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Objectives To describe the impact of the COVID‐19 pandemic on New York City's (NYC) 9‐1‐1 emergency medical services (EMS) system and assess the efficacy of pandemic planning to meet increased demands. Methods Longitudinal analysis of NYC 9‐1‐1 EMS system call volumes, call‐types, and response times during the COVID‐19 peak‐period (March 16–April 15, 2020) and post‐surge period (April 16–May 31, 2020) compared with the same 2019 periods. Results EMS system received 30,469 more calls from March 16–April 15, 2020 compared with March 16–April 15, 2019 (161,815 vs 127,962; P

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.

The importance of our inner microbial communities for proper immune responses against invading pathogens is now well accepted, but the mechanisms underlying this protection are largely unknown. In this study, we used Caenorhabditis elegans to investigate such mechanisms. Since very little is known about the microbes interacting with C. elegans in its natural environment, we began by taking the first steps to characterize the C. elegans microbiota. We established a natural-like environment in which initially germfree, wild-type larvae were grown on enriched soil. Bacterial members of the adult C. elegans microbiota were isolated by culture and identified using 16S rRNA gene sequencing. Using pure cultures of bacterial isolates as food, we identified two, Bacillus megaterium and Pseudomonas mendocina , that enhanced resistance to a subsequent infection with the Gram-negative pathogen Pseudomonas aeruginosa . Whereas protection by B. megaterium was linked to impaired egg laying, corresponding to a known trade-off between fecundity and resistance, the mechanism underlying protection conferred by P. mendocina depended on weak induction of immune genes regulated by the p38 MAPK pathway. Disruption of the p38 ortholog, pmk-1 , abolished protection. P. mendocina enhanced resistance to P. aeruginosa but not to the Gram-positive pathogen Enterococcus faecalis . Furthermore, protection from P. aeruginosa was similarly induced by a P. aeruginosa gacA mutant with attenuated virulence but not by a different C. elegans -associated Pseudomonas sp. isolate. Our results support a pivotal role for the conserved p38 pathway in microbiota-initiated immune protection and suggest that similarity between microbiota members and pathogens may play a role in such protection.

Context After the World Trade Center (WTC) collapse, 15% (1,767) of rescue workers from the Fire Department of the City of New York (FDNY) considered themselves to be current cigarette smokers. Post-WTC collapse, 98% reported acute respiratory symptoms, and 81% reported health concerns. Nonetheless, 29% of current smokers increased tobacco use, and 23% of ex-smokers resumed cigarette smoking. Objective To determine the effect of a comprehensive tobacco-cessation program using combination tobacco-dependency treatment medications adjusted to the individual's daily tobacco use. Design FDNY cigarette smokers enrolled in “Tobacco Free With FDNY,” a no-cost quit-smoking program providing counseling, support, and medications. At the end of the 3-month treatment phase and at the 6-month and 12-month follow-up visits, abstinence rates were confirmed by expired carbon monoxide levels or by the verification of a household member. Setting FDNY Bureau of Health Services between August 1, 2002 and October 30, 2002. Participants A total of 220 current cigarette smokers from the FDNY. Results At study enrollment, the mean (± SD) tobacco use was 20 ± 7 cigarettes per day, and the mean tobacco dependency, as assessed by a modified Fagerstrom test score, was 6.7 ± 2.5 (maximum score, 10). Based on tobacco use, 20% of enrollees used three types of nicotine medications, 64% used two types, 14% used one type, and 3% used no medications. Additionally, 14% of enrollees used bupropion sustained release. The confirmed continuous abstinence rates were 47%, 36%, and 37%, respectively, after 3 months of treatment and at the 6-month and 12-month follow-up. Abstinence rates did not correlate with the history of tobacco use but correlated inversely with tobacco dependency. Adverse events and maximal nicotine medication use were unrelated, and no one experienced a serious adverse event. Conclusion Tobacco dependency treatment using combination nicotine medications is effective and safe. Future studies should consider the following: (1) both history of tobacco use and withdrawal symptoms to determine the number and dose of nicotine medications; and (2) continuing combination treatment for > 3 months.

This study examines healthcare utilization over time in Bronx, New York schoolchildren with asthma who were previously identified via parent surveys in six elementary schools. Four of the schools have on-site school-based health centers (SBHCs), and two do not have on-site health services (control schools). At baseline, we reported an asthma prevalence of 20%, and high rates of emergency department (ED) use (46%) in the previous year. To determine if asthma morbidity (specifically, ED use, community provider use, and hospitalizations for asthma) could be reduced by incorporating an aggressive intervention at two schools with SBHCs, we prospectively followed children for up to 3 years. Parents were scheduled for interviews every 6 months, and were queried about their children's use of health services for asthma in the prior 6 months. In multivariate models, children in the two intervention SBHC schools were less likely to have visited a community provider for asthma (relative rate ratio, 0.52; 95% confidence interval (CI), 0.30-0.88) or an emergency department for asthma (odds ratio, 0.44; 95% CI, 0.14-1.38; P = 0.059) in the prior 6 months compared to children attending control schools. There was no difference in community provider use or emergency department use for asthma between children attending nonintervention SBHCs and control schools. However, school type did not affect asthma hospitalization rates, which declined in all groups. Our findings support the effectiveness of aggressive school-based asthma services provided by SBHCs to reduce asthma morbidity and complement community health services.

