).

CONCLUSIONS

This survey raises significant questions about the level of preparedness of Australian EDs for dealing with patients from both conventional and CBR incidents. Hospitals need to review their plans and functionality openly and objectively to ensure that their perceived preparedness is consistent with reality. In addition, they urgently require guidance as to reasonable expectations of their capacity. To that end, we recommend further development of national standards in hospital disaster planning and preparedness.

Chemical warfare and medical response during World War I

The first large-scale use of a traditional weapon of mass destruction (chemical, biological, or nuclear) involved the successful deployment of chemical weapons during World War I (1914-1918). Historians now refer to the Great War as the chemist's war because of the scientific and engineering mobilization efforts by the major belligerents. The development, production, and deployment of war gases such as chlorine, phosgene, and mustard created a new and complex public health threat that endangered not only soldiers and civilians on the battlefield but also chemical workers on the home front involved in the large-scale manufacturing processes. The story of chemical weapons research and development during that war provides useful insights for current public health practitioners faced with a possible chemical weapons attack against civilian or military populations.

Standoff detection of chemical and biological threats using laser-induced breakdown spectroscopy

Laser-induced breakdown spectroscopy (LIBS) is a promising technique for real-time chemical and biological warfare agent detection in the field. We have demonstrated the detection and discrimination of the biological warfare agent surrogates Bacillus subtilis (BG) (2% false negatives, 0% false positives) and ovalbumin (0% false negatives, 1% false positives) at 20 meters using standoff laser-induced breakdown spectroscopy (ST-LIBS) and linear correlation. Unknown interferent samples (not included in the model), samples on different substrates, and mixtures of BG and Arizona road dust have been classified with reasonable success using partial least squares discriminant analysis (PLS-DA). A few of the samples tested such as the soot (not included in the model) and the 25% BG:75% dust mixture resulted in a significant number of false positives or false negatives, respectively. Our preliminary results indicate that while LIBS is able to discriminate biomaterials with similar elemental compositions at standoff distances based on differences in key intensity ratios, further work is needed to reduce the number of false positives/negatives by refining the PLS-DA model to include a sufficient range of material classes and carefully selecting a detection threshold. In addition, we have demonstrated that LIBS can distinguish five different organophosphate nerve agent simulants at 20 meters, despite their similar stoichiometric formulas. Finally, a combined PLS-DA model for chemical, biological, and explosives detection using a single ST-LIBS sensor has been developed in order to demonstrate the potential of standoff LIBS for universal hazardous materials detection.

[Background of a new delineation of the medical profession]

The survival of mankind is jeopardized in a hitherto unprecedented manner by the three global-scale interacting worldillnesses, i.e., overpopulation, environmental deterioration, and the extermination potential of the modern arsenals of atomic, biologic and chemical weapons. These self-created hazards should appeal to new accountability, to a rethinking of our medical duties and actions. With their consequences they form the background of a new delineation of the medical profession.

Enhancing public health preparedness for a terrorist attack involving cyanide

The US government considers cyanide to be among the most likely agents of chemical terrorism. Cyanide differs from many other biological or chemical agents for which little or no defense is available because its individual and public health effects are largely remediable through appropriate preparedness and response. Because the toxicity of the cyanide antidote currently available in the United States renders it ill-suited for use in terrorist incidents and other situations requiring rapid out-of-hospital treatment, hydroxocobalamin--an effective and safe cyanide antidote being used in other countries--has been introduced in the United States. Unlike the other available cyanide antidote, hydroxocobalamin can be administered at the scene of a cyanide disaster, and it need not be reserved for cases of confirmed cyanide poisoning but can be administered in cases of suspected poisoning. Both of these attributes facilitate the rapid intervention necessary for saving lives. To realize the potential benefits of hydroxocobalamin, progress also needs to be realized in other aspects of readiness, including but not limited to developing plans for ensuring local and regional availability of antidote, educating emergency responders and health care professionals in the recognition and management of cyanide poisoning, and raising public awareness of the potential for a chemical weapons attack and of how to respond.

