Setting up the Largest Mass Vaccination Center in Europe: The One-Physician One-Nurse Protocol.

To manage mass vaccination without impacting medical resources dedicated to care, we proposed a new model of Mass Vaccination Centers (MVC) functioning with minimum attending staffing requirements. The MVC was under the supervision of one medical coordinator, one nurse coordinator, and one operational coordinator. Students provided much of the other clinical support. Healthcare students were involved in medical and pharmaceutical tasks, while non-health students performed administrative and logistical tasks. We conducted a descriptive cross-sectional study to describe data concerning the vaccinated population within the MVC and the number and type of vaccines used. A patient satisfaction questionnaire was collected to determine patient perception of the vaccination experience. From 28 March to 20 October 2021, 501,714 vaccines were administered at the MVC. A mean rate of 2951 ± 1804 doses were injected per day with a staff of 180 ± 95 persons working every day. At peak, 10,095 injections were given in one day. The average time spent in the MVC was 43.2 ± 15 min (time measured between entry and exit of the structure). The average time to be vaccinated was 26 ± 13 min. In total, 4712 patients (1%) responded to the satisfaction survey. The overall satisfaction with the organization of the vaccination was 10 (9-10) out of 10. By using one attending physician and one nurse to supervise a staff of trained students, the MVC of Toulouse optimized staffing to be among the most efficient vaccination centers in Europe.

Heterogeneity in mental health change during the COVID-19 pandemic in Germany: The role of social factors.

The COVID-19 pandemic constitutes a prolonged global crisis, but its effects on mental health seem inconsistent. This inconsistency highlights the importance of considering the differential impact of the pandemic on individuals. There is some evidence that mental health trajectories are heterogeneous and that both sociodemographic and personal characteristics are associated with higher risk for mental health issues. By contrast, information on the role of social factors as potential determinants of initial reactions to the pandemic and on heterogeneous trajectories over time is lacking. We analysed seven assessments of a large-scale (N = 2203) longitudinal study across 1.5 years, beginning in March 2020. Using self-report data on mental health and life satisfaction, we applied latent change models to examine initial reactions and mean changes across the pandemic. In addition, we applied latent class growth analyses to investigate whether there were distinct groups with different patterns of change. Results showed that on average, levels of life satisfaction and anxiety decreased (d = -0.31 and d = -0.11, respectively), levels of depressive symptoms increased (d = 0.13), and stress levels remained unchanged (d = -0.01) during the first year of the pandemic. For each outcome, we identified four distinct mental health trajectories. Between 5% (for anxiety) and 11% (for life satisfaction) of the sample reported consistently high-and even increasing-impairments in mental health and well-being. The trajectories of a sizeable number of people covaried with the course of the pandemic, such that people experienced better mental health when the number of COVID cases was low and when fewer restrictions were placed on public life. Low emotional support, high instrumental support, and the tendency to compare oneself with others were associated with more mental health issues. Findings show that whereas a substantial portion of people were largely unaffected by the pandemic, some individuals experienced consistently high levels of psychological distress. Social factors appear to play a crucial role in the maintenance of well-being.

Emergency Medical Services Preparedness in Dual Disasters: War in the Era of COVID-19 in Armenia.

INTRODUCTION: Emergency Medical Services (EMS) is a critical part of Disaster Medicine and has the ability to limit morbidity and mortality in a disaster event with sufficient training and experience. Emergency systems in Armenia are in an early stage of development and there is no Emergency Medicine residency training in the country. As a result, EMS physicians are trained in a variety of specialties.Armenia is also a country prone to disasters, and recently, the Armenian EMS system was challenged by two concurrent disasters when the 2020 Nagorno-Karabakh War broke out in the midst of the SARS-CoV-2/coronavirus disease 2019 (COVID-19) pandemic. STUDY OBJECTIVE: This study aims to assess the current state of disaster preparedness of the Armenian EMS system and the effects of the simultaneous pandemic and war on EMS providers. METHODS: This was a cross-sectional study conducted by anonymous survey distributed to physicians still working in the Yerevan EMS system who provided care to war casualties and COVID-19 patients. RESULTS: Survey response rate was 70.6%. Most participants had been a physician (52.1%) or EMS physician (66.7%) for three or less years. The majority were still in residency (64.6%). Experience in battlefield medicine was limited prior to the war, with the majority reporting no experience in treating mass casualties (52.1%), wounds from explosives (52.1%), or performing surgical procedures (52.1%), and many reporting minimal to no experience in treating gunshot wounds (62.5%), severe burns (64.6%), and severe orthopedic injuries (64.6%). Participants had moderate experience in humanitarian medicine prior to war. Greater experience in battlefield medicine was found in participants with more than three years of experience as a physician (z-score -3.26; P value <.01) or as an EMS physician (z-score -2.76; P value <.01) as well as being at least 30 years old (z-score -2.11; P value = .03). Most participants felt they were personally in danger during the war at least sometimes (89.6%). CONCLUSION: Prior to the COVID-19 pandemic and simultaneous 2020 Nagorno-Karabakh War, EMS physicians in Armenia had limited training and experience in Disaster Medicine. This system, and the frontline physicians on whom it relies, was strained by the dual disaster, highlighting the need for Disaster Medicine training in all prehospital medical providers.

