Effect of asthma and PTSD on persistence and onset of gastroesophageal reflux symptoms among adults exposed to the September 11, 2001, terrorist attacks

Psychological Processes, Not Physiological Parameters, Are Most Important Contributors to Symptom Severity in Patients With Refractory Heartburn/Regurgitation Symptoms

BACKGROUND & AIMS

Physiological and psychological factors have been found to influence esophageal symptom reporting. We aimed to evaluate which of these factors are associated with 3 reflux symptom severity outcomes (ie, Total Reflux, Heartburn, and Sleep Disturbance) through a traditional statistical and a complementary machine-learning approach.

METHODS

Consecutive adult patients with refractory heartburn/regurgitation symptoms underwent standard 24-hour pH-impedance monitoring and completed questionnaires assessing past and current gastrointestinal and psychological health. In the traditional statistical approach, hierarchical general linear models assessed relationships of psychological and physiological variables (eg, total number of reflux episodes) with reflux severity scores. Mediation analyses further assessed pathways between relevant variables. In the machine-learning approach, all psychological and physiological variables were entered into 11 different models and cross-validated model performance was compared among the different models to select the best model.

RESULTS

Three hundred ninety-three participants (mean [SD] age, 48.5 [14.1] years; 60% were female) were included. General psychological functioning emerged as an important variable in the traditional statistical approach, as it was significantly associated with all 3 outcomes and mediated the relationship between childhood trauma and both Total Reflux and Heartburn Severity. In the machine-learning analyses, general psychological variables (eg, depressive symptoms) were most important for Total Reflux and Sleep Disturbance outcomes, and symptom-specific variables, like visceral anxiety, were more influential for Heartburn Severity. Physiological variables were not significant contributors to reflux symptom severity outcomes in our sample across reflux classifications and statistical methodology.

CONCLUSIONS

Psychological processes, both general and symptom-specific, should be considered as another important factor within the multifactorial processes that impact reflux symptom severity reporting across the reflux spectrum.

World Trade Center Health Program best practices for the diagnosis and treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is one of the most common health conditions reported among persons exposed to the dust, debris and chemicals after the September 11, 2001 attacks in the United States. In the 9/11-exposed population, GERD is often found to be co-morbid with other conditions, such as asthma, post-traumatic stress disorder, and obesity. High-quality clinical practice guidelines for GERD are available from the American College of Gastroenterology. GERD diagnostic services and medically necessary treatment are covered by the WTC Health Program for persons who meet eligibility criteria.

Assessment of Post-traumatic Stress Disorder Among Objective Esophageal Motility and Reflux Phenotypes in Symptomatic Veterans

Prior research suggests post-traumatic stress disorder (PTSD) is associated with the development of esophageal symptoms. We aimed to evaluate the prevalence of PTSD in veterans with esophageal symptoms, and assess for differences in objective esophageal motility and reflux classifications. Consecutive veterans reporting esophageal symptoms (e.g., dysphagia and reflux) underwent clinical evaluation with standard reflux and motility testing. Relevant demographic, mental health, and clinical esophageal information was gathered. Patients were classified into "PTSD" and "Non-PTSD" groups based on the documentation of a clinician-confirmed diagnosis of PTSD in the medical chart. Of the 273 consecutive veterans (89% men, mean age: 62 years) that met inclusion criteria for the study, 34% had a clinician-confirmed diagnosis of PTSD. Differences existed between PTSD and non-PTSD groups on smoking, bipolar disorder, depression, ADHD, and opiate use. However, no differences existed in objectively determined motility or reflux phenotypes. While PTSD was highly prevalent among our sample of symptomatic veterans, the presence of PTSD was not associated with differences in motility classifications and reflux phenotypes. These findings are consistent with recent research in psychogastroenterology, which suggests psychological processes are important to consider across esophageal classifications.

