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Alahmad B, Khraishah H, Kamineni M, Royé D, Papatheodorou SI, Maria Vicedo-Cabrera A, Guo Y, Lavigne E, Armstrong B, Sera F, Bernstein AS, Zanobetti A, Garshick E, Schwartz J, Bell ML, Al-Mulla F, Koutrakis P, Gasparrini A. Extreme Temperatures and Stroke Mortality: Evidence From a Multi-Country Analysis. Stroke 2024; 55:1847-1856. [PMID: 38776169 PMCID: PMC11196199 DOI: 10.1161/strokeaha.123.045751] [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: 11/08/2023] [Accepted: 04/09/2024] [Indexed: 05/24/2024]
Abstract
BACKGROUND Extreme temperatures contribute significantly to global mortality. While previous studies on temperature and stroke-specific outcomes presented conflicting results, these studies were predominantly limited to single-city or single-country analyses. Their findings are difficult to synthesize due to variations in methodologies and exposure definitions. METHODS Within the Multi-Country Multi-City Network, we built a new mortality database for ischemic and hemorrhagic stroke. Applying a unified analysis protocol, we conducted a multinational case-crossover study on the relationship between extreme temperatures and stroke. In the first stage, we fitted a conditional quasi-Poisson regression for daily mortality counts with distributed lag nonlinear models for temperature exposure separately for each city. In the second stage, the cumulative risk from each city was pooled using mixed-effect meta-analyses, accounting for clustering of cities with similar features. We compared temperature-stroke associations across country-level gross domestic product per capita. We computed excess deaths in each city that are attributable to the 2.5% hottest and coldest of days based on each city's temperature distribution. RESULTS We collected data for a total of 3 443 969 ischemic strokes and 2 454 267 hemorrhagic stroke deaths from 522 cities in 25 countries. For every 1000 ischemic stroke deaths, we found that extreme cold and hot days contributed 9.1 (95% empirical CI, 8.6-9.4) and 2.2 (95% empirical CI, 1.9-2.4) excess deaths, respectively. For every 1000 hemorrhagic stroke deaths, extreme cold and hot days contributed 11.2 (95% empirical CI, 10.9-11.4) and 0.7 (95% empirical CI, 0.5-0.8) excess deaths, respectively. We found that countries with low gross domestic product per capita were at higher risk of heat-related hemorrhagic stroke mortality than countries with high gross domestic product per capita (P=0.02). CONCLUSIONS Both extreme cold and hot temperatures are associated with an increased risk of dying from ischemic and hemorrhagic strokes. As climate change continues to exacerbate these extreme temperatures, interventional strategies are needed to mitigate impacts on stroke mortality, particularly in low-income countries.
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Affiliation(s)
- Barrak Alahmad
- Environmental Health Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Haitham Khraishah
- Cardiology Division, University of Maryland Medical Center, University of Maryland, Baltimore, MD, USA
| | | | - Dominic Royé
- Climate Research Foundation, Madrid, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | | | - Ana Maria Vicedo-Cabrera
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland
| | - Yuming Guo
- Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Eric Lavigne
- School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, Canada
| | - Ben Armstrong
- Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Francesco Sera
- Department of Statistics, Computer Science and Applications G. Parenti, University of Florence, Florence, Italy
| | - Aaron S Bernstein
- Environmental Health Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Antonella Zanobetti
- Environmental Health Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Eric Garshick
- Pulmonary, Allergy, Sleep and Critical Care Medicine Section, Department of Medicine, Veterans Affairs Boston Healthcare System, West Roxbury, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Joel Schwartz
- Environmental Health Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Michelle L Bell
- School of the Environment, Yale University, New Haven, CT, USA
| | | | - Petros Koutrakis
- Environmental Health Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Antonio Gasparrini
- Environment & Health Modelling (EHM) Lab, Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
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2
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Liu J, Zhang M, Huang J, Guo C, Yang J, Yue C, Zi W, Yang Q. Short-Term Effect of Ambient Temperature in Acute Ischemic Stroke with Endovascular Treatment Due to Large Vessel Occlusion. Clin Interv Aging 2024; 19:627-638. [PMID: 38646590 PMCID: PMC11032672 DOI: 10.2147/cia.s453268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/04/2024] [Indexed: 04/23/2024] Open
Abstract
