Blood Leukocyte Concentrations, FEV1 Decline, and Airflow Limitation. A 15-Year Longitudinal Study of World Trade Center-exposed Firefighters.

RATIONALE: Rescue/recovery work at the World Trade Center disaster site (WTC) caused a proximate decline in lung function in Fire Department of the City of New York firefighters. A subset of this cohort experienced an accelerated rate of lung function decline over 15 years of post-September 11, 2001 (9/11) follow-up. OBJECTIVES: To determine if early postexposure blood leukocyte concentrations are biomarkers for subsequent FEV1 decline and incident airflow limitation. METHODS: Individual rates of forced expiratory volume in 1 second (FEV1) change were calculated for 9,434 firefighters using 88,709 spirometric measurements taken between September 11, 2001, and September 10, 2016. We categorized FEV1 change rates into three trajectories: accelerated FEV1 decline (FEV1 loss >64 ml/yr), expected FEV1 decline (FEV1 loss between 0 and 64 ml/yr), and improved FEV1 (positive rate of change >0 ml/yr). Occurrence of FEV1/FVC less than 0.70 after 9/11 defined incident airflow limitation. Using regression models, we assessed associations of post-9/11 blood eosinophil and neutrophil concentrations with subsequent FEV1 decline and airflow limitation, adjusted for age, race, smoking, height, WTC exposure level, weight change, and baseline lung function. RESULTS: Accelerated FEV1 decline occurred in 12.7% of participants (1,199 of 9,434), whereas post-9/11 FEV1 improvement occurred in 8.3% (780 of 9,434). Higher blood eosinophil and neutrophil concentrations were each associated with accelerated FEV1 decline after adjustment for covariates (odds ratio [OR], 1.10 per 100 eosinophils/µl; 95% confidence interval [CI], 1.05-1.15; and OR, 1.10 per 1,000 neutrophils/µl; 95% CI, 1.05-1.15, respectively). Multivariable-adjusted linear regression models showed that a higher blood neutrophil concentration was associated with a faster rate of FEV1 decline (1.14 ml/yr decline per 1,000 neutrophils/µl; 95% CI, 0.69-1.60 ml/yr; P < 0.001). Higher blood eosinophil concentrations were associated with a faster rate of FEV1 decline in ever-smokers (1.46 ml/yr decline per 100 eosinophils/µl; 95% CI, 0.65-2.26 ml/yr; P < 0.001) but not in never-smokers (P for interaction = 0.004). Higher eosinophil concentrations were also associated with incident airflow limitation (adjusted hazard ratio, 1.10 per 100 eosinophils/µl; 95% CI, 1.04-1.15). Compared with the expected FEV1 decline group, individuals experiencing accelerated FEV1 decline were more likely to have incident airflow limitation (adjusted OR, 4.12; 95% CI, 3.30-5.14). CONCLUSIONS: Higher post-9/11 blood neutrophil and eosinophil concentrations were associated with subsequent accelerated FEV1 decline in WTC-exposed firefighters. Both higher blood eosinophil concentrations and accelerated FEV1 decline were associated with incident airflow limitation in WTC-exposed firefighters.

Clinical Course of Sarcoidosis in World Trade Center-Exposed Firefighters.

BACKGROUND: Sarcoidosis is believed to represent a genetically primed, abnormal immune response to an antigen exposure or inflammatory trigger, with both genetic and environmental factors playing a role in disease onset and phenotypic expression. In a population of firefighters with post-World Trade Center (WTC) 9/11/2001 (9/11) sarcoidosis, we have a unique opportunity to describe the clinical course of incident sarcoidosis during the 15 years postexposure and, on average, 8 years following diagnosis. METHODS: Among the WTC-exposed cohort, 74 firefighters with post-9/11 sarcoidosis were identified through medical records review. A total of 59 were enrolled in follow-up studies. For each participant, the World Association of Sarcoidosis and Other Granulomatous Diseases organ assessment tool was used to categorize the sarcoidosis involvement of each organ system at time of diagnosis and at follow-up. RESULTS: The incidence of sarcoidosis post-9/11 was 25 per 100,000. Radiographic resolution of intrathoracic involvement occurred in 24 (45%) subjects. Lung function for nearly all subjects was within normal limits. Extrathoracic involvement increased, most prominently joints (15%) and cardiac (16%) involvement. There was no evidence of calcium dysmetabolism. Few subjects had ocular (5%) or skin (2%) involvement, and none had beryllium sensitization. Most (76%) subjects did not receive any treatment. CONCLUSIONS: Extrathoracic disease was more prevalent in WTC-related sarcoidosis than reported for patients with sarcoidosis without WTC exposure or for other exposure-related granulomatous diseases (beryllium disease and hypersensitivity pneumonitis). Cardiac involvement would have been missed if evaluation stopped after ECG, 48-h recordings, and echocardiogram. Our results also support the need for advanced cardiac screening in asymptomatic patients with strenuous, stressful, public safety occupations, given the potential fatality of a missed diagnosis.