This study analyzed health care utilization at three school-based health centers (SBHCs) in the Bronx, New York City, and compared characteristics of “frequent” and “average” service users. Encounter form data for visits by 2,795 students who received services at least once between September 7, 1998, and June 30, 1999, were reviewed. Demographic comparisons between clinic users and the total school population, and between “frequent” (five or more visits/year) and “average” (one to four visits/year) users were made. The two groups also were compared after primary diagnoses were classified into five general categories. Some 96% (3,469/3,614) of students were registered in the SBHCs, of whom 81% (2,795/3,469) used clinic services at least once during the school year. Clinic users did not differ from the general school population by gender, but were younger (p < 0.01). “Frequent” users were more likely than “average” users to be older (p < 0.01), but they did not differ by gender, race/ethnicity, or insurance status. “Frequent” users comprised 28% of the clinic-using population, but accounted for 72.5% of all visits. Similarly, “average” users comprised 72.4% of the clinic-using population, but accounted for 27.5% of all visits. “Frequent” users generated most visits for mental health and chronic medical conditions, while “average” users generated most visits for preventive care, acute medical care, and injuries/emergencies (p < 0.01 for all). Important challenges for elementary SBHCs include developing new approaches that meet children's needs while protecting clinic resources, like scheduling group interventions for those with on-going health care needs who require frequent use of school health services.

OBJECTIVES To describe the proportion of at-risk World Trade Center (WTC)-exposed rescue/recovery workers with polysomnogram-confirmed obstructive sleep apnea (OSA) and examine the relationship between WTC exposure, physician-diagnosed gastroesophageal reflux disease (GERD), and rhinosinusitis and OSA. METHODS A total of 636 male participants completed polysomnography from September 24, 2010, to September 23, 2012. Obstructive sleep apnea was classified as mild, moderate, or severe. Associations were tested using nominal polytomous logistic regression. RESULTS Eighty-one percent of workers were diagnosed with OSA. Using logistic regression models, severe OSA was associated with WTC exposure on September 11, 2001 (odds ratio, 1.91; 95% confidence interval, 1.15 to 3.17), GERD (odds ratio, 2.75; 95% confidence interval, 1.33 to 5.70), and comorbid GERD/rhinosinusitis (odds ratio, 2.31; 95% confidence interval, 1.22 to 4.40). CONCLUSIONS We found significant associations between severe OSA and WTC exposure, and with diseases prevalent in this population. Accordingly, we recommend clinical evaluation, including polysomnography, for patients with high WTC exposure, other OSA risk factors, and a physician diagnosis of GERD or comorbid GERD and rhinosinusitis.

Obstructive sleep apnea (OSA) is characterized by intermittent hypoxia (IH). In animal models, IH has been shown to protect the myocardium during periods of ischemia by reducing infarct size. However, this phenomenon of “ischemic preconditioning” has not been investigated among OSA patients with acute myocardial infarction (MI). This study investigates the role of OSA on MI severity as measured by cardiac enzymes, specifically troponin-T, among patients with an acute MI. This is an observational cohort study of patients ≥18 years of age who were hospitalized with an acute MI. Each participant underwent portable sleep monitoring (Apnea Link Plus); OSA was defined as an apnea–hypopnea index ≥5/h. Multivariable regression analysis was conducted to assess the relationship between OSA and highly sensitive troponin-T levels. In our entire cohort of acute MI patients (n = 136), 77 % of the sample had evidence of sleep disordered breathing, with 35 % of the sample having OSA (i.e., an AHI >5). Higher AHI was associated with lower peak troponin-T levels in partially adjusted models (β = −0.0320, p = 0.0074, adjusted for age, gender, and race) and fully adjusted models (β = −0.0322, p = 0.0085) (additionally adjusted for smoking, hypertension, hyperlipidemia, body mass index, history of prior cardiovascular or cerebrovascular disease, diabetes and baseline admission creatinine levels). The mean value of the log-transformed peak troponin-T variable was used to dichotomize the outcome variable. In both partially (OR 0.949, CI 0.905–0.995, p = 0.03) and fully adjusted (OR 0.918, CI 0.856–0.984, p = 0.0151) logistic regression models, the OR for AHI suggests a protective effect on high troponin-T level. Our study demonstrates that patients with OSA have less severe cardiac injury during an acute non-fatal MI when compared to patients without OSA. This may suggest a cardioprotective role of sleep apnea during acute MI via ischemic preconditioning.

