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Objective Doctors' health matters because healthy physicians are more productive and because physicians’ health practices affects their patient counseling habits, but there are few objective data on this topic. Methods An examination of differences in screening quality health indicators between physicians (n = 429) and 1621 age, gender, and socioeconomically matched patient controls from our district Health Maintenance Organization in Israel during the first half of 2008. Results Doctors and matched patients had similar rates for low-density lipoprotein measurement (85%/84% = NS), colorectal cancer screening (23%/27% = NS), influenza vaccine among the chronically ill (23%/24% = NS), and mammography (for women, 55%/57% = NS). Doctors with hypertension had blood pressures clinically recorded considerably less frequently than matched patients do (56%/77%, p

The combination of the AP2C unit with the SP4E kit composes a lightweight mobile detector of chemical warfare agents (CWA), such as nerve and mustard agents, with both vapor- and liquid-sampling capabilities. This apparatus was recently introduced into our military medical units as an aid for detection of CWA on casualties. Importantly, critical information regarding the applicability in the battlefield was absent. In view of the serious consequences that might follow a proclamation of CWA recognition in battlefield, a high false-positive rate positions the utilization of this apparatus as a medical decision tool in question. We have therefore conducted a field experiment to test the false-positive rate as well as analyze possible factors leading to false-positive readings with this device. The experiment was carried out before and after a 4-day army field exercise, using a standard AP2C device, a SP4E surface sampling kit, and a specially designed medical sampling kit for casualties, intended for medical teams. Soldiers were examined at rest, after mild exercise, and after 4 days in the field. The readings with AP2C alone were compared to the combination of AP2C and SP4E and to the medical sampling kit. Various body fluids served as negative controls. Remarkably, we found a false-positive rate of 57% at rest and after mild exercise, and an even higher rate of 64% after the 4-day field exercise with the AP2C detector alone, as compared to almost no false-positive readings with the combination of AP2C and SP4E. Strikingly, the medical sampling kit has yielded numerous false-positive readings, even in normal body fluids such as blood, urine, and saliva. We therefore see no place for using the medical sampling kit due to an unaccepted high rate of false-positive readings. Finally, we have designed an algorithm that uses the entire apparatus of AP2C and SP4E as a reliable validation tool for medical triage in the setting of exposure to nerve agents in the battlefield.

Objective: On March 20, 1995, sarin gas was used in Tokyo by members of the Japanese “Uhm-Shinrikiu” cult, killing 12 and injuring >5,500 innocent people. Most of the casualties were mildly injured. This article reviews the neurological follow-up data for some of the victims over the past decade. Methods: We reviewed the published literature regarding neurological follow-up of the victims, dividing the data according to the time elapsed after the attack. Results: The digit span test, fingertapping test, and computerized posturography were the only performance tests that showed statistically significant differences between the victims and the control groups in some of the surveys. The main sequela 7 years after the attack was post-traumatic stress disorder. Conclusions: The results emphasize the need for a national preparedness program for such mass casualty events, led by national health systems. This should include long-term, neurological, follow-up monitoring with performance tests and a post-t...

The clinical effects of self injections of atropine-trimedoxime auto-injectors distributed to the civilian population as a field antidote for nerve agent attack were assessed.Data on self injections by adults (or = 18 years) were collected from the Israel Poison Information Center and a hospital Emergency Department's records during a 2-year period. The data included demographics, time interval from injection, type of auto-injector, clinical manifestations and atropinization score.Sixty-five patients, all with unintentional self injections, were reported. Systemic atropine effects were observed in 24 patients, but no severe atropinization. The atropinization score was significantly higher in the 2 mg atropine dose group than in the two lower dose groups, which were in the normal range. No specific adverse effects attributable to trimedoxime were observed. Intravenous fluids and physostigmine were not required.Only mild reactions were observed following self-injection of atropine trimedoxime auto-injectors in adults, attesting to their relative safety under these conditions.

