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Background Occupational exposures at the WTC site after 11 September 2001 have been associated with presumably inflammatory chronic lower airway diseases. Aims In this study, we describe the trajectories of expiratory air flow decline, identify subgroups with adverse progression, and investigate the association of those trajectories with quantitative computed tomography (QCT) imaging measurement of increased and decreased lung density. Methods We examined the trajectories of expiratory air flow decline in a group of 1,321 former WTC workers and volunteers with at least three periodic spirometries, and using QCT‐measured low (LAV%, −950 HU) and high (HAV%, from −600 to −250 HU) attenuation volume percent. We calculated the individual regression line slopes for first‐second forced expiratory volume (FEV1slope), identified subjects with rapidly declining (“accelerated decliners”) and increasing (“improved”), and compared them to subjects with “intermediate” (0 to −66.5 mL/year) FEV1slope. We then used multinomial logistic regression to model those three trajectories, and the two lung attenuation metrics. Results The mean longitudinal FEV1 slopes for the entire study population, and its intermediate, decliner, and improved subgroups were, respectively, −40.4, −34.3, −106.5, and 37.6 mL/year. In unadjusted and adjusted analyses, LAV% and HAV% were both associated with “accelerated decliner” status (ORadj, 95% CI 2.37, 1.41–3.97, and 1.77, 1.08–2.89, respectively), compared to the intermediate decline. Conclusions Longitudinal FEV1 decline in this cohort, known to be associated with QCT proximal airway inflammation metric, is also associated with QCT indicators of increased and decreased lung density. The improved FEV1 trajectory did not seem to be associated with lung density metrics.

BACKGROUND: The most common abnormal spirometric pattern reported in WTC worker and volunteer cohorts has consistently been that of a nonobstructive reduced forced vital capacity (low FVC). Low FVC is associated with obesity, which is highly prevalent in these cohorts. We used quantitative CT (QCT) to investigate proximal and distal airway inflammation and emphysema in participants with stable low FVC pattern. METHODS: We selected study participants with at least two available longitudinal surveillance spirometries, and a chest CT with QCT measurements of proximal airway inflammation (wall area percent, WAP), end-expiratory air trapping, suggestive of distal airway obstruction (expiratory to inspiratory mean lung attenuation ratio, MLA(EI)), and emphysema (percentage of lung volume with attenuation below −950 HU, LAV%). The comparison groups in multinomial logistic regression models were participants with consistently normal spirometries, and participants with stable fixed obstruction (COPD). RESULTS: Compared to normal spirometry participants, and after adjusting for age, sex, race/ethnicity, BMI, smoking, and early arrival at the WTC disaster site, low FVC participants had higher WAP (OR(adj) 1.24, 95% CI 1.06, 1.45, per 5% unit), suggestive of proximal airway inflammation, but did not differ in MLA(EI), or LAV%. COPD participants did not differ in WAP with the low FVC ones and were more likely to have higher MLA(EI) or LAV% than the other two subgroups. DISCUSSION: WTC workers with spirometric low FVC have higher QCT-measured WAP compared to those with normal spirometries, but did not differ in distal airway and emphysema measurements, independently of obesity, smoking, and other covariates.

Introduction: Reports and associations of COPD and ACO with WTC occupational exposures have been inconsistent. Using spirometric case definitions, we examined that association in the largest WTC occupational surveillance cohort. Methods: We tested for association between ACO and COPD and early arrival (within 48 hr, when dust and fumes exposures were more intense) at the 2001 WTC disaster site in workers with at least two spirometries between 2002 and 2018. Case definitions of COPD required fixed obstruction, and, for ACO pre-bronchodilator obstruction with >400 ml FEV1 response to bronchodilator. We used a nested 1:4 case-control design matching on sex and height (within 5 cm) using density sampling. We imputed missing data. Results: The study population consisted of 17,996 former WTC workers, predominantly (85.4%) male and overweight or obese (85.6%), of whom 586 (3.3%) and 258 (1.4%) cases met the COPD and ACO case definition, respectively. In adjusted analyses, COPD and ACO were associated with early arrival at the WTC site, with adjusted odds ratio, and 95% confidence interval of 1.3, 1.03-1.64, and 1.66, 1.1-2.49, respectively, independently from covariates such as smoking, age, cohort entry period, metabolic syndrome indicators, and high peripheral eosinophil count, among others. Discussion: In this cohort of WTC workers, spirometrically defined COPD and ACO were both associated with WTC exposure intensity. With substantially lower prevalence and effect sizes, we confirmed the findings from another cohort where the case definitions were based on self-reported physician diagnoses (PMID 32930623).

OBJECTIVE: To investigate whether health care workers' (HCWs) return to work (RTW) after coronavirus disease 2019 (COVID-19) was associated with time to a negative viral detection test. METHODS: To evaluate the association of return to work (RTW) with an undetectable RT-PCR adjusting for different factors. RESULTS: 375 HCWs who required medical leave for COVID-19 at a hospital in Madrid. Multivariable analyses confirmed the association of delayed RTW with interval to negative PCR (ORadj 1.12, 95% CI 1.08, 1.17) as well as age, sex, and nursing staff and clinical support services compared to physicians. A predictive model based on those variables is proposed, which had an area under the receiver operating curve of 0.82. CONCLUSIONS: Delayed RTW was associated with longer interval to a negative RT-PCR after symptom onset, adjusting for occupational category, age, and sex.

Background Many respiratory conditions have been attributed to toxic dust and fume exposure in World Trade Center (WTC) rescue and recovery workers, who frequently report symptoms of OSA. We examined the prevalence of new-onset OSA and tested if the prevalence and severity of OSA are related to the presence of chronic rhinosinusitis (CRS). Methods A total of 601 subjects (83% men; age, 33-87 years; BMI, 29.9 ± 5.5 kg/m2) enrolled in the WTC Health Program, excluding those with significant pre-September 11, 2001, snoring or prior CRS, underwent two nights of home sleep testing. OSA was defined as Apnea Hypopnea Index 4% ≥ 5 events/h or respiratory disturbance index of ≥ 15 events/h. CRS was assessed using nasal symptom questionnaires. Results The prevalence of OSA was 75% (25% no OSA, 46% mild OSA, 19% moderate OSA, and 10% severe OSA), and the prevalence of CRS was 43.5%. Compared with no CRS, new and worsening CRS was a significant risk factor for OSA with an OR of 1.80 (95% CI, 1.18-2.73; P = .006) unadjusted and 1.76 (95% CI, 1.08-2.88; P = .02) after adjustment for age, BMI, sex, gastroesophageal reflux disorder, and alcohol use. Conclusions The high prevalence of OSA in WTC responders was not explained fully by obesity and sex. Possible mechanisms for the elevated risk of OSA in subjects with CRS include increased upper airway inflammation and/or elevated nasal/upper airway resistance, but these need confirmation.