Disasters and mass casualties: II. explosive, biologic, chemical, and nuclear agents

Terrorists' use of explosive, biologic, chemical, and nuclear agents constitutes the potential for catastrophic events. Understanding the unique aspects of these agents can help in preparing for such disasters with the intent of mitigating injury and loss of life. Explosive agents continue to be the most common weapons of terrorists and the most prevalent cause of injuries and fatalities. Knowledge of blast pathomechanics and patterns of injury allows for improved diagnostic and treatment strategies. A practical understanding of potential biologic, chemical, and nuclear agents, their attendant clinical symptoms, and recommended management strategies is an important prerequisite for optimal preparation and response to these less frequently used agents of mass casualty. Orthopaedic surgeons should be aware of the principles of management of catastrophic events. Stress is less an issue when one is adequately prepared. Decontamination is essential both to manage victims and prevent further spread of toxic agents to first responders and medical personnel. It is important to assess the risk of potential threats, thereby allowing disaster planning and preparation to be proportional and aligned with the actual casualty event.

The occupational role of women in military service: validation of occupation and prevalence of exposures in the Millennium Cohort Study

To better understand the US military's global peacekeeping and combat operations, which may expose a growing population of American service women to challenging occupations and environments. Concordance between self-reported and electronic occupation codes for female participants in the Millennium Cohort was measured using kappa statistics. Multivariable logistic regression modeling was used to assess the odds of five self-reported potentially toxic environmental exposures or disturbing experiences among different occupational categories, while adjusting for demographic and military characteristics, including deployment. Self-reported occupations were moderately to highly reliable when compared with electronic occupation data. Active-duty and Reserve/Guard females differentially reported witnessing death or trauma and exposure to chemical or biological warfare, depleted uranium, or pesticides. Findings suggest that self-reported occupation can be used with a high degree of confidence. Occupational groups with higher odds of reporting military exposures of concern will be followed longitudinally through 2022 and prospectively compared using baseline and follow-up evaluations.

Emergency department personal protective equipment requirements following out-of-hospital chemical biological or radiological events in Australasia

Recent events have led to a revision in ED equipment, preparedness and training for disasters. However, clinicians must still decide when, and what level of personal protection is required when a toxic threat exists. If possible, clear, simple and achievable protocols are required in such situations. Following an off‐site Australasian chemical biological or radiological incident, current evidence indicates that the initial receiving ED staff will be adequately protected from all known chemical biological and radiological inhalational threats by wearing a properly fitted P2 (N95) mask, or its equivalent. Protection from serious contact injury is offered by wearing double gloves, disposable fluid‐repellent coveralls or gown, eye protection, surgical mask, and ideally, a cap and shoe covers; in conjunction with universal precautions and procedures.

The Janus faces of botulinum neurotoxin: sensational medicine and deadly biological weapon

The botulinum neurotoxins are the most dangerous toxins known (BoNTs serotypes A-G) and induce profound flaccid neuromuscular paralysis by blocking nerve-muscle communication. Poisoned motoneurons react by emitting a sprouting network known to establish novel functional synapses with the abutting muscle fiber. Understanding how our motoneurons are capable of bypassing such transmission blockade, thereby overcoming paralysis, by an astonishing display of plasticity is one of the research goals that have numerous therapeutic ramifications. This Mini-Review aims at giving a brief update on the recent discoveries regarding the molecular mechanism of botulinum toxins intoxication. Curing botulism still is a challenge once the toxin has found his way inside motoneurons. In view of the potential use of botulinum toxins as biological weapon, more research is needed to find efficient ways of curing this disease.

Nonconventional terror--the anesthesiologist's role in a nerve agent event

The structure and biologic action of nerve agents is similar to organophosphates, commonly used as insecticides. Acetylcholine accumulation and binding to the cholinergic receptor site stimulates the affected organs producing a predictable set of clinical symptoms. Treatment of the affected patients will include decontamination, respiratory and hemodynamic support, as well as specific antidotes. The multiple casualties that may be expected present additional logistical and organizational problems. The specific skills of anesthesiologists will make them invaluable members of the care team in such a chemical mass casualty event.

[Cyanides--treatment beneath the shade of terror]

Although the use of cyanides as warfare agents has not been documented since the Iran-Iraq war in the 1980s, there are rising fears of cyanide being used by terrorists. An Al-Qaeda terror plot to use cyanide gas in the London Underground was foiled in 2002. The threat of similar events becomes more imminent in light of the terror attacks in our country and worldwide, accompanied by statements and threats by fundamentalist leaders to employ chemical weapons. Therefore, mass-intoxication with cyanides is not merely a hypothetical scenario. The treatment of cyanide poisoning is under constant evaluation and there is no international consensus on the subject. The medical treatment of victims at the scene and in hospitals should be rapid and efficient. Current treatment dictates establishing an intravenous line and a slow rate of administration of antidotes. Both demands are not feasible in this specific mass casualty event. The clinical signs of cyanide poisoning are complex, variable and not necessarily obvious for the medical team. There is great interest in reconsidering the existing treatment protocols for cyanide intoxication in light of current research. This review describes the mechanisms of cyanide toxicity, clinical signs of exposure, and current treatment protocols in use worldwide. On the basis of this evidence we suggest a medical treatment protocol for a mass casualty event caused by cyanide.

