The Association of Air Pollution Exposure With Glucose and Lipid Levels: The Role of an Extreme Air Pollution Event Alongside 2 Decades of Moderate Exposure.

Extreme air pollution events and moderate exposure to fine particulate matter (PM2.5) are associated with increased cardiometabolic risk. The World Trade Center (WTC) Health Program general responder cohort includes responders to the WTC disaster. We investigated whether their exposure to this extreme air pollution event (2001) was associated with long-term metabolic outcomes, independently from the associations of intermediate-term PM2.5 exposure later in life (2004-2019). We included 22,447 cohort members with cholesterol (n = 96,155) and glucose (n = 81,599) laboratory results. Self-reported WTC exposure was derived from a questionnaire. PM2.5 exposure was derived from a satellite-based model. We observed an increase of 0.78 mg/dL (95% confidence interval (CI): 0.30, 1.26) in glucose and 0.67 mg/dL (95% CI: 1.00, 2.35) in cholesterol levels associated with an interquartile range increase in PM2.5 averaged 6 months before the study visit. Higher WTC-exposure categories were also associated with higher cholesterol (0.99 mg/dL, 95% CI: 0.30, 1.67, for intermediate exposure) and glucose (0.82 mg/dL, 95% CI: 0.22, 1.43, for high exposure) levels. Most associations were larger among people with diabetes. Extreme air pollution events and intermediate PM2.5 exposure have independent metabolic consequences. These exposures contributed to higher glucose and lipids levels among WTC responders, which may be translated into increased cardiovascular risk.

Colorectal cancer screening: results from the World Trade Center Health Registry cohort.

PURPOSE: Little is known about colorectal cancer screening in 9/11 World Trade Center (WTC)-exposed populations. We utilized survey data from the WTC Health Registry (WTCHR) to examine associations between enrollees' characteristics and colorectal cancer (CRC) screening. METHODS: We studied 22,061 enrollees aged 50-75 who completed the WTCHR follow-up survey in 2015-2016. Those with a history of CRC were excluded. Screening was defined as a self-reported, routine colonoscopy or sigmoidoscopy during the 12-month period prior to the survey. Multivariable log binomial regression identified factors associated with screening in the 12 months preceding the survey. We also stratified by age group. RESULTS: Of 22,061 enrollees, 23% were screened, with largely similar rates across age groups. Higher screening percentages were seen in selected groups including non-Hispanic Black enrollees (26.4%), males (24.3%), those married/living with a partner (24.1%), those with a higher household income (≥ $150 k, 25.4%), those who received services from the WTC Health Program (25.6%), and those with greater perceived social support (24.4%). On multivariable analyses, non-Hispanic Black enrollees [adjusted relative risk (aRR) = 1.30, 95% confidence interval (CI) 1.19-1.42] were significantly more likely to report screening, even after stratifying by age group. Hispanic enrollees, those with a higher household income, those with increased perceived social support, and those with diagnosed medical conditions under 70 years old were also associated with screening. CONCLUSION: We found that non-Hispanic Black compared with non-Hispanic White enrollees were more likely to obtain screening for CRC. Continued efforts to promote health and wellness of WTC-exposed population is essential.

Behavioral Impairments and Increased Risk of Cortical Atrophy Risk Scores Among World Trade Center Responders.

Objective: World Trade Center (WTC) responders are susceptible to both cognitive and neuropsychiatric impairments, particularly chronic posttraumatic stress disorder. The present study examined self-reported behavioral impairments in a sample of 732 WTC responders, 199 of whom were determined to have high risk of WTC-related cortical atrophy by an artificial neural network. Results: We found that responders at increased risk of cortical atrophy showed behavioral impairment across five domains: motivation, mood, disinhibition, empathy, and psychosis (14.6% vs 3.9% in the low-risk group; P = 3.90 × 10-7). Factor analysis models revealed that responders at high risk of cortical atrophy tended to have deficits generalized across all aspects of behavioral impairment with focal dysfunction in sensory psychosis. We additionally describe how relationships are modulated by exposure severity and pharmacological treatments. Discussion: Our findings suggest a potential link between sensory deficits and the development of cortical atrophy in WTC responders and may indicate symptoms consistent with a clinical portrait of parietal dominant Alzheimer's disease or a related dementia (ADRD). Results underscore the importance of investigating neuropsychiatric symptomatology in clinical evaluations of possible ADRD.

