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The waiting room can be a potential time bomb if not handled properly, says the author. Communication with patients about waiting time and being aware of and dealing with potential problems are the key to preventing violence.
The dose-response relationship for radiation-induced leukemia was examined in a pooled analysis of three exposed populations: Japanese atomic bomb survivors, women treated for cervical cancer, and patients irradiated for ankylosing spondylitis. A total of 383 leukemias were observed among 283,139 study subjects. Considering all leukemias apart from chronic lymphocytic leukemia, the optimal relative risk model had a dose response with a purely quadratic term representing induction and an exponential term consistent with cell sterilization at high doses; the addition of a linear induction term did not improve the fit of the model. The relative risk decreased with increasing time since exposure and increasing attained age, and there were significant (P < 0.00001) differences in the parameters of the model between datasets. These differences were related in part to the significant differences (P = 0.003) between the models fitted to the three main radiogenic leukemia subtypes (acute myeloid leukemia, acute lymphocytic leukemia, chronic myeloid leukemia). When the three datasets were considered together but the analysis was repeated separately for the three leukemia subtypes, for each subtype the optimal model included quadratic and exponential terms in dose. For acute myeloid leukemia and chronic myeloid leukemia, there were reductions of relative risk with increasing time after exposure, whereas for acute lymphocytic leukemia the relative risk decreased with increasing attained age. For each leukemia subtype considered separately, there was no indication of a difference between the studies in the relative risk and its distribution as a function of dose, age and time (P > 0.10 for all three subtypes). The nonsignificant indications of differences between the three datasets when leukemia subtypes were considered separately may be explained by random variation, although a contribution from differences in exposure dose-rate regimens, inhomogeneous dose distribution within the bone marrow, inadequate adjustment forcell sterilization effects, or errors in dosimetry could have played a role.
This report updates the data on noncancer mortality for 86,572 atomic bomb survivors with dose estimates in the Radiation Effects Research Foundation's Life Span Study cohort. The primary analyses are based on more than 27,000 noncancer disease deaths that occurred in the cohort between October 1, 1950, and December 31, 1990, 30% more than in the previous report. The present analyses strengthen earlier findings of a statistically significant increase in noncancer disease death rates with radiation dose. Increasing trends are observed for diseases of the circulatory, digestive and respiratory systems. Rates for those exposed to 1 Sv are elevated about 10%, a relative increase that is considerably smaller than that for cancer. However, estimates of the number of radiation-related noncancer deaths in the cohort to date (140 to 280) are 50 to 100% of the number for solid cancer. The data do not yet clarify the shape of the dose response. There is no significant evidence against linearity, but the data are statistically consistent with curvilinear dose-response functions that posit essentially zero risk for doses below 0.5 Sv. Similarly, while the data are consistent with substantial variation in the excess relative risk with age at exposure or attained age, there is no statistically significant dependence on these factors. In view of the small relative risks and the lack of understanding of biological mechanisms, we emphasize consideration of whether the findings could be explained by misclassification, confounding or selection effects. Based on available data, we conclude that such factors are unlikely to fully explain the observed dose response. A significant dose response is also seen for deaths from blood diseases with an excess relative risk that is several times greater than that seen for solid cancer. Particular attention is paid to the possibility that this apparent effect is a consequence of the attribution of leukemia or other cancer deaths to noncancer blood diseases. We find that misclassification does not explain this excess risk. As in earlier reports, suicide rates tend to decrease with increasing dose.
The age-time patterns of excess cancer risk among A-bomb survivors followed up by the Radiation Effects Research Foundation inevitably carry implications regarding the mechanisms of radiation-related cancer. It has recently been found, quite surprisingly and in contrast to impressions given by the relative risks, that for most solid cancers the excess incidence rates themselves depend very little on age at exposure or time since exposure, but mainly on attained age. This paper investigates a mechanistic model that conforms to these age-time patterns. The essence of the model, which is highly idealized, is that: (a) a cancer is caused by mutations that accumulate in a stem cell throughout life, essentially the Armitage-Doll multistage model, and (b) radiation is a general mutagen that can cause virtually any of these mutations. Although postulate (b) departs from previous modeling considerations, the extent to which it explains various aspects of the data in substantial detail is remarkable. A strength of the model is that, similarly to the Armitage-Doll multistage model but differently from many others, it predicts characteristic age-time patterns of excess rates rather independently of its parameter values. The consequence of (a) is that, in Armitage-Doll fashion, background rates increase throughout life as a power of age. The consequence of (b) is that excess absolute rates do not depend on age at exposure and increase with age to a power one less than that of the background rates. Thus the excess relative risk, which is the ratio of these rates, decreases throughout life as 1/age with no dependence on age at exposure. Although this age pattern of relative risks corresponds closely to the RERF data for solid cancer, the interpretation of such a description is quite different from the usual one in which age at exposure plays a primary role.
