The correlation between Mental illness and mass shootings

All too often we are inundated with the same tragic cycle. An individual with an assault weapon opens fire on a large amount of people. The media talks about mental health problems in the individual, the victims are laid to rest and the story fades away then it happens again and the cycle repeats. Gun laws remain relatively unchanged as does the mental health system. This blog will attempt to shed some light on some of the current issues related to this horrible phenomenon.

Mr. Muncie speaking
While watching the recent events in Parkland, Florida unfold through the media in real time I was struck by an interview with the Parkland schools superintendent Mr. Robert Runcie. The full scope of the calamity as well as the identity of the shooter had yet to be announced, but he made a very ominous and all too familiar suggestion at the end of his interview, “Mental health issues are growing and they are a big challenge and it’s something that’s going to need to certainly be addressed.” As more information came out, we learned the shooter was essentially a ticking time-bomb, who had suffered many losses and displayed many red flags as to his ability to cope with them in the form of maladaptive behaviors.  We have heard how the community reached out to authorities to express their concerns relating to this individual and those calls went unheeded. There are many systemic failures in this case and I will attempt to shed light on some of them


Anyone who watches mainstream media, reads alternative media or just bops around social media can see that gun control is a hot topic following these events. The voices of certain groups call for a ban on everything from assault rifles, to a ban on guns altogether while another group rushes to defend the second amendment.  Within those two camps are litany of ideas and the one that I think bares the most relevance to this blog post is the idea of stopping mentally ill individuals from purchasing guns. Statistically the mentally ill are more likely to be victims of gun violence than they are to perpetrate it. (Gold, Simon & Knoll, 2015) Yet according to Knoll mass shootings by  people with serious mental illness represent only 1% of yearly gun related homicides or 110 individuals killed. Knoll also rightfully discusses the fact that calling out those with a mental health diagnosis reinforces a negative stigma to mental illness, which creates a major barrier to treatment and worsens the overall public health burden of mental illness.

110 people killed per year in mass shooting events is still a high number so what is being done about it? According to Knoll, attempting to bar the mentally ill from owning firearms will yield little return in terms of lives saved as only 1% of mass shooting deaths can be attributed to the mentally ill, yet lawmakers have written and passed plenty of legislation to do just that. Federal law dictates that anyone committed to a psychiatric hospital or anyone deemed incompetent by a court can be barred from purchasing or owning a firearm according to the Gun Control act of 1968. Yet there are many who don’t understand what that means. People can be held in a psychiatric hospital for anywhere from 72 hours to 10 days while they are being assessed. Those individuals are not necessarily barred from owning firearms. Someone may have had a very difficult day, and made a non-fatal attempt at suicide, at which point they were brought to a hospital against their will. After 72 hours they may report that they feel their suicide attempt was an error, they may discuss future oriented goals, and may then be released. These individuals would not be deemed certified and therefor would be able to walk out of the hospital, and barring any other issues, they would be able to purchase a gun. If after they are held, a psychiatrist deems they need to remain hospitalized that psychiatrist must bring that patient to mental health court and ask that the patient be committed to continue treatment. If the court agrees, the patient is then committed and according to federal law, they are now banned from purchasing or owning firearms.  Being deemed incompetent similarly requires court action in conjunction with a medical professional who must assess an individual. One must file a petition in court to have an individual assessed for competency through psychological testing and if the court sees fit, they will rely on the results of that competency evaluation. These cases may involve an elderly individual suffering from dementia, or someone who commits a crime, but is unable to understand the court proceedings and/or communicate meaningfully with their attorney secondary to mental illness, developmental disabilities, Brain injury, etc. (“How to Legally Declare Someone as Mentally Incompetent?”, 2018) For example, imagine someone who is involved in a car accident while driving intoxicated and is left in a vegetative state after the accident. That individual would be more than likely deemed incompetent, as they wouldn’t be able to understand the proceedings. This may also be the case in the event someone is deemed a threat to themselves or deemed unable to manage their own affairs.

Now that we understand the criteria for someone with mental illness to be banned from owning a gun, we can see that as long as an individual is not committed or deemed incompetent, then they cannot be barred from purchasing a weapon based on mental health issues.

