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Effects of radiation on the longitudinal trends of hemoglobin levels in the Japanese atomic bomb survivors.

The late effects of radiation on the hematopoietic system have not been fully evaluated. We examined the long-term effects of radiation exposure on hemoglobin levels in the Japanese atomic bomb survivors over a 40-year period from 1958 to 1998. Compared to the unexposed survivors, the mean hemoglobin levels for those exposed to a bone marrow dose of 1 Gy were significantly reduced by 0.10 g/dl (95% CI: 0.04 to 0.16) or 0.67% at 40 years of age (P < 0.0001) and by 0.24 g/dl (95% CI: 0.08 to 0.40) or 1.8% at 80 years of age. Radiation effects are greater for smokers than for nonsmokers at age less than 35 years (P < 0.01), although cigarette smoking was associated with increased hemoglobin levels. Sex and birth cohort differences in radiation effects were not found after adjusting for smoking. The radiation-induced reduction in hemoglobin levels could not be explained by the presence of certain anemia-associated diseases.

Adult↗

A method to differentiate between the levels of ESR signals induced by sunlight and by ionizing radiation in teeth from atomic bomb survivors.

Electron spin resonance (ESR, or electron paramagnetic resonance, EPR) analysis of tooth enamel is an effective method for the retrospective estimation of individual radiation doses. One problem with this technique is that the observed ESR signal may include a contribution from ultraviolet (UV) light exposure from sunlight, especially in front teeth. Thus there has been a need to find ways to estimate the UV-light effect in the total signal so that the net ESR dose from ionizing radiation can be determined. To examine this issue, we measured 96 teeth of various types, but with buccal and lingual parts measured separately, from a control group of atomic bomb survivors (estimated dose <5 mGy). We found that, except for molars, the mean ESR-estimated dose for the buccal halves was, on average, nearly twice that from the lingual side, which indicates that the UV-light-induced lingual dose equals the difference between the two halves. Using these corrections for UV-light exposure to front teeth that had been exposed to both ionizing radiation and UV light, it was found that the estimated radiation doses closely approximated the previously estimated ESR dose to molars from the same donors or the estimated dose arrived at with cytogenetic methods. We concluded that, when using ESR to estimate radiation dose, measuring molars is the first choice, but if only front teeth are available, separate measurements to the buccal and lingual parts can provide an estimation of the mean UV-light contribution to the ESR-determined dose.

Dose-Response Relationship, Radiation↗

Autoantibodies and immunoglobulins in atomic bomb survivors with human T-lymphotropic virus type I.

The association of human T-lymphotropic virus type I (HTLV-I) with autoimmune disorders was investigated on the basis of prevalence of antinuclear antibody (ANA), rheumatoid factor and anti-thyroglobulin antibody as well as immunoglobulin (Ig) serum level (IgG, IgA, and IgM). The subjects, all atomic bomb survivors, were 59 HTLV-I-seropositive people without HTLV-I-associated myelopathy or adult T-cell leukemia and 149 HTLV-I-seronegative persons. The mean serum level of IgM was higher in HTLV-I-seropositive subjects than in HTLV-I-seronegative subjects, and a significant association with HTLV-I and sex was indicated in the IgM serum level. No association with HTLV-I was indicated in the prevalence of the autoantibodies except for ANA. These results suggest some clear humoral immunity differences between HTLV-I-infected and noninfected subjects, but whether HTLV-I infection can lead to autoimmune disorders remains uncertain.

Adult↗

Vicarious stress: patterns of disturbance and use of mental health services by those indirectly affected by the Oklahoma City bombing.

This study explored the intermediate psychological effects of terrorism on adults not directly affected by the Oklahoma City bombing by examining the course of PTSD and subthreshold PTSD symptoms over time and whether treatment affected this course. The respondents were interviewed at 3-mo. intervals for 18 mo. following an initial 6-mo. survey. Analysis suggested avoidance, re-experiencing, and increased arousal symptoms in this population were limited over time, declining with or without treatment between 6 and 9 mo. Conversely, victimization symptoms remained high without mental health intervention for the first year after the disaster. The study also examined the nature and occurrence of comorbidity in groups seeking and not seeking treatment.

Adult↗

Did the defeat of Saddam Hussein reduce suicide bombing casualties and attacks in Israel? A statistical analysis.