Cold and Heat Strain during Cold-Weather Field Training with Nuclear, Biological, and Chemical Protective Clothing

The objective of this study was to quantify the thermal strain of soldiers wearing nuclear, biological, and chemical protective clothing during short-term field training in cold conditions. Eleven male subjects performed marching exercises at moderate and heavy activity levels for 60 minutes. Rectal temperature (Tre), skin temperatures, and heart rate were monitored. Ambient temperature (Ta) varied from -33 to 0 degrees C. Tre was affected by changes in metabolism, rather than in Ta. Tre increased above 38 degrees during heavy exercise even at -33 degrees C. The mean skin temperature decreased to tolerance level (25 degrees C) at Ta below -25 degrees C with moderate exercise. Finger temperature decreased below 15 degrees C (performance degradation) at Ta of -15 degrees C or cooler. The present results from the field confirm the previous results based on laboratory studies and show that risk of both heat and cold strain is evident, with cooling of extremities being most critical, while wearing nuclear, biological, and chemical protective clothing during cold-weather training.

Chemical or biological terrorist attacks: an analysis of the preparedness of hospitals for managing victims affected by chemical or biological weapons of mass destruction

The possibility of a terrorist attack employing the use of chemical or biological weapons of mass destruction (WMD) on American soil is no longer an empty threat, it has become a reality. A WMD is defined as any weapon with the capacity to inflict death and destruction on such a massive scale that its very presence in the hands of hostile forces is a grievous threat. Events of the past few years including the bombing of the World Trade Center in 1993, the Murrah Federal Building in Oklahoma City in 1995 and the use of planes as guided missiles directed into the Pentagon and New York's Twin Towers in 2001 (9/11) and the tragic incidents involving twentythree people who were infected and five who died as a result of contact with anthrax-laced mail in the Fall of 2001, have well established that the United States can be attacked by both domestic and international terrorists without warning or provocation. In light of these actions, hospitals have been working vigorously to ensure that they would be "ready" in the event of another terrorist attack to provide appropriate medical care to victims. However, according to a recent United States General Accounting Office (GAO) nationwide survey, our nation's hospitals still are not prepared to manage mass causalities resulting from chemical or biological WMD. Therefore, there is a clear need for information about current hospital preparedness in order to provide a foundation for systematic planning and broader discussions about relative cost, probable effectiveness, environmental impact and overall societal priorities. Hence, the aim of this research was to examine the current preparedness of hospitals in the State of Mississippi to manage victims of terrorist attacks involving chemical or biological WMD. All acute care hospitals in the State were selected for inclusion in this study. Both quantitative and qualitative methods were utilized for data collection and analysis. Six hypotheses were tested. Using a questionnaire survey, the availability of functional preparedness plans, specific preparedness education/training, decontamination facilities, surge capacity, pharmaceutical supplies, and laboratory diagnostic capabilities of hospitals were examined. The findings revealed that a majority (89.2%) of hospitals in the State of Mississippi have documented preparedness plans, provided specific preparedness education/training (89.2%), have dedicated facilities for decontamination (75.7%), and pharmaceutical plans and supplies (56.8%) for the treatment of victims in the event of a disaster involving chemical or biological WMD. However, over half (59.5%) of the hospitals could not increase surge capacity (supplies, equipment, staff, patient beds, etc.) and lack appropriate laboratory diagnostic services (91.9%) capable of analyzing and identifying WMD. In general, hospitals in the State of Mississippi, like a number of hospitals throughout the United States, are still not adequately prepared to manage victims of terrorist attacks involving chemical or biological WMD which consequently may result in the loss of hundreds or even thousands of lives. Therefore, hospitals continue to require substantial resources at the local, State, and national levels in order to be "truly" prepared.