The impact of coronavirus disease 2019 (COVID‐19) caused by the severe acute respiratory syndrome coronavirus 2 permeates all aspects of society worldwide. Initial medical reports and media coverage have increased awareness of the risk imposed on healthcare workers in particular, during this pandemic. However, the health implications of COVID‐19 for the global workforce are multifaceted and complex, warranting careful reflection and consideration to mitigate the adverse effects on workers worldwide. Accordingly, our review offers a framework for considering this topic, highlighting key issues, with the aim to prompt and inform action, including research, to minimize the occupational hazards imposed by this ongoing challenge. We address respiratory disease as a primary concern, while recognizing the multisystem spectrum of COVID‐19‐related disease and how clinical aspects are interwoven with broader socioeconomic forces.

Rationale: Continuous positive airway pressure (CPAP) adherence is often poor in obstructive sleep apnea (OSA) and may be influenced by nasal resistance. CPAP with a reduction of expiratory pressure (CPAPflex) may reduce discomfort in those with high nasal resistance and improve adherence in this subgroup. Objectives: To evaluate the association of positive airway pressure (PAP) treatment adherence to nasal resistance and examine if CPAPflex improves adherence over CPAP in subjects with high nasal resistance. Methods: A randomized double-blind crossover trial of 4 weeks each of CPAPflex versus CPAP in subjects exposed to World Trade Center dust with OSA stratified by nasal resistance, measured by 4-Phase Rhinomanometry. Results: Three hundred seventeen subjects with OSA (mean, apnea–hypopnea index with 4% O(2) desaturation for hypopnea = 17 ± 14/h) were randomized. Overall, PAP adherence was poor, but adherence to CPAP (n = 239; mean hours per night [95% confidence interval (CI)]), 1.97 h (1.68 to 2.26) was greater than adherence to CPAPflex (n = 249; 1.65 h [1.39 to 1.91]; difference of 0.31 h [0.03; 0.6]; P

INTRODUCTION: Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a newly redefined form of chronic airway disease and has not been well studied among 9/11-exposed populations with increased prevalence of asthma. We assessed the prevalence and risk factors associated with ACO in an exposure cohort of World Trade Center Health Registry (WTCHR) enrollees. METHODS: This is a longitudinal study, including enrollees with complete data on 9/11/01 exposure at enrollment (2003–2004, Wave 1), asthma and COPD diagnoses and at least 25 years of age at the time of the 2015–2016 (Wave 4) WTCHR survey. Probable ACO was defined as self-reported post-9/11 physician-diagnosed asthma and either emphysema, chronic bronchitis, or COPD. We evaluated whether probable ACO was associated with World Trade Center (WTC)-related exposures, using multivariable logistic regression. RESULTS: Of 36,864 Wave 4 participants, 29,911 were eligible for this analysis, and 1,495 (5.0%) had self-reported post-9/11 probable ACO. After adjusting for demographics and smoking status, we found 38% increased odds of having ACO in enrollees with exposure to the dust cloud, and up to 3.39 times the odds in those with ≥3 injuries sustained on 9/11. Among rescue/recovery workers, ever working on the pile, on the pile on 9/11 or 9/12/01, or working on the WTC site for >7 days showed increased odds ratios of having ACO. CONCLUSION: Probable ACO is associated with WTC exposures. Further study of ACO is needed to understand the development of this and other environmentally or occupationally-related airway diseases, and how to prevent these in disasters like 9/11.

Introduction: Although overweight or obesity have been linked to reduced lung function, no study has estimated the effects of lung function on weight in adults. Aim: We investigated the relation between expiratory flow and body size, and vice versa, in a cohort of adults. Methods: Prospective study in 1,329 former World Trade Center (WTC) workers who were included in the WTC Chest Imaging Archive and had a minimum of 2 spirometries between 2002 and 2018 (mean [SD] follow up=7.2 [3.9] years). We used mixed linear models to test for association between change in first-second forced expiratory volume (∆FEV1) or forced vital capacity (∆FVC) and change in body mass index (∆BMI) between sequential visits, and vice versa. All models included sex, race, educational level, age at each visit, smoking status, arrival at the WTC site within 48 hours, baseline value for the predictor of interest (lung function measure or change in body mass index), and intervals between test dates (accounting for unequal intervals). Results: In multivariable analyses, a 200 ml loss in FEV1 or FVC was associated with 0.29 kg/m2 (95% CI=0.26, 0.33) and 0.22 kg/m2 (95% CI=0.20, 0.22) increment in BMI, respectively. On the other hand, a 0.2 kg/m2 gain in BMI between visits was associated with losses of 7 ml (95% CI= -6 to -8 ml) and 9 ml (95% CI= -8 to -1) ml in FEV1 and FVC, respectively. Conclusion: Change in BMI and change in FEV1 or FVC were inversely associated with each other, and this association was bidirectional. Further work is needed to identify the mechanisms underlying these associations.

