Cancer risk among World Trade Center rescue and recovery workers: A review.

Twenty years after the September 11th, 2001 terrorist attacks, the association between exposures present at the World Trade Center (WTC) site and the risk of several specific types of cancer has been reported among rescue and recovery workers. The authors' objective was to conduct an updated review of these data. Most studies have found elevated rates of both prostate and thyroid cancers compared with rates in the general population, and some have reported statistically significant differences for the rates of all cancers as well. Studies including a larger combined cohort of WTC-exposed rescue and recovery workers from 3 main cohorts have since replicated findings for these cancers, with additional years of follow-up. Among this combined cohort, although a lower-than-expected standardized incidence ratio for all cancers was observed, WTC exposure was also related to an increased risk of cutaneous melanoma and tonsil cancer. Importantly, another study found that WTC-exposed rescue and recovery workers who are enrolled in the federally funded medical monitoring and treatment program experienced improved survival post-cancer diagnosis compared with New York state patients with cancer. On the basis of these combined cohort studies, the full effect of WTC exposure on cancer risk is becoming clearer. Consequently, the authors believe that surveillance of those with WTC exposure should be continued, and in-depth analysis of epidemiologic, molecular, and clinical aspects of specific cancers in these workers should be pursued.

A 15-year follow-up study of mortality in a pooled cohort of World Trade Center rescue and recovery workers.

INTRODUCTION: Hazardous exposures from the World Trade Center (WTC) terrorist attacks have been linked to increased incidence of adverse health conditions, often associated with increased mortality. We assessed mortality in a pooled cohort of WTC rescue/recovery workers over 15 years of follow-up. MATERIALS AND METHODS: We analyzed mortality through 2016 in a pooled and deduplicated cohort of WTC rescue/recovery workers from three WTC-exposed cohorts (N = 60,631): the Fire Department of the City of New York (FDNY); the WTC Health Registry (WTCHR); and the General Responder Cohort (GRC). Standardized mortality ratios (SMRs) were estimated to assess mortality vs. the US and NY state populations. Multivariable Cox proportional hazards models were used to examine associations of WTC exposures (date of first arrival, working on the WTC debris pile) with mortality risk. RESULTS: There were 1912 deaths over 697,943.33 person-years of follow-up. The SMR for all-cause mortality was significantly lower-than-expected, both when using US (SMR 0.43, 95% confidence interval [CI] 0.42-0.45) and NYS (SMR 0.51, 95% CI 0.49-0.53) as reference populations. SMRs were not elevated for any of the 28 major causes of death. Arriving at the WTC site on 9/11-9/17/2001 vs. 9/18/2001-6/30/2002 was associated with 30-50% higher risk of all-cause, heart disease and smoking-related mortality in non-FDNY/non-GRC members. Conversely, arriving on 9/11/2001 vs. 9/18/2001-6/30/2002 was associated with 40% lower all-cause and smoking-related mortality risk in FDNY members. Working on vs. off the WTC pile was associated with an increased risk of all-cause mortality in non-FDNY/non-GRC members (adjusted hazard ratio [aHR] 1.25, 95% CI 1.04-1.50), and cancer-specific mortality in GRC members (aHR 1.39, 95% CI 1.05-1.84), but lower mortality risks were found in FDNY members. CONCLUSIONS: We did not observe excess mortality among WTC rescue/recovery workers compared with general populations. However, significantly increased mortality risks among some sub-groups with high WTC exposure warrant further investigation.

The breakdown of antiracist norms: A natural experiment on hate speech after terrorist attacks.

Terrorist attacks often fuel online hate and increase the expression of xenophobic and antiminority messages. Previous research has focused on the impact of terrorist attacks on prejudiced attitudes toward groups linked to the perpetrators as the cause of this increase. We argue that social norms can contain the expression of prejudice after the attacks. We report the results of a combination of a natural and a laboratory-in-the-field (lab-in-the-field) experiment in which we exploit data collected about the occurrence of two consecutive Islamist terrorist attacks in Germany, the Würzburg and Ansbach attacks, in July 2016. The experiment compares the effect of the terrorist attacks in hate speech toward refugees in contexts where a descriptive norm against the use of hate speech is evidently in place to contexts in which the norm is ambiguous because participants observe antiminority comments. Hate toward refugees, but not toward other minority groups, increased as a result of the attacks only in the absence of a strong norm. These results imply that attitudinal changes due to terrorist attacks are more likely to be voiced if norms erode.

