50 Years of terrorism in Belgium: a review of 121 incidents in the global terrorism database.

OBJECTIVES: Belgium is not only prone to inland terrorism but also attracts terrorist factions aiming at various political, diplomatic, military, and/or religious targets. This study aimed to identify and characterize all documented terrorist attacks in Belgium reported to the Global Terrorism Database (GTD) over a period of 50 years. METHODS: The GTD was searched for all terrorist attacks in Belgium between 1970 and 2019. Analyses were performed on temporal factors, location, target type, attack and weapon type, attacker type, and number of casualties or hostages. RESULTS: In 50 years, 121 incidents accounted for 80 confirmed fatalities and 498 injured people. Bombings and explosions were the most frequently identified attack type (46.3%), followed by assassination (16.5%), infrastructure damage (15.7%) and armed or unarmed assaults (14.0%). Governmental and diplomatic institutions were the most frequent target (24.0%). For those perpetrators the GTD did have enough information we saw a timely change from far left and separatist dominating the early decades to Jihadi groups in the last decade, while anti-semitic factions were active in every decade. CONCLUSION: In contrast to other studies, this study did not show an increase over time. Left-wing perpetrators dominated the eighties. In 50 years of terrorist activity in Belgium, the health care system was spared. Devastating mass casualty attacks challenging the health care system are rare in Belgium.

Comparing the top 100 attacks in the Global Terrorism Database: high injury rate versus high fatality rate attacks.

BACKGROUND: Terrorist attacks have the potential to be mass casualty events, causing multiple injuries and deaths. High injury rate attacks will particularly place a high burden on emergency medical systems. This study aimed to assess if there is a difference between attacks with high injury rates and high fatality rates. METHODS: The top 100 terrorist events causing the highest number of fatalities versus the highest number of injuries were selected from the Global Terrorism Database. Analyses were performed on temporal factors, location, target type, attack and weapon type, and perpetrator type. RESULTS: The 9/11 attacks caused the highest number of both fatalities and injuries. With regards to injury rates, the sarin attacks in Tokyo, Japan ranked second. Events with high fatality rates were overrepresented in Sub-Saharan Africa, whereas events with high injury rates were predominant in the Middle East & North Africa. High fatality rates were most often associated with armed assaults and hostage takings. Bombings were responsible for the highest number of injuries. CBRN attacks were overrepresented in the top 100 injuries, and accounted for 11% of the incidents. CONCLUSION: High injury rate incidents place a heavy burden on the health care system as the number of injuries is nearly ten times as high as the number of injuries in high fatality rate incidents. Epidemiological analysis of high impact terrorist events may contribute to counter-terrorism preparedness, to an increased focus on dealing with CBRN-events, and thus to a proper medical response to future terrorist events.

Are Belgian military students in medical sciences better educated in disaster medicine than their civilian colleagues?

INTRODUCTION: Historically, medical students have been deployed to care for disaster victims but may not have been properly educated to do so. A previous evaluation of senior civilian medical students in Belgium revealed that they are woefully unprepared. Based on the nature of their military training, we hypothesised that military medical students were better educated and prepared than their civilian counterparts for disasters. We evaluated the impact of military training on disaster education in medical science students. METHODS: Students completed an online survey on disaster medicine, training, and knowledge, tested using a mixed set of 10 theoretical and practical questions. The results were compared with those of a similar evaluation of senior civilian medical students. RESULTS: The response rate was 77.5%, mean age 23 years and 59% were males. Overall, 95% of military medical students received some chemical, biological, radiological and nuclear training and 22% took part in other disaster management training; 44% perceived it is absolutely necessary that disaster management should be incorporated into the regular curriculum. Self-estimated knowledge ranged from 3.75 on biological incidents to 4.55 on influenza pandemics, based on a 10-point scale. Intention to respond in case of an incident ranged from 7 in biological incidents to 7.25 in chemical incidents. The mean test score was 5.52; scores improved with educational level attained. A comparison of survey data from civilian senior medical master students revealed that, except for influenza pandemic, military students scored higher on knowledge and capability, even though only 27% of them were senior master students. Data on willingness to work are comparable between the two groups. Results of the question/case set were significantly better for the military students. CONCLUSIONS: The military background and training of these students makes them better prepared for disaster situations than their civilian counterparts.

