1
|
Liu J, Wang W, Wang Z, Wu Q, Zhu Y, Wu W, Zhou Q. The Association between Dietary Habits and Rapid Postoperative Recovery of Rotator Cuff Repair. Nutrients 2023; 15:4587. [PMID: 37960241 PMCID: PMC10648498 DOI: 10.3390/nu15214587] [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: 09/14/2023] [Revised: 10/19/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Some nutritional factors have been suggested to improve postoperative outcomes in rotator cuff (RC) repair, but dietary effects on the recovery speed after the surgery remain undefined. To investigate the potential roles of dietary habits in this context, we analyzed the 12-month follow-up data of 55 patients with RC repair and found that these patients could be categorized into a rapid recovery group (n = 35) and slow recovery group (n = 20) according to their postoperative recovery patterns. Group-based logistic analysis revealed that habitual intakes of meat (OR = 1.84, 95%CI, 1.22-2.76, p = 0.003), fruits (OR = 2.33, 95%CI, 1.26-5.67, p = 0.01), and wheat-flour foods (OR = 1.62, 95%CI, 1.2-2.25, p = 0.002) were significantly associated with rapid recovery. Moreover, among all intakes of wheat-flour foods, intakes of steamed and boiled flour products were also associated with rapid recovery. Further mediation analysis showed that eosinophilic granulocytes (EOs) significantly mediated the association between rapid RC recovery and the habitual intakes of meat (mediation proportion = 17.5%, P-mediation < 0.0001), fruits (17.9%, p < 0.0001), and wheat-flour foods (11.4%, p < 0.0001). Thus, our study suggests that certain dietary habits play beneficial roles in the context of postoperative recovery for RC repair.
Collapse
Affiliation(s)
- Jiaxin Liu
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China; (J.L.); (W.W.); (Y.Z.)
- State Key Laboratory of Genetic Engineering and MOE Key Laboratory of Contemporary Anthropology, Human Phenome Institute, School of Life Sciences, Fudan University, Shanghai 200438, China; (Z.W.); (Q.W.)
- Rugao Research Institute of Longevity and Aging, Fudan University, Rugao 226500, China
| | - Wei Wang
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China; (J.L.); (W.W.); (Y.Z.)
| | - Zhifeng Wang
- State Key Laboratory of Genetic Engineering and MOE Key Laboratory of Contemporary Anthropology, Human Phenome Institute, School of Life Sciences, Fudan University, Shanghai 200438, China; (Z.W.); (Q.W.)
- Rugao Research Institute of Longevity and Aging, Fudan University, Rugao 226500, China
| | - Qingyun Wu
- State Key Laboratory of Genetic Engineering and MOE Key Laboratory of Contemporary Anthropology, Human Phenome Institute, School of Life Sciences, Fudan University, Shanghai 200438, China; (Z.W.); (Q.W.)
- Rugao Research Institute of Longevity and Aging, Fudan University, Rugao 226500, China
| | - Yunli Zhu
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China; (J.L.); (W.W.); (Y.Z.)
| | - Weicheng Wu
- State Key Laboratory of Genetic Engineering and MOE Key Laboratory of Contemporary Anthropology, Human Phenome Institute, School of Life Sciences, Fudan University, Shanghai 200438, China; (Z.W.); (Q.W.)
- Rugao Research Institute of Longevity and Aging, Fudan University, Rugao 226500, China
| | - Qi Zhou
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China; (J.L.); (W.W.); (Y.Z.)
| |
Collapse
|
2
|
Orysiak J, Młynarczyk M, Piec R, Jakubiak A. Lifestyle and environmental factors may induce airway and systemic inflammation in firefighters. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:73741-73768. [PMID: 36094704 PMCID: PMC9465149 DOI: 10.1007/s11356-022-22479-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 08/07/2022] [Indexed: 06/15/2023]
Abstract
Health status depends on multiple genetic and non-genetic factors. Nonheritable factors (such as lifestyle and environmental factors) have stronger impact on immune responses than genetic factors. Firefighters work is associated with exposure to air pollution and heat stress, as well as: extreme physical effort, mental stress, or a changed circadian rhythm, among others. All these factors can contribute to both, short-term and long-term impairment of the physical and mental health of firefighters. Increased levels of some inflammatory markers, such as pro-inflammatory cytokines or C-reactive protein (CRP) have been observed in firefighters, which can lead to local, acute inflammation that promotes a systemic inflammatory response. It is worth emphasizing that inflammation is one of the main hallmarks of cancer and also plays a key role in the development of cardiovascular and respiratory diseases. This article presents possible causes of the development of an inflammatory reaction in firefighters, with particular emphasis on airway inflammation caused by smoke exposure.