Cortical complexity in world trade center responders with chronic posttraumatic stress disorder

Approximately 23% of World Trade Center (WTC) responders are experiencing chronic posttraumatic stress disorder (PTSD) associated with their exposures at the WTC following the terrorist attacks of 9/11/2001, which has been demonstrated to be a risk factor for cognitive impairment raising concerns regarding their brain health. Cortical complexity, as measured by analyzing Fractal Dimension (FD) from T1 MRI brain images, has been reported to be reduced in a variety of psychiatric and neurological conditions. In this report, we hypothesized that FD would be also reduced in a case-control sample of 99 WTC responders as a result of WTC-related PTSD. The results of our surface-based morphometry cluster analysis found alterations in vertex clusters of complexity in WTC responders with PTSD, with marked reductions in regions within the frontal, parietal, and temporal cortices, in addition to whole-brain absolute bilateral and unilateral complexity. Furthermore, region of interest analysis identified that the magnitude of changes in regional FD severity was associated with increased PTSD symptoms (reexperiencing, avoidance, hyperarousal, negative affect) severity. This study confirms prior findings on FD and psychiatric disorders and extends our understanding of FD associations with posttraumatic symptom severity. The complex and traumatic experiences that led to WTC-related PTSD were associated with reductions in cortical complexity. Future work is needed to determine whether reduced cortical complexity arose prior to, or concurrently with, onset of PTSD.

Stroke hospitalizations, posttraumatic stress disorder, and 9/11-related dust exposure: Results from the World Trade Center Health Registry

BACKGROUND

Few studies have examined the association between disaster-related factors and stroke by subtype or number. We investigated the association between 9/11-related posttraumatic stress disorder (PTSD), dust exposure, and stroke subtype as well as recurrent strokes.

METHODS

The study included 29,012 individuals enrolled in the World Trade Center Health Registry. Stroke cases were obtained by matching Registry enrollees to the New York State Department of Health's discharge records for inpatient visits between 2000 and 2016. Cox proportional hazards regression models were performed to examine the association between 9/11-related risk factors and stroke by subtype. Multinomial logistic regression models were conducted to assess the associations between the same risk factors and the number of stroke hospitalizations.

RESULTS

Having PTSD significantly increased the risk of developing ischemic and hemorrhagic stroke, with adjusted hazards ratios (AHRs) of 1.64 (95% confidence interval [CI]: 1.28-2.10) and 1.73 (95% CI: 1.10-2.71), respectively. The point estimate for dust cloud exposure, although not significant statistically, suggested an increased risk of ischemic stroke (AHR = 1.20, 95% CI: 0.96-1.50). PTSD was significantly associated with recurrent strokes with an adjusted odds ratio of 1.79 (95% CI: 1.09-2.95).

CONCLUSIONS

PTSD is a risk factor for both ischemic and hemorrhagic stroke and is associated with recurrent strokes. Dust exposure on 9/11 is a possible risk factor for ischemic stroke but not for hemorrhagic stroke, and was not associated with recurrent strokes. Our findings warrant additional research on stroke-morbidity and mortality associated with 9/11-related PTSD and dust exposure.

Hospitalizations among World Trade Center Health Registry Enrollees Who Were under 18 Years of Age on 9/11, 2001-2016

Much of the literature on hospitalizations post-September 11, 2001 (9/11) focuses on adults but little is known about post-9/11 hospitalizations among children. Data for World Trade Center Health Registry enrollees who were under 18-years old on 9/11 were linked to New York State hospitalization data to identify hospitalizations from enrollment (2003-2004) to December 31, 2016. Logistic regression was used to analyze factors associated with hospitalization. Of the 3151 enrollees under age 18 on 9/11, 243 (7.7%) had at least one 9/11-related physical health hospitalization and 279 (8.9%) had at least one 9/11-related mental health hospitalization. Individuals of non-White race, those living in New York City Housing Authority housing, those exposed to the dust cloud on 9/11, and those with probable 9/11-related PTSD symptoms were more likely to be hospitalized for a 9/11-related physical health condition. Older age and having probable 9/11-related PTSD symptoms at baseline were associated with being hospitalized for a 9/11-related mental health condition. Dust cloud exposure on 9/11 and PTSD symptoms were associated with hospitalizations among those exposed to 9/11 as children. Racial minorities and children living in public housing were at greater risk of hospitalization. Continued monitoring of this population and understanding the interplay of socioeconomic factors and disaster exposure will be important to understanding the long-term effects of 9/11.

