Computer-assisted evaluation of small airway disease in CT scans of Iran-Iraq war victims of chemical warfare by a locally developed software: comparison between different quantitative methods

OBJECTIVE

Diagnosis of small airway disease on computed tomography (CT) scans is challenging in patients with a history of chemical warfare exposure. We developed a software package based on different methodologies to identify and quantify small airway disease in CT images. The primary aim was to identify the best automatic methodology for detecting small airway disease in CT scans of Iran-Iraq War victims of chemical warfare.

METHODS

This retrospective case-control study enrolled 46 patients with a history of chemical warfare exposure and 27 controls with inspiratory/expiratory (I/E) CT scans and spirometry tests. Image data were automatically segmented, and inspiratory images were registered into the expiratory images' frame using the locally developed software. Parametric response mapping (PRM) and air trapping index (ATI) mapping were performed on the CT images. Conventional QCT methods, including expiratory/inspiratory mean lung attenuation (E/I MLA) ratio, normal density E/I (ND E/I) MLA ratio, attenuation volume Index (AVI), %low attenuation areas (LAA) < -856 in exhale scans, and %LAA < -950 in inhale scans were also computed. QCT measurements were correlated with spirometry results and compared across the two study groups.

RESULTS

The correlation analysis showed a significant negative relationship between three air trapping (AT) measurements (PRM, ATI, and %LAAExp < -856) and spirometry parameters (Fev1, Fvc, Fev1/Fvc, and MMEF). Moreover, %LAAExp < -856 had the highest significant negative correlation with Fev1/Fvc (r = -0.643, P-value < 0.001). Three AT measurements demonstrated a significant difference between the study groups. The E/I ratio was also significantly different between the two groups (P-value < 0.001). Binary logistic regression models showed PRMFsad, %LAAExp < -856, and ATI as significant and strong predictors of the study outcome. Optimal cut-points for PRMFsad = 19%, %LAAExp < -856 = 23%, and ATI = 27% were identified to classify the participants into two groups with high accuracy.

CONCLUSION

QCT methods, including PRM, ATI, and %LAAExp < -856 can greatly advance the identification and quantification of SAD in chemical warfare victims. The results should be verified in well-designed prospective studies involving a large population.

Acute care for patients exposed to a chemical attack: protocol for an international multicentric observational study

INTRODUCTION

The use of weapons of mass destruction against civilian populations is of serious concern to public health authorities. Chemical weapons are of particular concern. A few studies have investigated medical responses in prehospital settings in the immediate aftermath of a chemical attack, and they were limited by the paucity of clinical data. This study aims to describe the acute management of patients exposed to a chemical attack from the incident site until their transfer to a medical facility.

METHODS AND ANALYSIS

This international multicentric observational study addresses the period from 1970 to 2036. An online electronic case report form was created to collect data; it will be hosted on the Biomedical Telematics Laboratory Platform of the Quebec Respiratory Health Research Network. Participating medical centres and their clinicians are being asked to provide contextual and clinical information, including the use of protective equipment and decontamination capabilities for the medical evacuation of the patient from the incident site of the chemical attack to the moment of admission at the medical facility. In brief, variables are categorised as follows: (1) chemical exposure (threat); (2) prehospital and hospital/medical facility capabilities (staffing, first aid, protection, decontamination, disaster plans and medical guidelines); (3) clinical interventions before hospital admission, including the use of protection and decontamination and (4) outcomes (survivability vs mortality rates). Judgement criteria focus on decontamination drills applied to any of the patient's conditions.

ETHICS AND DISSEMINATION

The Sainte-Justine Research Centre Ethics Committee approved this multicentric study and is acting as the main evaluating centre. Study results will be disseminated through various means, including conferences, indexed publications in medical databases and social media.

TRIAL REGISTRATION NUMBER

NCT05026645.

Implications of Neurological Directed-Energy Weapons for Military Medicine

Since 2016, there has been an increase in reported cases of intelligence officers and diplomats hearing pulsing sounds and experiencing neurophysiologic and cognitive symptoms. These varied and often intense symptoms manifest in ways similar to a traumatic brain injury (TBI) but without inciting trauma. Known formerly as "unconventionally acquired brain injury" (UBI), these events are now labeled "anomalous health incidents" (AHIs). Investigations of these incidents suggest reasons to be concerned that a specific type of neuroweapon may be the cause-a directed energy weapon (DEW). Neuroweapons that target the brain to influence cognition and behavior are leading to a new domain of warfare-neurowarfare. The implications and resultant stakes, especially for the Special Operations community, are significant. This article focuses specifically on the implications of DEWs as a neuroweapon causing UBIs/AHIs for military medical practitioners and suggests using a comprehensive strategy, analogous to that of chemical warfare or other weapons of mass destruction (WMD), to improve our preparedness for the medical repercussions of neurowarfare.

CTAB-functionalized δ-FeOOH for the simultaneous removal of arsenate and phenylarsonic acid in phenylarsenic chemical warfare

This study prepared a cetyltrimethylammonium bromide (CTAB) functionalized δ-FeOOH using the coprecipitation method to remove arsenate and phenylarsonic acid in water polluted by phenylarsonic chemical warfare agents. Under neutral conditions, the adsorption capacity for arsenate and phenylarsonic acid was 45.7 and 85.3 mg g^-1, respectively. The adsorption process conformed to the pseudo-second-order kinetics and Freundlich isothermal adsorption model, and the adsorption was spontaneous and endothermic. The CTAB-functionalized δ-FeOOH could effectively resist the interference of coexisting anions except for CO₃^2-, SiO₃^2- and PO₄^3-. Furthermore, the adsorption mechanism was proposed by combining the adsorption experimental results, Fourier transform infrared spectroscopy, X-ray photoelectron spectroscopy, and density functional theory analyses. The results showed that the adsorption of arsenate by the CTAB-functionalized δ-FeOOH was mainly through the formation of bidentate-dinuclear inner-sphere complexes and electrostatic interactions. While for phenylarsonic acid, the formation of monodentate-mononuclear inner-sphere complexes on (100) and (110) crystal facets, and the formation of bidentate-dinuclear inner-sphere complexes on the (002) crystal facet, as well as hydrogen bonding, electrostatic interaction, and π-hydrophobic interaction between organic compounds were the primary mechanism. Moreover, the CTAB-functionalized δ-FeOOH could maintain about 60% of the adsorption capacity for the two pollutants after five cycles. Overall, CTAB-functionalized δ-FeOOH has good potential for the remediation of inorganic and organic arsenic-contaminated water bodies.

