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Clinical ethics consultation has become an important resource, but it has no accreditation or accepted curriculum for training programs, no standards for practice, and no way to measure effectiveness. The Clinical Ethics Credentialing Project aims to change that. [ABSTRACT FROM AUTHOR]

Background: The degree to which routine, non-World Trade Center (WTC) firefighting exposures contribute to the WTC exposure-obstructive airway disease (OAD) relationship is unknown. Our objective was to compare the frequency of self-reported OAD diagnoses in WTC-exposed firefighters from the Fire Department of the City of New York (FDNY) compared with non-WTC-exposed firefighters from other cities and the general population., Methods: A total of 9792 WTC-exposed male FDNY firefighters and 3138 non-WTC-exposed male firefighters from Chicago, Philadelphia, and San Francisco who were actively employed on 9/11/01 and completed a health questionnaire were included. Logistic regression estimated odds ratios of self-reported asthma and COPD diagnoses in firefighters (WTC-exposed vs. non-WTC-exposed; all firefighters vs. general population), adjusting for age, race, smoking status, and last medical visit., Results: WTC-exposed firefighters were, on average, younger on 9/11 (mean ± SD = 40.2 ± 7.4 vs. 44.1 ± 9.1) and less likely to report ever-smoking (32.9% vs. 41.8%) than non-WTC-exposed firefighters. Odds of any OAD and asthma were 4.5 and 6.3 times greater, respectively, in WTC-exposed versus non-WTC-exposed. Odds of COPD were also greater in WTC-exposed versus non-WTC-exposed, particularly among never-smokers. Compared with the general population, WTC-exposed firefighters had greater odds of both asthma and COPD, while the nonexposed had lower odds of asthma and greater odds of COPD., Conclusions: Odds ratios for OAD diagnoses were greater in WTC-exposed firefighters versus both non-WTC-exposed and the general population after adjusting for covariates. While asthma and other OADs are known occupational hazards of firefighting, WTC exposure significantly compounded these adverse respiratory effects., (© 2023 The Authors. American Journal of Industrial Medicine published by Wiley Periodicals LLC.)

Background: Firefighting has been associated with posttraumatic stress disorder (PTSD) and other mental health conditions. We previously found that among Fire Department of the City of New York (FDNY) responders to the World Trade Center (WTC) disaster, higher-intensity WTC-exposure predicted PTSD symptoms, depressive symptoms, and subjective cognitive concerns. The present study aims to compare these symptoms in the FDNY WTC-exposed cohort versus a comparison cohort of non-FDNY, non-WTC-exposed firefighters., Methods: The study population included WTC-exposed male firefighters from FDNY (N = 8466) and non-WTC-exposed male firefighters from Chicago (N = 1195), Philadelphia (N = 770), and San Francisco (N = 650) fire departments who were employed on 9/11/2001 and completed a health questionnaire between 3/1/2018 and 12/31/2020. Current PTSD symptoms, depressive symptoms, and subjective cognitive concerns were assessed via validated screening instruments. Multivariable linear regression analyses stratified by fire department estimated the impact of covariates on each outcome., Results: Adjusted mean PTSD symptom scores ranged from 23.5 ± 0.6 in Chicago firefighters to 25.8 ± 0.2 in FDNY, and adjusted mean depressive symptom scores ranged from 7.3 ± 0.5 in Chicago to 9.4 ± 0.6 in Philadelphia. WTC-exposure was associated with fewer subjective cognitive concerns (β = -0.69 ± 0.05, p < .001) after controlling for covariates. Across cohorts, older age was associated with more cognitive concerns, but fewer PTSD and depressive symptoms., Conclusions: WTC-exposed firefighters had fewer cognitive concerns compared with non-WTC-exposed firefighters. We were unable to estimate associations between WTC exposure and PTSD symptoms or depressive symptoms due to variability between non-WTC-exposed cohorts. Longitudinal follow-up is needed to assess PTSD, depressive, and cognitive symptom trajectories in firefighter populations as they age., (© 2021 Wiley Periodicals LLC.)

