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Hines SE, Gaitens JM, Brown CH, Glick DR, Reback M, Chin KH, Lawrence E, Cavanaugh KL, Lawson WE, Sriram P, Beck L, Duch J, Aguayo SM, Permana P, McDiarmid MA. Respiratory Health Associated With Systemic Metal Exposure in Post-9/11 Veterans in the Department of Veterans Affairs Toxic Embedded Fragment Registry. J Occup Environ Med 2024; 66:722-730. [PMID: 38739926 DOI: 10.1097/jom.0000000000003143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
OBJECTIVE Adverse respiratory outcomes in post-9/11 veterans with elevated urinary metal measures and enrolled in the VA's Toxic Embedded Fragment registry were compared to those without elevated urinary metals. METHODS Veterans completed questionnaires, underwent pulmonary physiology tests (pulmonary function and oscillometry), and provided urine samples for analysis of 13 metals. Respiratory symptoms, diagnoses, and physiology measures were compared in veterans with ≥1 urine metal elevation to those without metal elevations, adjusted for covariates, including smoking. RESULTS Among 402 study participants, 24% had elevated urine metals, often just exceeding upper limits of reference values. Compared to veterans without elevated metals, those with elevated metals had had higher FEV 1 values but similar frequencies of respiratory symptoms and diagnoses and abnormalities on pulmonary physiology tests. CONCLUSIONS Mild systemic metal elevations in post-9/11 veterans are not associated with adverse respiratory health outcomes.
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Affiliation(s)
- Stella E Hines
- From the Department of Veterans Affairs Medical Center, Baltimore, Maryland (S.E.H., J.M.G., C.H.B., D.R.G., M.A.M.D.); University of Maryland School of Medicine, Baltimore, Maryland (S.E.H., J.M.G., C.H.B., D.R.G., M.R., K.H.C., E.L., M.A.M.D.); Tennessee Valley Healthcare System Veterans Affairs Medical Center, Nashville, Tennessee (K.L.C., W.E.L.); Malcolm Randall Veterans Affairs Medical Center, Gainesville, Florida (P.S.); Oklahoma City Veterans Affairs Medical Center, Oklahoma City, Oklahoma (L.B.); Audie L. Murphy Veterans Affairs Hospital, San Antonio, Texas (J.D.); and Phoenix Veterans Affairs Healthcare System, Phoenix, Arizona (S.M.A., P.P.)
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Zell-Baran LM, Krefft SD, Strand M, Rose CS. Longitudinal changes in lung function following post-9/11 military deployment in symptomatic veterans. Respir Med 2024; 227:107638. [PMID: 38641121 DOI: 10.1016/j.rmed.2024.107638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/05/2024] [Accepted: 04/15/2024] [Indexed: 04/21/2024]
Abstract
RATIONALE Exposure to burn pit smoke, desert and combat dust, and diesel exhaust during military deployment to Southwest Asia and Afghanistan (SWA) can cause deployment-related respiratory diseases (DRRDs) and may confer risk for worsening lung function after return. METHODS Study subjects were SWA-deployed veterans who underwent occupational lung disease evaluation (n = 219). We assessed differences in lung function by deployment exposures and DRRD diagnoses. We used linear mixed models to assess changes in lung function over time. RESULTS Most symptomatic veterans reported high intensity deployment exposure to diesel exhaust and burn pit particulates but had normal post-deployment spirometry. The most common DRRDs were deployment-related distal lung disease involving small airways (DDLD, 41%), deployment-related asthma (DRA, 13%), or both DRA/DDLD (24%). Those with both DDLD/DRA had the lowest estimated mean spirometry measurements five years following first deployment. Among those with DDLD alone, spirometry measurements declined annually, adjusting for age, sex, height, weight, family history of lung disease, and smoking. In this group, the forced expiratory volume in the first second/forced vital capacity (FEV1/FVC) ratio declined 0.2% per year. Those with more intense inhalational exposure had more abnormal lung function. We found significantly lower estimated FVC and total lung capacity five years following deployment among active duty participants (n = 173) compared to those in the reserves (n = 26). CONCLUSIONS More intense inhalational exposures were linked with lower post-deployment lung function. Those with distal lung disease (DDLD) experienced significant longitudinal decline in FEV1/FVC ratio, but other DRRD diagnosis groups did not.
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Affiliation(s)
- Lauren M Zell-Baran
- National Jewish Health, Division of Environmental and Occupational Health Sciences, Denver, CO, USA; Department of Epidemiology, Colorado School of Public Health, Colorado, Aurora, USA.
| | - Silpa D Krefft
- National Jewish Health, Division of Environmental and Occupational Health Sciences, Denver, CO, USA; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Colorado, Aurora, USA; Department of Environmental and Occupational Health, Colorado School of Public Health, Colorado, Aurora, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Health Care System, Colorado, Aurora, USA
| | - Matthew Strand
- National Jewish Health, Biostatistics, Denver, CO, USA; University of Colorado, Department of Biostatistics and Informatics, Aurora, CO, USA
| | - Cecile S Rose
- National Jewish Health, Division of Environmental and Occupational Health Sciences, Denver, CO, USA; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Colorado, Aurora, USA; Department of Environmental and Occupational Health, Colorado School of Public Health, Colorado, Aurora, USA
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Boster JM, Moore Iii WJ, Stoffel ST, Anderson JT, Gonzales MA, Houle MC, Walter RJ, Morris MJ. Bronchoalveolar Lavage Fluid Cytology of Deployed Military Personnel With Chronic Respiratory Symptoms From the STAMPEDE III Study. Mil Med 2024:usae056. [PMID: 38430524 DOI: 10.1093/milmed/usae056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 02/08/2024] [Indexed: 03/04/2024] Open
Abstract
INTRODUCTION Deployed military personnel may be at risk for developing acute and chronic lung disease. Prior studies of this patient population have revealed that unexplained exertional dyspnea is the most common diagnosis despite an extensive evaluation. There is a concern that an occult disorder may be affecting this population. This study evaluated the role for bronchoalveolar lavage (BAL) fluid analysis in the evaluation of chronic deployment-associated dyspnea. MATERIALS AND METHODS Military personnel who reported chronic respiratory symptoms were evaluated as part of the Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures III study. Participants underwent bronchoscopy with BAL as part of a standardized evaluation. RESULTS A total of 308 patients with a mean age of 38 ± 8.6 years underwent bronchoscopy with BAL. BAL cell-count percentages of macrophages, lymphocytes, neutrophils, and eosinophils were: 76.2 ± 17.0%, 16.3 ± 13.4%, 6.6 ± 8.9%, and 0.9 ± 3.2%, respectively. There was no clear differentiation between groups based on increases in lymphocyte counts (P = .640), although lymphocyte values were more elevated (21.4 ± 12.1%) in the interstitial lung disease category. Neutrophil counts (6.6 ± 8.9%) were elevated compared to the reported normal reference values and were increased in the isolated pulmonary function test abnormality (9.4 ± 11.6%), large airway disorder (10.0 ± 7.5%), miscellaneous (10.9 ± 20.2%), and obstructive lung disease (11.0 ± 15.6%) groups. Eosinophil counts were within normal limits (0.9 ± 3.2%) and showed no differences between groups (P = .545); asthma patients trended higher (1.6 ± 5.7%). BAL counts for the exertional dyspnea group were within normal reference values and showed no differences from the entire cohort. CONCLUSIONS The addition of BAL cytology did not help differentiate those patients with unexplained dyspnea from other etiologies.
