Trajectories of PTSD risk and resilience in World Trade Center responders: an 8-year prospective cohort study.

BACKGROUND: Longitudinal symptoms of post-traumatic stress disorder (PTSD) are often characterized by heterogeneous trajectories, which may have unique pre-, peri- and post-trauma risk and protective factors. To date, however, no study has evaluated the nature and determinants of predominant trajectories of PTSD symptoms in World Trade Center (WTC) responders. METHOD: A total of 10835 WTC responders, including 4035 professional police responders and 6800 non-traditional responders (e.g. construction workers) who participated in the WTC Health Program (WTC-HP), were evaluated an average of 3, 6 and 8 years after the WTC attacks. RESULTS: Among police responders, longitudinal PTSD symptoms were best characterized by four classes, with the majority (77.8%) in a resistant/resilient trajectory and the remainder exhibiting chronic (5.3%), recovering (8.4%) or delayed-onset (8.5%) symptom trajectories. Among non-traditional responders, a six-class solution was optimal, with fewer responders in a resistant/resilient trajectory (58.0%) and the remainder exhibiting recovering (12.3%), severe chronic (9.5%), subsyndromal increasing (7.3%), delayed-onset (6.7%) and moderate chronic (6.2%) trajectories. Prior psychiatric history, Hispanic ethnicity, severity of WTC exposure and WTC-related medical conditions were most strongly associated with symptomatic trajectories of PTSD symptoms in both groups of responders, whereas greater education and family and work support while working at the WTC site were protective against several of these trajectories. CONCLUSIONS: Trajectories of PTSD symptoms in WTC responders are heterogeneous and associated uniquely with pre-, peri- and post-trauma risk and protective factors. Police responders were more likely than non-traditional responders to exhibit a resistant/resilient trajectory. These results underscore the importance of prevention, screening and treatment efforts that target high-risk disaster responders, particularly those with prior psychiatric history, high levels of trauma exposure and work-related medical morbidities.

Dimensional structure and course of post-traumatic stress symptomatology in World Trade Center responders.

BACKGROUND: Post-traumatic stress disorder (PTSD) in response to the World Trade Center (WTC) disaster of 11 September 2001 (9/11) is one of the most prevalent and persistent health conditions among both professional (e.g. police) and non-traditional (e.g. construction worker) WTC responders, even several years after 9/11. However, little is known about the dimensionality and natural course of WTC-related PTSD symptomatology in these populations. METHOD: Data were analysed from 10 835 WTC responders, including 4035 police and 6800 non-traditional responders who were evaluated as part of the WTC Health Program, a clinic network in the New York area established by the National Institute for Occupational Safety and Health. Confirmatory factor analyses (CFAs) were used to evaluate structural models of PTSD symptom dimensionality; and autoregressive cross-lagged (ARCL) panel regressions were used to examine the prospective interrelationships among PTSD symptom clusters at 3, 6 and 8 years after 9/11. RESULTS: CFAs suggested that five stable symptom clusters best represent PTSD symptom dimensionality in both police and non-traditional WTC responders. This five-factor model was also invariant over time with respect to factor loadings and structural parameters, thereby demonstrating its longitudinal stability. ARCL panel regression analyses revealed that hyperarousal symptoms had a prominent role in predicting other symptom clusters of PTSD, with anxious arousal symptoms primarily driving re-experiencing symptoms, and dysphoric arousal symptoms primarily driving emotional numbing symptoms over time. CONCLUSIONS: Results of this study suggest that disaster-related PTSD symptomatology in WTC responders is best represented by five symptom dimensions. Anxious arousal symptoms, which are characterized by hypervigilance and exaggerated startle, may primarily drive re-experiencing symptoms, while dysphoric arousal symptoms, which are characterized by sleep disturbance, irritability/anger and concentration difficulties, may primarily drive emotional numbing symptoms over time. These results underscore the importance of assessment, monitoring and early intervention of hyperarousal symptoms in WTC and other disaster responders.

Exposure, probable PTSD and lower respiratory illness among World Trade Center rescue, recovery and clean-up workers.

