Clinical and Clinicopathologic Discriminators Between Canine Acute Monocytic Ehrlichiosis and Primary Immune Thrombocytopenia.

Acute canine monocytic ehrlichiosis due to Ehrlichia canis (aCME), and primary immune thrombocytopenia (pITP) are major differentials for dogs presented with thrombocytopenia, and the two diseases may clinically overlap. The aim of this study was to compare dogs diagnosed with naturally occurring aCME and pITP, to establish potentially useful clinical and clinicopathologic discriminators. A clinical record-based retrospective study was performed in 35 dogs diagnosed with aCME and 29 dogs with pITP. Dogs with aCME were significantly younger, and were more likely to experience depression or lethargy, anorexia, body weight loss, fever, lymphadenomegaly, tick infestation, and ocular discharge on admission, compared to dogs with pITP. In contrast, dogs with pITP presented more frequently with overt bleeding and had a significantly higher bleeding score compared to dogs with aCME. Dogs with aCME were more likely to be anemic and hypoalbuminemic on presentation compared to dogs with pITP. Dogs with pITP had higher white blood cell and neutrophil counts as well as lower platelet counts than dogs with aCME and were more likely to present with leukocytosis, neutrophilia and monocytosis. These clinical, hematological, and biochemical findings may be helpful discriminators between aCME and pITP, on the understanding that they will be interpreted in the context of disease-specific testing.

Post-9/11/2001 lung function trajectories by sex and race in World Trade Center-exposed New York City emergency medical service workers.

OBJECTIVE: To determine whether lung function trajectories after 9/11/2001 (9/11) differed by sex or race/ethnicity in World Trade Center-exposed Fire Department of the City of New York emergency medical service (EMS) workers. METHOD: Serial cross-sectional study of pulmonary function tests (PFTs) taken between 9/11 and 9/10/2015. We used data from routine PFTs (forced expiratory volume in 1 s (FEV1) and FEV1% predicted), conducted at 12-18 month intervals. FEV1 and FEV1% predicted were assessed over time, stratified by sex, and race/ethnicity. We also assessed FEV1 and FEV1% predicted in current, former and never-smokers. RESULTS: Among 1817 EMS workers, 334 (18.4%) were women, 979 (53.9%) self-identified as white and 939 (51.6%) were never-smokers. The median follow-up was 13.1 years (IQR 10.5-13.6), and the median number of PFTs per person was 11 (IQR 7-13). After large declines associated with 9/11, there was no discernible recovery in lung function. In analyses limited to never-smokers, the trajectory of decline in adjusted FEV1 and FEV1% predicted was relatively parallel for men and women in the 3 racial/ethnic groups. Similarly, small differences in FEV1 annual decline between groups were not clinically meaningful. Analyses including ever-smokers were essentially the same. CONCLUSIONS: 14 years after 9/11, most EMS workers continued to demonstrate a lack of lung function recovery. The trajectories of lung function decline, however, were parallel by sex and by race/ethnicity. These findings support the use of routine, serial measures of lung function over time in first responders and demonstrate no sex or racial sensitivity to exposure-related lung function decline.

Bronchial Reactivity and Lung Function After World Trade Center Exposure.

BACKGROUND: World Trade Center (WTC)-exposed rescue/recovery workers endured massive respiratory insult from inhalation of particulate matter and gases, resulting in respiratory symptoms, loss of lung function, and, for many, bronchial hyperreactivity (BHR). The persistence of respiratory symptoms and lung function abnormalities has been well-documented, whereas persistence of BHR has not been investigated. METHODS: A total of 173 WTC-exposed firefighters with bronchial reactivity measured within 2 years after September 11, 2001 (9/11) (baseline methacholine challenge test), were reevaluated in 2013 and 2014 (follow-up methacholine challenge test). FEV1 measurements were obtained from the late pre-9/11, early post-9/11, and late post-9/11 periods. Respiratory symptoms and corticosteroid treatment were recorded. RESULTS: Bronchial reactivity remained stable (within 1 doubling dilution) for most (n = 101, 58%). Sixteen of 28 (57%) with BHR (provocative concentration of methacholine producing a 20% decline in FEV1 <8 mg/mL) at baseline had BHR at follow-up, and an additional 27 of the 145 (19%) without BHR at baseline had BHR at follow-up. In multivariable models, we found that BHR baseline was strongly associated with BHR follow-up (OR, 6.46) and that BHR at follow-up was associated with an estimated 15.4 mL/y greater FEV1 decline than experienced by those without BHR at follow-up. Annual FEV1 decline was moderated by corticosteroid use. CONCLUSIONS: Persistent BHR and its deleterious influence on lung function suggest a role for airway inflammation in perpetuation of WTC-associated airway disease. In future massive occupational exposure to inorganic dust/gases, we recommend early and serial pulmonary function testing, including measurements of bronchial reactivity, when possible, and inhaled corticosteroid therapy for those with symptoms or pulmonary function tests consistent with airway disease.