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Affiliation(s)
- Joshua M Boster
- Pulmonary/Critical Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - William J Moore Iii
- Pulmonary/Critical Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Steven T Stoffel
- Pulmonary/Critical Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Jess T Anderson
- Pulmonary/Critical Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Michael A Gonzales
- Pulmonary/Critical Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Mateo C Houle
- Pulmonary/Critical Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Robert J Walter
- Pulmonary/Critical Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Michael J Morris
- Pulmonary/Critical Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
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Garshick E, Redlich CA, Korpak A, Timmons AK, Smith NL, Nakayama K, Baird CP, Ciminera P, Kheradmand F, Fan VS, Hart JE, Koutrakis P, Kuschner W, Ioachimescu O, Jerrett M, Montgrain PR, Proctor SP, Wan ES, Wendt CH, Wongtrakool C, Blanc PD. Chronic respiratory symptoms following deployment-related occupational and environmental exposures among US veterans. Occup Environ Med 2024; 81:59-65. [PMID: 37968126 PMCID: PMC10872566 DOI: 10.1136/oemed-2023-109146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/30/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVES Characterise inhalational exposures during deployment to Afghanistan and Southwest Asia and associations with postdeployment respiratory symptoms. METHODS Participants (n=1960) in this cross-sectional study of US Veterans (Veterans Affairs Cooperative Study 'Service and Health Among Deployed Veterans') completed an interviewer-administered questionnaire regarding 32 deployment exposures, grouped a priori into six categories: burn pit smoke; other combustion sources; engine exhaust; mechanical and desert dusts; toxicants; and military job-related vapours gas, dusts or fumes (VGDF). Responses were scored ordinally (0, 1, 2) according to exposure frequency. Factor analysis supported item reduction and category consolidation yielding 28 exposure items in 5 categories. Generalised linear models with a logit link tested associations with symptoms (by respiratory health questionnaire) adjusting for other covariates. OR were scaled per 20-point score increment (normalised maximum=100). RESULTS The cohort mean age was 40.7 years with a median deployment duration of 11.7 months. Heavy exposures to multiple inhalational exposures were commonly reported, including burn pit smoke (72.7%) and VGDF (72.0%). The prevalence of dyspnoea, chronic bronchitis and wheeze in the past 12 months was 7.3%, 8.2% and 15.6%, respectively. Burn pit smoke exposure was associated with dyspnoea (OR 1.22; 95% CI 1.06 to 1.47) and chronic bronchitis (OR 1.22; 95% CI 1.13 to 1.44). Exposure to VGDF was associated with dyspnoea (OR 1.29; 95% CI 1.14 to 1.58) and wheeze (OR 1.18; 95% CI 1.02 to 1.35). CONCLUSION Exposures to burn pit smoke and military occupational VGDF during deployment were associated with an increased odds of chronic respiratory symptoms among US Veterans.
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Affiliation(s)
- Eric Garshick
- Pulmonary, Allergy, Sleep, and Critical Care Medicine Section, Medical Service, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard Medical School, Brigham and Women's Hospital Channing Division of Network Medicine, Boston, Massachusetts, USA
| | - Carrie A Redlich
- Occupational and Environmental Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anna Korpak
- Seattle Epidemiologic Research and Information Center, Department of Veteran Affairs Office of Research and Development, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Andrew K Timmons
- Seattle Epidemiologic Research and Information Center, Department of Veteran Affairs Office of Research and Development, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Nicholas L Smith
- Seattle Epidemiologic Research and Information Center, Department of Veteran Affairs Office of Research and Development, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Karen Nakayama
- Seattle Epidemiologic Research and Information Center, Department of Veteran Affairs Office of Research and Development, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | | | - Paul Ciminera
- Health Services Policy and Oversight, Office of the Assistant Secretary of Defense for Health Affairs, Washington, District of Columbia, USA
| | - Farrah Kheradmand
- Department of Medicine, Michael E DeBakey VA Medical Center, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Vincent S Fan
- VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jaime E Hart
- Harvard Medical School, Brigham and Women's Hospital Channing Division of Network Medicine, Boston, Massachusetts, USA
- Department of Environmental Health, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Petros Koutrakis
- Department of Environmental Health, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Ware Kuschner
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Octavian Ioachimescu
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, USA
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael Jerrett
- University of California Los Angeles Jonathan and Karin Fielding School of Public Health, Los Angeles, California, USA
| | - Phillipe R Montgrain
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Susan P Proctor
- US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Emily S Wan
- Pulmonary, Allergy, Sleep, and Critical Care Medicine Section, Medical Service, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard Medical School, Brigham and Women's Hospital Channing Division of Network Medicine, Boston, Massachusetts, USA
| | - Christine H Wendt
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Medical Center, Minneapolis, Minnesota, USA
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Cherry Wongtrakool
- Atlanta VA Medical Center, Decatur, Georgia, USA
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Paul D Blanc
- San Francisco VA Health Care System, San Francisco, California, USA
- Division of Occupational, Environmental, and Climate Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Rose CS, Zell-Baran LM, Cool C, Moore CM, Wolff J, Oh AS, Koelsch T, Richards JC, Krefft SD, Wilson CG, Lynch DA. Findings on High Resolution Computed Tomography in Symptomatic Veterans with Deployment-Related Lung Disease. J Thorac Imaging 2023; 38:00005382-990000000-00093. [PMID: 37732711 PMCID: PMC10940183 DOI: 10.1097/rti.0000000000000742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
PURPOSE Military deployment to dusty, austere environments in Southwest Asia and Afghanistan is associated with symptomatic airways diseases including asthma and bronchiolitis. The utility of chest high-resolution computed tomographic (HRCT) imaging in lung disease diagnosis in this population is poorly understood. We investigated visual assessment of HRCT for identifying deployment-related lung disease compared with healthy controls. MATERIALS AND METHODS Chest HRCT images from 46 healthy controls and 45 symptomatic deployed military personnel with clinically confirmed asthma and/or biopsy-confirmed distal lung disease were scored by 3 independent thoracic radiologists. We compared demographic and clinical characteristics and frequency of imaging findings between deployers and controls, and between deployers with asthma and those with biopsy-confirmed distal lung disease, using χ2, Fisher exact or t tests, and logistic regression where appropriate. We also analyzed inter-rater agreement for imaging findings. RESULTS Expiratory air trapping was the only chest CT imaging finding that was significantly more frequent in deployers compared with controls. None of the 24 deployers with biopsy-confirmed bronchiolitis and/or granulomatous pneumonitis had HRCT findings of inspiratory mosaic attenuation or centrilobular nodularity. Only 2 of 21 with biopsy-proven emphysema had emphysema on HRCT. CONCLUSIONS Compared with surgical lung biopsy, visual assessment of HRCT showed few abnormalities in this small cohort of previously deployed symptomatic veterans with normal or near-normal spirometry.
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Affiliation(s)
- Cecile S Rose
- National Jewish Health, Division of Environmental and Occupational Health Sciences
- School of Medicine, University of Colorado
| | - Lauren M Zell-Baran
- National Jewish Health, Division of Environmental and Occupational Health Sciences
| | - Carlyne Cool
- National Jewish Health, Division of Environmental and Occupational Health Sciences
- School of Medicine, University of Colorado
| | - Camille M Moore
- National Jewish Health, Center for Genes, Environment and Health
- Department of Biostatistics and Informatics, University of Colorado
| | - Jenna Wolff
- National Jewish Health, Division of Environmental and Occupational Health Sciences
| | - Andrea S Oh
- National Jewish Health, Department of Radiology
| | | | - John C Richards
- National Jewish Health, Department of Radiology
- Radiology Imaging Associates
| | - Silpa D Krefft
- National Jewish Health, Division of Environmental and Occupational Health Sciences
- Veterans Administration Eastern Colorado Health Care System, Division of Pulmonary and Critical Care Medicine, Aurora, CO
| | - Carla G Wilson
- National Jewish Health, Research Informatics Services, Denver
| | - David A Lynch
- National Jewish Health, Department of Radiology
- School of Medicine, University of Colorado
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Krefft SD, Zell-Baran LM. Deployment-Related Respiratory Disease: Where Are We? Semin Respir Crit Care Med 2023; 44:370-377. [PMID: 37068518 DOI: 10.1055/s-0043-1764407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
Military personnel and veterans who have deployed to Afghanistan, Iraq, and parts of Southwest Asia (SWA) since 1990 are at risk of developing a host of respiratory symptoms and deployment-related respiratory diseases (DRRDs). This review aims to summarize our current understanding of DRRD and inform pulmonary practitioners of recent updates to DRRD screening, diagnosis, evaluation, and management. The most common respiratory diseases in these patients include asthma, chronic sinonasal disease, laryngeal disease/dysfunction, and distal lung disease. Pulmonary function testing and chest imaging are the most commonly used diagnostic tools, but techniques such as lung clearance index testing via multiple breath washout, forced oscillation testing/impulse oscillometry, and quantitative chest computed tomography (CT) assessment appear promising as noninvasive modalities to aid in lung disease detection in this population. We also summarize guidance on conducting an occupational and deployment exposure history as well as recommendations for testing. Finally, we discuss the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act) that includes a list of health conditions that are "presumptively" considered to be related to SWA military deployment toxic exposures, and provide resources for clinicians who evaluate and treat patients with DRRD.