Objective: A positive association between mental health conditions and poor asthma control has been documented in the World Trade Center-exposed population. Whether factors such as medication adherence mediate this association is unknown. Methods: The study population was drawn from adult participants of the World Trade Center Health Registry Cohort who self-reported as asthmatic after the disaster and who were currently prescribed a long-term control medication (LTCM). Multivariable linear regression was used to estimate the associations between mental health condition (PTSD, depression, or anxiety) and continuous adherence and Asthma Control Test (ACT) scores. Results: In the study sample of 1,293, 49% were not adherent to their LTCM and two thirds reported poorly or very poorly controlled asthma. Presence of any mental health condition was associated with a 2-point decline in ACT and half a point decrease in adherence scores. However, in the multivariable model, better adherence was statistically significantly associated with slightly worse control. Conclusions: The total effect of mental health on asthma control was opposite in sign from the product of the paths between mental health and adherence and adherence and asthma control; we therefore found no evidence to support the hypothesis that adherence mediated the negative association between poor mental health and adequate asthma control. More research is needed to understand the complex causal mechanisms that underlie the association between mental and respiratory health.

LiteBIRD has been selected as JAXA's strategic large mission in the 2020s, to observe the cosmic microwave background (CMB) $B$-mode polarization over the full sky at large angular scales. The challenges of LiteBIRD are the wide field-of-view (FoV) and broadband capabilities of millimeter-wave polarization measurements, which are derived from the system requirements. The possible paths of stray light increase with a wider FoV and the far sidelobe knowledge of $-56$ dB is a challenging optical requirement. A crossed-Dragone configuration was chosen for the low frequency telescope (LFT : 34--161 GHz), one of LiteBIRD's onboard telescopes. It has a wide field-of-view ($18^\circ \times 9^\circ$) with an aperture of 400 mm in diameter, corresponding to an angular resolution of about 30 arcminutes around 100 GHz. The focal ratio f/3.0 and the crossing angle of the optical axes of 90$^\circ$ are chosen after an extensive study of the stray light. The primary and secondary reflectors have rectangular shapes with serrations to reduce the diffraction pattern from the edges of the mirrors. The reflectors and structure are made of aluminum to proportionally contract from warm down to the operating temperature at $5\,$K. A 1/4 scaled model of the LFT has been developed to validate the wide field-of-view design and to demonstrate the reduced far sidelobes. A polarization modulation unit (PMU), realized with a half-wave plate (HWP) is placed in front of the aperture stop, the entrance pupil of this system. A large focal plane with approximately 1000 AlMn TES detectors and frequency multiplexing SQUID amplifiers is cooled to 100 mK. The lens and sinuous antennas have broadband capability. Performance specifications of the LFT and an outline of the proposed verification plan are presented., Comment: 21 pages, 14 figures

Asthma is a major source of morbidity among World Trade Center (WTC) rescue and recovery workers. While physical and mental health comorbidities have been associated with poor asthma control, the potential role and determinants of adherence to self-management behaviors (SMB) among WTC rescue and recovery workers is unknown.To identify modifiable determinants of adherence to asthma self-management behaviors in WTC rescue and recovery worker that could be potential targets for future interventions.We enrolled a cohort of 381 WTC rescue and recovery workers with asthma. Sociodemographic data and asthma history were collected during in-person interviews. Based on the framework of the Model of Self-regulation, we measured beliefs about asthma and controller medications. Outcomes included medication adherence, inhaler technique, use of action plans, and trigger avoidance.Medication adherence, adequate inhaler technique, use of action plans, and trigger avoidance were reported by 44%, 78%, 83%, and 47% of participants, respectively. Adjusted analyses showed that WTC rescue and recovery workers who believe that they had asthma all the time (odds ratio [OR]: 2.37; 95% confidence interval [CI]: 1.38-4.08), that WTC-related asthma is more severe (OR: 1.73; 95% CI: 1.02-2.93), that medications are important (OR: 12.76; 95% CI: 5.51-29.53), and that present health depends on medications (OR: 2.39; 95% CI: 1.39-4.13) were more likely to be adherent to their asthma medications. Illness beliefs were also associated with higher adherence to other SMB.Low adherence to SMB likely contributes to uncontrolled asthma in WTC rescue and recovery workers. Specific modifiable beliefs about asthma chronicity, the importance of controller medications, and the severity of WTC-related asthma are independent predictors of SMB in this population. Cognitive behavioral interventions targeting these beliefs may improve asthma self-management and outcomes in WTC rescue and recovery workers. Key message: This study identified modifiable beliefs associated with low adherence to self-management behaviors among World Trade Center rescue and recovery rescue and recovery workers with asthma which could be the target for future interventions.Improving World Trade Center-related asthma outcomes will require multifactorial approaches such as supporting adherence to controller medications and other self-management behaviors. This study identified several modifiable beliefs that may be the target of future efforts to support self-management in this patient population.

Introduction The heterogeneity of symptoms in obstructive sleep apnea (OSA) patients has been recently formalized into 3 distinct clusters: Sleepy, Disturbed Sleep, and Minimally Symptomatic. Our previous data showed that OSA is highly prevalent (>75%) in World Trade Center (WTC) responders, and positive airway pressure (PAP) treatment adherence is very poor ( Methods 643 subjects with no history of OSA or reported loud and frequent snoring before 9/11/2001 from the WTC health program clinical centers at Rutgers RWJMS, New Jersey, NYU School of Medicine, and Icahn School Medicine at Mount Sinai, New York underwent 2 nights of home sleep testing using the ARES unicorder (SleepMed, Inc., West Palm Beach, FL, USA). Epworth Sleepiness Scale (ESS), sleep onset insomnia, and sleep maintenance insomnia were assessed with questionnaires. OSA was defined as (AHI4%>=5 or RDI>=15/hr). The three clusters were defined as 1) Sleepy (ESS>10 and/or sleep onset/maintenance insomnia); 2) Disturbed Sleep (not sleepy (ESS Results Among the subjects diagnosed with OSA (N 440; AHI4%=13(15); RDI =28(19); median(iqr); 81% men; age, 33–87 years; BMI, 27.4±3.7 kg/m2), the distribution of clinical phenotypes was 31.4% sleepy, 48.9% disturbed sleep, and 19.7% minimally symptomatic, and did not differ between OSA severity groups. In comparison to SAGIC and HCHS/SOL, the WTC cohort exhibited significantly increased prevalence of the disturbed sleep phenotype (WTC vs SAGIC: 48.9% vs. 19.8%, □2=54.9; p Conclusion The predominant clinical phenotype of OSA in the WTC cohort is disturbed sleep (insomnia) and its prevalence is significantly greater than what has been observed in other large OSA cohorts. These findings may help explain the poor adherence to PAP treatment observed in the WTC cohort. Support (if any) NIOSH U01OH01415; AASM Foundation 233-BS-20.