Background: World Trade Center (WTC)-exposed responders may be eligible to receive no-cost medical monitoring and treatment for certified conditions, including cancer. The survival of responders with cancer has not previously been investigated., Methods: This study compared the estimated relative survival of WTC-exposed responders who developed cancer while enrolled in two WTC medical monitoring and treatment programs in New York City (WTC-MMTP responders) and WTC-exposed responders not enrolled (WTC-non-MMTP responders) to non-responders from New York State (NYS-non-responders), all restricted to the 11-southernmost NYS counties, where most responders resided. Parametric survival models estimated cancer-specific and all-cause mortality. Follow-up ended at death or on December 31, 2016., Results: From January 1, 2005 to December 31, 2016, there were 2,037 cancer cases and 303 deaths (248 cancer-related deaths) among WTC-MMTP responders, 564 cancer cases, and 143 deaths (106 cancer-related deaths) among WTC-non-MMTP responders, and 574,075 cancer cases and 224,040 deaths (158,645 cancer-related deaths) among the NYS-non-responder population. Comparing WTC-MMTP responders with NYS-non-responders, the cancer-specific mortality hazard ratio (HR) was 0.72 (95% confidence interval [CI] = 0.64-0.82), and all-cause mortality HR was 0.64 (95% CI = 0.58-0.72). The cancer-specific HR was 0.94 (95% CI = 0.78-1.14), and all-cause mortality HR was 0.93 (95% CI = 0.79-1.10) comparing WTC-non-MMTP responders to the NYS-non-responder population., Conclusions: WTC-MMTP responders had lower mortality compared with NYS-non-responders, after controlling for demographic factors and temporal trends. There may be survival benefits from no-out-of-pocket-cost medical care which could have important implications for healthcare policy, however, other occupational and socioeconomic factors could have contributed to some of the observed survival advantage., (© 2021 The Authors. American Journal of Industrial Medicine Published by Wiley Periodicals LLC.)

Background: A recent study of World Trade Center (WTC)-exposed firefighters and emergency medical service workers demonstrated that elevated thyroid cancer incidence may be attributable to frequent medical testing, resulting in the identification of asymptomatic tumors. We expand on that study by comparing the incidence of thyroid cancer among three groups: WTC-exposed rescue/recovery workers enrolled in a New York State (NYS) WTC-medical monitoring and treatment program (MMTP); WTC-exposed rescue/recovery workers not enrolled in an MMTP (non-MMTP); and the NYS population., Methods: Person-time began on 9/12/2001 or at enrollment in a WTC cohort and ended at death or on 12/31/2015. Cancer data were obtained through linkages with 13 state cancer registries. We used Poisson regression to estimate rate ratios (RRs) and 95% confidence intervals (CIs) for MMTP and non-MMTP participants. NYS rates were used as the reference. To estimate potential changes over time in WTC-associated risk, change points in RRs were estimated using profile likelihood., Results: The thyroid cancer incidence rate among MMTP participants was more than twice that of NYS population rates (RR = 2.31; 95% CI = 2.00-2.68). Non-MMTP participants had a risk similar to NYS (RR = 0.96; 95% CI = 0.72-1.28). We observed no change points in the follow-up period., Conclusion: Our findings support the hypothesis that no-cost screening (a benefit provided by WTC-MMTPs) is associated with elevated identification of thyroid cancer. Given the high survival rate for thyroid cancer, it is important to weigh the costs and benefits of treatment, as many of these cancers were asymptomatic and may have been detected incidentally., (© 2021 Wiley Periodicals LLC.)

Background: Studies of World Trade Center (WTC)-exposed rescue/recovery workers report the increased occurrence of health conditions after work at the WTC disaster site. However, the extent to which these associations are due to WTC exposure is unclear, in part due to the lack of suitable comparison groups. Accordingly, we identified a previously assembled National Institute for Occupational Safety and Health (NIOSH) cohort of career firefighters from three US cities (n = 29,992). Here, we document the challenges in establishing this non-WTC-exposed firefighter cohort for the goal of tracking and comparing cancer and chronic health conditions in WTC-exposed and non-WTC-exposed firefighters., Methods: Follow-up process included institutional review board applications, data use agreements, state cancer registry linkages and vital status determination for the NIOSH firefighter cohort. After completion of these steps, we undertook outreach to the three original city fire departments and union officials, before contact tracing and direct recruitment of 14,566 living firefighters to complete a confidential health survey. We staggered recruitment efforts by the city, using letters, postcards, emails, videos, and telephone outreach. Participants who completed the survey received $10., Results: A total of 4962 of 14,566 alive firefighters responded to the baseline survey (34.1% response rate). Respondents were older and more likely to be non-Hispanic white than nonrespondents., Conclusions: We provide an overview of the process for the first survey to collect information on physical and mental health conditions among US firefighters. The data collected will have an important impact on studies of WTC rescue/recovery work, firefighting, and related health conditions., (© 2021 Wiley Periodicals LLC.)

