Perspectives on Preparedness for Chemical, Biological, Radiological, and Nuclear Threats in the Middle East and North Africa Region: Application of Artificial Intelligence Techniques.

Over the past 3 decades, the diversity of ethnic, religious, and political backgrounds worldwide, particularly in countries of the Middle East and North Africa (MENA), has led to an increase in the number of intercountry conflicts and terrorist attacks, sometimes involving chemical and biological agents. This warrants moving toward a collaborative approach to strengthening preparedness in the region. In disaster medicine, artificial intelligence techniques have been increasingly utilized to allow a thorough analysis by revealing unseen patterns. In this study, the authors used text mining and machine learning techniques to analyze open-ended feedback from multidisciplinary experts in disaster medicine regarding the MENA region's preparedness for chemical, biological, radiological, and nuclear (CBRN) risks. Open-ended feedback from 29 international experts in disaster medicine, selected based on their organizational roles and contributions to the academic field, was collected using a modified interview method between October and December 2022. Machine learning clustering algorithms, natural language processing, and sentiment analysis were used to analyze the data gathered using R language accessed through the RStudio environment. Findings revealed negative and fearful sentiments about a lack of accessibility to preparedness information, as well as positive sentiments toward CBRN preparedness concepts raised by the modified interview method. The artificial intelligence analysis techniques revealed a common consensus among experts about the importance of having accessible and effective plans and improved health sector preparedness in MENA, especially for potential chemical and biological incidents. Findings from this study can inform policymakers in the region to converge their efforts to build collaborative initiatives to strengthen CBRN preparedness capabilities in the healthcare sector.

Development of a molecularly imprinted polymer-based electrochemical sensor for the selective detection of nerve agent VX metabolite ethyl methylphosphonic acid in human plasma and urine samples.

This study focuses on the detection of ethyl methyl phosphonic acid (EMPA), a metabolite of the banned organophosphorus nerve agent VX. We developed an electrochemical sensor utilizing the molecularly imprinted polymer (MIP) based on 4-aminobenzoic acid (4-ABA) and tetraethyl orthosilicate for the selective detection of EMPA in human plasma and urine samples. The 4-ABA@EMPA/MIP/GCE sensor was constructed by a thermal polymerization process on a glassy carbon electrode and sensor characterization was performed by cyclic voltammetry and electrochemical impedance spectroscopy. The 4-ABA@EMPA/MIP/GCE sensor demonstrated impressive linear ranges 1.0 × 10-10 M-2.5 × 10-9 M for the standard solution, 1.0 × 10-10 M-2.5 × 10-9 M for the urine sample, and 1.0 × 10-10 M-1 × 10-9 M of EMPA for the plasma sample with outstanding detection limits of 2.75 × 10-11 M (standard solution), 2.11 × 10-11 M (urine), and 2.36 × 10-11 M (plasma). The sensor exhibited excellent recovery percentages ranging from 99.86 to 101.30% in urine samples and 100.62 to 101.08% in plasma samples. These findings underscore the effectiveness of the 4-ABA@EMPA/MIP/GCE as a straightforward, highly sensitive, and selective interface capable of detecting the target analyte EMPA in human plasma and urine samples.

In vitro evaluation of two different types of obidoxime-loaded nanoparticles for cytotoxicity and blood-brain barrier transport.

Nerve agents (NA) are chemical warfare munitions and their exposure causes a progressive inhibition of acetylcholinesterase (AChE). This inhibition causes NA-induced brain damage in central nervous system (CNS). Oximes reactivate AChE in both the peripheral nervous system and the CNS. Transport of the oxime across the blood-brain barrier (BBB) in the existed therapeutic concentrations at the brain parenchyma determines the effectiveness of antidote therapy on respiratory depression and NA-induced brain damage. However, oximes could not cross the BBB in therapeutic concentrations. The aim of this study was to load AChE reactivator obidoxime chloride to PLGA and PEG-b-PLGA nanoparticles and to improve the BBB transport of the molecule. Brain microvascular endothelial cells were used as the BBB model. 79.3 ± 4.2% of obidoxime was released from PLGA nanoparticles and 88.2 ± 4.4% of obidoxime was released from PEG-b-PLGA nanoparticles within 24 h. It was found that PEG-b-PLGA nanoparticles were ideal drug carrier because of its low tissue toxicity, few side effects, and controllable drug release profile. Transport efficiency of obidoxime across the BBB is a major challenge in the prevention of the CNS, the effectiveness of NA poisoning and new strategies like using obidoxime-loaded PEG-b-PLGA nanoparticles could overcome this challenge for the management of NA-induced brain damage.