Interstitial Lung Disease and Progressive Pulmonary Fibrosis: a World Trade Center Cohort 20-Year Longitudinal Study.

PURPOSE: World Trade Center (WTC) exposure is associated with obstructive airway diseases and sarcoidosis. There is limited research regarding the incidence and progression of non-sarcoidosis interstitial lung diseases (ILD) after WTC-exposure. ILD encompasses parenchymal diseases which may lead to progressive pulmonary fibrosis (PPF). We used the Fire Department of the City of New York's (FDNY's) WTC Health Program cohort to estimate ILD incidence and progression. METHODS: This longitudinal study included 14,525 responders without ILD prior to 9/11/2001. ILD incidence and prevalence were estimated and standardized to the US 2014 population. Poisson regression modeled risk factors, including WTC-exposure and forced vital capacity (FVC), associated with ILD. Follow-up time ended at the earliest of incident diagnosis, end of study period/case ascertainment, transplant or death. RESULTS: ILD developed in 80/14,525 FDNY WTC responders. Age, smoking, and gastroesophageal reflux disease (GERD) prior to diagnosis were associated with incident ILD, though FVC was not. PPF developed in 40/80 ILD cases. Among the 80 cases, the average follow-up time after ILD diagnosis was 8.5 years with the majority of deaths occurring among those with PPF (PPF: n = 13; ILD without PPF: n = 6). CONCLUSIONS: The prevalence of post-9/11 ILD was more than two-fold greater than the general population. An exposure-response gradient could not be demonstrated. Half the ILD cases developed PPF, higher than previously reported. Age, smoking, and GERD were risk factors for ILD and PPF, while lung function was not. This may indicate that lung function measured after respirable exposures would not identify those at risk for ILD or PPF.

A pilot study to identify factors associated with frailty within the World Trade Center general responder cohort.

BACKGROUND: Given the significant exposures experienced by the World Trade Center (WTC) general responders, there is increasing interest in understanding the effect of these exposures on aging in this population. We aim to identify factors that may be associated with frailty, a clinical syndrome characterized by a decrease in one's reserve that has been linked to poor health outcomes. METHODS: WTC general responders enrolled in the WTC Health Program aged 50 and older provided informed consent. Validated frailty assessments, the Frailty Phenotype (with the Johns Hopkins Frailty Assessment Calculator) along with the FRAIL scale, categorized nonfrail from prefrail/frail. Fall risk, functional status, and cognition were also assessed. WTC variables, including an identified WTC-certified condition, were utilized. The risk of frailty was estimated using log binomial regression analysis. A 95% confidence interval (CI) was used to estimate the prevalence ratio (PR). RESULTS: One hundred and six participants were included; 38 (35.8%) were classified as pre-frail or frail. More of the pre-frail/frail group were obese (57.9% vs. 25%; p = 0.004) and had a WTC-certified condition (78.9% vs. 58.8%; p = 0.036). Obesity (PR = 2.43, 95% CI = 1.31, 4.53), a WTC-certified condition (PR = 1.77, 95% CI = 1.09, 2.89), and risk of falling (PR = 1.97, 95% CI = 1.01, 3.84) were independently associated with frailty. CONCLUSIONS: Obesity and having a WTC-certified condition were found to be risk factors for frailty in our pilot study. Future work may focus on further identifying risk factors for frailty in the larger WTC general responder population.

Cross-sectional association between posttraumatic stress and cognition is moderated by pulmonary functioning in world trade center responders.