Post-Traumatic Stress Disorder among Survivors of the September 11, 2001 World Trade Center Attacks: A Review of the Literature

Prior reviews of 9/11-related post-traumatic stress disorder (PTSD) have not focused on the civilian survivors most directly exposed to the attacks. Survivors include those individuals who were occupants of buildings in or near the World Trade Center (WTC) towers, those whose primary residence or workplace was in the vicinity, and persons who were on the street passing through the area. This review reports published information on the prevalence of and risk factors for PTSD, as well as comorbidities associated with PTSD among 9/11 survivors. Articles selected for inclusion met the following criteria: (1) full-length, original peer-reviewed empirical articles; (2) published in English from 2002-2019; (3) collected data from persons directly exposed; (4) adult populations; and (5) focused on non-rescue or recovery workers (i.e., survivors). Data were extracted with focus on study design, sample size, time frame of data collection post-9/11, PTSD assessment instrument, and PTSD prevalence, risk factors, and comorbidities. Our review identified the use of cross-sectional and longitudinal designs, finding multiple direct comorbidities with PTSD, as well as the prevalence and persistence of PTSD. Future research would benefit from incorporating more mixed methods designs, and exploring the mediating mechanisms and protective factors of the known associations of PTSD among the 9/11 survivor population.

Associations between Respiratory Health Outcomes and Coal Mine Fire PM2.5 Smoke Exposure: A Cross-Sectional Study

In 2014, wildfires ignited a fire in the Morwell open cut coal mine, Australia, which burned for six weeks. This study examined associations between self-reported respiratory outcomes in adults and mine fire-related PM_2.5 smoke exposure. Self-reported data were collected as part of the Hazelwood Health Study Adult Survey. Eligible participants were adult residents of Morwell. Mine fire-related PM_2.5 concentrations were provided by the Commonwealth Scientific and Industrial Research Organisation Oceans & Atmosphere Flagship. Personalised mean 24-h and peak 12-h mine fire-related PM_2.5 exposures were estimated for each participant. Data were analysed by multivariate logistic regression. There was some evidence of an association between respiratory outcomes and mine fire PM_2.5 exposure. Chronic cough was associated with an odds ratio (OR) of 1.13 (95% confidence interval 1.03 to 1.23) per 10 μg/m³ increment in mean PM_2.5 and 1.07 (1.02 to 1.12) per 100 μg/m³ increment in peak PM_2.5. Current wheeze was associated with peak PM_2.5, OR = 1.06 (1.02 to 1.11) and chronic phlegm with mean PM_2.5 OR = 1.10 (1.00 to 1.20). Coal mine PM_2.5 smoke exposure was associated with increased odds of experiencing cough, phlegm and wheeze. Males, participants 18–64 years, and those residing in homes constructed from non-brick/concrete materials or homes with tin/metal roofs had higher estimated ORs. These findings contribute to the formation of public health policy responses.

Coal-mine fire-related fine particulate matter and medical-service utilization in Australia: a time-series analysis from the Hazelwood Health Study

Background

This study assessed the association between coal-mine-fire-related fine particulate matter (PM2.5) and medical-service utilization, following a 6-week coal-mine fire in Australia, in 2014. Areas in the immediate vicinity of the mine experienced hourly mine-fire-related PM2.5 concentrations of up to 3700 μg/m3.

Methods

Data on medical-service utilization were collected from the Medicare Benefits Schedule—a national database of payment for medical services. PM2.5 concentrations were modelled using atmospheric chemical transport modelling. Quasi-Poisson interrupted distributed lag time-series analysis examined the association between daily mine-fire-related PM2.5 concentrations and medical-service utilization, including General Practitioner (GP) consultations and respiratory, cardiovascular and mental health services. Confounders included seasonality, long-term trend, day of the week, maximum daily temperature and public holidays. Gender and age stratification were conducted.

Results

A 10-μg/m3 increase in PM2.5 was associated with an increased relative risk of service usage for all long and short GP consultations [11% (95% confidence interval: 7 to 15%)] and respiratory services [22% (4 to 43%)] in both men and women. Sex stratification found an increased relative risk in mental health consultations in men [32% (2 to 72%)] but not women. No associations were found for cardiovascular services in men or women.