Learning from terrorist mass casualty incidents: a global survey.

BACKGROUND: Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses. METHODS: We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale. RESULTS: Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement). CONCLUSION: This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21-036.

Local alliances and rivalries shape near-repeat terror activity of al-Qaeda, ISIS, and insurgents.

We study the spatiotemporal correlation of terrorist attacks by al-Qaeda, the Islamic State of Iraq and Syria (ISIS), and local insurgents, in six geographical areas identified via k-means clustering applied to the Global Terrorism Database. All surveyed organizations exhibit near-repeat activity whereby a prior attack increases the likelihood of a subsequent one by the same group within 20 km and on average 4 (al-Qaeda) to 10 (ISIS) weeks. Near-response activity, whereby an attack by a given organization elicits further attacks from a different one, is found to depend on the adversarial, neutral, or collaborative relationship between the two. When in conflict, local insurgents respond quickly to attacks by global terror groups while global terror groups delay their responses to local insurgents, leading to an asymmetric dynamic. When neutral or allied, attacks by one group enhance the response likelihood of the other, regardless of hierarchy. These trends arise consistently in all clusters for which data are available. Government intervention and spillover effects are also discussed; we find no evidence of outbidding. Understanding the regional dynamics of terrorism may be greatly beneficial in policy making and intervention design.

Design and validation of a preparedness evaluation tool of pre-hospital emergency medical services for terrorist attacks: a mixed method study.

INTRODUCTION: Terrorist attacks are one of the human problems that affect many countries, leaving behind a huge toll of disabilities and deaths. The aim of this study was to use a mixed-method analysis to design and validate an evaluation tool for pre-hospital emergency medical services for terrorist attacks. METHODS: The present study is a mixed-method (qualitative and quantitative) study that was conducted in two phases. In the qualitative phase (item generation), semi-structured interviews were conducted with 34 Iranian emergency medical technicians who were selected through a purposive sampling method and a scoping literature review was conducted to generate an item pool for the preparedness evaluation of Emergency Medical Services (EMS) in terrorist attacks. In the quantitative phase (item reduction), for validity of tool face, content and construct validity, were performed; for tool reliability, the test and retest and intra-class correlation coefficient were evaluated. RESULTS: At the first stage, 7 main categories and 16 subcategories were extracted from the data, the main categories including "Policy and Planning", "Education and Exercise "," Surge Capacity", "Safety and Security", "Command, Control and Coordination", "Information and Communication Management "and "Response Operations Management". The initial item pool included 160 items that were reduced to 110 after assessment of validity (face, content and construct). intra-class correlation coefficient (ICC = 0.71) examination and Pearson correlation test (r = 0.81) indicated that the tool was also reliable. CONCLUSION: The research findings provide a new perspective to understand the preparedness of pre-hospital emergency medical services for terrorist attacks. The existing 110-item tool can evaluate preparedness of pre-hospital emergency medical services for terrorist attacks through collecting data with appropriate validity and reliability.

No Local Birth Sex Ratio Changes following the August 2019 Shootings in Montgomery County, Ohio, and in El Paso County, Texas.

OBJECTIVE: In humans, males are born slightly in excess of females. Many factors have been shown to affect this ratio, including stressful events such as terrorist attacks. Two shootings occurred in early August 2019 in the Oregon District in Dayton, Montgomery County, Ohio, and in El Paso County, Texas, in the USA. This study was carried out in order to identify whether there were any effects on sex ratio at birth at the state or county level 3-5 months later. SUBJECT AND METHODS: Births by sex, month of birth (2015-2019), and county were obtained for Ohio and Texas from the website of the Centers for Disease Control and Prevention. Ordinary linear logistic regression was used to assess the time trend in the probability of boys and to investigate changes in the trend functions. Poisson regression (SAS GENMOD) and linear logistic regression using SAS procedure LOGISTIC was applied. RESULTS: This study analyzed 2,623,714 live births, 1,939,938 in Texas (sex odds [SO] 1.044) and 683,776 in Ohio (SO 1.045). The only significant effect noted was seasonality (month) at the state level. CONCLUSION: It has been postulated that male fetal loss in pregnant women during stressful periods may occur in accordance with the Trivers-Willard hypothesis. Several studies have found significant effects after terrorist attacks in the USA (as well as in other countries), but this study did not reveal such effects. This may be due to several reasons including underpowered datasets and the possibility that populations may be becoming relatively immured to these events.