Since the 1995 Tokyo subway sarin attack, terrorist attacks involving weapons of mass destruction or other industrial chemicals present worldwide security and health concerns. On-scene medical triage and treatment in such events is crucial to save as many lives as possible and minimize the deleterious effects of the toxic agent involved. Since there are many chemicals that can be used as potential terrorist weapons, the medical challenge for the emergency medical services (EMS) is a combination of: (1) recognizing that a chemical terrorist attack (non-conventional) has occurred; and (2) identifying the toxic agent followed by proper antidotal treatment. The latter must be done as quickly as possible, preferably on-scene. The most valuable decision at this stage should be whether the agent is organophosphate (OP) or not OP, based on clinical findings observed by pre-trained, first responders. This decision is crucial, since only OP intoxication has readily available, rapidly acting, onscene, specific agents such as atropine and one of the oximes, preferably administered using autoinjectors. Due to the lack of a specific antidote, exposure to other agents (such as industrial chemicals, e.g., chlorine, bromide, or ammonia) should be treated on-scene symptomatically with non-specific measures, such as decontamination and supportive treatment. This paper proposes an algorithm as a cognitive framework for the medical teams on-scene. This algorithm should be part of the medical team's training for preparedness for chemical terrorist attacks, and the team should be trained to use it in drills. Implementing this path of thinking should improve the medical outcome of such an event.

September 11, 2001, forever changed the landscape surrounding terrorism. The oceans no longer protected the United States from terrorists. And as incidences in the Philippines, Spain, Iraq, and other corners of the globe have found, no place on the planet can be considered risk-free. Unfortunately, not only must the world be concerned with acts of violence and destruction, but also with the threat of a more insidious nature—chemical and biological terrorism. According to a March 29, 2004, article in the New York Times, the Pentagon released parts of an unclassified document suggesting that the United States is “woefully ill-prepared to detect and respond to a bioterrorist assault.” In this article, our authors offer us a first-hand window into an important and regrettably necessary area of medicine that could affect us both as physicians and citizens in the twenty-first century.Fig 1 —The Editors Biochemical terrorism—the deliberate dispersion of viruses, bacteria, fungi, and organic or inorganic toxin agents, to kill, mutilate, and create chaos—is a real threat that all countries must cope with today. Both sovereign nations and terror organizations now have the capability to produce and use biochemical agents, and some of them have already demonstrated their eagerness to do so. The development of instant communication has been a further inducement to the terrorists. Each event is reported almost immediately in the media, bringing recognition and reputation to the executors (1–3).

September 11, 2001, forever changed the landscape surrounding terrorism. The oceans no longer protected the United States from terrorists. And as incidences in the Philippines, Spain, Iraq, and other corners of the globe have found, no place on the planet can be considered risk-free. Unfortunately, not only must the world be concerned with acts of violence and destruction, but also with the threat of a more insidious nature-chemical and biological terrorism. According to a March 29, 2004, article in the New York Times, the Pentagon released parts of an unclassified document suggesting that the United States is "woefully ill-prepared to detect and respond to a bioterrorist assault." In this article, our authors offer us a first-hand window into an important and regrettably necessary area of medicine that could affect us both as physicians and citizens in the twenty-first century.Fig 1 -The Editors Biochemical terrorism-the deliberate dispersion of viruses, bacteria, fungi, and organic or inorganic toxin agents, to kill, mutilate, and create chaos-is a real threat that all countries must cope with today. Both sovereign nations and terror organizations now have the capability to produce and use biochemical agents, and some of them have already demonstrated their eagerness to do so. The development of instant communication has been a further inducement to the terrorists. Each event is reported almost immediately in the media, bringing recognition and reputation to the executors (1-3).

The relative accessibility to various chemical agents, including chemical warfare agents and toxic industrial compounds, places a toxicological mass casualty event, including chemical terrorism, among the major threats to homeland security. TMCE represents a medical and logistic challenge with potential hazardous exposure of first-response teams. In addition, TMCE poses substantial psychological and economic impact. We have created a simple response algorithm that provides practical guidelines for participating forces in TMCE. Emphasis is placed on the role of first responders, highlighting the importance of early recognition of the event as a TMCE, informing the command and control centers, and application of appropriate self-protection. The medical identification of the toxidrome is of utmost importance as it may dictate radically different approaches and life-saving modalities. Our proposed emergency management of TMCE values the "ScoopRun" approach orchestrated by an organized evacuation plan rather than on-site decontamination. Finally, continuous preparedness of health systems - exemplified by periodic CBRN (Chemical, Biological, Radio-Nuclear) medical training of both first responders and hospital staff, mandatory placement of antidotal auto-injectors in all ambulances and CBRN emergency kits in the emergency departments - would considerably improve the emergency medical response to TMCE.