Health Emergency and Disaster Risk Management Workforce Development Strategies: Delphi Consensus Study.

INTRODUCTION: Health workforce development is essential for achieving the goals of an effective health system, as well as establishing national Health Emergency and Disaster Risk Management (Health EDRM). STUDY OBJECTIVE: The objective of this Delphi consensus study was to identify strategic recommendations for strengthening the workforce for Health EDRM in low- and middle-income countries (LMIC) and high-income countries (HIC). METHODS: A total of 31 international experts were asked to rate the level of importance (one being strongly unimportant to seven being strongly important) for 46 statements that contain recommendations for strengthening the workforce for Health EDRM. The experts were divided into a LMIC group and an HIC group. There were three rounds of rating, and statements that did not reach consensus (SD ≥ 1.0) proceeded to the next round for further ranking. RESULTS: In total, 44 statements from the LMIC group and 34 statements from the HIC group attained consensus and achieved high mean scores for importance (higher than five out of seven). The components of the World Health Organization (WHO) Health EDRM Framework with the highest number of recommendations were "Human Resources" (n = 15), "Planning and Coordination" (n = 7), and "Community Capacities for Health EDRM" (n = 6) in the LMIC group. "Policies, Strategies, and Legislation" (n = 7) and "Human Resources" (n = 7) were the components with the most recommendations for the HIC group. CONCLUSION: The expert panel provided a comprehensive list of important and actionable strategic recommendations on workforce development for Health EDRM.

The Impact of Moral Distress on Clinicians Treating Patients during the COVID-19 Pandemic and the Concurrent Armenian War in 2020: Implications for WHO – EMT Teams

Background/Introduction:Moral distress is a well-described phenomenon in medical providers. It has been linked to mental health deterioration, decreased job satisfaction, and early retirement. No study has been done on the level of moral distress associated with treating patients in simultaneous disasters.Objectives:1. To learn what is known about the experience of moral distress in frontline health care providers during the COVID-19 pandemic and the concurrent conflict in Armenia during 2020.2. To determine how WHO EMTs can support their frontline staff experiencing moral distress.Method/Description:A survey was designed to test the moral distress felt by Armenian EMS providers who had cared for both COVID-19 and war casualty patients. This was adapted from the Moral Distress Scale Revised (MDS-R).Results/Outcomes:Of the questions asked, respondents most often responded that they were disturbed by: “Continuing to participate in care for a hopelessly ill or injured person who is being sustained on a ventilator when no one will make a decision to withdraw support” (Mean 2.68/Median 3/Mode 4);and “Initiated extensive life-saving actions when I think they only prolong death” (2.47/3/3), which caused the next most distress to subjects.Conclusion:It is expected that some health care workers in Armenia are likely facing on-going consequences of the moral distress they faced during this unprecedented period of global pandemic and war. Clinics and teams who are more likely to encounter potentially morally distressing events, such as disaster medicine workers, need to address their moral distress mitigation plan by identifying strategies across the continuum of disaster management.

COVID-19 Increased Residency Applications and How Virtual Interviews Impacted Applicants.

