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Chapter 20 - Civil Unrest and Terrorism Involving Mass Gathering Events
- Edited by William J. Brady, University of Virginia, Mark R. Sochor, University of Virginia, Paul E. Pepe, Metropolitan EMS Medical Directors Global Alliance, Florida, John C. Maino II, Michigan International Speedway, Brooklyn, K. Sophia Dyer, Boston University Chobanian and Avedisian School of Medicine, Massachusetts
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- Book:
- Mass Gathering Medicine
- Published online:
- 11 April 2024
- Print publication:
- 18 April 2024, pp 284-304
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Summary
Civil unrest or terrorism at mass gathering events can erupt with significant violence and multiple casualties. These are high-risk situations, not only because of physical casualties, but also because of ethical, political and psychological sequelae. Beyond specialized planning, multi-agency drills and proficient tactical medicine training, medical teams should co-create secured access and egress, alternative medical responses and rapidly-adapting coordination and secure communications with other agencies. Civil protests can escalate, especially when extremist groups infiltrate them. Multi-site violence and assaults can evolve, particularly in terroristic attacks. Key lessons include unrelenting vigilance until all participants have left the mass gathering scene in its entirety. Violence (bombs, shootings, vehicle attacks) will often erupt when mass gatherings are dispersing and considered over. Terrorists can also purposely target medical personnel or incite one event (fire, bomb, shooting) to create crushing stampedes or to herd crowds into more vulnerable areas where they can be further attacked more directly with other modern weapons. Terrorists often attack from elevated perches or generate “protracted suicide” incidents while holding hostages, including many severely-wounded. The resulting frustration, anger and guilt commonly can consume medical rescuers when beholding slaughtered innocents or simply because they were (appropriately) staged during containment of on-going violence.
3 Fluoride Exposure and Hypothyroidism in Pregnant Women: A Potential Mechanism of Fluoride Neurotoxicity
- Meaghan Hall, Bruce Lanphear, Jonathan Chevrier, Richard Hornung, Rivka Green, Carly Goodman, Pierre Ayotte, E. Angeles Martinez-Mier, Christine Till
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 866-867
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Objective:
Fluoride exposure has been associated with thyroid dysfunction, but fluoride's impact on thyroid function in pregnancy is unclear, especially during early gestation when the fetus is dependent on maternal thyroid hormone. We examined the potential thyroid-disrupting effects of maternal fluoride exposure in pregnancy and tested whether thyroid disruption in pregnancy mediates the association between maternal fluoride exposure and child intelligence quotient (IQ) among Canadian mother-child dyads living in areas with optimal fluoridation.
Participants and Methods:We measured fluoride concentrations in drinking water and in spot urine samples collected in each trimester from pregnant women enrolled in the Maternal-Infant Research on Environmental Chemicals study. We also measured thyroid hormone (thyroid stimulating hormone [TSH], free thyroxine [FT4], and total thyroxine [TT4]) levels during the first trimester of pregnancy and categorized women as euthyroid (n=1301), subclinical hypothyroid (n=100), or primary hypothyroid (n=28). Those categorized as primary hypothyroid were combined with an additional 79 women who reported clinical diagnoses at time of study enrolment (total n=107). In a sample of 1508 women, we used logistic regression to estimate the association between fluoride exposure and risk of either subclinical or primary hypothyroidism, separately, and linear regression to estimate associations between fluoride exposure and women's thyroid hormone levels (TSH, FT4, TT4). We tested effect modification by child sex and thyroid peroxidase (TPO) antibody status. In a subsample of 439 mother-child pairs, we measured child Full-Scale IQ (FSIQ) at 3-4 years of age using the Wechsler Preschool and Primary Scale of Intelligence. We used linear regression to test associations between maternal hypothyroidism or thyroid hormone levels, and children's FSIQ scores. Finally, mediation analysis in the counterfactual framework was used to estimate the proportion of the effect of maternal fluoride exposure on child FSIQ mediated by maternal hypothyroidism, through evaluation of the natural direct (not through hypothyroidism) and indirect (through hypothyroidism) effects.