Post-traumatic stress disorder and the association with overweight, obesity, and weight change among individuals exposed to the World Trade Center disaster, 2003-2016.

BACKGROUND: Among Veterans, post-traumatic stress disorder (PTSD) has been shown to be associated with obesity and accelerated weight gain. Less is known among the general population. We sought to determine the impact of PTSD on body mass index (BMI) and weight change among individuals with exposure to the World Trade Center (WTC) disaster. METHODS: We examined individuals from the WTC Health Registry. PTSD symptoms were assessed on multiple surveys (Waves 1-4) using the PTSD Checklist-Specific. Three categories of post-9/11 PTSD were derived: no, intermittent, and persistent. We examined two outcomes: (1) Wave 3 BMI (normal, overweight, and obese) and (2) weight change between Waves 3 and 4. We used multivariable logistic regression to assess the association between PTSD and BMI (N = 34 958) and generalized estimating equations to assess the impact of PTSD on weight change (N = 26 532). Sex- and age-stratified analyses were adjusted for a priori confounders. RESULTS: At Wave 3, the observed prevalence of obesity was highest among the persistent (39.5%) and intermittent PTSD (36.6%) groups, compared to the no PTSD group (29.3%). In adjusted models, persistent and intermittent PTSD were consistently associated with a higher odds of obesity. Weight gain was similar across all groups, but those with persistent and intermittent PTSD had higher estimated group-specific mean weights across time. CONCLUSIONS: Our findings that those with a history of PTSD post-9/11 were more likely to have obesity is consistent with existing literature. These findings reaffirm the need for an interdisciplinary focus on physical and mental health to improve health outcomes.

[The urologist confronted with a mass killing]. / Le chirurgien urologue face à une tuerie de masse.

INTRODUCTION: Following the Paris attacks in 2015, the French hospital system has had to organize itself in mass casualties of serious injuries, especially hemorrhagic shock. Recent experience shows that the first flow of casualties is spontaneously directed to the structure closest to the events, whether it is suitable or not. Any surgeon can face such a crisis regardless of their practice structure, because terrorist attacks are unpredictable. The urologist must anticipate the responsibilities that they might be forced to shoulder in such a situation. MATERIAL AND METHOD: A systematic literature review based on PubMed, Embase and Google Scholar was conducted between January 2000 and June 2021. RESULTS: In addition to a coordinator role, reserved for the most experienced, his visceral surgical expertise would allow a urologist to apply damage control (DC) at each stage. We describe here the principles of DC, in particular the DC laparotomy including its strategy concerning genitourinary lesions. DISCUSSION: Whatever his role (sorter, organizer, technician) in the management of a mass casualties of hemorrhagic injuries, an urologist has to know the principles of DC. A damage control laparotomy (stage 1 of DC) requires the urologist surgeon to never seek to perform a primary reconstruction procedure but to favor speed and efficiency (both on the hemostatic and urostatic side) to lead the injured patient stabilized to faster in intensive care unit (stage 2). Revision surgery called "definitive surgical management" (stage 3) will be performed anyway at the end of this period.

Use of mental health supports by civilians exposed to the November 2015 terrorist attacks in Paris.