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Affiliation(s)
- Silpa D Krefft
- Division of Environmental and Occupational Health Sciences, Department of Medicine, National Jewish Health, Denver, Colorado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Environmental and Occupational Health, Colorado School of Public Health, Aurora, Colorado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Veterans Administration Eastern Colorado Health Care System, Aurora, Colorado
| | - Lauren M Zell-Baran
- Division of Environmental and Occupational Health Sciences, Department of Medicine, National Jewish Health, Denver, Colorado
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
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Alexander T, Watson MA, Klein-Adams JC, Ndirangu DS, Serrador JM, Falvo MJ, Lindheimer JB. Deployed Veterans exhibit distinct respiratory patterns and greater dyspnea during maximal cardiopulmonary exercise: A case-control study. PLoS One 2023; 18:e0286015. [PMID: 37224153 DOI: 10.1371/journal.pone.0286015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Exertional dyspnea and exercise intolerance are frequently endorsed in Veterans of post 9/11 conflicts in Southwest Asia (SWA). Studying the dynamic behavior of ventilation during exercise may provide mechanistic insight into these symptoms. Using maximal cardiopulmonary exercise testing (CPET) to experimentally induce exertional symptoms, we aimed to identify potential physiological differences between deployed Veterans and non-deployed controls. MATERIALS AND METHODS Deployed (n = 31) and non-deployed (n = 17) participants performed a maximal effort CPET via the Bruce treadmill protocol. Indirect calorimetry and perceptual rating scales were used to measure rate of oxygen consumption ([Formula: see text]), rate of carbon dioxide production ([Formula: see text]), respiratory frequency (f R), tidal volume (VT), minute ventilation ([Formula: see text]), heart rate (HR), perceived exertion (RPE; 6-20 scale), and dyspnea (Borg Breathlessness Scale; 0-10 scale). A repeated measures analysis of variance (RM-ANOVA) model (2 groups: deployed vs non-deployed X 6 timepoints: 0%, 20%, 40%, 60%, 80%, and 100% [Formula: see text]) was conducted for participants meeting valid effort criteria (deployed = 25; non-deployed = 11). RESULTS Significant group (η2partial = 0.26) and interaction (η2partial = 0.10) effects were observed such that deployed Veterans exhibited reduced f R and a greater change over time relative to non-deployed controls. There was also a significant group effect for dyspnea ratings (η2partial = 0.18) showing higher values in deployed participants. Exploratory correlational analyses revealed significant associations between dyspnea ratings and fR at 80% (R2 = 0.34) and 100% (R2 = 0.17) of [Formula: see text], but only in deployed Veterans. CONCLUSION Relative to non-deployed controls, Veterans deployed to SWA exhibited reduced fR and greater dyspnea during maximal exercise. Further, associations between these parameters occurred only in deployed Veterans. These findings support an association between SWA deployment and affected respiratory health, and also highlight the utility of CPET in the clinical evaluation of deployment-related dyspnea in Veterans.
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Affiliation(s)
- Thomas Alexander
- VA Airborne Hazards and Burn Pits Center of Excellence, VA New Jersey Health Care System, East Orange, New Jersey, United States of America
| | - Matthew A Watson
- VA Airborne Hazards and Burn Pits Center of Excellence, VA New Jersey Health Care System, East Orange, New Jersey, United States of America
| | - Jacquelyn C Klein-Adams
- VA Airborne Hazards and Burn Pits Center of Excellence, VA New Jersey Health Care System, East Orange, New Jersey, United States of America
| | - Duncan S Ndirangu
- VA Airborne Hazards and Burn Pits Center of Excellence, VA New Jersey Health Care System, East Orange, New Jersey, United States of America
| | - Jorge M Serrador
- Department of Pharmacology, Physiology and Neuroscience, New Jersey Medical School, Rutgers - The State University of New Jersey, Newark, New Jersey, United States of America
| | - Michael J Falvo
- VA Airborne Hazards and Burn Pits Center of Excellence, VA New Jersey Health Care System, East Orange, New Jersey, United States of America
- Department of Pharmacology, Physiology and Neuroscience, New Jersey Medical School, Rutgers - The State University of New Jersey, Newark, New Jersey, United States of America
- Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers - The State University of New Jersey, Newark, New Jersey, United States of America
| | - Jacob B Lindheimer
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States of America
- Department of Kinesiology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
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Abstract
PURPOSE OF REVIEW Military personnel deployed to Southwest Asia and Afghanistan were potentially exposed to high levels of fine particulate matter and other pollutants from multiple sources, including dust storms, burn pit emissions from open-air waste burning, local ambient air pollution, and a range of military service-related activities that can generate airborne exposures. These exposures, individually or in combination, can have adverse respiratory health effects. We review exposures and potential health impacts, providing a framework for evaluation. RECENT FINDINGS Particulate matter exposures during deployment exceeded U.S. National Ambient Air Quality Standards. Epidemiologic studies and case series suggest that in postdeployment Veterans with respiratory symptoms, asthma is the most commonly diagnosed illness. Small airway abnormalities, most notably particularly constrictive bronchiolitis, have been reported in a small number of deployers, but many are left without an established diagnosis for their respiratory symptoms. The Promise to Address Comprehensive Toxics Act was enacted to provide care for conditions presumed to be related to deployment exposures. Rigorous study of long-term postdeployment health has been limited. SUMMARY Veterans postdeployment to Southwest Asia and Afghanistan with respiratory symptoms should undergo an exposure assessment and comprehensive medical evaluation. If required, more advanced diagnostic considerations should be utilized in a setting that can provide multidisciplinary expertise and long-term follow-up.
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Affiliation(s)
- Eric Garshick
- Pulmonary, Allergy, Sleep and Critical Care Medicine Section, Veterans Affairs Boston Healthcare System; Harvard Medical School and Brigham and Women’s, Boston, Massachusetts
| | - Paul D. Blanc
- San Francisco VA Medical Center, UC San Francisco School of Medicine, San Francisco; Division of Occupational and Environmental Medicine, Department of Medicine, University of California San Francisco, California, USA
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Falvo MJ, Sotolongo AM, Osterholzer JJ, Robertson MW, Kazerooni EA, Amorosa JK, Garshick E, Jones KD, Galvin JR, Kreiss K, Hines SE, Franks TJ, Miller RF, Rose CS, Arjomandi M, Krefft SD, Morris MJ, Polosukhin VV, Blanc PD, D'Armiento JM. Consensus Statements on Deployment-Related Respiratory Disease, Inclusive of Constrictive Bronchiolitis: A Modified Delphi Study. Chest 2023; 163:599-609. [PMID: 36343686 PMCID: PMC10154857 DOI: 10.1016/j.chest.2022.10.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/10/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The diagnosis of constrictive bronchiolitis (CB) in previously deployed individuals, and evaluation of respiratory symptoms more broadly, presents considerable challenges, including using consistent histopathologic criteria and clinical assessments. RESEARCH QUESTION What are the recommended diagnostic workup and associated terminology of respiratory symptoms in previously deployed individuals? STUDY DESIGN AND METHODS Nineteen experts participated in a three-round modified Delphi study, ranking their level of agreement for each statement with an a priori definition of consensus. Additionally, rank-order voting on the recommended diagnostic approach and terminology was performed. RESULTS Twenty-five of 28 statements reached consensus, including the definition of CB as a histologic pattern of lung injury that occurs in some previously deployed individuals while recognizing the importance of considering alternative diagnoses. Consensus statements also identified a diagnostic approach for the previously deployed individual with respiratory symptoms, distinguishing assessments best performed at a local or specialty referral center. Also, deployment-related respiratory disease (DRRD) was proposed as a broad term to subsume a wide range of potential syndromes and conditions identified through noninvasive evaluation or when surgical lung biopsy reveals evidence of multicompartmental lung injury that may include CB. INTERPRETATION Using a modified Delphi technique, consensus statements provide a clinical approach to possible CB in previously deployed individuals. Use of DRRD provides a broad descriptor encompassing a range of postdeployment respiratory findings. Additional follow-up of individuals with DRRD is needed to assess disease progression and to define other features of its natural history, which could inform physicians better and lead to evolution in this nosology.
