scholarly journals Biosurveillance: A Review and Update

2012 ◽  
Vol 2012 ◽  
pp. 1-9 ◽  
Author(s):  
Nicholas E. Kman ◽  
Daniel J. Bachmann
Keyword(s):  
Health Care ◽  
Syndromic Surveillance ◽  
Laboratory Data ◽  
Clinical Manifestations ◽  
Ambient Air ◽  
Terrorist Attacks ◽  
Environmental Surveillance ◽  
Laboratory Surveillance ◽  
The Usa ◽  
Systematic Collection

Since the terrorist attacks and anthrax release in 2001, almost $32 billion has been allocated to biodefense and biosurveillance in the USA alone. Surveillance in health care refers to the continual systematic collection, analysis, interpretation, and dissemination of data. When attempting to detect agents of bioterrorism, surveillance can occur in several ways. Syndromic surveillance occurs by monitoring clinical manifestations of certain illnesses. Laboratory surveillance occurs by looking for certain markers or laboratory data, and environmental surveillance is the process by which the ambient air or environment is continually sampled for the presence of biological agents. This paper focuses on the ways by which we detect bioterrorism agents and the effectiveness of these systems.

Cerebral Amyloid Angiopathy in Combination with Paroxysmal Atrial Fibrillation

2020 ◽  
Vol 25 (4) ◽  
pp. 31-37
Author(s):  
A. A. Kornilova ◽  
O. V. Lagoda ◽  
M. M. Tanashyan
Keyword(s):  
Atrial Fibrillation ◽  
Cerebral Amyloid Angiopathy ◽  
Paroxysmal Atrial Fibrillation ◽  
Past History ◽  
Laboratory Data ◽  
Clinical Manifestations ◽  
Cerebral Haemorrhage ◽  
Exclusion Criterion ◽  
Amyloid Angiopathy ◽  
Cerebral Amyloid

The present article addresses the definition of cerebral amyloid angiopathy (CAA) and its symptoms based on the analysis of the medical case; the issues of diagnosis and treatment of this pathology are discussed. The Boston criteria, which became the basis for diagnosis, study of clinical manifestations and progression of CAA and approaches to its therapy, are presented. Methods and modes of neuroimaging, including magnetic resonance imaging (MRI), which verify micro cerebral haemorrhage, are described. At the same time, the role and significance of cardiac arrhythmias in the genesis of ischemic stroke are discussed, and scales for assessing the risk of its occurrence are presented. The observation of the neurological, somatic, neuroimaging, neuropsychological status of a 62-year-old patient confirms quite rare combination of probable CAA, paroxysmal atrial fibrillation and repeated hemorrhagic functional apoplexy (FA). The relevance of the case described, is a complex clinical dilemma based on mutually exclusive recommendations for the pharmacological correction of such conditions. It is emphasized that in many multicenter clinical studies on the effectiveness of antithrombotic medication (antiaggregants, anticoagulants) in the treatment and prevention of ischaemic functional apoplexy , an important exclusion criterion is a hemorrhagic stroke in past history (including the multiple changes in haemostasis indicators). Taking into account the obtained clinical and laboratory data in the dynamics, the tactics of treating the described patient were determined. The results of studies related to the treatment of comorbid pathology that should become the subject of the development of a personalized algorithm for managing patients in each specific case, are discussed.

The Language of New Terrorism: Differences in Psychological Dimensions of Communication in Dabiq and Inspire

2017 ◽  
Author(s):  
Matteo Vergani ◽  
Ana-Maria Bliuc
Keyword(s):  
Experimental Study ◽  
English Language ◽  
Terrorist Attacks ◽  
Al Qaeda ◽  
Positive Attitudes ◽  
Terrorist Groups ◽  
The Usa ◽  
Psychological Dimensions ◽  
New Terrorism