World Health Organization defined anemia of aging (AOA) when men and women greater than 65 years, respectively, have unexplained hemoglobin (Hgb) less than 13 and 12 g/dl. Recent evidence suggests that this is likely a chronic inflammatory process involving interleukins (IL) 6, 12, and C-reactive protein. Among elderly with obstructive sleep apnea (OSA), hypoxic stimulation of erythropoiesis may obscure AOA. Treatment of OSA may paradoxically restore AOA. We sought to identify OSA and AOA coexistence and OSA treatment AOA interaction. Records of 101 successive patients older than 65 years and with OSA who were treated with continuous positive airway pressure were analyzed retrospectively. Differences among pre/post-treatment of OSA hemograms were assessed using paired two-tailed Student’s t test. Hemogram changes were compared to apnea–hypopnea index (AHI), respiratory effort related arousals (RERA), and duration patients slept with oxyhemoglobin saturation

Chronic volume overload from chronic severe mitral regurgitation (MR) results in neuroendocrine activation similar to the heart failure syndrome despite normal left ventricular (LV) ejection fraction (EF). Hence, the hypothesis that beta-blocker (BB) therapy may have a beneficial effect in these patients was tested using a large observational cohort. Our echocardiographic database was searched for patients with severe MR and normal LVEF. Full chart reviews were conducted for clinical and pharmacologic data. Survival was analyzed as a function of BB therapy. The search produced 895 patients aged 68 +/- 17 years, 44% men, with LVEF 66 +/- 7%. Of these, 32% were on BB therapy. Use of a BB was associated with a significantly decreased mortality hazard of 0.62 (95% confidence interval 0.46 to 0.83, p = 0.002), which was unchanged after adjusting for age, gender, LVEF, coronary artery disease, diabetes mellitus, hypertension, and cardiac valve surgery. The independent beneficial effect of BBs was seen in patients with or without coronary artery disease, those with or without hypertension, and patients managed both medically and surgically. In conclusion, use of BB therapy was associated with a significant independent survival benefit in patients with chronic severe MR with normal LVEF. This benefit was seen in patients with or without coronary artery disease, as well as patients managed both medically and surgically. Use of BBs in patients with severe MR despite normal LVEF is suggested.

Our kinetic studies have characterized the mechanisms of deoxyhemoglobin S polymer depolymerization when exposed to CO (used as a model for oxygen because rates can be controlled photolytically). Fibers dissolve slowly, losing monomers from their ends at low partial pressure, and very rapidly at higher partial pressures that induce fiber fracture and therefore many new ends. Slow dissolution that is not complete in the time red cells traverse the pulmonary microvasculature will generate residual arterial polymers (RAPs), enhancing pathogenesis by seeding nucleation of new polymers, accelerating repolymerization and increasing its extent.We now demonstrate, to the best of our knowledge for the first time by direct observation, that anaerobically drawn arterial blood of sickle patients shows birefringence in many red cells and therefore RAPs exist, which we confirm by EM observation of aligned polymers. RAPs exist not only under hypoxemic conditions, when they can be explained by limited solubility due to the presence of deoxyHbS, but also when hypoxemia is absent. RAPs without hypoxemia imply that slow depolymerization kinetics are responsible. One minute of voluntary hyperventilation and (separately) brief nasal oxygen greatly decrease RAPs. RAPs increase during sleep. We attribute these results to accelerated depolymerization at increasing levels of oxygen that cooperatively induce polymer fracture (fracture, using CO, exhibits a 4.7 power dependence on pCO). These results and the interdependent progress of oxygen saturation, partial pressure, fracture rate and remaining polymer that we model bear on pathogenesis and particularly on vaso-occlusive crises, which result from red cell rigidification and from cellular adhesion due to polymer-dependent cellular damage. Under these mechanisms, the lungs may play an important role in initiating pathology; and remediation of dysfunction by breathing assists is potentially prophylactic.