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Affiliation(s)
- Michael J Falvo
- Airborne Hazards and Burn Pits Center of Excellence, Department of Veterans Affairs New Jersey Health Care System, East Orange, NJ; New Jersey Medical School, Rutgers-The State University of New Jersey, Newark, NJ.
| | - Anays M Sotolongo
- Airborne Hazards and Burn Pits Center of Excellence, Department of Veterans Affairs New Jersey Health Care System, East Orange, NJ; New Jersey Medical School, Rutgers-The State University of New Jersey, Newark, NJ
| | - John J Osterholzer
- Pulmonary Section, Department of Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Michelle W Robertson
- Airborne Hazards and Burn Pits Center of Excellence, Department of Veterans Affairs New Jersey Health Care System, East Orange, NJ
| | - Ella A Kazerooni
- Department of Radiology, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Judith K Amorosa
- Department of Radiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; University Radiology Group, East Brunswick, NJ
| | - Eric Garshick
- Pulmonary, Allergy, Sleep, and Critical Care Medicine Section, Veterans Affairs Boston Healthcare System, Boston, MA; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA
| | - Kirk D Jones
- Department of Anatomic Pathology, University of California, San Francisco, CA
| | - Jeffrey R Galvin
- Department of Radiology and Nuclear Medicine (Chest Imaging), University of Maryland School of Medicine, Baltimore, MD
| | - Kathleen Kreiss
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV
| | - Stella E Hines
- Divisions of Occupational and Environmental Medicine and Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD; VA Maryland Health Care System, Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Teri J Franks
- Department of Pulmonary and Mediastinal Pathology, Joint Pathology Center, Department of Defense, Silver Spring, MD
| | - Robert F Miller
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Cecile S Rose
- Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, CO; Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Denver, CO
| | - Mehrdad Arjomandi
- Department of Anatomic Pathology, University of California, San Francisco, CA; Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Silpa D Krefft
- Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, CO; Division of Pulmonary and Critical Care Medicine, Veterans Administration Eastern Colorado Health Care System, Aurora, CO; Division of Pulmonary and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Michael J Morris
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA-Sam Houston, Fort Sam Houston, TX
| | | | - Paul D Blanc
- Department of Anatomic Pathology, University of California, San Francisco, CA; Division of Occupational and Environmental Medicine, University of California, San Francisco, CA; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jeanine M D'Armiento
- Center for LAM and Rare Lung Disease, Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY
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10
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Howard RE, Rabin AS, Heaney DS, Osterholzer JJ. A Sacred Obligation: Meeting the Needs of Veterans with Airborne Hazard Exposures. Ann Am Thorac Soc 2023; 20:354-357. [PMID: 36350334 DOI: 10.1513/annalsats.202208-691ps] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/09/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Rachel E Howard
- Clinical Research Group
- Ann Arbor Site of the Post-Deployment Cardiopulmonary Evaluation Network (PDCEN)
| | - Alexander S Rabin
- Ann Arbor Site of the Post-Deployment Cardiopulmonary Evaluation Network (PDCEN)
- Pulmonary Section, Department of Medicine, and
- Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Deborah S Heaney
- Ann Arbor Site of the Post-Deployment Cardiopulmonary Evaluation Network (PDCEN)
- Ambulatory Care Section, Environmental Health, Lieutenant Colonel Charles S. Kettles VA Medical Center, Ann Arbor, Michigan; and
| | - John J Osterholzer
- Ann Arbor Site of the Post-Deployment Cardiopulmonary Evaluation Network (PDCEN)
- Pulmonary Section, Department of Medicine, and
- Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, Michigan
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11
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Onofrei CD, Gottschall EB, Zell‐Baran L, Rose CS, Kraus R, Pang K, Krefft SD. Unexplained dyspnea linked to mitochondrial myopathy following military deployment to Southwest Asia and Afghanistan. Physiol Rep 2023; 11:e15520. [PMID: 36695704 PMCID: PMC9875744 DOI: 10.14814/phy2.15520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/29/2022] [Accepted: 11/03/2022] [Indexed: 06/17/2023] Open
Abstract
We identified a case of probable mitochondrial myopathy (MM) in a soldier with dyspnea and reduced exercise tolerance through cardiopulmonary exercise testing (CPET) following Southwest Asia (SWA) deployment. Muscle biopsy showed myopathic features. We compared demographic, occupational exposure, and clinical characteristics in symptomatic military deployers with and without probable MM diagnosed by CPET criteria. We evaluated 235 symptomatic military personnel who deployed to SWA and/or Afghanistan between 2010 and 2021. Of these, 168 underwent cycle ergometer maximal CPET with an indwelling arterial line. We defined probable MM based on five CPET criteria: arterial peak exercise lactate >12 mEq/L, anaerobic threshold (AT) ≤50%, maximum oxygen consumption (VO2max ) <95% predicted, oxygen (O2) pulse percent predicted (pp) at least 10% lower than heart rate pp, and elevated ventilatory equivalent for O2 at end exercise (VE/VO2 ≥ 40). We characterized demographics, smoking status/pack-years, spirometry, and deployment exposures, and used descriptive statistics to compare findings in those with and without probable MM. We found 9/168 (5.4%) deployers with probable MM. Compared to symptomatic deployers without probable MM, they were younger (p = 0.0025) and had lower mean BMI (p = 0.02). They had a higher mean forced expiratory volume (FEV1)pp (p = 0.02) and mean arterial oxygen partial pressure (PaO2) at maximum exercise (p = 0.0003). We found no significant differences in smoking status, deployment frequency/duration, or inhalational exposures. Our findings suggest that mitochondrial myopathy may be a cause of dyspnea and reduced exercise tolerance in a subset of previously deployed military personnel. CPET with arterial line may assist with MM diagnosis and management.
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Affiliation(s)
- Claudia Daniela Onofrei
- Division of Pulmonary and Critical Care Medicine, Department of MedicineNational Jewish HealthDenverColoradoUSA
| | - Eva Brigitte Gottschall
- Division of Environmental and Occupational Health Sciences, Department of MedicineNational Jewish HealthDenverColoradoUSA
- Division of Pulmonary and Critical Care Medicine, Department of MedicineUniversity of Colorado Anschutz Medical CampusColoradoAuroraUSA
- Department of Environmental and Occupational HealthColorado School of Public HealthColoradoAuroraUSA
| | - Lauren Zell‐Baran
- Division of Environmental and Occupational Health Sciences, Department of MedicineNational Jewish HealthDenverColoradoUSA
- Department of Environmental and Occupational HealthColorado School of Public HealthColoradoAuroraUSA
| | - Cecile Stephanie Rose
- Division of Environmental and Occupational Health Sciences, Department of MedicineNational Jewish HealthDenverColoradoUSA
- Division of Pulmonary and Critical Care Medicine, Department of MedicineUniversity of Colorado Anschutz Medical CampusColoradoAuroraUSA
- Department of Environmental and Occupational HealthColorado School of Public HealthColoradoAuroraUSA
| | - Richard Kraus
- Division of Environmental and Occupational Health Sciences, Department of MedicineNational Jewish HealthDenverColoradoUSA
| | - Kathy Pang
- Division of Environmental and Occupational Health Sciences, Department of MedicineNational Jewish HealthDenverColoradoUSA
| | - Silpa Dhoma Krefft
- Division of Environmental and Occupational Health Sciences, Department of MedicineNational Jewish HealthDenverColoradoUSA
- Division of Pulmonary and Critical Care Medicine, Department of MedicineUniversity of Colorado Anschutz Medical CampusColoradoAuroraUSA
- Department of Environmental and Occupational HealthColorado School of Public HealthColoradoAuroraUSA
- Division of Pulmonary and Critical Care Medicine, Department of MedicineVeterans Administration Eastern Colorado Health Care SystemColoradoAuroraUSA
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12
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Kupsová B, Pavlík V, Horáček JM, Šafka V, Lašák P, Fajfrová J, Husárová M, Boušová K, Tuček M. Occupational diseases arising in the area of the Ministry of Defence in the Czech Republic and their relationship to work categorization. Cent Eur J Public Health 2022; 30:235-240. [PMID: 36718926 DOI: 10.21101/cejph.a7235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/25/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The article deals with occupational health protection and identification of health risks in the work environment of the Ministry of Defence (MoD) of the Czech Republic (CR). It focuses on the assessment of the incidence of occupational diseases (OD) in high-risk and risk-free occupational categories in the years 2010-2019 and compares them with data from the civilian sector. It identifies the differences between military staff and civilian employees of the MoD. METHODS From the records of OD at the Department of Occupational Diseases of the Central Military Hospital in Prague, the data on acknowledged OD from the years 2010 to 2019 were obtained and then a retrospective analysis focusing on the classification of work at risk was performed. The obtained data were compared with the data from the Czech National Registry of Occupational Diseases (NROD), which are published annually by the National Institute of Public Health. RESULTS In the years under review, 191 OD were confirmed at the area of MoD, 26% of all OD occurred in employees classified in the occupational risk category. Compared with the data in the NROD, where 50% of OD were found to have been caused by high-risk work, the incidence of OD caused by high-risk work in professional soldiers is lower. Only 1.6% of all OD occurred in professional soldiers whose work was classified as high-risk one. In civilian employees of MoD 24.6% of all OD were connected with high-risk work. On the contrary, the proportion of OD occurring in professional soldiers working in risk-free categories was 57.6%, in civilian employees of MoD was the ratio much lower - 16.2%. CONCLUSION Work at the Ministry of Defence was not adequately categorized, therefore, in 2020 a new categorization of work was introduced, which together with preventive measures could contribute to reducing the incidence of OD at the Ministry of Defence.