BACKGROUND: Posttraumatic stress disorder (PTSD) symptomatology and poorer pulmonary function are highly prevalent psychiatric and medical conditions. In the present study, we tested for the individual, additive, and modifying associations of PTSD symptomatology and pulmonary function with cognitive performance. METHODS: In this cross-sectional study, a total of 1,401 World Trade Center (WTC) responders (mean age = 53, SD = 8 years, 92% males) participated in the study. Cogstate assessment measured cognitive performance. PTSD symptomatology was measured using the trauma-specific version of the posttraumatic stress disorder checklist (PCL-17) adapted for the WTC attacks. The 1-second forced expiratory volume and forced vital capacity (FEV1/FVC) ratio was used to measure pulmonary function. Linear regressions with cognitive performance as the outcome were conducted to assess individual, additive, and moderating associations of PTSD symptomatology and pulmonary function. RESULTS: Higher PTSD symptomatology and poorer pulmonary function were negatively associated with cognitive performance. A 10% increase on the FEV1/FVC ratio moderated the association between PTSD symptomatology and cognition, whereby its association with cognition was stronger when PTSD symptomatology was higher (est. = 0.01, 95%CI = 0.004, 0.01, p < 0.001). When stratified by responder type, these associations persisted in trained (est. = 0.01, 95%CI = 0.01, 0.02, p < 0.001), but not in non-trained (est. = 0.004, 95% C.I. = -0.01, 0.02, p = 0.39) responders. CONCLUSIONS: In the presence of higher PTSD, better pulmonary functioning is associated with better cognitive performance. Early intervention efforts to mitigate preventable cognitive decline in high-risk populations should be studied, especially since intervention in one modality may have an impact on others.

World Trade Center responders in their own words: predicting PTSD symptom trajectories with AI-based language analyses of interviews.

BACKGROUND: Oral histories from 9/11 responders to the World Trade Center (WTC) attacks provide rich narratives about distress and resilience. Artificial Intelligence (AI) models promise to detect psychopathology in natural language, but they have been evaluated primarily in non-clinical settings using social media. This study sought to test the ability of AI-based language assessments to predict PTSD symptom trajectories among responders. METHODS: Participants were 124 responders whose health was monitored at the Stony Brook WTC Health and Wellness Program who completed oral history interviews about their initial WTC experiences. PTSD symptom severity was measured longitudinally using the PTSD Checklist (PCL) for up to 7 years post-interview. AI-based indicators were computed for depression, anxiety, neuroticism, and extraversion along with dictionary-based measures of linguistic and interpersonal style. Linear regression and multilevel models estimated associations of AI indicators with concurrent and subsequent PTSD symptom severity (significance adjusted by false discovery rate). RESULTS: Cross-sectionally, greater depressive language (ß = 0.32; p = 0.049) and first-person singular usage (ß = 0.31; p = 0.049) were associated with increased symptom severity. Longitudinally, anxious language predicted future worsening in PCL scores (ß = 0.30; p = 0.049), whereas first-person plural usage (ß = -0.36; p = 0.014) and longer words usage (ß = -0.35; p = 0.014) predicted improvement. CONCLUSIONS: This is the first study to demonstrate the value of AI in understanding PTSD in a vulnerable population. Future studies should extend this application to other trauma exposures and to other demographic groups, especially under-represented minorities.

Daily Sleep-Stress Reactivity and Functional Impairment in World Trade Center Responders.

BACKGROUND: How sleep is impacted by stress ("sleep reactivity to stress") and how stress is impacted by sleep ("stress reactivity to sleep") are trait-like characteristics of individuals that predict depression, anxiety, and insomnia. However, pathways between reactivity and functional impairment (e.g., impairment in social relationships and interpersonal functioning) have not been explored, which may be a critical pathway in understanding the link between reactivity and the development of psychological disorders. PURPOSE: We examined associations between reactivity and changes in functional impairment among a cohort of 9/11 World Trade Center responders. METHODS: Data from 452 responders (Mage = 55.22 years; 89.4% male) were collected between 2014 and 2016. Four baseline sleep and stress reactivity indices (i.e., sleep duration and efficiency reactivity to stress; stress reactivity to sleep duration and efficiency) were calculated from 14 days of sleep and stress data using random slopes from multilevel models. Functional impairment was assessed approximately 1 year and 2 years after baseline via semi-structured interviews. Latent change score analyses examined associations between baseline reactivity indices and changes in functional impairment. RESULTS: Greater baseline sleep efficiency reactivity to stress was associated with decreases in functioning (ß = -0.05, p = .039). In addition, greater stress reactivity to sleep duration (ß = -0.08, p = .017) and sleep efficiency (ß = -0.22, p < .001) was associated with lower functioning at timepoint one. CONCLUSION: People who are more reactive to daily fluctuations in stress and sleep have poorer interpersonal relationships and social functioning. Identifying individuals with high reactivity who could benefit from preventative treatment may foster better social integration.