Spirometry Reference Equations from the HCHS/SOL (Hispanic Community Health Study/Study of Latinos).

RATIONALE: Accurate reference values for spirometry are important because the results are used for diagnosing common chronic lung diseases such as asthma and chronic obstructive pulmonary disease, estimating physiologic impairment, and predicting all-cause mortality. Reference equations have been established for Mexican Americans but not for others with Hispanic/Latino backgrounds. OBJECTIVES: To develop spirometry reference equations for adult Hispanic/Latino background groups in the United States. METHODS: The HCHS/SOL (Hispanic Community Health Study/Study of Latinos) recruited a population-based probability sample of 16,415 Hispanics/Latinos aged 18-74 years living in the Bronx, Chicago, Miami, and San Diego. Participants self-identified as being of Puerto Rican, Cuban, Dominican, Mexican, or Central or South American background. Spirometry was performed using standardized methods with central quality control monitoring. Spirometric measures from a subset of 6,425 never-smoking participants without respiratory symptoms or disease were modeled as a function of sex, age, height, and Hispanic/Latino background to produce background-specific reference equations for the predicted value and lower limit of normal. MEASUREMENTS AND MAIN RESULTS: Dominican and Puerto Rican Americans had substantially lower predicted and lower limit of normal values for FVC and FEV1 than those in other Hispanic/Latino background groups and also than Mexican American values from NHANES III (Third National Health and Nutrition Examination Survey). CONCLUSIONS: For patients of Dominican and Puerto Rican background who present with pulmonary symptoms in clinical practice, use of background-specific spirometry reference equations may provide more appropriate predicted and lower limit of normal values, enabling more accurate diagnoses of abnormality and physiologic impairment.

Post-9/11/2001 lung function trajectories by sex and race in World Trade Center-exposed New York City emergency medical service workers.

OBJECTIVE: To determine whether lung function trajectories after 9/11/2001 (9/11) differed by sex or race/ethnicity in World Trade Center-exposed Fire Department of the City of New York emergency medical service (EMS) workers. METHOD: Serial cross-sectional study of pulmonary function tests (PFTs) taken between 9/11 and 9/10/2015. We used data from routine PFTs (forced expiratory volume in 1 s (FEV1) and FEV1% predicted), conducted at 12-18 month intervals. FEV1 and FEV1% predicted were assessed over time, stratified by sex, and race/ethnicity. We also assessed FEV1 and FEV1% predicted in current, former and never-smokers. RESULTS: Among 1817 EMS workers, 334 (18.4%) were women, 979 (53.9%) self-identified as white and 939 (51.6%) were never-smokers. The median follow-up was 13.1 years (IQR 10.5-13.6), and the median number of PFTs per person was 11 (IQR 7-13). After large declines associated with 9/11, there was no discernible recovery in lung function. In analyses limited to never-smokers, the trajectory of decline in adjusted FEV1 and FEV1% predicted was relatively parallel for men and women in the 3 racial/ethnic groups. Similarly, small differences in FEV1 annual decline between groups were not clinically meaningful. Analyses including ever-smokers were essentially the same. CONCLUSIONS: 14 years after 9/11, most EMS workers continued to demonstrate a lack of lung function recovery. The trajectories of lung function decline, however, were parallel by sex and by race/ethnicity. These findings support the use of routine, serial measures of lung function over time in first responders and demonstrate no sex or racial sensitivity to exposure-related lung function decline.

Bronchial Reactivity and Lung Function After World Trade Center Exposure.