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

The recent attempt to poison Ukrainian President, Viktor Yuschenko with dioxins, raised public concern regarding this toxic chemical. In industrial countries, there is a constitutive exposure of humans to dioxin compounds, which are formed as by-products in manufacturing processes of various chlorinated organic chemicals and in waste incinerators. Dioxins are extremely stable in the environment and have a low turnover rate in the body--sometimes they are detected years after the original exposure. Of the dioxins, the most notoriously famous is the TCDD (2,3,7,8 tetrachlorodibenzo-p-dioxin). Dioxins exhibit high acute toxicity in various animal species. Humans, however, are considered less susceptible and so far there were no reported deaths following acute dioxin poisoning. Nevertheless, numerous adverse health effects are attributed to dioxin exposure. The most prominent is the chloracne--an acute acneiform eruption, usually appearing on facial skin. There is a solid evidence base that some dioxins are carcinogens. Other long-term deleterious effects of dioxin include: immunosuppression, effects on reproduction, impairments in developmental, neurological and cognitive functions in infants, increased risk for diabetes and cardiovascular diseases and various hormonal alterations. The action of dioxins resembles that of hormones, since their toxicity is mostly receptor-mediated. Dioxins manifest their toxicity in extremely low concentrations. Although there are compounds that exhibit their biological activity at even lower dose range (e.g. nerve gases), this potency of dioxins is considered extraordinary, since there is an every-day exposure to dioxins through environmental vectors mostly via the food chain. Until now, there is no antidotal cure for dioxins, but only symptomatic treatment combined with techniques that accelerate its excretion rate from the body.

The Tokyo subway sarin attack in March 1995 demonstrated the importance of preparedness toward a chemical terrorist attack. Emergency medical teams on the scene are valuable, beside the medical treatment of casualties, in the cognition of toxicant involvement and later in the recognition of the specific toxidrome involved. The chemical terrorism scene is a contaminated area; therefore, first responders have to be protected from both percutaneous and inhalational exposure to toxic materials. This protection is also against secondary evaporation (gas-off) from contaminated casualty, hence the importance of disrobing casualties on the scene as soon as possible. Once the recognition of toxicological involvement have been made, the next crucial decision is whether the clinical toxidrome is of cholinergic toxicity (e.g. organophosphate or carbamate intoxication) in which there are automatic injectors for treatment available on the scene, or any other toxidrome (such as irritation or vesicants) in which, beside general measures, like oxygen delivery and airway support, there is not a specific antidotal treatment on the scene. The clinical detection and identification of the chemical toxidrome involved is of utmost importance since it promotes the antidotal treatment quickly and efficiently. The key to the medical management of such events is based on decisions that have to be taken as soon as possible according to the clinical judgment of medical teams on the scene.

Nerve agent poisoning is characterized by the rapid progression of toxic signs, including hypersecretions, tremor, convulsions and profound brain damage. In the political arena of today's world, the threat of nerve agent use against military troops has prompted armies to search for prophylactic protection. The two main strategies for prophylaxis include biological scavengers that can bind or cleave nerve agents before they react with acetylcholinesterase, and antidotes as prophylactic treatment. Pyridostigmine is the current pretreatment for nerve agent poisoning and is in use by most of the armed forces in Western countries. However, since pyridostigmine barely crosses the blood-brain barrier it provides no protection against nerve agent-induced central injury. Pyridostigmine is ineffective when administered without post-exposure treatment adjuncts. Therefore, other directions for prophylactic treatment should be explored. These include combinations of carbamates (reversible AChE inhibitors) and central anticholinergics or NMDA receptor antagonists, benzodiazepines or partial agonists for benzodiazepine receptor, and other central AChE inhibitors approved for Alzheimer's disease. The transdermal route is an alternative way for delivering the prophylactic agent. Administration of prophylaxis can be extended also for civilian use during wartime.

