Epidemiologic Analysis of Warfare To the Editor.\p=m-\I was extremely dismayed to read the sterilized historical review by Garfield and Neugut1 on their
"Epidemiologic Analysis of Warfare." They claim to have assessed "risk factors for injury and death," and they dis-
cussed the reasons for increased casualties among "civilians" during wars of the 20th century. Table 4 of the article details the number of civilian casualties estimated in World War II but contains at least three factual errors when it is compared with their own reference2 and amounts to a difference of more than 2 million casualties. More than 6 million civilians were killed in Poland, with millions more killed in Germany and other European countries. The authors then gave percentages of populations who were decimated by this "warfare," ie, 20% of "Polish" people lost their lives. What the authors in their five pages did not find room to express, however, was that the clear majority of Axis civilian casualties were not at all related to warfare but resulted from the pre¬ meditated, cruel, barbaric torture and murder ofJews and fellow countrymencountrymen who were not considered to be human beings or civilians in the eyes of their murderers. Their statement re¬ garding the "rapidly increasing fire power and modern technology of war" had absolutely nothing to do with these "proportionally high civilian losses." The sole reason that well over 6 mil¬ lion Jewish civilians were killed in World War II was their "risk factor" of being Jewish. Genocide must not be sterilized into statistical nonsense by revisionists. More than 6 million facts, at least 1 mil¬ lion of which were children, cannot be erased by "historical reviews." The 3 million Polish Jews (10% of that coun¬ try's population) who were systemati¬ cally tortured and asphyxiated were not considered "Polish people" by the Poles and Germans. Their blessed memory is disgraced by this appellation. The authors also commented on the wide range of mortality rates among "prisoners, stating that the highest rate was 26% (among allies in German is con¬ camps). "The cause of death centrated overwhelmingly in the cate¬ gories of nonbattle injuries and dis"
...
Edited by Drummond Rennie, MD, Deputy (West), and Bruce B. Dan, MD, Senior Editor.
Editor
eases," the authors stated. Not even mentioned was that Jewish prisoner mortality in many concentration camps approached 100%. Death was also due to "nonbattle" injuries, such as uneth¬ ical human experimentation and surgery without anesthesia, outright torture and brutality, gassing, and burning of help¬ less men, women, and children. Such a misleading article will only be used by others to try to cover-up the single most barbaric episode in the his¬ tory of humankind. Aaron E. Glatt, MD Nassau County Medical Center East Meadow, NY
RM, Neugut AI. Epidemiologic analysis of warfare:a historical review. JAMA. 1991;266:688-692. 2. Sivard RL. World Military and Social Expenditures 1985. Washington DC: Worldwatch Institute;
tims. In this case, it is hoped we high¬ lighted an important historical trend. Finally, we find the tone of Glatt's letter to be inappropriate in a scholarly discussion of this type. It is hard to take the accusation of revisionism lightly, or seriously, for that matter, as we have each lost relatives in the Holocaust (in¬ cluding a sister and grandparents). Glatt would do well to remember that the rab¬ bis of the Talmud were highly critical of those who publicly tried to embarrass or insult others and who, in judging oth¬ ers, did not give them the benefit of the
doubt.2·8
Richard M. Garfield, RN, DrPH Alfred I. Neugut, MD, PhD Columbia University New York, NY
1. Garfield
1986:8-11.
1. Sivard RL. World tures 1985.
In
Reply. \p=m-\Weare sorry that Dr Glatt offended, but we defend the meth-
was
ods used in our article, which was an overview of 200 years of warfare, with only limited space devoted to World War II. The point of Table 4 was to highlight the increase in war-related deaths among civilians, including captive civilian populations, which has occurred in the 20th century. More than 33 million war-related deaths occurred among civilians in World War II (Table 4), which include 6 million Jews killed in the Holocaust. Glatt calls the destruction of European Jewry "the single most barbaric episode in the history of humankind." We agree with his assessment. However, the vast majority of these deaths would not have occurred outside the context of war. Our analysis was intended to show that the indirect effects of warfare on civilians are increasing rapidly. These conclusions are not altered whether the Jewish deaths are included by country or listed separately, or whether they are excluded altogether. We followed the format used in our ref¬ ' erence 35. The figures given in our article for prisoner deaths clearly relate to pris¬ oners of war. Deaths in concentration camps, as Glatt notes himself, were among civilians and noncombatants. A quantitative analysis of injuries and deaths in warfare does not imply that we are in favor of war and certainly does not attempt to justify the crimes re¬ ferred to by Glatt, just as a quantitative analysis of cancer deaths does not min¬ imize the pain and suffering of its vie-
1986:8-11. 2. Tractate 3. Tractate
Military and Social ExpendiWashington, DC: Worldwatch Institute; Avot; 1:6. Avot; 3:15.