BACKGROUND: World Trade Center (WTC)-exposed rescue/recovery workers endured massive respiratory insult from inhalation of particulate matter and gases, resulting in respiratory symptoms, loss of lung function, and, for many, bronchial hyperreactivity (BHR). The persistence of respiratory symptoms and lung function abnormalities has been well-documented, whereas persistence of BHR has not been investigated. METHODS: A total of 173 WTC-exposed firefighters with bronchial reactivity measured within 2 years after September 11, 2001 (9/11) (baseline methacholine challenge test), were reevaluated in 2013 and 2014 (follow-up methacholine challenge test). FEV1 measurements were obtained from the late pre-9/11, early post-9/11, and late post-9/11 periods. Respiratory symptoms and corticosteroid treatment were recorded. RESULTS: Bronchial reactivity remained stable (within 1 doubling dilution) for most (n = 101, 58%). Sixteen of 28 (57%) with BHR (provocative concentration of methacholine producing a 20% decline in FEV1 <8 mg/mL) at baseline had BHR at follow-up, and an additional 27 of the 145 (19%) without BHR at baseline had BHR at follow-up. In multivariable models, we found that BHR baseline was strongly associated with BHR follow-up (OR, 6.46) and that BHR at follow-up was associated with an estimated 15.4 mL/y greater FEV1 decline than experienced by those without BHR at follow-up. Annual FEV1 decline was moderated by corticosteroid use. CONCLUSIONS: Persistent BHR and its deleterious influence on lung function suggest a role for airway inflammation in perpetuation of WTC-associated airway disease. In future massive occupational exposure to inorganic dust/gases, we recommend early and serial pulmonary function testing, including measurements of bronchial reactivity, when possible, and inhaled corticosteroid therapy for those with symptoms or pulmonary function tests consistent with airway disease.

Blood Eosinophils and World Trade Center Exposure Predict Surgery in Chronic Rhinosinusitis. A 13.5-Year Longitudinal Study.

RATIONALE: The World Trade Center (WTC) collapse generated caustic airborne particulates that caused chronic rhinosinusitis in exposed Fire Department of New York firefighters. Surgery was performed when symptoms remained uncontrolled despite medical management. OBJECTIVES: To identify predictors of surgical intervention for chronic rhinosinusitis in firefighters exposed to airborne irritants at the WTC collapse site. METHODS: We assessed in 8,227 firefighters with WTC exposure between September 11, 2001 (9/11), and September 25, 2001, including WTC-site arrival time, months of rescue and recovery work, and eosinophil concentration measured between 9/11 and March 10, 2003. We assessed the association of serum cytokines and immunoglobulins with eosinophil concentration and surgery for rhinosinusitis in 112 surgical cases and 376 control subjects with serum available from the first 6 months after exposure to the WTC collapse site. MEASUREMENTS AND MAIN RESULTS: Between 9/11 and March 10, 2015, the surgery rate was 0.47 cases per 100 person-years. In the first 18 months post-9/11, surgical patients had higher mean blood eosinophil levels than study cohort patients (219 ± 155 vs. 191 ± 134; P < 0.0001). Increased surgery risk was associated with increasing blood eosinophil counts (hazard ratio [HR], 1.12 per 100 cells/µl; 95% confidence interval [CI], 1.07-1.17; P < 0.001); arriving at the WTC site on 9/11 or September 12, 2001 (HR, 1.43; 95% CI, 1.04-1.99; P = 0.03); and working 6 months or longer at the WTC site (HR, 1.48; 95% CI, 1.14-1.93; P < 0.01). Median blood eosinophil levels for surgical patients were above levels for the cohort in all 18-month intervals March 11, 2000, through March 10, 2015, using 51,163 measurements representing 97,733 person-years of observation. Increasing age, increasing IL-17A, and low IgA in serum from 2001 to 2002 predicted blood eosinophil concentration in surgical patients but not in control subjects (R(2) = 0.26, P < 0.0001; vs. R(2) = 0.008, P = 0.56). CONCLUSIONS: Increasing blood eosinophil concentration predicts surgical intervention for chronic rhinosinusitis, particularly in those with intense acute and prolonged exposure to airborne irritants. WTC-exposed Fire Department of New York firefighters who underwent irritant-associated sinus surgery are immunologically different from the cohort. Surgical patients have a higher blood eosinophil levels that is associated with mediators of mucosal immunity.