How sleep is impacted by stress ("sleep reactivity to stress") and how stress is impacted by sleep ("stress reactivity to sleep") are trait-like characteristics of individuals that may contribute to an individual's risk of developing of psychological disorders, such as depression, anxiety, and insomnia. It is possible that individuals with high sleep-stress reactivity are more likely to experience long-term functional impairment (e.g., impairment in social relationships and interpersonal functioning)­a predisposing factor for psychological disorders, yet this pathway has not been explored. Therefore, we examined associations between sleep-stress reactivity and changes in functional impairment across a 1-year period in a large sample of 9/11 World Trade Center responders. The study results suggest that 9/11 World Trade Center responders who are more reactive to daily fluctuations in stress and sleep have poorer interpersonal relationships and social functioning. Identifying individuals with high sleep-stress reactivity who could benefit from preventative treatment may foster better social integration.

A 15-year follow-up study of mortality in a pooled cohort of World Trade Center rescue and recovery workers.

INTRODUCTION: Hazardous exposures from the World Trade Center (WTC) terrorist attacks have been linked to increased incidence of adverse health conditions, often associated with increased mortality. We assessed mortality in a pooled cohort of WTC rescue/recovery workers over 15 years of follow-up. MATERIALS AND METHODS: We analyzed mortality through 2016 in a pooled and deduplicated cohort of WTC rescue/recovery workers from three WTC-exposed cohorts (N = 60,631): the Fire Department of the City of New York (FDNY); the WTC Health Registry (WTCHR); and the General Responder Cohort (GRC). Standardized mortality ratios (SMRs) were estimated to assess mortality vs. the US and NY state populations. Multivariable Cox proportional hazards models were used to examine associations of WTC exposures (date of first arrival, working on the WTC debris pile) with mortality risk. RESULTS: There were 1912 deaths over 697,943.33 person-years of follow-up. The SMR for all-cause mortality was significantly lower-than-expected, both when using US (SMR 0.43, 95% confidence interval [CI] 0.42-0.45) and NYS (SMR 0.51, 95% CI 0.49-0.53) as reference populations. SMRs were not elevated for any of the 28 major causes of death. Arriving at the WTC site on 9/11-9/17/2001 vs. 9/18/2001-6/30/2002 was associated with 30-50% higher risk of all-cause, heart disease and smoking-related mortality in non-FDNY/non-GRC members. Conversely, arriving on 9/11/2001 vs. 9/18/2001-6/30/2002 was associated with 40% lower all-cause and smoking-related mortality risk in FDNY members. Working on vs. off the WTC pile was associated with an increased risk of all-cause mortality in non-FDNY/non-GRC members (adjusted hazard ratio [aHR] 1.25, 95% CI 1.04-1.50), and cancer-specific mortality in GRC members (aHR 1.39, 95% CI 1.05-1.84), but lower mortality risks were found in FDNY members. CONCLUSIONS: We did not observe excess mortality among WTC rescue/recovery workers compared with general populations. However, significantly increased mortality risks among some sub-groups with high WTC exposure warrant further investigation.

Association of World Trade Center (WTC) Occupational Exposure Intensity with Chronic Obstructive Pulmonary Disease (COPD) and Asthma COPD Overlap (ACO).