BACKGROUND: The use of mental health supports by populations exposed to terrorist attacks is rarely studied despite their need for psychotrauma care. This article focuses on civilians exposed to the November 2015 terrorist attacks in Paris and describes the different combinations of mental health supports (MHSu) used in the following year according to type of exposure and type of mental health disorder (MHD). METHODS: Santé publique France conducted a web-based survey of civilians 8-11 months after their exposure to the November 2015 terrorist attacks in Paris. All 454 respondents met criterion A of the DSM-5 definition of post-traumatic stress disorder (PTSD). MHD (anxiety, depression, PTSD) were assessed using the PCL-5 checklist and the Hospital Anxiety and Depression Scale. MHSu provided were grouped under outreach psychological support, visits for psychological difficulties to a victims' or victim support association, consultation with a general practitioner (GP), consultation with a psychiatrist or psychologist (specialist), and initiation of regular mental health treatment (RMHT). Chi-squared tests highlighted differences in MHSu use according to type of exposure (directly threatened, witnessed, indirectly exposed) and MHD. Phi coefficients and joint tabulations were employed to analyse combinations of MHSu use. RESULTS: Two-thirds of respondents used MHSu in the months following the attacks. Visits to a specialist and RMHT were more frequent than visits to a GP (respectively, 39, 33, 17%). These were the three MHSu most frequently used among people with PTSD (46,46,23%), with depression (52,39,20%), or with both (56,58, 33%). Witnesses with PTSD were more likely not to have RMHT than those directly threatened (respectively, 65,35%). Outreach support (35%) and visiting an association (16%) were both associated with RMHT (Phi = 0.20 and 0.38, respectively). Very few (1%) respondents initiated RMHT directly. Those who indirectly initiated it (32%) had taken one or more intermediate steps. Visiting a specialist, not a GP, was the most frequent of these steps. CONCLUSION: Our results highlight possibilities for greater coordination of mental health care after exposure to terrorist attacks including involving GP for screening and referral, and associations to promote targeted RMHT. They also indicate that greater efforts should be made to follow witnesses.

Adapting meaning-centered psychotherapy for World Trade Center responders.

OBJECTIVE: To date, nearly 10,000 World Trade Center (WTC) responders have been diagnosed with at least one type of WTC-related cancer, and over 70 types of cancer have been related to WTC occupational exposure. Due to the observed latency period for malignancies, the WTC Health Program anticipates increases in rates of new cancer diagnoses. Given the growing number of cancer diagnoses in this population, there is an urgent need to develop a novel intervention to address the psychosocial needs of WTC responders with cancer. Meaning-centered psychotherapy (MCP) is a structured psychotherapeutic intervention originally developed to help patients with advanced cancer find and sustain meaning in life despite illness-related limitations. Existential distress and loss of meaning are critical and understudied elements of psychological health that have been widely overlooked among WTC responders with cancer. METHOD: We have adapted MCP for WTC responders (MCP-WTC) for the treatment of WTC responders who have been diagnosed with WTC-certified cancers. MCP-WTC aims to target the complex crisis in meaning faced by those responders who responded to the 9/11 attacks and subsequently were diagnosed with cancer as a result of their service. RESULTS: We describe the adaptation of MCP-WTC and the application of this intervention to meet the unique needs of those exposed to the terrorist attacks of September 11, 2001 (9/11), participated in the rescue, recovery, and clean-up effort at Ground Zero, and were diagnosed with WTC-related cancer. We highlight the novel aspects of this intervention which have been designed to facilitate meaning-making in the context of the patient's response to 9/11 and subsequent diagnosis of cancer. SIGNIFICANCE OF RESULTS: This work provides a rationale for MCP-WTC and the potential for this intervention to improve the quality of life of WTC responders and help these patients navigate life after 9/11 and cancer.

Persistent mental and physical health impact of exposure to the September 11, 2001 World Trade Center terrorist attacks.

BACKGROUND: Asthma, gastroesophageal reflux disease (GERD), posttraumatic stress disorder (PTSD) and depression have each been linked to exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We described the prevalence and patterns of these conditions and associated health-related quality of life (HRQOL) fifteen years after the attacks. METHODS: We studied 36,897 participants in the WTC Health Registry, a cohort of exposed rescue/recovery workers and community members, who completed baseline (2003-2004) and follow-up (2015-16) questionnaires. Lower respiratory symptoms (LRS; cough, dyspnea, or wheeze), gastroesophageal reflux symptoms (GERS) and self-reported clinician-diagnosed asthma and GERD history were obtained from surveys. PTSD was defined as a score > 44 on the PTSD checklist, and depression as a score > 10 on the Patient Health Questionnaire (PHQ). Poor HRQOL was defined as reporting limited usual daily activities for > 14 days during the month preceding the survey. RESULTS: In 2015-16, 47.8% of participants had ≥1 of the conditions studied. Among participants without pre-existing asthma, 15.4% reported asthma diagnosed after 9/11; of these, 76.5% had LRS at follow up. Among those without pre-9/11 GERD, 22.3% reported being diagnosed with GERD after 9/11; 72.2% had GERS at follow-up. The prevalence of PTSD was 14.2%, and of depression was 15.3%. HRQOL declined as the number of comorbidities increased, and was particularly low among participants with mental health conditions. Over one quarter of participants with PTSD or depression reported unmet need for mental health care in the preceding year. CONCLUSIONS: Nearly half of participants reported having developed at least one of the physical or mental health conditions studied by 2015-2016; comorbidity among conditions was common. Poor HRQOL and unmet need for health were frequently reported, particularly among those with post-9/11 PTSD or depression. Comprehensive physical and mental health care are essential for survivors of complex environmental disasters, and continued efforts to connect 9/11-exposed persons to needed resources are critical.