Healthcare Utilization and Expenditures among Iranian Chemical Warfare Survivors Exposed to Sulfur Mustard

BACKGROUND

This study aims to explore the healthcare utilization (HCU) and expenditures from complementary health insurance among Iranian people who survived sulfur mustard (SM) exposure during the Iran-Iraq war.

METHODS

This study was conducted between March 21, 2018 and March 21, 2019 using secondary data. Data on the HCU and expenditure of war survivors after their exposure to SM were obtained from the Iran Veterans and Martyr Affair Foundation (VMAF) database and the national complementary insurance organization that covers their medical expenses. Multiple linear and zero-inflated poison regression (ZIP) models were used to estimate the costs and HCU. Analyses were performed in R software version 3.6.3.

RESULTS

Among 58880 survivors who were included in study, 36383 (61.7%) used at least one service during a year. The total frequency of HCU was 15.6 services per person per year. The annual mean medical cost of each survivor was US$807.6 (±2901.2). The highest number of utilizations was related to medicine and physician visits. The highest median cost was related to rehabilitation (US$151.7), medical equipment (US$84.5), medicine (US$83.3) and inpatient services (US$ 48.8). With increasing age, disability, weight, severity of injury in lung or eye injuries, the rate of health service utilization rose significantly.

CONCLUSION

Over 30 years after the Iran-Iraq war, Iranian people who were exposed to SM and survived still suffer from injuries and pose a significant drain on healthcare resources.

Counteracting poisoning with chemical warfare nerve agents

Phosphylation of the pivotal enzyme acetylcholinesterase (AChE) by nerve agents (NAs) leads to irreversible inhibition of the enzyme and accumulation of neurotransmitter acetylcholine, which induces cholinergic crisis, that is, overstimulation of muscarinic and nicotinic membrane receptors in the central and peripheral nervous system. In severe cases, subsequent desensitisation of the receptors results in hypoxia, vasodepression, and respiratory arrest, followed by death. Prompt action is therefore critical to improve the chances of victim's survival and recovery. Standard therapy of NA poisoning generally involves administration of anticholinergic atropine and an oxime reactivator of phosphylated AChE. Anticholinesterase compounds or NA bioscavengers can also be applied to preserve native AChE from inhibition. With this review of 70 years of research we aim to present current and potential approaches to counteracting NA poisoning.

Biodegradation of Organophosphorus Compounds Predicted by Enzymatic Process Using Molecular Modelling and Observed in Soil Samples Through Analytical Techniques and Microbiological Analysis: A Comparison

Organophosphorus compounds (OP) are chemicals widely used as pesticides in different applications such as agriculture and public health (vector control), and some of the highly toxic forms have been used as chemical weapons. After application of OPs in an environment, they persist for a period, suffering a degradation process where the biotic factors are considered the most relevant forms. However, to date, the biodegradation of OP compounds is not well understood. There are a plenty of structure-based biodegradation estimation methods, but none of them consider enzymatic interaction in predicting and better comprehending the differences in the fate of OPs in the environment. It is well known that enzymatic processes are the most relevant processes in biodegradation, and that hydrolysis is the main pathway in the natural elimination of OPs in soil samples. Due to this, we carried out theoretical studies in order to investigate the interactions of these OPs with a chosen enzyme—the phosphotriesterase. This one is characteristic of some soils’ microorganisms, and has been identified as a key player in many biodegradation processes, thanks to its capability for fast hydrolyzing of different OPs. In parallel, we conducted an experiment using native soil in two conditions, sterilized and not sterilized, spiked with specific amounts of two OPs with similar structure—paraoxon-ethyl (PXN) and O-(4-nitrophenyl) O-ethyl methylphosphonate (NEMP). The amount of OP present in the samples and the appearance of characteristic hydrolysis products were periodically monitored for 40 days using analytical techniques. Moreover, the number of microorganisms present was obtained with plate cell count. Our theoretical results were similar to what was achieved in experimental analysis. Parameters calculated by enzymatic hydrolysis were better for PXN than for NEMP. In soil, PXN suffered a faster hydrolysis than NEMP, and the cell count for PXN was higher than for NEMP, highlighting the higher microbiological toxicity of the latter. All these results pointed out that theoretical study can offer a better comprehension of the possible mechanisms involved in real biodegradation processes, showing potential in exploring how biodegradation of OPs relates with enzymatic interactions.

[Chemical warfare agents]

This review presents an overview of the different classes of chemical warfare agents and the toxidromes associated with these agents. An increasing terrorist threat to Denmark and the Danish armed forces operating internationally mandates increased awareness of chemical warfare agents in clinicians working with emergency and military medicine. Rapid recognition of the classical toxidromes produced by different classes of chemical warfare agents aids in providing the medical support necessary for reducing mortality and morbidity.

Biosecurity Threat Posed by Botulinum Toxin

The deliberate release of biological agents with terrorist or criminal intent continues to pose concerns in the current geopolitical situation. Therefore, attention is still needed to ensure preparedness against the potential use of pathogens as unconventional weapons. Botulinum neurotoxin (BoNT) is one such biological threat, characterized by an extremely low lethal dose, high morbidity and mortality when appropriately disseminated, and the capacity to cause panic and social disruption. This paper addresses the risks of a potential release of the botulinum neurotoxin and summarizes the relevant aspects of the threat.