Collapse
Affiliation(s)
- Joanna Orysiak
- Central Institute for Labour Protection - National Research Institute, Czerniakowska St. 16, 00-701, Warsaw, Poland.
| | - Magdalena Młynarczyk
- Central Institute for Labour Protection - National Research Institute, Czerniakowska St. 16, 00-701, Warsaw, Poland
| | - Robert Piec
- Institute of Internal Security, The Main School of Fire Service, Słowackiego St. 52/54, 01-629, Warsaw, Poland
| | - Agnieszka Jakubiak
- Department of Heart Failure and Cardiac Rehabilitation, Medical University of Warsaw, Żwirki and Wigury St. 61, 02-091, Warsaw, Poland
| |
Collapse
|
3
|
Hernandez M, Vaughan J, Gordon T, Lippmann M, Gandy S, Chen LC. World Trade Center dust induces nasal and neurological tissue injury while propagating reduced olfaction capabilities and increased anxiety behaviors. Inhal Toxicol 2022; 34:175-188. [PMID: 35533138 PMCID: PMC9728549 DOI: 10.1080/08958378.2022.2072027] [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] [Indexed: 11/05/2022]
Abstract
Objective: Previous in vitro and in vivo World Trade Center particulate matter (WTCPM) exposure studies have provided evidence of exposure-driven oxidative/nitrative stress and inflammation on respiratory tract and aortic tissues. What remains to be fully understood are secondary organ impacts due to WTCPM exposure. This study was designed to test if WTC particle-induced nasal and neurologic tissue injury may result in unforeseen functional and behavioral outcomes.Material and Methods: WTCPM was intranasally administered in mice, evaluating genotypic, histopathologic, and olfaction latency endpoints.Results: WTCPM exposure was found to incite neurologic injury and olfaction latency in intranasally (IN) exposed mice. Single high-dose and repeat low-dose nasal cavity insults from WTCPM dust resulted in significant olfaction delays and enduring olfaction deficits. Anxiety-dependent behaviors also occurred in mice experiencing olfaction loss including significant body weight loss, increased incidence and time spent in hind stretch postures, as well as increased stationary time and decreased exploratory time. Additionally, WTCPM exposure resulted in increased whole brain wet/dry ratios and wet whole brain to body mass ratios that were correlated with exposure and increased exposure dose (p<0.05).Discussion: The potential molecular drivers of WTCPM-driven tissue injury and olfaction latency may be linked to oxidative/nitrative stress and inflammatory cascades in both upper respiratory nasal and brain tissues.Conclusion: Cumulatively, these data provide evidence of WTCPM exposure in relation to tissue damage related to oxidative stress-driven inflammation identified in the nasal cavity, propagated to olfactory bulb tissues and, potentially, over extended periods, to other CNS tissues.
Collapse
Affiliation(s)
- Michelle Hernandez
- Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| | - Joshua Vaughan
- Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| | - Terry Gordon
- Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| | - Morton Lippmann
- Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| | - Sam Gandy
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J Peter VA Medical Center, Bronx, NY, USA
| | - Lung-Chi Chen
- Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| |
Collapse
|
4
|
Kwon S, Lee M, Crowley G, Schwartz T, Zeig-Owens R, Prezant DJ, Liu M, Nolan A. Dynamic Metabolic Risk Profiling of World Trade Center Lung Disease: A Longitudinal Cohort Study. Am J Respir Crit Care Med 2021; 204:1035-1047. [PMID: 34473012 DOI: 10.1164/rccm.202006-2617oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale: Metabolic syndrome (MetSyn) increases the risk of World Trade Center (WTC) lung injury (LI). However, the temporal relationship of MetSyn, exposure intensity, and lung dysfunction is not well understood. Objective: To model the association of longitudinal MetSyn characteristics with WTC lung disease to define modifiable risk. Methods: Firefighters, for whom consent was obtained (N = 5,738), were active duty on September 11, 2001 (9/11). WTC-LI (n = 1,475; FEV1% predicted <lower limit of normal [LLN]) and non-WTC-LI (n = 4,263; FEV1% predicted ⩾LLN at all exams) was the primary outcome, and FVC% predicted <LLN and FEV1/FVC <0.70 were secondary outcomes. We assessed 1) the effect of concurrent MetSyn on longitudinal lung function by linear mixed models, 2) the temporal effect of MetSyn and exposure by Weibull proportional hazards, 3) the effects of MetSyn's rate of change by two-stage models, and 4) the nonlinear joint effect of longitudinal MetSyn components by a partially linear single-index model (PLSI). Measurements and Main Results: WTC-LI cases were more often ever-smokers, arrived in the morning (9/11), and had MetSyn. Body mass index ⩾30 kg/m2 and high-density lipoprotein <40 mg/dl were most contributory to concurrent loss of FEV1% predicted and FVC% predicted while conserving FEV1/FVC. Body mass index ⩾30 kg/m2 and dyslipidemia significantly predicted WTC-LI, FVC% predicted <LLN in a Weibull proportional hazards model. Dynamic risk assessment of WTC-LI on the basis of MetSyn and exposure showed how reduction of MetSyn factors further reduces WTC-LI likelihood in susceptible populations. PLSI demonstrates that MetSyn has a nonlinear relationship with WTC lung disease, and increases in cumulative MetSyn risk factors exponentially increase WTC-LI risk. An interactive metabolic-risk modeling application was developed to simplify PLSI interpretation. Conclusions: MetSyn and WTC exposure contribute to the development of lung disease. Dynamic risk assessment may be used to encourage treatment of MetSyn in susceptible populations. Future studies will focus on dietary intervention as a disease modifier.