Early psychological impact of Paris terrorist attacks on healthcare emergency staff: A cross-sectional study.

BACKGROUND: The terrorist attacks in Paris and Saint Denis on November 13, 2015 were an unprecedented traumatic event in France. It was an especially distressing ordeal for the healthcare personnel involved in the care of the victims. The aim of this study was to estimate the effect of direct participation in the rescue on posttraumatic stress disorder (PTSD) symptoms among these workers. METHODS: Less than a month later, 613 healthcare providers (professionals and paraprofessionals) from three hospitals in the Paris suburbs were asked to complete an anonymous questionnaire. A multivariable Poisson model estimated the effect of participating onsite in the rescue (exposure variable) on the number of PTSD symptoms measured by the Trauma Screening Questionnaire (TSQ; outcome variable), adjusted for covariates. RESULTS: Two hundred thirty-three providers completed the assessment (38% response rate), 130 participated directly in the rescue (56%). Participation was associated with a higher number of symptoms of PTSD (RR = 1.34, P = .002) than for nonparticipants. Female gender (RR = 1.39, P < .001) and basic (vs. advanced or intermediate) life-saving training (RR = 1.42, P = .004) were also associated with more PTSD symptoms. Participants in the rescue were at 2.76 times more risk of a probable PTSD diagnosis (OR = 2.76, P = .037), defined as reporting at least six PTSD symptoms. Sensitivity analyses using propensity score matching supported the robustness of our findings. CONCLUSIONS: Healthcare providers directly involved in the rescue of the victims of the Paris and Saint Denis attacks reported a significantly higher psychological impact, defined by PTSD symptoms, than those not directly involved.

Mortality among rescue and recovery workers and community members exposed to the September 11, 2001 World Trade Center terrorist attacks, 2003-2014.

BACKGROUND: Multiple chronic health conditions have been associated with exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We assessed whether excess deaths occurred during 2003-2014 among persons directly exposed to 9/11, and examined associations of 9/11-related exposures with mortality risk. MATERIALS AND METHODS: Deaths occurring in 2003-2014 among members of the World Trade Center Health Registry, a cohort of rescue/recovery workers and lower Manhattan community members who were exposed to 9/11, were identified via linkage to the National Death Index. Participants' overall levels of 9/11-related exposure were categorized as high, intermediate, or low. We calculated standardized mortality ratios (SMR) using New York City reference rates from 2003 to 2012. Proportional hazards were used to assess associations of 9/11-related exposures with mortality, accounting for age, sex, race/ethnicity and other potential confounders. RESULTS: We identified 877 deaths among 29,280 rescue/recovery workers (3.0%) and 1694 deaths among 39,643 community members (4.3%) during 308,340 and 416,448 person-years of observation, respectively. The SMR for all causes of death was 0.69 [95% confidence interval (CI) 0.65-0.74] for rescue/recovery workers and 0.86 (95% CI 0.82-0.90) for community members. SMRs for diseases of the cardiovascular and respiratory systems were significantly lower than expected in both groups. SMRs for several other causes of death were significantly elevated, including suicide among rescue recovery workers (SMR 1.82, 95% CI 1.35-2.39), and brain malignancies (SMR 2.25, 95% CI 1.48-3.28) and non-Hodgkin's lymphoma (SMR 1.79, 95% CI 1.24-2.50) among community members. Compared to low exposure, both intermediate [adjusted hazard ratio (AHR) 1.36, 95% CI 1.10-1.67] and high (AHR 1.41, 95% CI 1.06-1.88) levels of 9/11-related exposure were significantly associated with all-cause mortality among rescue/recovery workers (p-value for trend 0.01). For community members, intermediate (AHR 1.13, 95% CI 1.01-1.27), but not high (AHR 1.14, 95% CI 0.94-1.39) exposure was significantly associated with all-cause mortality (p-value for trend 0.03). AHRs for associations of overall 9/11-related exposure with heart disease- and cancer-related mortality were similar in magnitude to those for all-cause mortality, but with 95% CIs crossing the null value. CONCLUSIONS: Overall mortality was not elevated. Among specific causes of death that were significantly elevated, suicide among rescue/recovery workers is a plausible long-term consequence of 9/11 exposure, and is potentially preventable. Elevated mortality due to other causes, including non-Hodgkin's lymphoma and brain cancer, and small but statistically significant associations of 9/11-related exposures with all-cause mortality hazard warrant additional surveillance.