INTRODUCTION: Reported associations between World Trade Center (WTC) occupational exposure and chronic obstructive pulmonary disease (COPD) or asthma COPD overlap (ACO) have been inconsistent. Using spirometric case definitions, we examined that association in the largest WTC occupational surveillance cohort. METHODS: We examined the relation between early arrival at the 2001 WTC disaster site (when dust and fumes exposures were most intense) and COPD and ACO in workers with at least one good quality spirometry with bronchodilator response testing between 2002 and 2019, and no physician-diagnosed COPD before 9/11/2001. COPD was defined spirometrically as fixed airflow obstruction and ACO as airflow obstruction plus an increase of ≥ 400 ml in FEV1 after bronchodilator administration. We used a nested 1:4 case-control design matching on age, sex and height using incidence density sampling. RESULTS: Of the 17,928 study participants, most were male (85.3%) and overweight or obese (84.9%). Further, 504 (2.8%) and 244 (1.4%) study participants met the COPD and ACO spirometric case definitions, respectively. In multivariable analyses adjusted for smoking, occupation, cohort entry period, high peripheral blood eosinophil count and other covariates, early arrival at the WTC site was associated with both COPD (adjusted odds ratio [ORadj] = 1.34, 95% confidence interval [CI] 1.01-1.78) and ACO (ORadj = 1.55, 95%CI 1.04-2.32). CONCLUSION: In this cohort of WTC workers, WTC exposure intensity was associated with spirometrically defined COPD and ACO. Our findings suggest that early arrival to the WTC site is a risk factor for the development of COPD or of fixed airway obstruction in workers with pre-existing asthma.

Perceived social support and longitudinal trajectories of depression and anxiety in World Trade Center responders.

PURPOSE: While severely distressing events are known to affect mental health adversely, some survivors develop only short-lived or no psychiatric symptoms in the aftermath of a disaster. In the WTC Health Program General Responder Cohort (WTCHP GRC) we examined whether social support was protective against the development of depression or anxiety symptoms after the 9/11 WTC attacks and explored in a subsample whether trait resilience moderated this relationship. METHODS: We analyzed data from 14,033 traditional and 13,478 non-traditional responders who attended at least three periodic health monitoring visits between 2002 and 2019. Linear mixed-effects models were used to examine depression (Patient Health Questionnaire-9; PHQ-9) and anxiety (Generalized Anxiety Disorder screener; GAD-7) scores. In a subsample of 812 participants, we also assessed if the association between social support and symptoms was moderated by an individual's trait resilience level (Connor-Davidson Resilience Scale, CD-RISC). RESULTS: For both traditional and non-traditional responders, perceived social support around 9/11 was associated with lower levels of depressive (ß = - 0.24, S.E. = 0.017, z = - 14.29, p < 0.001) and anxiety symptoms (ß = - 0.17, S. E. = 0.016, z = - 10.48, p < 0.001). Trait resilience scores were higher in responders with at least one source of social support during the aftermath of 9/11 compared to those without (mean 71.56, SD 21.58 vs mean 76.64, SD 17.06; ß = 5.08, S.E. = 0.36, p < 0.001). Trait resilience moderated the association between social support and depressive (p < 0.001) and anxiety trajectories (p < 0.001) for traditional responders. CONCLUSION: Our findings suggest that perceived social support around a severely distressing event may have long-term protective effects on symptoms of depression and anxiety.

Opioid prescriptions among the World Trade Center Health Program population.

BACKGROUND: The World Trade Center Health Program (Program) provides limited health care to those directly affected by the 9/11 terrorist attacks. Because of physical/mental trauma arising from the 9/11 attacks, Program members might be at high risk of opioid use. To prevent prescription opioid overuse, in 2018 the Program implemented various measures to improve opioid prescribing and expand access to non-opioid pain management among Program members. However, the characteristics of opioid prescriptions dispensed among this population has never been described. METHODS: Administrative and claims data from 07/01/2011 to 09/30/2022 were used to describe opioid prescriptions dispensed during 2013-2021. RESULTS: From 2013-2021, 108,285 members were Program-enrolled for ≥ 10 months, 4,053 (3.7%) had 22,938 outpatient opioid prescriptions, of which, 62.1% were for cancer-related pain, 11.1% for hospice/end of life care, 4.8% for surgery pain, and 9.8% for acute/chronic pain. Among members with Program-paid diagnostic/treatment claims (n = 70,721), the proportion with opioid prescriptions for cancer/hospice/end of life care increased from 0.5% in 2013 to 1.6% in 2018 (p = 0.010), then decreased to 1.1% in 2021 (p = 0.070), and the proportion for non-cancer surgery/acute/chronic pain decreased from 0.6% in 2013 to 0.23% in 2021 (p = 0.0005). Among members prescribed opioids without cancer/hospice/sickle cell disease, the proportion who started with long-acting opioids or had opioid prescriptions from ≥ 4 prescribers were below 6.5% annually; the proportion receiving a high-dose (≥ 90 morphine milligram equivalents per day [MED]), or with concurrent opioids and benzodiazepines use, or who started opioids with MED ≥ 50 or with long duration (≥ 7 days' supply) were above 10% annually, but decreased since 2017. CONCLUSIONS: Prevalence of outpatient opioid prescriptions paid by the Program was very low and prescriptions were primarily dispensed for cancer/hospice/end of life care. Although Program efforts to improve opioid prescribing coincided with improvements in outcomes, ongoing surveillance is needed.