Qualitative accounts from Syrian health professionals regarding violations of the right to health, including the use of chemical weapons, in opposition-held Syria

OBJECTIVES

To explore the impact of the conflict, including the use of chemical weapons, in Syria on healthcare through the experiences of health providers using a public health and human rights lens.

DESIGN

A qualitative study using semi-structured interviews conducted in-person or over Skype using a thematic analysis approach.

SETTING

Interviews were conducted with Syrian health workers operating in opposition-held Syria in cooperation with a medical relief organisation in Gaziantep, Turkey.

PARTICIPANTS

We examined data from 29 semi-structured in-depth interviews with a sample of health professionals with current or recent work-related experience in opposition-controlled areas of Syria, including respondents to chemical attacks.

RESULTS

Findings highlight the health worker experience of attacks on health infrastructure and services in Syria and consequences in terms of access and scarcity in availability of essential medicines and equipment. Quality of services is explored through physicians' accounts of the knock-on effect of shortages of equipment, supplies and personnel on the right to health and its ethical implications. Health workers themselves were found to be operating under extreme conditions, in particular responding to the most recent chemical attacks that occurred in 2017, with implications for their own health and mental well-being.

CONCLUSIONS

The study provides unique insight into the impact war has had on Syrian's right to health through the accounts of a sample of Syrian health professionals, with continuing relevance to the current conflict and professional issues facing health workers in conflict settings.

Environmental Decontamination of a Chemical Warfare Simulant Utilizing a Membrane Vesicle-Encapsulated Phosphotriesterase

While technologies for the remediation of chemical contaminants continue to emerge, growing interest in green technologies has led researchers to explore natural catalytic mechanisms derived from microbial species. One such method, enzymatic degradation, offers an alternative to harsh chemical catalysts and resins. Recombinant enzymes, however, are often too labile or show limited activity when challenged with nonideal environmental conditions that may vary in salinity, pH, or other physical properties. Here, we demonstrate how phosphotriesterase encapsulated in a bacterial outer membrane vesicle can be used to degrade the organophosphate chemical warfare agent (CWA) simulant paraoxon in environmental water samples. We also carried out remediation assays on solid surfaces, including glass, painted metal, and fabric, that were selected as representative materials, which could potentially be contaminated with a CWA.

High-resolution CT in chronic pulmonary changes after mustard gas exposure

Purpose: To identify the findings of high‐resolution CT (HRCT) of the lung in patients with previous sulfur mustard gas exposure, and to correlate these findings with clinical and chest X-ray (CXR) results.

Material and Methods: 50 consecutive patients were studied prospectively. The clinical data were recorded. Standard p.a. CXR and HRCT of the lung and spirometry were performed. The findings of CXR, HRCT and clinical and spirometry results were scored between 0 and 3 according to the severity of the findings.

Results: HRCT abnormality was detected in all 50 patients (100%), while CXR was abnormal in 40 patients (80%). The most common HRCT findings was airway abnormalities (bronchial wall thickening in 100% of cases). Other important findings were suggestive of interstitial lung disease (ILD) (80%), bronchiectasis (26%), and emphysema (24%). A statistically significant correlation was found between the severity of clinical presentation and that of the HCTR scores in patients with bronchiectasis, bronchitis and ILD ( p< 0.05), but not with severity scores of HRCT in patients with emphysema. No significant correlation was found between severity scores of CXR findings. HRCT evidence of bronchial wall thickening and with a lower frequency ILD were present despite normal CXR in 20% of the patients.

Conclusion: The results of this study suggest that bronchial wall thickening, ILD and emphysema are common chronic pulmonary sequelae of sulfur mustard injury. HRCT of the chest should be considered as the imaging modality of choice in chemical war injury.

Pharmacokinetics of sternal intraossesous atropine administration in normovolemic and hypovolemic swine

OBJECTIVE

Characterize and compare the pharmacokinetics of atropine administered via the sternal intraosseous (IO) route in a normovolemic and hypovolemic swine model.

DESIGN

Prospective, experimental study.

SETTING

Vivarium.

SUBJECTS

Yorkshire-cross swine (N = 12).

INTERVENTION

Atropine was administered via the sternal IO route to normovolemic and hypovolemic swine. Blood samples were drawn at regular intervals after atropine administration and analyzed for plasma atropine concentration. Pharmacokinetic parameters were obtained from modeling the plasma concentrations.

MAIN OUTCOME MEASUREMENTS

Pharmacokinetic parameters, maximum concentration (Cmax), and time to maximum concentration (Tmax).

RESULTS

The normovolemic and hypovolemic models reached peak plasma concentration immediately and had a very rapid distribution phase with no apparent absorption phase for the IO groups. The hypovolemic group had slower clearance and longer half-life compared to the normovolemic group.

CONCLUSION

The sternal IO route is an effective method of administering atropine and is comparable to the previously reported tibial IO and intravenous data even under conditions of significant hemorrhage.

The effect of mustard gas on salivary trace metals (Zn, Mn, Cu, Mg, Mo, Sr, Cd, Ca, Pb, Rb)

We have determined and compared trace metals concentration in saliva taken from chemical warfare injures who were under the exposure of mustard gas and healthy subjects by means of inductively coupled plasma optical emission spectroscopy (ICP-OES) for the first time. The influence of preliminary operations on the accuracy of ICP-OES analysis, blood contamination, the number of restored teeth in the mouth, salivary flow rate, and daily variations in trace metals concentration in saliva were also considered. Unstimulated saliva was collected at 10:00-11:00 a.m. from 45 subjects in three equal groups. The first group was composed of 15 healthy subjects (group 1); the second group consisted of 15 subjects who, upon chemical warfare injuries, did not use Salbutamol spray, which they would have normally used on a regular basis (group 2); and the third group contained the same number of patients as the second group, but they had taken their regular medicine (Salbutamol spray; group 3). Our results showed that the concentration of Cu in saliva was significantly increased in the chemical warfare injures compared to healthy subjects, as follows: healthy subjects 15.3± 5.45 (p.p.b.), patients (group 2) 45.77±13.65, and patients (Salbutamol spray; group 3) 29 ±8.51 (P <0.02). In contrast, zinc was significantly decreased in the patients, as follows: healthy subjects 37 ± 9.03 (p.p.b.), patients (group 2) 12.2 ± 3.56, and patients (Salbutamol spray; group 3) 20.6 ±10.01 (P < 0.01). It is important to note that direct dilution of saliva samples with ultrapure nitric acid showed the optimum ICP-OES outputs.

