Post-traumatic stress disorder dimensions and asthma morbidity in World Trade Center rescue and recovery workers.

OBJECTIVE: Using data from a cohort of World Trade Center (WTC) rescue and recovery workers with asthma, we assessed whether meeting criteria for post-traumatic stress disorder (PTSD), sub-threshold PTSD, and for specific PTSD symptom dimensions are associated with increased asthma morbidity. METHODS: Participants underwent a Structured Clinical Interview for Diagnostic and Statistical Manual to assess the presence of PTSD following DSM-IV criteria during in-person interviews between December 2013 and April 2015. We defined sub-threshold PTSD as meeting criteria for two of three symptom dimensions: re-experiencing, avoidance, or hyper-arousal. Asthma control, acute asthma-related healthcare utilization, and asthma-related quality of life data were collected using validated scales. Unadjusted and multiple regression analyses were performed to assess the relationship between sub-threshold PTSD and PTSD symptom domains with asthma morbidity measures. RESULTS: Of the 181 WTC workers with asthma recruited into the study, 28% had PTSD and 25% had sub-threshold PTSD. Patients with PTSD showed worse asthma control, higher rates of inpatient healthcare utilization, and poorer asthma quality of life than those with sub-threshold or no PTSD. After adjusting for potential confounders, among patients not meeting the criteria for full PTSD, those presenting symptoms of re-experiencing exhibited poorer quality of life (p = 0.003). Avoidance was associated with increased acute healthcare use (p = 0.05). Sub-threshold PTSD was not associated with asthma morbidity (p > 0.05 for all comparisons). CONCLUSIONS: There may be benefit in assessing asthma control in patients with sub-threshold PTSD symptoms as well as those with full PTSD to more effectively identify ongoing asthma symptoms and target management strategies.

Frequency dependence of compliance in the evaluation of patients with unexplained respiratory symptoms.

Frequency dependence of compliance (FDC) reflects non-homogeneous ventilatory distribution and, in the presence of a normal measured airway resistance, suggests peripheral airways dysfunction. This study evaluated peripheral airway function and bronchial reactivity in irritant exposed or non-exposed individuals with normal routine pulmonary function tests (PFTs) who had persistent unexplained lower respiratory symptoms. Twenty-two patients were identified with persistent respiratory symptoms and with normal chest X-ray and PFTs. Twenty were non-smokers; two had stopped smoking more than 10 years before evaluation. Twelve patients had been exposed to irritants in their workplaces or at home. Non-specific bronchial hyper-reactivity (nsBHR) and FDC, pre- and post-bronchodilator, were measured in all patients. Studies were repeated in 6/12 irritant-exposed subjects after exposure removal and inhaled corticosteroid treatment. Whereas 12/22 patients had nsBHR, all 22 subjects demonstrated FDC [dynamic lung compliance/static lung compliance Cdyn,1 / Cst,1 at respiratory frequency 60 min(-1) (f60), mean 46%, range 27-67%]. After bronchodilator administration, a 15% improvement Cdyn,1 was observed most consistently at f60 (mean% improvement 26%, 95% CI 14-38%) and in subjects without nsBHR. However, Cdyn,1 at f60 did not return to normal after inhaled bronchodilator. Irritant-exposed and unexposed individuals appeared similar in results of testing for FDC and nsBHR. FDC and its response to bronchodilators provide objective physiological measures of an airway abnormality which may provide a basis for clinical symptoms in patients with normal routine pulmonary function studies. The presence of persistently abnormal FDC after bronchodilator (BD) and on follow up studies may reflect chronic inflammatory and/or structural changes in the airways in addition to bronchoconstriction.

Occupational and environmental medicine in Colombia.

Colombia is a country rich in natural resources, with a steadily developing economy. Occupational and environmental medicine (OEM) education and practice have developed relatively recently in Colombia, mainly in response to a series of long overdue (and still partially implemented) reforms to the health care, social benefits, and education systems. Expansion in general and occupational health coverage of the Colombian population and development of OEM education and training were to be achieved through a clear stimulus to private sector initiatives. Despite some measurable overall progress, the goals remain elusive. This article discusses several aspects and the perspectives for further development of the specialty in this country, in the context of the socioeconomic factors involved in that process.

Reactive airways dysfunction syndrome following exposure to a fluorocarbon.

This report describes the case of a 43-yr-old male who developed reactive airways dysfunction syndrome after exposure to a high level of bromotrifluoromethane (CF3Br, Halon 1301), a fluorocarbon widely used in automatic fire extinguishing systems. The patient was a previously healthy, nonatopic male, who developed wheezing and intermittent and reversible obstructive ventilatory impairment starting immediately after a large accidental nonfire-related release of CF3Br in a confined space.

Altitude-related pulmonary disorders.

The major physiologic stress encountered at high altitude is caused by the occurrence of hypobaric hypoxia. In this article, acute and chronic pulmonocardiac adaptation to altitude is reviewed, including possible genetic differences among highlanders from the Himalayan versus the Andean Mountains. The origin, symptoms, and treatment of acute mountain sickness and high altitude pulmonary edema are outlined. In addition, the prediction and prevention of pulmonary complications that may be encountered or exacerbated during commercial airflight are noticed.

Diagnosis of cytomegalovirus infection in HIV-infected patients with respiratory disease.

