Reduction in lead exposures with lead-free ammunition in an advanced urban assault course.

The training of soldiers for urban conflict involves marksmanship instruction on outdoor flat ranges and the teaching of close-quarter battle techniques in indoor facilities, referred to as shoot houses, where intense firing exercises can generate high air lead levels from small arms ammunition, flash bang grenades, and explosive devices. Levels of lead and copper in air were evaluated during five training activities of a 45-day training course using both stationary general area and breathing zone sampling over a 2-year period. Individual blood lead values were determined prior to and at course completion. Mean breathing zone lead concentrations for the five training activities ranged from 0.014 on the outdoor flat range to 0.064 mg/m3 inside shoot houses; with a change to lead-free ammunition the values were reduced to a range of 0.006-0.022 mg/m3. Isolated flash bang grenades generated very high general area lead concentrations (2.0 mg/m3), which in training were associated with the highest measured breathing zone concentration (0.16 mg/m3). For copper, mean breathing zone concentrations increased from 0.010 to 0.037 mg/m3 with the change to lead-free frangible ammunition on the outdoor range, but remained below the permissible exposure limit for copper fume. Inside shoot houses, mean breathing zone copper concentrations exceeded the permissible exposure limit with ball and lead-free frangible ammunition, ranging from 0.077-0.13 mg/m3. With the introduction of lead-free ammunition, when comparing the blood lead differences between start and finish of the course, there was a significant reduction in the mean blood lead difference from 13.3 µg/dL to 5.4 µg/dL. Options for mitigation of potentially high exposure areas using improved ventilation designs are discussed. These results advocate for improved designs for shoot house training facilities, stress the importance of removing lead from ammunition and explosive devices for training, and promote the continued need for implementation of controls to mitigate and manage metal exposures during training.

Relationship to Deployment on Sarcoidosis Staging and Severity in Military Personnel.

INTRODUCTION: Ongoing studies are investigating the potential link between deployment to Operation Iraqi Freedom and Operation Enduring Freedom and relationship to increases in pulmonary disease. While increases in certain diseases such as asthma and airway hyperreactivity are well established, data on other chronic pulmonary diseases such as sarcoidosis have not been defined. MATERIAL AND METHODS: A retrospective chart review was conducted of all active duty military personnel diagnosed with sarcoidosis from 2005 to 2010. Deployment dates and locations were obtained through the Armed Forces Health Surveillance Branch. Electronic medical records were reviewed to determine the following parameters: dates of diagnosis, temporal relationship of diagnosis and deployment, symptoms (pre- and/or post-deployment), spirometry, diffusing capacity, radiographic staging, and treatment course. Pulmonary sarcoidosis incidence rates were estimated using International Classification of Diseases (ICD-9) coded medical encounter data from the Defense Medical Surveillance System and compared between Army and nonArmy personnel, as well as between ever-deployed and never-deployed personnel. RESULTS: A cohort of 478 Army soldiers was identified with sarcoidosis based on ICD-9 codes and individual review of the medical records. The cohort was 80% male. 38.7% of soldiers with sarcoidosis never deployed. 11.7% were diagnosed prior to deployment, and 50.2% were diagnosed postdeployment. The diagnosis of sarcoidosis was established with a tissue diagnosis in 68% of the deployed cohort. Overall differences in spirometry were not identified. Obstructed spirometry was similar in all deployment groups (never, pre, and post) at 9.2%, 15.8% and 8.7%, respectively. Restrictive patterns based on total lung capacity (<70%) were similar at 9.2%, 12.5%, and 11.0%, respectively. Radiographic staging showed a similar distribution in the populations with the never/pre versus postdeployment groups having Stage 0 = 2.3 versus 3.5%, Stage I = 43.8 versus 41.6%, Stage II = 33.1 versus 41.0%, Stage III = 15.1 versus 12.1%, and Stage IV = 2.2 versus 1.7%, respectively. During 2005-2010, the estimated incidence rate of pulmonary sarcoidosis was low among active duty Army personnel (16.5 cases/100,000 person-years), and no trend in annual rates was observed, p = 0.89. Based on overall Department of Defense medical data, estimated pulmonary sarcoidosis rates were lower among ever-deployed personnel, relative to nondeployed personnel. CONCLUSION: Based on this analysis of Army sarcoidosis patients, there was no difference in the rates of sarcoidosis diagnosis in deployed and nondeployed soldiers. Spirometry values, total lung capacity, and radiographic staging did not show significant differences between deployment groups.