Cancer incidence in World Trade Center rescue and recovery workers by race and ethnicity.

INTRODUCTION: It is unclear whether differences in health outcomes by racial and ethnic groups among World Trade Center (WTC) rescue and recovery workers reflect those of the population of New York State (NYS) or show distinct patterns. We assessed cancer incidence in WTC workers by self-reported race and ethnicity, and compared it to population figures for NYS. METHODS: A total of 61,031 WTC workers enrolled between September 11, 2001 and January 10, 2012 were followed to December 31, 2015. To evaluate the association between race/ethnicity and cancer risk, Poisson regression analysis was used to estimate hazard ratios (HR) adjusted for WTC exposure, age, calendar year, sex and, for lung cancer, cigarette smoking. RESULTS: In comparison to Whites, Black workers had a higher incidence of prostate cancer (HR = 1.99, 95% CI = 1.69-2.34) and multiple myeloma (HR = 3.57, 95% CI = 1.97-6.45), and a lower incidence of thyroid (HR = 0.41, 95% CI = 0.22-0.78) and colorectal cancer (HR = 0.57; 95% CI = 0.33-0.98). Hispanic workers had a higher incidence of liver cancer (HR = 4.03, 95% CI = 2.23-7.28). Compared with NYS population, White workers had significantly higher incidence of prostate cancer (HR = 1.26, 95% CI = 1.18-1.35) and thyroid cancer (HR = 1.80, 95% CI = 1.55-2.08), while Black workers had significantly higher incidence of prostate cancer (HR = 1.22, 95% CI = 1.05-1.40). CONCLUSION: Cancer incidence in WTC workers generally reflects data from the NYS population, but some differences were identified that merit further investigation.

Comparing self-reported obstructive airway disease in firefighters with and without World Trade Center exposure.

BACKGROUND: The degree to which routine, non-World Trade Center (WTC) firefighting exposures contribute to the WTC exposure-obstructive airway disease (OAD) relationship is unknown. Our objective was to compare the frequency of self-reported OAD diagnoses in WTC-exposed firefighters from the Fire Department of the City of New York (FDNY) compared with non-WTC-exposed firefighters from other cities and the general population. METHODS: A total of 9792 WTC-exposed male FDNY firefighters and 3138 non-WTC-exposed male firefighters from Chicago, Philadelphia, and San Francisco who were actively employed on 9/11/01 and completed a health questionnaire were included. Logistic regression estimated odds ratios of self-reported asthma and COPD diagnoses in firefighters (WTC-exposed vs. non-WTC-exposed; all firefighters vs. general population), adjusting for age, race, smoking status, and last medical visit. RESULTS: WTC-exposed firefighters were, on average, younger on 9/11 (mean ± SD = 40.2 ± 7.4 vs. 44.1 ± 9.1) and less likely to report ever-smoking (32.9% vs. 41.8%) than non-WTC-exposed firefighters. Odds of any OAD and asthma were 4.5 and 6.3 times greater, respectively, in WTC-exposed versus non-WTC-exposed. Odds of COPD were also greater in WTC-exposed versus non-WTC-exposed, particularly among never-smokers. Compared with the general population, WTC-exposed firefighters had greater odds of both asthma and COPD, while the nonexposed had lower odds of asthma and greater odds of COPD. CONCLUSIONS: Odds ratios for OAD diagnoses were greater in WTC-exposed firefighters versus both non-WTC-exposed and the general population after adjusting for covariates. While asthma and other OADs are known occupational hazards of firefighting, WTC exposure significantly compounded these adverse respiratory effects.

Trajectories of psychological distress among individuals exposed to the 9/11 World Trade Center disaster.