We investigate differences in the psychological aspects underpinning Western mobilisation of two terrorist groups by analysing their English-language propaganda. Based on a computerized analysis of the language used in two English-language online magazines circulated by ISIS and al-Qaeda (i.e., Dabiq and Inspire), we found significant differences in their language - the ISIS’ language being higher in authoritarianism and its level of religiousness. In a follow-up experimental study, we found that being high in religiousness and authoritarianism predicts more positive attitudes towards the language used by ISIS, but not towards the language used by al-Qaeda. The results suggest that ISIS’ propaganda may be more effective in mobilising individuals who are more authoritarian and more focused on religion than that of al-Qaeda. These findings are consistent with the behaviour observed in recent homegrown terrorist attacks in the USA and Europe.

scholarly journals AB0521 COST OF ILLNESS OF ANCA-ASSOCIATED VASCULITIS IN ITALY: DATA LINKAGE ANALYSIS OF MULTIPLE CLINICAL AND ADMINISTRATIVE DATABASES IN THE PROVINCE OF UDINE, ITALY

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1558.1-1558
Author(s):  
L. Quartuccio ◽  
E. Treppo ◽  
S. De Vita ◽  
F. Valent
Keyword(s):  
Health Care ◽  
Cost Of Illness ◽  
Systemic Vasculitis ◽  
Health Information System ◽  
Clinical Manifestations ◽  
Administrative Databases ◽  
Rank Test ◽  
Hospital Discharges ◽  
Severe Infections ◽  
Regional Population

Background:ANCA-associated vasculitides (AAV) are a group of systemic vasculitis carrying a high risk of hospitalization because the multiorgan involvement, the acute nature of some clinical manifestations, the chronic but very disabling course of some other manifestations and finally the risk of severe infections due to chronic glucocorticoid and immunosuppressor administration. However, data on cost of illness due to AAV are lacking.Objectives:to estimate the cost of illness in patients suffering from AAV in the province of Udine (about 500,000 inhabitants), Friuli Venezia Giulia (FVG), Italy, from year 2010 to 2018.Methods:integration of the information coming from many administrative databases were used to this end. The Regional Health Information System of FVG was used as the source of information for this retrospective cohort study. The system covers the entire regional population and includes various electronic health administrative databases that can be linked with one another on an individual basis through a unique encrypted identifier. In particular, the following databases were matched: the database of the health care beneficiaries (including demographic information and the residential history of all of the subjects living in FVG), the hospital discharge database, the database of exemptions from medical charges, the database of the laboratories. The population under study was selected based on the following inclusion criteria: patients were residents in the province of Udine and they had to carry the exemption code for AAV, including GPA, or EGPA, or MPA. This population was observed from 2010 to 2018.Results:57 patients (201 patient-years) with AAV were identified. They were ANCA-positive in 44/57 (77%). GPA, EGPA and MPA was diagnosed in 18 (31,6%), 15 (26,3%), 11 (19,3%) patients, respectively. The mean age at diagnosis was 54,5 (17,5) years. The disease itself was the main cause of hospitalization in almost half of the hospital discharges (60/126, 47,6%). Four patients died during the observation period due to vasculitis itself (1), pneumonia (2), or haematological malignancy (1). Time to the first event (death or hospitalization) was significantly higher in ANCA-negative AAV patients than in ANCA-positive AAV patients (p=0,03, Log-Rank test), ANCA-positive AAV patients having a three-times higher risk (HR 3,38 95%CI 1,13-10,08, p=0,03). Total estimated cost was € 1,215,078, corresponding to € 6,168 patient-year. Costs for ANCA-positive AAV patients were much higher than those for ANCA-negative AAV patients (€ 1,115,253 vs € 99,825, and € 7058 per person-year vs € 2,559 per person-year, respectively). GPA and MPA showed the highest costs if compared to EGPA [GPA: € 239,168 (€ 5199 per person-year) vs MPA: € 281,502 (€ 4771 per person-year) vs EGPA: € 214,287 (2329 per person-year), respectively]. Costs for hospitalization were the highest [€ 734,957 (€ 3731 per person-year) vs other costs € 480,121 (€ 2437 per person-year)].Conclusion:costs for AAV are very high, confirming the high health care burden of this illness. Management of ANCA-positive patients rather than ANCA-negative patients was burdened by the highest costs. GPA and MPA showed the highest direct costs for hospitalization, which very frequently occurred due to the vasculitis itself.Disclosure of Interests:Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Elena Treppo: None declared, Salvatore De Vita Consultant of: Roche, GSK, Speakers bureau: Roche, GSK, Novartis, Francesca Valent: None declared