Lung Function Trajectories in World Trade Center-Exposed New York City Firefighters Over 13 Years: The Roles of Smoking and Smoking Cessation.

BACKGROUND: World Trade Center (WTC)-exposed Fire Department of the City of New York firefighters lost, on average, 10% of lung function after September 11, 2011, and >10% developed new obstructive airways disease. There was little recovery (on average) over the first 6 years. Follow-up into the next decade allowed us to determine the longer-term exposure effects and the roles of cigarette smoking and cessation on lung function trajectories. METHODS: We examined serial measurements of FEV1 from March 11, 2000, to September 10, 2014, among 10,641 WTC-exposed Fire Department of the City of New York firefighters with known smoking and body weight histories. RESULTS: The median number of FEV1 measurements during follow-up was 9; 15% of firefighters arrived at the WTC during the morning of September 11, 2001; and 65% never smoked. Firefighters arriving the morning of September 11, 2001 averaged lower lung function than did lesser exposed firefighters; this difference remained significant during most of follow-up (P < .05). Never smokers had significantly better lung function than current smokers; former smokers fell in between, depending upon their cessation date. Those arriving the morning of September 11, 2001 were more likely to have an FEV1 < lower limits of normal compared with those arriving between September 13, 2001, and September 24, 2001 (OR = 1.70, P < .01). Current smokers were more likely to have an FEV1 < lower limits of normal compared with never smokers (OR = 2.06, P < .01), former smokers who quit before September 11, 2001 (OR = 1.96, P < .01), or those who quit between September 11, 2001 and March 10, 2008 (OR = 1.49, P < .01). CONCLUSIONS: Thirteen years after September 11, 2001, most firefighters continued to show a lack of lung function recovery, with the trajectory of decline differing by WTC exposure and smoking status. Unlike the immutable effect of WTC exposure, we demonstrated the benefit on lung function of smoking cessation in this unique occupational/environmental cohort.

Refractory sarcoid arthritis in World Trade Center-exposed New York City firefighters: a case series.

OBJECTIVE: The objective of this study was to describe cases of sarcoid arthritis in firefighters from the Fire Department of the City of New York (FDNY) who worked at the World Trade Center (WTC) site. METHODS: All WTC-exposed FDNY firefighters with sarcoidosis and related chronic inflammatory arthritis (n = 11) are followed jointly by the FDNY-WTC Health Program and the Rheumatology Division at the Hospital for Special Surgery. Diagnoses of sarcoidosis were based on clinical, radiographic, and pathological criteria. Patient characteristics, WTC exposure information, smoking status, date of diagnosis, and pulmonary findings were obtained from FDNY-WTC database. Joint manifestations (symptoms and duration, distribution of joints involved), radiographic findings, and treatment responses were obtained from chart review. RESULTS: Nine of 60 FDNY firefighters who developed sarcoidosis since 9/11/2001 presented with polyarticular arthritis. Two others diagnosed pre-9/11/2001 developed sarcoid arthritis after WTC exposure. All 11 were never cigarette smokers, and all performed rescue/recovery at the WTC site within 3 days of the attacks. All had biopsy-proven pulmonary sarcoidosis, and all required additional disease-modifying antirheumatic drugs for adequate control (stepwise progression from hydroxychloroquine to methotrexate to anti-tumor necrosis factor α agents) of their joint manifestations. CONCLUSIONS: Chronic inflammatory polyarthritis appears to be an important manifestation of sarcoidosis in FDNY firefighters with sarcoidosis and WTC exposure. Their arthritis is chronic and, unlike arthritis in non-WTC-exposed sarcoid patients, inadequately responsive to conventional oral disease-modifying antirheumatic drugs, often requiring anti-tumor necrosis factor α agents. Further studies are needed to determine the generalizability of these findings to other groups with varying levels of WTC exposure or with other occupational/environmental exposures.

Estimating the time interval between exposure to the World Trade Center disaster and incident diagnoses of obstructive airway disease.