Objective: To determine whether World Trade Center (WTC)-exposure intensity and post-traumatic stress disorder (PTSD) are associated with subjective cognitive change in rescue/recovery workers., Method: The population included 7875 rescue/recovery workers who completed a subjective cognition measure, the Cognitive Function Instrument (CFI), between 3/1/2018 and 2/28/2019 during routine monitoring, indicating whether they had experienced cognitive and functional difficulties in the past year. Higher scores indicated greater self-perceived cognitive change. Probable PTSD, depression, and alcohol abuse were evaluated by validated mental health screeners. Logistic regression assessed the associations of WTC exposure and current PTSD with top-quartile (≥2) CFI score, and of early post-9/11 PTSD with top-quartile CFI in a subpopulation (N = 6440). Models included demographics, smoking, depression, and alcohol abuse as covariates., Results: Mean age at CFI completion was 56.7 ± 7.7 (range: 36-81). Participants with high-intensity WTC exposure had an increased likelihood of top-quartile CFI score (odds ratio[OR] vs. low exposure: 1.32, 95%CI: 1.07-1.64), controlling for covariates. Current and early PTSD were both associated with top-quartile CFI (OR: 3.25, 95%CI: 2.53-4.19 and OR: 1.56, 95%CI: 1.26-1.93) respectively., Conclusions: High-intensity WTC exposure was associated with self-reported cognitive change 17 years later in rescue/recovery workers, as was PTSD. Highly WTC-exposed subgroups may benefit from additional cognitive evaluation and monitoring of cognition over time., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: The goal of this study was to estimate the impact of exposure to the World Trade Center (WTC) site on annual and persistent rates of otalgia and hearing impairment among Fire Department of the City of New York (FDNY) Firefighters and Emergency Medical Service Workers (EMS)., Methods: Responders completed routine physical health questionnaires at monitoring visits. We used logistic and marginal logistic regression models to explore the association between otalgia and hearing impairment and WTC arrival time., Results: The highest-exposed group had greater odds of persistent ear symptoms (OR 1.33, 95%CI 1.11-1.59) compared with the least-exposed; the odds of persistent hearing problems between the groups were not significantly different. We found consistent WTC-exposure gradients when the average population odds of these outcomes were assessed each year., Conclusions: Our findings demonstrate that the odds of long-term ear symptoms were significantly associated with the intensity of WTC exposure., (© 2018 Wiley Periodicals, Inc.)

Background: The goals of this study were to assess the impact of work at the World Trade Center (WTC) site in relation to new, post-9/11/2001 (9/11) antibody to hepatitis C Virus (anti-HCV); and, evaluate secular trends in WTC-exposed male Fire Department of New York City (FDNY) Firefighters and Emergency Medical Services (EMS) responders., Methods: FDNY monitors responder health through physical exams and routine blood work. We used descriptive statistics to compare trans-9/11 and post-9/11 incidence and to assess trends in prevalence from 2000 to 2012., Results: Trans-9/11 incidence of new anti-HCV was 0.42 per 100 persons compared with post-9/11 incidence of 0.34 (P = 0.68). Overall seroprevalence was 1.3%; rates declined from 1.79 per 100 to 0.49 per 100 over time (P < 0.0001)., Conclusions: Work at the WTC was not associated with new infection. Biennial seroprevalence in responders declined over time, supporting the FDNY decision to discontinue routine annual testing in this cohort., (© 2018 Wiley Periodicals, Inc.)