Collapse
Affiliation(s)
- Sophia Kwon
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine
| | - Myeonggyun Lee
- Division of Biostatistics, Department of Population Health, and
| | - George Crowley
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine
| | - Theresa Schwartz
- Bureau of Health Services and Office of Medical Affairs, Fire Department of New York, Brooklyn, New York; and
| | - Rachel Zeig-Owens
- Bureau of Health Services and Office of Medical Affairs, Fire Department of New York, Brooklyn, New York; and.,Department of Epidemiology and Population Health and
| | - David J Prezant
- Bureau of Health Services and Office of Medical Affairs, Fire Department of New York, Brooklyn, New York; and.,Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Mengling Liu
- Division of Biostatistics, Department of Population Health, and.,Department of Environmental Medicine, New York University School of Medicine, New York, New York
| | - Anna Nolan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine.,Department of Environmental Medicine, New York University School of Medicine, New York, New York.,Bureau of Health Services and Office of Medical Affairs, Fire Department of New York, Brooklyn, New York; and
| |
Collapse
|
5
|
Barros B, Oliveira M, Morais S. Firefighters' occupational exposure: Contribution from biomarkers of effect to assess health risks. ENVIRONMENT INTERNATIONAL 2021; 156:106704. [PMID: 34161906 DOI: 10.1016/j.envint.2021.106704] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 06/04/2021] [Accepted: 06/07/2021] [Indexed: 06/13/2023]
Abstract
Firefighting is physically and physiologically exhausting besides encompassing exposure to toxic fire emissions. Biomonitoring studies from the past five years have been significantly contributing to characterize the occupational-related health effects in this group of professionals and to improve risk assessment. Therefore, this study gathers and critically discusses the most characterized biomarkers of effect (oxidative stress, DNA and protein damage, stress hormones, inflammation, and vascular, lung, and liver injury), including those potentially more promising to be explored in future studies, and their relation with health outcomes. Various studies proved an association between exposures to fire emissions and/or heat and significantly altered values of biomarkers of inflammation (soluble adhesion molecules, tumor necrosis factor, interleukins, and leucocyte count), vascular damage and tissue injury (pentraxin-3, vascular endothelial growth factor, and cardiac troponin T) in firefighting forces. Moreover, preliminary data of DNA damage in blood, urinary mutagenicity and 8-isoprostaglandin in exhaled breath condensate suggest that these biomarkers of oxidative stress should be further explored. However, most of the reported studies are based on cross-sectional designs, which limit full identification and characterization of the risk factors and their association with development of work-related diseases. Broader studies based on longitudinal designs and strongly supported by the analysis of several types of biomarkers in different biological fluids are further required to gain deeper insights into the firefighters occupational related health hazards and contribute to implementation of new or improved surveillance programs.
Collapse
Affiliation(s)
- Bela Barros
- REQUIMTE-LAQV, Instituto Superior de Engenharia do Porto, Instituto Politécnico do Porto, Rua Dr. António Bernardino de Almeida 431, 4249-015 Porto
| | - Marta Oliveira
- REQUIMTE-LAQV, Instituto Superior de Engenharia do Porto, Instituto Politécnico do Porto, Rua Dr. António Bernardino de Almeida 431, 4249-015 Porto
| | - Simone Morais
- REQUIMTE-LAQV, Instituto Superior de Engenharia do Porto, Instituto Politécnico do Porto, Rua Dr. António Bernardino de Almeida 431, 4249-015 Porto.
| |
Collapse
|
6
|
Weiden MD, Singh A, Goldfarb DG, Putman B, Zeig‐Owens R, Schwartz T, Cohen HW, Prezant DJ. Serum Th-2 cytokines and FEV 1 decline in WTC-exposed firefighters: A 19-year longitudinal study. Am J Ind Med 2021; 64:845-852. [PMID: 34288008 PMCID: PMC9290799 DOI: 10.1002/ajim.23276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 01/07/2023]
Abstract
Background Accelerated‐FEV1‐decline, defined as rate of decline in FEV1 > 64 ml/year, is a risk factor for asthma and chronic obstructive pulmonary disease in World Trade Center (WTC)‐exposed firefighters. Accelerated‐FEV1‐decline in this cohort is associated with elevated blood eosinophil concentrations, a mediator of Th‐2 response. We hypothesized that an association exists between Th‐2 biomarkers and FEV1 decline rate in those with accelerated‐FEV1‐decline. Methods Serum was drawn from Fire Department of the City of New York (FDNY) firefighters 1–6 months (early) (N = 816) and 12–13 years (late) (N = 983) after 9/11/2001. Th‐2 biomarkers IL‐4, IL‐13, and IL‐5 were assayed by multiplex Luminex. Individual FEV1 decline rates were calculated using spirometric measurements taken: (1) between 9/11/2001 and 9/10/2020 for the early biomarker group and (2) between late measurement date and 9/10/2020 for the late biomarker group. Associations of early and late Th‐2 biomarkers with subsequent FEV1 decline rates were analyzed using multivariable linear regression controlling for demographics, smoking status, and other potential confounders. Results In WTC‐exposed firefighters with accelerated‐FEV1‐decline, IL‐4, IL‐13, and IL‐5 measured 1–6 months post‐9/11/2001 were associated with greater FEV1 decline ml/year between 9/11/2001 and 9/10/2020 (−2.9 ± 1.4 ml/year per IL‐4 doubling; −8.4 ± 1.2 ml/year per IL‐13 doubling; −7.9 ± 1.3 ml/year per IL‐5 doubling). Among late measured Th‐2 biomarkers, only IL‐4 was associated with subsequent FEV1 decline rate (−4.0 ± 1.6 ml/year per IL‐4 doubling). Conclusions In WTC‐exposed firefighters with accelerated‐FEV1‐decline, elevated serum IL‐4 measured both 1–6 months and 12–13 years after 9/11 is associated with greater FEV1 decline/year. Drugs targeting the IL‐4 pathway may improve lung function in this high‐risk subgroup.