Respiratory Health after Military Service in Southwest Asia and Afghanistan. An Official American Thoracic Society Workshop Report.

Since 2001, more than 2.7 million U.S. military personnel have been deployed in support of operations in Southwest Asia and Afghanistan. Land-based personnel experienced elevated exposures to particulate matter and other inhalational exposures from multiple sources, including desert dust, burn pit combustion, and other industrial, mobile, or military sources. A workshop conducted at the 2018 American Thoracic Society International Conference had the goals of: 1) identifying key studies assessing postdeployment respiratory health, 2) describing emerging research, and 3) highlighting knowledge gaps. The workshop reviewed epidemiologic studies that demonstrated more frequent encounters for respiratory symptoms postdeployment compared with nondeployers and for airway disease, predominantly asthma, as well as case series describing postdeployment dyspnea, asthma, and a range of other respiratory tract findings. On the basis of particulate matter effects in other populations, it also is possible that deployers experienced reductions in pulmonary function as a result of such exposure. The workshop also gave particular attention to constrictive bronchiolitis, which has been reported in lung biopsies of selected deployers. Workshop participants had heterogeneous views regarding the definition and frequency of constrictive bronchiolitis and other small airway pathologic findings in deployed populations. The workshop concluded that the relationship of airway disease, including constrictive bronchiolitis, to exposures experienced during deployment remains to be better defined. Future clinical and epidemiologic research efforts should address better characterization of deployment exposures; carry out longitudinal assessment of potentially related adverse health conditions, including lung function and other physiologic changes; and use rigorous histologic, exposure, and clinical characterization of patients with respiratory tract abnormalities.

Sinai Abbreviated Geriatric Evaluation: Development and Validation of a Practical Test.

OBJECTIVE: To develop and validate a simple geriatric screening tool that performs as well as more complex assessments BACKGROUND:: Many tools that predict treatment risk in older adults are impractical for routine clinical use. METHODS: We prospectively conducted comprehensive preoperative evaluations on 1025 patients age ≥75 years who presented to Sinai Hospital of Baltimore for major elective surgery, then retrospectively reviewed patients' medical records for occurrence of postoperative outcomes. Using logistic regression modeling and receiver operating characteristic curve analysis we selected the best combination of simple tests, labeling this the Sinai Abbreviated Geriatric Evaluation (SAGE). The performance of the SAGE was then compared with 3 standard tools in its power to predict postoperative outcomes. RESULTS: The SAGE is a statistically significant predictor of postoperative outcomes. Each unit decrease in SAGE score was significantly associated with a 51% (95% CI 1.30-1.77) increase in odds of a complication, a 2-fold increase in odds of postoperative delirium (95% CI 1.65-2.66), a 27% increase in odds of length of hospital stay >2 days (95% CI 1.10-1.47), a 54% increase in odds of a hospital readmission within 30 days (95% CI 1.25-2.88), and a 38% increase in odds of an unanticipated discharge to higher-level care (95% CI 1.18-1.61). We estimated the receiver operating characteristic curve area under the curve (AUC) for the SAGE of 0.69, 0.77, 0.73, 0.66, and 0.78 for the above outcomes, respectively. The SAGE performed as well in predicting postoperative outcomes as Fried's frailty phenotype, Charlson Comorbidity Index, and American Society of Anesthesiologists Physical Status Class (ASA). CONCLUSION: The SAGE performs as well as other geriatric evaluations that require equipment or memorization.