Background: After the World Trade Center (WTC) attacks on September 11, 2001, the Fire Department of the City of New York (FDNY) instituted a WTC medical monitoring and treatment program and established a data center to document health outcomes in the WTC-exposed workforce of ∼16,000 firefighters and EMS workers., Methods: FDNY schedules routine monitoring exams every 12-18 months and physical and mental health treatment appointments, as required., Results: FDNY research studies have consistently found that early arrival to work and/or prolonged work at the WTC-site increased the risks for adverse physical and mental health outcomes. To date, a substantial proportion has been diagnosed with obstructive airways disease, chronic rhinosinusitis, and gastroesophageal reflux disease; a quarter has two or more of these conditions., Conclusions: While much has been learned, the entire spectrum and trajectory of WTC-related disorders and their mechanisms of onset and persistence remain to be fully described. Am. J. Ind. Med. 59:695-708, 2016. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background: We previously reported a modest excess of cancer in World Trade Center (WTC)-exposed firefighters versus the general population. This study aimed to separate the potential carcinogenic effects of firefighting and WTC exposure by comparing to a cohort of non-WTC-exposed firefighters., Methods: Relative rates (RRs) for all cancers combined and individual cancer subtypes from 9/11/2001 to 12/31/2009 were modeled using Poisson regression comparing 11,457 WTC-exposed firefighters to 8,220 urban non-WTC-exposed firefighters., Results: Compared with non-WTC-exposed firefighters, there was no difference in the RR of all cancers combined for WTC-exposed firefighters (RR = 0.96, 95%CI: 0.83-1.12). Thyroid cancer was significantly elevated (RR = 3.82, 95%CI: 1.07-20.81) from 2001 to 2009; this was attenuated (RR = 3.43, 95%CI: 0.94-18.94) and non-significant when controlling for possible surveillance bias. Prostate cancer was elevated during the latter half (2005-2009; RR = 1.38, 95%CI: 1.01-1.88)., Conclusions: Further follow-up is needed to assess the relationship between WTC exposure and cancers with longer latency periods. Am. J. Ind. Med. 59:722-730, 2016. © 2016 Wiley Periodicals, Inc., Competing Interests: (Authors): The authors declare no conflicts of interest., (© 2016 Wiley Periodicals, Inc.)

Background: Three longitudinal studies of cancer incidence in varied populations of World Trade Center responders have been conducted., Methods: We compared the design and results of the three studies., Results: Separate analyses of these cohorts revealed excess cancer incidence in responders for all cancers combined and for cancers of the thyroid and prostate. Methodological dissimilarities included recruitment strategies, source of cohort members, demographic characteristics, overlap between cohorts, assessment of WTC and other occupational exposures and confounders, methods and duration of follow-up, approaches for statistical analysis, and latency analyses., Conclusions: The presence of three cohorts strengthens the effort of identifying and quantifying the cancer risk; the heterogeneity in design might increase sensitivity to the identification of cancers potentially associated with exposure. The presence and magnitude of an increased cancer risk remains to be fully elucidated. Continued long-term follow up with minimal longitudinal dropout is crucial to achieve this goal., (© 2016 Wiley Periodicals, Inc.)

Background: The Fire Department of the City of New York World Trade Center Health Program (FDNY-WTCHP) monitors and treats WTC-related illnesses through regular physical exams, self-administered health questionnaires and treatment visits, as indicated., Methods: We measured positive and negative predictive values (PPV, NPV) of self-reported diagnoses of GERD and rhinosinusitis from the health questionnaires in relation to FDNY physician diagnoses from the medical record., Results: Self-reported GERD had PPV and NPV of 54.0% and 95.7%, respectively; for rhinosinusitis, the PPV and NPV were 48.2% and 91.9%. These characteristics improved considerably (PPV 78.0% GERD and PPV 76.5% rhinosinusitis) in a subpopulation receiving medications from the FDNY-WTCHP., Conclusion: The PPV of self-reported diagnoses demonstrates only modest value in predicting physician diagnoses, although high NPVs suggest benefit in ruling out disease. In subgroups selected for their higher disease prevalence, self-reported diagnoses may be considerably more useful., (© 2014 Wiley Periodicals, Inc.)