Individualized dosimetry-based activity reduction of 9°Y-DOTATOC prevents severe and rapid kidney function deterioration from peptide receptor radionuclide therapy.

PURPOSE: Assessment of kidney function evolution after (90)Y-DOTATOC peptide receptor radionuclide therapy (PRRT) with capped activity administration based on a 37-Gy threshold of biological effective dose (BED) to the kidney. METHODS: In a prospective phase II study, patients with metastasized neuroendocrine tumours were evaluated for therapy using 185 MBq (111)In-pentetreotide with amino acid coinfusion. Planar whole-body images were acquired at four time-points after injection and kidney volumes were measured using CT/MRI. BED to the kidneys was estimated using an extended BED formula and biexponential renal clearance. Based on published BED dose-toxicity relationships, we allowed a maximal kidney BED of 37 Gy; if the calculated BED exceeded 37 Gy, treatment activity was reduced accordingly. Kidney function was assessed at baseline and at 18 months, predominantly using (51)Cr-EDTA. The rate of renal function decline was expressed as annual glomerular filtration rate loss (aGFRL). RESULTS: Only 22 of 50 patients reached the 18-months time-point, with most missing patients having died due to disease progression. In the 22 patients who reached 18 months, no rapid kidney function deterioration was observed over the 18 months, aGFRL >33% was not seen, and only three patients showed an increase of one toxicity grade and one patient an increase of two grades. No significant correlations between kidney volume (p = 0.35), baseline GFR (p = 0.18), risk factors for renal function loss (p = 0.74) and aGFRL were observed. Among the 28 patients who did not reach 18 months, one developed grade 4 kidney toxicity at 15 months after PRRT. CONCLUSION: Prospective dosimetry using a 37 Gy BED as the threshold for kidney toxicity is a good guide for (90)Y-DOTATOC PRRT and is associated with a low risk of rapid renal function deterioration and evolution to severe nephrotoxicity.

Worldwide Trends in COVID-19-Related Attacks Against Healthcare: A Review of the Safeguarding Health in Conflict Coalition Database.

During the COVID-19 pandemic, violence targeting healthcare reportedly increased. Attacks against healthcare can severely hamper the public health response during a pandemic. Descriptive data analysis of these attacks may be helpful to develop prevention and mitigation strategies. This study aimed to investigate trends regarding COVID-19-related attacks against healthcare from January 2020 until January 2023. COVID-19-related incidents occurring between January 2020 and January 2023 were extracted from the Safeguarding Health in Conflict Coalition database and screened for eligibility. Included incidents were linked to COVID-19 health measures or were attacks directly interfering with COVID-19 healthcare, including conflict-related attacks. Data collected per incident included temporal factors; country; setting; attack and weapon type; perpetrator; motive; number of healthcare workers (HCWs) killed, injured, or kidnapped; and health facility damage. The study identified 255 COVID-19-related attacks against healthcare, with 18 HCWs killed, 147 HCWs injured, and 86 facilities damaged. The highest attack frequency was reported during the beginning of the pandemic and predominantly concerned stigma-related attacks against healthcare. Reported incidents in 2021 included attacks targeting vaccination campaigns, as well as conflict-related attacks interfering with COVID-19 healthcare. COVID-19-related attacks against healthcare occurred in heterogeneous contexts throughout the pandemic. Due to underreporting, the data presented are a minimum estimate of the actual magnitude of violence. The findings of this study emphasize the importance of public education campaigns, improved coordination between healthcare organizations and law enforcement, and the possible need to bolster the security of medical facilities and health workers.