scholarly journals AB0520 FIVE-YEAR RATE OF HOSPITALIZATIONS IN ANCA-ASSOCIATED VASCULITIDES IN THE ITALIAN REGION OF FRIULI VENEZIA GIULIA (2013-2017)

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1557.2-1558
Author(s):  
L. Quartuccio ◽  
E. Treppo ◽  
S. De Vita ◽  
F. Valent
Keyword(s):  
Health Care ◽  
Granulomatosis With Polyangiitis ◽  
Burden Of Illness ◽  
Clinical Manifestations ◽  
Administrative Databases ◽  
Eosinophilic Granulomatosis With Polyangiitis ◽  
Italian Region ◽  
Potential Health ◽  
Number Of Patients ◽  
Friuli Venezia Giulia

Background:ANCA-associated vasculitides (AAV) are a group of systemic vasculitis carrying a high risk of hospitalization because the multiorgan involvement, the acute nature of some clinical manifestations, the chronic but very disabling course of some other manifestations and finally the risk of severe infections due to chronic glucocorticoid and immunosuppressor administration. However, data on hospitalization due to ANCA-associated vasculitis are still scarce.Objectives:to estimate the rate of the first hospitalization or the death in patients suffering from AAV in the Italian region of Friuli Venezia Giulia (about 1,200,000 inhabitants) from year 2013 to 2017.Methods:integration of the information coming from many administrative databases were used to this end. The Regional Health Information System of Friuli Venezia Giulia was used as the source of information for this retrospective cohort study. The system covers the entire regional population and includes various electronic health administrative databases that can be linked with one another on an individual basis through a unique encrypted identifier. In particular, the following databases were matched: the database of the regional potential health care beneficiaries (including demographic information and the residential history of all of the subjects living in the region), the hospital discharge database, the database of exemptions from medical charges were used for this study, the database of the different regional laboratories. The population under study was selected based on the following inclusion criteria: patients were residents in Friuli Venezia Giulia and they had to carry the exemption code for AAV, including Granulomatosis with Polyangiitis (GPA), or Eosinophilic Granulomatosis with Polyangiitis (EGPA), or Microscopic Polyangiitis (MPA). This population was observed from 2013 to 2017. The coded event was the occurrence of the first hospitalization or the death. Also, all the hospitalization and their main discharge diagnoses were registered.Results:103 patient with AAV were identified. The number of patients with at least one hospitalization/death was 74/103 (71,8%). Seven patients died during the observation period (6,6%). The whole number of hospitalizations was 285 in 74 patients. 55/74 (74,3%) patients experienced more than one hospitalization. In the majority of the hospitalizations (119/285, 41,7%), the cause of hospitalization was directly attributable to the disease itself, while the second cause of hospitalization was the infections (26/285, 9,1%). In 10/103 patients (9,7%), an end stage renal disease was recorded as event. The presence of at least one positivity for ANCA antibodies was documented in 76/103 patients (73,8%), mainly in patients carrying GPA. Globally, the presence of ANCA antibody seems to be associated with greater likelihood of an event (p=0,07, log-rank test). The first event occurred in 50% of ANCA-positive patients within 180 days from diagnosis, while in 50% of ANCA negative patients in 859 days. 6 out of the 7 deaths occurred in ANCA positive patients.Conclusion:the rate of hospitalization in AAV is very high confirming the high health care burden of illness. The disease itself is often the cause of the hospitalization, as well as the infectious complication, highlighting the need for more effective treatments, and glucocorticoid sparing therapies. ANCA antibody may represent a biomarker of a more serious disease.Disclosure of Interests:Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Elena Treppo: None declared, Salvatore De Vita Consultant of: Roche, GSK, Speakers bureau: Roche, GSK, Novartis, Francesca Valent: None declared

scholarly journals Novel repurposing of a Laerdal Airway trainer to simulate aerosolisation