Respiratory disorders are associated with occupational and environmental exposures. The latency period between exposure and disease onset remains uncertain. The World Trade Center (WTC) disaster presents a unique opportunity to describe the latency period for obstructive airway disease (OAD) diagnoses. This prospective cohort study of New York City firefighters compared the timing and incidence of physician-diagnosed OAD relative to WTC exposure. Exposure was categorized by WTC arrival time as high (on the morning of September 11, 2001), moderate (after noon on September 11, 2001, or on September 12, 2001), or low (during September 13-24, 2001). We modeled relative rates and 95% confidence intervals of OAD incidence by exposure over the first 5 years after September 11, 2001, estimating the times of change in the relative rate with change point models. We observed a change point at 15 months after September 11, 2001. Before 15 months, the relative rate for the high- versus low-exposure group was 3.96 (95% confidence interval: 2.51, 6.26) and thereafter, it was 1.76 (95% confidence interval: 1.26, 2.46). Incident OAD was associated with WTC exposure for at least 5 years after September 11, 2001. There were higher rates of new-onset OAD among the high-exposure group during the first 15 months and, to a lesser extent, throughout follow-up. This difference in relative rate by exposure occurred despite full and free access to health care for all WTC-exposed firefighters, demonstrating the persistence of WTC-associated OAD risk.

The upper respiratory pyramid: early factors and later treatment utilization in World Trade Center exposed firefighters.

BACKGROUND: We investigated early post 9/11 factors that could predict rhinosinusitis healthcare utilization costs up to 11 years later in 8,079 World Trade Center-exposed rescue/recovery workers. METHODS: We used bivariate and multivariate analytic techniques to investigate utilization outcomes; we also used a pyramid framework to describe rhinosinusitis healthcare groups at early (by 9/11/2005) and late (by 9/11/2012) time points. RESULTS: Multivariate models showed that pre-9/11/2005 chronic rhinosinusitis diagnoses and nasal symptoms predicted final year healthcare utilization outcomes more than a decade after WTC exposure. The relative proportion of workers on each pyramid level changed significantly during the study period. CONCLUSIONS: Diagnoses of chronic rhinosinusitis within 4 years of a major inhalation event only partially explain future healthcare utilization. Exposure intensity, early symptoms and other factors must also be considered when anticipating future healthcare needs.

Longitudinal pulmonary function in newly hired, non-World Trade Center-exposed fire department City of New York firefighters: the first 5 years.

BACKGROUND: Few longitudinal studies characterize firefighters' pulmonary function. We sought to determine whether firefighters have excessive FEV(1) decline rates compared with control subjects. METHODS: We examined serial measurements of FEV(1) from about 6 months prehire to about 5 years posthire in newly hired male, never smoking, non-Hispanic black and white firefighters, hired between 2003 and 2006, without prior respiratory disease or World Trade Center exposure. Similarly defined Emergency Medical Service (EMS) workers served as control subjects. RESULTS: Through June 30, 2011, 940 firefighters (82%) and 97 EMS workers (72%) who met study criteria had four or more acceptable posthire spirometries. Prehire FEV(1) % averaged higher for firefighters than EMS workers (99% vs 95%), reflecting more stringent job entry criteria. FEV(1) (adjusted for baseline age and height) declined by an average of 45 mL/y both for firefighters and EMS workers, with Fire 2 EMS decline rate differences averaging 0.2 mL/y (CI, 2 9.2 to 9.6). Four percent of each group had FEV(1) less than the lower limit of normal before hire, increasing to 7% for firefighters and 17.5% for EMS workers, but similar percentages of both groups had adjusted FEV(1) decline rates 10%. Mixed effects modeling showed a significant influence of weight gain but not baseline weight: FEV(1) declined by about 8 mL/kg gained for both groups. Adjusting for weight change, FEV(1) decline averaged 38 mL/y for firefighters and 34 mL/y for EMS workers. CONCLUSIONS: During the first 5 years of duty, firefighters do not show greater longitudinal FEV(1) decline than EMS control subjects, and fewer of them develop abnormal lung function. Weight gain is associated with a small loss of lung function, of questionable clinical relevance in this fit and active population.

Metabolic syndrome biomarkers predict lung function impairment: a nested case-control study.