BackgroundExposure to violence has been associated with lower lung function in cross-sectional studies.MethodsWe examined whether increasing violence-related distress over time is associated with worse lung function and worse asthma control or quality of life in a secondary analysis of a 48-week randomised clinical trial in 98 youth with asthma (aged 9–16 years) treated with low-dose inhaled corticosteroids (Vitamin D Kids Asthma Study (VDKA)). We then replicated our findings for lung function in a prospective study of 232 Puerto Rican youth followed for an average of 5.4 years. Violence-related distress was assessed using the Checklist of Children's Distress Symptoms (CCDS) scale. Our outcomes of interest were percent predicted lung function measures and (in VDKA only) asthma control (assessed using the Asthma Control Test) and asthma-related quality of life (assessed using the Pediatric Asthma Quality of Life Questionnaire (PAQLQ)).ResultsIn a multivariable analysis in VDKA, each 1-point increment in CCDS score was associated with decrements of 3.27% in forced expiratory volume in 1 s (FEV1) % pred (95% CI −6.44– −0.22%; p=0.04), 2.65% in forced vital capacity (FVC) % pred (95% CI −4.86– −0.45%; p=0.02) and 0.30 points in the overall PAQLQ score (95% CI −0.50– −0.10 points; p1 and FVC were obtained in the prospective study of Puerto Rican youth.ConclusionsOur findings suggest that violence-related distress may worsen lung function and quality of life in youth with asthma (even those treated with low-dose inhaled corticosteroids), and further support policies to reduce exposure to violence among children in the USA and Puerto Rico.

To analyze possible alterations of thyroid function related to dosimetric values in health care workers exposed to ionizing radiation.Forty-six health care workers exposed to ionizing radiation at a tertiary hospital previously exposed to ionizing radiation were included in the study. Age, sex, history of thyroid diseases, thyroid hormones, work post, service, dosimetric values of previous year, and 5 y period were considered. Alterations of thyroid function and other variables were analyzed by exact logistic regression univariate model.7.1% workers showed an increased serum thyroid-stimulating hormone without free T3 or free T4 alteration. A significant relationship between workers with increased thyroid-stimulating hormone and dosimetric values of previous year (odds ratio 6.35, 95% confidence interval 1.20-98.1, p = 0.021) and previous 5 y period of radiation exposure (odds ratio 1.72, 95% confidence interval 1.12-3.34, p = 0.007) was obtained.An increased risk of subclinical hypothyroidism related to radiation doses was observed in this pilot study on a group of health care workers exposed to ionizing radiation.

BACKGROUND: We previously reported that wall area percent (WAP), a quantitative CT (QCT) indicator of airway wall thickness and, presumably, inflammation, is associated with adverse longitudinal expiratory flow trajectories in WTC workers, but that obesity and weight gain also seemed to be independently predictive of the latter. Previous studies have reported no association between WAP and obesity, so we investigated that association in nonsmoking WTC-exposed individuals and healthy unexposed controls. METHODS: We assessed WAP using the Chest Imaging Platform QCT system in a segmental bronchus in 118 former WTC workers, and 89 COPDGene® WTC-unexposed and asymptomatic subjects. We used multiple regression to model WAP vs. body mass index (BMI) in the two groups, adjusting for important subject and CT image characteristics. RESULTS: Unadjusted analyses revealed significant differences between the two groups with regards to WAP, age, gender, scan pixel spacing and slice interval, but not BMI or total lung capacity. In adjusted analysis, there was a significant interaction between BMI and WTC exposure on WAP. BMI was significantly and positively associated with WAP in the WTC group, but not in the COPDGene® group, but stratified analyses revealed that the effect was significant in WTC subjects with clinical evidence of lower airway disease (LAD). DISCUSSION: Unlike non-diseased subjects, BMI was significantly associated with WAP in WTC workers and, in stratified analyses, the association was significant only among those with LAD. Our findings suggest that this adverse effect of obesity on airway structure and inflammation may be confined to already diseased individuals.

We examined the chest CT scans of 1,453 WTC responders using the International Classification of High-resolution CT for Occupational and Environmental Respiratory Diseases. Univariate and bivariate analyses of potential work-related pleural abnormalities were performed with pre-WTC and WTC-related occupational exposure data, spirometry, demographics and quantitative CT measurements. Logistic regression was used to evaluate occupational predictors of those abnormalities. Chest CT scans were performed first at a median of 6.8 years after 9/11/2001. Pleural abnormalities were the most frequent (21.1%) across all occupational groups In multivariable analyses, significant pre-WTC occupational asbestos exposure, and work as laborer/cleaner were predictive of pleural abnormalities, with prevalence being highest for the Polish subgroup (n = 237) of our population. Continued occupational lung disease surveillance is warranted in this cohort.

BACKGROUND: A reduced forced vital capacity without obstruction (low FVC) is the predominant spirometric abnormality reported in workers and volunteers exposed to dust, gases, and fumes at the World Trade Center (WTC) disaster site in 2001–2002. While low FVC has been associated with obesity and metabolic syndrome, its association with WTC occupational exposures has not been demonstrated. We estimated the prevalence of this abnormality and examined its association with WTC exposure level. METHODS: Longitudinal study of the relation between arrival at the WTC site within 48 hours and FVC below the lower limit of normal (FVC

Background: We previously found that wall area percent (WAP), a quantitative CT (QCT) indicator of bronchial airway wall thickness and, presumably, inflammation, is associated with adverse longitudinal expiratory flow trajectories in WTC workers, but that obesity and weight gain are also independently predictive of the latter. Studies in asymptomatic nondiseased subjects have not reported an association of WAP with obesity, so we decided to examine the predictors of WAP in diseased and nondiseased individuals. Methods: We assessed WAP using the Chest Imaging Platform QCT system in the 3rd bronchial generation of the right upper lobe in 285 former WTC workers, and 91 COPDGene WTC-unexposed and asymptomatic subjects. We used multiple regression to model the determinants of WAP in the two groups, including age, height, gender, body mass index (BMI), total lung capacity (TLC CT ), and CT pixel spacing and slice thickness. Results: Unadjusted analyses revealed significant differences between the two groups with regard to WAP, age, height, gender, pixel spacing and slice interval (all p CT (p Discussion: Unlike non-diseased subjects, BMI was linked to WAP among WTC workers, who have a high prevalence of lower airway diseases. Our findings suggest that the adverse effects of obesity on airway inflammation is confined to diseased individuals.