Lung Function Trajectories in World Trade Center-Exposed New York City Firefighters Over 13 Years: The Roles of Smoking and Smoking Cessation.

BACKGROUND: World Trade Center (WTC)-exposed Fire Department of the City of New York firefighters lost, on average, 10% of lung function after September 11, 2011, and >10% developed new obstructive airways disease. There was little recovery (on average) over the first 6 years. Follow-up into the next decade allowed us to determine the longer-term exposure effects and the roles of cigarette smoking and cessation on lung function trajectories. METHODS: We examined serial measurements of FEV1 from March 11, 2000, to September 10, 2014, among 10,641 WTC-exposed Fire Department of the City of New York firefighters with known smoking and body weight histories. RESULTS: The median number of FEV1 measurements during follow-up was 9; 15% of firefighters arrived at the WTC during the morning of September 11, 2001; and 65% never smoked. Firefighters arriving the morning of September 11, 2001 averaged lower lung function than did lesser exposed firefighters; this difference remained significant during most of follow-up (P < .05). Never smokers had significantly better lung function than current smokers; former smokers fell in between, depending upon their cessation date. Those arriving the morning of September 11, 2001 were more likely to have an FEV1 < lower limits of normal compared with those arriving between September 13, 2001, and September 24, 2001 (OR = 1.70, P < .01). Current smokers were more likely to have an FEV1 < lower limits of normal compared with never smokers (OR = 2.06, P < .01), former smokers who quit before September 11, 2001 (OR = 1.96, P < .01), or those who quit between September 11, 2001 and March 10, 2008 (OR = 1.49, P < .01). CONCLUSIONS: Thirteen years after September 11, 2001, most firefighters continued to show a lack of lung function recovery, with the trajectory of decline differing by WTC exposure and smoking status. Unlike the immutable effect of WTC exposure, we demonstrated the benefit on lung function of smoking cessation in this unique occupational/environmental cohort.

Longitudinal pulmonary function in newly hired, non-World Trade Center-exposed fire department City of New York firefighters: the first 5 years.

BACKGROUND: Few longitudinal studies characterize firefighters' pulmonary function. We sought to determine whether firefighters have excessive FEV(1) decline rates compared with control subjects. METHODS: We examined serial measurements of FEV(1) from about 6 months prehire to about 5 years posthire in newly hired male, never smoking, non-Hispanic black and white firefighters, hired between 2003 and 2006, without prior respiratory disease or World Trade Center exposure. Similarly defined Emergency Medical Service (EMS) workers served as control subjects. RESULTS: Through June 30, 2011, 940 firefighters (82%) and 97 EMS workers (72%) who met study criteria had four or more acceptable posthire spirometries. Prehire FEV(1) % averaged higher for firefighters than EMS workers (99% vs 95%), reflecting more stringent job entry criteria. FEV(1) (adjusted for baseline age and height) declined by an average of 45 mL/y both for firefighters and EMS workers, with Fire 2 EMS decline rate differences averaging 0.2 mL/y (CI, 2 9.2 to 9.6). Four percent of each group had FEV(1) less than the lower limit of normal before hire, increasing to 7% for firefighters and 17.5% for EMS workers, but similar percentages of both groups had adjusted FEV(1) decline rates 10%. Mixed effects modeling showed a significant influence of weight gain but not baseline weight: FEV(1) declined by about 8 mL/kg gained for both groups. Adjusting for weight change, FEV(1) decline averaged 38 mL/y for firefighters and 34 mL/y for EMS workers. CONCLUSIONS: During the first 5 years of duty, firefighters do not show greater longitudinal FEV(1) decline than EMS control subjects, and fewer of them develop abnormal lung function. Weight gain is associated with a small loss of lung function, of questionable clinical relevance in this fit and active population.

Autonomic nervous system modulation during an archery competition in novice and experienced adolescent archers.

We assessed autonomic nervous system modulation through changes in heart rate variability during an archery competition as well as archery performance by comparing novice and experienced adolescent archers. Seven novice (age 14.0 ± 8.5 years, body mass index 22.9 ± 4.3 kg · m(-2), training experience 0.4 ± 0.3 years) and ten experienced archers (age 16.5 ± 10.3 years, body mass index 22.4 ± 3.1 kg · m(-2), training experience 4.1 ± 0.9 years) volunteered. Using beat-by-beat heart rate monitoring, heart rate variability was measured for 20 s before each arrow shot during two rounds of competition. We found that, compared with novices, experienced adolescent archers: (i) take more time per shot; (ii) have a higher low frequency band, square root of the mean of squared differences between successive R-R intervals (i.e. the time elapsing between two consecutive R waves in the electrocardiogram), and percentage of successive normal-to-normal intervals greater than 50 ms; and (iii) demonstrate an increase in parasympathetic nervous system activity compared with pre-competition values. We propose that these characteristics of experienced archers are appropriate for optimal performance during competition.

Accelerated spirometric decline in New York City firefighters with α1-antitrypsin deficiency.