In his film entitled “Bowling For Columbine” Michael Moore went after the pharmaceutical industry and their role in the current spate of mass shootings.  Moore suggests that the Columbine shooting occurred for no other reason than the fact that the shooters were prescribed Prozac. If we consider that claim we find a mixed bag of data. According to Yasmina Molero and her research, the data regarding homicidal behavior is inconclusive and individuality cannot be ruled out. She did report an interesting observation regarding dosing of Selective Serotonin Reuptake Inhibitors IE: Prozac, Zoloft Etc. and increased potential for violence. She found that adolescents on low doses of SSRI medications are at a greater risk for the potential to violence and suggests further study on this topic. She did not find the same risks in older patients or adolescents on higher doses of SSRI’s. Since 2004 Fluoxetine also known as Prozac carries a black box warning regarding increased risk of suicidal ideation. When we combine the black box warning with the observation of Molero, one may see an easy leap to the conclusion that Prozac was to blame for Columbine, but like many areas of information in the modern world this is only a superficial correlation. A study from Hungary showed the exact opposite to be true. The authors of this study found contradictory data to the FDA warning and rather than seeing a decrease in completed suicides, the countries where the black box warning was displayed saw decreased usage of antidepressants and increased numbers of completed suicides. In Hungary where the black box warning was not issued the authors found increased usage of antidepressants and decreased numbers of completed suicides. (Ekundayo et al. 1-18). In the case of mass shooters who are taking psychotropic medications it is important to realize that they were prescribed these medications for a reason. Someone was concerned enough to take these individuals to a Doctor and that doctor saw enough behavioral symptoms (maladaptive behaviors) to decide to try a medication to help alleviate those symptoms. In other words, theoretically the behavior of the individual was already outside the societal norms and the current medical model is to treat maladaptive behaviors with therapy and/or medicine.

When we look at mass shooting events we need to remember one thing, At the end of the day, an individual carries out an act. That individual may be suffering from a mental illness, they may not be. They may or may not be able to manage their thoughts or their moods. They may be on specific medication, they may not be, but for all mass shooting events two variables remain the same. The individual who perpetrates a mass shooting needs a gun and themselves to complete the act. Without that combination there is no mass shooting.  That to me is the area where we have the most pressing need to make changes. The media plays a very important role in pushing agendas after these tragic events, whether filling the airwaves with pundits calling for more gun control, or calling for more guns. It is very difficult to find answers and I hope this blog helps one to understand at least some of the mental health debate that often comes up. At the end of the day, we will never know who is going to perpetrate a horrendous crime such as a mass shooting. We can certainly look for warning signs, but how to decipher a cry for help versus an imminent threat remains an area where we must be vigilant. We also must be vigilant not to make assumptions about someone because they have a mental illness. Mental illness is a disease like diabetes, or heart disease. Sometimes lifestyle choices may have led them into it, sometimes it is completely organic and there was nothing anyone can do. We must remain empathetic if we are to create avenues to treatment and healing as opposed to pathways to a police state. In the early 1960’s Bob Dylan penned his song “Blowing in The Wind” “/” as I worked on this blog I was reminded of the line “How many times must the cannonballs fly, before they are forever banned.” We all know, the answer is blowing in the wind.

References:

Ekundayo, Otuyelu et al. “ANTIDEPRESSANT DRUGS AND TEENAGE SUICIDE IN HUNGARY: TIME TREND AND SEASONALITY ANALYSIS.” International Journal of Psychiatry in Clinical Practice (2015): 1-18. Web. 6 Feb. 2018.

Gold, L., Simon, R., & Knoll, J. (2015). Gun violence and mental illness (1st ed., pp. 81-99). Arlington Virginia: American Psychiatric publishing.

How to Legally Declare Someone as Mentally Incompetent?. (2018). The Law Dictionary. Retrieved 20 February 2018, from https://thelawdictionary.org/article/how-to-legally-declare-someone-as-mentally-incompetent/

Molero, Yasmina et al. “Selective Serotonin Reuptake Inhibitors And Violent Crime: A Cohort Study.” PLOS Medicine 12.9 (2015): e1001875. Web.

Fact vs Fiction: How to Give CPR

CPR, also known as Cardiopulmonary resuscitation, is a medical procedure involving repeated compression of a patient’s chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest. CPR certification is needed for a variety of jobs and professions, from doctors all the way through to lifeguards. While the steps performed for CPR have been revised over the years, the technique has largely stayed the same.