Conclusions

Coal-mine-fire-related PM2.5 exposure was associated with increased use of medical services for GP consultations and respiratory services in men and women and mental health consultations in men. These findings can inform the development of future public-health-policy responses in the event of major air-pollution episodes.

The anxiolytic-like effects of puerarin on an animal model of PTSD

Post traumatic stress disorder (PTSD) is a mental illness that affected numerous people. The anti-PTSD-like effects of puerarin is unknown, although the antidepressant- and anxiolytic- like effects of puerarin have been reported. The PTSD behavioral deficits in rats were induced by single prolonged stress (SPS), mainly including the reduced time/entries in the open arms and the elevated time/entries in the closed arms in elevated plus maze test, increased freezing duration in contextual fear paradigm and lowered time/entries in the central zone in open field test. However, the behavioral deficits were attenuated by puerarin (50 and 100 mg/kg) without affecting the locomotor activity. For the evaluation of mechanism, the decreased levels of progesterone, allopregnanolone, and the increased levels of corticosterone, corticotropin releasing hormone, and adrenocorticotropic hormone in the brain or serum were induced by SPS, which is blocked by puerarin. In summary, the anti-PTSD-like effects of puerarin were associated with biosynthesis of neurosteroids and normalized levels of stress hormones in HPA axis.

A Cognitive Reserve and Social Support-Focused Latent Class Analysis to Predict Self-Reported Confusion or Memory Loss among Middle-Aged World Trade Center Health Registry Enrollees

The World Trade Center Health Registry includes 9/11 survivors who have been surveyed about their health conditions over time. The prevalence of posttraumatic stress disorder (PTSD) remains high among the cohort and is a risk factor for cognitive impairment or dementia. We thus sought to examine the degree to which confusion or memory loss (CML)—potential symptoms of cognitive decline—are occurring among enrollees aged 35–64 years. Cognitive reserve theory suggests that higher levels of education and engaging in cognitively challenging activities can create stronger neural connections, offering protection against cognitive decline. We hypothesized that enrollees with less cognitive reserve would be more likely to report CML. In this study, we: (1) estimated the incidence of CML in our study sample; (2) identified indicators of cognitive reserve (e.g., indicators of educational attainment, social support); and (3) determined whether CML is associated with cognitive reserve level, stratified by PSTD status. First, we described demographics of the study sample (n = 14,574) and probable PTSD status, also stratifying by CML. Next, we conducted a latent class analysis on two groups: those with probable PTSD and those without probable PTSD, creating classes with varying cognitive reserve levels. Finally, using adjusted log binomial models, we predicted risk of CML based on cognitive reserve level. The probable PTSD group (n = 1213) and not probable PTSD group (n = 13,252) each had four latent classes: low, medium-low, medium-high, and high cognitive reserve. In the probable PTSD model, compared to the high cognitive reserve class, those with medium-low cognitive reserve were 35% more likely to report CML (relative risk (RR) = 1.4, 95% confidence interval (CI): 1.1, 1.7). Among the not probable PTSD group, those with low and medium levels of cognitive reserve were significantly more likely to report CML (RR = 1.8 and 1.4, respectively). Overall, those with less cognitive reserve were more likely to report CML regardless of PTSD status.

Fine particulate matter exposure and medication dispensing during and after a coal mine fire: A time series analysis from the Hazelwood Health Study

Limited research has examined the impacts of coal mine fire smoke on human health. The aim of this study was to assess the association between prolonged smoke PM_2.5 exposure from a brown coal mine fire that burned over a seven week period in 2014 and medications dispensed across five localities in South-eastern Victoria, Australia. Spatially resolved PM_2.5 concentrations were retrospectively estimated using a dispersion model coupled with a chemical transport model. Data on medications dispensed were collected from the national Pharmaceutical Benefits Schedule database for 2013-2016. Poisson distributed lag time series analysis was used to examine associations between daily mine fire-related PM_2.5 concentrations and daily counts of medications dispensed for respiratory, cardiovascular or psychiatric conditions. Factors controlled for included: seasonality, long-term trend, day of the week, maximum ambient temperature and public holidays. Positive associations were found between mine fire-related PM_2.5 and increased risks of medications dispensed for respiratory, cardiovascular and psychiatric conditions, over a lag range of 3-7 days. A 10 μg/m³ increase in coal mine fire-related PM_2.5 was associated with a 25% (95%CI 19-32%) increase in respiratory medications, a 10% (95%CI 7-13%) increase in cardiovascular medications and a 12% (95%CI 8-16%) increase in psychiatric medications dispensed. These findings have the potential to better prepare for and develop more appropriate public health responses in the event of future coal mine fires.