2021 ◽  
pp. bmjstel-2020-000802
Author(s):  
Sven Peter Oman ◽  
Scott Helgeson ◽  
Philip Lowman ◽  
Pablo Moreno Franco ◽  
Jonathan Tomshine ◽  
...  
Keyword(s):  
Airway Management ◽  
Ultraviolet Light ◽  
Healthcare Workers ◽  
Saline Solution ◽  
Size Range ◽  
Ambient Air ◽  
Airborne Particles ◽  
Exposure Risk ◽  
Aerosol Model ◽  
The Usa

COVID-19 has claimed over 200 000 lives in the USA and put healthcare workers at risk. Healthcare workers have an increased exposure risk from aerosol-generating procedures such as endotracheal intubation. New barrier designs such as the acrylic box and horizontal plastic drape have emerged to reduce exposure to airborne particles. Particle generating models are needed to test aerosol generating procedure (AGP) barrier designs. To achieve this, an aerosol model that generates a visible and measurable increase in particles which SARS-CoV-2 could travel on and that can also be intubated was created. The model was created using a Laerdal Airway Management Trainer (Laerdal Medical, Stavanger, Norway) combined with a nebuliser and Ambu bag-valve resuscitator (Ambu, Columbia, Maryland, USA). Nebulised Glo Germ (Glo Germ, Moab, Utah, USA) dissolved in saline solution was moved through the tubing and out of the mannequin’s mouth with compression of the Ambu bag. This nebulisation was visualised under ultraviolet light and the quantity of particles between 0.3 and 10.0 μm was measured with a particle counter. Nebulisation was visible exiting the mouth of the mannequin. Nebulised Glo Germ was visualised under ultraviolet light moving in the ambient air. Particles in the size range of 0.3–0.5 µm increased by 20-fold and 1–10 µm increased by 10 252%. SARS-CoV-2 can travel on aerosol and droplet particles and particle generating models are needed to visualise and measure exposure areas and the path particles take during AGPs. We used existing medical and simulation supplies to create a particle simulator.

scholarly journals Myocardial amyloidosis following multiple myeloma in a 38-year-old female patient: A case report

Open Medicine ◽  
2020 ◽  
Vol 15 (1) ◽  
pp. 396-402
Author(s):  
Qisi Zhang ◽  
Yingli Qiao ◽  
Dongmei Yan ◽  
Yuhui Deng ◽  
Mengyang Zhang ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Plasma Cells ◽  
Laboratory Data ◽  
Young Patients ◽  
Clinical Manifestations ◽  
The Elderly ◽  
First Episode ◽  
Rapid Progression ◽  
Congo Red Staining ◽  
Impaired Cardiac Function

AbstractMultiple myeloma (MM) is an immunoglobulin-producing tumor of plasma cells, which occurs commonly in the elderly. The incidence of myocardial amyloidosis with MM is extremely low and early clinical manifestations are nonspecific. The diversity of clinical manifestations and first episode symptoms often cause misdiagnosis in young patients with myocardial amyloidosis following MM. In this study, we analyzed the clinical data of a young woman with MM and impaired cardiac function combined with echocardiography, electrocardiography (ECG), laboratory data, cell Congo Red staining, and other manifestations to diagnose amyloidosis. Considering the rapid progression, short survival, and poor prognosis in most patients, a clear, definitive, and timely diagnosis is essential for the treatment of patients with MM complicated with myocardial amyloidosis.