RATIONALE: Cross-sectional studies demonstrate an association between metabolic syndrome and impaired lung function. OBJECTIVES: To define if metabolic syndrome biomarkers are risk factors for loss of lung function after irritant exposure. METHODS: A nested case-control study of Fire Department of New York personnel with normal pre-September 11th FEV(1) and who presented for subspecialty pulmonary evaluation before March 10, 2008. We correlated metabolic syndrome biomarkers obtained within 6 months of World Trade Center dust exposure with subsequent FEV(1). FEV(1) at subspecialty pulmonary evaluation within 6.5 years defined disease status; cases had FEV(1) less than lower limit of normal, whereas control subjects had FEV(1) greater than or equal to lower limit of normal. MEASUREMENTS AND MAIN RESULTS: Clinical data and serum sampled at the first monitoring examination within 6 months of September 11, 2001, assessed body mass index, heart rate, serum glucose, triglycerides and high-density lipoprotein (HDL), leptin, pancreatic polypeptide, and amylin. Cases and control subjects had significant differences in HDL less than 40 mg/dl with triglycerides greater than or equal to 150 mg/dl, heart rate greater than or equal to 66 bpm, and leptin greater than or equal to 10,300 pg/ml. Each increased the odds of abnormal FEV(1) at pulmonary evaluation by more than twofold, whereas amylin greater than or equal to 116 pg/ml decreased the odds by 84%, in a multibiomarker model adjusting for age, race, body mass index, and World Trade Center arrival time. This model had a sensitivity of 41%, a specificity of 86%, and a receiver operating characteristic area under the curve of 0.77. CONCLUSIONS: Abnormal triglycerides and HDL and elevated heart rate and leptin are independent risk factors of greater susceptibility to lung function impairment after September 11, 2001, whereas elevated amylin is protective. Metabolic biomarkers are predictors of lung disease, and may be useful for assessing risk of impaired lung function in response to particulate inhalation.

Physician-diagnosed respiratory conditions and mental health symptoms 7-9 years following the World Trade Center disaster.

BACKGROUND: This study examines the prevalence of physician-diagnosed respiratory conditions and mental health symptoms in firefighters and emergency medical service workers up to 9 years after rescue/recovery efforts at the World Trade Center (WTC). METHODS: We analyzed Fire Department of New York (FDNY) physician and self-reported diagnoses by WTC exposure and quintiles of pulmonary function (FEV1% predicted). We used screening instruments to assess probable post-traumatic stress disorder (PTSD) and probable depression. RESULTS: FDNY physicians most commonly diagnosed asthma (8.8%) and sinusitis (9.7%). The highest prevalence of physician-diagnosed obstructive airway disease (OAD) was in the lowest FEV1% predicted quintile. Participants who arrived earliest on 9/11 were more likely to have physician-diagnosed asthma (OR = 1.4). Seven percent had probable PTSD. 19.4% had probable depression. CONCLUSIONS: Self-reported and physician-diagnosed respiratory conditions remain common, especially among those who arrived earliest at the WTC site. OAD was associated with the lowest pulmonary function. Since respiratory and mental health conditions remain prevalent, ongoing monitoring and treatment is important.

Early assessment of cancer outcomes in New York City firefighters after the 9/11 attacks: an observational cohort study.

BACKGROUND: The attacks on the World Trade Center (WTC) on Sept 11, 2001 (9/11) created the potential for occupational exposure to known and suspected carcinogens. We examined cancer incidence and its potential association with exposure in the first 7 years after 9/11 in firefighters with health information before 9/11 and minimal loss to follow-up. METHODS: We assessed 9853 men who were employed as firefighters on Jan 1, 1996. On and after 9/11, person-time for 8927 firefighters was classified as WTC-exposed; all person-time before 9/11, and person-time after 9/11 for 926 non-WTC-exposed firefighters, was classified as non-WTC exposed. Cancer cases were confirmed by matches with state tumour registries or through appropriate documentation. We estimated the ratio of incidence rates in WTC-exposed firefighters to non-exposed firefighters, adjusted for age, race and ethnic origin, and secular trends, with the US National Cancer Institute Surveillance Epidemiology and End Results (SEER) reference population. CIs were estimated with overdispersed Poisson models. Additional analyses included corrections for potential surveillance bias and modified cohort inclusion criteria. FINDINGS: Compared with the general male population in the USA with a similar demographic mix, the standardised incidence ratios (SIRs) of the cancer incidence in WTC-exposed firefighters was 1·10 (95% CI 0·98-1·25). When compared with non-exposed firefighters, the SIR of cancer incidence in WTC-exposed firefighters was 1·19 (95% CI 0·96-1·47) corrected for possible surveillance bias and 1·32 (1·07-1·62) without correction for surveillance bias. Secondary analyses showed similar effect sizes. INTERPRETATION: We reported a modest excess of cancer cases in the WTC-exposed cohort. We remain cautious in our interpretation of this finding because the time since 9/11 is short for cancer outcomes, and the reported excess of cancers is not limited to specific organ types. As in any observational study, we cannot rule out the possibility that effects in the exposed group might be due to unidentified confounders. Continued follow-up will be important and should include cancer screening and prevention strategies. FUNDING: National Institute for Occupational Safety and Health.