BACKGROUND: Thousands of rescue and recovery workers descended on the World Trade Center (WTC) in the wake of the terrorist attack of September 11, 2001 (9/11). Recent studies show that respiratory illness and post-traumatic stress disorder (PTSD) are the hallmark health problems, but relationships between them are poorly understood. The current study examined this link and evaluated contributions of WTC exposures. METHOD: Participants were 8508 police and 12 333 non-traditional responders examined at the WTC Medical Monitoring and Treatment Program (WTC-MMTP), a clinic network in the New York area established by the National Institute for Occupational Safety and Health (NIOSH). We used structural equation modeling (SEM) to explore patterns of association among exposures, other risk factors, probable WTC-related PTSD [based on the PTSD Checklist (PCL)], physician-assessed respiratory symptoms arising after 9/11 and present at examination, and abnormal pulmonary functioning defined by low forced vital capacity (FVC). RESULTS: Fewer police than non-traditional responders had probable PTSD (5.9% v. 23.0%) and respiratory symptoms (22.5% v. 28.4%), whereas pulmonary function was similar. PTSD and respiratory symptoms were moderately correlated (r=0.28 for police and 0.27 for non-traditional responders). Exposure was more strongly associated with respiratory symptoms than with PTSD or lung function. The SEM model that best fit the data in both groups suggested that PTSD statistically mediated the association of exposure with respiratory symptoms. CONCLUSIONS: Although longitudinal data are needed to confirm the mediation hypothesis, the link between PTSD and respiratory symptoms is noteworthy and calls for further investigation. The findings also support the value of integrated medical and psychiatric treatment for disaster responders.

Unraveling the chronic toxicity of lead: an essential priority for environmental health.

Although population exposure to lead has declined, chronic lead toxicity remains a major public health problem in the United States affecting millions of children and adults. Important gaps exist in knowledge of the pathophysiology of chronic lead intoxication. These gaps have impeded development of control strategies. To close current gaps in knowledge of chronic lead toxicity, we propose an integrated, multidisciplinary, marker-based research program. This program combines a) direct measurement of individual lead burden by 109Cd X-ray fluorescence analysis of lead in bone, b) determination of ALA-D phenotype, an index of individual susceptibility to lead, and c) assessments of subclinical injury produced by lead in the kidneys, nervous system and, reproductive organs. Data from this research will provide answers to questions of great public health importance: a) Are current environmental and occupational standards adequate to prevent chronic lead intoxication? b) is lead mobilized from the skeleton during pregnancy or lactation to cause fetal toxicity? c) Is lead mobilized from bone during menopause to cause neurotoxicity? d) What is the significance of genetic variation in determining susceptibility to lead? e) What is the contribution of lead to hypertension, renal disease, chronic neurodegenerative disease or declining sperm counts? f) Is chelation therapy effective in reducing body lead burden in persons with chronic overexposure to lead?

A cluster of pediatric metallic mercury exposure cases treated with meso-2,3-dimercaptosuccinic acid (DMSA)

Nine children and their mother were exposed to vapors of metallic mercury. The source of the exposure appears to have been a 6-oz vial of mercury taken from a neighbor's home. The neighbor reportedly operated a business preparing mercury-filled amulets for practitioners of the Afro-Caribbean religion Santeria. At diagnosis, urinary mercury levels in the children ranged from 61 to 1,213 microg/g creatinine, with a geometric mean of 214.3 microg/m creatinine. All of the children were asymptomatic. To prevent development of neurotoxicity, we treated the children with oral meso-2,3-dimercaptosuccinic acid (DMSA). During chelation, the geometric mean urine level rose initially by 268% to 573.2 microg mercury/g creatinine (p<0.0005). At the 6-week follow-up examination after treatment, the geometric mean urine mercury level had fallen to 102.1 microg/g creatinine, which was 17.8% of the geometric mean level observed during treatment (p<0.0005) and 47.6% of the original baseline level (p<0.001). Thus, oral chelation with DMSA produced a significant mercury diuresis in these children. We observed no adverse side effects of treatment. DMSA appears to be an effective and safe chelating agent for treatment of pediatric overexposure to metallic mercury.

Exposure to hazardous substances and male reproductive health: a research framework.