Collapse
Affiliation(s)
- Michael D. Weiden
- The Bureau of Health Services and the FDNY World Trade Center Health Program Brooklyn New York USA
- Fire Department of the City of New York Brooklyn New York USA
- Department of Medicine New York University School of Medicine New York New York USA
- Department of Environmental Medicine, Pulmonary, Critical Care and Sleep Medicine Division New York University School of Medicine New York New York USA
| | - Ankura Singh
- The Bureau of Health Services and the FDNY World Trade Center Health Program Brooklyn New York USA
- Fire Department of the City of New York Brooklyn New York USA
- Department of Medicine, Pulmonary Medicine Division Montefiore Medical Center and Albert Einstein College of Medicine Bronx New York USA
| | - David G. Goldfarb
- The Bureau of Health Services and the FDNY World Trade Center Health Program Brooklyn New York USA
- Fire Department of the City of New York Brooklyn New York USA
- Department of Medicine, Pulmonary Medicine Division Montefiore Medical Center and Albert Einstein College of Medicine Bronx New York USA
| | - Barbara Putman
- Department of Medicine New York University School of Medicine New York New York USA
- Department of Environmental Medicine, Pulmonary, Critical Care and Sleep Medicine Division New York University School of Medicine New York New York USA
- Department of Bioanalysis, Faculty of Pharmaceutical Sciences Ghent University Ghent Belgium
| | - Rachel Zeig‐Owens
- The Bureau of Health Services and the FDNY World Trade Center Health Program Brooklyn New York USA
- Fire Department of the City of New York Brooklyn New York USA
- Department of Medicine, Pulmonary Medicine Division Montefiore Medical Center and Albert Einstein College of Medicine Bronx New York USA
- Department of Epidemiology and Population Health, Division of Epidemiology Albert Einstein College of Medicine Bronx New York USA
| | - Theresa Schwartz
- The Bureau of Health Services and the FDNY World Trade Center Health Program Brooklyn New York USA
- Fire Department of the City of New York Brooklyn New York USA
- Department of Medicine, Pulmonary Medicine Division Montefiore Medical Center and Albert Einstein College of Medicine Bronx New York USA
| | - Hillel W. Cohen
- Department of Epidemiology and Population Health, Division of Epidemiology Albert Einstein College of Medicine Bronx New York USA
| | - David J. Prezant
- The Bureau of Health Services and the FDNY World Trade Center Health Program Brooklyn New York USA
- Fire Department of the City of New York Brooklyn New York USA
- Department of Medicine, Pulmonary Medicine Division Montefiore Medical Center and Albert Einstein College of Medicine Bronx New York USA
| |
Collapse
|
7
|
Crowley G, Kim J, Kwon S, Lam R, Prezant DJ, Liu M, Nolan A. PEDF, a pleiotropic WTC-LI biomarker: Machine learning biomarker identification and validation. PLoS Comput Biol 2021; 17:e1009144. [PMID: 34288906 PMCID: PMC8328304 DOI: 10.1371/journal.pcbi.1009144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 08/02/2021] [Accepted: 06/03/2021] [Indexed: 12/01/2022] Open
Abstract
Biomarkers predict World Trade Center-Lung Injury (WTC-LI); however, there remains unaddressed multicollinearity in our serum cytokines, chemokines, and high-throughput platform datasets used to phenotype WTC-disease. To address this concern, we used automated, machine-learning, high-dimensional data pruning, and validated identified biomarkers. The parent cohort consisted of male, never-smoking firefighters with WTC-LI (FEV1, %Pred< lower limit of normal (LLN); n = 100) and controls (n = 127) and had their biomarkers assessed. Cases and controls (n = 15/group) underwent untargeted metabolomics, then feature selection performed on metabolites, cytokines, chemokines, and clinical data. Cytokines, chemokines, and clinical biomarkers were validated in the non-overlapping parent-cohort via binary logistic regression with 5-fold cross validation. Random forests of metabolites (n = 580), clinical biomarkers (n = 5), and previously assayed cytokines, chemokines (n = 106) identified that the top 5% of biomarkers important to class separation included pigment epithelium-derived factor (PEDF), macrophage derived chemokine (MDC), systolic blood pressure, macrophage inflammatory protein-4 (MIP-4), growth-regulated oncogene protein (GRO), monocyte chemoattractant protein-1 (MCP-1), apolipoprotein-AII (Apo-AII), cell membrane metabolites (sphingolipids, phospholipids), and branched-chain amino acids. Validated models via confounder-adjusted (age on 9/11, BMI, exposure, and pre-9/11 FEV1, %Pred) binary logistic regression had AUCROC [0.90(0.84–0.96)]. Decreased PEDF and MIP-4, and increased Apo-AII were associated with increased odds of WTC-LI. Increased GRO, MCP-1, and simultaneously decreased MDC were associated with decreased odds of WTC-LI. In conclusion, automated data pruning identified novel WTC-LI biomarkers; performance was validated in an independent cohort. One biomarker—PEDF, an antiangiogenic agent—is a novel, predictive biomarker of particulate-matter-related lung disease. Other biomarkers—GRO, MCP-1, MDC, MIP-4—reveal immune cell involvement in WTC-LI pathogenesis. Findings of our automated biomarker identification warrant further investigation into these potential pharmacotherapy targets. Disease related to air pollution causes millions of deaths annually. Large swathes of the general population, as well as certain occupations such as 1st responders and military personnel, are exposed to particulate matter (PM)—a major component of air pollution. Our longitudinal cohort of FDNY firefighters exposed to the World Trade Center dust cloud on 9/11 is a unique research opportunity to characterize the impact of a single, intense PM exposure by looking at pre- and post-exposure phenotype; however, PM-related lung disease and PM’s systemic effects are complex and call for a systems biological approach coupled with novel computational modelling techniques to fully understand pathogenesis. In the present study, we integrate clinical and environmental biomarkers with the serum metabolome, cytokines, and chemokines to develop a model for early disease detection and identification of potential signaling cascades of PM-related chronic lung disease.