A comparison of physical comorbidities in patients with posttraumatic stress disorder developed after a terrorist attack or other traumatic event

No study investigated whether the presence of specific medical comorbidities is associated with the type of traumatic event, in particular with terrorist attack (TA). In a group of subjects with posttraumatic stress disorder (PTSD), the current study investigated the association between the types of traumatic event (TA vs. other traumatic event [OTE]) and medical comorbidities, controlling for sex and PTSD duration. The Mini International Neuropsychiatric Interview, the Clinician-Administered PTSD Scale, and the Davidson Trauma Scale were administered to 84 subjects diagnosed with PTSD. Thirty-nine were victims of TA and 45 victims of OTE. TA was associated with higher prevalence of neoplasms (β = 2.60, p = 0.02). Females were more protected than males from circulatory system comorbidities (β = 1.47, p = 0.04), while PTSD duration was associated with higher prevalence of such comorbidities (β = 0.005, p = 0.01). Females showed a higher prevalence of neoplasms than males (β = 2.50, p = 0.02). Female sex was protective against metabolic syndrome (β = -1.79, p = 0.02). Patients with PTSD due to TA and female patients should be considered for their higher prevalence of neoplasms, while male patients and those with higher symptom duration should be monitored for circulatory disease and metabolic syndrome. Symptom duration might be associated with circulatory and metabolic disease. Implications for tailored and timely psychopharmacological and psychotherapeutic intervention for PTSD are discussed focusing on these specific medical comorbidities.

Mortality among rescue and recovery workers and community members exposed to the September 11, 2001 World Trade Center terrorist attacks, 2003-2014

BACKGROUND

Multiple chronic health conditions have been associated with exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We assessed whether excess deaths occurred during 2003-2014 among persons directly exposed to 9/11, and examined associations of 9/11-related exposures with mortality risk.

MATERIALS AND METHODS

Deaths occurring in 2003-2014 among members of the World Trade Center Health Registry, a cohort of rescue/recovery workers and lower Manhattan community members who were exposed to 9/11, were identified via linkage to the National Death Index. Participants' overall levels of 9/11-related exposure were categorized as high, intermediate, or low. We calculated standardized mortality ratios (SMR) using New York City reference rates from 2003 to 2012. Proportional hazards were used to assess associations of 9/11-related exposures with mortality, accounting for age, sex, race/ethnicity and other potential confounders.

RESULTS

We identified 877 deaths among 29,280 rescue/recovery workers (3.0%) and 1694 deaths among 39,643 community members (4.3%) during 308,340 and 416,448 person-years of observation, respectively. The SMR for all causes of death was 0.69 [95% confidence interval (CI) 0.65-0.74] for rescue/recovery workers and 0.86 (95% CI 0.82-0.90) for community members. SMRs for diseases of the cardiovascular and respiratory systems were significantly lower than expected in both groups. SMRs for several other causes of death were significantly elevated, including suicide among rescue recovery workers (SMR 1.82, 95% CI 1.35-2.39), and brain malignancies (SMR 2.25, 95% CI 1.48-3.28) and non-Hodgkin's lymphoma (SMR 1.79, 95% CI 1.24-2.50) among community members. Compared to low exposure, both intermediate [adjusted hazard ratio (AHR) 1.36, 95% CI 1.10-1.67] and high (AHR 1.41, 95% CI 1.06-1.88) levels of 9/11-related exposure were significantly associated with all-cause mortality among rescue/recovery workers (p-value for trend 0.01). For community members, intermediate (AHR 1.13, 95% CI 1.01-1.27), but not high (AHR 1.14, 95% CI 0.94-1.39) exposure was significantly associated with all-cause mortality (p-value for trend 0.03). AHRs for associations of overall 9/11-related exposure with heart disease- and cancer-related mortality were similar in magnitude to those for all-cause mortality, but with 95% CIs crossing the null value.

