Faculty Bibliography

BACKGROUND: Sarcoidosis is thought 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-WTC-9/11/2001 (9/11) sarcoidosis, we have a unique opportunity to describe the clinical course of incident sarcoidosis during the 15-years post-exposure and, on average, 8-years after diagnosis. METHODS: Among the WTC-exposed cohort, 74 firefighters with post-9/11 sarcoidosis were identified through medical records review. 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 sarcoidosis involvement of each organ system at time of diagnosis and at follow-up. RESULTS: The incidence of sarcoidosis post-9/11 was 25/100,000. Radiographic resolution of intrathoracic involvement occurred in 24 (45%). Lung function for nearly all was within normal limits. Extrathoracic involvement increased, most prominently joints (15%) and cardiac (16%). There was no evidence for calcium dysmetabolism. Few had ocular (5%) or skin (2%) involvement. None had beryllium sensitization. Most (76%) did not receive any treatment. CONCLUSIONS: Extrathoracic disease was more prevalent in WTC-related sarcoidosis than reported for sarcoidosis patients 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 electrocardiogram, 48-hour 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.

Introduction/UNASSIGNED:Biomarkers of metabolic syndrome expressed soon after World Trade Center (WTC) exposure predict development of WTC Lung Injury (WTC-LI). The metabolome remains an untapped resource with potential to comprehensively characterise many aspects of WTC-LI. This case-control study identified a clinically relevant, robust subset of metabolic contributors of WTC-LI through comprehensive high-dimensional metabolic profiling and integration of machine learning techniques. Methods/UNASSIGNED:Never-smoking, male, WTC-exposed firefighters with normal pre-9/11 lung function were segregated by post-9/11 lung function. Cases of WTC-LI (forced expiratory volume in 1s <lower limit of normal, n=15) and controls (n=15) were identified from previous cohorts. The metabolome of serum drawn within 6 months of 9/11 was quantified. Machine learning was used for dimension reduction to identify metabolites associated with WTC-LI. Results/UNASSIGNED:580 metabolites qualified for random forests (RF) analysis to identify a refined metabolite profile that yielded maximal class separation. RF of the refined profile correctly classified subjects with a 93.3% estimated success rate. 5 clusters of metabolites emerged within the refined profile. Prominent subpathways include known mediators of lung disease such as sphingolipids (elevated in cases of WTC-LI), and branched-chain amino acids (reduced in cases of WTC-LI). Principal component analysis of the refined profile explained 68.3% of variance in five components, demonstrating class separation. Conclusion/UNASSIGNED:Analysis of the metabolome of WTC-exposed 9/11 rescue workers has identified biologically plausible pathways associated with loss of lung function. Since metabolites are proximal markers of disease processes, metabolites could capture the complexity of past exposures and better inform treatment. These pathways warrant further mechanistic research.

PURPOSE: Our overall goal is to create a sustainable ultrasound(US) intervention in resource-limited settings in Dhaka, Bangladesh. Our baseline needs-assessment of the intensive care unit (ICU) of Dhaka Medical College Hospital (DMCH) found that reliable imaging is not available, including ultrasound. The lack of adequate imaging was found to be a deterrent to the proper care of patients. The growing use of point-of-care ultrasound in the ICU as a tool for rapid diagnosis and management led to the creation of the Bangladesh Ultrasound Initiative. This project is designed to bring a successful point-of-care ultrasound training program to physicians in the ICU and emergency room of DMCH. METHODS: Participants were recruited via posters and emails. Training workshops spanned the course of two days. All sessions included individuals that represented all levels of physician training. The following topics were covered: technical aspects, basic echocardiography, pleural ultrasound, DVT and IVC assessment, US-guided CVL placement, US-guided thoracentesis and FAST exam. Training sessions were divided into three parts: lecture-based learning (2 hours), image interpretation with normal and pathological images shown to participants(1.5 hours), and hands-on practical use with the aid of volunteers(2.5 hours). A pre-test and post-test with the same questions was distributed before and after each workshop respectively. Statistical analysis was completed with the use of a chi-square test and paired t-test. RESULTS: Fifty individuals were included in the final analysis. The pre-test/post-test had a total of 37 questions, 25 of which were knowledge-based. Knowledge-based questions were grouped into the topics covered as listed in the methods section. There was a statistically significant (p<0.05) difference between pre- and post-test scores; the mean pre-test score was 3 (SD=3) and the mean post-test score was 12 (SD=3). A 5-point Likert scale was used to ask questions regarding level of confidence. The mean confidence level on the pre-test was 1 (very unconfident) in every category to 5 (very confident) in the post-test(p<0.05). A subgroup analysis showed no difference in mean pre-test and post-test scores of participants who had attended an ultrasound course at any point prior to our intervention compared to those who had never attended a previous ultrasound course. CONCLUSIONS: The results of this study show that a simple workshop in point-of-care ultrasound, using lectures and hands-on practice, can improve knowledge and confidence with statistical significance. This study also shows that the pre- and post-test scores are similar despite some participants having had training in ultrasound prior to the current intervention