Collapse
Affiliation(s)
- George Crowley
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York, United States of America
| | - James Kim
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York, United States of America
| | - Sophia Kwon
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York, United States of America
| | - Rachel Lam
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York, United States of America
| | - David J. Prezant
- Bureau of Health Services, Fire Department of New York, Brooklyn, New York, United States of America
- Department of Medicine, Pulmonary Medicine Division, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Mengling Liu
- Department of Environmental Medicine, New York University School of Medicine, New York, New York, United States of America
- Department of Population Health, Division of Biostatistics, New York University School of Medicine, New York, New York, United States of America
| | - Anna Nolan
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York, United States of America
- Bureau of Health Services, Fire Department of New York, Brooklyn, New York, United States of America
- Department of Environmental Medicine, New York University School of Medicine, New York, New York, United States of America
- * E-mail:
| |
Collapse
|
8
|
Cohen HW, Zeig-Owens R, Joe C, Hall CB, Webber MP, Weiden MD, Cleven KL, Jaber N, Skerker M, Yip J, Schwartz T, Prezant DJ. Long-term Cardiovascular Disease Risk Among Firefighters After the World Trade Center Disaster. JAMA Netw Open 2019; 2:e199775. [PMID: 31490535 PMCID: PMC6735414 DOI: 10.1001/jamanetworkopen.2019.9775] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Published studies examining the association between World Trade Center (WTC) exposure on and after September 11, 2001, and longer-term cardiovascular disease (CVD) outcomes have reported mixed findings. OBJECTIVE To assess whether WTC exposure was associated with elevated CVD risk in Fire Department of the City of New York (FDNY) firefighters. DESIGN, SETTINGS, AND PARTICIPANTS In this cohort study, the association between WTC exposure and the risk of CVD was assessed between September 11, 2001, and December 31, 2017, in FDNY male firefighters. Multivariable Cox regression analyses were used to estimate CVD risk in association with 2 measures of WTC exposure: arrival time to the WTC site and duration of work at the WTC site. Data analyses were conducted from May 1, 2018, to March 8, 2019. MAIN OUTCOMES AND MEASURES The primary CVD outcome included myocardial infarction, stroke, unstable angina, coronary artery surgery or angioplasty, or CVD death. The secondary outcome (all CVD) included all primary outcome events or any of the following: transient ischemic attack; stable angina, defined as either use of angina medication or cardiac catheterization without intervention; cardiomyopathy; and other CVD (aortic aneurysm, peripheral arterial vascular intervention, and carotid artery surgery). RESULTS There were 489 primary outcome events among 9796 male firefighters (mean [SD] age on September 11, 2001, was 40.3 [7.4] years and 7210 individuals [73.6%] were never smokers). Age-adjusted incident rates of CVD were higher for firefighters with greater WTC exposure. The multivariable adjusted hazard ratio (HR) for the primary CVD outcome was 1.44 (95% CI, 1.09-1.90) for the earliest arrival group compared with those who arrived later. Similarly, those who worked at the WTC site for 6 or more months vs those who worked less time at the site were more likely to have a CVD event (HR, 1.30; 95% CI, 1.05-1.60). Well-established CVD risk factors, including hypertension (HR, 1.41; 95% CI, 1.10-1.80), hypercholesterolemia (HR, 1.56; 95% CI, 1.28-1.91), diabetes (HR, 1.99; 95% CI, 1.33-2.98), and smoking (current: HR, 2.13; 95% CI, 1.68-2.70; former: HR, 1.55; 95% CI, 1.23-1.95), were significantly associated with CVD in the multivariable models. Analyses with the all-CVD outcome were similar. CONCLUSIONS AND RELEVANCE The findings of the study suggest a significant association between greater WTC exposure and long-term CVD risk. The findings appear to reinforce the importance of long-term monitoring of the health of survivors of disasters.