Bacillus anthracis, the causative agent of anthrax, is well known in human history as a major cause of disease in domestic and wild animals and as a rare condition in humans. For the last seventy years, anthrax was developed and occasionally stored as an agent of biological weapon arsenal in numerous countries. The incubation period in humans is 1-6 days and the disease may be present as three distinct clinical syndromes: cutaneous, inhalational, and gastrointestinal disease. The major concern in regard of biological warfare is the inhalational form of anthrax, which starts as a febrile flu-like disease. The development of malaise, fatigue, cough and mild chest discomfort is followed by severe respiratory distress with dyspnea, diaphoresis, stridor, and cyanosis. Shock and death occur within 24-36 hours after onset of severe symptoms. Physical findings are non-specific, but a widened mediastinum is usually seen on chest x-ray. A positive blood culture, immunohistochemical methods and the use of the polymerase chain reaction method confirm the diagnosis. Although effectiveness may be limited after severe symptoms are present, a high dose of antibiotic treatment should be administered and aggressive supportive therapy may be necessary. In the situation of an anthrax attack, as was recently seen in the United States, penicillin is no longer recommended as an acceptable first line therapy. In this case, ciprofloxacin or doxycycline is the recommended drug of choice since penicillin-resistant strains may be used, as well as the possibility of the emergence of an inducible beta-lactamase positive bacterium. Since a high infecting dose may exacerbate the clinical course of the disease, a combination antibiotic regimen should be considered. The disease is not contagious and standard precautions are sufficient. Pre-exposure prophylaxis is based on a vaccine administration, while post-exposure prophylaxis is feasible by the initial use of oral ciprofloxacin or doxycycline. In this article we reviewed the literature with emphasis on the recent medical reports from the United States analyzing the eleven cases of inhalational anthrax as well as the new guidelines for diagnosis and treatment that resulted from the bioterrorism attack in October 2001. Although physical findings were non-specific, abnormal findings on chest x-rays were present in all the eleven cases. A positive blood culture, immunohistochemical methods and the use of the polymerase chain reaction method were highly valuable in revealing and confirming the diagnosis of anthrax. In the case of an attack with anthrax spores, the likelihood of exposure to a large infective dose of high quality spores, may require a prolonged period of treatment as well as prolonged post-exposure therapy.

Selected events in the history of biological weapons are highlighted to increase the physician's awareness of this crucial threat. The deliberate use of biological substances originated in antiquity and has pervaded the history of human wars throughout time until the 21th century. The history of biological warfare is difficult to assess because of a number of confounding factors. These include the difficulty in verification of allegation, the use of the threat of this weapon for propaganda purposes, the lack of microbiological or epidemiological data, and the incidence of natural occurring endemic or epidemic diseases during hostilities. Although it may be problematic to verify at times, the use of such weapons has not been limited to national armies or militia. Frustrated civilians, terrorists and even physicians have used biological substances to promote their interests. Today, the biological threat has become more serious. It's potency, cost-effectiveness, and the ability to manufacture and deploy it with little sophistication, or under the semblance of legitimate commercial endeavors, will ensure that biological weapons remain a constant threat to human health.

The use of biological agents as weapons is a well-known and established fact in the modern world. Biological warfare can be used both in terrorist events and in war and they pose a real threat and a formidable challenge to the defender. Biological weapons, in their various forms such as germs, viruses or toxins, can harm both living creatures and their surroundings. The relative simplicity of their production and use, compared to other non-conventional weapons, renders them to be a highly accessible system that can cause numerous casualties. Therefore, it is extremely important to study the threat and learn its characteristics, so as to be appropriately prepared in order to minimize potential damage. This review summarizes the characteristics of biological weapons (physical and biological), the means of use in bioterrorism and war, the advantages and disadvantages, comparisons to other non-conventional weapons and both tactical and strategical uses.