BACKGROUND: Individuals present in lower Manhattan during the 9/11 World Trade Center (WTC) disaster suffered from significant physical and psychological trauma. Studies of longitudinal psychological distress among those exposed to trauma have been limited to relatively short durations of follow-up among smaller samples. METHODS: The current study longitudinally assessed heterogeneity in trajectories of psychological distress among WTC Health Registry enrollees - a prospective cohort health study of responders, students, employees, passersby, and residents in the affected area (N = 30 839) - throughout a 15-year period following the WTC disaster. Rescue/recovery status and exposure to traumatic events of 9/11, as well as sociodemographic factors and health status, were assessed as risk factors for trajectories of psychological distress. RESULTS: Five psychological distress trajectory groups were found: none-stable, low-stable, moderate-increasing, moderate-decreasing, and high-stable. Of the study sample, 78.2% were classified as belonging to the none-stable or low-stable groups. Female sex, being younger at the time of 9/11, lower education and income were associated with a higher probability of being in a greater distress trajectory group relative to the none-stable group. Greater exposure to traumatic events of 9/11 was associated with a higher probability of a greater distress trajectory, and community members (passerby, residents, and employees) were more likely to be in greater distress trajectory groups - especially in the moderate-increasing [odds ratios (OR) 2.31 (1.97-2.72)] and high-stable groups [OR 2.37 (1.81-3.09)] - compared to the none-stable group. CONCLUSIONS: The current study illustrated the heterogeneity in psychological distress trajectories following the 9/11 WTC disaster, and identified potential avenues for intervention in future disasters.

Change in 9/11-related post-traumatic stress symptoms following cancer diagnosis.

OBJECTIVE: Cancer can be a life-threatening stressor that may evoke pre-existing post-traumatic stress disorder (PTSD). We assessed change in 9/11-related PTSD symptoms following cancer diagnosis in a 9/11-exposed cohort, the World Trade Center Health Registry. METHODS: We examined enrollees who had a first-time post-9/11 invasive cancer diagnosis and at least one pre- and two post-diagnosis 9/11-related PTSD assessments from enrolment through 2015. PTSD symptoms were measured using 17-item PTSD Checklist (PCL, range 17-85). Cancer was identified from New York State Cancer Registry and categorized as localized or advanced stage. We used piecewise spline linear mixed-effects models to examine rate of change in PCL scores from pre- to post-diagnosis periods, and whether the change differed by gender or stage, with time as fixed and random effects, adjusting for baseline age, race, and education. RESULTS: 9/11-related PTSD symptoms were slightly increasing in the pre-diagnosis period, while this trend reversed in the post-diagnosis period (ß: -0.38; 95% CI: -0.60, -0.15). This trend was driven by male rescue/recovery workers (RRW), among whom significant decrease in rate of change in PCL scores was observed for those with advanced stage (slope change difference [95% CI]: -1.81 [-2.73, -0.90]). No significant difference in rate of change was observed among non-RRW. Among females, PCL scores tended to decrease slightly, with no significant difference in rate of change between pre- and post-diagnosis periods. CONCLUSIONS: We observed significant reduction in the rate of change in 9/11-related PTSD symptoms among male RRW. The underlying mechanism is unknown, necessitating future research.

Dynamic Metabolic Risk Profiling of World Trade Center Lung Disease: A Longitudinal Cohort Study.

Rationale: Metabolic syndrome (MetSyn) increases the risk of World Trade Center (WTC) lung injury (LI). However, the temporal relationship of MetSyn, exposure intensity, and lung dysfunction is not well understood. Objective: To model the association of longitudinal MetSyn characteristics with WTC lung disease to define modifiable risk. Methods: Firefighters, for whom consent was obtained (N = 5,738), were active duty on September 11, 2001 (9/11). WTC-LI (n = 1,475; FEV1% predicted

World Trade Center dust induces nasal and neurological tissue injury while propagating reduced olfaction capabilities and increased anxiety behaviors.