According to the American Red Cross, British Heart Foundation, and Healthdirect Australia, the steps to performing CPR are mostly simple and straightforward:

 

Before Giving CPR-

  • Check the scene and make sure it’s safe.
  • Call 911 for assistance .
  • Open the airway. With the person lying on their back, tilt their head slightly to life their chin.
  • Check for breathing. Listen carefully, for no more than 10 seconds, for sounds of breathing. If there is no breathing, being CPR.

 

CPR Steps-

  • Push hard, push fast. Place your hands, one on top of the other, in the middle of the chest. Use your body weight to help you administer compression’s that are at least 2 inches deep and delivered at a rate of at least 100 compression’s per minute.
  • Deliver rescue breaths. With the person’s head tilted back slightly and the chin lifted, pinch the nose shut and place your mouth over the person’s mouth to make a complete seal. Blow into the person’s mouth to make the chest rise. Deliver two rescue breaths, then continue compression’s.
  • Continue CPR steps. Keep performing cycles of chest compression’s and breathing until the person exhibits signs of life, such as breathing, an AED becomes available, or EMS or a trained medical responder arrives on scene.

 

For all intents and purposes, this is the universal method for performing CPR. You’re on a safari trip in Africa and some has a heart attack? This is how you perform CPR. Enjoying a swim in the Mediterranean Sea and someone drowns? This is how you perform CPR. Skiing down to side of Mount Everest and someone collapses? This is how you perform CPR.

So if this is the case, one question must be asked: Why is CPR performed so poorly throughout our media? Take this clip from the movie “Poseidon” for example:

Aside from the steps performed prior to giving CPR (after all, they are on a sinking, upside down cruise ship), how does Kurt Russell’s character fail to perform quality CPR? Well first off, he is performing the steps out of order. Kurt decides to first give rescue breaths, followed by embarrassingly small amount of compression’s, and THEN decided to check to see if the person is breathing. Secondly, he is not performing CPR for long enough in order for it to have its desired effect.

How about we take a look at a different clip from the popular show “Lost”:

In this scene, Jack, one of the foremost cardiac surgeons in the world, is giving his buddy, Charlie, CPR. While keeping in mind the CPR steps listed above, we see Jack doing a pretty admirable job performing CPR… until the 2:07 mark of the video. Now, I get dramatic effect and everything, but word to the wise- don’t start hammer fisting the chest of a person who is not breathing. This will not have the effect it did in this clip and will likely decrease the chances of saving that person.

Well, if you think that clip is comical, this clip from “Breaking Bad” is even worse:

Here we have Jesse attempting CPR on his girlfriend, who likely had an overdose, and boy do we see some problems here. To start it off (and unlike the previous two clips where they were stranded on a sinking boat and hidden island) Jesse should have started the process off by calling 911. His positioning is also off, as he is straddling the victim instead of kneeling perpendicular to her. Not only that, he’s performing CPR while on a mattress. How are you supposed compress the chest down two inches when you are essentially bouncing them up and down on springs? On top of that, the procedure is performed completely wrong, with no rescue breaths being given.

 

So what can we learn from this? First off, don’t try CPR without getting the proper training and certification. CPR classes are given all throughout the country, and can be taken, in some states, starting at 9 years old. Secondly, don’t imitate the techniques or procedures used in popular or mainstream media. CPR is universal, and performed the same way everywhere. If you see a new method used somewhere else, they are likely performing it incorrectly. Lastly, keep up to date with all advances and changes made for CPR. The ratio of compression’s to breaths in children vs adults have changed in the last 10 years. Also, the invention of the AED, or automated external defibrillator, has revolutionized CPR. Keep up to date with these new inventions and regulations and it could be the difference between life and death.

 

 

Resources:

 

 

 

 

The #MeToo Movement: Fact vs. Fiction

The #metoo movement began in October of 2017 as a virtual hashtag to demonstrate the widespread prevalence of sexual assault and harassment. Tarana Burke originally founded the me too movement to help survivors of sexual violence find a pathway to healing. The movement promoted the idea of “empowerment through empathy” as millions of women posted #metoo across social media. 

The #metoo movement has encouraged millions to speak out against sexual violence towards women, particularly in the workplace. Time magazine named the movement person of the year. The cover proudly displayed the “silence breakers,” brave women who first confronted sexual harassment and assault. 

The Time magazine article highlights the frustration women in the workplace face when as their bosses cross boundaries or make them feel powerless. The article conveys women do not speak out for they fear retaliation or being fired. These “silence breakers” speak out in support of preventing sexual harassment in the workplace and are encouraging others to do the same.