Results:Using categorical measures of thyroid status, a 0.5 mg/L increase in water fluoride concentration was associated with a 1.64 (95% confidence interval [CI], 1.04 to 2.58) increased odds of primary hypothyroidism. This association was stronger among women with normal TPO antibody levels (< 5.61 IU/mL) (odds ratio, 2.80; 95% CI, 1.24 to 6.36). In contrast, we did not find a significant association between maternal urinary fluoride and hypothyroidism. For continuous measures of thyroid hormone levels, a 1 mg/L increase in maternal urinary fluoride was associated with a 35% (p=0.01) increase in TSH among women pregnant with a female fetus. In our subsample analyses, children born to women with primary hypothyroidism had lower FSIQ than children of euthyroid women, especially among boys (B, 8.78; 95% CI, -16.78 to -0.79). In contrast, maternal TSH, FT4, and TT4 levels were not significantly associated with child FSIQ scores. Maternal primary hypothyroidism did not significantly mediate the relationship between maternal water fluoride concentration and child FSIQ (p natural indirect effect= .35).
Conclusions:Fluoride in drinking water may increase the risk of hypothyroidism in pregnancy. Thyroid dysfunction in pregnancy may be one mechanism underlying developmental neurotoxicity of fluoride.
Mental health difficulties and suicidal behaviours among young migrants: multicentre study of European adolescents
- Elaine M. McMahon, Paul Corcoran, Helen Keeley, Mary Cannon, Vladimir Carli, Camilla Wasserman, Marco Sarchiapone, Alan Apter, Judit Balazs, Raphaela Banzer, Julio Bobes, Romuald Brunner, Doina Cozman, Christian Haring, Michael Kaess, Jean-Pierre Kahn, Agnes Kereszteny, Ursa Mars Bitenc, Bogdan Nemes, Vita Poštuvan, Pilar A. Sáiz, Merike Sisask, Alexandra Tubiana, Peeter Värnik, Christina W. Hoven, Danuta Wasserman
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- Journal:
- BJPsych Open / Volume 3 / Issue 6 / November 2017
- Published online by Cambridge University Press:
- 02 January 2018, pp. 291-299
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Background
Migration has been reported to be associated with higher prevalence of mental disorders and suicidal behaviour.
AimsTo examine the prevalence of emotional and behavioural difficulties, suicidal ideation and suicide attempts among migrant adolescents and their non-migrant peers.
MethodA school-based survey was completed by 11 057 European adolescents as part of the Saving and Empowering Young Lives in Europe (SEYLE) study.
ResultsA previous suicide attempt was reported by 386 (3.6%) adolescents. Compared with non-migrants, first-generation migrants had an elevated prevalence of suicide attempts (odds ratio (OR) 2.08; 95% CI 1.32–3.26; P=0.001 for European migrants and OR 1.86; 95% CI 1.06–3.27; P=0.031 for non-European migrants) and significantly higher levels of peer difficulties. Highest levels of conduct and hyperactivity problems were found among migrants of non-European origin.
ConclusionsAppropriate mental health services and school-based supports are required to meet the complex needs of migrant adolescents.
Terrorism in France
- Pierre Carli, Caroline Telion, David Baker
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- Journal:
- Prehospital and Disaster Medicine / Volume 18 / Issue 2 / June 2003
- Published online by Cambridge University Press:
- 28 June 2012, pp. 92-99
- Print publication:
- June 2003
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France has experienced two waves of major terrorist bombings since 1980. In the first wave (1985–1986), eight bombings occurred in Paris, killing 13 and injuring 281. In the second wave (1995–1996), six bombings occurred in Paris and Lyon, killing 10 and injuring 262. Based on lessons learned during these events, France has developed and improved a sophisticated national system for prehospital emergency response to conventional terrorist attacks based on its national emergency medical services (EMS) system, Service d' Aide Medicale Urgente (SAMU). According to the national plan for the emergency medical response to mass-casualty events (White Plan), the major phases of EMS response are: (1) alert; (2) search and rescue; (3) triage of victims and provision of critical care to first priority victims; (4) regulated dispatch of victims to hospitals; and (5) psychological assistance.
Following the 1995 Tokyo subway sarin attack, a national plan for the emergency response to chemical and biological events (PIRATOX) was implemented. In 2002, the Ministries of Health and the Interior collaborated to produce a comprehensive national plan (BIOTOX) for the emergency response to chemical, biological, radiological, and nuclear events. Key aspects of BIOTOX are the prehospital provision of specialized advance life support for toxic injuries and the protection of responders in contaminated environments. BIOTOX was successfully used during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak in France.