scholarly journals Autoimmune encephalitis in a South Asian population

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Nilanka Wickramasinghe ◽  
Dhanushka Dasanayake ◽  
Neelika Malavige ◽  
Rajiva de Silva ◽  
Thashi Chang
Keyword(s):  
Sri Lanka ◽  
Psychiatric Symptoms ◽  
South Asians ◽  
Laboratory Data ◽  
Clinical Manifestations ◽  
Autoimmune Encephalitis ◽  
Asian Population ◽  
South Asian Population ◽  
Clinical Presentations

Abstract Background Autoimmune encephalitis (AE) is now considered a main, potentially curable cause of encephalitis, but remains conspicuously underreported from South Asia. We studied the clinical characteristics in relation to their antibody status and outcomes of patients presenting with AE in Sri Lanka. Methods Patients admitting to government hospitals who were clinically suspected of AE by an on-site neurologist were prospectively recruited over a period of 12 months. Sera and cerebrospinal fluid were tested for NMDAR, AMPAR1, AMPAR2, LGI1, CASPR2, GABARB1/B2 antibodies (Ab) using commercial cell-based assays. Demographic, clinical and laboratory data were compiled into an investigator-administered proforma. Patients were reviewed at 1 year follow up either in person or via telephone. Results One-hundred and forty-two patients from 21 of 25 districts in Sri Lanka (median age = 20.5 years; range 1–86 years; females = 61.3%) were recruited. Of them, 65 (45.8%; median age = 19 years; range 1–86 years; females = 64.6%) fulfilled diagnostic criteria for probable NMDAR-antibody encephalitis (NMDARE) and 6 (4.2%; median age = 44 years; range 28–71 years; females = 83.3%) limbic encephalitis (LE). Abnormal behaviour (95.3%), seizures (81.5%) and movement disorders (69.2%) were the most frequent clinical manifestations of probable NMDARE. NMDAR-antibodies were detectable in 29 (44.6%) and not detectable in 36 in CSF of probable-NMDARE patients. Abnormal EEG was more frequent (p = 0.003) while a worse outcome (OR = 2.78; 95% CI = 0.88–9.09) and deaths (OR = 2.38; 95% CI = 0.67–8.33) were more likely in antibody-negative than antibody-positive probable-NMDARE. Most patients with LE had amnesia (50%) and/or confusion (100%) with agitation (83.3%) and seizures (100%) but none had detectable antibodies to any of the antigens tested. Conclusions NMDARE is the commonest type of AE among South Asians as is the case worldwide. Clinical presentations of NMDARAb-positive and NMDARAb-negative AE patients do not significantly differ but EEG may be a useful marker of an autoimmune basis for psychiatric symptoms.

scholarly journals Person-Centered Health Care: An Approach That Integrates Acute and Long-Term Care

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 704-704
Author(s):  
Yuchi Young ◽  
Barbara Resnick
Keyword(s):  
Older Adults ◽  
Health Care ◽  
Health Systems ◽  
Long Term Care ◽  
The United States ◽  
World Population ◽  
Term Care ◽  
The Usa ◽  
Aged Society

Abstract The world population is aging. The proportion of the population over 60 will nearly double from 12% in 2015 to 22% in 2050. Global life expectancy has more than doubled from 31 years in 1900 to 72.6 years in 2019. The need for long-term care (LTC) services is expanding with the same rapidity. A comprehensive response is needed to address the needs of older adults. Learning from health systems in other countries enables health systems to incorporate best long-term care practices to fit each country and its culture. This symposium aims to compare long-term care policies and services in Taiwan, Singapore, and the USA where significant growth in aging populations is evidenced. In 2025, the aging population will be 20% in Taiwan, 20% in Singapore and 18 % in the USA. In the case of Taiwan, it has moved from aging society status to aged society, and to super-aged society in 27 years. Such accelerated rate of aging in Taiwan is unparalleled when compared to European countries and the United States. In response to this dramatic change, Taiwan has passed long-term care legislation that expands services to care for older adults, and developed person-centered health care that integrates acute and long-term care services. Some preliminary results related to access, care and patterns of utilization will be shared in the symposium. International Comparisons of Healthy Aging Interest Group Sponsored Symposium.