The terrorist attack on 9/11/2001, and subsequent rescue, recovery, and service restoration of the World Trade Centre disaster site in New York City, created an unprecedented and unique occupational and environmental exposure that affected a large and diverse group of rescue workers and volunteers. The workers were exposed to a mixture of poorly characterised inhaled toxicants. A variety of acute and chronic respiratory illnesses have been reported among all exposed workers, which are the subject of large scale ongoing investigation and follow up. The predominant WTC related chronic lower airway disorders have been clinically characterised as irritant-induced asthma, nonspecific chronic bronchitis, chronic bronchiolitis, and aggravated pre-existent chronic airway disease. In addition to those, several often limited case reports, case series, and small studies have suggested other associated lung diseases among those workers. Lung function surveillance, which demonstrated an exaggerated one time expiratory flow loss (about 500 ml), has shown an average expiratory flow decline in subsequent years that seems to follow age-related rates. This episode clearly invited reflection on the characterisation of chronic airway diseases, risk factors for respiratory health, and respiratory epidemiology methods.

Aim of special session Advances with chest CT scanning and CT scan-based lung cancer screening are changing the way diagnosis and screening for occupational lung diseases are conducted. We plan to review existing methodologies and experience-based emerging strategies. Thomas Kraus, MD, PhD 1 , Kurt G. Hering, MD 2 , Narufumi Suganuma, MD, PhD 3 , and Rafael E. de la Hoz, MD, MPH, MSc 4 1 RWTH Aachen, Aachen, Germany 2 Knappschafstkrankenhaus Dortmund, Dortmund, Germany 3 Kochi Medical School, Kochi University, Nankoku 783–8505, Japan 4 Icahn School of Medicine at Mount Sinai, New York, NY, USA

The terrorist attack on 9/11/2001, and subsequent rescue, recovery, and service restoration of the World Trade Centre disaster site in New York City, created an unprecedented and unique occupational and environmental exposure that affected a large and diverse group of rescue workers and volunteers. The workers were exposed to a mixture of poorly characterised inhaled toxicants. A variety of acute and chronic respiratory illnesses have been reported among all exposed workers, which are the subject of large scale ongoing investigation and follow up. Our group created the WTC Chest Imaging Archive as a repository for more than 3500 chest CT scan studies in about 1700 WTC workers. We systematically assessed imaging abnormalities by means of the International CT Classification of Occupational and Environmental Respiratory Diseases. An examination of the first available chest CT scan for each subject (n=1453) with complete available data, a median of 6.8 years after September 11, 2001 revealed that the most frequent recorded abnormalities were pleural abnormalities (parietal in 7.9% of the workers, and visceral in 12.8% of them), inhomogeneous attenuation (13.2%), irregular/linear opacities (12.9%), and emphysema (12.0%). With regards to pleural abnormalities, although we found them across all 5 broad occupational groups, they were more frequent among construction labourers/asbestos handlers/building cleaners, most of whom were first-generation immigrants. Many of those abnormalities were not reported by clinical radiological readings. Visceral, but not parietal pleural changes were associated with mild pulmonary function impairment. Future studies will examine the evolution of imaging abnormalities, and add computerised quantitative CT scan to their assessment.

Occupational exposures at the WTC site after September 11, 2001 have been associated with several presumably inflammatory lower airway diseases. In this study, we describe the trajectories of expiratory air flow decline, identify subgroups with adverse progression, and investigate the association of a quantitative computed tomography (QCT) imaging measurement of airway wall thickness, and other risk factors for adverse progression. We examined the trajectories of expiratory air flow decline in a group of 799 former WTC workers and volunteers with QCT-measured (with two independent systems) wall area percent (WAP) and at least 3 periodic spirometries. We calculated individual regression lines for first–second forced expiratory volume (FEV1), identified subjects with rapidly declining and increasing (“gainers”), and compared them to subjects with normal and “stable” FEV1 decline. We used multivariate logistic regression to model decliner vs. stable trajectories. The mean longitudinal FEV1slopes for the entire study population, and its stable, decliner, and gainer subgroups were, respectively, − 35.8, − 8, − 157.6, and + 173.62 ml/year. WAP was associated with “decliner” status (ORadj 1.08, 95% CI 1.02, 1.14, per 5% increment) compared to stable. Age, weight gain, baseline FEV1 percent predicted, bronchodilator response, and pre-WTC occupational exposures were also significantly associated with accelerated FEV1 decline. Analyses of gainers vs. stable subgroup showed WAP as a significant predictor in unadjusted but not consistently in adjusted analyses. The apparent normal age-related rate of FEV1 decline results from averaging widely divergent trajectories. WAP is significantly associated with accelerated air flow decline in WTC workers.

Summary Occupational exposure is an important, global cause of respiratory disease. Unlike many other non-communicable lung diseases, the proximal causes of many occupational lung diseases are well understood and they should be amenable to control with use of established and effective approaches. Therefore, the risks arising from exposure to silica and asbestos are well known, as are the means of their prevention. Although the incidence of occupational lung disease has decreased in many countries, in parts of the world undergoing rapid economic transition and population growth—often with large informal and unregulated workforces—occupational exposures continue to impose a heavy burden of disease. The incidence of interstitial and malignant lung diseases remains unacceptably high because control measures are not implemented or exposures arise in novel ways. With the advent of innovative technologies, new threats are continually introduced to the workplace (eg, indium compounds and vicinal diketones). In developed countries, work-related asthma is the commonest occupational lung disease of short latency. Although generic control measures to reduce the risk of developing or exacerbating asthma are well recognised, there is still uncertainty, for example, with regards to the management of workers who develop asthma but remain in the same job. In this Review, we provide recommendations for research, surveillance, and other action for reducing the burden of occupational lung diseases.