A recent article published by Brunner and Dever (2014) investigated the prevalence of sexual harassment in the “new economy”. Male and female participants simply could not imagine a workplace free from the influence of appearance and sexuality. They further discussed examples of how power and sexuality infiltrated daily, routine interactions. These findings further support the motivations behind the #metoo movement.

CNN further supports the #metoo movement, speculating the social hashtag could result in social change and reduce sexual abuse of women. The article further calls for men to begin speaking up to truly institute change. Velasquez and LaRose (2015) investigate the impact of effective social media campaigns and determined positive experience online with activism to encourage political activism. This theory applies directly to the #metoo movement. Increased online involvement will lead to increased public awareness and support.

References:

Brunner, L. K., & Dever, M. (2014). Work, Bodies and Boundaries: Talking Sexual Harassment in the New Economy. Gender, Work & Organization, 21(5), 459-471. doi:10.1111/gwao.12048

Eliana, D., Hayley, E., & Stephanie, Z. (2017, December 18). Person of the Year 2017: The Silence Breakers. Time Magazine. Retrieved February 15, 2018, from http://time.com/time-person-of-the-year-2017-silence-breakers/

LaMotte, S. (2017, November 09). #MeToo: From social campaign to social change? Retrieved February 19, 2018, from https://www.cnn.com/2017/10/30/health/metoo-legacy/index.html

Velasquez, A., & LaRose, R. (2015). Social Media for Social Change: Social Media Political Efficacy and Activism in Student Activist Groups. Journal Of Broadcasting & Electronic Media, 59(3), 456-474. doi:10.1080/08838151.2015.1054998

 

 

Hospital acquired infection

What is an Hospital Acquired Infection?

A Hospital Acquired Infection is an infection that a patient receives in the hospital during their stay. It can happen after surgery by getting and infection in the surgical incision, pneumonia, MRSA and or C-DIFF for example. “health care–associated infections, 1 in 25 patients in the acute care setting will develop a health care–associated infection during their hospital stay. In 2011, roughly 722 000 patients had a hospital acquired infection and around 75 000 of those patients died” (Haversack, 2017).

 

What can a Hospital Acquired Infection lead too?

If a patient develops a hospital acquired infection it can lead to a longer hospital stay, health complications and may lead to death. Education on how to prevent hospital acquired infection should be taught to all patients. The more knowledge we know the less chance a patient will develop a hospital acquired infection.

 

 

How to prevent Hospital Acquired Infections?

The best way to prevent the spread of germs is hand washing.

How to properly wash your hands

  1. Turn on water and wet hands.
  2. Add a coin size amount of soap
  3. Scrub hands together for 20 seconds, or sing happy birthday twice.
  4. Since hands from wrist to finger tips.
  5. Dry hands with paper towel.
  6. Grab new paper towel and shut off sink.

When should we wash our hands?

“Hand decontamination should take place before and after patient contact, after contact with the patient’s environment or body fluids, when hands are visibly soiled, before and after an aseptic procedure and after removing gloves” (Rigby,2017).

  • Before, during, and after preparing food
  • Before eating food
  • Before and after caring for someone who is sick
  • Before and after treating a cut or wound
  • After using the toilet
  • After blowing your nose, coughing, or sneezing
  • After touching an animal, animal feed, or animal waste
  • After touching garbage
  • Decontaminated hands

 

 Reasons for Poor Hand Hygiene 

  • Ineffective placements of dispensers or sinks
  • Hand hygiene isn’t stressed
  • Ineffective of insufficient education on hand washing
  • Health professionals carrying supplies and having their hands full
  • Wearing gloves
  • Thinking hand hygiene isn’t needed if they are wearing gloves
  • Health professionals forget to wash their hands
  • Distractions happen during the hand hygiene process

 

To prevent the spread of germs to patient to patient we in healthcare need to wash our hands and we need to continuously educate our patients and other staff members of the importance of hand hygiene. Washing your hands will save lives 

References 

Haverstick, S. (2017). Patients’ Hand Washing and Reducing Hospital-Acquired Infection. Critical Care Nurse37(3), e1-e8. doi:10.4037/ccn2017694

Karsh, J. A. (2017). Hand Hygiene Do’s & Don’ts. H&HN: Hospitals & Health Networks91(5), 39-42.

