Integrating Disaster and Dignitary Medicine Principles into a Medical Framework for Organizational Travel Health and Security Planning.

This Editorial explores organizational travel risk management and advocates for a comprehensive approach to fortify health security for travelers, emphasizing proactive risk management, robust assessments, and strategic planning. Leveraging insights from very important persons (VIP) protocols, organizations can enhance duty of care and ensure personnel safety amidst global travel complexities.

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.

Attacks on Ukrainian healthcare facilities during the first year of the full-scale Russian invasion of Ukraine.

BACKGROUND: Although the Geneva Conventions and Rome Statute demand protections for healthcare facilities during war, breaches of these protections are frequently reported. The ongoing war in Ukraine is no exception, with several healthcare attacks eliciting widespread condemnation. The Ukrainian Healthcare Center (UHC) has been collecting, verifying and documenting attacks on health infrastructure since the Russia-Ukraine War was launched. The aim of this study was to assess UHC documented healthcare facility attacks during the first year (24 February 2022 to 25 February 2023) of the full-scale Russian invasion of Ukraine. METHODS: The Berkeley Protocol on Digital Open Source Investigations was used to document healthcare attacks. Data collection included temporal factors, location, facility type, attack and weapon type, number of killed and injured healthcare personnel and civilians, and whether facilities were damaged, destroyed or attacked more than once. RESULTS: There were 334 documented attacks on 267 Ukrainian healthcare facilities, with 230 facilities being damaged and 37 destroyed. General hospitals, primary care clinics, emergency departments and children's hospitals were most frequently targeted. The majority of attacks took place during the first three months and in eastern Ukrainian oblasts. Heavy weaponry was employed in almost all attacks. The total number of casualties included 97 fatalities and 114 injuries. CONCLUSIONS: During the first year of the full-scale Russian invasion of Ukraine, there were 334 attacks on 267 Ukrainian healthcare facilities documented by the UHC. Heavy weaponry was commonly used, and the direct impact of attacks was considerable in terms of facility damage and casualty tolls.

A Gray Future: The Role of the Anesthesiologist in Hybrid Warfare.

During the last few decades, the increasing use of asymmetric and multimodal tactics by terrorists has led anesthesiologists worldwide to analyze and discuss their role in mass casualty scenarios in more depth. Now anesthesiologists must address the new situation of hybrid threats and hybrid warfare. This will have a direct impact on anesthesiology and intensive care, and in the end, the health and well-being of critical patients of all ages. To be able to respond to a hybrid threat efficiently and effectively, it is imperative that anesthesiologists play an early and integral role in mitigation and response planning.

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.

A Descriptive Analysis of the Use of Chemical, Biological, Radiological, and Nuclear Weapons by Violent Non-State Actors and the Modern-Day Environment of Threat.

INTRODUCTION: The use of chemical, biological, radiation, and nuclear (CBRN) weapons is not new, and though rare, it is an issue of concern around the world due to their ability to cause large-scale mass-casualty events and their potential threat to global stability. The purpose of this study is to explore the use of CBRN weapons by non-state actors through analysis of the Violent Non-State Actor (VNSA) CBRN Event database, and aims to better inform health care systems of the potential risks and consequences of such events. METHODS: Data collection was performed using a retrospective database search through the VNSA CBRN Event database. RESULTS: A total of 565 events were recorded. Five hundred and five (505) events (89.4%) involved single agents while 60 events (10.6%) involved multiple agents. Fatalities numbered 965 for chemical agents, 19 for biological agents, and none for radiological and nuclear events. Injuries numbered 7,540 for chemical agents, 59 for biological agents, 50 for radiological events, and none for nuclear attacks. Fatality and injury per attack was 2.22 and 17.37, respectively, for chemical event agents and 0.15 and 0.48, respectively, for biological event agents. CONCLUSION: Violent Non-State Actors were responsible for 565 unique events around the world involving the use of CBRN weapons from 1990-2020. The United States (118), Russia (49), and Iraq (43) accounted for the top three countries where these events occurred. While CBRN events remain relatively rare, technological advances have the potential to facilitate the use of such weapons as part of a hybrid warfare strategy with significant repercussions for civilian health and health care systems.

Cyberthreats: A primer for healthcare professionals.