Due to the complexity of the radiative transfer equation, light transport problems are commonly solved using either models under restrictive assumptions, e.g., N-flux models where infinite lateral extension is assumed, or numerical methods. While the latter can be applied to more general cases, it is difficult to relate their parameters to the physical properties of the systems under study. Hence in this contribution we present, first, a review of a four-flux formalism to study the light transport problem in a plane-parallel system together with a derivation of equations to evaluate the different contributions to the total absorptance and, second, as a complementary tool, a Monte Carlo algorithm with a direct correspondence between its inputs and the properties of the system. The combination of the four-flux model and the Monte Carlo approach provides (i) all convergence warranties since the formalism has been established as a limit and (ii) new added capabilities, i.e., both temporal (transient states) and spatial (arbitrarily inhomogeneous media) resolution. The support between the theoretical model and the numerical tool is reciprocal since the model is utilized to set a Monte Carlo discretization criterion, while the Monte Carlo approach is used to validate the aforementioned model. This reinforces the parallel approach used in this work. Furthermore, we provide some examples to show its capabilities and potential, e.g., the study of the temporal distribution of a delta-like pulse of light.

Introduction: The nature and risk factors for chronicity of the WTC-related lower airway diseases remain to be characterized. We hypothesized that accelerated air flow decline was associated with increased airway wall thickness (AWT), as assessed by QCT. Methods: from a group of 467 former WTC workers who had both chest CT scans performed since 2006, and available QCT measurements with the Airway Inspector software, we identified subjects with evidence on longitudinal spirometry surveillance of accelerated FEV 1 decline (“decliners”, >100 ml/year for ≥5 years), and subjects with normal and stable FEV 1 (“stable”). AWT was measured by QCT in the 3 rd bronchial generation of the right upper lobe. We determined body mass index (BMI)-based baseline weight status and BMIslope (kg/m 2 /year). Covariates included age, gender, height, and tobacco smoking and both pre-WTC and WTC occupational exposure categories. We used logistic regression to model decliner status vs. AWT, adjusting for smoking and WTC exposure. Results: The study group consisted of 70 decliners and 33 stable subjects, 82.6% male, aged 42.0±8.8 years. Accelerated FEV 1 decline was associated with AWT, BMIslope, age, height and pre-WTC exposure in unadjusted analyses. Adjusted analyses confirmed the association for AWT (OR 1.35 per 0.05 mm, 95% CI 1.08, 1.72), BMIslope (OR 2.65 per 0.2 kg/m2/year, 95% CI 1.65, 4.25), and age (OR 1.84 per 5 years, 95% CI 1.22, 2.77). Discussion: Accelerated air flow decline on longitudinal spirometry of former WTC workers is associated with increased AWT, accelerated weight gain, and age, adjusting for smoking and occupational WTC exposure level.

Post-traumatic stress disorder (PTSD) has been associated with asthma in cross-sectional studies. Whether PTSD leads to clinically significant bronchodilator response (BDR) or new-onset asthma is unknown.We sought to determine the relationship between probable PTSD and both BDR and incident asthma in a high-risk cohort of World Trade Center workers in New York (NY).This study was conducted on data from a high-risk cohort of 11,481 World Trade Center workers in New York, including 6,133 never smokers without a previous diagnosis of asthma. Of the 6,133 never smokers without asthma, 3,757 (61.3%) completed a follow-up visit several years later (mean = 4.95 yr, interquartile range = 3.74-5.90 yr). At the baseline visit, probable PTSD was defined as a score 44 points or greater in the PTSD Checklist questionnaire, and BDR was defined as both a change of 12% or greater and an increment of 200 ml or greater in FEVIn a cohort of adult workers exposed to a severe traumatic event, probable PTSD is significantly associated with BDR at baseline and predicts incident asthma.

A high prevalence of obesity has been observed among former World Trade Center (WTC) workers and volunteers. We hypothesized that unemployment and disability status would predict obesity. We surveyed 220 participants at the [INST] Mount Sinai WTC Clinical Center to assess their obesity and current employment and disability status, WTC occupational exposure level, medical comorbidities, and dietary and exercise habits. Bivariate and logistic regression multivariate analyses were used to explore associated risk factors. Obesity was associated with active employment status. Other significant covariates included non-Latino African American race, having a high number of comorbid chronic diseases, low exercise frequency, and not drinking any glass of juice daily. The association of obesity with active employment suggests that interventions that favor healthy habits among actively employed individuals are warranted.

Incidence of musculoskeletal disorders (MSDs) is high among health care workers (HCWs). To determine whether MSDs are associated with preexisting anxiety and/or depression, a case-control study was carried out in female HCWs (56 cases/55 controls). Cases were HCWs with a first-time clinical diagnosis of MSD within the previous 2 years. Occupation, workplace, work shift, direct patient assistance, and anxiety/depression scores (Goldberg scale) were assessed. Increased risk of incident MSDs (multivariate logistic regression) was found in workers with preexisting anxiety/depression compared to those without (OR 5.01; 95% CI 2.20-12.05; p < .01). Other significant risk factors were direct patient assistance (OR 2.59; 95% CI 1.03-6.92; p = .04) and morning work shift (OR 2.47; 95% CI 0.99-6.48; p = .05). Preexisting anxiety/depression was associated with incident MSDs in HCWs, adjusting for occupational exposure risk factors.

An increased risk for obstructive sleep apnea (OSA) has been suggested for World Trade Center (WTC)-exposed workers. The authors reviewed the results from nocturnal polysomnograms (PSGs), to investigate diagnostic differences between WTC-exposed and -unexposed subjects. Six hundred fifty-six nocturnal PSGs performed at our sleep center were reviewed, 272 of them in former WTC workers. Seven diagnostic categories were compared between the 2 groups by bivariate and logistic regression analyses. The WTC group had a significantly higher predominance of the male gender, but slightly lower body mass index (BMI). There was no significant difference in the distribution of PSG diagnoses between the 2 groups in unadjusted (p = .56) or adjusted (p = .49) analyses. The authors did not identify a significant difference in PSG diagnoses between the WTC-exposed and -unexposed subjects. OSA was significantly associated with age, BMI, and gender in this patient population.