Background The number of residency applications submitted by medical students has risen at an alarming rate, causing increased cost of applications and subsequent interview travel. These both contribute to increased cost for medical students. In light of these concerns, specialty governing bodies have proposed ideas to fight these trends including, application limits, interview limits, using a preference signaling system, and continuing virtual interviews. During the Covid-19 pandemic, all residency interviews were performed virtually, essentially making travel expenses negligible. However, this created a new concern with regards to assessing program and applicant compatibility, as compared to in-person interactions and did nothing to combat the increases in application numbers. Therefore, we want to critically assess the effects of virtual interviews on number of applications submitted, number of interview invites received, and number of interviews attended. We also aim to analyze how applicants viewed the virtual process. Methods 600 medical students were eligible to participate. 456 students from years 2018-2020 were eligible to be surveyed following the NRMP match. 144 students were eligible to be surveyed following 2021 NRMP match. The survey was distributed to medical school graduates just prior to graduation and asked how many programs each student applied to, how many interview invites they received, and how many interviews they attended. The 2021 survey also asked, "How did virtual interviews affect your interview experience?" The quantitative results were compared with student's t-test and qualitative results are presented below.  Results The average number of programs each applicant applied to increased from 35.4 to 47.7 (p-value=0.002) when residency interviews switched from in-person to virtual. However, interview invites received and interviews attended did not change (16.8 vs 16.3, p-value=0.91, 11.8 vs 12.7, p-value=0.18). There were 188 participants in the in-person interview group (response rate=41.2%) and 128 participants in the virtual interview group (response rate=83.3%). The standard deviation and range also increased for number of applications, number of interview invites received, and number of interviews attended.  There were 123 responses to the free response question. 36 had a positive experience, 44 were neutral, 47 were negative. The positive themes included 15 noted less expenses, 18 noted more convenient/less time, and 18 were able to attend more interviews. Negative themes included, 38 noted difficulty assessing program fit, 19 wanted to see the program or city in person, eight had increased interest in home/local programs, six found it difficult to make connections or stand out.  Conclusion Sixty-three percent of students reported a positive or neutral experience with virtual interviews. Students applied to more programs when interviews were virtual, but did not receive more interview invites or attend more interviews. These results suggest that virtual interviews are sufficient to conduct residency interviews, however the number of applications continues to rise with no increase in the number interview invites received or number of interviews attended. The increase in the standard deviation and range for all three variables may point to some applicants being able to get more invites and attend more interviews leaving less available spots for other applicants.

No party no joy?-Changes in university students' extraversion, neuroticism, and subjective well-being during two COVID-19 lockdowns.

The COVID-19 lockdowns represent a major life event with an immense impact on university students' lives. Findings prior to the pandemic suggest that changes in personality and subjective well-being (SWB) can occur after critical life events or psychological interventions. The present study examined how university students' extraversion, neuroticism, and SWB changed during two COVID-19 lockdowns in Germany. To this end, we conducted a partly preregistered, two-cohort study with four measurement points each from October 2019 to May 2021 (NStudy 1 = 81-148, NStudy 2 = 82-97). We used both multilevel contrast analyses and multi-group random-intercept cross-lagged panel models to examine within-person changes over time. Levels of life satisfaction, extraversion, and, unexpectedly, neuroticism were lower during both lockdowns. Students' affect improved during the first but deteriorated during the second lockdown, suggesting that similar experiences with the deceleration of daily life were associated with different affective outcomes during the two lockdown periods. Following the introduction or termination of a lockdown, changes in extraversion (neuroticism) were consistently positively (negatively) associated with changes in SWB. Our results stress the importance of disentangling between- and within-person processes and using pre-COVID baseline levels to examine changes in personality and SWB.

Opioid Attack and the Implications for Counter-Terrorism Medicine.

While the opioid epidemic engulfing the United States and the globe is well-documented, the potential use of powerful fentanyl derivatives as a weapon of terror is increasingly a concern. Carfentanyl, a powerful and deadly fentanyl derivative, is seeing a surge in popularity as an illegal street drug, and there is increasing congressional interest surrounding the classification of opioid derivatives under the Chemical Weapons Convention (CWC) given their potential to cause harm. The combination of the potency of opioid derivatives along with the ease of accessibility poses a potential risk of the use of these deadly agents as chemical weapons, particularly by terrorist organizations. Disaster Medicine specialists in recent years have established a sub-specialty in Counter-Terrorism Medicine (CTM) to address and research the unique terrorism-related issues relating to mitigation, preparedness, and response measures to asymmetric, multi-modality terrorist attacks.

Evaluation of a prototype decontamination mobile unit (UMDEO) for COVID-19 vaccination: A cross-sectional survey in France.