[Preparedness of health system in Israel for mass emergencies]

The vast number of outbreaks of tension on the planet shows that it is impossible to underestimate the preparation level of population protection in emergencies. The possibility of a terrorist attack, including the use of particularly toxic or biological substances cannot be excluded or totally prevented at this point. In fact, there may not only be a terrorist attack. Rampant population migration increases the risk of the transmission of infectious diseases, even to considerable distances from the states where the epidemiological situation might not be completely under control. The current state of the Czech healthcare system in terms of preparedness for mass emergencies is insufficient and requires prompt correction, though not through hastily adopted measures. Ideally, looking into the success of the Israeli preparedness system, where the public has been exposed to high levels of threat from a variety of causes for decades, could greatly aid the Czech Republic in moving forward effectively. The number of victims of terrorist attacks there outpaces 10000, a fact that shows Israel is experienced in responding to emergency incidents.

[On necessity to modify biochemical methods for detecting organophosphorus componds in chemical weapons extinction objects (review of literature)]

The article covers problems of biochemical methods assessing organophosphorus toxic compounds in objects of chemical weapons extinction. The authors present results of works developing new, more specific and selective biochemical methods.

[On new screening biomarker to evaluate health state in personnel engaged into chemical weapons extinction]

The work was aimed to find new screeding parameters (biomarkers) for evaluation of health state of workers engaged into enterprises with hazardous work conditions, as exemplified by "Maradykovskyi" object of chemical weapons extinction. Analysis of 27 serum cytokines was conducted in donors and the object personnel with various work conditions. Findings are statistically significant increase of serum eotaxin in the personnel of "dirty" zone, who are regularly exposed to toxic agents in individual filter protective means over the working day. For screening detection of health disorders in the object personnel, the authors suggested new complex biomarker--ratio Eotaxin* IFNγ/TNFα that demonstrates 67.9% sensitivity and 87.5% specificity in differentiating the "dirty" zone personnel and other staffers.

Investigation of the relationship between illogical thoughts and dependence on others and marriage compatibility in the Iranian Veterans exposed to chemicals in Iran-Iraq War

BACKGROUND

Marital satisfaction is one of the main determinants of a family's correct function. A large number of veterans have been reported to suffer from depression, anxiety, mood disorders, post-traumatic stress disorder, and physical disorders. The objective of this study is to examine association between Illogical thoughts and Dependence on Others and Marriage Compatibility in the Iranian Veterans Exposed to Chemicals in Iran-Iraq War.

METHODS

The present cross-sectional, analytical study was conducted on 200 veterans exposed to chemicals who were covered by the Foundation of Martyrs and Veterans Affairs, Gilangharb, Kermanshah, Iran. The study sample size was determined according to Krejcie and Morgan formula and the subjects were selected through random sampling. The study data were collected using marriage compatibility questionnaire, illogical thoughts questionnaire, and dependence on others questionnaire. The study data were analyzed using the SPSS statistical software (version18). Pearson correlation coefficient, multiple regression, and t-test were used in order to determine the relationships among the variables and compare the means.

RESULTS

The findings of the current study revealed no significant relationship between dependence on others, anxious attention, helplessness, avoiding problems, perfectionism, and autonomy and marriage compatibility. However, a significant relationship was found between failure and marriage compatibility.

DISCUSSION

Overall, the findings of the present study showed that the veterans of Gilangharb did not have disorders, but depended on others, particularly their spouses, due to their abnormal physical status. Sometimes, they cannot even do their personal tasks which results in their dependence on others eventually putting the veterans under pressure and stress.

[Long-term complications of sulfur mustard exposure: a therapeutic update]

Sulfur mustard (SM) is an alkylating chemical warfare agent with high military significance due to its high toxicity, resistance and availability. SM was widely used in military conflicts, the last being the Iran-Iraq war with more than 100,000 Iranians exposed, one-third of whom are still suffering from late effects. The intensity of the delayed complications correlates to the extent, the area and the route of exposure. The clinical manifestations most commonly involve respiratory, ocular and dermal effects. Respiratory complications include dyspnea, cough and expectorations and various obstructive and restrictive lung diseases. Dermal complications are itching, burning sensation, blisters, dry skin, dermatitis and pigmentary changes. Ocular complications include photophobia, red eye, tearing, corneal ulcers and blindness. Although the picture remains incomplete the major mechanisms responsible for the clinical and pathological effects of SM are: DNA alkylation and cross-linking, protein modification and membrane damage in addition to induction of inflammatory mediators in the target tissues causing extensive necrosis, apoptosis and loss of tissue structure. The current report reviews long-term complications of SM exposure, focusing on new treatments tested in clinical trials conducted on humans. Such treatments include: N-acetyl cysteine, bronchodilators, corticosteroids, Interferon-gamma, furosemide and morphine for the respiratory complications. Ocular complications may entail: Invasive procedures treating corneal complication, limbal ischemia and stem cell deficiency. Treatment for dermatological complications include: anti-depressants, pimercrolimus, Unna's boot, capsaicin, phenol and menthol, Aloe vera and olive oil, curcumin and Interferon-gamma.