50 Years of Terrorism against the Nuclear Industry: A Review of 91 Incidents in the Global Terrorism Database.

BACKGROUND: The on-going Russo-Ukrainian war has resulted in a renewed global interest in the safety and security of nuclear installations and the possibility of nuclear disasters caused by warfare and terrorism.The objective of this study was to identify and characterize all documented terrorist attacks against nuclear transport, nuclear facilities, and nuclear scientists as reported to the Global Terrorism Database (GTD) over a 50-year period. METHODS: The GTD was searched for all terrorist attacks against nuclear facilities, nuclear scientists, nuclear transport, and other nuclear industry-related targets in the period from 1970-2020. Analyses were performed on temporal factors, location, target type, attack and weapon type, perpetrator type, number of casualties, and property value loss. RESULTS: Ninety-one incidents that occurred from 1970 through 2020 were included. Incidents took place in 25 countries and nine world regions, with most (42; 46.1%) occurring in Western Europe.During these 50 years, 91 incidents resulted in 19 fatalities and 117 injuries. One perpetrator was killed during an incident and one other assailant was injured.Bombings and explosions were the most frequently identified attack type (n = 40; 44.0%), followed by facility/infrastructure damage (n = 24; 26.4%) and armed assaults and assassinations (both n = 7; 7.7%).Nuclear power plants and reactors under construction were targeted in 13 (14.3%) and eight (8.8%) incidents, respectively. Most of the attacks took place on other nuclear industry-related sites. CONCLUSION: Terrorist attacks carried out by non-state perpetrators against nuclear facilities, nuclear scientists, nuclear transport, and other nuclear industry-related targets are rare, with only 91 incidents in a 50-year period. None of the attacks resulted in radioactive fallout or environmental contamination. Most of the attacks took place outside a nuclear power plant.

Terrorist Attacks against Health Care Targets that Provide Abortion Services.

INTRODUCTION: Terrorist attacks against hospitals and health care providers have disproportionally increased during the last decades. A significant proportion of these attacks targeted abortion clinics and abortion providers. In the light of the overturning of Roe v. Wade in 2022, an increase of anti-abortion terrorist attacks is anticipated. Therefore, it becomes imperative to gain further insight into the risk and characteristics of past terrorist attacks. This study aimed to review terrorist attacks against health care targets providing abortion services from 1970 through 2020. METHODS: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database functions for all terrorist attacks against abortion health care providers from January 1, 1970 - December 31, 2020. Temporal factors, location, attack and weapon type, and number of casualties or hostages were analyzed using descriptive statistics. RESULTS: In total, 262 terrorist attacks were identified in five different countries. The majority (96.6%) occurred in the United States, with the highest counts during the last 20 years of the 20th century. Facility and infrastructure attacks were the most common attack types, followed by bombings and explosions. The attacks resulted in 34 injuries and nine fatalities. Kidnapping took place in three incidents. Of all successful attacks, 96.9% resulted in property damage. CONCLUSION: Abortion-related health care facilities and providers have repeatedly been the target of terrorists over the past decades. Nearly all of these attacks took place in the United States, with the highest counts during the last 20 years of the 20th century.

An Epidemiological Analysis of Terrorist Attacks in the Nordic and Baltic Countries from 1970 through 2020.