Objective: Previous in vitro and in vivo World Trade Center particulate matter (WTCPM) exposure studies have provided evidence of exposure-driven oxidative/nitrative stress and inflammation on respiratory tract and aortic tissues. What remains to be fully understood are secondary organ impacts due to WTCPM exposure. This study was designed to test if WTC particle-induced nasal and neurologic tissue injury may result in unforeseen functional and behavioral outcomes.Material and Methods: WTCPM was intranasally administered in mice, evaluating genotypic, histopathologic, and olfaction latency endpoints.Results: WTCPM exposure was found to incite neurologic injury and olfaction latency in intranasally (IN) exposed mice. Single high-dose and repeat low-dose nasal cavity insults from WTCPM dust resulted in significant olfaction delays and enduring olfaction deficits. Anxiety-dependent behaviors also occurred in mice experiencing olfaction loss including significant body weight loss, increased incidence and time spent in hind stretch postures, as well as increased stationary time and decreased exploratory time. Additionally, WTCPM exposure resulted in increased whole brain wet/dry ratios and wet whole brain to body mass ratios that were correlated with exposure and increased exposure dose (p<0.05).Discussion: The potential molecular drivers of WTCPM-driven tissue injury and olfaction latency may be linked to oxidative/nitrative stress and inflammatory cascades in both upper respiratory nasal and brain tissues.Conclusion: Cumulatively, these data provide evidence of WTCPM exposure in relation to tissue damage related to oxidative stress-driven inflammation identified in the nasal cavity, propagated to olfactory bulb tissues and, potentially, over extended periods, to other CNS tissues.

Anxiety sensitivity and Pain Experience: a prospective investigation among World Trade Center Responders.

Chronic pain is a significant public health problem and is exacerbated by stress. The World Trade Center (WTC) Disaster represents a unique stressor, and responders to the WTC disaster are at increased risk for pain and other health complaints. Therefore, there is a significant need to identify vulnerability factors for exacerbated pain experience among this high-risk population. Anxiety sensitivity (AS), defined as fear of anxiety-related sensations, is one such vulnerability factor associated with pain intensity and disability. Yet, no work has tested the predictive effects of AS on pain, limiting conclusions regarding the predictive utility and direction of associations. Therefore, the current study examined the prospective associations of AS, pain intensity, and pain interference among 452 (Mage = 55.22, SD = 8.73, 89.4% male) responders to the WTC disaster completing a 2-week daily diary study. Using multi-level modeling, AS total score was positively associated with both pain intensity and pain interference, and that AS cognitive concerns, but not social or physical concerns, were associated with increased pain. These results highlight the importance of AS as a predictor of pain complaints among WTC responders and provide initial empirical evidence to support AS as a clinical target for treating pain complaints among WTC responders.

Autoimmune conditions in the World Trade Center general responder cohort: A nested case-control and standardized incidence ratio analysis.

BACKGROUND: The World Trade Center (WTC) general responder cohort (GRC) was exposed to environmental toxins possibly associated with increased risk of developing autoimmune conditions. OBJECTIVES: Two study designs were used to assess incidence and risks of autoimmune conditions in the GRC. METHODS: Three clinically trained professionals established the status of possible GRC cases of autoimmune disorders adhering to diagnostic criteria, supplemented, as needed, by specialists' review of consenting responders' medical records. Nested case-control analyses using conditional logistic regression estimated the risk associated with high WTC exposure (being in the 9/11/2001 dust cloud or ≥median days' response worked) compared with low WTC exposure (all other GRC members'). Four controls were matched to each case on age at case diagnosis (±2 years), sex, race/ethnicity, and year of program enrollment. Sex-specific and sensitivity analyses were performed. GRC age- and sex-adjusted standardized incidence ratios (SIRs) were compared with the Rochester Epidemiology Project (REP). Complete REP inpatient and outpatient medical records were reviewed by specialists. Conditions meeting standardized criteria on ≥2 visits were classified as REP confirmed cases. RESULTS: Six hundred and twenty-eight responders were diagnosed with autoimmune conditions between 2002 and 2017. In the nested case-control analyses, high WTC exposure was not associated with autoimmune domains and conditions (rheumatologic domain odds ratio [OR] = 1.03, 95% confidence interval [CI] = 0.77, 1.37; rheumatoid arthritis OR = 1.12, 95% CI = 0.70, 1.77). GRC members had lower SIR than REP. Women's risks were generally greater than men's. CONCLUSIONS: The study found no statistically significant increased risk of autoimmune conditions with WTC exposures.