Lung function abnormalities among service members returning from Iraq or Afghanistan with respiratory complaints.

BACKGROUND: Service members deploying to Afghanistan (OEF) and Iraq (OIF) often return with respiratory symptoms. We sought to determine prevalence of lung function abnormalities following OEF/OIF. METHODS: We identified OEF/OIF patients who had unexplained respiratory symptoms evaluated using lung function testing. Lung function data were summarized and analyzed for associations with demographic and deployment characteristics. RESULTS: We found 267 patients with unexplained cough or dyspnea, lung function testing and a history of OEF/OIF deployment. All patients had basic spirometry performed and 82 had diffusion capacity for carbon dioxide (DLCO) measured. The median (IQR) number of deployments and total days deployed were 1 (1-2) and 352.0 (209-583), respectively. There were 83 (36.6%) patients with abnormal spirometry, 53 (63.9%) of whom had an abnormal FEV1/FVC. Only one (1.2%) patient had an abnormal DLCO adjusted for alveolar volume. Of 104 patients who had post bronchodilator (BD) testing performed, six (5.8%) had a positive response by ATS criteria. We found no relationships between lung function and time in theater, deployment location, deployment frequency, or land based-deployment. Dyspnea and enlisted rank were associated with tobacco use and lower FEV1, and cough was associated with total number of deployments. CONCLUSIONS: Service members with respiratory complaints following OEF/OIF have a high prevalence of abnormalities on spirometry. Tobacco use, enlisted rank and total number of deployments were associated with symptoms or spirometric abnormalities.

Bronchodilator Responsiveness and Airflow Limitation Are Associated With Deployment Length in Iraq and Afghanistan Veterans.

OBJECTIVE: The aim of this study was to determine the relationship between deployment length and indices of airflow obstruction in Iraq and Afghanistan veterans with airborne hazards exposure. METHODS: One hundred twenty-four post-9/11 veterans completed pulmonary function testing and questionnaires. We examined the association of airflow limitation [forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC)] and bronchodilator responsiveness (ΔFEV1 and ΔFVC) with deployment length, adjusting for smoking. RESULTS: Longer deployment length was associated with lower FEV1/FVC [ß = -0.19; 95% confidence interval (95% CI), -0.39 to 0.01], greater ΔFEV1 (ß = 0.27; 95% CI, 0.09 to 0.45) and ΔFVC (ß = 0.19; 95% CI, 0.05 to 0.33). In our model adjusted for smoking history, longer deployment length remained associated with greater ΔFEV1 and ΔFVC (P < 0.01), but not with FEV1/FVC (P = 0.059). CONCLUSION: In our sample of post-9/11 veterans, longer deployment lengths were associated with significant bronchodilator responsiveness and a trend toward airflow limitation independent of tobacco use.

Postdeployment Respiratory Health Care Encounters Following Deployment to Kabul, Afghanistan: A Retrospective Cohort Study.

Inhalational hazards are numerous in operational environments. A retrospective cohort study was conducted to investigate associations between deployment to Kabul, Afghanistan and subsequent respiratory health among U.S. military personnel. The study population consisted of personnel who deployed to Kabul, select Operation Enduring Freedom locations, personnel stationed in the Republic of Korea, and U.S.-stationed personnel. Incidence rate ratios (IRRs) were estimated for respiratory symptoms, signs, and ill-defined conditions, asthma, and chronic obstructive pulmonary disease. A significantly elevated rate of symptoms, signs, and ill-defined conditions was observed among Kabul-deployed personnel compared to personnel deployed or stationed in Bagram (IRR 1.12; 95% confidence interval [CI], 1.05-1.19), Republic of Korea (IRR 1.20; 95% CI, 1.10-1.31), and the United States (IRR 1.52; 95% CI, 1.43-1.62). A statistically elevated rate of asthma was observed among personnel deployed to Kabul, relative to U.S.-stationed personnel (IRR 1.61; 95% CI, 1.22-2.12). Statistically significant rates were not observed for chronic obstructive pulmonary disease among Kabul-deployed personnel compared to other study groups. These findings suggest that deployment to Kabul is associated with an elevated risk of postdeployment respiratory symptoms and new-onset asthma.