AIM OF THE STUDY: In the context of the worldwide vaccination campaign against COVID-19, France has been deploying multiple sites for mass vaccination. This study aimed to assess the perceived usefulness of a prototype decontamination mobile unit (UMDEO) for COVID-19 vaccination among both the patient and healthcare providers perspectives. METHODS: This was a descriptive cross-sectional study conducted in Toulouse over two days. UMDEO is a fully comprehensive, versatile solution that was deployed as a 5-row vaccination unit. A written questionnaire was distributed from March 6th-7th, 2021 among all patients presenting for vaccination at the mobile center, as well as the team participating in the vaccination campaign. RESULTS: Among the vaccinated patients (n = 1659), 1409 participants (84.9%) filled out the survey, as well as 68 out of 85 (80%) within the UMDEO team. The maximum patient rate was 98 people per hour. The majority of participants and caregivers (1307 [93.2%] and 67 [98.5%] respectively) agreed that the mobile unit increased access to vaccination. A total of 91.3% patients (n = 1281) and 95.6% caregivers (n = 65) believed that it would speed up the overall vaccination campaign. CONCLUSION: The majority of the vaccinated population and of the team participating in the survey were satisfied with the usefulness of UMDEO as a vaccination center. Toulouse is currently the only city to have used such a structure for vaccination, but it could be used as a basis for planning other mobile units to increase vaccination access.

Developing Telemedicine Curriculum Competencies for Graduate Medical Education: Outcomes of a Modified Delphi Process.

PURPOSE: Telemedical applications have only recently begun to coalesce into the field of telemedicine due to varying definitions of telemedicine and issues around reimbursement. This process has been accelerated by the COVID-19 pandemic and the ensuing expansion of telemedicine delivery. This article demonstrates the development of a set of proposed competencies for a telemedicine curriculum in graduate medical education. METHOD: A modified Delphi process was used to create a panel of competencies. This included a systematic review of the telemedicine literature through November 2019 to create an initial set of competencies, which were analyzed and edited by a focus group of experts in January 2020. Initial competencies were distributed in a series of 3 rounds of surveys to a group of 23 experts for comments and rating from April to August 2020. Competencies that obtained a score of 4.0 or greater on a 5-point Likert scale in at least 2 rounds were recommended. RESULTS: Fifty-five competencies were developed based on the systematic review. A further 32 were added by the expert group for a total of 87. After 3 rounds of surveys, 34 competencies reached the recommendation threshold. These were 10 systems-based practice competencies, 7 professionalism, 6 patient care, 4 practice-based learning and improvement, 4 interpersonal and communication skills, and 3 medical knowledge competencies. CONCLUSIONS: Half (17/34) of the competencies approved by the focus group and surveyed expert panel pertained to either systems-based practice or professionalism. Both categories exhibit more variation between telemedicine and in-person practice than other categories. The authors offer a set of proposed educational competencies that can be used in the development of curricula for a wide range of providers and are based on the best evidence and expert opinion available.

Health Workforce Development in Health Emergency and Disaster Risk Management: The Need for Evidence-Based Recommendations.

The Sendai Framework for Disaster Risk Reduction 2015-2030 placed human health at the centre of disaster risk reduction, calling for the global community to enhance local and national health emergency and disaster risk management (Health EDRM). The Health EDRM Framework, published in 2019, describes the functions required for comprehensive disaster risk management across prevention, preparedness, readiness, response, and recovery to improve the resilience and health security of communities, countries, and health systems. Evidence-based Health EDRM workforce development is vital. However, there are still significant gaps in the evidence identifying common competencies for training and education programmes, and the clarification of strategies for workforce retention, motivation, deployment, and coordination. Initiated in June 2020, this project includes literature reviews, case studies, and an expert consensus (modified Delphi) study. Literature reviews in English, Japanese, and Chinese aim to identify research gaps and explore core competencies for Health EDRM workforce training. Thirteen Health EDRM related case studies from six WHO regions will illustrate best practices (and pitfalls) and inform the consensus study. Consensus will be sought from global experts in emergency and disaster medicine, nursing, public health and related disciplines. Recommendations for developing effective health workforce strategies for low- and middle-income countries and high-income countries will then be disseminated.

50 Years of Mass-Fatality Terrorist Attacks: A Retrospective Study of Target Demographics, Modalities, and Injury Patterns to Better Inform Future Counter-Terrorism Medicine Preparedness and Response.