BACKGROUND: The role of the cytomegalovirus (CMV) in the respiratory morbidity and mortality of HIV-infected patients remains unclear. This is due in part to difficulties in making an accurate and rapid diagnosis. There has been a limited number of studies, often with few or no AIDS patients, on the use of DNA-DNA in situ hybridization (ISH) and polymerase chain reaction to diagnose CMV respiratory infection directly on bronchoalveolar fluid samples. OBJECTIVES: To compare the centrifugation culture (CC), ISH, and nested-primer polymerase chain reaction (npPCR) techniques (npPCR) techniques on bronchoalveolar fluid for the diagnosis of respiratory CMV infection. STUDY DESIGN: Samples were obtained prospectively from a group of 35 HIV-infected homosexual men evaluated for pneumonia at a university hospital. Sensitivity, specificity, and predictive values of the three techniques were measured and compared, using the conventional roller tube cell culture (CRTC) as the gold standard. RESULTS: Sensitivity, specificity, positive and negative predictive values were as follows: 86%, 86%, 90%, and 80% for the CC; 5%, 100%, 100%, and 41% for ISH; and 86%, 57%, 75%, and 73% for npPCR. Of the six false positive samples by npPCR, two were positive by CC (none by ISH). If the latter were considered true positives, the specificity and positive predictive values of npPCR would increase to 67% and 83%, respectively. CONCLUSIONS: CC appeared to be the best of the three techniques compared in this study for diagnosis of respiratory CMV infection in HIV-infected patients. The sensitivity and predictive values of DNA-DNA ISH were very poor. Results with npPCR were acceptable, and this technique may be considered in situations when rapid diagnosis of CMV infection is necessary.

Occupational and environmental medicine in the United States.

The history and the current status of occupational and environmental medicine (OEM) research, educational resources, clinical practice patterns, and regulatory framework in the United States are reviewed. Current or anticipated changes in health-care financing, clinical practice patterns, occupational safety and health regulations and enforcement, and funding for research and medical education at the national level are already having an impact on OEM activities in this country.

Exposure to potential occupational asthmogens: prevalence data from the National Occupational Exposure Survey.

Few data are available about the prevalence of occupational exposures to agents which can cause occupational asthma or aggravate preexisting asthma (asthmogens). Using potential occupational exposure data from the National Occupational Exposure Survey (NOES) of 1980-1983, we investigated the number of asthmogen exposures, asthmogen-exposure(s) per production worker, and unprotected occupational asthmogen exposures in different industries and occupations. Data for the entire United States were used to generate estimates of occupational exposure at two selected state and local levels. It was estimated that 7,864,000 workers in the surveyed industries were potentially exposed to one or more occupational asthmogen(s) in the United States. The average number of observed potential exposures per asthmogen-exposed worker was 4.4, and varied from 11.9, in the Water Transportation industry, to 1.2 in Local and Suburban transportation. The largest number of observed potential exposures was recorded in the Apparel and Other Finished Products (garment) industry. This work and further analyses using this approach are expected to contribute to a better understanding of the epidemiology of occupational asthma, and to serve as a guide to target future occupational asthma surveillance efforts.

Initial screening for antituberculous drug resistance at an inpatient facility in Leon, Nicaragua.

Antituberculous (anti-TB) drug resistance has become a major tuberculosis control issue in the United States, where this situation has closely paralleled the current acquired immunodeficiency syndrome epidemic associated with human immunodeficiency virus type-1 (HIV-1) infections. In less developed countries, especially those like Nicaragua with an apparently low prevalence of known HIV-1 infections, less is known about the epidemiology of antituberculous drug resistance. To understand the potential extent of this problem in Nicaragua, we conducted a cross-sectional prevalence study at Nicaragua's only inpatient tuberculosis treatment facility, located in Leon, Nicaragua. A radiometric method was used during recovery, purification, and drug susceptibility testing of clinical Mycobacterium tuberculosis isolates. Resistance to at least one of the major anti-TB medications was found in 15 (40.5%) of 37 sputum isolates, of which seven (19%) were resistant to either isoniazid alone, or to isoniazid plus another agent other than rifampin. Five were resistant to at least isoniazid and rifampin (i.e., 13.5% demonstrated multidrug resistance). Two isolates were resistant to pyrazinamide alone, and one was resistant to streptomycin alone. These initial results suggest that anti-TB drug resistance is a defined problem for tuberculosis control programs in Nicaragua, a problem that is largely related to individual noncompliance, lack of extensive drug susceptibility testing facilities, and a general unavailability of expensive anti-TB medications for re-treatment. Ongoing surveillance for drug resistance, using the methodology presented here, might assist Nicaraguan public health officials in their tuberculosis control programs.

Occupational and environmental medicine in New York State.

New York State (NYS) is home to 7.2% of the population and producer of 8.4% of the gross domestic product of the United States. The history and the current status of occupational and environmental medicine (OEM) research, educational resources, clinical practice patterns, and regulatory framework in NYS are reviewed. Changes anticipated or already taking place in health care financing, clinical practice patterns, occupational safety and health regulations and enforcement, and funding for research and medical education at the national level, are already having an impact in OEM activities in NYS.

Chronic lung disease secondary to ammonia inhalation injury: a report on three cases.

Inhalation of highly hydrosoluble toxicants, like ammonia, can be associated with chronic lung diseases, which have been partially characterized. We present the case of three patients who were evaluated 2 years after massive exposure to ammonia in occupational settings. They presented with chronic dyspnea, and clinical pictures consistent with restrictive lung dysfunction, obstructive lung disease, and bronchial hyper-reactivity and small airways disease, respectively. The findings in 94 reported cases of inhalation injury due to massive exposure to ammonia are reviewed; in 35 cases follow-up for at least 1 year was available. The range of chronic pulmonary diseases associated with ammonia inhalation injury is reviewed, and suggestions for appropriate diagnostic evaluation are made.