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World Trade Center-related asthma: clinical care essentials

Harrison, Denise; Reibman, Joan
Asthma is defined as a heterogeneous disease with respiratory symptoms (wheeze, shortness of breath, chest tightness and cough) that vary over time and intensity, and variable expiratory airflow limitation. Environmental and occupational exposures contribute to its causation. WTC-related or aggravated asthma is considered a World Trace Center (WTC) Health Program certifiable disease. Criteria include defined exposures to the WTC dust and fumes, the presence of symptoms, or aggravated symptoms that are present within 5 years after the last potential for WTC dust/fume exposures (the last 9/11 exposures occurred on July 31, 2002), and a WTC-provider diagnosis of asthma. Asthma is the 3rd most common non-cancer certification among WTC responders and survivors. In this review we provide evidence-based information on the evaluation, diagnosis, and treatment of patients with WTC-related or aggravated asthma and include peer-reviewed research findings in WTC-exposed populations.
PMID: 36938642
ISSN: 2154-4700
CID: 5462692

The World Trade Center Health Program: an introduction to best practices

Calvert, Geoffrey M; Anderson, Kristi; Cochran, John; Cone, James E; Harrison, Denise J; Haugen, Peter T; Lilly, Gerald; Lowe, Sandra M; Luft, Benjamin J; Moline, Jacqueline M; Reibman, Joan; Rosen, Rebecca; Udasin, Iris G; Werth, Aditi S
More than 20 years have elapsed since the September 11, 2001 (9/11) terrorist attacks on the World Trade Center (WTC), Pentagon and at Shanksville, PA. Many persons continue to suffer a variety of physical and mental health conditions following their exposures to a mixture of incompletely characterized toxicants and psychological stressors at the terrorist attack sites. Primary care and specialized clinicians should ask patients who may have been present at any of the 9/11 sites about their 9/11 exposures, especially patients with cancer, respiratory symptoms, chronic rhinosinusitis, gastroesophageal reflux disease, psychiatric symptoms, and substance use disorders. Clinicians, especially those in the NY metropolitan area, should know how to evaluate, diagnose, and treat patients with conditions that could be associated with exposure to the 9/11 attacks and its aftermath. As such, this issue of Archives contains a series of updates to clinical best practices relevant to medical conditions whose treatment is covered by the WTC Health Program. This first paper in the 14-part series describes the purpose of this series, defines the WTC Health Program and its beneficiaries, and explains how relevant Clinical Practice Guidelines were identified. This paper also reminds readers that because physical and mental health conditions are often intertwined, a coordinated approach to care usually works best and referral to health centers affiliated with the WTC Health Program may be necessary, since all such Centers offer multidisciplinary care.
PMID: 36533439
ISSN: 2154-4700
CID: 5380112

Prevalence and correlates of suicidal ideation in World Trade Center responders: Results from a population-based health monitoring cohort

Gibson, Rachel; Whealin, Julia M; Dasaro, Christopher R; Udasin, Iris G; Crane, Michael; Moline, Jacqueline M; Harrison, Denise J; Luft, Benjamin J; Todd, Andrew C; Schechter, Clyde; Lowe, Sandra M; Feder, Adriana; Pietrzak, Robert H
BACKGROUND:Suicidal ideation (SI) is an early risk factor for suicide among disaster responders. To date, however, no known study has examined the prevalence, and pre-, peri-, and post-disaster risk correlates of SI in World Trade Center (WTC) responders, one of the largest disaster response populations in U.S. HISTORY/METHODS/: METHODS:The prevalence, and pre-, peri- and post-event correlates of SI were assessed in a population-based health monitoring cohort of 14,314 police responders and 16,389 non-traditional responders (e.g., construction workers) who engaged in response, recovery, and clean-up efforts following the 9/11/2001 terrorist attacks on the WTC. Multivariable analyses were conducted to identify correlates and individual psychiatric symptoms associated with SI in each group. RESULTS:A total 12.5% of non-traditional and 2.2% of police WTC responders reported SI. Depression, functional impairment, alcohol use problems, and lower family support while working at the WTC site were associated with SI in both groups of responders. Symptom-level analyses revealed that three symptoms accounted for approximately half of the variance in SI for both groups-feeling bad about oneself, or that one has let down oneself or family; feeling down, depressed, or hopeless; and sense of foreshortened future (44.7% in non-traditional and 71% in police). LIMITATIONS/CONCLUSIONS:Use of self-report measures and potentially limited generalizability. CONCLUSIONS:SI is prevalent in WTC disaster responders, particularly non-traditional responders. Post-9/11 psychiatric symptoms reflecting guilt, shame, hopelessness, and associated functional impairment are most strongly linked to SI, suggesting that interventions targeting these factors may help mitigate suicide risk in this population.
PMID: 35283182
ISSN: 1573-2517
CID: 5190482