BACKGROUND: Terrorism-related deaths have fallen year after year since peaking in 2014, and whilst the coronavirus disease 2019 (COVID-19) pandemic has disrupted terrorist organizations capacity to conduct attacks and limited their potential targets, counter-terrorism experts believe this is a short-term phenomenon with serious concerns of an escalation of violence and events in the near future. This study aims to provide an epidemiological analysis of all terrorism-related mass-fatality events (>100 fatalities) sustained between 1970-2019, including historical attack strategies, modalities used, and target selection, to better inform health care responders on the injury types they are likely to encounter. METHODS: The Global Terrorism Database (GTD) was searched for all attacks between the years 1970-2019. Attacks met inclusion criteria if they fulfilled the three terrorism-related criteria as set by the GTD codebook. Ambiguous events were excluded. State-sponsored terrorist events do not meet the codebook's definition, and as such, are excluded from the study. Data analysis and subsequent discussions were focused on events causing 100+ fatal injuries (FI). RESULTS: In total, 168,003 events were recorded between the years 1970-2019. Of these, 85,225 (50.73%) events recorded no FI; 67,356 (40.10%) events recorded 1-10 FI; 5,791 (3.45%) events recorded 11-50 FI; 405 (0.24%) events recorded 51-100 FI; 149 (0.09%) events recorded over 100 FI; and 9,077 (5.40%) events recorded unknown number of FI.Also, 96,905 events recorded no non-fatal injuries (NFI); 47,425 events recorded 1-10 NFI; 8,313 events recorded 11-50 NFI; 867 events recorded 51-100 NFI; 360 events recorded over 100 NFI; and 14,130 events recorded unknown number of NFI. Private citizens and property were the primary targets in 67 of the 149 high-FI events (100+ FI). Of the 149 events recording 100+ FI, 46 (30.87%) were attributed to bombings/explosions as the primary attack modality, 43 (28.86%) were armed assaults, 23 (15.44%) hostage incidents, two (1.34%) were facility/infrastructure attacks (incendiary), one (0.67%) was an unarmed assault, seven (4.70%) had unknown modalities, and 27 (18.12%) were mixed modality attacks. CONCLUSIONS: The most common attack modality causing 100+ FI was the use of bombs and explosions (30.87%), followed by armed assaults (28.86%). Private citizens and properties (44.97%) were most commonly targeted, followed by government (6.04%), businesses (5.37%), police (4.70%), and airports and aircrafts (4.70%). These data will be useful for the development of training programs in Counter-Terrorism Medicine (CTM), a rapidly emerging Disaster Medicine sub-specialty.

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.

Emergency Physician Twitter Use in the COVID-19 Pandemic as a Potential Predictor of Impending Surge: Retrospective Observational Study.

BACKGROUND: The early conversations on social media by emergency physicians offer a window into the ongoing response to the COVID-19 pandemic. OBJECTIVE: This retrospective observational study of emergency physician Twitter use details how the health care crisis has influenced emergency physician discourse online and how this discourse may have use as a harbinger of ensuing surge. METHODS: Followers of the three main emergency physician professional organizations were identified using Twitter's application programming interface. They and their followers were included in the study if they identified explicitly as US-based emergency physicians. Statuses, or tweets, were obtained between January 4, 2020, when the new disease was first reported, and December 14, 2020, when vaccination first began. Original tweets underwent sentiment analysis using the previously validated Valence Aware Dictionary and Sentiment Reasoner (VADER) tool as well as topic modeling using latent Dirichlet allocation unsupervised machine learning. Sentiment and topic trends were then correlated with daily change in new COVID-19 cases and inpatient bed utilization. RESULTS: A total of 3463 emergency physicians produced 334,747 unique English-language tweets during the study period. Out of 3463 participants, 910 (26.3%) stated that they were in training, and 466 of 902 (51.7%) participants who provided their gender identified as men. Overall tweet volume went from a pre-March 2020 mean of 481.9 (SD 72.7) daily tweets to a mean of 1065.5 (SD 257.3) daily tweets thereafter. Parameter and topic number tuning led to 20 tweet topics, with a topic coherence of 0.49. Except for a week in June and 4 days in November, discourse was dominated by the health care system (45,570/334,747, 13.6%). Discussion of pandemic response, epidemiology, and clinical care were jointly found to moderately correlate with COVID-19 hospital bed utilization (Pearson r=0.41), as was the occurrence of "covid," "coronavirus," or "pandemic" in tweet texts (r=0.47). Momentum in COVID-19 tweets, as demonstrated by a sustained crossing of 7- and 28-day moving averages, was found to have occurred on an average of 45.0 (SD 12.7) days before peak COVID-19 hospital bed utilization across the country and in the four most contributory states. CONCLUSIONS: COVID-19 Twitter discussion among emergency physicians correlates with and may precede the rising of hospital burden. This study, therefore, begins to depict the extent to which the ongoing pandemic has affected the field of emergency medicine discourse online and suggests a potential avenue for understanding predictors of surge.