Myelosuppression and acute hematological complications of sulfur mustard exposure in victims of chemical terrorism.

Sulfur mustard (SM) is a vesicant chemical warfare agent. Recent studies reported alleged use of SM by non-state actors in Syria and Iraq. It has been shown that SM induced immunological and hematological complications. The aim of this study was to determine acute toxic effects of SM exposure on hematological parameters. Blood samples from a group of Syrian exposed to SM in 2016 were taken daily during the follow-up of the patients in intensive care unit. Initial leukocytosis was observed in all patients (100%) on the first 48 h after exposure. Following leukocytosis, isolated lymphopenia was observed in all patients (100%) between 2nd and 4th days. A decrease in hemoglobin level was noted in five patients (62.5%) between 4th and 5th days. Thrombocytopenia was observed in 75% of patients between 4th and 6th days for mild cases and between 9th and 11th days for severe cases. Three patients (37.5%) developed distinct leucopenia/neutropenia on 11th and 12th days. It was observed that human exposure to high dose of SM has direct toxic effect on hematological cells and bone marrow. New strategies on treatment of SM-induced myelosuppression could reduce the effects of hematological complications and could increase the survival rate in these patients.

Evidence of sulfur mustard exposure in victims of chemical terrorism by detection of urinary ß-lyase metabolites.

Background: Sulfur mustard (SM) is a vesicant chemical warfare agent. Ocular, dermal, and respiratory systems are the primary targets of SM exposure. The aims of this study were to perform a quantitative analysis of ß-lyase metabolites of SM as 1,1'-sulfonylbis[2-(methylthio) ethane] (SBMTE) in urine samples of chemical casualties and to investigate the relationship between the measured SBMTE levels and the severity of characteristic symptoms of SM poisoning.Methods: A bioanalytical method which is based on titanium (III) chloride reduction of ß-lyase metabolites was employed to analyze urine samples of individuals (n = 13, collected 30 h after SM exposure) using gas chromatography-tandem mass spectrometry.Results: Various levels of SBMTE were measured in urine samples of seven individuals, confirming SM exposure for each. There was a correlation observed between measured levels of SBMTE in human urine samples and severity of clinical findings including ocular, respiratory, and cutaneous lesions of SM.Discussion: In combination with clinical examination, measurement of SBMTE levels in human urine could be used as a prognostic factor for clinical outcomes in victims of SM exposure. This bioanalytical verification is also important for the documentation of alleged use of SM.Conclusion: SBMTE is an unambiguous biomarker of potential SM poisoning as it does not exist in urine samples of an unexposed population. Quantitation of urinary SBMTE concentrations in victims of SM could be used in order to enable improved interpretation of clinical findings.

Recent sulfur mustard attacks in Middle East and experience of health professionals.

Sulfur mustard (SM) is a vesicant chemical warfare agent which affects ocular, respiratory, and cutaneous system. In this study, we aimed to share recent experiences on medical management of chemical casualties that were exposed to SM in Middle East. We reported medical management of 17 contaminated patients. After the evacuation from the hot zone, all chemical casualties should be transferred to the designated intensive care units. After detailed medical decontamination and stabilization, biological samples should be collected from all chemical casualties as soon as possible for the verification of the exposure. Medical history and existing symptoms reveal the clinical diagnosis of SM exposure. Medical management of SM casualties should focus on "good nursing care" including treatment of pain and itching, fluid and electrolyte replacement therapy, respiration and nutrition support. Despite of improved clinical skills, treatment of SM lesions is still non-specific which aims to relieve symptoms and to prevent infections. Existing diagnostic capabilities and treatment approaches could be improved by sharing recent clinical experiences on medical management of SM casualties where there are still important major gaps.