The discovery in the mid-1970s that occupational exposures to pesticides could diminish or destroy the fertility of workers sparked concern about the effects of hazardous substances on male reproductive health. More recently, there is evidence that sperm quantity and quality may have declined worldwide, that the incidence of testicular cancer has progressively increased in many countries, and that other disorders of the male reproductive tract such as hypospadias and cryptorchidism may have also increased. There is growing concern that occupational factors and environmental chemical exposures, including in utero and childhood exposures to compounds with estrogenic activity, may be correlated with these observed changes in male reproductive health and fertility. We review the evidence and methodologies that have contributed to our current understanding of environmental effects on male reproductive health and fertility and discuss the methodologic issues which confront investigators in this area. One of the greatest challenges confronting researchers in this area is assessing and comparing results from existing studies. We elaborate recommendations for future research. Researchers in the field of male reproductive health should continue working to prioritize hazardous substances; elucidate the magnitude of male reproductive health effects, particularly in the areas of testicular cancer, hypospadias, and cryptorchidism; develop biomarkers of exposure to reproductive toxins and of reproductive health effects for research and clinical use; foster collaborative interdisciplinary research; and recognize the importance of standardized laboratory methods and sample archiving.

Professionals and professions: a philosophical examination of an ideal.

Being regarded as a professional and having one's occupational group regarded as a profession are often deemed desirable. It is not immediately apparent why this is so. 'Professional' often contrasts simply with 'amateur', and as a label conveys not honor but the recognition that the one so labelled is paid for doing what others do for free. But there is a distinct, honorific sense in which the professional contrasts not with the amateur but with the person who simply has a job rather than a life-long calling. It is in this honorific sense that physicians, attorneys and members of the clergy serve as paradigm professionals. Aspiring professionals in disciplines other than the paradigm ones regard themselves as more nearly like these paradigms than is usually recognized, and this is their claim to recognition as professionals. The paper explores several possible points of similarity by developing an account of the ideal for professionals which has been held in Western society at least since the time of the Hippocratic Oath, which best captures its spirit. As the Oath makes clear, professionals have fiduciary relations with their patients or clients, and provide services of a personal nature. The paper explores the principal demands of this ideal, the principal steps which physicians have taken in pursuit of it, and some of the implications of this ideal for various groups of social scientists associated with medicine. Finally, it recognizes a professional spirit or attitude which transcends occupation.

KIE: The term 'professional' is used with different meanings, sometimes as simply the opposite of 'amateur' but at other times in an honorific sense to suggest a calling in contrast to a job. Physicians, attorneys, and members of the clergy serve as paradigm professionals, but persons with other occupations may aspire to similar status. Moline explores the ideal of professionalism that has been present in Western society since the time of the Hippocratic Oath. As the Oath makes clear, professionals have relationships with their patients or clients, and they provide services of a personal nature. After discussing how physicians express this ideal in practice, Moline suggests that it is possible in almost any occupation to express the spirit of the paradigm professional by putting the good of the weaker party over one's own interest, maintaining standards of strict confidentiality regarding personal information, and treating one's working relationships with others as fiduciary.

Lactation and lead body burden turnover: a pilot study in Mexico.

A pilot study was conducted in Morelos, Mexico in March 1999 to assess the body burden of lead in 24 Mexican women of childbearing age. Lead levels were measured in whole blood and at three bone sites: two primarily trabecular (calcaneus and patella) and one primarily cortical (tibia). Demographic and reproductive characteristics of the women and potential sources of lead exposure were gathered by a direct interview. An inverse relationship was noted between months of lactation and age-adjusted calcaneus lead level (P = 0.001). No association was observed between age-adjusted patella or tibia lead level and months of lactation (P = 0.15). Blood lead levels were positively associated with the use of lead-glazed ceramics (P = 0.01). Bone and blood lead levels were observed to be 77% higher in these rural Mexican women than in urban New York City women. This pilot study provides further limited evidence for the hypothesis that lead mobilization occurs during lactation.

Dietary flavonoids and hypertension: is there a link?

High blood pressure, defined as systolic blood pressure of greater than 140 mmHg or diastolic blood pressure of greater than 90 mmHg affects millions of people throughout the world. A number of studies have shown that consumption of fruit, vegetables, wine and tea may protect against stroke, for which hypertension is the major risk factor. Flavonoid compounds, including flavonols, flavones and isoflavones, represent an important source of antioxidants in the diet. Flavonoid intake has been inversely associated with mortality from coronary heart disease and stroke. We hypothesize that individuals with hypertension have lower circulating flavonoid levels. Increased consumption of flavonoid-rich foods may decrease rates of hypertension. Lowering blood pressure through increased dietary consumption of dietary antioxidants may decrease the rate of end-organ damage that is secondary to hypertension.

Virtual reality for health care: a survey.