Identifying Signs and Symptoms of Obstructive Sleep Apnea in a Men's Health Clinic: The Utility of Home Sleep Apnea Testing During COVID-19.

The objective of the study was to identify symptoms of men presenting for an outpatient urology visit that prompted referral for a Home Sleep Apnea Test (HSAT) to assess for obstructive sleep apnea (OSA) by a single provider. To assess the proportion of patients referred for the HSAT who underwent the test and, out of these patients, the proportion of men diagnosed with sleep apnea, we performed a retrospective chart review of men 18-99 years old seen by a single provider in the Department of Urology referred for an HSAT to evaluate for presenting symptoms. Patients with a prior diagnosis of OSA were excluded. Eighteen patients were identified (mean age at time of referral 51 + SD 13 years). Half of patients reported erectile dysfunction/concerns, 56% reported nocturia, 44% had been diagnosed with testosterone deficiency, and 39% reported low libido. Nearly all (89%) of patients snored, all reported fatigue, 56% were over the age of 50, 44% had a BMI >35, and 78% had hypertension. Twelve patients completed the HSAT, all of whom were diagnosed with OSA for which continuous positive airway pressure (CPAP) therapy was initiated. Men presenting with genitourinary concerns to an outpatient urology clinic may also have OSA. About half of included patients reported genitourinary concerns. Hundred percent of patients who completed their sleep study were diagnosed with OSA. Genitourinary concerns, in addition to signs and symptoms commonly associated with OSA, should prompt consideration of sleep apnea evaluation.

A Decade of Terrorism in the United States and the Emergence of Counter-Terrorism Medicine.

BACKGROUND: The United States (US) is ranked 22nd on the Global Terrorism Index (2019), a scoring system of terrorist activities. While the global number of deaths from terrorism over the past five years is down, the number of countries affected by terrorism is growing and the health care repercussions remain significant. Counter-Terrorism Medicine (CTM) is rapidly emerging as a necessary sub-specialty, and this study aims to provide the epidemiological context over the past decade supporting this need by detailing the unique injury types responders are likely to encounter and setting the stage for the development of training programs utilizing these data. METHODS: The Global Terrorism Database (GTD) was searched for all attacks in the US from 2008-2018. Attacks met inclusion criteria if they fulfilled the three terrorism-related criteria as set by the GTD. Ambiguous events were excluded when there was uncertainty as to whether the incident met all of the criteria for inclusion in the GTD. The grey literature was reviewed, and each event was cross-matched with reputable international and national newspaper sources online to confirm or add details regarding weapon type used and, whenever available, details of victim and perpetrator fatalities and injuries. RESULTS: In total, 304 events were recorded during the period of study. Of the 304 events, 117 (38.5%) used incendiary-only weapons, 80 (26.3%) used firearms as their sole weapon, 55 (18.1%) used explosives, bombs, or dynamite (E/B/D), 23 (7.6%) were melee-only, six (2.0%) used vehicles-only, four (1.3%) were chemicals-only, two (0.7%) used sabotage equipment, two (0.7%) were listed as "others," and one (0.3%) used biological weapon. There was no recorded nuclear or radiological weapon use. In addition, 14 (4.6%) events used a mix of weapons. CONCLUSIONS: In the decade from 2008 through 2018, terrorist attacks on US soil used weapons with well-understood injury-causing modalities. A total of 217 fatal injuries (FI) and 660 non-fatal injuries (NFI) were sustained as a result of these events during that period.Incendiary weapons were the most commonly chosen methodology, followed by firearms and E/B/D attacks. Firearm events contributed to a disproportionality high fatality count while E/B/D events contributed to a disproportionally high NFI count.