BACKGROUND: Russia's annexation of Crimea in 2014, and the recent Russo-Ukrainian war that started in 2022, were triggers that radically changed the perception of security in the Nordic and Baltic countries. The on-going Russian hybrid war has resulted in a renewed global interest in the safety and security of many countries (eg, the Nordic-Baltic Eight). The prospective North Atlantic Treaty Organization (NATO) membership of Finland and Sweden may drastically change the regional military and political landscape.The objective of this study was to identify and characterize all documented terrorist attacks in this region as reported to the Global Terrorism Database (GTD) from 1970 through 2020. METHODS: The GTD was searched using the internal database functions for all terrorism incidents in the Nordic-Baltic states: Denmark, Estonia, Finland, Iceland, Latvia, Lithuania, Norway, and Sweden.Temporal factors, location, target type, attack and weapon type, perpetrator type, number of casualties, and property value loss were collated. Results were exported into an Excel spreadsheet for analysis. RESULTS: There were 298 terrorism-related incidents from 1970 through 2020. Most attacks occurred in Sweden, followed by Norway and Finland. No entries were recorded for the Baltic states prior to their independency in 1991. The 298 incidents resulted in a total of 113 fatalities and 277 injuries.Facility/infrastructure attacks were the most frequently identified attack type (35.0%), followed by bombings and explosions (30.9%). Armed assaults were responsible for 80 fatalities and 105 injuries, followed by bombings/explosions with 15 fatalities and 72 injuries. The predominant target types were immigrants and refugee shelters (64/298 incidents). In only 33.6% of the incidents, perpetrators were known. Right-wing assailants represented the largest group, accounting for 27 incidents. CONCLUSION: From 1970 through 2020, there were 298 terrorist attacks in the Nordic-Baltic Eight. Sweden accounted for 50% of incidents.The profile of terrorist attacks was very diverse, as were the perpetrators and targets. Every country had its own incident characteristics. The surge of right-wing extremism must be closely monitored.

Primary Care as Primary Target: A Review of Terrorist Attacks Against Primary Care Providers and Their Offices.

BACKGROUND: Violence against primary care providers (PCPs) has increased during the current pandemic. While some of these violent acts are not defined as terrorist events, they are intentional events with an aim to disrupt, kill, or injure. Despite their pivotal role in health care, little is known about the risk for PCPs as targets of terrorism. METHODS: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all terrorist attacks against PCPs and their offices from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. Primary attack and weapon type, location (country, world region), and number of deaths and injuries were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. RESULTS: There were 29 terrorist attacks against PCPs and their offices from 1970-2019. The majority of attacks occurred during or after 2010. There were 58 fatalities, 52 injured, and 13 hostages. Most documented attacks took place in Pakistan, the United States, and Sri Lanka. Bombings concerned 55% of cases and 21% were hostage-takings. CONCLUSION: Although less common than attacks on other health care related targets, terrorist attacks against PCPs have occurred. The majority of attacks occurred during the last decade. Future studies are warranted to further assess the risk of terrorist attacks against PCPs: before, during, and beyond the current pandemic.

Attacks on Health Care Workers in Historical Pandemics and COVID-19.

Previous pandemics have been (mis)used for (geo)political reasons, for terrorism purposes, and in times of conflict. Coronavirus disease (COVID-19) has been no exception with populist politicians challenging the relations with China, calling it the "Chinese virus," certain state actors setting up cyberterrorist actions against health care organizations in the United States and Europe, and a reported increase of violent acts against health care workers.Aside from state-driven factors, both left- and right-wing activists and anti-vaccination activists adhering to conspiracy theories are a threat for health care organizations. Furthermore, socioeconomic, religious, and cultural factors play a role in why health care is a possible target of violence. Fear of viral pathogens, fury about financial losses due to the pandemic and governmental measures such as lockdowns, anger because of mandatory quarantines, and the disruption of burial rituals are among the reasons for people to revolt against health care providers.Here, we provide a narrative review of the impact of violence against health care workers during the COVID-19 pandemic and earlier pandemics, and suggest preventive strategies.

Terrorist Attacks in Western Europe: A Counter-Terrorism Medicine Analysis.