[Logistic preparedness of chosen urban agglomeration hospitals to act during massive chemical disasters]

Twelve hospitals--five form Warsaw, three from Kraków, and four from Gdańsk and Gdynia were randomized for the study. The logistic preparedness of hospitals during massive chemical accidents has been investigated. There were 146 probands (9 managers, 31 ward heads, 75 assistants and 31 ward nurses) included in the study. In statistical analysis the generalized linear model extended by random factors, particularly the Poisson's regression has been used. No hospital in the three big cities in the country was prepared for any logistic action in case of massive chemical disaster. There were no stationary and mobile decontamination units in the investigated hospitals. There was no individual protective equipment in any of the analyzed hospitals. There were serious deficits in assortment and amount of antidotes which can be used in the treatment of contaminated patients. As much as 97.2% of respondents pointed the poison information centers as a main source of information in case of chemical accidents.

[Essential preparedness of physician to act during massive chemical disasters]

The aim of the study was the evaluation of some aspects of doctors knowledge about the treatment in case of massive chemical accidents. The study was conducted in twelve hospitals in Kraków, Warsaw, and the Triple City. There were 106 doctors (31 ward heads and 75 assistants) included in the study. The questions contained some aspects of: external decontamination, the usage of 0.5% of sodium hypochlorite, the knowledge about the use of selected antidotes and the symptoms of chosen toxidromes. In statistical analysis the generalized linear model extended by random factors, particularly the Poisson's regression was used. The results confirm, that the medical staff is not well prepared to take an effective action in case of a chemical contamination. The essential knowledge of the medical staff in all investigated aspects of chemical safety has been found out to be not satisfactory. There is an urgent need for medical staff to undergo theoretical and practical courses about toxicity of major chemicals. The clinical toxicologists should be asked to prepare up-to-date, advanced methods and regulations for life support in case of heavy chemical accidents.

Arsenic in sediments from the southeastern Baltic Sea

Arsenic occurs as a persistent constituent in many of the chemical weapons dumped into the Baltic Sea; it can be used as an indicator of leakage and dispersal of released munitions to the marine environment. Total arsenic was analysed in sediment samples taken from the Lithuanian economic zone in the Baltic Sea, which included samples from the chemical munitions dumpsite in the Gotland Basin and national monitoring stations in the southeastern Baltic Sea. Arsenic concentrations in sediments ranged from 1.1 to 19.0 mg kg(-1), with an average of 3.4 mg kg(-1). Although there was evidence of slightly elevated arsenic content in sediments near the weapons dumpsite, arsenic concentrations were nevertheless quite low relative to other investigations in the Baltic and North Seas.

Health-related quality of life in patients with chemical warfare-induced chronic obstructive pulmonary disease

BACKGROUND

It is well known that inhalation of chemical warfare, mostly sulfur mustard, causes injury of the respiratory system. Chronic obstructive pulmonary disease is a common disease among these patients. Health-related quality of life is a common feature of studies in chronic obstructive pulmonary disease. The objective of our study was to assess the quality of life in these patients.

METHODS

A total of 43 male patients with stable chronic obstructive pulmonary disease due to chemical gas injury were enrolled into this study. Severity of disease was defined by the global initiative for chronic obstructive lung disease (GOLD) guideline. Health-related quality of life was assessed using the St George Respiratory Questionnaire. Symptoms, activity, impact, and total score were calculated for each patient.

RESULTS

The mean +/- SD age of patients was 42.5 +/- 7.4 years. According to the GOLD guideline, most (72%) of the patients were in stage 2 (mean: FEV1 1.9 +/- 0.75 L, 53.1% +/- 18.5% predicted). The mean +/- SD scores for each section of the St George Respiratory Questionnaire were 77.9 +/- 16.3 for "symptoms;" 70.2 +/- 19.6 for "activity;" 57.8 +/- 22.5 for "impact", and 64.9 +/- 19.5 as the "total score." There was a reverse correlation between FEV1 (% predicted) with symptoms (r = -0.47), activity (r = -0.61), impact (r = -0.44), and total score (r = -0.51) of the St George Respiratory Questionnaire.

CONCLUSION

This study showed that lower lung functions as assessed by the St George Respiratory Questionnaire worsen the quality of life in patients with chemical warfare-induced chronic obstructive pulmonary disease.

Myocardial perfusion abnormalities in chemical warfare patients intoxicated with mustard gas

BACKGROUND

Mustard agents are of the major chemical agents used during Iran-Iraq war. There are no reports concerning long-term cardiac effects. The aim was to assess the scintigraphic pattern of myocardial perfusion in patients intoxicated with blistering gases.

METHOD

We analyzed myocardial perfusion scans of 22 consecutive intoxicated patients (21 male and 1 female, all < 44 years) and compared results with 14 controls. Only those patients and controls were entered whose 10-year risk of coronary artery disease (Framingham criteria) was <5%. Also only those patients were experimented upon that had currently other confirmed complications of intoxication (respiratory, cutaneous and ocular complications). All patients underwent a 1-day stress and rest protocol using (99m)Tc-MIBI. Images were assessed visually and quantitatively using Cedars Sinai program.