The Oklahoma City bombing is considered by most historians the worst act of domestic terrorism ever to have occurred in the United States. The response to the disaster, however, is considered by most experts in the field as being the best; creating what is known as the "Oklahoma Standard". The roles of the dental teams in the resolution were pivotal and until now, the recognition of these roles have not been described, due to this being considered a case of mass murder. The purpose of this paper is to give an overview of the preparations, the initial responses, the roles of the dental teams in the resolution, the preparations for the criminal trials, and some of the lessons that were learned.
The small-scale explosivity device (SSED) has been used to assess the explosive power of a number of low explosives-smokeless powders (WC-870, Red Dot, Bullseye, Winchester Action Pistol, and IMR-PB), Pyrodex, black powder, and an improvised explosive (TATP). The device requires 2 g of energetic material, a heavy-walled containment vessel, and a standard blast shield to permit use in most laboratories. The data from the SSED are compared with the fragmentation of pipe bombs which contained 300 to 700 g of powder. The SSED provided the same relative ordering of explosivity as suggested by the fragmentation of the real devices. In addition, the SSED was used to evaluate the chemical residue remaining after an explosion. Issues in using the device such as optimal detonators and restricted reaction volume were probed using three high explosives--TNT, Tetryl, and RDX.
This paper documents the clinical course of the casualties treated at University College Hospital, following the detonation of a terrorist nail bomb in a public house in Soho, London. The need for adequate primary debridement is paramount, including consideration of definitive primary limb amputation.
Suicidal deaths caused by pipe bombs are rare. An 18-year-old man was found dead in a forest by hikers. In immediate proximity to the body, a crater was located obviously induced by a detonation. The postmortem examination revealed severe damage of the head, upper-body and both arms and hands along with the extensive presence of soot and dirt. Particularly noticeable were numerous "entry wounds" and the presence of five bullet like pieces of metal in the body. The young man had a history of drug abuse and psychiatric problems. On the basis of autopsy findings, the conclusions of the police investigation and psychopathological considerations regarding the victim's case-history, discussion centers upon the differentiation between suicide by self-explosion, homicide by explosion or death as a consequence of numerous bullet wounds followed by an attempt to burn the body. Also considered is the possibility of paranoid psychosis induced by cannabis use as a cause of suicide.
This is a personal account of the author's involvement as an adviser in the wake of the Nairobi terrorist bombing in 1998. Much has been written in the literature about the problems for and reactions of first responders, emergency personnel and those who provide care for victims of trauma. Less is known about the role of the specialist adviser. The author describes the terrorist incident, how the Kenyans responded to it and his own role. He also highlights important learning points, dilemmas and challenges which an adviser might encounter.
Almost half of hospitals lack a plan for nuclear terrorism; however, disaster management experts say it's not difficult to add this to an existing disaster plan. Screen all incoming patients for radiation if a disaster involves the use of explosives. Provide staff with training in radiologic monitoring. Use a dirty bomb scenario for your next disaster drill.
The Research Institute for Radiation Biology and Medicine has a cohort of atomic bomb survivors, residents of Hiroshima Prefecture, followed up since 1968. An epidemiological project on cancer mortality has been extended by the 5 years from 1992 to 1997. In this paper we aim to evaluate the relative risk pattern of specific cancers by radiation dose over time and during this recent 5 years. We obtained the late effects and temporary changes from cancer sites on mortality such as leukemia, all cancers except leukemia, and cancers of the lung, esophagus, liver, stomach, colon, pancreas, breast and uterus. Although results for the additional 5 years were not statistically significant due to the relatively small sample size, we observed decreasing trends for many cancer sites including all cancers except leukemia, esophagus, colon, stomach, liver and breast cancers. In particular the sharply increased excess relative risk for female breast cancer shown in 1988-1992 dramatically declined during the period 1993-1997.
Bombings and other blast-related events place severe demands on pre-hospital and in-hospital systems. The resulting surge of victims can overwhelm the resources of any facility not prepared for such an event. The September 11 terrorist attacks underscore the urgency of our need for preparedness. The challenges become even more daunting when there is possible hazmat exposure as well; this means that adequate and rapid disposition of victims is even more critical in order to avoid contamination of hospitals systems or whole communities. Federal agencies have been designated and federal mandates have been issued to address mass casualty events, but federal or even regional systems cannot respond in time to address the massive and immediate needs generated by an explosion. Local communities must take the lead in developing incident command systems for initial management of such events. Hospital and pre-hospital providers play a key role in such planning. Ultimate management and disposition of large numbers of casualties, especially if contaminated, cannot follow standard patient management protocols; new protocols are needed. To avoid a total, overwhelming break down of in-hospital resources, hospitals need to assume a lead role in addressing such issues in their local communities.