Obstructive airways disease with air trapping among firefighters exposed to World Trade Center dust.

BACKGROUND: The World Trade Center (WTC) collapse produced a massive exposure to respirable particulates in New York City Fire Department (FDNY) rescue workers. This group had spirometry examinations pre-September 11, 2001, and post-September 11, 2001, demonstrating declines in lung function with parallel declines in FEV(1) and FVC. To date, the underlying pathophysiologic cause for this has been open to question. METHODS: Of 13,234 participants in the FDNY-WTC Monitoring Program, 1,720 (13%) were referred for pulmonary subspecialty evaluation at a single institution. Evaluation included 919 full pulmonary function tests, 1,219 methacholine challenge tests, and 982 high-resolution chest CT scans. RESULTS: At pulmonary evaluation (median 34 months post-September 11, 2001), median values were FEV(1) 93% predicted (interquartile range [IQR], 83%-101%), FVC 98% predicted (IQR, 89%-106%), and FEV(1)/FVC 0.78 (IQR, 0.72-0.82). The residual volume (RV) was 123% predicted (IQR, 106%-147%) with nearly all participants having normal total lung capacity, functional residual capacity, and diffusing capacity of carbon monoxide. Also, 1,051/1,720 (59%) had obstructive airways disease based on at least one of the following: FEV(1)/FVC, bronchodilator responsiveness, hyperreactivity, or elevated RV. After adjusting for age, gender, race, height and weight, and tobacco use, the decline in FEV(1) post-September 11, 2001, was significantly correlated with increased RV percent predicted (P < .0001), increased bronchodilator responsiveness (P < .0001), and increased hyperreactivity (P = .0056). CT scans demonstrated bronchial wall thickening that was significantly associated with the decline in FEV(1) post-September 11, 2001 (P = .024), increases in hyperreactivity (P < .0001), and increases in RV (P < .0001). Few had evidence for interstitial disease. CONCLUSIONS: Airways obstruction was the predominant physiologic finding underlying the reduction in lung function post-September 11, 2001, in FDNY WTC rescue workers presenting for pulmonary evaluation.

The prevalence of coronary artery disease in end-stage pulmonary disease: is pulmonary fibrosis a risk factor?

BACKGROUND: It has been suggested that coronary artery disease (CAD) is a common complicating condition in pulmonary fibrosis. OBJECTIVE: To establish and compare the incidence of coronary artery disease in lung-transplantation candidates with emphysema and lung fibrosis METHOD: All adult patients (age>40 years old) with emphysema or lung fibrosis, candidates for lung transplantation between January 1997 and December 2003, were included. All patients underwent pretransplant coronary angiography. RESULTS: A total of 100 patients were enrolled; 51 with emphysema and 49 with fibrosis. CAD (at least one 50% stenotic coronary artery) was diagnosed in fourteen of 49 (28.6%) patients with lung fibrosis as compared to five out of 51 (9.8%) with emphysema, [p=0.019] despite the fact that 98% of patients with emphysema but only 31% of the patients with lung fibrosis were heavy smokers. The groups didn't significantly differ in any other cardiovascular risks. CONCLUSIONS: There is significantly more CAD in lung-transplantation candidates with lung fibrosis as compared to those with emphysema, despite the fact that smoking was much more prevalent in the emphysema patients. These results suggest that the inflammatory process in lung fibrosis may involve the coronary arteries as a part of a systemic inflammation rather than an idiopathic fibrotic disease confined to the lungs.

Upper and lower respiratory diseases after occupational and environmental disasters.