RESULTS

The prevalence of nonhomogeneity of uptake and left and right ventricular enlargement in both visual and quantitative analyses were higher in the mustard exposed patients than unexposed controls. The prevalence of ischemia was higher in the exposed patients (P < 0.05). Cavity to myocardium ratio, as an established and validated measure of ejection fraction, was also significantly lower in the warfare patients than the controls.

CONCLUSION

In so far it lies in our knowledge, this is the first report concerning the scintigraphic pattern of myocardial perfusion in mustard intoxicated patients. Based on the results, the pattern of myocardial perfusion in these patients is significantly different from normal controls, which could resemble either coronary artery disease or mild cardiomyopathic changes.

Options for the Destruction of Chemical Weapons and Management of the Associated Risks

The destruction of chemical weapons is a hazardous operation. The degree of hazard posed, however, is not uniform and is dependent on the specific chemical agent and the configuration of the weapon or bulk storage vessel in which it is contained. For example, a highly volatile nerve agent in an explosively configured munition, such as a rocket, poses a very different hazard from that of a bulk storage container of viscous mustard gas. Equally the handling of recovered, often highly corroded, World War (WW)I or WWII chemical munitions will pose a very different hazard from that associated with dealing with modern chemical weapons stored under the appropriate conditions. Over the years, a number of technologies have been developed for the destruction of chemical weapons. Each has its advantages and disadvantages. None of them provide a universal solution to the problem. When assessing options for the destruction of these weapons and the management of the associated risks, therefore, it is important to give due consideration and weight to these differences. To ensure that the destruction technology selected takes due account of them and that the resulting overall risk assessment accurately reflects the actual risks involved.

Health and Environmental Threats Associated with the Destruction of Chemical Weapons

Still existing arsenals of chemical weapons (CW) pose not only security threats for possible use in hostilities by state actors or misuse by terrorists but also safety threats to humans and biota due to leakages and possible accidents. The Chemical Weapons Convention (CWC) commits the States Parties (SPs) to destroy CW using technologies taking into consideration human health and environmental protection. It does not allow methods, routinely used up to the 1970s, such as earth burial, open-pit burning, and sea dumping. Long-term health and environmental threats and some accidents that have already occurred in the known localities of the sea-dumped and earth-buried arsenals of Nazi-German armed forces in the Baltic Region and of Imperial Japanese forces in the Far East Region are analyzed according to the impact of major CW and ammunition types (i.e., sulfur mustard--HD, tabun--GA, arsenicals--DA, DC, DM, arsine oil, and chloroacetophenone--CN). Any possible operations and handling with CW envisaged by the CWC as well as their verification are summarized taking into account the health threat they pose. CW and toxic armament waste to be destroyed and applied technologies (both developed and under current use in operational CW destruction facilities [CWDF]) are reviewed as are systems of health safety and environmental protection of the destruction/demilitarization stems from the extraordinary high toxicity of supertoxic lethal agents in man and biota. Problems of currently used Russian and U.S. standards for maximum allowable workplace concentrations and general population limits and possibilities of their determination by available analytical instrumentation are discussed.

Airborne exposure limits for chemical and biological warfare agents: is everything set and clear?

Emergency response strategies (guidelines) for biological, chemical, nuclear, or radiological terrorist events should be based on scientifically established exposure limits for all the agents or materials involved. In the case of a radiological terrorist event, emergency response guidelines (ERG) have been worked out. In the case of a terrorist event with the use of chemical warfare (CW) agents the situation is not that clear, though the new guidelines and clean-up values are being generated based on re-evaluation of toxicological and risk data. For biological warfare (BW) agents, such guidelines do not yet exist. In this paper the current status of airborne exposure limits (AELs) for chemical and biological warfare (CBW) agents are reviewed. Particular emphasis is put on BW agents that lack such data. An efficient, temporary solution to bridge the gap in experimental infectious data and to set provisional AELs for BW agents is suggested. It is based on mathematically generated risks of infection for BW agents grouped by their alleged ID50 values in three categories: with low, intermediate and high ID50 values.