BACKGROUND: The modern concept of terrorism has its roots in the "old continent" of Western Europe, more specifically in France, during the "Reign of Terror" period of the French Revolution. At the time, this form of state terror had a positive connotation: it was a legitimate means of defending the young state. While no single accepted definition of terrorism exists today, it is universally considered an attack on both state and society. The health care impacts of terrorist attacks often extend disproportionally beyond the casualty toll, but the potential for such events to induce mass casualties remains a concern to Disaster Medicine and Counter-Terrorism Medicine (CTM) specialists. METHOD: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all events which occurred in Western Europe from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. Primary weapon type, country where the incident occurred, and number of deaths and injured were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. RESULTS: A total of 15,306 events were recorded in Western Europe out of a total of 201,183 events world-wide between the years 1970 and 2019 inclusive. This resulted in a total of 5,548 deaths and 17,187 injuries. Explosives were used as a primary weapon/attack modality in 8,103 attacks, followed by incendiary attacks in 3,050 events and firearm use in 2,955 events. The use of chemical, biological, radiation, and nuclear (CBRN) weapons was rare and only accounted for 47 events. CONCLUSION: From 1970 through 2019, 9.11% of all terrorist attacks occurred in Western Europe. Compared to global trends of attack methodologies in the same study period, the use of explosives as a primary attack modality in Western Europe was similar (52.94% in Western Europe versus 48.78% Global). Firearm use was comparatively low (19.31% versus 26.77%) and the use of CBRN as an attack modality was rare (0.30% versus 0.20%). The United Kingdom, Spain, and France accounted for over 65% of all terrorist attacks and over 75% of terrorism-related deaths in Western Europe.

Terrorist Attacks against Concerts and Festivals: A Review of 146 Incidents in the Global Terrorism Database.

BACKGROUND: Mass gatherings are vulnerable to terrorist attacks and are considered soft targets with potential to inflict high numbers of casualties. The objective of this study was to identify and characterize all documented terrorist attacks targeted at concerts and festivals reported to the Global Terrorism Database (GTD) over a 50-year period. METHODS: The GTD was searched for all terrorist attacks against concerts and festivals that occurred world-wide from 1970 through 2019. Analyses were performed on temporal factors, location, target type, attack and weapon type, attacker type, and number of casualties or hostages. Ambiguous incidents were excluded if there was doubt about whether they were exclusively acts of terrorism. Chi-square tests were performed to evaluate trends over time and differences in attack types. RESULTS: In total, 146 terrorist attacks were identified. In addition to musical concerts, festivals included religious, cultural, community, and food festivals. With 53 incidents, South Asia was the most heavily hit region of the world, followed by the Middle East & North Africa with 25 attacks. Bombings and explosions were the most common attack types. The attacks targeted attendees, pilgrims, politicians, or police/military members who secured the concerts and festivals. CONCLUSION: This analysis of the GTD, which identified terrorist attacks aimed at concerts and festivals over a 50-year period, demonstrates that the threat is significant, and not only in world regions where terrorism is more prevalent or local conflicts are going on. The findings of this study may help to create or enhance contingency plans.

Terrorist Attacks Against COVID-19-Related Targets during the Pandemic Year 2020: A Review of 165 Incidents in the Global Terrorism Database.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic enabled a situational type of terrorism with mixed racist, anti-government, anti-science, anti-5G, and conspiracy theorist backgrounds and motives. OBJECTIVE: The objective of this study was to identify and characterize all documented COVID-19-related terrorist attacks reported to the Global Terrorism Database (GTD) in 2020. METHODS: The GTD was searched for all COVID-19-related terrorist attacks (aimed at patients, health care workers, and at all actors involved in pandemic containment response) that occurred world-wide in 2020. Analyses were performed on temporal factors, location, target type, attack and weapon type, attacker type, and number of casualties or hostages. Ambiguous incidents were excluded if there was doubt about whether they were exclusively acts of terrorism. RESULTS: In total, 165 terrorist attacks were identified. With 50% of incidents, Western Europe was the most heavily hit region of the world. Nonetheless, most victims were listed in Southeast Asia (19 fatalities and seven injured). The most frequent but least lethal attack type concerned arson attacks against 5G telephone masts (105 incidents [60.9%] with only one injured). Armed assaults accounted for most fatalities, followed by assassinations. Incendiary and firearms were the most devastating weapon types. CONCLUSION: This analysis of the GTD, which identified 165 COVID-19-related terrorist attacks in 2020, demonstrates that the COVID-19 pandemic truly resulted in new threats for COVID-19 patients, aid workers, hospitals, and testing and quarantine centers. It is anticipated that vaccination centers have become a new target of COVID-19-related terrorism in 2021 and 2022.