INTRODUCTION: Cyberattacks are one of the most widespread, damaging, and disruptive forms of action against healthcare entities. Data breaches, ransomware attacks, and other intrusions can lead to significant cost both in monetary and personal harm to those affected and may result in large payouts to cyber criminals, crashes of information technology systems, leaks of protected health and personal information, as well as fines and lawsuits. This study is a descriptive analysis of healthcare-related cyber breaches affecting 500 or more individuals in the past decade in the United States. METHODS: The publicly available U.S. breach report database was downloaded in the Microsoft Excel (Microsoft, Redmond, Washington, USA) format and searched for all reported breaches occurring between January 1, 2011 - December 31, 2021 (10 years). Breaches were subdivided by category and analyzed by states, breach submission dates, types of breach, location of breached information, entity type, and individuals affected. All subcategories were predefined by the breach report. RESULTS: There were a total of 3822 PHI breaches that affected 283,335,803 people in the United States from January 1, 2011 to December 31, 2021. Of the 3822 PHI breaches, 1593 (41.7%) were hacking/ IT related, 1055 (27.6%) were listed as unknown, 819 (21.4%) were theft related, 194 (5.1%) were loss related, 97 (2.5%) were related to improper disposal and 64 (1.7%) were listed as "others". Year 2020 saw the most breaches with 631 and California was the state with the highest number of breaches at 403. CONCLUSION: Cyberattacks and healthcare breaches are one of the most costly and disruptive situations facing healthcare today. A total of 3822 breaches affecting 283,335,803 people in the United States were recorded from January 1, 2011 to December 31, 2021. By understanding the extent of cyberthreats this will better prepare healthcare organizations and providers to mitigate, respond, and recover from these devastating attacks.

Hybrid warfare and counter-terrorism medicine.

INTRODUCTION: March 9, 2022. An airstrike by Russian forces destroying a maternity hospital in Mariupol, Ukraine. The image of a severely injured pregnant woman covered in blood being stretchered away against the backdrop of destroyed buildings. Mutterings of the use of chemical weapons. This paper is a primer for healthcare personnel and health systems on hybrid warfare and counter-terrorism medicine. DISCUSSION: While recent events and images arising from conflicts around the world represent a cruel hallmark in today's history, attacks against healthcare facilities and innocent civilians are not new and continue to be perpetrated around the world. In war, the Geneva Convention protects civilians and healthcare institutions from harm but when war crimes are being committed and civilians knowingly targeted, parallels from a healthcare perspective can be drawn with terrorism events. Increasingly, civilian institutions and in particular the healthcare sector, are drawn into such conflicts and understanding the health system impact of hybrid warfare and other asymmetrical attack methods is of great importance. CONCLUSION: The field of Counter-Terrorism Medicine (CTM) explores the healthcare impacts of intentional, man-made attacks and much recent research and discussions around this topic are extremely relevant and applicable not just to the ongoing hybrid war in Ukraine, but to today's threat climate all around us.

Not war, not terrorism, the impact of hybrid warfare on emergency medicine.

INTRODUCTION: Healthcare facilities and medical providers are not immune to aggression and threat from terrorists, criminals and rogue states. The concept of Hybrid Warfare is often described as a mix of conventional warfare, irregular warfare, terrorism, criminality and different types of other hybrid threats such as cyberattacks and drone technology. Healthcare systems can either be primary or secondary targets of hybrid warfare with potentially devastating consequences. OBJECTIVE: The aim of this paper is to serve as a primer for clinicians, researchers and emergency managers in understanding the basic aspects of hybrid warfare, how healthcare can be affected, and to provide a framework for mitigation and resilience, especially in an emergency medicine setting. Different hybrid threats and their effect on emergency medicine, and healthcare in general, is discussed. DISCUSSION: Hybrid warfare is an increasing, multimodal, threat for all segments of healthcare, particularly prehospital care and emergency medicine. Disrupting the healthcare system in a country using hybrid warfare has the ultimate aim of destabilizing organizations and society as well as directly reducing the effectiveness and capabilities of healthcare as a key strategic resource. In this aspect prehospital care and emergency medicine are main targets of aggression. CONCLUSION: Clinicians and healthcare managers of all levels should have a basic knowledge of the different components of hybrid warfare so as to mitigate effects of an attack. It is suggested that an emergency department do not aim to create totally new solutions for hybrid threats but use an all hazards approach and the available guidelines for handling generic threats. However, there must be a preparedness for the different ways hybrid warfare can play out, how the threats can be combined in synergistic ways and the potential compounding effects on healthcare and society.