Trends in rates of chronic obstructive respiratory conditions among US military personnel, 2001-2013.

BACKGROUND: The US military has been continuously engaged in combat operations since 2001. Assessing trends in respiratory health diagnoses during this time of prolonged military conflict can provide insight into associated changes in the burden of pulmonary conditions in the US military population. PURPOSE: To estimate and evaluate trends in rates of chronic obstructive pulmonary diseases in the active duty US military population from 2001 through 2013. METHODS: A retrospective analysis of ambulatory medical encounter diagnosis data corresponding to a study base of over 18 million personnel-years was performed to estimate average rates and evaluate temporal trends in rates of chronic obstructive lung conditions. Differences in rates and the time trends of those rates were evaluated by branch of military service, military occupation, and military rank. RESULTS: During the 13-year period, we observed 482,670 encounters for chronic obstructive pulmonary disease and allied conditions (ICD-9 490-496) among active duty military personnel. Over half (57%) of the medical encounters in this category were for a diagnosis of bronchitis, not specified as acute or chronic. There was a statistically significant 17.2% average increase in the annual rates of this nonspecific bronchitis diagnosis from 2001-2009 (95% CI: 13.5% to 21.1%), followed by a 23.6% annual decline in the rates from 2009 through 2013 (95% CI: 8.6% to 36.2%). Statistically significant declines were observed in the rates of chronic bronchitis over time (annual percentage decline: 3.1%; 95% CI: 0.5% to 6.6%) and asthma (annual percentage decline: 5.9%; 95% CI: 2.5% to 9.2%). A 1.6% annual increase in the rate of emphysema and a 0.1% increase in the rate of chronic airways obstruction (not elsewhere classified) over the study period were not statistically significant (P>.05). The magnitude of the estimated rates of these chronic obstructive lung conditions, and, to a lesser extent, the temporal trends in these rates, were sensitive to the requirement that there be persistence of the diagnosis evidenced in the medical record in order qualify as an incident case. CONCLUSIONS: We observed decreases in the rates of asthma and chronic bronchitis over the 13-year study period. The increase, and then decrease, over time in rates of bronchitis that has not been specified as acute or chronic drives the overall trends in chronic respiratory disease trends.

A retrospective cohort study of military deployment and postdeployment medical encounters for respiratory conditions.

Deployed military personnel are exposed to inhalational hazards that may increase their risk of chronic lung conditions. This evaluation assessed associations between Operation Iraqi Freedom (OIF) deployment and postdeployment medical encounters for respiratory symptoms and medical conditions. This retrospective cohort study was conducted among military personnel who, between January 2005 and June 2007, were deployed to either of two locations with burn pits in Iraq, or to either of two locations without burn pits in Kuwait. Incidence rate ratios (IRRs) were estimated using two nondeployed reference groups. Rates among personnel deployed to burn pit locations were also compared directly to those among personnel deployed to locations without burn pits. Significantly elevated rates of encounters for respiratory symptoms (IRR = 1.25; 95% confidence interval [CI]: 1.20-1.30) and asthma (IRR = 1.54; 95% CI: 1.33-1.78) were observed among the formerly deployed personnel relative to U.S.-stationed personnel. Personnel deployed to burn pit locations did not have significantly elevated rates for any of the outcomes relative to personnel deployed to locations without burn pits. These results are consistent with the hypothesis that OIF deployment is associated with subsequent risk of respiratory conditions. Elevated medical encounter rates were not uniquely associated with burn pits.

Use of the word "cure" in oncology.