This report surveys the state of the art in applications of virtual environments and related technologies for health care. Applications of these technologies are being developed for health care in the following areas: surgical procedures (remote surgery or telepresence, augmented or enhanced surgery, and planning and simulation of procedures before surgery); medical therapy; preventive medicine and patient education; medical education and training; visualization of massive medical databases; skill enhancement and rehabilitation; and architectural design for health-care facilities. To date, such applications have improved the quality of health care, and in the future they will result in substantial cost savings. Tools that respond to the needs of present virtual environment systems are being refined or developed. However, additional large-scale research is necessary in the following areas: user studies, use of robots for telepresence procedures, enhanced system reality, and improved system functionality.

[Atmospheric and respiratory contamination by waste water aerosols]. / Contamination atmosphérique et respiratoire par les aérosols d'eaux résiduaires.

A study was undertaken of the particle size of aerosols, emitted by a treatment plant for urban waste water, by counting the total flora, using and Andersen apparatus. Evidence of significant bacterial contamination was obtained on the perimeter of the installations. Calculations were made on the data obtained using a method to show the number of viable particles deposited at different levels within the pulmonary tree. During the working day approximately 10(4) viable particles, representing 1.5 x 10(6) organisms, products of the common flora of activated sludge were inhaled. Only a small fraction enters the pulmonary acini; the greater part are swallowed or excreted via the nose or on coughing.

[Bronchial provocation tests in 59 asthmatic children. Comparison with skin tests and specific serum allergens]. / Epreuves de provocation bronchique chez 59 enfants asthmatiques. Comparaison avec les tests cutanés et les réagines sériques spécifiques.

Fifty nine asthmatic children were assessed by skin tests (prick-tests) (TC), specific serum IgE level (R.A.S.T.) and bronchial provocation tests (TPB) with house dust, mites, grass pollen, animal scales and moulds. The concordance of the skin and R.A.S.T. tests with the provocation test, chosen for reference and their diagnostic value was analysed using decision matrices. There was a significant connection between the results of the three tests. The concordance level was only moderate not passing 68%. By comparison to TPB there were numerous false positive Prick-tests and false negative R.A.S.T. The negative predictive value of TC was satisfactory. The most discriminatory threshold for the positive R.A.S.T. was the class 3 response. These results allow the following diagnostic possibilities to be considered. For a common allergen a negative prick-test (TC) would lead to the end of the investigations except for certain particular cases; for an allergen of low prevalence a positive TC should be taken into account, and completing this with RAST and TPB. One could envisage a reduction in the number of TPB and R.A.S.T. performed, reserving them for cases where a discordance between the clinical history and the T.C.

[Pulmonary siderosis and long-term respiratory risks of arc welders]. / Sidérose pulmonaire et risques respiratoires à long terme du soudage à l'arc.

Pulmonary siderosis and bronchial cancer are respiratory risks in the long term in arc welders. We report a case of siderosis discovered from radiological abnormalities in a patient of 56 who had been an arc welder for 30 years. An analysis of the broncho-alveolar lavage liquid and transbronchial biopsy confirmed an iron overload and revealed patchy interstitial fibrosis. The toxic risks in arc welders arise from the gaseous fumes produced and inhaled particles at the alveolar level. The pulmonary siderosis is currently considered as a simple pneumoconiosis with a good prognosis. Some recent studies suggest the possibility of a more serious outcome with fibrosis even in the absence of any associated silicosis. The risks of bronchial cancer seem to be principally linked to exposure to chrome. A better understanding of these risks could be furnished by data from epidemiological studies which are still lacking.

[Electrogastroenterographic study of the digestive motor effects of prolonged psychotropic treatment]. / Etude électrogastro-entérographique des effets moteurs digestifs des traitements psychotropes prolongés