Organophosphorus pesticide and ester analysis by using comprehensive two-dimensional gas chromatography with flame photometric detection

Thirty-seven phosphorus (P)-containing compounds comprising organophosphorus pesticides and organophosphate esters were analyzed by using comprehensive two-dimensional gas chromatography with flame photometric detection in P mode (GC × GC-FPD(P)), with a non-polar/moderately polar column set. A suitable modulation temperature and period was chosen based on experimental observation. A number of co-eluting peak pairs on the (1)D column were well separated in 2D space. Excellent FPD(P) detection selectivity, responding to compounds containing the P atom, produces clear 2D GC × GC plots with little interference from complex hydrocarbon matrices. Limits of detection (LOD) were within the range of 0.0021-0.048 μmol L(-1), and linear calibration correlation coefficients (R(2)) for all 37 P-compounds were at least 0.998. The P-compounds were spiked in 2% diesel and good reproducibility for their response areas and retention times was obtained. Spiked recoveries were 88%-157% for 5 μg L(-1) and 80%-138% for 10 μg L(-1) spiked levels. Both (1)tR and (2)tR shifts were noted when the content of diesel was in excess of 5% in the matrix. Soil samples were analyzed by using the developed method; some P-compounds were positively detected. In general, this study shows that GC × GC-FPD(P) is an accurate, sensitive and simple method for P-compound analysis in complicated environmental samples.

Chlorine and hydrogen cyanide gas interactions with human skin: in vitro studies to inform skin permeation and decontamination in HAZMAT incidents

Accidental or intentional toxic gas releases may result in significant public health and psychological consequences. Management of exposed individuals during HAZMAT incidents should be risk-based and supported by a suitable scientific evidence base. There appear to be large evidence gaps in relation to dermal absorption of gases, as well as management advice for potentially exposed individuals. Chlorine and hydrogen cyanide are two common HAZMAT gases and this paper addresses the need for experimental data tailored to HAZMAT scenarios and first responders. In addition to time variations of gas concentration, the modifying effects of clothing, temperature, and oil-based sunscreen on epidermal absorption and penetration are assessed. Results for chlorine show little penetration up to 500 ppm but with small enhancing effects due to heavy cotton and oil-based sunscreen. Hydrogen cyanide up to 800 ppm shows minor penetration consistent with previous studies, with little variability in the presence of sunscreen and clothing. Practical guidelines to support the decision-making of emergency responders with regard to personal decontamination have been derived.

Physiological strain of next generation combat uniforms with chemical and biological protection: importance of clothing vents

This study examined whether vents in the arms, legs and chest of new protective assault uniforms (PTAU) reduced heat strain at 35 °C during a low dressed state (DSlow), and subsequently improved tolerance time (TT) after transitioning to DShigh compared with the battle dress uniform and overgarment (BDU+O). Small but significant reductions in rectal temperature (Tre), heart rate and vapour pressures over the thigh and shin were observed during DSlow with vents open (37.9 ± 0.2 °C, 120 ± 10 b/min, 3.7 ± 0.4 and 3.5 ± 1.0 kPa) versus closed (38.0 ± 0.1 °C, 127 ± 5 b/min, 4.3 ± 0.3 and 4.6 ± 0.5 kPa). During DShigh Tre was reduced and TT increased significantly with the PTAUs (1.1 ± 0.2 °C/h and 46 ± 24 min) versus BDU+O (1.6 ± 0.2 °C/h and 33 ± 16 min). The vents marginally reduced heat strain during DSlow and extended TT during DShigh) compared with BDU+O. Practitioner Summary: Clothing vents in chemical and biological protective uniforms can assist with heat transfer in situations where the uniforms must be worn for extended periods prior to exposure to a hazardous condition. Once the vents are closed, exposure time is increased and the increase in body temperature reduced.

[Formation of therapeutic group of casualties in local wars and armed conflicts]

The necessity of improvement of the therapeutic care organization in the RF Armed Forces is dictated by the existing military threats. Conflicts between states or within a single country along with inefficiency of diplomatic, social and political efforts may lead to armed conflicts or local wars. Analysis of medical support results shows the consistent prevalence of therapeutic group of casualties in the overall structure of medical losses. 35-50% of all sanitary losses is accounted for by somatic diseases. Moreover, their structure is similar to the structure of the army's peacetime morbidity rate. Respiratory diseases head the list of somatic diseases in military personnel. Next--diseases of the digestive and circulatory systems. One of the most important tasks for physicians in wartime is early diagnosis and treatment of visceral pathology in the wounded. An additional point is that the use of tactical nuclear weapons during the armed conflict or local war cannot be completely excluded. There is also a real risk of nuclear and chemical facilities damage, with consequences that are comparable to the use of nuclear or chemical weapons. Thus, in the course of armed conflict or local war, military physicians can meet all possible therapeutic spectrum of pathology: from visceral pathology of peace and wartime to combat related therapeutic pathology.

Selective real-time detection of gaseous nerve agent simulants using multiwavelength photoacoustics

An optical detection method is presented that is designed to detect and identify the presence of macromolecular gas species (e.g., organophosphate-based nerve agent simulants) at trace level concentrations. The technique is based on a modified version of conventional laser photoacoustic (PA) spectroscopy, in which optical absorption is typically measured using a single laser source. We demonstrate the ability to simultaneously measure multiple absorption-related parameters that serve as a concentration-independent identifier. Three continuous wave mid-infrared laser sources, operating at 8.68, 9.29, and 10.35 μm, are combined and propagated axially through a specially designed flow through PA cell. Each laser is modulated at a different frequency and the resultant acoustic signal(s) are detected and deconvolved using a PC-based 24 bit dynamic signal acquisition device. Species detection and identification is achieved by tabulating independent ratios of the acoustic response for each laser source. Quantitative absorption measured is verified using a Fourier transform infrared spectrometer. Results show good detection and species separation/identification at moderately low ppm concentrations.

Who Should Worry for the “Worried Well”? Analysis of Mild Casualties Center Drills in Non-Conventional Scenarios

Introduction:

A mass toxicological event (MTE) caused by an act of terrorism or an industrial incident can create large numbers of ambulatory casualties suffering from mild intoxication, acute stress reaction (ASR), and exacerbation of chronic diseases or iatrogenic insult (such as atropine overdose). The logistical and medical management of this population may present a challenge insuch a scenario. The aim of this article is to describe the concept of the Israeli Home Front Command (HFC) of a “Mild Casualties Center” (MCC) for a chemical scenario, and to analyze the results of two large-scale drills that have been used to evaluate this concept.