Optimized Gas Chromatography-Tandem Mass Spectrometry for 1,1'-sulfonylbis[2-(methylthio) ethane] Quantification in Human Urine.

Sulfur mustard (SM) which is a bifunctional alkylating vesicant is one of the mostly used chemical warfare agent in First World War and the Iran-Iraq War. ß-Lyase metabolites of SM especially 1,1'-sulfonylbis[2-(methylthio)ethane] (SBMTE) is an unequivocal biomarker of the exposure. An optimized gas chromatography-tandem mass spectrometry method was developed and validated for the retrospective detection of SBMTE in human urine. Urine samples were treated with acidic titanium trichloride to reduce ß-lyase metabolites to the single analyte SBMTE. After neutralization and precipitation, SBMTE was extracted from urine by C8 solid-phase extraction cartridge and analyzed in the multiple-reaction monitoring mode. The lower limit of quantification was 1 ng/mL with relative standard deviation of <10%. Acceptable intra-day and inter-day precisions and accuracies were obtained. The developed method was successfully measured various levels of SBMTE which could be used as the forensic evidence of such a chemical attack.

Acute intensive care unit management of mustard gas victims: the Turkish experience.

PURPOSE: Sulphur mustard (SM) is an highly toxic and vesicant chemical weapon that was used in various military conflicts several times in the history. The severity of ocular, dermal, and pulmonary symptoms that may appear following a characteristic asymptomatic period are depending on the SM concentration and exposure duration. The aim of this study is to present the clinical features and share the intensive care unit (ICU) experiences for the medical management of mustard gas victims. MATERIALS AND METHODS: Thirteen Free Syrian Army soldiers near Al-Bab region of North Syria were reportedly exposed to oily blackish smoke with garlic smell due to the explosion of a trapped bomb without causing any blast or thermal effect on 26th November 2016. None of them wore any chemical protective suits or gas masks during explosion. Since they observed skin lesions including bullous formation next day, they were admitted to the Turkish Field Hospital at the Turkish - Syrian border and then evacuated to the State Hospital of Gaziantep Province, Turkey for further management. Eight victims who were very close to point of explosion suffered burning eyes, sore throat, dry cough and dyspnoea after the chemical attack. RESULTS: On admission to hospital, all cases had conjunctivitis, hoarseness and bullae on various body areas. Blepharospasm and opacity were found in 8 patients and 5 of them had corneal erosions and periorbital oedema. Temporary loss of vision in 4 cases lasted for 24 h. Multiple fluid-filled blisters were observed especially on the scalp, neck, arms and hands, where direct skin exposure to the agent occurred. A definitive clinical care and infection prophylaxis measures along with the burn treatment and bronchodilators for respiratory effects were applied in ICU. Two patients received granulocyte-colony-stimulating factor due to the SM-mediated bone marrow suppression on the 16th day of exposure and one of them died because of necrotic bronchial pseudomembrane obstruction resulting in cardiopulmonary arrest. CONCLUSIONS: SM was first used during the First World War and it is still considered one of the major chemical weapons recently used by non-state actors in Syria and Iraq. In case of SM exposure, medical treatment of SM-induced lesions is symptomatic because no antidote or causal therapy does exist even though SM is very well known for over 100 years. However, clinical management in intensive care medicine of SM victims have improved since the 1980s, this study which is one of the largest recent SM-exposed case series since that time is important for the contribution to the clinical experience.

Evaluation of Gamma-Radiation Inactivation of a Bioterrorism Agent, Bacillus anthracis Spores, on Different Materials.