Respiratory consequences from occupational and environmental disasters are the result of inhalation exposures to chemicals, particulate matter (dusts and fibers) and/or the incomplete products of combustion that are often liberated during disasters such as fires, building collapses, explosions and volcanoes. Unfortunately, experience has shown that environmental controls and effective respiratory protection are often unavailable during the first days to week after a large-scale disaster. The English literature was reviewed using the key words-disaster and any of the following: respiratory disease, pulmonary, asthma, bronchitis, sinusitis, pulmonary fibrosis, or sarcoidosis. Respiratory health consequences after aerosolized exposures to high-concentrations of particulates and chemicals can be grouped into 4 major categories: 1) upper respiratory disease (chronic rhinosinusitis and reactive upper airways dysfunction syndrome), 2) lower respiratory diseases (reactive [lower] airways dysfunction syndrome, irritant-induced asthma, and chronic obstructive airways diseases), 3) parenchymal or interstitial lung diseases (sarcoidosis, pulmonary fibrosis, and bronchiolitis obliterans, and 4) cancers of the lung and pleura. This review describes several respiratory consequences of occupational and environmental disasters and uses the World Trade Center disaster to illustrate in detail the consequences of chronic upper and lower respiratory inflammation.

World Trade Center "sarcoid-like" granulomatous pulmonary disease in New York City Fire Department rescue workers.

BACKGROUND: Previous reports suggest that sarcoidosis occurs with abnormally high frequency in firefighters. We sought to determine whether exposure to World Trade Center (WTC) "dust" during the collapse and rescue/recovery effort increased the incidence of sarcoidosis or "sarcoid-like" granulomatous pulmonary disease (SLGPD). METHODS: During the 5 years after the WTC disaster, enrollees in the Fire Department of New York (FDNY) WTC monitoring and treatment programs who had chest radiograph findings suggestive of sarcoidosis underwent evaluation, including the following: chest CT imaging, pulmonary function, provocative challenge, and biopsy. Annual incidence rates were compared to the 15 years before the WTC disaster. RESULTS: After WTC dust exposure, pathologic evidence consistent with new-onset sarcoidosis was found in 26 patients: all 26 patients had intrathoracic adenopathy, and 6 patients (23%) had extrathoracic disease. Thirteen patients were identified during the first year after WTC dust exposure (incidence rate, 86/100,000), and 13 patients were identified during the next 4 years (average annual incidence rate, 22/100,000; as compared to 15/100,000 during the 15 years before the WTC disaster). Eighteen of 26 patients (69%) had findings consistent with asthma. Eight of 21 patients (38%) agreeing to challenge testing had airway hyperreactivity (AHR), findings not seen in FDNY sarcoidosis patients before the WTC disaster. CONCLUSION: After the WTC disaster, the incidence of sarcoidosis or SLGPD was increased among FDNY rescue workers. This new information about the early onset of WTC-SLGPD and its association with asthma/AHR has important public health consequences for disease prevention, early detection, and treatment following environmental/occupational exposures.

Smoking cessation in the elderly.

Today, two generations after the first Surgeon General's report, and with abundant evidence of the catastrophic consequences of smoking, no serious person can be unaware that smokers risk their lives and health. We also know that quitting smoking--at any age--promises significant health benefits. When offered the tools they need, older smokers quit smoking at rates comparable to those of younger smokers despite their skepticism, fatalism, and self-doubt. Older smokers should be encouraged to enter programs that stress the health benefits derived and identify the risks they are avoiding by quitting smoking. These programs establish quit dates, use sound behavioral modification techniques, provide strategies for stress management and relaxation, treat withdrawal symptoms, and provide regular and continuing follow-up. The patient is asked to make an existential change, and the physician should provide encouragement and promote self-confidence by emphasizing that, despite setbacks, with repeated efforts, success can be achieved. Clinicians can influence patients to quit smoking, and they should.

Lymphoepithelial cyst in the lung: a case report.

An unusual endobronchial presentation of lymphoepithelial cysts (LECs) is described in a HIV-seropositive patient. The bilateral infrahilar cysts had followed an apparently benign course for 2 years. Bronchoscopy revealed an endobronchial mass occluding the anterior basilar segment of the left lower lobe. Biopsy resulted in emptying of the cyst and showed the typical pseudostratified columnar epithelium with intraepithelial lymphocytes of an LEC. This diagnosis should be considered in patients with HIV infection and pulmonary cysts on CT.