Methods:

Two large-scale drills were conducted. One MCC drill was located in a school building and the second MCC drill was located in a basketball stadium. These medical centers were staffed by physicians, nurses, and medics, both military (reservists) and civilian (community, non-hospital teams). Two hundred simulated patients entered the MCC during each of the drills, and drill observers assessed how these patients were managed for two hours.

Results:

Of the casualties, 28 were treated in the “medical treatment site”, 10 of which were relocated to a nearby hospital. Only four casualties were treated in the large “mental care site”, planned for a much higher burden of “worried well” patients. Documentation of patient data and medical care was sub-optimal.

Conclusion:

A MCC is a logistically suitable solution for the challenge of managing thousands of ambulatory casualties. The knowledge of the medical team must be bolstered, as most are unfamiliar with both nerve gas poisoning and with ASR. Mild casualties centers should not be located within hospitals and must be staffed by non-hospital, medical personnel to achieve the main task of allowing hospital teams to focus on providing medical care to the moderate and severe nerve gas casualties, without the extra burden of caring for thousands of mild casualties.

Public Health Preparedness for Mass-Casualty Events: A 2002 State-by-State Assessment

Introduction:

The ongoing threat of a terrorist attack places public agencies under increasing pressure to ensure readiness in the event of a disaster. Yet, little published information exists regarding the current state of readiness, which would allow local and regional organizations to develop disaster preparedness plans that would function seamlessly across service areas. The objective of this study is to characterize state-level disaster readiness soon after September 2001 and correlate readiness with existing programs providing an organized response to medical emergencies.

Methods:

During the first quarter of 2002, a cross-sectional survey assessing five components of disaster readiness was administered in all 50 states. The five components of disaster readiness included: (1) statewide disaster planning; (2) coordination; (3) training; (4) resource capacity; and (5) preparedness for biological/chemical terrorism.

Results:

Most states reported the presence of a statewide disaster plan (94%), but few are tested by activation, (48%) and still fewer contain a bioterrorism component (38%). All states have designated disaster operations centers (100%), but few states have an operating communications system linking health and medical resources (36%). Approximately half of states offer disaster training to medical professionals; about 10% of states require the training. Between 22–48% of states have various contingency plans to treat victims when service capacity is exceeded. Biochemical protective equipment for health professionals is lacking in all but one state, and only 10% of states indicate that all hospitals have decontamination capabilities. States with a functioning statewide trauma system were significantly more likely to possess key attributes of a functioning disaster readiness plan.

Conclusion:

These findings suggest that disaster plans are prevalent among states. However, key programs and policies were noticeably absent. Communication systems remain fragmented and adequate training programs and protective equipment for health personnel are markedly lacking. Statewide trauma systems may provide a framework upon which to build future medical disaster readiness capacity.

Civilian Exposure to Toxic Agents: Emergency Medical Response

Civilian populations are at risk from exposure to toxic materials as a result of accidental or deliberate exposure. In addition to industrial hazards, toxic agents designed for use in warfare now are a potential hazard in everyday life through terrorist action. Civil emergency medical responders should be able to adapt their plans for dealing with casualties from hazardous materials (HazMat) to deal with the new threat.

Chemical and biological warfare (CBW) and HazMat agents can be viewed as a continuous spectrum. Each of these hazards is characterized by qualities of toxicity, latency of action, persistency, and transmissibility. The incident and medical responses to release of any agent is determined by these characteristics.

Chemical and biological wardare agents usually are classified as weapons of mass destruction, but strictly, they are agents of mass injury. The relationship between mass injury and major loss of life depends very much on the protection, organization, and emergency care provided.

Detection of a civil toxic agent release where signs and symptoms in casualties may be the first indicator of exposure is different from the military situation where intelligence information and tuned detection systems generally will be available.

It is important that emergency medical care should be given in the context of a specific action plan. Within an organized and protected perimeter, triage and decontamination (if the agent is persistent) can proceed while emergency medical care is provided at the same time.

The provision of advanced life support (TOXALS) in this zone by protected and trained medical responders now is technically feasible using specially designed ventilation equipment. Leaving life support until after decontamination may have fatal consequences. Casualties from terrorist attacks also may suffer physical as well as toxic trauma and the medical response also should be capable of dealing with mixed injuries.

The Threat of Mid-Spectrum Chemical Warfare Agents

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. 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.

Treatment of neuroterrorism

Bioterrorism is defined as the intentional use of biological, chemical, nuclear, or radiological agents to cause disease, death, or environmental damage. Early recognition of a bioterrorist attack is of utmost importance to minimize casualties and initiate appropriate therapy. The range of agents that could potentially be used as weapons is wide, however, only a few of these agents have all the characteristics making them ideal for that purpose. Many of the chemical and biological weapons can cause neurological symptoms and damage the nervous system in varying degrees. Therefore, preparedness among neurologists is important. The main challenge is to be cognizant of the clinical syndromes and to be able to differentiate diseases caused by bioterrorism from naturally occurring disorders. This review provides an overview of the biological and chemical warfare agents, with a focus on neurological manifestation and an approach to treatment from a perspective of neurological critical care.