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Affiliation(s)
- Blanka Kupsová
- Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health Sciences, University of Defence, Hradec Kralove, Czech Republic
| | - Vladimír Pavlík
- Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health Sciences, University of Defence, Hradec Kralove, Czech Republic
| | - Jan M Horáček
- Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health Sciences, University of Defence, Hradec Kralove, Czech Republic
| | - Václav Šafka
- Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health Sciences, University of Defence, Hradec Kralove, Czech Republic
| | - Petr Lašák
- Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health Sciences, University of Defence, Hradec Kralove, Czech Republic
| | - Jana Fajfrová
- Administration Activities Department, Section of Military Health Care, Ministry of Defence, Prague, Czech Republic
| | - Michaela Husárová
- Department of Hygiene, Military Health Institute, Military Medical Agency, Hradec Kralove, Czech Republic
| | - Karin Boušová
- Department of Occupational Medicine, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Milan Tuček
- Institute of Hygiene and Epidemiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
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13
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Van De Graaff J, Poole JA. A Clinician's Guide to Occupational Exposures in the Military. Curr Allergy Asthma Rep 2022; 22:259-264. [PMID: 36370335 PMCID: PMC10926886 DOI: 10.1007/s11882-022-01051-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE OF REVIEW Adverse occupational and environmental exposures are common causes of respiratory disease and health consequences requiring medical care. Understanding how these various exposures affect patients and how to elicit an adequate history is critical for any clinician. Military personnel are often overlooked when discussing groups at risk for environmental exposure-associated airway disease. There are close to 20 million active duty and veterans in the USA, and nearly all clinicians will at some point care for a patient that has served in the military. RECENT FINDINGS Exposures related to military work include burn pits, chemicals/toxins, sandstorms, and living conditions. Burn pits and military waste are increasingly recognized as potential hazards attributed to the ongoing conflicts in the Middle East. The link between these various military exposures and acute or chronic airway diseases remains difficult. Epidemiological studies are emerging to demonstrate correlations with chronic lung disease and prolonged burn pit exposure. This review provides an overview of potential occupational and environmental exposures that may affect current and/or former military service men and women.
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Affiliation(s)
| | - Jill A Poole
- 985990 Nebraska Medical Center, Omaha, NE, 68198, USA
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14
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Davis CW, Lopez CL, Bell AJ, Miller RF, Rabin AS, Murray S, Falvo MJ, Han MK, Galban CJ, Osterholzer JJ. The Severity of Functional Small Airway Disease in Military Personnel with Constrictive Bronchiolitis as Measured by Quantitative Computed Tomography. Am J Respir Crit Care Med 2022; 206:786-789. [PMID: 35608541 DOI: 10.1164/rccm.202201-0153le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
| | | | | | | | - Alexander S Rabin
- University of Michigan Ann Arbor, Michigan.,VA Ann Arbor Health Care System Ann Arbor, Michigan
| | | | - Michael J Falvo
- Rutgers University Newark, New Jersey.,VA New Jersey Health Care System East Orange, New Jersey
| | | | | | - John J Osterholzer
- University of Michigan Ann Arbor, Michigan.,VA Ann Arbor Health Care System Ann Arbor, Michigan
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15
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Hines SE, Gaitens JM, Brown CH, Glick DR, Chin KH, Reback M, McDiarmid MA. Self-reported respiratory outcomes associated with blast exposure in post 9/11 veterans. Respir Med 2022; 202:106963. [DOI: 10.1016/j.rmed.2022.106963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/05/2022] [Accepted: 08/17/2022] [Indexed: 11/28/2022]
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16
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Davis CW, Rabin AS, Jani N, Osterholzer JJ, Krefft S, Hines SE, Arjomandi M, Robertson MW, Sotolongo AM, Falvo MJ. Postdeployment Respiratory Health: The Roles of the Airborne Hazards and Open Burn Pit Registry and the Post-Deployment Cardiopulmonary Evaluation Network. Fed Pract 2022; 39:337-343. [PMID: 36425809 PMCID: PMC9652027 DOI: 10.12788/fp.0307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background Following deployment to the Southwest Asia theater of operations and Afghanistan, many service members and veterans report respiratory symptoms and concerns about their military and environmental exposures. The US Department of Veterans Affairs (VA) established the national Airborne Hazards and Open Burn Pit Registry (AHOBPR) in 2014 to help better understand long-term health conditions that may be related to these exposures. Observations The AHOBPR provides an online questionnaire and optional health evaluation performed by a primary care or environmental health clinician. The clinical evaluation provides an opportunity for the service member or veteran to talk with a health care professional about their symptoms, exposures, and potential treatment. Data derived from questionnaire responses and health evaluations facilitate medical surveillance and research. The VA also established a network of specialists, referred to as the Post-Deployment Cardiopulmonary Evaluation Network (PDCEN). The PDCEN identifies veterans within the AHOBPR who self-report certain conditions or have unexplained dyspnea and conducts comprehensive diagnostic evaluations. Primary objectives of PDCEN evaluations are to define respiratory and related conditions that are present, determine whether conditions are related to deployment, and work with the veteran's clinician to identify treatments and/or follow-up care to improve their health. We utilize a case example to illustrate the role of the primary care practitioner in connecting veterans to PDCEN clinical evaluations. Conclusions AHOBPR clinical evaluations represent an initial step to better understand postdeployment health conditions. The PDCEN clinical evaluation extends the AHOBPR evaluation by providing specialty care for certain veterans requiring more comprehensive evaluation while systematically collecting and analyzing clinical data to advance the field.
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Affiliation(s)
- Caroline W Davis
- Veterans Affairs Ann Arbor Health Care System, LTC Charles S. Kettles Veterans Affaris Medical Center, Michigan
- University of Michigan, Ann Arbor
| | - Alexander S Rabin
- Veterans Affairs Ann Arbor Health Care System, LTC Charles S. Kettles Veterans Affaris Medical Center, Michigan
- University of Michigan, Ann Arbor
| | - Nisha Jani
- Airborne Hazards and Burn Pits Center of Excellence, War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, East Orange
| | - John J Osterholzer
- Veterans Affairs Ann Arbor Health Care System, LTC Charles S. Kettles Veterans Affaris Medical Center, Michigan
- University of Michigan, Ann Arbor
| | - Silpa Krefft
- Veterans Affairs Eastern Colorado Health Care System, Aurora
- National Jewish Health, Division of Environmental and Occupational Health Sciences, Denver, Colorado
- University of Colorado, School of Medicine, Aurora
| | - Stella E Hines
- Veterans Affairs Maryland Health Care System, Baltimore Veterans Affairs Medical Center
- Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Mehrdad Arjomandi
- San Francisco Veterans Affairs Medical Center, California
- Division of Pulmonary, Critical Care, Allergy and Immunology, and Sleep Medicine, Department of Medicine, University of California, San Francisco
- Division of Occupational and Environmental Medicine; Department of Medicine, University of California, San Francisco
| | - Michelle W Robertson
- Airborne Hazards and Burn Pits Center of Excellence, War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, East Orange
| | - Anays M Sotolongo
- Airborne Hazards and Burn Pits Center of Excellence, War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, East Orange
- Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark
| | - Michael J Falvo
- Airborne Hazards and Burn Pits Center of Excellence, War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, East Orange
- Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark
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17
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Hill CJ, Meyer CD, McLean JE, Anderson DC, Hao Y, Lin FC, Kimple AJ, Capra GG. Burn Pit Exposure Is Associated With Increased Sinonasal Disease. J Occup Environ Med 2022; 64:629-634. [PMID: 35673272 PMCID: PMC9357047 DOI: 10.1097/jom.0000000000002551] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether self-reported burn pit exposure is associated with increased subjective and objective sinus disease. DESIGN A cross-sectional study was performed evaluating consecutive adult patients presenting to a US Military rhinology clinic. Demographics, medical histories, sinonasal quality-of-life scores, and nasal endoscopy examinations were obtained. Participants were divided into three cohorts based on self-reported exposure histories and outcomes compared. RESULTS One hundred eighty-six patients met the inclusion criteria, the majority of whom were male. Patients with burn pit exposure had worse Sinonasal Outcome Test-22 scores (49.9) compared with those deployed without burn pit exposure (31.8) or never deployed (31.5). Endoscopic findings demonstrated worse disease within those exposed (Lund-Kennedy score, 3.3) compared with the other cohorts (1.8 and 1.7, respectively). CONCLUSIONS These novel findings suggest that deployment-related burn pit exposure is associated with increased subjective and objective sinus disease.