Disaster health education framework for short and intermediate training in Saudi Arabia: A scoping review.

Background: Saudi Arabia has made extensive efforts to manage disasters using unique national approaches; however, challenges and obstacles concerning disaster health handling persist. The nation has a reactive strategy to disaster management with a need for increased involvement of health professionals in disaster management and improvement of healthcare facilities emergency preparedness including competency-based education training. Objective: A comprehensive and consistent approach of disaster education programs for short and intermediate training of health professionals involved in disaster responses in Saudi Arabia is still not evident. Therefore, it is vital to explore and map the current state of the disaster education framework in Saudi Arabia. Methods: The Joanna Briggs Institute approach for scoping reviews was used to assess research articles and preprints between January 2000 and September 2021 from Saudi Digital Library; PubMed, CINAHL, and Google Scholar. Five experts identified key aspects of the disaster education approach and eligibility criteria to facilitate identification of relevant articles. Results: Only five articles met the specified criteria and described two short and three intermediate courses on disaster health management in Saudi Arabia. All courses involved competency-specific training aimed at basic or foundational level and involved a range of activities and learning types. None had refresher courses within 12 months. Conclusion: The review highlights the obvious scarcity of short and intermediate term evidence-based disaster health programs in Saudi Arabia. Adoption of the education framework proposed by the authors based on international frameworks could improve the quality and consistency of the disaster education curriculum in Saudi Arabia.

The Incident Management Response of the Emergency Departments in Belgium During the First Wave of the COVID-19 Pandemic.

The COVID-19 pandemic has demonstrated that emergency departments (EDs) need to reorganize their operations rapidly. This study investigated the impact of the pandemic on structural and logistical issues at EDs and the measures taken. Belgian EDs were surveyed on the implemented changes at the start of the pandemic in relation to the 4 S's in disaster medicine: Structure, Staff, Supplies, and System. The study demonstrated that Belgian EDs felt largely unprepared for this pandemic, but nevertheless dynamically restructured their organization. A 46% increase in ED beds was created in different types of structures and more than 50% of all ED beds were reserved for COVID-19 care, but overall the number of patient presentations dropped by 29%. EDs deployed extra personnel, additional training, and psychological support. More than 50% reported an acute shortage of personal protective equipment, and several reported a shortage of ventilatory equipment and medications.

Terrorist Attacks against Hospitals: World-Wide Trends and Attack Types.

BACKGROUND: Analysts have warned on multiple occasions that hospitals are potential soft targets for terrorist attacks. Such attacks will have far-reaching consequences, including decreased accessibility, possible casualties, and fear among people. The extent, incidence, and characteristics of terrorist attacks against hospitals are unknown. Therefore, the objective of this study was to identify and to characterize terrorist attacks against hospitals reported to the Global Terrorism Database (GTD) over a 50-year period. METHODS: The GTD was used to search for all terrorist attacks against hospitals from 1970-2019. Analyses were performed on temporal factors, location, attack and weapon type, and number of casualties or hostages. Chi-square tests were performed to evaluate trends over time and differences in attack types per world region. RESULTS: In total, 454 terrorist attacks against hospitals were identified in 61 different countries. Of these, 78 attacks targeted a specific person within the hospital, about one-half (52.6%) involved medical personnel. There was an increasing trend in yearly number of attacks from 2008 onwards, with a peak in 2014 (n = 41) and 2015 (n = 41). With 179 incidents, the "Middle East & North Africa" was the most heavily hit region of the world, followed by "South Asia" with 125 attacks. Bombings and explosions were the most common attack type (n = 270), followed by 77 armed assaults. Overall, there were 2,746 people injured and 1,631 fatalities. In three incidents, hospitals were identified as secondary targets (deliberate follow-up attack on a hospital after a primary incident elsewhere). CONCLUSION: This analysis of the GTD identified 454 terrorist attacks against hospitals over a 50-year period. It demonstrates that the threat is real, especially in recent years and in world regions where terrorism is prevalent. The findings of this study may help to create or further improve contingency plans for a scenario wherein the hospital becomes a target of terrorism.