A Feasibility Study on the Identification of Potential Biomarkers in Pulmonary Embolism Using Proteomic Analysis.

Acute pulmonary embolism (PE) is a common emergency with a high morbidity and mortality. Most clinical presentations are non-specific and there is a lack of suitable biomarkers for PE. For example, the traditional D-dimer tests shows a rather high sensitivity for PE, but yet a rather low positive predictive value due to its lack of specificity. Research on novel biomarkers for PE is thus of interest to improve early diagnostics and reduce the number of unnecessary computed tomography pulmonary angiogram (CTPA) scans performed. In this study we evaluate the feasibility to use label-free quantitative proteomics to discover potential biomarkers for acute PE and to monitor changes in proteins levels in PE patients over time. Blood was collected from 8 patients with CTPA verified PE and from 8 patients presenting with same symptoms but with a negative CTPA. The samples were analyzed by liquid chromatography-mass spectrometry and thirteen protein concentrations were found to be significantly changed in PE patients compared to the CTPA negative controls. This exploratory study shows that proteomic analysis can be used to identify potential biomarkers for PE as well as to monitor changes of protein levels over time.The complement proteins play a part in PE but further studies are needed to clarify their specific role in the pathophysiological process and to look for more specific proteins.

Terrorism-Related Chemical, Biological, Radiation, and Nuclear Attacks: A Historical Global Comparison Influencing the Emergence of Counter-Terrorism Medicine.

BACKGROUND: Terrorist attacks are growing in complexity, increasing concerns around the use of chemical, biological, radiation, and nuclear (CBRN) agents. This has led to increasing interest in Counter-Terrorism Medicine (CTM) as a Disaster Medicine (DM) sub-specialty. This study aims to provide the epidemiology of CBRN use in terrorism, to detail specific agents used, and to develop training programs for responders. METHODS: The open-source Global Terrorism Database (GTD) was searched for all CBRN attacks from January 1, 1970 through December 31, 2018. Attacks were included if they fulfilled the terrorism-related criteria as set by the GTD's Codebook. Ambiguous events or those meeting only partial criteria were excluded. The database does not include acts of state terrorism. RESULTS: There were 390 total CBRN incidents, causing 930 total fatal injuries (FI) and 14,167 total non-fatal injuries (NFI). A total of 347 chemical attacks (88.9% of total) caused 921 FI (99.0%) and 13,361 NFI (94.3%). Thirty-one biological attacks (8.0%) caused nine FI (1.0%) and 806 NFI (5.7%). Twelve radiation attacks (3.1%) caused zero FI and zero NFI. There were no nuclear attacks. The use of CBRN accounted for less than 0.3% of all terrorist attacks and is a high-risk, low-frequency attack methodology.The Taliban was implicated in 40 of the 347 chemical events, utilizing a mixture of agents including unconfirmed chemical gases (grey literature suggests white phosphorous and chlorine), contaminating water sources with pesticides, and the use of corrosive acid. The Sarin gas attack in Tokyo contributed to 5,500 NFI. Biological attacks accounted for 8.0% of CBRN attacks. Anthrax was used or suspected in 20 of the 31 events, followed by salmonella (5), ricin (3), fecal matter (1), botulinum toxin (1), and HIV (1). Radiation attacks accounted for 3.1% of CBRN attacks. Monazite was used in 10 of the 12 events, followed by iodine 131 (1) and undetermined irradiated plates (1). CONCLUSION: Currently, CBRN are low-frequency, high-impact attack modalities and remain a concern given the rising rate of terrorist events. Counter-Terrorism Medicine is a developing DM sub-specialty focusing on the mitigation of health care risks from such events. First responders and health care workers should be aware of historic use of CBRN weapons regionally and globally, and should train and prepare to respond appropriately.

Monitoring concussion in a knocked-out boxer by CSF biomarker analysis.

Concussion is common in many sports, and the incidence is increasing. The medical consequences after a sport-related concussion have received increased attention in recent years since it is known that concussions cause axonal and glial damage, which disturbs the cerebral physiology and makes the brain more vulnerable for additional concussions. This study reports on a knocked-out amateur boxer in whom cerebrospinal fluid (CSF) neurofilament light (NFL) protein, reflecting axonal damage, was used to identify and monitor brain damage. CSF NFL was markedly increased during 36 weeks, suggesting that neuronal injury persists longer than expected after a concussion. CSF biomarker analysis may be valuable in the medical counselling of concussed athletes and in return-to-play considerations.