[Vascular surgical training concept for military surgeons in Germany]. / Gefäßchirurgisches Ausbildungskonzept für Militärchirurgen in Deutschland.

BACKGROUND: Due to the increasing threat of terrorist attacks and assassinations even in Europe, the interest in management of severe vascular injuries, which, with an increased incidence of 10% are to be expected with such penetrating wounds, is also growing; however, with increasing subspecialization in surgery there is a threat that the know-how in vascular surgery will become lost among non-vascular surgical specialists. Therefore, the Germany military established an educational program, the so-called DUOplus concept, to ensure that future military surgeons acquire and retain the experience and skills to fulfill the demanding role of a deployed surgeon. OBJECTIVE: The DUOplus concept of the German Medical Forces is introduced with a special focus on vascular surgery training. RESULTS: All trainee German military surgeons attain a second specialization alongside general surgery. This residency includes several courses in various surgical specialties as well as a 12-month rotation in a vascular surgery department. The core elements of vascular trauma training are two practical courses on life-like models. In these courses, which were developed especially for the needs of non-vascular surgeons in hands-on training, open surgical techniques and damage control measures including resuscitative endovascular balloon occlusion of the aorta (REBOA) are taught on suitable models and intensively practiced. CONCLUSION: All surgeons potentially confronted with traumatic and iatrogenic vascular injuries should have some basic competence in the management of vascular trauma. Especially the courses in vascular surgery for non-vascular surgeons offer such a skill set for every surgeon. Next to the German military surgeons, the courses are attended more and more by civilian and military surgeons from different surgical specialties and nationalities.

[Defusing of victims of the terrorist attacks in Paris. Elements of assessment one-month post-event]. / Defusing des victimes des attentats de Paris. Éléments d'évaluation un mois après.

The terrorist attacks (fusillades and suicide attacks) in Paris on 13 November 2015 have had a major psychic impact on all individuals directly or secondarily exposed to them. Medico-psychological unit (CUMP) of the Paris Île-de-France region's immediate care services were immediately mobilized and rapidly strengthened by all regional medico-psychological units (CUMP) throughout the country. Psychological assistance has been provided in several key points of Paris and specifically in the 11th district City Hall of Paris where Lyon's Medico-psychological unit was located. These specific immediate psychological assistances, referred to as a "defusing process" by the medico-psychological unit (CUMP), are mostly devoted to provide the victims with an entry point to a psychological healthcare relationship and give them a first sense of soothing and relief even though they do not prevent further psychological care follow up for the victims. Nonetheless, the potential therapeutic effect of this "defusing process" has not yet been sufficiently established nor demonstrated by any scientific study. A phoning survey was carried out one-month post-terrorist attacks and interviewed the 129 victims who benefited from the "defusing process" conducted by Lyon's medico-psychological unit (CUMP) in order to collect data and assess its effects. These people, whether directly exposed, bereaved relatives or witnesses, whose average age is 35, are mostly living in the Île-de-France region. Most of them present a high score on the IES-R scale, whether they were directly exposed, bereaved relatives or witnesses. Almost all of them (96.5%) experienced at least one medical care contact within this one-month post-trauma period with psychotropic medication for 37% of them. Regarding the defusing conducted by Lyon's medico-psychological unit (CUMP) in the 11th district City Hall of Paris, it appears that 93% of the victims who were looked after indicated that they were satisfied and 87.4% of them stated that they were soothed afterwards.

[Victims of terrorist attacks: forensic issues]. / Victimes d'attentats : aspects médico-légaux.

Victims of terrorist attacks: forensic issues. France has recently suffered multiple terrorist attacks. A lot of physicians had to face massive incoming victims. The first priority was somatic and psychological care. However, lack of juridical counseling led to delay in victim status recognition. Legal procedures are essentials in patients' recovery. We propose guidelines for medical certificate writing and first response legal orientation of terrorism victims.