Altered gene expression and PTSD symptom dimensions in World Trade Center responders

Marchese, Shelby; Cancelmo, Leo; Diab, Olivia; Cahn, Leah; Aaronson, Cindy; Daskalakis, Nikolaos P; Schaffer, Jamie; Horn, Sarah R; Johnson, Jessica S; Schechter, Clyde; Desarnaud, Frank; Bierer, Linda M; Makotkine, Iouri; Flory, Janine D; Crane, Michael; Moline, Jacqueline M; Udasin, Iris G; Harrison, Denise J; Roussos, Panos; Charney, Dennis S; Koenen, Karestan C; Southwick, Steven M; Yehuda, Rachel; Pietrzak, Robert H; Huckins, Laura M; Feder, Adriana
Despite experiencing a significant trauma, only a subset of World Trade Center (WTC) rescue and recovery workers developed posttraumatic stress disorder (PTSD). Identification of biomarkers is critical to the development of targeted interventions for treating disaster responders and potentially preventing the development of PTSD in this population. Analysis of gene expression from these individuals can help in identifying biomarkers of PTSD. We established a well-phenotyped sample of 371 WTC responders, recruited from a longitudinal WTC responder cohort using stratified random sampling, by obtaining blood, self-reported and clinical interview data. Using bulk RNA-sequencing from whole blood, we examined the association between gene expression and WTC-related PTSD symptom severity on (i) highest lifetime Clinician-Administered PTSD Scale (CAPS) score, (ii) past-month CAPS score, and (iii) PTSD symptom dimensions using a 5-factor model of re-experiencing, avoidance, emotional numbing, dysphoric arousal and anxious arousal symptoms. We corrected for sex, age, genotype-derived principal components and surrogate variables. Finally, we performed a meta-analysis with existing PTSD studies (total N = 1016), using case/control status as the predictor and correcting for these variables. We identified 66 genes significantly associated with total highest lifetime CAPS score (FDR-corrected p < 0.05), and 31 genes associated with total past-month CAPS score. Our more granular analyses of PTSD symptom dimensions identified additional genes that did not reach statistical significance in our analyses with total CAPS scores. In particular, we identified 82 genes significantly associated with lifetime anxious arousal symptoms. Several genes significantly associated with multiple PTSD symptom dimensions and total lifetime CAPS score (SERPINA1, RPS6KA1, and STAT3) have been previously associated with PTSD. Geneset enrichment of these findings has identified pathways significant in metabolism, immune signaling, other psychiatric disorders, neurological signaling, and cellular structure. Our meta-analysis revealed 10 genes that reached genome-wide significance, all of which were downregulated in cases compared to controls (CIRBP, TMSB10, FCGRT, CLIC1, RPS6KB2, HNRNPUL1, ALDOA, NACA, ZNF429 and COPE). Additionally, cellular deconvolution highlighted an enrichment in CD4 T cells and eosinophils in responders with PTSD compared to controls. The distinction in significant genes between total lifetime CAPS score and the anxious arousal symptom dimension of PTSD highlights a potential biological difference in the mechanism underlying the heterogeneity of the PTSD phenotype. Future studies should be clear about methods used to analyze PTSD status, as phenotypes based on PTSD symptom dimensions may yield different gene sets than combined CAPS score analysis. Potential biomarkers implicated from our meta-analysis may help improve therapeutic target development for PTSD.
PMID: 35177824
ISSN: 1476-5578
CID: 5163612

Race/ethnic differences in prevalence and correlates of posttraumatic stress disorder in World Trade Center responders: Results from a population-based, health monitoring cohort

Whealin, Julia M; Ciro, Dianne; Dasaro, Christopher R; Udasin, Iris G; Crane, Michael; Moline, Jacqueline M; Harrison, Denise J; Luft, Benjamin J; Todd, Andrew C; Feder, Adriana; Pietrzak, Robert H
OBJECTIVE:This study evaluated race/ethnic differences in the prevalence and correlates of World Trade Center (WTC) related posttraumatic stress disorder (PTSD) in WTC responders. METHOD/METHODS:Data were analyzed from a population-based, health monitoring cohort of 15,440 nontraditional (i.e., construction workers) and 13,403 police WTC responders. RESULTS:Among nontraditional responders, the prevalence of WTC-related PTSD was highest in Latino/a (40.4%) versus Black (27.3%) and White (26.5%) responders; among police responders, Latino/a (10.4%) responders also had higher prevalence of PTSD relative to Black (9.8%) and White (8.7%) responders. However, multivariable analyses revealed that prior psychiatric diagnosis, greater severity of WTC-related exposures, post-9/11 stressful life events, (in police responders only) older age, and (in nontraditional responders only) lower income and education levels accounted for substantially higher prevalence of WTC-related PTSD across ethnic/racial groups. Additionally, among nontraditional responders, subgroups with added risk included responders who were: Latino/a or White had high post-911 stressful events; Latino/a or Black and had pre-9/11 psychiatric history; and Latinas. Among police responders, subgroups with added risk were Latino/a or Black police with a low annual income. CONCLUSIONS:Collectively, results of this study underscore the burden of differential vulnerability that can contribute to higher prevalence of PTSD in certain cultural subgroups following large magnitude traumatic events. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
PMID: 34647790
ISSN: 1942-969x
CID: 5070362