Sulphur mustard degradation on zirconium doped Ti-Fe oxides

Zirconium doped mixed nanodispersive oxides of Ti and Fe were prepared by homogeneous hydrolysis of sulphate salts with urea in aqueous solutions. Synthesized nanodispersive metal oxide hydroxides were characterised as the Brunauer-Emmett-Teller (BET) surface area and Barrett-Joiner-Halenda porosity (BJH), X-ray diffraction (XRD), infrared (IR) spectroscopy, scanning electron microscopy (SEM) with energy-dispersive X-ray (EDX) microanalysis, and acid-base titration. These oxides were taken for an experimental evaluation of their reactivity with sulphur mustard (chemical warfare agent HD or bis(2-chloroethyl)sulphide). The presence of Zr(4+) dopant tends to increase both the surface area and the surface hydroxylation of the resulting doped oxides in such a manner that it can contribute to enabling the substrate adsorption at the oxide surface and thus accelerate the rate of degradation of warfare agents. The addition of Zr(4+) to the hydrolysis of ferric sulphate with urea shifts the reaction route and promotes formation of goethite at the expense of ferrihydrite. We discovered that Zr(4+) doped oxo-hydroxides of Ti and Fe exhibit a higher degradation activity towards sulphur mustard than any other yet reported reactive sorbents. The reaction rate constant of the slower parallel reaction of the most efficient reactive sorbents is increased with the increasing amount of surface base sites.

Loss of expression of TGF-βs and their receptors in chronic skin lesions induced by sulfur mustard as compared with chronic contact dermatitis patients

BACKGROUND

Sulfur mustard (SM) is a blister-forming agent that has been used as a chemical weapon. Sulfur mustard can cause damage in various organs, especially the skin, respiratory system, and eyes. Generally, the multiple complications of mustard gas result from its alkalizing potency; it reacts with cellular components like DNA, RNA, proteins, and lipid membranes.TGF-β is a multi-functional cytokine with multiple biological effects ranging from cell differentiation and growth inhibition to extracellular matrix stimulation, immunosuppression, and immunomodulation. TGF-β has 3 isoforms (TGF-β 1, 2, 3) and its signaling is mediated by its receptors: R1, R2 and intracellular Smads molecules.TGF-β has been shown to have anti-inflammatory effects. TGF-βs and their receptors also have an important role in modulation of skin inflammation, proliferation of epidermal cells, and wound healing, and they have been implicated in different types of skin inflammatory disorders.

METHODS

Seventeen exposed SM individuals (48.47 ± 9.3 years), 17 chronic dermatitis patients (46.52 ± 14.6 years), and 5 normal controls (44.00 ± 14.6 years) were enrolled in this study.Evaluation of TGF-βs and their receptors expressions was performed by semiquantitative RT-PCR. Only TGF1 was analyzed immunohistochemically.

RESULTS

Our results showed significant decreases in the expression percentages of TGF-β 1, 2 and R1, R2 in chemical victims in comparison with chronic dermatitis and normal subjects and significant decreases in the intensity of R1 and R2 expressions in chemical victims in comparison with chronic dermatitis and normal controls. (P value < 0.05)

CONCLUSIONS

TGF-βs and their receptors appear to have a noticeable role in chronic inflammatory skin lesions caused by sulfur mustard.

Disaster management mobile protocols: a technology that will save lives

Although training and education have long been accepted as integral to disaster preparedness, many currently taught practices are neither evidence based nor standardized. The need for effective evidence-based disaster education for healthcare workers at all levels in the multidisciplinary medical response to major events has been designated by the disaster response community as a high priority. This article describes a disaster management mobile application of systematic evidence-based practice. The application is interactive and comprises portable principles, algorithms, and emergency protocols that are agile, concise, comprehensive, and response relevant to all healthcare workers. Early recognition through clinical assessment versus laboratory and diagnostic procedures in chemical, biological, radiological, and nuclear (CBRNE) exposures grounded in an evidence-based skill set is especially important. During the immediate threat, the clinical diagnosis can get frustrating because CBRNE casualties can mimic everyday healthcare illnesses and initially present with nonspecific respiratory or flu-like symptoms. As there is minimal time in a catastrophic event for the medical provider to make accurate decisions, access to accurate, timely, and comprehensive information in these situations is critical. The CBRNE mobile application is intended to provide a credible source for treatment and management of numerous patients in an often intimidating environment with scarce resources and overwhelming tasks.

Effects of using human patient simulator versus a CD-ROM on learning the management of patients exposed to chemical agents

INTRODUCTION

Very little prospective, randomized, experimental research exists on the use of simulation as a teaching method, and no studies have compared the effects of 2 strategies of using the Human Patient Simulator (HPS) and a CD-ROM on the management of patients exposed to chemical agents.

METHODS

A prospective, pretest-posttest experimental, mixed design (within and between) was used to determine if there were statistically significant differences between educational strategies using HPS, CD-ROM, and a control group in the care of patients exposed to chemical agents. Care was operationally defined as the score on the Management of Chemical Warfare Patients Performance (MCWPP) instrument. Participants included active duty and reserve military nurses (n=92). They were randomly assigned to one of 3 teaching groups: HPS (n=30), CD-ROM (n=31), or a control group (n=31).

RESULTS

Analysis of variance and a Tukey post-hoc test were used to analyze the data. The means on MCWPP instrument were as follows: HPS (pretest: mean=65.13, SD ± 8.9; posttest mean=73.0, SD ± 8.6); CD-ROM (pretest: mean=67.74, SD ± 11.18, posttest mean=65.67, SD ± 10.82); control (pretest: mean=68.51 SD ± 8.5; posttest mean=62.6, SD ± 8.6). There were no significant differences between the groups on the pretest (P=.363), but there were significant differences on the posttest (P=.001). Post-hoc analyses indicated the HPS group performed better than the CD-ROM group (P=.017) and the control group (P=.000). There was no significant difference between the CD-ROM and control groups (P=.485).

CONCLUSION

Based on the results of this study, the HPS is more effective than the CD-ROM in teaching nurses about the care of patients exposed to chemical agents.