Operating
Under the Threat of
Chemical-Biological Warfare To the Editor.\p=m-\On January20,1991, at
10:15 PM, while serving in the US Army for Operation Desert Storm, surgeons from the Eighth Evacuation Hospital (the first of the army's new Deployable Medical System [DEPMEDS] hospi-
tals)
were
operating
on a
23-year-old
soldier for small-bowel obstruction from adhesions. During the procedure, an explosion shook the operating theater, followed by warning sirens. Since this was the third night of Iraqi SCUD missile at-
Guidelines for Letters Letters will be published at the discretion of the editor as space permits and subject to editing and abridgment. They should be typewritten double-spaced and submitted in duplicate. They should not exceed 500 words of text. References, if any, should be held to a minimum, preferably five or fewer. Let¬ ters discussing a recent JAMA article should be received within 1 month of the article's publication. Letters must not duplicate other material published or submitted for publication. A signed statement for copy¬ right, authorship responsibility, and finan¬ cial disclosure is essential for publication. It is not feasible routinely to return unpub¬ lished letters unless such is requested. Let¬ ters not meeting these guidelines are gener¬ ally not acknowledged. Also see Instructions for Authors.
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 06/07/2015
tacks, we were concerned that the hospital was under attack. Chemical protective masks were immediately donned;
the surgeons and surgical technicians regowned and regloved while other members of the team put on their complete chemical protective suits, gloves, and boots. The air conditioning system was immediately turned off. The procedure was completed uneventfully and the "all-clear" siren sounded as the incisional dressings were being applied. The patient had an uncomplicated postoperative recovery. The explosion was apparently a sonic boom from the launch of a Patriot missile.
Performing surgical procedures
un¬
der the threat of chemical-biological war¬ fare poses several interesting issues: 1. The operation was performed in a completely metal-encased DEPMEDS operating room, which provided protec¬ tion from direct contact with liquid chem¬ ical agents. 2. The operating room air condition¬ ing was immediately turned off to limit the amount of potential air contamina¬
tion from the external environment— the current air-filtration system is not capable of eliminating chemical-biologi¬ cal agents. 3. The patient was protected from aerosolized chemical-biological agents because he was intubated under general anesthesia. Had the threat persisted, he would have remained intubated and connected to a closed system until the threat passed. 4. The surgeons and surgical techni¬ cians were able to protect themselves from airborne agents by donning their gas masks and were partially protected from contact agents by surgical gowns and gloves. Had an attack been antici¬ pated, full chemical suits could have been worn under the gowns, even though the bulkiness and sweating might have im¬ paired the surgeons' performance. 5. The anesthesia personnel and any remaining persons were fully protected because full chemical protective cloth¬ ing could be put on. 6. The butyl rubber antichemical gloves reduced tactile sensation and fine motor skills, making arterial or venous cannulation difficult. 7. By using an "earpiece," the anes¬ thesia personnel were able to monitor the patient's blood pressure, respira¬ tion, and precordial heart sounds while in full chemical protective gear. An au¬ tomatic blood pressure monitor would have been invaluable under these cir¬ cumstances. Due to limited
access
for review of
literature, this may be the first re¬ port of a surgical procedure performed the
during the threat of chemical-biological warfare.
MAJ Victor L. Modesto, MC, USA COL Richard M. Satava, MC, USA Eighth Evacuation Hospital Saudi Arabia The views expressed herein do not purport to re¬ flect the position of the Department of the Army or the Department of Defense (Para 4- 3, AR 360-5). Acknowledgment should be made to the coura¬ geous members of the anesthesia and operating room staff, including MAJ Robert Wadley, MD; MAJ Paul Roble, DO; MAJ Roger Baxter, CRNA; MAJ Sandra Collins, RN; SGT Clifford Hopkins, 91D; and PFC Marcus McGee.