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

Sacks, Henry S; Smirnoff, Margaret; Carson, Deborah; Cooney, Michael L; Shapiro, Moshe Z; Hahn, Christopher J; Dasaro, Christopher R; Crowson, Cynthia; Tassiulas, Ioannis; Hirten, Robert P; Cohen, Benjamin L; Haber, Richard S; Davies, Terry F; Simpson, David M; Crane, Michael A; Harrison, Denise J; Luft, Benjamin J; Moline, Jacqueline M; Udasin, Iris G; Todd, Andrew C; Sloan, Nancy L; Teitelbaum, Susan L
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/OBJECTIVE: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.
PMID: 34825393
ISSN: 1097-0274
CID: 5063852

Longitudinal Trajectories of PTSD Symptoms Predict Levels of Posttraumatic Growth in World Trade Center Responders

Kautz, Marin M.; Collins, Abigail; Schechter, Clyde B.; Salim, Ryan; Rodriguez, Janice; Singh, Ritika; Dasaro, Christopher R.; Todd, Andrew C.; Crane, Michael; Moline, Jacqueline M.; Udasin, Iris G.; Harrison, Denise J.; Luft, Benjamin J.; Southwick, Steven M.; Pietrzak, Robert H.; Feder, Adriana
Background: Prior research has indicated that posttraumatic growth (PTG) often co-occurs with symptoms of posttraumatic stress disorder (PTSD). However, it is yet unclear what longitudinal patterns of posttraumatic symptom levels may predict the development of PTG. Methods: World Trade Center (WTC) rescue and recovery workers (2038 police and 2103 non-traditional responders) were assessed an average of 3, 6, 8, and 12 years post-9/11/2001. Responders"™ WTC-related PTSD symptoms were characterized by No/Low Symptom, Worsening/Subtly Worsening, Steeply Worsening (only for non-traditional responders), Improving, and Chronic trajectories. PTSD symptom trajectories were examined as predictors of PTG, which was assessed using total scores on the Posttraumatic Growth Inventory-Short Form. Results: Across both occupational groups, being female, older, Hispanic, and experiencing more post-9/11 traumatic events were independently associated with self-reported PTG. Among police responders, a greater number of WTC exposures and supportive family members while working at the WTC site were linked to higher PTG. Among non-traditional responders, Black race/ethnicity, less education, fewer pre-9/11 traumatic events, and the presence of support while working at the WTC site were additionally linked to higher PTG. Only the moderate PTSD symptom trajectories (ie, worsening and improving) for police responders and all symptomatic trajectories for non-traditional responders were associated with higher levels of PTG. Conclusions: Symptomatic 12-year trajectories of PTSD symptoms and certain sociodemographic characteristics, stressor exposures, and supportive resources were associated with PTG in traditional and non-traditional WTC responders. Results provide insight into subgroups of WTC responders who may benefit from PTG-promoting interventions, as well as potentially modifiable targets to help foster PTG in this population.
SCOPUS:85137210294
ISSN: 2470-5470
CID: 5330022

PAP Adherence and Nasal Resistance: A Randomized Control Trial of CPAPFlex vs CPAP

Sunderram, Jag; Ayappa, Indu; Lu, Shou-En; Wang, Han; Black, Kathleen; Twumasi, Akosua; Sanders, Haley; Harrison, Denise; Udasin, Iris; Chitkara, Nishay; de la Hoz, Rafael E; Carson, Jeffrey L; Rapoport, David M
RATIONALE/BACKGROUND:) may reduce discomfort in those with high nasal resistance and improve adherence in this subgroup. OBJECTIVES/OBJECTIVE:improves adherence over CPAP in subjects with high nasal resistance. METHODS:versus CPAP in World Trade Center dust-exposed subjects with OSA stratified by nasal resistance measured by 4-Phase Rhinomanometry. RESULTS:(mean Δ hours (95% CI)) in subjects with low resistance (0.33h (-0.10, 0.76)) or high nasal resistance (0.26h (-0.14, 0.66)). No significant differences were observed in any of the secondary outcomes between PAP modes. CONCLUSIONS:than to CPAP in subjects with high or low nasal resistance, and, show clinically insignificant better adherence overall with CPAP. Clinical Trial registered with Clinicaltrials.gov (NCT01753999).
PMID: 33202147
ISSN: 2325-6621
CID: 4672622