Summary Background More than 50 000 people participated in the rescue and recovery work that followed the Sept 11, 2001 (9/11) attacks on the World Trade Center (WTC). Multiple health problems in these workers were reported in the early years after the disaster. We report incidence and prevalence rates of physical and mental health disorders during the 9 years since the attacks, examine their associations with occupational exposures, and quantify physical and mental health comorbidities. Methods In this longitudinal study of a large cohort of WTC rescue and recovery workers, we gathered data from 27 449 participants in the WTC Screening, Monitoring, and Treatment Program. The study population included police officers, firefighters, construction workers, and municipal workers. We used the Kaplan-Meier procedure to estimate cumulative and annual incidence of physical disorders (asthma, sinusitis, and gastro-oesophageal reflux disease), mental health disorders (depression, post-traumatic stress disorder [PTSD], and panic disorder), and spirometric abnormalities. Incidence rates were assessed also by level of exposure (days worked at the WTC site and exposure to the dust cloud). Findings 9-year cumulative incidence of asthma was 27·6% (number at risk: 7027), sinusitis 42·3% (5870), and gastro-oesophageal reflux disease 39·3% (5650). In police officers, cumulative incidence of depression was 7·0% (number at risk: 3648), PTSD 9·3% (3761), and panic disorder 8·4% (3780). In other rescue and recovery workers, cumulative incidence of depression was 27·5% (number at risk: 4200), PTSD 31·9% (4342), and panic disorder 21·2% (4953). 9-year cumulative incidence for spirometric abnormalities was 41·8% (number at risk: 5769); three-quarters of these abnormalities were low forced vital capacity. Incidence of most disorders was highest in workers with greatest WTC exposure. Extensive comorbidity was reported within and between physical and mental health disorders. Interpretation 9 years after the 9/11 WTC attacks, rescue and recovery workers continue to have a substantial burden of physical and mental health problems. These findings emphasise the need for continued monitoring and treatment of the WTC rescue and recovery population. Funding Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health.

On September 11, 2001, events at the World Trade Center (WTC) exposed residents ofNew York City to WTC dust and products of combustion and pyrolysis. The majority ofWTC-exposed fire department rescue workers experienced a substantial decline in airflowover the first 12 months post-9/11, in addition to the normal age-related declinethat affected all responders, followed by a persistent plateau in pulmonary function inthe 6 years thereafter. The spectrum of the resulting pulmonary diseases consists ofchronic inflammation, characterized by airflow obstruction, and expressing itself indifferent ways in large and small airways. These conditions include irritant-inducedasthma, non-specific chronic bronchitis, aggravated pre-existing obstructive lung disease(asthma or COPD), and bronchiolitis. Conditions concomitant with airwaysobstruction, particularly chronic rhinosinusitis and upper airway disease, and gastroesophagealreflux, have been prominent in this population. Less common have beenreports of sarcoidosis or interstitial pulmonary fibrosis. Pulmonary fibrosis and bronchiolitisare generally characterized by long latency, relatively slow progression, and asilent period with respect to pulmonary function during its evolution. For these reasons,the incidence of these outcomes may be underestimated and may increase overtime. The spectrum of chronic obstructive airways disease is broad in this populationand may importantly include involvement at the bronchiolar level, manifested as smallairways disease. Protocols that go beyond conventional screening pulmonary functiontesting and imaging may be necessary to identify these diseases in order to understandthe underlying pathologic processes so that treatment can be most effective.

PURPOSE OF REVIEW: To summarize the knowledge about the occupational lower airway diseases that seem related to exposures at the World Trade Center disaster site. RECENT FINDINGS: Those diseases have been characterized as irritant-induced asthma, chronic nonspecific bronchitis, chronic bronchiolitis/small airway disease, and aggravated preexistent chronic obstructive lung disease (most frequently chronic obstructive pulmonary disease, but also asthma), with the expected overlapping features among them. One remarkable characteristic of the irritant-induced asthma observed among these workers was the slow onset of symptoms and long delay in clinical diagnoses. SUMMARY: Longitudinal studies suggest that both the incidence and the associated functional decline of these predominantly obstructive lung diseases stabilized several years ago, but longer follow-up is clearly necessary.

There is growing interest in evaluating the impacts at the watershed scale of agricultural best management practices (BMPs) designed to improve water quality. Many approaches to impact assessment require detailed information about actual BMP use by farmers and landowners in a watershed. This paper examines the strengths and weaknesses of using formal USDA Natural Resources Conservation Service records of conservation program participation as an indicator of spatial and temporal patterns of BMP implementation and maintenance. Field interviews with conservation program participants revealed potential limitations with official records regarding (1) documentation of the incidence of successful BMP implementation, (2) the nature of the BMPs that were implemented, (3) accurate measurement of the timing and location of BMP implementations, and (4) information about the long-term use and maintenance of implemented BMPs. The results suggest that official records should be field-verified before being used as indicators of BMP use. The findings also point to a larger need for development of more robust and accurate systems for tracking BMP implementation and maintenance over periods of time.

The World Trade Center (WTC) disaster and its recovery work involved a range of hazardous occupational exposures that have not been fully characterized but can be reasonably assumed to have the potential to cause mucosal inflammation in the upper and lower airways. A high prevalence of lower airway disease (LAD) symptoms was reported by several early surveys. Clinical studies further categorized the diagnoses as irritant-induced asthma (of subacute onset), nonspecific chronic bronchitis, chronic bronchiolitis, or aggravated preexistent obstructive pulmonary disease in a substantial proportion of patients. Risk factors for WTC-related LAD included early (on September 11 or 12, 2001) arrival at the WTC site and work at the pile of the collapsed towers. Cigarette smoking (but not atopy) also seemed to be a risk factor for LAD. No data thus far suggest an increased incidence of neoplastic or interstitial lung disease, but ongoing surveillance is clearly necessary.