This study was conducted in an attempt to develop a metallographic method for the investigation of pipe bombings. Three common pipe materials, ASTM A53 steel, AISI 304L stainless steel, and 6061-T6 aluminum, were shock-loaded using five high explosives and three propellants. The explosives used were ANFO, Composition C4, C6 detasheet, nitroglycerine-based dynamite, and flake TNT. The propellants used were FFFFg black powder. Red Dot smokeless powder, and Turbo Fuel A. The post-blast microstructure, hardness, and, in the case of 304L, transformed martensite content were examined for each test. The damage done to the microstructure was found to increase with increasing detonation velocity of the explosives and increase in pressure generated by the shock-metal interaction. Material hardness and, in the case of 304L, martensite content showed a sharp increase followed by a plateau as the shock pressure and detonation velocity increased.
A "dirty bomb," a conventional explosive packed with radioactive material, kills or injures through the initial blast and by airborne radiation and contamination. Adult-health nurses need an understanding of the consequences of blast injuries and radiation exposure, and the management of victims.
OBJECTIVE: To elucidate the association of serum uric acid concentration with cardiovascular mortality risk. METHODS: Serum uric acid level measured from 1966 through 1970 in 10,615 Japanese individuals from a cohort of atomic bomb survivors was analyzed for association with subsequent cardiovascular and all-cause mortality until 1999 using the Cox proportional hazard model. RESULTS: During an average followup of 24.9 years, 5225 deaths occurred, of which 1984 were ascribed to cardiovascular disease. In men, after adjustment for age, elevated serum uric acid level was associated with both cardiovascular and all-cause mortality. After additional adjustment for potential cardiovascular disease risk factors including body mass index, smoking status, alcohol consumption, systolic blood pressure, cholesterol level, and histories of hypertension, diabetes and cardiovascular disease, elevated serum uric acid level in men was associated with all-cause mortality but not with cardiovascular mortality. In women, even after these adjustments, elevated serum uric acid level was significantly associated with cardiovascular and all-cause mortality. CONCLUSION: Increased serum uric acid level is a significant and independent risk factor for cardiovascular mortality in women and for all-cause mortality in both men and women.
The authors emphasize the need in coordination when conducting expert examinations in investigation of accidents with a great number of victims. Coordination is of special importance for combined application of molecular-genetic technologies and standard forensic medical investigations. The experience in experts cooperation in investigation of terroristic bombing in Moscow underground on February 6, 2004, according to algorithm of combined use of conventional forensic medical methods and innovating techniques of molecular-genetic identification for personal identification of dead bodies in accidents with a great number of victims is demonstrated.
A descriptive study was carried out in pregnant women who were affected by the 1998 bomb blast in Nairobi, Kenya, and their babies who were in utero at the time of the blast. The psychological effects of the event on the exposed women were severe. After three years, the average score on the Impact of Event Scale - Revised was still higher than 29 for the three subscales combined, suggesting that most of the study group was still suffering from clinical post-traumatic stress disorder (PTSD). The scores on all Childhood Personality Scale (CPS) subscales were significantly higher in children of the study group than in controls. The mothers' PTSD symptom levels at one month after the blast correlated with the children's CPS profiles.
In The Netherlands the threat of terrorist attacks also exist. Both doctors and hospitals alike should be prepared for such attacks both on the logistical as well as the medical level. Most terrorist attacks are carried out with explosives. This results in many victims and in cases of explosions in closed or semi-closed areas, often results in complex medical problems in many of the victims. An explosion that occurs as the result ofa bomb detonating can result in 4 patterns of injury: the primary explosion injury caused by the pressure of the blast, the secondary injuries caused by flying debris, the tertiary injuries caused by the explosion wind, and the quaternary caused by heat and fire. Common injuries seen following an explosion include: lung damage, neurological damage, abdominal injuries, bone fractures and skeletal damage and crush-syndrome. The triage occurs at the site of the explosion as well as on arrival in hospital. One especially important aspect of this is the sorting and selecting between victims who are likely to develop complex problems and who therefore need to receive aggressive treatment in a specially equipped centre and those patients for whom the nearest emergency department will suffice their needs. The triage should be repeated considering the possibility that initial estimates on these points may have been wrong. Epidemiological research should be carried out for each attack in order to make an inventory of the number of victims, the injuries incurred, the assessment of the effects of the medical help received and an assessment of the effectiveness of the total aid received.