Decontamination of suspected packages, such as sealed envelopes, liquids and tools that are likely contaminated with biological agents is of great importance. In this study, we aimed to determine the gamma radiation dose required for the decontamination of paper, fabric and liquid materials without causing any damage to the structure of these materials. Each study group included 11 pieces of paper, fabric and sterile saline contaminated with 0.8 × 105 virulent Bacillus anthracis (B. anthracis) spores. These specimens were exposed to doses of 5.49, 11.58, 17.21, 21.75, 27 and 33.1 kilogray (kGy) of gamma radiation from a cobalt-60 source. After irradiation of all the samples, a viability assessment of the B. anthracis spores was performed. It was found that full decontamination was achieved with 11.58 kGy on the paper samples and 17.21 kGy on the fabric and liquid samples. It was concluded that a dose of 20 kGy of gamma radiation may be recommended for the inactivation of B. anthracis for some surfaces when especially sensitive and valuable materials cannot be wet decontaminated were exposed. In addition, serologic and molecular assays of the suspected packets can be performed for forensic purposes without damaging existing evidence in a bioterror incident.

The relationship between nonsuicidal self-injurious behavior and manners of death: a multicenter autopsy study

Background/aim: This study aimed to determine the relationship between nonsuicidal self-injurious behavior (NSSIB) and manners of death.Materials and methods: This study retrospectively evaluated 6604 autopsy cases evaluated at forensic medicine institutes of six major cities of Turkey. The study group consisted of all cases with NSSIB findings. The control group was created from cases without signs of NSSIB. Results: We found that the numbers of possible suicide and homicide cases in the NSSIB (+) group were significantly higher than in the NSSIB (-) group. The possibility of death due to suicide was 3.213 times and homicide was 2.004 times higher than natural deaths in the NSSIB (+) group compared with the NSSIB (-) group.Conclusion: The presence of NSSIB might increase the risk of death due to suicide and homicide, especially in adolescence.

Relationship Between Self-Injurious Behaviors and Levels of Aggression in Children and Adolescents Who Were Subject to Medicolegal Examination.

Aggression, which is defined as a behavior causing harm or pain, is a behavioral pattern typically expected in children and adolescents who are involved in criminal activities. The aim of this study was to examine the relationship between aggression and self-injurious behavior (SIB) in children and adolescents. The study was performed in 295 cases which were sent for medicolegal examination. The mean age of the subjects was 14.27 ± 1.05 years (age range 10-18 years). The aggression levels of the subjects were determined using the Aggression Questionnaire (AQ), which is an updated form of the Buss-Durkee Hostility Inventory. The mean total AQ score of the subjects with and without SIB was 78.04 ± 21.0 and 62.75 ± 18.05, respectively (p < 0.01). There were significant statistical differences between the two groups with respect to their subscale scores (p < 0.01). It was concluded that the levels of aggression increased in children and adolescents who were involved in criminal activities when the SIBs increased.

Mass casualties from acute inhalation of chlorine gas.

OBJECTIVES: Chlorine gas is a potent pulmonary irritant that affects the mucous membranes and induces severe disturbances of pulmonary gas exchange within minutes of inhalation. The present study evaluated an extraordinary type of mass inhalational exposure. MATERIAL AND METHODS: Clinical reports of 25 soldiers who were admitted to the emergency department of Maresal Cakmak Military Hospital, Erzurum were retrospectively evaluated. All patients were exposed to chlorine gas as a result of mixing sodium hypochlorite with hydrochloric acid during cleaning activities. RESULTS: All patients were male and the mean age of patients was 22.04+/-2.98 years. The main symptoms were coughing and dyspnea in 18 patients (72%). Forced expiratory volume in 1 second (FEV1) and FEV1/forced volume capacity (FVC) ratio were found to be normal in all patients but FVC and peak expiratory flow (PEF) were below the normal range (80%) in 9 patients (36%). All patients received warmed humidified oxygen combined with nebulized salbutamol. Inhaled budesonide and nebulized sodium bicarbonate were ordered additionally for 19 patients (76%). Thirteen patients (52%) were discharged from the emergency department and 12 patients (48%) were hospitalized. No mortality was observed. CONCLUSION: Chlorine gas is a potent pulmonary irritant that causes acute damage in both the upper and lower respiratory tract. We suggest that inhaled steroids combined with nebulized sodium bicarbonate could be a safe and effective alternative for the treatment of symptomatic patients. Education of the public about the dangers of mixing of hypochlorite bleach with acidic cleaning agents is also very important.