PURPOSE: Use of the word "cure" in cancer care reflects a balance of physician and patient optimism, realism, medico-legal concerns, and even superstition. This study surveyed a group of oncology specialists regarding the frequency and determinants of using the word cure. METHODS: Oncology clinicians at the Dana-Farber Cancer Institute (n = 180) were invited to complete a survey regarding the word cure in cancer care. Participants completed a 19-question survey regarding how commonly their patients are cured, how often they use the word cure in their practice, and details about its use. Three case scenarios were presented to elicit participants' views. RESULTS: Of the 117 participants (65%) who provided responses, 81% were hesitant to tell a patient that they are cured, and 63% would never tell a patient that they are cured. Only 7% felt that greater than 75% of their patients are, or will be, cured. The participating clinicians reported that only 34% of patients ask if they are cured. For 20-year survivors of testicular cancer, large-cell lymphoma, and estrogen receptor-positive breast cancer, 84%, 76%, and 48% of clinicians, respectively, believed that the patients were cured, and 35%, 43%, and 56% recommended annual oncology follow-up of the patients. Twenty-three percent of oncology clinicians believed that patients should never be discharged from the cancer center. CONCLUSION: Oncology clinicians report that patients are hesitant to ask whether they are cured, and the clinicians are hesitant to tell patients they are cured. Annual oncology follow-up was frequently endorsed, even after 20 years in remission.

Does deployment to Iraq and Afghanistan affect respiratory health of US military personnel?

OBJECTIVE: To evaluate the association between postdeployment respiratory conditions and deployment to Iraq or Afghanistan. METHODS: We linked deployment history of US military personnel with postdeployment medical records. We then conducted a nested case-control study. RESULTS: Relative to a single deployment, multiple deployments were not significantly associated with obstructive pulmonary disease (odds ratio, 1.08; 95% confidence interval, 0.82 to 1.42). Cumulative time deployed was also not significantly associated with obstructive pulmonary disease. Nevertheless, we did note that the rate of respiratory symptoms and encounters for obstructive pulmonary diseases (predominantly asthma and bronchitis) increased from before to after deployment. CONCLUSIONS: In a population of active duty US military personnel, we observed an increase in postdeployment respiratory symptoms and medical encounters for obstructive pulmonary diseases, relative to predeployment rates, in the absence of an association with cumulative deployment duration or total number of deployments.

Respiratory health status of US Army personnel potentially exposed to smoke from 2003 Al-Mishraq Sulfur Plant fire.

OBJECTIVE: To assess the impact of exposure to a 2003 sulfur plant fire on the health of deployed US Army personnel. METHODS: The authors identified a small firefighter group known to be at the fire source and a larger, more dispersed population. Self-reported health status and respiratory health outcomes for these two groups were reviewed compared with two unexposed groups. RESULTS: Self-reported health concerns, difficulty breathing, and shortness of breath were common in the exposed. Rates for chronic respiratory conditions increased in all groups from before to after deployment. Postdeployment medical encounters for chronic respiratory conditions among the exposed did not differ significantly from the unexposed comparison groups. CONCLUSION: Potential exposure to the sulfur fire was positively associated with self-reported health concerns and symptoms but not with clinical encounters for chronic respiratory health conditions.

A case-crossover study of ambient particulate matter and cardiovascular and respiratory medical encounters among US military personnel deployed to southwest Asia.

OBJECTIVE: To evaluate the impact of ambient particulate matter (PM) on acute cardiorespiratory morbidity among US military personnel in southwest Asia. METHODS: We linked ambient PM data collected between December 2005 and June 2007 with personnel, medical, and meteorological data. We implemented a case-crossover analysis to estimate base-specific associations and pooled those estimates using meta-analytic methods. RESULTS: The adjusted odds ratios for a 10-µg/m increase in ambient PM2.5 and a qualifying medical encounter were 0.92 (95% confidence interval [CI]: 0.77 to 1.11) and 1.01 (95% CI: 0.95 to 1.07) for the current (lag_0) and previous (lag_1) days. The estimates for a 10-µg/m increase in PM10 were 0.99 (95% CI: 0.97 to 1.03) at lag_0, and 1.00 (95% CI: 0.97 to 1.02) at lag_1. CONCLUSIONS: No statistically significant associations between PM and cardiorespiratory outcomes were observed in this young, relatively healthy, deployed military population.