It was hypothesized that one of the reasons for the U.S. invasion of Iraq was to stop the payments being made by Saddam Hussein to the families of suicide (homicide) bombers in Israel. The consequences of suicide (homicide) bombing attacks against Israel between March 2001 and August 2004 were evaluated as related to the time of the U.S. invasion of Iraq. On average per month during this period, there were fewer overall casualties after the invasion than before it. As many as nearly 1,100 casualties may have been prevented in Israel as a consequence of the U.S. invasion of Iraq, suggesting that at least one possible goal of the U.S. invasion may have been achieved, at least as averaged over the first 17 months after the invasion.

Explosions↗

Rehabilitation after a letter-bomb attack causing bilateral hand loss and other injuries: case report.

The rehabilitation of patients after terrorist attacks has received scant attention in the literature. A case is reported of a patient injured in a letter-bomb explosion; his injuries were bilateral hand loss, loss of one eye, and perforated ear-drums. The successful rehabilitation of this patient to normal work in 8 months is described. A rehabilitation plan for management of similar patients is given.

Activities of Daily Living↗

Historical vignette: The radium bomb: Harvey Cushing and the interstitial irradiation of gliomas.

Harvey Cushing performed over 2000 operations on patients with brain tumors, including 832 for gliomas. He implanted radioactive radium needles, known as a "radium bomb," in a small number of these patients. He was not impressed with the results and did not pursue this method of treatment in a serious way. The authors present here Cushing's little-known experience with brachytherapy and discuss the reasons for his lack of interest in this technique, despite his advocacy of radiotherapy for certain lesions. An interesting perspective is offered for contemporary neurosurgeons involved in the treatment of brain tumors with cranial irradiation.

Brachytherapy↗

Perspective: National Cancer Institute summary report about estimated exposures and thyroid doses received from iodine 131 in fallout after Nevada atmospheric nuclear bomb tests.

Environmental 131I contamination from atmospheric nuclear bomb tests conducted at the NTS from 1951 to 1958 exposed Americans nationwide to a cumulative average dose of 1 to 4 rad to the thyroid gland. By comparison, 10 years of exposure to natural background sources of thyroid radiation results in a cumulative dose of 1 rad. Americans living in certain high-deposition areas received an average cumulative thyroid dose of as much as 16 rad. Individual dose rates vary considerably as a function of age at the time of exposure, site of residence, and dietary habits with respect to milk consumption. The individual cumulative thyroid dose for persons born between 1945 and 1958 may be significantly higher than the reported averages for their locale. The NCI report contains voluminous data tables permitting detailed calculations of individual dose. Additionally, color-coded dose maps allow one to approximate individual dose conveniently. Translation of cumulative thyroid dose attributable to 131I to predictions of increased rates of thyroid cancer appears problematic and is the subject of further study. In contrast to studies of patients receiving external thyroid irradiation, existing studies of patients treated with 131I for diagnostic and therapeutic medical purposes do not document increased rates of thyroid cancer. An Institute of Medicine task force is expected to issue a report on this subject in September 1998. This review also briefly summarizes the evaluation, diagnosis, and treatment of patients with papillary and follicular thyroid cancers. Data from 53,856 patients with thyroid cancer accessioned to the NCDB from 1985 to 1995 document extremely high survival rates for patients in the United States with papillary and follicular thyroid cancer.

Adult↗

Australian doctors in Bali: the initial medical response to the Bali bombing.

Several Australian medical practitioners were holidaying in Bali at the time of the nightclub bombing on 12 October 2002. On learning of the disaster, they went to Sanglah Hospital to assist. With the very limited resources of the hospital, they helped in providing emergency treatment, stabilising patients, and preparing Australian patients for evacuation.

Australia↗

The Bali bombing: civilian aeromedical evacuation.

After the Bali bombing on 12 October 2002, many injured Australians required evacuation to Darwin, and then to burns units around Australia. Many patients were evacuated from Denpasar by Qantas, with assistance from staff of civilian medical retrieval services. The transport of patients from Darwin to specialist burns units involved a coordinated response of civilian and military services. Some issues in responding to such disasters were identified, and a national coordinating network could improve future responses.

Air Ambulances↗

Forensic dental and medical response to the Bali bombing. A personal perspective.