Strategic National Stockpile Program: Implications for Military Medicine

The Strategic National Stockpile (SNS) program, managed by the Centers for Disease Control and Prevention, Department of Health and Human Services, is designed to deliver critical medical resources to the site of a national emergency. A recent interagency agreement between the Department of Defense and the Department of Health and Human Services indicates that military medical treatment facility commanders should be actively engaged in cooperative planning with local and state public health officials, so that reception, storage, distribution, and dispensing of SNS materials as a consequence of an actual event could occur without disruption or delay. This article describes the SNS program and discusses issues of relevance to medical treatment facility commanders and Department of Defense medical planners and logisticians.

Analyzing acute-chemical-release data to describe chemicals that may be used as weapons of terrorism

The authors analyzed a database of acute chemical releases to describe characteristics of chemicals that may be used as weapons of terrorism. Chemicals of primary concern (Priority I) on the Chemical Terrorism Listing of the Centers for Disease Control and Prevention were cross-referenced with data for 1993-2002 from the Hazardous Substances Emergency Events Surveillance (HSEES) system. HSEES captured 58,043 single-substance releases of 2,366 chemicals during this time period. The 48 Priority I chemicals accounted for 11,567 (20 percent) of the releases, while representing only 2.0 percent of reported chemicals. Events involving Priority I chemicals resulted in twice as many victims, more injured members of the general public, more victims treated at hospitals, a higher frequency of respiratory irritation, more evacuations, more people evacuated per event, and more decontaminations than did all other HSEES events. Industry, responders, and hospitals should consider the results of this analysis in preparing for and responding to acute chemical releases.

Are Surgical Residents Prepared for Mass Casualty Incidents?

OBJECTIVE

We hypothesized that resident education is inadequate with respect to management of mass casualty incidents that may involve chemical, biological, and nuclear exposures.

METHODS

Chief level residents in surgery (n = 10), emergency medicine (n = 10), and anesthesia (n = 8) were asked to complete a survey questionnaire. Responses were tabulated and statistically analyzed with Mann-Whitney Rank Sum, Student's t test, and Kruskal-Wallis one-way analysis of variance.

RESULTS

All of the residents were similar with respect to age, sex, and intended setting of clinical practice. Only a single resident reported military experience. Two residents (7.1%) had administered medical care while wearing a protective suit. Compared with emergency medicine residents, surgical residents reported significantly less formal teaching in mass casual incidents (P = 0.02), trauma triage (P = 0.01), and nuclear, biological, chemical agents (P = 0.002). When surgical residents were compared with anesthesia residents, there was significantly less training for surgical residents in nuclear, chemical, and biological agents (P = 0.02). Multiple/mass casualty incident experience did not differ between residents. However, the most common incident involved only three to five patients with blunt trauma. Emergency medicine residents were significantly more comfortable in treating patients with exposure to anthrax (P = 0.01), sarin (P = 0.04), and nuclear exposure (P = 0.01).

CONCLUSIONS

Surgical residents have significantly less formal training in mass casualties, triage, and chemical, biological, and nuclear exposures than residents in other specialties. Therefore, surgical residents are less comfortable treating these types of patients. Because surgeons often are expected to take leadership roles in mass casualty incidents, surgical education should be modified to match or exceed that of other specialties.

Exposure to a First World War blistering agent

Sulfur mustards act as vesicants and alkylating agents. They have been used as chemical warfare since 1917 during the first world war. This brief report illustrates the progression of injury on a primary exposed patient to a first world war blistering agent. This case documents the rapid timeline and progression of symptoms. It emphasises the importance of appropriate personal protective equipment and immediate medical response plan with rapid decontamination and proper action from military and civilian medical treatment facilities. This case reports the first US active duty military exposure to a blistering agent in the age of global terrorism.

The effects of weapons of mass destruction on children

PURPOSE

Children are especially vulnerable to the effects of chemical and biological weapons of mass destruction (WMD) because of physiologic, pharmacologic, and developmental characteristics. Presentation of signs and symptoms of exposure to biological and chemical agents are similar to those seen in adults. Pediatric considerations for decontamination and treatment of child victims of biological and chemical agents are discussed.

CONCLUSION

As front-line providers, nurses need to be aware of potential agents, their uses and effects as WMD, and recommended treatments.

PRACTICE IMPLICATIONS

Understanding the additional physiologic and situational needs of children, nurses can optimize the survival and outcomes of children when disaster strikes.