Collapse
Affiliation(s)
- Hillel W. Cohen
- Division of Epidemiology, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Rachel Zeig-Owens
- Division of Epidemiology, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
- The Bureau of Health Services and the Fire Department of the City of New York World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, New York
- Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Cynthia Joe
- The Bureau of Health Services and the Fire Department of the City of New York World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, New York
- Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Charles B. Hall
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Mayris P. Webber
- The Bureau of Health Services and the Fire Department of the City of New York World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, New York
- Department of Epidemiology and Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Michael D. Weiden
- The Bureau of Health Services and the Fire Department of the City of New York World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, New York
- Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, New York University School of Medicine, New York
- Pulmonary, Critical Care, and Sleep Medicine Division, Department of Environmental Medicine, New York University School of Medicine, New York
| | - Krystal L. Cleven
- Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Nadia Jaber
- The Bureau of Health Services and the Fire Department of the City of New York World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, New York
| | - Molly Skerker
- The Bureau of Health Services and the Fire Department of the City of New York World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, New York
- Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Jennifer Yip
- The Bureau of Health Services and the Fire Department of the City of New York World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, New York
- Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Theresa Schwartz
- The Bureau of Health Services and the Fire Department of the City of New York World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, New York
- Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - David J. Prezant
- The Bureau of Health Services and the Fire Department of the City of New York World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, New York
- Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
9
|
Putman B, Zeig-Owens R, Singh A, Hall CB, Schwartz T, Webber MP, Cohen HW, Prezant DJ, Bachert C, Weiden MD. Risk factors for post-9/11 chronic rhinosinusitis in Fire Department of the City of New York workers. Occup Environ Med 2018; 75:884-889. [DOI: 10.1136/oemed-2018-105297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/14/2018] [Accepted: 09/28/2018] [Indexed: 12/12/2022]
Abstract
ObjectivesChronic rhinosinusitis (CRS) has high socioeconomic burden but underexplored risk factors. The collapse of the World Trade Center (WTC) towers on 11 September 2001 (9/11) caused dust and smoke exposure, leading to paranasal sinus inflammation and CRS. We aim to determine which job tasks are risk factors for CRS in WTC-exposed Fire Department of the City of New York (FDNY) firefighters and emergency medical services (EMS) workers.MethodsThis cohort study included a 16-year follow-up of 11 926 WTC-exposed FDNY rescue/recovery workers with data on demographics, WTC exposure, job tasks and first post-9/11 complete blood counts. Using multivariable Cox regression, we assessed the associations of WTC exposure, work assignment (firefighter/EMS), digging and rescue tasks at the WTC site and blood eosinophil counts with subsequent CRS, adjusting for potential confounders.ResultsThe rate of CRS was higher in firefighters than EMS (1.80/100 person-years vs 0.70/100 person-years; p<0.001). The combination of digging and rescue work was a risk factor for CRS (HR 1.54, 95% CI 1.23 to 1.94, p<0.001) independent of work assignment and WTC exposure.ConclusionsCompared with EMS, firefighters were more likely to engage in a combination of digging and rescue work, which was a risk factor for CRS. Chronic irritant exposures associated with digging and rescue work may account for higher post-9/11 CRS rates among firefighters.
Collapse
|
10
|
Zeig-Owens R, Singh A, Aldrich TK, Hall CB, Schwartz T, Webber MP, Cohen HW, Kelly KJ, Nolan A, Prezant DJ, Weiden MD. Blood Leukocyte Concentrations, FEV 1 Decline, and Airflow Limitation. A 15-Year Longitudinal Study of World Trade Center-exposed Firefighters. Ann Am Thorac Soc 2018; 15:173-183. [PMID: 29099614 PMCID: PMC5802620 DOI: 10.1513/annalsats.201703-276oc] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 10/19/2017] [Indexed: 12/25/2022] Open
Abstract
RATIONALE Rescue/recovery work at the World Trade Center disaster site (WTC) caused a proximate decline in lung function in Fire Department of the City of New York firefighters. A subset of this cohort experienced an accelerated rate of lung function decline over 15 years of post-September 11, 2001 (9/11) follow-up. OBJECTIVES To determine if early postexposure blood leukocyte concentrations are biomarkers for subsequent FEV1 decline and incident airflow limitation. METHODS Individual rates of forced expiratory volume in 1 second (FEV1) change were calculated for 9,434 firefighters using 88,709 spirometric measurements taken between September 11, 2001, and September 10, 2016. We categorized FEV1 change rates into three trajectories: accelerated FEV1 decline (FEV1 loss >64 ml/yr), expected FEV1 decline (FEV1 loss between 0 and 64 ml/yr), and improved FEV1 (positive rate of change >0 ml/yr). Occurrence of FEV1/FVC less than 0.70 after 9/11 defined incident airflow limitation. Using regression models, we assessed associations of post-9/11 blood eosinophil and neutrophil concentrations with subsequent FEV1 decline and airflow limitation, adjusted for age, race, smoking, height, WTC exposure level, weight change, and baseline lung function. RESULTS Accelerated FEV1 decline occurred in 12.7% of participants (1,199 of 9,434), whereas post-9/11 FEV1 improvement occurred in 8.3% (780 of 9,434). Higher blood eosinophil and neutrophil concentrations were each associated with accelerated FEV1 decline after adjustment for covariates (odds ratio [OR], 1.10 per 100 eosinophils/μl; 95% confidence interval [CI], 1.05-1.15; and OR, 1.10 per 1,000 neutrophils/μl; 95% CI, 1.05-1.15, respectively). Multivariable-adjusted linear regression models showed that a higher blood neutrophil concentration was associated with a faster rate of FEV1 decline (1.14 ml/yr decline per 1,000 neutrophils/μl; 95% CI, 0.69-1.60 ml/yr; P < 0.001). Higher blood eosinophil concentrations were associated with a faster rate of FEV1 decline in ever-smokers (1.46 ml/yr decline per 100 eosinophils/μl; 95% CI, 0.65-2.26 ml/yr; P < 0.001) but not in never-smokers (P for interaction = 0.004). Higher eosinophil concentrations were also associated with incident airflow limitation (adjusted hazard ratio, 1.10 per 100 eosinophils/μl; 95% CI, 1.04-1.15). Compared with the expected FEV1 decline group, individuals experiencing accelerated FEV1 decline were more likely to have incident airflow limitation (adjusted OR, 4.12; 95% CI, 3.30-5.14). CONCLUSIONS Higher post-9/11 blood neutrophil and eosinophil concentrations were associated with subsequent accelerated FEV1 decline in WTC-exposed firefighters. Both higher blood eosinophil concentrations and accelerated FEV1 decline were associated with incident airflow limitation in WTC-exposed firefighters.