Rigby, R., Pegram, A., & Woodward, S. (2017). Hand decontamination in clinical practice: a review of the evidence. British Journal Of Nursing26(8), 448-451.

 

Type 2 Diabetes

The Truth about Type 2 Diabetes

 

By: Agência Brasil Fotografias

 

Type 2 diabetes is also known as non-insulin dependent diabetes. It can sometimes be managed with a healthy diet and exercise. It is known to appear in adulthood however can affect children especially if they are obese.

Those with diabetes may not produce enough insulin or may have an insulin resistance. Insulin is a hormone produced by the pancreas that help the body bring sugar from the blood into the cells as a source of energy.

The goal of treatment is to maintain blood sugar levels, prevent complications and to control symptoms

 

By: Matthew Hutchinson

 

The recommended diet for those with this diagnosis is:

 

  • Limit refined sugars like the sugar in candy or soda
  • Limit salt in diet
  • Limit fat
  • Drink alcohol in moderation
  • Focus on eating starches, vegetables, fruit and proteins low in fat

It is important to manage blood sugar levels because with increased sugar in the blood it puts a person at risk for heart disease, kidney disease and vision loss.

 

Some Important Facts About Type 2 Diabetes:

With a lack of insulin there is excess sugar in the blood which acts like glass shards tearing at the arteries lining. This causes scarring and a smaller passageway for blood to pass (Arthrosclerosis).
• Excess sugar and atherosclerosis increases the risk for heart attack and heart disease
• Because it is so easy for the sugar to damage arteries in the kidneys there is an increased risk for kidney disease

 

 

Debunking the myths:

 

All those diagnosed with type 2 are overweight.

FALSE But it is more likely.

• You cannot eat any carbs.

FALSE carbs should be limited but can be eaten.

• Food that is labeled “Diabetic” can be eaten as much as you want.

FALSE They can be high in sorbitol and fructose.

• You will know if you have type 2 diabetes.

FALSE Type 2 diabetes is often described as insidious and many are not aware of their symptoms. It is type 1 diabetes where people are more symptomatic

 

 

The most reliable sources state that the risk for type 2 is higher when the person is overweight but not always because diet and insulin production vary in every person.

 

 

Because carbs can be a source or energy it is not recommended to eat 0 carbs, but to limit them as explained in the video below

 

 

 

 

References
Mathews, M. J., Liebenberg, L., & Mathews, E. H. (2015). How do high glycemic load diets influence coronary heart disease?. Nutrition & Metabolism, 12(1), 1-15. doi:10.1186/s12986-015-0001-x
Nazarko, L. (2010). Treatment of type 2 diabetes. British Journal Of Healthcare Assistants, 4(3), 124-1
Mellor, D. (2012). A review of the current nutritional guidelines for diabetes. Practice Nursing, 23(5), 234-240.

Newborn Care

Newborn Needs    

  • Newborn Hygiene. 
  • Skin Care.
  • Feeding and weight gain.
  • Skin to Skin (Kangaroo Care).
  • Warning Signs for Parents.

 

 

Newborn Hygiene

Umbilical Care:

  1. Use gentle soap.
  2. Use of 70% alcohol or 0.5% alcoholic chlorhexidine after bathing and diaper changes.
  3. Give sponge baths until the stump separates.
  4. Notify pediatrician if there is any redness or drainage.
  5. The World Health Organization recommends that the “stump be clean and dry”.

Skin Care:

  1. Wash your hands before bathing or changing baby.
  2. Bath baby in a warm room, either in a tub or bath.
  3. Temperature of the bath water should not go over 37°C.
  4. Poop should be cleaned off baby’s skin before bath.
  5. Use low level of water, aids drop in body temperature.
  6. Gently dry, use a soft towel to avoid friction.

Feeding & Weight Gain

  1. Feed every 2-3 hours.
  2. Good intake measured by: Bowel movements.
  3. Skin to skin contact with feeding.
  4. Weight Gain:
    1. First few days of life: weight loss occurs.
    2. Newborn gains weight back and gains some and grows.
    3. Call Pediatrician if:
      • Not regaining weight.
      • Less than 5 wet diapers/day.
      • Strong smelling urine for 5 days.
      • Less than 2 soft/loose mustard-yellow stools/day in 1st week.

Skin to Skin (Kangaroo Care)

  • Increases oxytocin hormone release.
  • Helps with newborn stress, temperature, breathing, heart rate, and pain.
    1. Reduces stress.
    2. Relieves pain.
    3. Elevates temperature, regulating it.
    4. Regulates heart rate thus controlling breathing.
  • Prevents heat loss.
  • Increases breastfeeding performance.
  • Helps with sleeping.