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Affiliation(s)
- Christopher J. Hill
- Department of Otolaryngology - Head & Neck Surgery, Naval Medical Center Portsmouth, VA
| | - Charles D. Meyer
- Department of Otolaryngology - Head & Neck Surgery, Naval Medical Center Portsmouth, VA
| | - James E. McLean
- Department of Otolaryngology - Head & Neck Surgery, Naval Medical Center Portsmouth, VA
| | - Danielle C. Anderson
- Department of Otolaryngology - Head & Neck Surgery, Naval Medical Center Portsmouth, VA
| | - Yajing Hao
- Department of Biostatistics, Gillings School of Global Public Health
| | - Feng-Chang Lin
- Department of Biostatistics, Gillings School of Global Public Health
| | - Adam J. Kimple
- Department of Otolaryngology - Head & Neck Surgery, University of North Carolina Chapel Hill
| | - Gregory G. Capra
- Department of Otolaryngology - Head & Neck Surgery, Naval Medical Center Portsmouth, VA
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18
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Zell-Baran LM, Humphries SM, Moore CM, Lynch DA, Charbonnier JP, Oh AS, Rose CS. Quantitative imaging analysis detects subtle airway abnormalities in symptomatic military deployers. BMC Pulm Med 2022; 22:163. [PMID: 35477425 PMCID: PMC9047334 DOI: 10.1186/s12890-022-01960-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Exposure to inhalational hazards during post-9/11 deployment to Southwest Asia and Afghanistan puts military personnel at risk for respiratory symptoms and disease. Pulmonary function and qualitative chest high resolution computed tomography (HRCT) are often normal in “deployers” with persistent respiratory symptoms. We explored the utility of quantitative HRCT imaging markers of large and small airways abnormalities, including airway wall thickness, emphysema, and air trapping, in symptomatic deployers with clinically-confirmed lung disease compared to controls. Methods Chest HRCT images from 45 healthy controls and 82 symptomatic deployers with asthma, distal lung disease or both were analyzed using Thirona Lung quantification software to calculate airway wall thickness (by Pi10), emphysema (by percentage of lung volume with attenuation < -950 Hounsfield units [LAA%-950]), and three parameters of air trapping (expiratory/inspiratory total lung volume and mean lung density ratios, and LAA%-856). SAS v.9.4 was used to compare demographic and clinical characteristics between deployers and controls using Chi-Square, Fisher Exact or t-tests. Linear regression was used to assess relationships between pulmonary function and quantitative imaging findings. Results Gender and smoking status were not statistically significantly different between groups, but deployers were significantly younger than controls (42 vs 58 years, p < 0.0001), had higher body mass index (31 vs 28 kg/m2, p = 0.01), and had fewer total smoking pack-years (8 vs. 26, p = 0.007). Spirometric measures were not statistically significantly different between groups. Pi10 and LAA%-950 were significantly elevated in deployers compared to controls in unadjusted analyses, with the emphysema measure remaining significantly higher in deployers after adjustment for age, sex, smoking, BMI, and expiratory total lung volume. Air trapping parameters were more common in control images, likely due to differences in age and smoking between groups. Among deployers, LAA%-950 and Pi10 were significantly correlated with spirometric markers of obstruction based on ratio of forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) and/or percent predicted FEV1. Conclusions Quantitative chest HRCT imaging analysis identifies emphysema in deployers with asthma and distal lung disease, and may be useful in detecting and monitoring deployment-related lung disease in a population where spirometry is typically normal.
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Affiliation(s)
- Lauren M Zell-Baran
- Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, CO, USA.
| | | | - Camille M Moore
- Center for Genes, Environment and Health, National Jewish Health, Denver, CO, USA.,Department of Biostatistics and Informatics, University of Colorado, Aurora, CO, USA
| | - David A Lynch
- Department of Radiology, National Jewish Health, Denver, CO, USA.,School of Medicine, University of Colorado, Aurora, CO, USA
| | | | - Andrea S Oh
- Department of Radiology, National Jewish Health, Denver, CO, USA
| | - Cecile S Rose
- Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, CO, USA.,School of Medicine, University of Colorado, Aurora, CO, USA
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Affiliation(s)
- Alexander S Rabin
- From the Division of Pulmonary and Critical Care, Department of Medicine, Veterans Affairs Ann Arbor Healthcare System, and the Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan - both in Ann Arbor (A.S.R., C.W.D., J.J.O.); and the Airborne Hazards and Burn Pits Center of Excellence, War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, East Orange (A.M.S., M.J.F.), and the Division of Pulmonary and Critical Care, Department of Medicine (A.M.S.), and the Departments of Pharmacology, Physiology and Neuroscience, and Physical Medicine and Rehabilitation (M.J.F.), Rutgers New Jersey Medical School, Newark
| | - Caroline W Davis
- From the Division of Pulmonary and Critical Care, Department of Medicine, Veterans Affairs Ann Arbor Healthcare System, and the Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan - both in Ann Arbor (A.S.R., C.W.D., J.J.O.); and the Airborne Hazards and Burn Pits Center of Excellence, War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, East Orange (A.M.S., M.J.F.), and the Division of Pulmonary and Critical Care, Department of Medicine (A.M.S.), and the Departments of Pharmacology, Physiology and Neuroscience, and Physical Medicine and Rehabilitation (M.J.F.), Rutgers New Jersey Medical School, Newark
| | - Anays M Sotolongo
- From the Division of Pulmonary and Critical Care, Department of Medicine, Veterans Affairs Ann Arbor Healthcare System, and the Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan - both in Ann Arbor (A.S.R., C.W.D., J.J.O.); and the Airborne Hazards and Burn Pits Center of Excellence, War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, East Orange (A.M.S., M.J.F.), and the Division of Pulmonary and Critical Care, Department of Medicine (A.M.S.), and the Departments of Pharmacology, Physiology and Neuroscience, and Physical Medicine and Rehabilitation (M.J.F.), Rutgers New Jersey Medical School, Newark
| | - Michael J Falvo
- From the Division of Pulmonary and Critical Care, Department of Medicine, Veterans Affairs Ann Arbor Healthcare System, and the Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan - both in Ann Arbor (A.S.R., C.W.D., J.J.O.); and the Airborne Hazards and Burn Pits Center of Excellence, War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, East Orange (A.M.S., M.J.F.), and the Division of Pulmonary and Critical Care, Department of Medicine (A.M.S.), and the Departments of Pharmacology, Physiology and Neuroscience, and Physical Medicine and Rehabilitation (M.J.F.), Rutgers New Jersey Medical School, Newark
| | - John J Osterholzer
- From the Division of Pulmonary and Critical Care, Department of Medicine, Veterans Affairs Ann Arbor Healthcare System, and the Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan - both in Ann Arbor (A.S.R., C.W.D., J.J.O.); and the Airborne Hazards and Burn Pits Center of Excellence, War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, East Orange (A.M.S., M.J.F.), and the Division of Pulmonary and Critical Care, Department of Medicine (A.M.S.), and the Departments of Pharmacology, Physiology and Neuroscience, and Physical Medicine and Rehabilitation (M.J.F.), Rutgers New Jersey Medical School, Newark
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20
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Krefft SD, Oh A, Zell-Baran LM, Wolff J, Moore CM, Macedonia TV, Rose CS. Semiquantitative Chest Computed Tomography Assessment Identifies Expiratory Central Airway Collapse in Symptomatic Military Personnel Deployed to Iraq and Afghanistan. J Thorac Imaging 2022; 37:117-124. [PMID: 34121086 PMCID: PMC8876438 DOI: 10.1097/rti.0000000000000596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE We noted incidental findings on chest computed tomography (CT) imaging of expiratory central airway collapse (ECAC) in dyspneic patients after military deployment to southwest Asia (mainly Iraq and Afghanistan). We developed a standardized chest CT protocol with dynamic expiration to enhance diagnostic reliability and investigated demographic, clinical, and deployment characteristics possibly associated with ECAC. MATERIALS AND METHODS We calculated ECAC in 62 consecutive post-9/11 deployers with dyspnea who underwent multi-detector chest CT acquisition. ECAC was defined as ≥70% reduction in the cross-sectional tracheal area at dynamic expiration. We compared demographics (age, smoking, body mass index), comorbid conditions (gastroesophageal reflux, obstructive sleep apnea [OSA]), and clinical findings (air trapping, forced expiratory volume in 1 second percent predicted) in deployers with and without ECAC. We examined associations between ECAC and forced expiratory volume in 1 second percent predicted, air trapping, OSA, deployment duration, and blast exposure. RESULTS Among 62 consecutive deployers with persistent dyspnea, 37% had ECAC. Three had severe (>85%) collapse. Those with ECAC were older (mean age 46 vs. 40 y, P=0.02), but no other demographic or clinical characteristics were statistically different among the groups. Although not statistically significant, ECAC odds were 1.5 times higher (95% confidence interval: 0.9, 2.5) for each additional year of southwest Asia deployment. Deployers with ECAC had 1.6 times greater odds (95% confidence interval: 0.5, 4.8) of OSA. CONCLUSIONS Findings suggest that ECAC is common in symptomatic southwest Asia deployers. Chest high-resolution CT with dynamic expiration may provide an insight into the causes of dyspnea in this population, although risk factors for ECAC remain to be determined. A standardized semiquantitative approach to CT-based assessment of ECAC should improve reliable diagnosis in dyspneic patients.