Collapse
Affiliation(s)
- Rachel Zeig-Owens
- The Bureau of Health Services and Office of Medical Affairs, Fire Department of the City of New York, Brooklyn, New York
- Division of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
- Division of Epidemiology and
| | - Ankura Singh
- The Bureau of Health Services and Office of Medical Affairs, Fire Department of the City of New York, Brooklyn, New York
- Division of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Thomas K. Aldrich
- Division of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Charles B. Hall
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York; and
| | - Theresa Schwartz
- The Bureau of Health Services and Office of Medical Affairs, Fire Department of the City of New York, Brooklyn, New York
- Division of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Mayris P. Webber
- The Bureau of Health Services and Office of Medical Affairs, Fire Department of the City of New York, Brooklyn, New York
- Division of Epidemiology and
| | | | - Kerry J. Kelly
- The Bureau of Health Services and Office of Medical Affairs, Fire Department of the City of New York, Brooklyn, New York
| | - Anna Nolan
- The Bureau of Health Services and Office of Medical Affairs, Fire Department of the City of New York, Brooklyn, New York
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, and
- Department of Environmental Medicine, New York University School of Medicine, New York, New York
| | - David J. Prezant
- The Bureau of Health Services and Office of Medical Affairs, Fire Department of the City of New York, Brooklyn, New York
- Division of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Michael D. Weiden
- The Bureau of Health Services and Office of Medical Affairs, Fire Department of the City of New York, Brooklyn, New York
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, and
- Department of Environmental Medicine, New York University School of Medicine, New York, New York
| |
Collapse
|
11
|
Liu X, Yip J, Zeig-Owens R, Weakley J, Webber MP, Schwartz TM, Prezant DJ, Weiden MD, Hall CB. The Effect of World Trade Center Exposure on the Timing of Diagnoses of Obstructive Airway Disease, Chronic Rhinosinusitis, and Gastroesophageal Reflux Disease. Front Public Health 2017; 5:2. [PMID: 28229067 PMCID: PMC5296346 DOI: 10.3389/fpubh.2017.00002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 01/16/2017] [Indexed: 01/21/2023] Open
Abstract
Objectives In a cohort of rescue/recovery workers exposed to the dust that resulted from the collapse of the World Trade Center (WTC), we assessed how a diagnosis of obstructive airways disease (OAD) affected the likelihood of a subsequent diagnosis of chronic rhinosinusitis (CRS) or gastroesophageal reflux disease (GERD). We also assessed whether OAD acted as a mediator of the association between exposure to the WTC rescue/recovery effort and CRS and GERD diagnoses. Methods In this prospective cohort study, we analyzed Fire Department of the City of New York physician diagnoses of OAD, CRS, and GERD that were first documented between September 11, 2001, and September 10, 2011, among 8,968 WTC-exposed firefighters. We used piecewise exponential survival models to evaluate whether OAD was a risk factor for either CRS or GERD and to assess OAD as a possible mediator. Results An OAD diagnosis significantly increased the risks for subsequent CRS [relative rate (RR), 4.24; 95% CI, 3.78–4.76] and GERD (RR, 3.21; 95% CI, 2.93–3.52) diagnoses. Further, 21% of the WTC exposure effect (high vs. low intensity) on GERD and 13% of the effect (high vs. low intensity) on CRS were mediated by a prior OAD diagnosis. Conclusion Individuals with an OAD diagnosis had elevated risks for subsequent diagnoses of CRS or GERD. Part of the effect of WTC exposure on CRS and GERD diagnoses is mediated by prior diagnoses of OAD; this mediation effect of OAD may reflect biological pathways or healthcare utilization practices.