After the Bali bombing on 12 October 2002, once the survivors had been treated or evacuated, many dead, severely burned and fragmented bodies were left. Formal identification was required before any remains could be released to grieving families. Australia sent a team to assist the Indonesians in this daunting and disturbing task. The "disaster victim identification" process eventually confirmed 202 people as dead, including 88 Australians. Personal and professional relationships between the Indonesians and our team were important factors in our acceptance into the Indonesian emergency response.

Australia↗

Otologic blast injuries due to the Kenya embassy bombing.

Otologic injuries are frequently associated with large blasts. On August 7, 1998, a large truck bomb exploded next to the U.S. Embassy in Nairobi, Kenya. Initial patient findings and care are reviewed. Five months later, an otologic screening and care mission was then sent to comprehensively screen all remaining blast victims on site in Nairobi and to determine degree of persistent injury. Surgical care appropriate for an outpatient environment was provided. Five of 14 tympanic membranes without intervention failed to heal, while 3 of 3 with previous intervention had. Blast injury severity did not correlate to distance from blast epicenter. This may be due to channeling of the blast through the embassy building and an unpredictable pattern of blast overpressure within the building. It is recommended that comprehensive otologic screening be performed after blast events to identify occult injuries and improve outcomes. Early intervention for tympanic membrane perforation (suctioning, eversion of perforations, and paper patch) is recommended.

Blast Injuries↗

After the bomb. Oklahoma City rescuers talk about their experiences.

Rather than trying to write a second-hand description of the response to the April 19 bombing of the Federal Building in Oklahoma City, we thought we'd let some of the people who were there caring for patients and searching for victims share their experiences in their own words. Marion Angell Garza, JEMS editorial/news coordinator, spoke at length with six responders, including paramedics, the triage and treatment officer, a firefighter/EMT-1 and an emergency physician. The following excerpts are from those interviews.

Anecdotes as Topic↗

Special report. The Oklahoma City bombing: mass casualties and the local hospital response.

A morning blast at the Alfred P. Murrah Federal Building, Oklahoma City, OK, on April 19, 1995, killed 168 persons and injured more than 500 in the worst terrorist attack in U.S. history. Hospital workers, physicians, and volunteers at nine hospitals there mobilized, put their disaster emergency plans into operation, and treated 466 persons in emergency rooms--many of them later being admitted as patients. To complicate matters, two of the hospitals received bomb threats called in after the disaster. This report will look at the security plans put into force by each of the nine hospitals; the handling of the great influx of persons, including victims, relatives, friends, concerned persons, volunteers, and the news media; and the lessons hospital officials learned from their experiences.

Communication↗

The EMS response to the Oklahoma City bombing.

This is a descriptive study of the Emergency Medical Services response to a bombing of a United States Federal Building in Oklahoma City, Oklahoma on 19 April 1995. The explosion emanated from a rented truck parked in the front of the building. The force of the explosion destroyed three of the four support columns in the front of the building and resulted in a pancaking effect of the upper floors onto the lower floors. There were three distinct phases of the medical response: 1) Immediately available local EMS ambulances and staff; 2) Additional ambulances staffed by recalled, off-duty personnel; and 3) mutual-aid ambulances and personnel from the surrounding communities. There were 361 persons in the building at the time of the explosion, 163 of these perished. Within the first hour of the explosion, 139 patients were transported to area hospitals. Of these, 32% were in critical condition. During the day of the explosion, 444 persons were treated for physical injuries: 410 of these were related to the explosion and 14, including one with fatal injuries, were sustained during search and rescue attempts. A total of 354 (80%) were treated and released from emergency departments, and 90 (20%) were admitted to hospitals. Six of the transported victims either were dead on arrival to the emergency department or died after admission to the hospital. Of those who died, 95% of the deaths were related to blunt trauma associated with the collapse of the structure. Only three persons were extricated alive after the first five hours following the explosion. The scene became flooded with volunteers who, although their intentions were to provide help and aid to those injured, created a substantial logistical problem for Incident Command. Several other lessons were learned: 1) Telephone lines and cells became overloaded, but the Hospital Emergency Administrative Radio system was operational only in three of the 15 hospitals; 2) Volunteer personnel should have responded to the hospitals and not to the scene; and 3) Training was an essential for the success of such a response. Thus, the success of this operation was a function of the intense training, practice, and coordination between multiple agencies.