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., (© 2014 Wiley Periodicals, Inc.)

Background: This study utilizes a four-level pyramid framework to understand the relationship between symptom reports and/or abnormal pulmonary function and diagnoses of airway diseases (AD), including asthma, recurrent bronchitis and COPD/emphysema in WTC-exposed firefighters. We compare the distribution of pyramid levels at two time-points: by 9/11/2005 and by 9/11/2010., Methods: We studied 6,931 WTC-exposed FDNY firefighters who completed a monitoring exam during the early period and at least two additional follow-up exams 9/11/2005-9/11/2010., Results: By 9/11/2005 the pyramid structure was as follows: 4,039 (58.3%) in Level 1, no respiratory evaluation or treatment; 1,608 (23.2%) in Level 2, evaluation or treatment without AD diagnosis; 1,005 (14.5%) in Level 3, a single AD diagnosis (asthma, emphysema/COPD, or recurrent bronchitis); 279 (4.0%) in Level 4, asthma and another AD. By 9/11/2010, the pyramid distribution changed considerably, with Level 1 decreasing to 2,612 (37.7% of the cohort), and Levels 3 (N = 1,530) and 4 (N = 796) increasing to 22.1% and 11.5% of the cohort, respectively. Symptoms, spirometry measurements and healthcare utilization were associated with higher pyramid levels., Conclusions: Respiratory diagnoses, even four years after a major inhalation event, are not the only drivers of future healthcare utilization. Symptoms and abnormal FEV-1 values must also be considered if clinicians and healthcare administrators are to accurately anticipate future treatment needs, years after initial exposure., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: Our goal was to examine the effect of the World Trade Center (WTC) attack and subsequent New York City Fire Department (FDNY) rescue/recovery activities on firefighter retirements. We also analyzed the financial impact associated with the increased number and proportion of service-connected "accidental" disability retirements on the FDNY pension system., Methods: A total of 7,763 firefighters retired between 9/11/1994 and 9/10/2008. We compared the total number of retirements and the number and proportion of accidental disability retirements 7 years before and 7 years after the WTC attack. We categorized WTC-related accidental disability retirements by medical cause and worked with the New York City Office of the Actuary to approximate the financial impact by cause., Results: In the 7 years before 9/11 there were 3,261 retirements, 48% (1,571) of which were accidental disability retirements. In the 7 years after 9/11, there were 4,502 retirements, 66% (2,970) were accidental disability retirements, of which 47% (1,402) were associated with WTC-related injuries or illnesses. After 9/11, the increase in accidental disability retirements was, for the most part, due to respiratory-related illnesses. Additional increases were attributed to psychological-related illnesses and musculoskeletal injuries incurred at the WTC site. Pension benefits associated with WTC-related accidental disability retirements have produced an increased financial burden of over $826 million on the FDNY pension system., Conclusions: The WTC attacks affected the health of the FDNY workforce resulting in more post-9/11 retirements than expected, and a larger proportion of these retirees with accidental disability pensions., (Copyright © 2011 Wiley-Liss, Inc.)

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., (Copyright © 2011 Wiley-Liss, Inc.)

Background: Symptoms of post-traumatic stress disorder (PTSD) have been reported even years after the terrorist attacks of September 11, 2001 (9/11)., Methods: We used screening tools to assess the prevalence of probable PTSD in 9/11-exposed firefighters at two time points, within 6 months of 9/11 (baseline) and 3-4 years post-disaster (follow-up)., Results: Five thousand six hundred fifty-six individuals completed assessments at both times. 15.5% reported probable PTSD post-9/11, 8.6% at baseline and 11.1% at follow-up, on average 2.9 (SD 0.5) years later. Analyses revealed that nearly half of all probable PTSD occurred as delayed onset (absent baseline, present follow-up). Compared with the resilient group (no probable PTSD at either time), probable PTSD at baseline, and delayed onset at follow-up were each associated with concomitant functional impairment (OR 19.5 and 18.9), respectively., Conclusion: Similar percentages of firefighters met criteria for baseline and delayed onset probable PTSD at follow-up, years later. Both were associated with substantial functional impairment. Early risk identification could provide opportunities for mental health interventions before symptoms compromise work and social relationships.