Terrorist Attacks Against Emergency Medical Services: Secondary Attacks are an Emerging Risk.

INTRODUCTION: Terrorists increasingly aim at so-called soft targets, such as hospitals. However, little is known about terrorist attacks against Emergency Medical Services (EMS). OBJECTIVE: This study aims to review all documented terrorist attacks against EMS that occurred world-wide from 1970-2019 using the Global Terrorism Database (GTD). METHODS: Reports of terrorist attacks against EMS were extracted from the GTD from 1970-2019. Data collection included temporal factors, attack and weapon type, number of casualties, and if it was a primary or secondary attack (secondary attack: deliberate attack against the first responders of an initial terrorist attack). Reports were excluded if EMS were not a target or if it was unclear whether they were a target. Chi-square tests were performed to evaluate trends over time. RESULTS: There were 184 terrorist attacks against EMS, resulting in 748 deaths and 1,239 people injured. Terrorist attacks against EMS significantly increased over the past two decades. The "Middle East & North Africa" was the most frequently affected region with 81 attacks (44.0%) followed by "South Asia" with 41 attacks (22.3%). Bombings and explosions were the most common attack type (85 incidents; 46.2%) followed by armed assaults (68 incidents; 35.3%). Combined prehospital and hospital attacks were first reported in 2005 and occurred seven times. The first secondary attack against EMS dates from 1997, after which an increase was observed from 10 to 39 incidents in the periods 2000-2009 and 2010-2019, respectively. CONCLUSIONS: This analysis of the GTD, which identified 184 terrorist attacks against EMS over a 50-year period, demonstrates that terrorist attacks against EMS have significantly increased during the years and that secondary attacks are an emerging risk. Bombings and explosions are the most common attack type. Terrorist attacks against EMS are most prevalent in countries with high level of internal conflicts, however, they have also occurred in western countries. These incidents may hold valuable information to prevent future attacks.

Current Perspectives and Concerns Facing Hospital Evacuation: The Results of a Pilot Study and Literature Review.

OBJECTIVE: To analyze the evacuation preparedness of hospitals within the European Union (EU). METHOD: This study consisted of 2 steps. In the first step, a systematic review of the subject matter, according to the PRISMA flow diagram, was performed. Using Scopus (Elsevier, Amsterdam, Netherlands), PubMed (National Library of Medicine, Bethesda, MD), and Gothenburg University´s search engine, 11 questions were extracted from the review and were sent to representatives from 15 European Union (EU)- and non-EU countries. RESULTS: The findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the EU or other non-EU countries in this study. A major shortcoming revealed by this study is the lack of awareness of the untoward consequences of medical decision-making during an evacuation. Some countries did not respond to the questions due to the lack of relevant guidelines, instructions, or time. CONCLUSION: Hospitals are exposed to internal and external incidents and require an adequate evacuation plan. Despite many publications, reports, and conclusions on successful and unsuccessful evacuation, there is still no common guide for evacuation, and many hospitals lack the proper preparedness. There is a need for a multinational collaboration, specifically within the EU, to establish such an evacuation planning or guideline to be used mutually within the union and the international community.

A dual-targeting anticancer approach: soil and seed principle.