Background: Snoring is a common symptom among workers with adverse health effects from their World Trade Center (WTC) occupational exposures. Rhinitis and upper airway disease are highly prevalent among these workers. Rhinitis has been associated with snoring and, in some studies, with obstructive sleep apnea (OSA). We examined the association of WTC exposure and findings on nocturnal polysomnogram, as well as known predictors of OSA in this patient population. Methods: One hundred participants with snoring underwent a polysomnogram to exclude OSA. Comorbidities had been previously evaluated and treated. The apnea-hypopnea index (AHI) defined and categorized the severity of OSA. Age, sex, body mass index (BMI), and WTC exposure variables were examined in bivariate and multiple regression analyses. Results: Our study sample had a similar prevalence of five major disease categories, as we previously reported. OSA was diagnosed in 62% of the patients and was not associated with any of those disease categories. A trend toward increasing AHI with increasing WTC exposure duration failed to reach the statistical significance (P = 0.14) in multiple regression analysis. An elevated AHI was associated with BMI (P = 0.003) and male sex (P < 0.001). Conclusions: OSA was associated with BMI and male sex but not with occupational WTC exposure indicators in this patient population.

OBJECTIVE: A large number of workers seemed to have developed upper and lower airway disease (UAD and LAD, respectively) in relation to their occupational exposures at the World Trade Center (WTC) disaster site. This study examined atopy as a risk factor for presumably WTC-related UAD and LAD. METHODS: Atopy was examined in 136 former WTC workers and volunteers by radioallergosorbent test, skin prick testing or both. Overall prevalence of atopy was estimated, and bivariate and multivariate logistic regression analyses were conducted to examine associations of atopy with WTC-related UAD and LAD. RESULTS: Atopy was prevalent in 54.4% of these WTC workers. Atopy was associated with higher symptom severity scores for both WTC-related UAD and LAD. Atopy was a predictor of WTC-related UAD but not LAD. Early arrival at the WTC site, and pre-2001 asthma diagnosis were predictors of LAD. CONCLUSION: The prevalence of atopy in this population is similar to what has been described for the general U.S. population. Atopy seemed to be a risk factor for presumably WTC-related UAD but not for LAD.

This article reviews the experience of a unique occupational group of World Trade Center (WTC) workers: immigrant workers. This group is comprised largely of men, laborers, who are first-generation immigrants. The majority of these workers are from Latin America (predominantly from Ecuador and Colombia) or from Eastern Europe (predominantly from Poland). Our data shows that the disease profile observed in these workers was what we have previously reported for WTC working population as a whole. Recent reports have begun to document the disproportionate burden of occupational hazards, injuries, and illnesses experienced by immigrant workers in the United States. The WTC experience of immigrants exemplified this burden but, additionally, highlighted that this burden is exacerbated by limitations in access to appropriate health care, disability and compensation benefits, and vocational rehabilitation services. A clinical program that was designed to address the complex medical and psychosocial needs of these workers in a comprehensive manner was successfully established. Full justice for these workers depends on larger societal changes. Language: en

Background Vocal cord dysfunction (VCD) is a condition characterized by paradoxical partial adduction of the vocal cords on inspiration. It has been associated with exposures to irritants, as well as with psychological illnesses and conditions. Workers who participated in the recovery of the WTC disaster site were exposed to a large amount of irritants as well as considerable psychological stressors. We describe the clinical characteristics of 10 symptomatic former WTC workers diagnosed with this condition, as well as the frequency of spirometric findings suggestive of variable extrathoracic obstruction. Methods Workers who became symptomatic after their WTC work experience have been evaluated clinically by a multidisciplinary team at an academic medical center. The evaluation included history, physical examination, chest radiograph, blood tests, and pre- and post-bronchodilator spirometry in all patients. Additional evaluations and diagnostic tests included otolaryngological evaluation with flexible rhinolaryngoscopy and stroboscopy, gastroenterological and psychiatric evaluations. A randomly selected sample of 172 spirometry results were reviewed for evidence of inspiratory flow limitation. Results Variable extrathoracic obstruction was found in 18.6% of the spirometries. Ten patients were diagnosed with VCD. In addition to symptoms suggestive of co-morbid conditions (particularly rhinitis and acid reflux disease), most of the 10 patients had (1) hoarseness, (2) dyspnea that was not associated with bronchial hyperreactivity, or (3) dyspnea associated with asthma, with either mild bronchial hyperreactivity and/or poor response to asthma treatment. Conclusions VCD appears to be part of the spectrum of airway disorders caused by occupational exposures at the WTC disaster site. Further study of this association is warranted. Am. J. Ind. Med. 51:161–165, 2008. © 2008 Wiley-Liss, Inc.

Objective: The diffuse parenchymal lung diseases (DPLDs) are a heterogeneous group of disorders that result from damage to the lung parenchyma. While the cause of most DPLDs remains unknown, extensive epidemiological and experimental evidence has linked exposure to environmental toxins to the pathogenesis of some of those diseases. The purpose of this review is to examine the potential relation between exposure to toxins released from the World Trade Center (WTC) collapse on September 11th, 2001 and the development of DPLD based on published evidence up to date. Methods: We examine such evidence from two points of view, (1) exposure, and (2) histopathogenesis. Exposure: Analyses of WTC-dust and particle size demonstrate that some portion of the dust was composed of particles small enough to penetrate deep into the lungs, reaching distal airways and alveoli. The presence of such particles has been confirmed in studies of induced sputum and bronchoalveolar lavage in WTC-exposed firefighters. Histopathogenesis: In vitro and animal experiments and patient evidence suggest that WTC dust is capable of inducing a pulmonary interstitial inflammatory response. Results: To date, there have been limited clinical reports documenting the development of diffuse parenchymal responses following exposure to WTC dust. No single common pathologic response has been described. The one common denominator in the reports is that the individuals who developed disease were heavily exposed either during the disaster or during the initial 2-to-3 days following the disaster. Conclusion: DLPDs are probably associated with heavy or extended exposure to the toxins released at the WTC disaster site. Coupled with the historical experience with exposures to occupational toxins this mandates continued long-term clinical observation of this cohort. Mt Sinai J Med 75:101–107, 2008© 2008 Mount Sinai School of Medicine