More on Desert Storm To the Editor.\p=m-\The recent article by Keeler et al1 regarding the effects of pyridostigmine bromide on the troops in Operation Desert Storm is pertinent. We have recently had experience with a unique first trimester exposure related to Operation Desert Storm. With the initial return of 2000 troops to Hawaii, two young women presented to Tripler Army Medical Center, Honolulu, Hawaii for counseling because of first trimester exposure to pyridostigmine and anthrax vaccine. Chemical agents classified as nerve gases are organophosphate compounds and act primarily by inhibiting acetylcholinesterase at cholinergic receptor sites. As a result, the neurotransmitter
acetylcholine accumulates, causing hyperactivity at both muscarinic and nicotinic receptors.2 Pyridostigmine, an acetylcholinesterase inhibitor used to treat myasthenia gravis, can be used as a pretreatment for these chemical agents because
occupies the active site of acetylcholinesterase, thereby blocking the action of the nerve agent. The drug has it
been used in pregnancy without producing fetal malformations.3 Because it is ionized at physiologic pH, it would not be expected to cross the placenta in sig¬ nificant amounts. Pyridostigmine is clas¬ sified as "risk factor C" because no con¬ trolled studies in women have been done, or because these studies in women and animals are not available.3 Anthrax is caused by the bacterium Bacillus anthracis, an aerobic, sporeforming, gram-positive rod and is ac¬ quired by the uptake of resistant spores present in the soil. Contamination of the soil with spores can last up to 10 or more years. The virulence of the organism is determined by the capsular polysaccharide and exotoxin.4 Both an attenuated live vaccine and nonliving vaccine have been developed. However, the only human vaccine in current use in the United States is the nonliving vaccine derived from a com¬ ponent of the exotoxin. The vaccine is
manufactured only by the Michigan De¬ partment of Public Health (anthrax vac¬
cine, adsorbed).
As with most bacterial vaccines, an¬ imal reproduction studies have not been performed with anthrax and its labeling must include its designation as a preg¬
nancy category c product as required by the Food and Drug Administration. Un¬ der category c, it must be stated that it is not known whether the vaccine can cause fetal harm when administered to a pregnant woman. As with any sim¬ ilar vaccines, patients exposed to an¬ thrax vaccine in the first trimester of pregnancy require counseling and
follow-up.
Because of the
uncertainty of the im¬
plications" of these exposures, I believe that patients exposed to these two agents in the first trimester should re¬
genetic counseling and be offered screening for congenital anomalies with maternal serum a-fetoprotein screen¬ ing at 15 weeks' gestation and a tar¬ geted ultrasound for fetal anomalies by a skilled ultrasonographer at approxi¬ mately 18 weeks' gestation. ceive
MAJ Albert P. Sarno, Jr, MC, USA Tripler Army Medical Center Honolulu, Hawaii 1. Keeler JR, Hurst CG, Dunn MA. Pyridostigmine used as a nerve agent pretreatment under wartime conditions. JAMA. 1991;266:693-695. 2. Prevention and treatment of nerve gas poisoning. Med Lett Drugs Ther. 1990; 32:103-105. 3. Briggs GC, Freeman RK, Yaffe SJ, eds. Drugs in Pregnancy and Lactation. Baltimore, Md: Williams & Wilkins; 1990:543-544. 4. Hambleton P, Carman JA, Melling J. Anthrax: the disease in relation to vaccines. Vaccine. 1984;2:125\x=req-\ 132.