[The five commandments for preparing the Israeli healthcare system for emergencies]

In the last decade, the Israeli healthcare system dealt with many casualties that resulted from terrorist actions and at the same time maintained preparedness for other potential hazards such as natural disasters, toxicological, chemical, radiological and biological events. There are various models for emergency preparedness that are utilized in different countries. The aim of the article is to present the structure and the methodology of the Israeli healthcare system for emergencies. Assuring emergency preparedness for the different scenarios is based on 5 major components that include: comprehensive contingency planning; control and command of operations; central control of readiness; capacity building; coordination and collaboration among the numerous emergency agencies. CLose working relationships between the military and civilian systems characterize the operations of the emergency system. There is a mutual sharing of information, coordinated operations to achieve risk assessment and determine priorities, and consensual allocation of resources. The ability of the medical system to operate in optimal coordination with interface bodies, including the Israel Defense Forces, is derived from three main elements: the shortage of resources necessitate that all agencies work together to develop an effective response to emergencies; the Israeli society is characterized by transition of personnel from the military to the civilian system which promotes joint operations, whereas in most other countries these systems are completely separated; and also developing mechanisms for continuous and coordinated operation in routine and emergency times, such as the Supreme Health Authority. The Israeli healthcare system was put to the test several times in the Last decade, during the terror wave that occurred between 2001-2006, the 2nd Lebanon War and in operation "Cast Lead". An extensive process of learning lessons, conducted during and following each of these periods, and the existence of a mechanism which facilitated the definition of a systematic policy and the examination of its implementation, enabled the healthcare system to provide medical services to the population and to improve its preparedness by an ongoing process.

[Normative and legal aspects of medical support of the persons working with toxic chemicals relating to the chemical weapons]

In article the existing lows and other legislation acts of state regulation in the field of medical maintenance of the works connected to destruction of toxic chemicals concerning to the chemical weapon is analysed. Features of carrying out of medical examinations and expertise of diseases at the soldiers and officers occupied on these works are submitted. The conclusion that the existing legislation acts allows to carry out qualitative medical service of the personnel of objects of storage and destruction of the chemical weapon, the military men occupied on works with toxic chemicals and the inhabitants living in sanitary-protective zones is made.

Chemical warfare agents

Chemical warfare agents are compounds of different chemical structures. Simple molecules such as chlorine as well as complex structures such as ricin belong to this group. Nerve agents, vesicants, incapacitating agents, blood agents, lung-damaging agents, riot-control agents and several toxins are among chemical warfare agents. Although the use of these compounds is strictly prohibited, the possible misuse by terrorist groups is a reality nowadays. Owing to this fact, knowledge of the basic properties of these substances is of a high importance. This chapter briefly introduces the separate groups of chemical warfare agents together with their members and the potential therapy that should be applied in case someone is intoxicated by these agents.

Direct detection of alkylphosphonic acids in environmental matrices by proton coupled phosphorus NMR

A simple, convenient, and direct one-dimensional (1D) (31)P NMR technique is demonstrated for the detection of alkylphosphonic acids (marker of nerve agents). The results of detection were validated after conducting various in-house exercises. The confidence generated by this study was found very useful in detection of different alkylphosphonic acids spiked in various official interlaboratory proficiency tests conducted by Organisation for the Prohibition of Chemical Weapons (OPCW).

Geochemistry of chemical weapon breakdown products on the seafloor: 1,4-thioxane in seawater

The long-term fate of chemical weapon debris disposed of in the ocean some 50 years ago, now sinking into marine sediments and leaking into the ocean environment, is poorly known. Direct evidence exists showing chemical weapon agents actively being released on the sea floor with detrimental effects including harm to marine life. Thus there is strong interest in determining the fate and lifetime of these materials, their decomposition products, and the affected zones around these sites. Here we study the geochemical properties of a mustard gas breakdown product, 1,4-thioxane (TO), using Raman spectroscopy. We show that TO forms a hydrate with a help-gas (a second guest added to stabilize the hydrate), such as methane or hydrogen sulfide, with the hydrate stability regime some 10 degrees C above pure methane hydrate. The temperature, pressure, and reducing conditions required for hydrate formation commonly occur at known disposal sites. The TO solubility was measured in seawater and found to vary from 0.65 to 0.63 mol/kg water between 4.5 and 25.0 degrees C. Similar to other hydrate systems, the TO solubility decreased in the presence of hydrate. A low solubility in water coupled with its ability to form a hydrate within marine sediments can greatly decrease molecular mobility and increase its lifetime. These results demonstrate how unanticipated reactions with marine sediments can occur, and how little is known of the processes controlling the environmental science of these materials.

A decontamination system for chemical weapons agents using a liquid solution on a solid sorbent

A decontamination system for chemical warfare agents was developed and tested that combines a liquid decontamination reagent solution with solid sorbent particles. The components have fewer safety and environmental concerns than traditional chlorine bleach-based products or highly caustic solutions. The liquid solution, based on Decon Greentrade mark, has hydrogen peroxide and a carbonate buffer as active ingredients. The best solid sorbents were found to be a copolymer of ethylene glycol dimethacrylate and n-lauryl methacrylate (Polytrap 6603 Adsorber); or an allyl methacrylate cross-linked polymer (Poly-Pore E200 Adsorber). These solids are human and environmentally friendly and are commonly used in cosmetics. The decontaminant system was tested for reactivity with pinacolyl methylphosphonofluoridate (Soman, GD), bis(2-chloroethyl)sulfide (Mustard, HD), and S-(2-diisopropylaminoethyl) O-ethyl methylphosphonothioate (VX) by using NMR Spectroscopy. Molybdate ion (MoO(4)(-2)) was added to the decontaminant to catalyze the oxidation of HD. The molybdate ion provided a color change from pink to white when the oxidizing capacity of the system was exhausted. The decontaminant was effective for ratios of agent to decontaminant of up to 1:50 for VX (t(1/2) < or = 4 min), 1:10 for HD (t(1/2) < 2 min with molybdate), and 1:10 for GD (t(1/2) < 2 min). The vapor concentrations of GD above the dry sorbent and the sorbent with decontamination solution were measured to show that the sorbent decreased the vapor concentration of GD. The E200 sorbent had the additional advantage of absorbing aqueous decontamination solution without the addition of an organic co-solvent such as isopropanol, but the rate depended strongly on mixing for HD.