Simulation and Virtual Reality in Medical Education and Therapy: A Protocol

Continuing medical education has historically been provided primarily by didactic lectures, though adult learners prefer experiential or self-directed learning. Young physicians have extensive experience with computer-based or "video" games, priming them for medical education--and treating their patients--via new technologies. We report our use of standardized patients (SPs) to educate physicians on the diagnosis and treatment of biological and chemical warfare agent exposure. We trained professional actors to serve as SPs representing exposure to biological agents such as anthrax and smallpox. We rotated workshop participants through teaching stations to interview, examine, diagnose and treat SPs. We also trained SPs to simulate a chemical mass casualty (MASCAL) incident. Workshop participants worked together to treat MASCAL victims, followed by discussion of key teaching points. More recently, we developed computer-based simulation (CBS) modules of patients exposed to biological agents. We compare the strengths and weaknesses of CBS vs. live SPs. Finally, we detail plans for a randomized controlled trial to assess the efficacy of virtual reality (VR) exposure therapy compared to pharmacotherapy for post-traumatic stress disorder (PTSD). PTSD is associated with significant disability and healthcare costs, which may be ameliorated by the identification of more effective therapy.

[Impact of chemical weapon destruction on the structure of lake zoohydrobiont community]

Community structure of zoohydrobionts in the lake affected by chemical weapon destruction was studied for the first time. Low pH favored species specific to acidic water bodies as well as bidominant zooplankton community. The long-term effects of chemical pollution determined the stage of community succession, namely, the absence of the key predator (fishes), abundance of detritus consumers in the zoobenthic community (dipteran larvae), diversity of amphibiotic insects, and low species diversity in the zooplankton community with the prevalence of cladocerans and rotifers. Unbalanced composition of higher trophic levels results in an unstable functioning of the lake and accumulation of significant amounts of detritus, which is utilized by the abundant microzoobenthic component of the ecosystem.

Tracheobronchomalacia and Air Trapping after Mustard Gas Exposure

RATIONALE

Mustard gas primarily affects the eyes, skin, and particularly the respiratory tract. Tracheobronchomalacia (TBM) and air trapping are often observed in high-resolution computerized tomography (HRCT) scans of the chest of mustard gas-exposed patients.

OBJECTIVES

To examine the frequency and severity of TBM in a group of Iranian wartime mustard gas-exposed victims, and to investigate the correlation between TBM and air trapping in these cases.

MATERIALS AND METHODS

Chest HRCT films obtained from 300 randomly selected subjects who had been exposed to mustard gas 15.5 yr previously were reviewed to determine the existence of TBM and air trapping. The HRCT films of a healthy control group were also analyzed for comparison.

RESULTS

Out of 300 reviewed cases, 13 had TBM. From these 13 TBM cases, 11 (85%) showed air trapping with mean score of 5.5. In the control group, 5 (25%) of 20 subjects showed air trapping, with mean score of 0.6. The total air trapping was significantly higher in the TBM group (p < 0.001). There was an association between the severity of tracheomalacia and air trapping in the TBM group (p = 0.01, r = 0.69), but no association was observed between severity of bronchomalacia and air trapping.

CONCLUSION

The results show that air trapping and TBM are correlated, both as long-term sequelae in mustard gas-exposed cases. Because air trapping is highly suggestive of bronchiolitis obliterans, we conclude that both bronchiolitis obliterans and TBM are caused by a single underlying process affecting small and large airways, respectively, in this group of patients.

Mass casualty triage in the chemical, biological, radiological, or nuclear environment

Field trauma triage systems currently used by emergency responders at mass casualty incidents and disasters do not adequately account for the possibility of contamination of patients with chemical, biological, radiological, or nuclear material. Following a discussion of background issues regarding mass casualty triage schemes, this paper proposes chemical, biological, radiological, or nuclear-compatible trauma triage algorithms, based on a review of the literature and the input of recognized content experts. A basic trauma triage template is first proposed, with patient assessment limited to ability to walk, presence of breathing, and ability to follow commands. This template is then modified for use in chemical, biological, and radiation/nuclear situations in which the exposed or contaminated victims have also sustained conventional trauma. The proposed algorithms will need further refinement and testing.

Cutaneous reactions in nuclear, biological and chemical warfare

Nuclear, biological and chemical warfare have in recent times been responsible for an increasing number of otherwise rare dermatoses. Many nations are now maintaining overt and clandestine stockpiles of such arsenal. With increasing terrorist threats, these agents of mass destruction pose a risk to the civilian population. Nuclear and chemical attacks manifest immediately while biological attacks manifest later. Chemical and biological attacks pose a significant risk to the attending medical personnel. The large scale of anticipated casualties in the event of such an occurrence would need the expertise of all physicians, including dermatologists, both military and civilian. Dermatologists are uniquely qualified in this respect. This article aims at presenting a review of the cutaneous manifestations in nuclear, chemical and biological warfare and their management.