Potential health implications associated with particulate matter exposure in deployed settings in southwest Asia.

There is a recognized need to identify the potential impact of air pollution exposure on the health of military personnel deployed to Southwest Asia (SWA). The exposure characterization reported by Engelbrecht et al. in this issue summarizes the results of a remarkable effort to conduct environmental sampling at locations where US military personnel are deployed in support of Operation Enduring Freedom and Operation Iraqi Freedom. This is an important first step in better understanding the relationship between the health of soldiers deployed in SWA and air pollution in the area of operations. We discuss here what is currently known about the effects of particulate matter (PM) on human health, focusing on the limited evidence specific to US military personnel, and outline current and planned efforts to utilize sampling data to assess health outcomes in deployed military populations.

Within-home versus between-home variability of house dust endotoxin in a birth cohort.

Endotoxin exposure has been proposed as an environmental determinant of allergen responses in children. To better understand the implications of using a single measurement of house dust endotoxin to characterize exposure in the first year of life, we evaluated room-specific within-home and between-home variability in dust endotoxin obtained from 470 households in Boston, Massachusetts. Homes were sampled up to two times over 5-11 months. We analyzed 1,287 dust samples from the kitchen, family room, and baby's bedroom for endotoxin. We fit a mixed-effects model to estimate mean levels and the variation of endotoxin between homes, between rooms, and between sampling times. Endotoxin ranged from 2 to 1,945 units per milligram of dust. Levels were highest during summer and lowest in the winter. Mean endotoxin levels varied significantly from room to room. Cross-sectionally, endotoxin was moderately correlated between family room and bedroom floor (r = 0.30), between family room and kitchen (r = 0.32), and between kitchen and bedroom (r = 0.42). Adjusting for season, the correlation of endotoxin levels within homes over time was 0.65 for both the bedroom and kitchen and 0.54 for the family room. The temporal within-home variance of endotoxin was lowest for bedroom floor samples and highest for kitchen samples. Between-home variance was lowest in the family room and highest for kitchen samples. Adjusting for season, within-home variation was less than between-home variation for all three rooms. These results suggest that room-to-room and home-to-home differences in endotoxin influence the total variability more than factors affecting endotoxin levels within a room over time.

Infant home endotoxin is associated with reduced allergen-stimulated lymphocyte proliferation and IL-13 production in childhood.

BACKGROUND: Infant endotoxin exposure has been proposed as a factor that might protect against allergy and the early childhood immune responses that increase the risk of IgE production to allergens. OBJECTIVE: Using a prospective study design, we tested the hypothesis that early-life endotoxin exposure is associated with allergen- and mitogen-induced cytokine production and proliferative responses of PBMCs isolated from infants with a parental history of physician-diagnosed asthma or allergy. METHODS: We assessed household dust endotoxin at age 2 to 3 months and PBMC proliferative and cytokine responses to cockroach allergen (Bla g 2), dust mite allergen (Der f 1), cat allergen (Fel d 1), and the nonspecific mitogen PHA at age 2 to 3 years. RESULTS: We found that increased endotoxin levels were associated with decreased IL-13 levels in response to cockroach, dust mite, and cat allergens, but not mitogen stimulation. Endotoxin levels were not correlated with allergen- or mitogen-induced IFN-gamma, TNF-alpha, or IL-10. Increased endotoxin levels were associated with decreased lymphocyte proliferation after cockroach allergen stimulation. An inverse, although nonsignificant, association was also found between endotoxin and proliferation to the other tested stimuli. CONCLUSION: Increased early-life exposure to household endotoxin was associated with reduced allergen-induced production of the TH2 cytokine IL-13 and reduced lymphoproliferative responses at age 2 to 3 years in children at risk for allergy and asthma. Early-life endotoxin-related reduction of IL-13 production might represent one pathway through which increased endotoxin decreases the risk of allergic disease and allergy in later childhood.