To the Editor.\p=m-\Weread the article by Keeler et al1 with great interest. We were deployed in support of Operations Desert Shield and Desert Storm with the 1st Infantry Division and the 1st Cavalry Division. We were responsible for the medical care of thousands of soldiers who were taking pyridostigmine bromide during the preparation for the ground war and during the ground war. Unfortunately, the article suffers from retrospective analysis of data collected in a poorly designed and uncontrolled fashion. No prospective, detailed assessment specific for pyridostigmine effects or the temporal relationship of dosing to such effects was undertaken during Operation Desert Storm. Perhaps this would have been logistically impossible. In fact, the querying of only 30 medical officers is probably insufficient to draw conclusions and accurately assess the overall "incidence of general physiologic response to pyridostigmine and potential adverse effects." Within the XVIII Airborne Corps (the group of soldiers studied in the article)
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 06/07/2015
"Epidemiologic Analysis of Warfare." They claim to have assessed "risk factors for injury and death," and they dis-
cussed the reasons for increased casualties among "civilians" during wars of the 20th century. Table 4 of the article details the number of civilian casualties estimated in World War II but contains at least three factual errors when it is compared with their own reference2 and amounts to a difference of more than 2 million casualties. More than 6 million civilians were killed in Poland, with millions more killed in Germany and other European countries. The authors then gave percentages of populations who were decimated by this "warfare," ie, 20% of "Polish" people lost their lives. What the authors in their five pages did not find room to express, however, was that the clear majority of Axis civilian casualties were not at all related to warfare but resulted from the pre¬ meditated, cruel, barbaric torture and murder ofJews and fellow countrymencountrymen who were not considered to be human beings or civilians in the eyes of their murderers. Their statement re¬ garding the "rapidly increasing fire power and modern technology of war" had absolutely nothing to do with these "proportionally high civilian losses." The sole reason that well over 6 mil¬ lion Jewish civilians were killed in World War II was their "risk factor" of being Jewish. Genocide must not be sterilized into statistical nonsense by revisionists. More than 6 million facts, at least 1 mil¬ lion of which were children, cannot be erased by "historical reviews." The 3 million Polish Jews (10% of that coun¬ try's population) who were systemati¬ cally tortured and asphyxiated were not considered "Polish people" by the Poles and Germans. Their blessed memory is disgraced by this appellation. The authors also commented on the wide range of mortality rates among "prisoners, stating that the highest rate was 26% (among allies in German is con¬ camps). "The cause of death centrated overwhelmingly in the cate¬ gories of nonbattle injuries and dis"
...
Edited by Drummond Rennie, MD, Deputy (West), and Bruce B. Dan, MD, Senior Editor.
Editor
eases," the authors stated. Not even mentioned was that Jewish prisoner mortality in many concentration camps approached 100%. Death was also due to "nonbattle" injuries, such as uneth¬ ical human experimentation and surgery without anesthesia, outright torture and brutality, gassing, and burning of help¬ less men, women, and children. Such a misleading article will only be used by others to try to cover-up the single most barbaric episode in the his¬ tory of humankind. Aaron E. Glatt, MD Nassau County Medical Center East Meadow, NY
RM, Neugut AI. Epidemiologic analysis of warfare:a historical review. JAMA. 1991;266:688-692. 2. Sivard RL. World Military and Social Expenditures 1985. Washington DC: Worldwatch Institute;
tims. In this case, it is hoped we high¬ lighted an important historical trend. Finally, we find the tone of Glatt's letter to be inappropriate in a scholarly discussion of this type. It is hard to take the accusation of revisionism lightly, or seriously, for that matter, as we have each lost relatives in the Holocaust (in¬ cluding a sister and grandparents). Glatt would do well to remember that the rab¬ bis of the Talmud were highly critical of those who publicly tried to embarrass or insult others and who, in judging oth¬ ers, did not give them the benefit of the
doubt.2·8
Richard M. Garfield, RN, DrPH Alfred I. Neugut, MD, PhD Columbia University New York, NY
1. Garfield
1986:8-11.
1. Sivard RL. World tures 1985.
In
Reply. \p=m-\Weare sorry that Dr Glatt offended, but we defend the meth-
was
ods used in our article, which was an overview of 200 years of warfare, with only limited space devoted to World War II. The point of Table 4 was to highlight the increase in war-related deaths among civilians, including captive civilian populations, which has occurred in the 20th century. More than 33 million war-related deaths occurred among civilians in World War II (Table 4), which include 6 million Jews killed in the Holocaust. Glatt calls the destruction of European Jewry "the single most barbaric episode in the history of humankind." We agree with his assessment. However, the vast majority of these deaths would not have occurred outside the context of war. Our analysis was intended to show that the indirect effects of warfare on civilians are increasing rapidly. These conclusions are not altered whether the Jewish deaths are included by country or listed separately, or whether they are excluded altogether. We followed the format used in our ref¬ ' erence 35. The figures given in our article for prisoner deaths clearly relate to pris¬ oners of war. Deaths in concentration camps, as Glatt notes himself, were among civilians and noncombatants. A quantitative analysis of injuries and deaths in warfare does not imply that we are in favor of war and certainly does not attempt to justify the crimes re¬ ferred to by Glatt, just as a quantitative analysis of cancer deaths does not min¬ imize the pain and suffering of its vie-
1986:8-11. 2. Tractate 3. Tractate
Military and Social ExpendiWashington, DC: Worldwatch Institute; Avot; 1:6. Avot; 3:15.