CONCLUSIONS

Overall mortality was not elevated. Among specific causes of death that were significantly elevated, suicide among rescue/recovery workers is a plausible long-term consequence of 9/11 exposure, and is potentially preventable. Elevated mortality due to other causes, including non-Hodgkin's lymphoma and brain cancer, and small but statistically significant associations of 9/11-related exposures with all-cause mortality hazard warrant additional surveillance.

Review of Non-Respiratory, Non-Cancer Physical Health Conditions from Exposure to the World Trade Center Disaster

After the World Trade Center attacks on 11 September 2001 (9/11), multiple cohorts were developed to monitor the health outcomes of exposure. Respiratory and cancer effects have been covered at length. This current study sought to review the literature on other physical conditions associated with 9/11-exposure. Researchers searched seven databases for literature published in English from 2002 to October 2017, coded, and included articles for health condition outcome, population, 9/11-exposures, and comorbidity. Of the 322 titles and abstracts screened, 30 studies met inclusion criteria, and of these, 28 were from three cohorts: the World Trade Center Health Registry, Fire Department of New York, and World Trade Center Health Consortium. Most studies focused on rescue and recovery workers. While many of the findings were consistent across different populations and supported by objective measures, some of the less studied conditions need additional research to substantiate current findings. In the 16 years after 9/11, longitudinal cohorts have been essential in investigating the health consequences of 9/11-exposure. Longitudinal studies will be vital in furthering our understanding of these emerging conditions, as well as treatment effectiveness.

Hospitalizations for asthma among adults exposed to the September 11, 2001 World Trade Center terrorist attack

OBJECTIVE

We described the patterns of asthma hospitalization among persons exposed to the 2001 World Trade Center (WTC) attacks, and assessed whether 9/11-related exposures or comorbidities, including posttraumatic stress disorder (PTSD) and gastroesophageal reflux symptoms (GERS), were associated with an increased rate of hospitalization.

METHODS

Data for adult enrollees in the WTC Health Registry, a prospective cohort study, with self-reported physician-diagnosed asthma who resided in New York State on 9/11 were linked to administrative hospitalization data to identify asthma hospitalizations during September 11, 2001-December 31, 2010. Multivariable zero-inflated Poisson regression was used to examine associations among 9/11 exposures, comorbid conditions, and asthma hospitalizations.

RESULTS

Of 11 471 enrollees with asthma, 406 (3.5%) had ≥1 asthma hospitalization during the study period (721 total hospitalizations). Among enrollees diagnosed before 9/11 (n = 6319), those with PTSD or GERS had over twice the rate of hospitalization (adjusted rate ratio (ARR) = 2.5, 95% CI = 1.4-4.1; ARR = 2.1, 95% CI = 1.3-3.2, respectively) compared to those without. This association was not statistically significant in enrollees diagnosed after 9/11. Compared to higher educational attainment, completing less than college was associated with an increased hospitalization rate among participants with both pre-9/11- and post-9/11-onset asthma (ARR = 1.9, 95% CI = 1.2-2.9; ARR = 2.6, 95% CI = 1.6-4.1, respectively). Sinus symptoms, exposure to the dust cloud, and having been a WTC responder were not associated with asthma hospitalization.

CONCLUSIONS

Among enrollees with pre-9/11 asthma, comorbid PTSD and GERS were associated with an increase in asthma hospitalizations. Management of these comorbidities may be an important factor in preventing hospitalization.

Airway Disease in Rescue/Recovery Workers: Recent Findings from the World Trade Center Collapse

PURPOSE OF REVIEW

Our goal is to summarize the airway disease literature since September 11, 2001 (9/11), focusing on studies published since 2011 in World Trade Center-exposed rescue/recovery workers.

RECENT FINDINGS

Since 2011, studies have confirmed relationships between initial World Trade Center exposure intensity, severity of symptoms, airway disease diagnoses, and biomarkers of disease progression. Studies continue to document ongoing morbidity in rescue/recovery workers over 10 years after 9/11. Future research should further identify correlates of symptom persistence and new airway disease diagnoses. The unique characteristics of the airway diseases in this population warrant ongoing monitoring and treatment.