Victimes d'attentats : aspects médico-légaux. La France a récemment été le terrain de multiples attaques terroristes confrontant de nombreux médecins, parfois non spécialisés, à prendre en charge un afflux soudain et massif de personnes exposées. Dans ce cadre, l'urgence médicale initiale se complète d'un accompagnement dans les démarches médico-judiciaires. Celles-ci, souvent peu connues des non-spécialistes, sont nécessaires à la reconnaissance du statut de victime. Elles comportent plusieurs étapes bien définies. Nous proposons des recommandations afin de guider le praticien dans la rédaction du certificat médical initial, et dans l'accompagnement aux démarches de plainte pénale et d'indemnisation.

Increased Incidence Rate of Trauma- and Stressor-Related Disorders in Denmark After the September 11, 2001, Terrorist Attacks in the United States.

The terrorist attacks that occurred on September 11, 2001 (hereafter referred to as 9/11) in the United States had a profound impact on the physical and mental health of Americans, but the effects beyond the United States are largely unknown. To understand the wider aftermath, we examined the consequences of the 9/11 attacks on mental disorders in the Kingdom of Denmark. Utilizing population data from the Danish Psychiatric Central Research Register from 1995 to 2012, we used a time-series intervention approach to estimate the change in the incidence rate of mental disorders after the 9/11 attacks. Based on analyses of 1,448,250 contacts with psychiatric services, we found that the attacks were followed by an immediate 16% increase in the incidence rate of trauma- and stressor-related disorders. This surge dissipated approximately a year after 9/11. In contrast, no similar increases were found for other disorders. This is consistent with the prominent role of external stressors in the etiology of trauma- and stressor-related disorders. The results indicate that the effects of 9/11 on mental disorders extended across the Atlantic Ocean to Denmark. Thus, the impact of terrorist attacks on mental health is likely not limited to inhabitants of the country under attack; it also extends to people far away and without immediate relation to it.

Effect of asthma and PTSD on persistence and onset of gastroesophageal reflux symptoms among adults exposed to the September 11, 2001, terrorist attacks.

BACKGROUND: Little is known about the direction of causality among asthma, posttraumatic stress disorder (PTSD), and onset of gastroesophageal reflux symptoms (GERS) after exposure to the 9/11/2001 World Trade Center (WTC) disaster. METHODS: Using data from the WTC Health Registry, we investigated the effects of early diagnosed post-9/11 asthma and PTSD on the late onset and persistence of GERS using log-binomial regression, and examined whether PTSD mediated the asthma-GERS association using structural equation modeling. RESULTS: Of 29,406 enrollees, 23% reported GERS at follow-up in 2011-2012. Early post-9/11 asthma and PTSD were each independently associated with both the persistence of GERS that was present at baseline and the development of GERS in persons without a prior history. PTSD mediated the association between early post-9/11 asthma and late-onset GERS. CONCLUSIONS: Clinicians should assess patients with post-9/11 GERS for comorbid asthma and PTSD, and plan medical care for these conditions in an integrated fashion. Am. J. Ind. Med. 59:805-814, 2016. © 2016 Wiley Periodicals, Inc.

FDNY and 9/11: Clinical services and health outcomes in World Trade Center-exposed firefighters and EMS workers from 2001 to 2016.

BACKGROUND: After the World Trade Center (WTC) attacks on September 11, 2001, the Fire Department of the City of New York (FDNY) instituted a WTC medical monitoring and treatment program and established a data center to document health outcomes in the WTC-exposed workforce of ∼16,000 firefighters and EMS workers. METHODS: FDNY schedules routine monitoring exams every 12-18 months and physical and mental health treatment appointments, as required. RESULTS: FDNY research studies have consistently found that early arrival to work and/or prolonged work at the WTC-site increased the risks for adverse physical and mental health outcomes. To date, a substantial proportion has been diagnosed with obstructive airways disease, chronic rhinosinusitis, and gastroesophageal reflux disease; a quarter has two or more of these conditions. CONCLUSIONS: While much has been learned, the entire spectrum and trajectory of WTC-related disorders and their mechanisms of onset and persistence remain to be fully described. Am. J. Ind. Med. 59:695-708, 2016. © 2016 Wiley Periodicals, Inc.