PURPOSE: To test the hypothesis that targeting the microenvironment (soil) may effectively kill cancer cells (seeds) through a small-molecular weight sequential dual-targeting theragnostic strategy, or dual-targeting approach. MATERIALS AND METHODS: With approval from the institutional animal care and use committee, 24 rats were implanted with 48 liver rhabdomyosarcomas (R1). First, the vascular-disrupting agent combretastatin A4 phosphate (CA4P) was injected at a dose of 10 mg/kg to cause tumor necrosis, which became a secondary target. Then, the necrosis-avid agent hypericin was radiolabeled with iodine 131 to form (131)I-hypericin, which was injected at 300 MBq/kg 24 hours after injection of CA4P. Both molecules have small molecular weight, are naturally or synthetically derivable, are intravenously injectable, and are of unique targetablities. The tumor response in the dual-targeting group was compared with that in vehicle-control and single-targeting (CA4P or (131)I-hypericin) groups with in vivo magnetic resonance imaging and scintigrams and ex vivo gamma counting, autoradiography, and histologic analysis. Tumor volumes, tumor doubling time (TDT), and radiobiodistribution were analyzed with statistical software. P values below .05 were considered to indicate a significant difference. RESULTS: Eight days after treatment, the tumor volume of rhabdomyosarcoma in the vehicle-control group was double that in both single-targeting groups (P < .001) and was five times that in the dual-targeting group (P < .0001), without treatment-related animal death. The TDT was significantly longer in the dual-targeting group (P < .0001). Necrosis appeared as hot spots on scintigrams, corresponding to 3.13% of the injected dose of (131)I-hypericin per gram of tissue (interquartile range, 2.92%-3.97%) and a target-to-liver ratio of 20. The dose was estimated to be 100 times the cumulative dose of 50 Gy needed for radiotherapeutic response. Thus, accumulated (131)I-hypericin from CA4P-induced necrosis killed residual cancer cells with ionizing radiation and inhibited tumor regrowth. CONCLUSION: This dual-targeting approach may be a simple and workable solution for cancer treatment and deserves further exploitation.

Do androgens control the uptake of 18F-FDG, 11C-choline and 11C-acetate in human prostate cancer cell lines?

PURPOSE: The aim of this study was to evaluate the impact of androgen ablation therapy in different prostate cancer (PCa) cell lines--reflecting different stages of the disease--on (18)F-fluorodeoxyglucose (FDG), 11C-choline and 11C-acetate uptake. METHODS: Uptake experiments were performed in androgen-sensitive (LNCaP, PC346C) and independent cell lines (22Rv1, PC346DCC, PC-3) as well as in a benign prostatic hyperplasia (BPH-1) cell line. Tracer uptake was assessed under androgen ablation. Results of the cancer cell lines were normalized to those of BPH-1. To evaluate the effect of androgen on the uptake of 18F-FDG, 11C-choline and 11C-acetate in PCa cell lines, 10(-8) M R1881, 10(-10) M R1881, the combination of 10(-10) M R1881 plus 10(-6) M Casodex or 10(-6) M Casodex alone were added in parallel cell cultures 1 day before uptake experiments. Uptake in androgen-supplemented cell cultures was compared to the uptake under androgen deprivation. Uptake was corrected for cell number using protein content. RESULTS: Compared to BPH-1, a higher 18F-FDG uptake was observed only in PC346C cells, whereas a higher 11C-choline and markedly increased 11C-acetate uptake was seen in all cancer cell lines. Androgens significantly modulated the uptake of 18F-FDG in LNCaP, PC346C and 22Rv1 cells, and of 11C-choline in the PC346C and 22Rv1 cell line. No androgenic effect on 11C-choline and 18F-FDG uptake was observed in PC-3 and PC346DCC cells. 11C-Acetate uptake was independent of androgen status in all PCa cell lines studied. CONCLUSION: 18F-FDG uptake in PCa cell lines showed the highest variability and strongest androgen effect, suggesting its poor potential for metabolic imaging of advanced PCa. In contrast to 18F-FDG and 11C-choline, 11C-acetate uptake was unaffected by androgens and thus 11C-acetate seems best for monitoring PCa progression.