Emergency Medical Services↗

The role of the medical examiner in mass casualty situations with special reference to the Alfred P. Murrah Building bombing.

OBJECTIVE: To describe the events that shaped the investigation by the Oklahoma Office of the Chief Medical Examiner with regard to the terrorist bombing of the Alfred P. Murrah Federal Building in Oklahoma City in 1995 and to provide lessons learned for reinforcement and future planning. STUDY POPULATION: All persons known to have been killed by the blast. METHODS: Standard forensic techniques with regard to crime scene investigation, documentation, body identification and cause of death determinations were followed. MAIN OUTCOME MEASURES: Fatality injury and related evidence documentation. RESULTS: A total of 168 people died principally from secondary and tertiary injuries caused by projectiles, victim displacement, and crushing. Emphasis is placed on the methods of operation required to find, remove, identify, and determine cause of death in these individuals. Simultaneously, evidence must be identified and preserved in a homicide investigation of this type. Close cooperation must exist among multiple varied agencies and disciplines to accomplish the task and to prepare for subsequent analysis and courtroom testimony required by the criminal justice system. CONCLUSIONS: Terrorism, both foreign and domestic, is a current fact and will be a problem in many forms in the 21st century. No one is immune. The key to success is to plan ahead and be aware of available resources. Preplanning for short comings and difficult issues, and most importantly, relying on team work will allow future participants to successfully meet and complete the challenge. The investigation developed detailed injury data and mechanisms that were available for subsequent judicial proceedings and for in-depth epidemiological studies spearheaded by the Injury Prevention Service of the Oklahoma State Department of Health.

Coroners and Medical Examiners↗

After the bombing: public scenarios and the construction of meaning.

In both our folk psychology and mental health practice, we adhere to the modernist view that a crisis is something that an individual has. A crisis is either something that happens to people or which people bring on themselves because of character pathology. On the other hand, postmodern theorists now draw our attention to how processes of interaction provide opportunities for certain characterizations to emerge and disipate. Both the conceptualization of an event as a crisis and the scenarios of how it is best understood arise within a community and emerge out of the communal construction of meaning. In this process in Oklahoma City, bystanders, politicians, pilgrims and news media played a role of great significance. Whether local or from afar, they became a community of observers who interacted with one another and looked to one another for verification as to what counted as a crisis and what behavior was appropriate. Lindy has observed that traumatized individuals are often surrounded quickly by a small network of trusted people who serve to buffer and protect them and who define what is helpful and what constitutes further trauma. Here, in Oklahoma, however, a wider public defined the event as a crisis, elaborated on it, and have gradually transformed it into almost mythic proportions, a process now exemplified in the construction of the Oklahoma City National Monument. However, they have also endorsed diverse other scenarios, not all of which have facilitated appropriate grieving, repair of life-disruption, or moving on. All, however, seem to have given a sense of meaning to the event. In this rich matrix, some survivors and their families have felt helped. Others have felt exploited. Still others have wanted to forget the whole thing and to avoid anything that reminded them of it. Of the would-be helpers, some felt unjustly rejected and unappreciated. Others felt appreciated, useful, and even enriched. However, a true legacy of the bombing may well be the metalogue it can precipitate and advance about the relationship between individuals and society, and especially the relationship between our individual life-stories and larger public scenarios, and the effects these scenarios have on the questions we can ask, what we can perceive and what solutions we can create.

Crime Victims↗

Long-term care policies: defusing a financial time bomb.

Most Americans have little or no private health insurance for chronic illness or disability, largely because of forces restricting the development of a market for long-term care insurance. Properly structured incentives could alter this situation and help defuse a financial time bomb confronting the nation. Spending for long-term care has grown dramatically in the last 20 years and is expected to continue escalating. The question is who will pay for it. Considerable room exists to increase private insurance's proportion of long-term care expenses, which are now largely paid by the patient out-of-pocket or by Medicaid. The current market, however, is under-developed because demand is thin and private third-party insurers are reluctant to write policies. But the potential demand is substantial because of the increasing elderly population. To develop a long-term care insurance market, tax incentives should be offered, the elderly need to be educated about the limited coverage provided by Medicare, and beneficiaries need to be made aware that relying on Medicaid's safety net could lead to impoverishment.

Aged↗