scholarly journals AB0533 ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODY (ANCA) IN GENERAL POPULATION WITHOUT ANCA ASSOCIATED VASCULITIS

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1563.3-1563
Author(s):  
H. Tamaki ◽  
S. Fukui ◽  
T. Nakai ◽  
G. Kidoguchi ◽  
S. Kawaai ◽  
...  
Keyword(s):  
Risk Factors ◽  
Autoimmune Disease ◽  
General Population ◽  
Granulomatosis With Polyangiitis ◽  
Dietary Habits ◽  
Laboratory Data ◽  
Clinical Manifestations ◽  
Anca Associated Vasculitis ◽  
The Mean

Background:Currently it is hypothesized that many systemic autoimmune diseases occur due to environmental risk factors in addition to genetic risk factors. Anti-Neutrophil Cytoplasmic Antibody (ANCA) is mainly associated with three systemic autoimmune disease including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA). It is known that ANCA can be positive before clinical symptoms in patients with known diagnosis of GPA and ANCA titers rise before clinical manifestations appear. However, prevalence of ANCA among general population is not well known. It has not been described as well how many of people with positive ANCA eventually develop clinical manifestations of ANCA associated Vasculitis.Objectives:This study aims to estimate prevalence of ANCA in general population without ANCA associated Vasculitis. It also describes natural disease course of people with positive ANCA without ANCA associated Vasculitis. Risk factors for positive ANCA are also analyzed.Methods:This is a single center retrospective study at Center for Preventive Medicine of St. Luke’s International Hospital in Tokyo. ANCA was checked among the patients who wished to between 2018 and 2019. St. Luke’s Health Check-up Database (SLHCD) was utilized to collect the data. The patients whose serum was measured for ANCA were identified. The data for basic demographics, social habits, dietary habits and laboratory data were extracted. The charts of the patients with positive ANCA were reviewed.Results:Sera of total 1204 people were checked for ANCA. Of these 1204 people, 587 (48.8%) are male and the mean age was 55.8 years (32.6 to 79). There were total 11 patients with positive ANCA. Myeloperoxidase ANCA (MPO-ANCA) was positive for 3 patients and proteinase 3 ANCA (PR3-ANCA) was positive for 8 patients. Of these 11 patients, 5 were male (45.5%) and the mean age was 54.6 years. Two patients had history of autoimmune disease (primary biliary cirrhosis and ulcerative colitis). Five patients were evaluated by rheumatologists with the median follow-up period of 274 days. None of them developed clinical signs and symptoms of ANCA associated Vasculitis. Four out of five patients had ANCA checked later, two of which turned negative. The prevalence of ANCA in this cohort was 0.9% (95% confidence interval [95% CI]: 0.5% to 1.6%). Univariate analysis was performed to identify risk factors of positive ANCA. The variables analyzed include age, gender, body mass index (BMI), smoking habits, alcohol intake, dietary habits (fruits, fish, red meat), hypertension, dyslipidemia, and laboratory data. None of these variables demonstrated statistically significant differences except for positive rheumatoid factor (ANCA positive group: 33 % vs ANCA negative group: 9.1%, p value = 0.044).Conclusion:The prevalence of ANCA in this cohort was 0.9% (95% CI: 0.5% to 1.6%). None of them who had a follow-up developed ANCA associated Vasculitis during the follow-up period. Longer follow-up and more patients are necessary to determine natural course of people with positive ANCA.Disclosure of Interests:None declared

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

2021 ◽  
pp. 1-4
Author(s):  
Derrick Tin ◽  
Fredrik Granholm ◽  
Alexander Hart ◽  
Gregory R. Ciottone
Keyword(s):  
Health Care ◽  
Grey Literature ◽  
Low Frequency ◽  
Disaster Medicine ◽  
Terrorist Attacks ◽  
Fecal Matter ◽  
Counter Terrorism ◽  
Global Comparison ◽  
State Terrorism ◽  
Fatal Injuries

Abstract 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.

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