BACKGROUND: On September 11, 2001, the World Trade Center (WTC) collapse caused massive air pollution, producing variable amounts of lung function reduction in the New York City Fire Department (FDNY) rescue workforce. α1-Antitrypsin (AAT) deficiency is a risk factor for obstructive airway disease. METHODS: This prospective, longitudinal cohort study of the first 4 years post-September 11, 2001, investigated the influence of AAT deficiency on adjusted longitudinal spirometric change (FEV1) in 90 FDNY rescue workers with WTC exposure. Workers with protease inhibitor (Pi) Z heterozygosity were considered moderately AAT deficient. PiS homozygosity or PiS heterozygosity without concomitant PiZ heterozygosity was considered mild deficiency, and PiM homozygosity was considered normal. Alternately, workers had low AAT levels if serum AAT was ≤ 20 µmol/L. RESULTS: In addition to normal aging-related decline (37 mL/y), significant FEV(1) decline accelerations developed with increasing AAT deficiency severity (110 mL/y for moderate and 32 mL/y for mild) or with low AAT serum levels (49 mL/y). Spirometric rates pre-September 11, 2001, did not show accelerations with AAT deficiency. Among workers with low AAT levels, cough persisted in a significant number of participants at 4 years post-September 11, 2001. CONCLUSIONS: FDNY rescue workers with AAT deficiency had significant spirometric decline accelerations and persistent airway symptoms during the first 4 years after WTC exposure, representing a novel gene-by-environment interaction. Clinically meaningful decline acceleration occurred even with the mild serum AAT level reductions associated with PiS heterozygosity (without concomitant PiZ heterozygosity).

Lung function in rescue workers at the World Trade Center after 7 years.

BACKGROUND: The terrorist attacks on the World Trade Center on September 11, 2001, exposed thousands of Fire Department of New York City (FDNY) rescue workers to dust, leading to substantial declines in lung function in the first year. We sought to determine the longer-term effects of exposure. METHODS: Using linear mixed models, we analyzed the forced expiratory volume in 1 second (FEV(1)) of both active and retired FDNY rescue workers on the basis of spirometry routinely performed at intervals of 12 to 18 months from March 12, 2000, to September 11, 2008. RESULTS: Of the 13,954 FDNY workers who were present at the World Trade Center between September 11, 2001, and September 24, 2001, a total of 12,781 (91.6%) participated in this study, contributing 61,746 quality-screened spirometric measurements. The median follow-up was 6.1 years for firefighters and 6.4 years for emergency-medical-services (EMS) workers. In the first year, the mean FEV(1) decreased significantly for all workers, more for firefighters who had never smoked (a reduction of 439 ml; 95% confidence interval [CI], 408 to 471) than for EMS workers who had never smoked (a reduction of 267 ml; 95% CI, 263 to 271) (P<0.001 for both comparisons). There was little or no recovery in FEV(1) during the subsequent 6 years, with a mean annualized reduction in FEV(1) of 25 ml per year for firefighters and 40 ml per year for EMS workers. The proportion of workers who had never smoked and who had an FEV(1) below the lower limit of the normal range increased during the first year, from 3% to 18% for firefighters and from 12% to 22% for EMS workers, stabilizing at about 13% for firefighters and 22% for EMS workers during the subsequent 6 years. CONCLUSIONS: Exposure to World Trade Center dust led to large declines in FEV(1) for FDNY rescue workers during the first year. Overall, these declines were persistent, without recovery over the next 6 years, leaving a substantial proportion of workers with abnormal lung function.

Trial of prophylactic inhaled steroids to prevent or reduce pulmonary function decline, pulmonary symptoms, and airway hyperreactivity in firefighters at the world trade center site.

BACKGROUND: Inhaled corticosteroids (ICS) are the most effective anti-inflammatory treatment for asthmatics. This trial evaluated the effects of prophylactic ICS in firefighters exposed to the World Trade Center disaster. METHODS: Inhaled budesonide via a dry powder inhaler (Pulmicort Turbuhaler, AstraZeneca, Wilmington, DE) was offered on-site to New York City firefighters between September 18 and 25, 2001. One to 2 years later, firefighters (n = 64) who completed 4 weeks of daily ICS treatment were evaluated and compared with an age- and exposure-matched comparison group (n = 72) who did not use ICS. RESULTS: When spirometry results at the final visit were compared with those from the weeks following the 9/11 disaster, the treatment group had a greater increase in forced vital capacity (P = .009) and possibly a slower decline in forced expiratory volume at 1 second (P = .11), as well as a greater improvement in perceived well-being as assessed by the St George's Respiratory Questionnaire (P < .01). There was no difference in airway hyperreactivity and no evidence of adverse effects from ICS. CONCLUSIONS: Because the potential for hazardous exposures is great at many disasters, disease prevention programs based on environmental controls and respiratory protection are warranted immediately. Our results suggest that, pending further study with a larger sample, prophylactic ICS should be considered, along with respiratory protection, to minimize possible lung insult.