Background About 1400 school-based health centers (SBHCs) provide care to 1.1 million children. However, it is unknown if access to on-site services is associated with a better outcome. Objective To compare outcomes including hospitalizations, emergency department visits, and school absenteeism in elementary schoolchildren with asthma who were grouped according to their enrollment at schools that have or do not have SBHCs. Setting Six elementary schools in The Bronx, NY (4 schools with and 2 without SBHCs). Participants Nine hundred forty-nine inner-city schoolchildren with asthma. Design To collect baseline data for a longitudinal study, we surveyed parents to identify children with asthma, and to obtain information about symptoms and the use of health services in the last 12 months. Participating schools provided absenteeism information. Results Of 6433 parents surveyed, 74% completed the questionnaires. The prevalence of asthma was 19.9% and the morbidity was high—during the previous year, 46.2% had been treated for asthma in an emergency department; 12.6% had been hospitalized. Emergency department use was not associated with SBHCs. However, in univariate and multivariate analyses, the rate of hospitalization was higher among children enrolled at schools without an SBHC (rate ratio, 1.5; 95% confidence interval, 1.1-1.9). In addition, schoolchildren with asthma enrolled in the schools without an SBHC missed more days of school than those enrolled in schools with an SBHC (mean [SD], 21.3 [15.4] vs 18.2 [13.0], respectively; P = .02). Conclusion Access to SBHCs was associated with a reduction in the rate of hospitalization and a gain of 3 days of school for schoolchildren who have asthma.

American inner-city children are disproportionately affected by asthma. During the 1999–2000 school year, we conducted a survey of 6 Bronx, New York City elementary schools to assess the prevalence of asthma and asthma-like symptoms as reported by parents. Children with probable asthma had symptoms within the last 12 months and parents who indicated that their child had asthma. Children with possible asthma had symptoms within the last 12 months but lacked a diagnosis. Overall, 74% (4,775/6,433) of parents returned completed surveys, identifying 20% (949/4,775) of children as probable asthmatics, and 12% (589/4,775) as possible asthmatics. In multivariate analyses, probable asthma was associated with: Puerto Rican, Black, and white race/ethnicity, male gender, having health insurance, and registration at the poorest school. Possible asthma was associated with lack of health insurance and female gender, but was not associated with any specific race/ethnicity. Our findings support the effectiveness of school-based surveys to identify children at high risk for asthma. The challenge remains to engage children and families in appropriate follow-up care and to manage their illness, either through the use of school-based health centers or stronger links to community services.Pediatr Pulmonol. 2002; 34:105–111. © 2002 Wiley-Liss, Inc.

Fifteen years ago, Open Airways for Schools (OAS) was found to be an effective asthma education program for elementary school children when taught by professionals. To determine whether OAS is effective when taught by college students and whether it could withstand potential cohort effects, 54 inner-city fourth and fifth graders were taught OAS. Paired t-tests revealed that OAS improved asthma knowledge, self-efficacy, self-management skills, social support, and perception of well-being (p < 0.05). Fifteen years later, OAS continues to improve children's self-management skills. Facilitators with little prior experience who received brief training in asthma knowledge and group leadership skills can effectively teach OAS.

R. C. KaplanDepartment of Epidemiology and Population Health,Albert Einstein College of Medicine, Bronx, NY, USAS. RedlineBrigham and Women’s Hospital and Beth Israel DeaconessMedical Center, Harvard Medical School, Boston, MA, USAH. K. YaggiSection of Pulmonary, Critical Care, and Sleep Medicine,DepartmentofInternalMedicine,YaleUniversitySchoolofMedicine,New Haven, CT, USASleep Breath (2013) 17:1119DOI 10.1007/s11325-012-0793-0

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Twelve patients with severe asthma in whom lactic acidosis developed are presented. All had an arterial blood pH level lower than that expected for the measured partial pressure of arterial carbon dioxide, all had an abnormally large anion gap, and the blood lactate level exceeded 2.8 mmol/liter. Respiratory acidosis subsequently developed in eight patients, and six required intubation. Lactic acidosis can develop in patients with severe asthma. Such patients are in danger of the development of respiratory failure and must be treated vigorously and observed closely.

Pulmonary endometriosis is manifested as either asymptomatic pulmonary nodules or as pneumothorax, hemothorax, or hemoptysis during menses. We review 84 cases of pulmonary endometriosis in the English literature and report 3 additional patients. One of our patients is the first reported to have hemoneumothorax. Catamenial pneumothorax usually involved the right chest, and occurred in young nulliparous women without pelvic endometrosis. Pleuroscopy, laparoscopy with pneumoperitoneum, and thoracotomy produced a tissue diagnosis infrequently. Hormonal suppression of ovulation and pleurodesis usually corrected this disorder. Catamenial hemothorax only affected the right chest, but occurred in older multiparous women with pelvic endometriosis. While thoracotomy or laparotomy produced a tissue diagnosis, these procedures were not curative. In contrast, our patient with this disorder was treated successfully with pleurectomy. Catamenial hemoptysis occurred in multiparous women without pelvic endometriosis. Bronchoscopy localized bleeding but never produced a tissue diagnosis. Thoracotomy produced endometrial tissue. Endometrial pulmonary nodules require a diagnosis but do not otherwise produce problems.