Operating
Under the Threat of
Chemical-Biological Warfare To the Editor.\p=m-\On January20,1991, at
10:15 PM, while serving in the US Army for Operation Desert Storm, surgeons from the Eighth Evacuation Hospital (the first of the army's new Deployable Medical System [DEPMEDS] hospi-
tals)
were
operating
on a
23-year-old
soldier for small-bowel obstruction from adhesions. During the procedure, an explosion shook the operating theater, followed by warning sirens. Since this was the third night of Iraqi SCUD missile at-
Guidelines for Letters Letters will be published at the discretion of the editor as space permits and subject to editing and abridgment. They should be typewritten double-spaced and submitted in duplicate. They should not exceed 500 words of text. References, if any, should be held to a minimum, preferably five or fewer. Let¬ ters discussing a recent JAMA article should be received within 1 month of the article's publication. Letters must not duplicate other material published or submitted for publication. A signed statement for copy¬ right, authorship responsibility, and finan¬ cial disclosure is essential for publication. It is not feasible routinely to return unpub¬ lished letters unless such is requested. Let¬ ters not meeting these guidelines are gener¬ ally not acknowledged. Also see Instructions for Authors.
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 06/07/2015
tacks, we were concerned that the hospital was under attack. Chemical protective masks were immediately donned;
the surgeons and surgical technicians regowned and regloved while other members of the team put on their complete chemical protective suits, gloves, and boots. The air conditioning system was immediately turned off. The procedure was completed uneventfully and the "all-clear" siren sounded as the incisional dressings were being applied. The patient had an uncomplicated postoperative recovery. The explosion was apparently a sonic boom from the launch of a Patriot missile.
Performing surgical procedures
un¬
der the threat of chemical-biological war¬ fare poses several interesting issues: 1. The operation was performed in a completely metal-encased DEPMEDS operating room, which provided protec¬ tion from direct contact with liquid chem¬ ical agents. 2. The operating room air condition¬ ing was immediately turned off to limit the amount of potential air contamina¬
tion from the external environment— the current air-filtration system is not capable of eliminating chemical-biologi¬ cal agents. 3. The patient was protected from aerosolized chemical-biological agents because he was intubated under general anesthesia. Had the threat persisted, he would have remained intubated and connected to a closed system until the threat passed. 4. The surgeons and surgical techni¬ cians were able to protect themselves from airborne agents by donning their gas masks and were partially protected from contact agents by surgical gowns and gloves. Had an attack been antici¬ pated, full chemical suits could have been worn under the gowns, even though the bulkiness and sweating might have im¬ paired the surgeons' performance. 5. The anesthesia personnel and any remaining persons were fully protected because full chemical protective cloth¬ ing could be put on. 6. The butyl rubber antichemical gloves reduced tactile sensation and fine motor skills, making arterial or venous cannulation difficult. 7. By using an "earpiece," the anes¬ thesia personnel were able to monitor the patient's blood pressure, respira¬ tion, and precordial heart sounds while in full chemical protective gear. An au¬ tomatic blood pressure monitor would have been invaluable under these cir¬ cumstances. Due to limited
access
for review of
literature, this may be the first re¬ port of a surgical procedure performed the
during the threat of chemical-biological warfare.
MAJ Victor L. Modesto, MC, USA COL Richard M. Satava, MC, USA Eighth Evacuation Hospital Saudi Arabia The views expressed herein do not purport to re¬ flect the position of the Department of the Army or the Department of Defense (Para 4- 3, AR 360-5). Acknowledgment should be made to the coura¬ geous members of the anesthesia and operating room staff, including MAJ Robert Wadley, MD; MAJ Paul Roble, DO; MAJ Roger Baxter, CRNA; MAJ Sandra Collins, RN; SGT Clifford Hopkins, 91D; and PFC Marcus McGee.