Protein biotoxins of military significance

There is a spectrum of several threat agents, ranging from nerve agents and mustard agents to natural substances, such as biotoxins and new, synthetic, bioactive molecules produced by the chemical industry, to the classical biological warfare agents. The new, emerging threat agents are biotoxins produced by animals, plants, fungi, and bacteria. Many types of organisms produce substances that are toxic to humans. Examples of such biotoxins are botulinum toxin, tetanus toxin, and ricin. Several bioactive molecules produced by the pharmaceutical industry can be even more toxic than are the classical chemical warfare agents. Such new agents, like the biotoxins and bioregulators, often are called mid-spectrum agents. The threat to humans from agents developed by modern chemical synthesis and by genetic engineering also must be considered, since such agents may be more toxic or more effective in causing death or incapacitation than classical warfare agents. By developing effective medical protection and treatment against the most likely chemical and mid-spectrum threat agents, the effects of such agents in a war scenario or following a terrorist attack can be reduced. Toxin-mediated diseases have made humans ill for millennia. Unfortunately, the use of biological agents as weapons of terror has now been realized, and separating naturally occurring disease from bioterroristic events has become an important public health goal. The key to timely identification of such attacks relies on education of primary care physicians, first responders, and public health officials.

Toxicological aspects of preparedness and aftercare for chemical-incidents

The threat of using chemical warfare agents still exists despite the 1993 Chemical Weapons Convention. Preparedness for attacks with chemical agents has become an important issue of national security programs. It can be anticipated that toxicologists will be increasingly involved in preparedness programs of their institutions and of the government, no matter whether they work in agencies, industry or universities. Toxicologists must get prepared to give fast and reliable advice in the case of an attack, a sabotage or an accident with release of toxic chemicals. They should be familiar with the principles of hazard management and with incident command structures and cooperate with first responders of other organizations involved such as fire department and medical emergency teams already in the planning phase. In the emergency planning phase, toxicologists are expected to help identifying possible hazards. Moreover, they consult public health services with regard to toxicosurveillance and advice hospitals regarding antidotes, decontamination procedures and shelters. They may be involved in the procurement of antidotes and of protective equipment and will support qualified analytical laboratories. In the response phase, toxicologists must be ready to gain and to interpret analytical data, to support the medical care of poisoned victims and to provide repeated risk assessment reports. This requires an on-scene access to databases and registries. The aftercare phase includes the identification of exposed persons, mapping of contaminated areas, organization of decontamination measures and the release of areas. A medical study may be initiated to observe long-term health effects. Good cooperation between regulatory and clinical toxicologists, specific education of toxicologist in the field of chemical emergencies and regular trainings are essential elements of good preparedness.

Respiratory agents: irritant gases, riot control agents, incapacitants, and caustics

There are many chemical respiratory agents suitable for use by terrorists. They are the oldest chemical agents used and have caused the most casualties throughout the 20th century. Many are available in large quantities for industrial use and are susceptible to potential sabotage. This paper will concentrate on respiratory agents that are readily available and have the potential to cause a large number of casualties and panic. These agents have a lower rate of lethality when compared to other chemical agents but could produce many casualties that may overwhelm the emergency medical system.

[The influence of aminostigmine on the parameters of nonspecific resistance and immune system of the organism upon acute poisoning of benzyl 3-quinuclidylate]

The results of experiments on outbred rats weighing 180 -240 g showed that the acute poisoning with benzyl 3-quinuclidylate decreases the parameters of nonspecific resistance of the organism, reduces the antibody production mainly to T-dependent antigens (sheep red blood cells), decreases the activity of natural killers and the antibody-dependent cell-mediated cytotoxicity, and suppresses the formation of delayed-type hypersensitivity. Aminostigmine partly inhibits the immunotoxicity benzyl 3-quinuclidylate.

Cyanides

Cyanide is a likely weapon for terrorists due to its notoriety, lethality, and availability. Poisoning results in central nervous system and cardiovascular dysfunction due to inhibition of oxidative phosphorylation. Laboratory findings of anion gap metabolic acidosis and hyperlactemia aid in confirming the diagnosis. Treatment for significant poisonings includes aggressive supportive care and administration of antidotes such as sodium nitrite, sodium thiosulfate, and hydroxocobalamin. Survivors of significant poisonings can have long-term neurologic dysfunction.