Functional digestive complaints are frequent in psychiatri patients: simple constipation, which cannot be explained solely by the loss of the sensation of rectal fullness; occlusions, occasionally hemorragies; the late complication of dolichomegacolon (Bourgeois, 1973). In 160 subjects, an attempt to understand the physio-pathology were made by recording diurnal digestive motor activity using skin electrodes placed on the abdomen and extremities (electrogastroenterography or E.G.E.G.). A hypoactive E.G.E.G. was observed in 2/3 of 18 psychotic depressive patients, in 3/4 of 36 schizophrenies. The nocive effect of giving sedative phenothiazine and antiparkinsonian drugs (trihexyphenidyl or ethybenzatropine) during long periods is clear. Whereas non sedative phenothiazine and clotiapine gicen in small doses, do not have an undesirable effect. Sulpiride has been used in gastroduodenal dyskinesia. The dyskinesia noted by the E.G.E.G., sometimes found in the large intestin, were found in 55% of 30 patients with caracter disorders; they coincide with the high frequency of electro-encephalogram dysrythmies. Finally, in hysterical patients, one usually observes normal E.G.E.G., tracings which confirms the clinical observation that hysterical and psychosomatic symptoms, may succeed each other, but do not appear at the same time. In the same categories of patients, no longer treated in a classical psychiatric environment but in a group with institutional objectives, the same clinic results were obtained with fewer digestive disturbances. This tends to show the inutility and nocivity of excessive doses of psychotropic drugs given alone or in complexe association.

[Measurement of peak expiratory flow and altitude]. / Mesure du débit de pointe et altitude.

Readings of peak-expiratory flow rate (PEFR) in twelve healthy alpinists at sea level (Lima) and at 3800 m (Yanganugo) show a significant slight fall with altitude (p less than 0.05). This study corroborates previous reports (Singh et al., 1969; Stockley et al., 1979). However, Forster (1983) taking in account the effect of air density on the functioning of peak-flow meter suggested that actual PEFR increases slightly with altitude. In the present study, corrected data show an increase of PEFR by about 3% at 3800 m, similar to Forster's results (at 4200 m). Air density must be considered in future studies in altitude and in estimation of clinical improvement of asthmatic people living in mountain health resort.

Nutritional value of dried fermentation biomass, hydrolyzed porcine intestinal mucosa products, and fish meal fed to weanling pigs.

Dried fermentation biomass (DFB) and hydrolyzed porcine intestinal mucosa are co-products of L-Lys • HCl production and heparin extraction, respectively. Three experiments were conducted to determine standardized ileal digestibility (SID) of AA (Exp. 1), concentration of DE and ME (Exp. 2), and standardized total tract digestibility (STTD) of P (Exp. 3) in DFB and 2 hydrolyzed porcine intestinal mucosa products (PEP50 and PEP2+), and compare these values with values for fish meal. In Exp. 1, 12 ileal cannulated barrows (BW = 11.5 ± 1.1 kg) were allotted to a replicated 6 × 6 Latin square design with 6 diets and 6 periods. A N-free diet, diet based on soybean meal (SBM), and 4 diets based on a combination of SBM and DFB, PEP50, PEP2+, or fish meal were formulated. With the exception of Lys, there were no differences in SID of indispensable AA between DFB and fish meal. Except for Thr, no differences in SID of indispensable AA between PEP50 and fish meal were observed, but SID of all indispensable AA, except Lys and Trp, was less (P < 0.05) in PEP2+ than in the other ingredients. In Exp. 2, 40 barrows (BW = 12.8 ± 1.4 kg) were allotted to 5 diets with 8 pigs/diet. A basal diet containing 96.4% corn and 4 diets containing corn and DFB, PEP50, PEP2+, or fish meal were formulated. The DE (5,445 kcal/kg DM) and ME (5,236 kcal/kg DM) in DFB were greater (P < 0.01) than in PEP50 (4,758 and 4,512 kcal/kg DM for DE and ME, respectively) and fish meal (4,227 and 3,960 kcal/kg DM for DE and ME, respectively). Also, DE in DFB was greater (P < 0.01) than in PEP2+ (4,935 kcal/kg DM), but ME in DFB was not different from that in PEP2+ (4,617 kcal/kg DM). Furthermore, DE in PEP50 and PEP2+ were greater (P < 0.01) than in fish meal, but ME did not differ from that in fish meal. In Exp. 3, 40 barrows (BW = 12.4 ± 1.3 kg) were randomly allotted to 5 diets with 8 pigs/diet. A P-free diet and 4 diets in which the sole source of P was from DFB, PEP50, PEP2+, or fish meal were formulated. The STTD of P in DFB (96.9%) and PEP2+ (97.6%) were greater (P < 0.01) than in PEP50 and fish meal (76.2% and 68.5%, respectively), and STTD of P in PEP50 was greater (P < 0.01) than in fish meal. In summary, SID of most indispensable AA did not differ among DFB, PEP50, and fish meal, but DE and ME and STTD of P in DFB were greater than in PEP50 and fish meal.