Newborn Warning Signs

Newborn
  1. Fever: > 38.0C notify Pediatrician.
  2. Jaundice:
    • First few days of life normal, if continues call MD.
  3. Non-stop crying.
  4. Sudden Infant Death Syndrome (SIDS):
    • Newborn needs to sleep on back ONLY!

Heart Failure Facts

By: Sharon Sinclair

The term “heart failure” makes it sound like the heart is no longer working at all. The fact is, in heart failure, the heart isn’t pumping as well as it should be, preventing the heart from keeping up with its workload.

Your body depends on the heart’s pumping action to deliver oxygen and nutrient-rich blood to the body’s cells. When the cells are nourished properly, the body can function normally.

With heart failure, the weakened heart can’t supply the cells with enough blood. This results in fatigue and shortness of breath and some people have coughing.

Can Heart Failure Occur in Postpartum? 

The claims made about heart failure in the media are often surprising, like the claim that heart failure can develop during or in the months following pregnancy, especially in news sources like the Donner County Daily Bee. In the January 18, 2018, the online edition of the Bee included an article claiming that women pregnant women were most likely to develop heart failure in the weeks following the delivery. The article revealed that symptoms of heart failure in this case are manifested by a chronic cough, especially when prone as well as exhaustion, dizziness and pains in the chest (“For Pregnant, 2018).

This news source was right on target as far as facts go because the information was derived from the results of a recently published study by Mogos, Piano, McFarlin, Salemi, Liese and Briller (2018). The study was predicated on the fact that, while heart failure has long-been identified as a leading cause of maternal morbidity and mortality, little evidence exists on the prevalence, correlates and outcomes of heart failure before, during and after delivery. FACT: In this case, Mogos et al. (2018) established that 60% of heart failure cases associated with pregnancy developed post-partum and in many cases as much as six weeks after delivery (p. e004005).

Can Smoke-inhalation be a Cause of Heart Failure?

A clip from Dr. Oz’s Inside Edition on February 6, 2018 included a comment on a recent episode from the popular TV show “This is Us,” suggesting that the death of main character Jack Pearson could be explained by a heart attack that he suffered because of trying to rescue his family from their burning house. The comment was based on research conducted by the Environmental Protection Agency, which reported that fine particulate matter like that found in smoke can get deep into the lungs and ultimately into the bloodstream and cause a non-fatal heart attack (“Heart”).

In the case of character Jack Pearson, the clip suggests that he apparently died from a heart attack. A recent systematic review and meta-analysis of studies on the subject confirmed that the short-term exposure to and inhalation of fine particulate matter like smoke can cause a myocardial infarction. FACT: Although the researchers do not mention heart failure, the contribution of inhaled smoke to chronic heart failure could be inferred because heart attack and other cardiac events can weaken the heart and cause heart failure (Luo, Zhu, Yao, Hou, Zhang, Cao, & Wang, 2015; “Heart Failure”).

Can Lifestyle Changes Improve Heart Failure?

Heart failure is a chronic disease needing lifelong management. However, with treatment, signs and symptoms of heart failure can improve, and the heart sometimes becomes stronger. Treatment may help you live longer and reduce your chance of dying suddenly.

Fact: Lifestyle changes often improve or control some of the factors contributing to heart failure.

 

References

For pregnant women, heart failure most likely in weeks after
delivery. (2018, Jan. 12). Bonner County Daily Bee. Retrieved from http://www.bonnercountydailybee.com/article/20180112/AP/301129979

Health and environmental effects of particulate matter. EPA.
Retrieved from https://www.epa.gov/pm-pollution/health-and-environmental-effects-particulate-matter-pm

Luo, C., Zhu, X., Yao, C., Hou, L., Zhang, J., Cao, J., & Wang,
A. (2015). Short-term exposure to particulate air pollution and risk of myocardial infarction: A systematic review and meta-analysis. Environmental Science & Pollution Research, 22(19), 14651-14662

Mogos, M. F., Piano, M. R., McFarlin, B. L., Salemi, J. L.,
Liese, K. L., & Briller, J. E. (2018). Heart failure in pregnant women: A concern across the pregnancy continuum. Circulation: Heart Failure, 11(1), e004005.