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Affiliation(s)
- Silpa D. Krefft
- National Jewish Health, Division of Environmental and Occupational Health Sciences
- Veterans Administration Eastern Colorado Health Care System, Division of Pulmonary and Critical Care Medicine
- Division of Pulmonary and Critical Care, School of Medicine
| | - Andrea Oh
- National Jewish Health, Department of Radiology
| | - Lauren M. Zell-Baran
- National Jewish Health, Division of Environmental and Occupational Health Sciences
- Department of Epidemiology, Colorado School of Public Health
| | - Jenna Wolff
- Child Health Associate/Physician Assistant Program, School of Medicine
| | - Camille M. Moore
- National Jewish Health, Center for Genes, Environment and Health, Denver
- Department of Biostatistics and Informatics, University of Colorado Aurora, CO
| | - Tony V. Macedonia
- Division of Pulmonary and Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Cecile S. Rose
- National Jewish Health, Division of Environmental and Occupational Health Sciences
- Division of Pulmonary and Critical Care, School of Medicine
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Teitz-Tennenbaum S, Viglianti SP, Jomma A, Palone Q, Andrews H, Selbmann KN, Lahiri S, Subbotina N, Walker N, Perl AKT, Lama VN, Sisson TH, Osterholzer JJ. Sustained Club Cell Injury in Mice Induces Histopathologic Features of Deployment-Related Constrictive Bronchiolitis. THE AMERICAN JOURNAL OF PATHOLOGY 2022; 192:410-425. [PMID: 34954211 PMCID: PMC8895425 DOI: 10.1016/j.ajpath.2021.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 10/29/2021] [Accepted: 11/29/2021] [Indexed: 02/03/2023]
Abstract
Histopathologic evidence of deployment-related constrictive bronchiolitis (DRCB) has been identified in soldiers deployed to Southwest Asia. While inhalational injury to the airway epithelium is suspected, relatively little is known about the pathogenesis underlying this disabling disorder. Club cells are local progenitors critical for repairing the airway epithelium after exposure to various airborne toxins, and a prior study using an inducible transgenic murine model reported that 10 days of sustained targeted club cell injury causes constrictive bronchiolitis. To further understand the mechanisms leading to small airway fibrosis, a murine model was employed to show that sustained club cell injury elicited acute weight loss, caused increased local production of proinflammatory cytokines, and promoted accumulation of numerous myeloid cell subsets in the lung. Transition to a chronic phase was characterized by up-regulated expression of oxidative stress-associated genes, increased activation of transforming growth factor-β, accumulation of alternatively activated macrophages, and enhanced peribronchiolar collagen deposition. Comparative histopathologic analysis demonstrated that sustained club cell injury was sufficient to induce epithelial metaplasia, airway wall thickening, peribronchiolar infiltrates, and clusters of intraluminal airway macrophages that recapitulated key abnormalities observed in DRCB. Depletion of alveolar macrophages in mice decreased activation of transforming growth factor-β and ameliorated constrictive bronchiolitis. Collectively, these findings implicate sustained club cell injury in the development of DRCB and delineate pathways that may yield biomarkers and treatment targets for this disorder.
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Affiliation(s)
- Seagal Teitz-Tennenbaum
- Research Service and the Pulmonary Section Medical Service, VA Ann Arbor Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Steven P Viglianti
- Research Service and the Pulmonary Section Medical Service, VA Ann Arbor Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan
| | - Ahmad Jomma
- Research Service and the Pulmonary Section Medical Service, VA Ann Arbor Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Quentin Palone
- Research Service and the Pulmonary Section Medical Service, VA Ann Arbor Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Halia Andrews
- Research Service and the Pulmonary Section Medical Service, VA Ann Arbor Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kayla N Selbmann
- Research Service and the Pulmonary Section Medical Service, VA Ann Arbor Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Shayanki Lahiri
- Research Service and the Pulmonary Section Medical Service, VA Ann Arbor Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Natalia Subbotina
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Natalie Walker
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Anne-Karina T Perl
- Pulmonary Biology, The Perinatal Institute and Section of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Thomas H Sisson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - John J Osterholzer
- Research Service and the Pulmonary Section Medical Service, VA Ann Arbor Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
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22
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Rose CS, Moore CM, Zell-Baran LM, Krefft S, Wolff J, Pang K, Parr J, Cool C. Small airways and airspace inflammation and injury distinguish lung histopathology in deployed military personnel from healthy and diseased lungs. Hum Pathol 2022; 124:56-66. [PMID: 35240130 DOI: 10.1016/j.humpath.2022.02.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 01/29/2023]
Abstract
The link between military deployment to Southwest Asia and Afghanistan and risk for lung disease, including bronchiolitis, is increasingly well-recognized. However, histopathologic features that distinguish deployment-related lung diseases from other diseases affecting the small airways and airspaces are uncertain. A computer-based scoring system was developed to characterize surgical lung biopsy findings in 65 soldiers with persistent respiratory symptoms following military deployment ('deployers'). Deployer lung biopsies were compared to those from eight patients with chronic hypersensitivity pneumonitis (cHP), 10 with smoking-related respiratory bronchiolitis, 11 with autoimmune or post-transplant obliterative bronchiolitis, and 10 normal donor lungs. Upper, middle, and lower lobe-specific findings in deployer samples were analyzed to inform optimum biopsy location choice for future patients.
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Affiliation(s)
- Cecile S Rose
- National Jewish Health, Division of Environmental and Occupational Health Sciences, Denver, CO, USA; University of Colorado, School of Medicine, Aurora, CO, USA.
| | - Camille M Moore
- National Jewish Health, Center for Genes, Environment and Health, Denver, CO, USA; University of Colorado, Department of Biostatistics and Informatics, Aurora, CO, USA
| | - Lauren M Zell-Baran
- National Jewish Health, Division of Environmental and Occupational Health Sciences, Denver, CO, USA
| | - Silpa Krefft
- National Jewish Health, Division of Environmental and Occupational Health Sciences, Denver, CO, USA; Veterans Administration Eastern Colorado Health Care System, Division of Pulmonary and Critical Care Medicine, Aurora, CO, USA
| | - Jenna Wolff
- National Jewish Health, Division of Environmental and Occupational Health Sciences, Denver, CO, USA
| | - Kathy Pang
- National Jewish Health, Division of Environmental and Occupational Health Sciences, Denver, CO, USA
| | - Jane Parr
- National Jewish Health, Division of Environmental and Occupational Health Sciences, Denver, CO, USA
| | - Carlyne Cool
- National Jewish Health, Division of Environmental and Occupational Health Sciences, Denver, CO, USA; University of Colorado, School of Medicine, Aurora, CO, USA; University of Colorado, Department of Pathology, Aurora, CO, USA
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23
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Berman R, Rose CS, Downey GP, Day BJ, Chu HW. Role of Particulate Matter from Afghanistan and Iraq in Deployment-Related Lung Disease. Chem Res Toxicol 2021; 34:2408-2423. [PMID: 34808040 DOI: 10.1021/acs.chemrestox.1c00090] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Approximately 3 million United States military personnel and contractors were deployed to Southwest Asia and Afghanistan over the past two decades. After returning to the United States, many developed persistent respiratory symptoms, including those due to asthma, rhinosinusitis, bronchiolitis, and others, which we collectively refer to as deployment-related lung diseases (DRLD). The mechanisms of different DRLD have not been well defined. Limited studies from us and others suggest that multiple factors and biological signaling pathways contribute to the onset of DRLD. These include, but are not limited to, exposures to high levels of particulate matter (PM) from sandstorms, burn pit combustion products, improvised explosive devices, and diesel exhaust particles. Once inhaled, these hazardous substances can activate lung immune and structural cells to initiate numerous cell-signaling pathways such as oxidative stress, Toll-like receptors, and cytokine-driven cell injury (e.g., interleukin-33). These biological events may lead to a pro-inflammatory response and airway hyperresponsiveness. Additionally, exposures to PM and other environmental hazards may predispose military personnel and contractors to more severe disease due to the interactions of those hazardous materials with subsequent exposures to allergens and cigarette smoke. Understanding how airborne exposures during deployment contribute to DRLD may identify effective targets to alleviate respiratory diseases and improve quality of life in veterans and active duty military personnel.