Collapse
Affiliation(s)
- Xiaoxue Liu
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA; Bureau of Health Services, Fire Department of the City of New York, Brooklyn, NY, USA
| | - Jennifer Yip
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA; Bureau of Health Services, Fire Department of the City of New York, Brooklyn, NY, USA
| | - Rachel Zeig-Owens
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA; Bureau of Health Services, Fire Department of the City of New York, Brooklyn, NY, USA; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jessica Weakley
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA; Bureau of Health Services, Fire Department of the City of New York, Brooklyn, NY, USA
| | - Mayris P Webber
- Bureau of Health Services, Fire Department of the City of New York, Brooklyn, NY, USA; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Theresa M Schwartz
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA; Bureau of Health Services, Fire Department of the City of New York, Brooklyn, NY, USA
| | - David J Prezant
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA; Bureau of Health Services, Fire Department of the City of New York, Brooklyn, NY, USA
| | - Michael D Weiden
- Bureau of Health Services, Fire Department of the City of New York, Brooklyn, NY, USA; Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Charles B Hall
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine , Bronx, NY , USA
| |
Collapse
|
12
|
Zeig-Owens R, Nolan A, Putman B, Singh A, Prezant DJ, Weiden MD. Biomarkers of patient intrinsic risk for upper and lower airway injury after exposure to the World Trade Center atrocity. Am J Ind Med 2016; 59:788-94. [PMID: 27582481 DOI: 10.1002/ajim.22643] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND High rates of upper and lower airways disease have occurred in Fire Department of the City of New York (FDNY) workers exposed to the World Trade Center (WTC) disaster site. Most experienced acute declines in pulmonary function, and some continued to experience decline over 14 years of follow-up. Similarly, some with rhinosinusitis had symptoms requiring sinus surgery. AIM To increase generalizability of biomarker investigation, we describe biomarkers of risk for upper and lower airway injury that do not require stored serum. METHODS We review WTC biomarker literature. RESULTS Cytokines expressed in stored serum from the first 6 months post-9/11 can identify individuals at higher risk for future abnormal pulmonary function. CONCLUSION This research will help identify individuals at high risk of lung and sinus disease that develop after these, or future, irritant exposures for intensive monitoring and treatment. It may also identify targets for effective therapeutic interventions. Am. J. Ind. Med. 59:788-794, 2016. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Rachel Zeig-Owens
- The Bureau of Health Services; Fire Department of New York City; Brooklyn New York
- Department of Medicine; Montefiore Medical Center; Bronx New York
| | - Anna Nolan
- The Bureau of Health Services; Fire Department of New York City; Brooklyn New York
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine; New York University School of Medicine; New York New York
| | - Barbara Putman
- Department of Respiratory Medicine; Ghent University Hospital; Ghent Belgium
| | - Ankura Singh
- The Bureau of Health Services; Fire Department of New York City; Brooklyn New York
- Department of Medicine; Montefiore Medical Center; Bronx New York
| | - David J. Prezant
- The Bureau of Health Services; Fire Department of New York City; Brooklyn New York
- Division of Pulmonary Medicine; Montefiore Medical Center; Bronx New York
| | - Michael D. Weiden
- The Bureau of Health Services; Fire Department of New York City; Brooklyn New York
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine; New York University School of Medicine; New York New York
| |
Collapse
|
13
|
Yip J, Webber MP, Zeig-Owens R, Vossbrinck M, Singh A, Kelly K, Prezant DJ. FDNY and 9/11: Clinical services and health outcomes in World Trade Center-exposed firefighters and EMS workers from 2001 to 2016. Am J Ind Med 2016; 59:695-708. [PMID: 27427498 DOI: 10.1002/ajim.22631] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND After the World Trade Center (WTC) attacks on September 11, 2001, the Fire Department of the City of New York (FDNY) instituted a WTC medical monitoring and treatment program and established a data center to document health outcomes in the WTC-exposed workforce of ∼16,000 firefighters and EMS workers. METHODS FDNY schedules routine monitoring exams every 12-18 months and physical and mental health treatment appointments, as required. RESULTS FDNY research studies have consistently found that early arrival to work and/or prolonged work at the WTC-site increased the risks for adverse physical and mental health outcomes. To date, a substantial proportion has been diagnosed with obstructive airways disease, chronic rhinosinusitis, and gastroesophageal reflux disease; a quarter has two or more of these conditions. CONCLUSIONS While much has been learned, the entire spectrum and trajectory of WTC-related disorders and their mechanisms of onset and persistence remain to be fully described. Am. J. Ind. Med. 59:695-708, 2016. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Jennifer Yip
- Department of Medicine; Montefiore Medical Center; Bronx New York
- Bureau of Health Services; Fire Department of the City of New York; Brooklyn New York
| | - Mayris P. Webber
- Bureau of Health Services; Fire Department of the City of New York; Brooklyn New York
- Department of Epidemiology and Population Health; Albert Einstein College of Medicine; Bronx New York
| | - Rachel Zeig-Owens
- Department of Medicine; Montefiore Medical Center; Bronx New York
- Bureau of Health Services; Fire Department of the City of New York; Brooklyn New York
| | - Madeline Vossbrinck
- Department of Medicine; Montefiore Medical Center; Bronx New York
- Bureau of Health Services; Fire Department of the City of New York; Brooklyn New York
| | - Ankura Singh
- Department of Medicine; Montefiore Medical Center; Bronx New York
- Bureau of Health Services; Fire Department of the City of New York; Brooklyn New York
| | - Kerry Kelly
- Bureau of Health Services; Fire Department of the City of New York; Brooklyn New York
| | - David J. Prezant
- Bureau of Health Services; Fire Department of the City of New York; Brooklyn New York
- Pulmonary Medicine Division; Montefiore Medical Center; Bronx New York
| |
Collapse
|