Mental health stigma and barriers to care in World Trade Center responders: Results from a large, population-based health monitoring cohort

DePierro, Jonathan; Lowe, Sandra M; Haugen, Peter T; Cancelmo, Leo; Schaffer, Jamie; Schechter, Clyde B; Dasaro, Christopher R; Todd, Andrew C; Crane, Michael; Luft, Benjamin J; Moline, Jacqueline M; Harrison, Denise; Udasin, Iris G; Feder, Adriana; Southwick, Steven M; Pietrzak, Robert H
BACKGROUND:Nearly 20 years after the terrorist attacks of September 11, 2001, multiple studies have documented the adverse mental consequences among World Trade Center (WTC) rescue, recovery, and clean-up workers. However, scarce research has examined mental health stigma and barriers to care in WTC-exposed individuals, and no known study has examined whether rates of endorsement may differ between police and "nontraditional" responders, the latter comprising a heterogeneous group of workers and volunteers. OBJECTIVE:To identify the prevalence and correlates of mental health stigma and barriers to care in WTC responders. METHODS:Mental health stigma and barriers to care and their correlates were examined in 6,777 police and 6,272 nontraditional WTC responders. RESULTS:Nontraditional responders endorsed more stigma or barriers to care concerns than police responders. Within a subsample who screened positive for a psychiatric disorder, police were more likely than nontraditional responders to endorse "concerns that negative job consequences might result" (17.9% vs. 9.1%), while nontraditional responders were more likely to endorse "I don't know where to go to find counseling services" (18.4% vs.6.6%). Within this subsample, mental health service need and more severe WTC-related posttraumatic stress disorder symptoms were associated with increased likelihood of endorsing stigma or barriers; pre-9/11 psychiatric history and non-Hispanic Black race/ethnicity were associated with lower likelihood of endorsing stigma or barriers. CONCLUSIONS:Results of this study underscore the burden of mental health stigma and barriers to care in WTC responders, and highlight the need for targeted interventions to address these concerns and promote mental healthcare utilization in this population.
PMID: 33241583
ISSN: 1097-0274
CID: 4702812

Cardiovascular disease in the World Trade Center Health Program General Responder Cohort

Sloan, Nancy L; Shapiro, Moshe Z; Sabra, Ahmad; Dasaro, Christopher R; Crane, Michael A; Harrison, Denise J; Luft, Benjamin J; Moline, Jacqueline M; Udasin, Iris G; Todd, Andrew C; Teitelbaum, Susan L
BACKGROUND:Over 90,000 rescue and recovery responders to the September 2001 World Trade Center (WTC) attacks were exposed to toxic materials that can impair cardiac function and increase cardiovascular disease (CVD) risk. We examined WTC-related exposures association with annual and cumulative CVD incidence and risk over 17 years in the WTC Health Program (HP) General Responder Cohort (GRC). METHODS:Post 9/11 first occurrence of CVD was assessed in 37,725 responders from self-reported physician diagnosis of, or current treatment for, coronary artery disease, myocardial infarction, stroke and/or congestive heart failure from WTCHP GRC monitoring visits. Kaplan-Meier estimates of CVD incidence used the generalized Wilcoxon test statistic to account for censored data. Cox proportional hazards regression analyses estimated the CVD hazard ratio associated with 9/11/2001 arrival in responders with and without dust cloud exposure, compared with arrival on or after 9/12/2001. Additional analyses adjusted for comorbidities. RESULTS:To date, 6.3% reported new CVD. In covariate-adjusted analyses, men's CVD 9/11/2001 arrival risks were 1.40 (95% confidence interval [CI] = 1.26, 1.56) and 1.43 (95% CI = 1.29, 1.58) and women's were 2.16 (95% CI = 1.49, 3.11) and 1.59 (95% CI = 1.11, 2.27) with and without dust cloud exposure, respectively. Protective service employment on 9/11 had higher CVD risk. CONCLUSIONS:WTCHP GRC members with 9/11/2001 exposures had substantially higher CVD risk than those initiating work afterward, consistent with observations among WTC-exposed New York City firefighters. Women's risk was greater than that of men's. GRC-elevated CVD risk may also be occurring at a younger age than in the general population.
PMID: 33315266
ISSN: 1097-0274
CID: 4717552