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Affiliation(s)
- Reena Berman
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, Colorado 80206, United States
| | - Cecile S Rose
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, Colorado 80206, United States
| | - Gregory P Downey
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, Colorado 80206, United States
| | - Brian J Day
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, Colorado 80206, United States
| | - Hong Wei Chu
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, Colorado 80206, United States
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24
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Gutor SS, Richmond BW, Du RH, Wu P, Sandler KL, MacKinnon G, Brittain EL, Lee JW, Ware LB, Loyd JE, Johnson JE, Miller RF, Newman JH, Rennard SI, Blackwell TS, Polosukhin VV. Postdeployment Respiratory Syndrome in Soldiers With Chronic Exertional Dyspnea. Am J Surg Pathol 2021; 45:1587-1596. [PMID: 34081035 PMCID: PMC8585675 DOI: 10.1097/pas.0000000000001757] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
After deployment to Southwest Asia, some soldiers develop persistent respiratory symptoms, including exercise intolerance and exertional dyspnea. We identified 50 soldiers with a history of deployment to Southwest Asia who presented with unexplained dyspnea and underwent an unrevealing clinical evaluation followed by surgical lung biopsy. Lung tissue specimens from 17 age-matched, nonsmoking subjects were used as controls. Quantitative histomorphometry was performed for evaluation of inflammation and pathologic remodeling of small airways, pulmonary vasculature, alveolar tissue and visceral pleura. Compared with control subjects, lung biopsies from affected soldiers revealed a variety of pathologic changes involving their distal lungs, particularly related to bronchovascular bundles. Bronchioles from soldiers had increased thickness of the lamina propria, smooth muscle hypertrophy, and increased collagen content. In adjacent arteries, smooth muscle hypertrophy and adventitial thickening resulted in increased wall-to-lumen ratio in affected soldiers. Infiltration of CD4 and CD8 T lymphocytes was noted within airway walls, along with increased formation of lymphoid follicles. In alveolar parenchyma, collagen and elastin content were increased and capillary density was reduced in interalveolar septa from soldiers compared to control subjects. In addition, pleural involvement with inflammation and/or fibrosis was present in the majority (92%) of soldiers. Clinical follow-up of 29 soldiers (ranging from 1 to 15 y) showed persistence of exertional dyspnea in all individuals and a decline in total lung capacity. Susceptible soldiers develop a postdeployment respiratory syndrome that includes exertional dyspnea and complex pathologic changes affecting small airways, pulmonary vasculature, alveolar tissue, and visceral pleura.
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Affiliation(s)
- Sergey S. Gutor
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine
| | - Bradley W. Richmond
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine
- Veterans Affairs Medical Center
| | - Rui-Hong Du
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine
| | - Pingsheng Wu
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine
- Department of Biostatistics, Vanderbilt University School of Medicine
| | | | - Grant MacKinnon
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Evan L. Brittain
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jae Woo Lee
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA
| | - Lorraine B. Ware
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine
- Pathology, Microbiology and Immunology, Vanderbilt University Medical Center
| | - James E. Loyd
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine
| | - Joyce E. Johnson
- Pathology, Microbiology and Immunology, Vanderbilt University Medical Center
| | - Robert F. Miller
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine
| | - John H. Newman
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine
| | - Stephen I. Rennard
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, University of Nebraska Medical Center, Omaha, NE
| | - Timothy S. Blackwell
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine
- Veterans Affairs Medical Center
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Berman R, Min E, Huang J, Kopf K, Downey GP, Riemondy K, Smith HA, Rose CS, Seibold MA, Chu HW, Day BJ. Single-Cell RNA Sequencing Reveals a Unique Monocyte Population in Bronchoalveolar Lavage Cells of Mice Challenged With Afghanistan Particulate Matter and Allergen. Toxicol Sci 2021; 182:297-309. [PMID: 34051097 DOI: 10.1093/toxsci/kfab065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Upon returning from deployment to Afghanistan, a substantial number of U.S. military personnel report deployment-related lung disease (DRLD) symptoms, including those consistent with an asthma-like airways disease. DRLD is thought to be caused by prolonged inhalation of toxic desert particulate matter, which can persist in the postdeployment setting such as exposure to common household allergens. The goal of this study was to define the transcriptomic responses of lung leukocytes of mice exposed to Afghanistan desert particulate matter (APM) and house dust mite (HDM). C57BL/6 mice (n = 15/group) were exposed to filtered air or aerosolized APM for 12 days, followed by intranasal PBS or HDM allergen challenges for 24 h. Bronchoalveolar lavage (BAL) cells were collected for single-cell RNA sequencing (scRNAseq), and assessment of inflammation and airway hyper-responsiveness. Unsupervised clustering of BAL cell scRNAseq data revealed a unique monocyte population induced only by both APM and allergen treatments. This population of monocytes is characterized by the expression of genes involved in allergic asthma, including Alox15. We validated Alox15 expression in monocytes via immunostaining of lung tissue. APM pre-exposure, followed by the HDM challenge, led to significantly increased total respiratory system resistance compared with filtered air controls. Using this mouse model to mimic DRLD, we demonstrated that inhalation of airborne PM during deployment may prime airways to be more responsive to allergen exposure after returning home, which may be linked to dysregulated immune responses such as induction of a unique lung monocyte population.
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Affiliation(s)
- Reena Berman
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Elysia Min
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Jie Huang
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Katrina Kopf
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Gregory P Downey
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Kent Riemondy
- RNA Bioscience Initiative, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Harry A Smith
- RNA Bioscience Initiative, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Cecile S Rose
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Max A Seibold
- Center for Genes, Environment, and Health, National Jewish Health, Denver, CO 80206, USA
| | - Hong Wei Chu
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Brian J Day
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
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26
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Multiple breath washout: A noninvasive tool for identifying lung disease in symptomatic military deployers. Respir Med 2020; 176:106281. [PMID: 33340829 DOI: 10.1016/j.rmed.2020.106281] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 01/08/2023]
Abstract
RATIONALE Military deployments to austere environments since November 9, 2001 may put "deployers" at risk for respiratory disease. Sensitive, noninvasive tools for detecting large and small airways injury are needed to identify early disease and help inform management for this at-risk population. OBJECTIVES We examined multiple breath washout (MBW) as a tool for identifying deployment-related airways disease and assessed host and exposure risk factors compared to healthy controls. METHODS Between March 2015 and March 2020, 103 healthy controls and 71 symptomatic deployers with asthma and/or distal lung disease completed a questionnaire, spirometry and MBW testing. SAS v. 9.4 was used to compare MBW parameters between deployers and controls via univariate analyses and adjusted for demographic factors using multiple linear regression. MEASUREMENTS AND MAIN RESULTS Deployers were significantly more likely than controls to have an abnormal lung clearance index (LCI) score indicating global ventilation inhomogeneity. Adjusting for sex, smoking status, smoking pack-years and body mass index, LCI scores were significantly more abnormal among those with deployment-related asthma and distal lung disease compared to controls. The unadjusted variable Sacin (a marker of ventilation inhomogeneity in the acinar airways) was higher and thus more abnormal in those with both proximal and distal airways disease. Deployers who reported more frequent exposure to explosive blasts had significantly higher LCI scores. CONCLUSIONS This study demonstrates the utility of MBW in evaluating exposure-related airways disease in symptomatic military personnel following deployment to austere environments, and is the first to link exposure to explosive blasts to measurable small airways injury.
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Abstract
Occupational bronchiolitis is characterized by inflammation of the small airways, and represents a heterogeneous set of lung conditions that can occur following a range of inhalation exposures related to work. The most common clinical presentation includes insidious onset of exertional dyspnea and cough. Multiple reports in recent years have drawn attention to previously unrecognized risk factors for occupational bronchiolitis following exposures in several settings. Both current and past occupational exposures, including prior military deployment-related exposures, should be considered in patients undergoing evaluation for unexplained dyspnea. Diagnostic testing for potential bronchiolitis should include a thorough assessment of the small airways.
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