More on Desert Storm To the Editor.\p=m-\The recent article by Keeler et al1 regarding the effects of pyridostigmine bromide on the troops in Operation Desert Storm is pertinent. We have recently had experience with a unique first trimester exposure related to Operation Desert Storm. With the initial return of 2000 troops to Hawaii, two young women presented to Tripler Army Medical Center, Honolulu, Hawaii for counseling because of first trimester exposure to pyridostigmine and anthrax vaccine. Chemical agents classified as nerve gases are organophosphate compounds and act primarily by inhibiting acetylcholinesterase at cholinergic receptor sites. As a result, the neurotransmitter
acetylcholine accumulates, causing hyperactivity at both muscarinic and nicotinic receptors.2 Pyridostigmine, an acetylcholinesterase inhibitor used to treat myasthenia gravis, can be used as a pretreatment for these chemical agents because
occupies the active site of acetylcholinesterase, thereby blocking the action of the nerve agent. The drug has it
been used in pregnancy without producing fetal malformations.3 Because it is ionized at physiologic pH, it would not be expected to cross the placenta in sig¬ nificant amounts. Pyridostigmine is clas¬ sified as "risk factor C" because no con¬ trolled studies in women have been done, or because these studies in women and animals are not available.3 Anthrax is caused by the bacterium Bacillus anthracis, an aerobic, sporeforming, gram-positive rod and is ac¬ quired by the uptake of resistant spores present in the soil. Contamination of the soil with spores can last up to 10 or more years. The virulence of the organism is determined by the capsular polysaccharide and exotoxin.4 Both an attenuated live vaccine and nonliving vaccine have been developed. However, the only human vaccine in current use in the United States is the nonliving vaccine derived from a com¬ ponent of the exotoxin. The vaccine is
manufactured only by the Michigan De¬ partment of Public Health (anthrax vac¬
cine, adsorbed).
As with most bacterial vaccines, an¬ imal reproduction studies have not been performed with anthrax and its labeling must include its designation as a preg¬
nancy category c product as required by the Food and Drug Administration. Un¬ der category c, it must be stated that it is not known whether the vaccine can cause fetal harm when administered to a pregnant woman. As with any sim¬ ilar vaccines, patients exposed to an¬ thrax vaccine in the first trimester of pregnancy require counseling and
follow-up.
Because of the
uncertainty of the im¬
plications" of these exposures, I believe that patients exposed to these two agents in the first trimester should re¬
genetic counseling and be offered screening for congenital anomalies with maternal serum a-fetoprotein screen¬ ing at 15 weeks' gestation and a tar¬ geted ultrasound for fetal anomalies by a skilled ultrasonographer at approxi¬ mately 18 weeks' gestation. ceive
MAJ Albert P. Sarno, Jr, MC, USA Tripler Army Medical Center Honolulu, Hawaii 1. Keeler JR, Hurst CG, Dunn MA. Pyridostigmine used as a nerve agent pretreatment under wartime conditions. JAMA. 1991;266:693-695. 2. Prevention and treatment of nerve gas poisoning. Med Lett Drugs Ther. 1990; 32:103-105. 3. Briggs GC, Freeman RK, Yaffe SJ, eds. Drugs in Pregnancy and Lactation. Baltimore, Md: Williams & Wilkins; 1990:543-544. 4. Hambleton P, Carman JA, Melling J. Anthrax: the disease in relation to vaccines. Vaccine. 1984;2:125\x=req-\ 132.
To the Editor.\p=m-\Weread the article by Keeler et al1 with great interest. We were deployed in support of Operations Desert Shield and Desert Storm with the 1st Infantry Division and the 1st Cavalry Division. We were responsible for the medical care of thousands of soldiers who were taking pyridostigmine bromide during the preparation for the ground war and during the ground war. Unfortunately, the article suffers from retrospective analysis of data collected in a poorly designed and uncontrolled fashion. No prospective, detailed assessment specific for pyridostigmine effects or the temporal relationship of dosing to such effects was undertaken during Operation Desert Storm. Perhaps this would have been logistically impossible. In fact, the querying of only 30 medical officers is probably insufficient to draw conclusions and accurately assess the overall "incidence of general physiologic response to pyridostigmine and potential adverse effects." Within the XVIII Airborne Corps (the group of soldiers studied in the article)
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 06/07/2015