Purpose Acute ischemic stroke (AIS) stands as the primary cause of mortality and extended disability globally. While prior studies have examined the connection between stroke and local weather, they have produced conflicting results. Our goal was to examine the correlation between temperature and functional prognosis in patients with large vessel occlusion (LVO) undergoing endovascular therapy (EVT). Patients and methods This study included a total of 1809 patients. Temperatures from stroke onset to groin puncture were categorized into Cold (10th percentile of temperature), Cool (10th-50th percentile of temperature), Warm (50th-90th percentile of temperature), and Hot (90th percentile of temperature) groups. The primary efficacy result was the modified Rankin Scale (mRS) score at 90 days. Safety outcomes included mortality, symptomatic intracranial hemorrhage (sICH) and complications after cerebral infarction. Results The primary efficacy results demonstrated a statistical enhancement in functional outcomes at 90 days for patients in the Warm group compared to the Cold group (adjusted common odds ratio [OR]: 1.386; 95% confidence interval [CI]: 1.024-1.878, P=0.035). Secondary efficacy results showed that temperature was associated with a higher rate of 90-day functional independence (adjusted OR: 1.016; 95% CI: 1.004-1.029; P=0.009), which was higher in the Warm group compared with patients in the Cold group (adjusted OR: 1.646; 95% CI: 1.107-2.448, P=0.014). There were no significant differences between groups in terms of sICH, 90-day mortality, and post-infarction complications. Conclusion Compared with Cold temperature, Warm temperature is associated with better functional outcomes and reduced mortality risk without increasing the risk of sICH.
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Affiliation(s)
- Juan Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
| | - Min Zhang
- Department of Neurology, Jiangmen Central Hospital, Jiangmen, People’s Republic of China
| | - Jiandi Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
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3
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Danh N, Ho C, Ford E, Zhang J, Hong H, Reid C, Xu D. Association between ambient temperature and stroke risk in high-risk populations: a systematic review. Front Neurol 2024; 14:1323224. [PMID: 38259643 PMCID: PMC10801432 DOI: 10.3389/fneur.2023.1323224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Background Significant associations exist between ambient temperature and stroke risk, but results in high cardiovascular risk populations are lacking. This systemic review summarised current evidence on ambient temperature and overall stroke risk in a high cardiovascular risk population. Methods We performed a systematic literature search across MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and GEOBASE, from inception to 3 July 2023, to identify all population-based studies. Eligible studies screened by independent reviewers recruited individuals aged 18 years and over, where minimum 80% of participants had a high cerebral vascular disease (CVD) risk profile. The primary outcomes are stroke morbidity and mortality, while the secondary outcomes are morbidity and mortality of ischaemic stroke (IS), intracranial cerebral haemorrhage (ICH), and subarachnoid haemorrhage (SH). Results The database searches identified 9,025 articles. After removing duplicates, 7,647 articles were screened in title and abstract to identify 380 articles for full-text screening. After the full-text screening of 380 articles by two independent reviewers, 23 articles were included in the review. Conclusion The evidence for an association between ambient temperature and stroke incidence is that lower temperatures were more likely to increase morbidity and mortality risk of both haemorrhagic and ischaemic stroke in older people. Conversely, higher ambient temperature is significantly associated with intracranial haemorrhage risk, but decreased risk with IS. Higher and lower ambient temperatures consistently increase stroke risks in patients with comorbidities of congestive heart failure and dyslipidaemia. This evidence implies the need to establish clinical guidelines for preventive intervention in patients with high stroke risks during extreme ambient temperatures.
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Affiliation(s)
- Nathan Danh
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Chau Ho
- Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Emily Ford
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Jian Zhang
- Department of Neurology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hua Hong
- Department of Neurology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Christopher Reid
- Department of Neurology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dan Xu
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
- Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
- Department of Neurology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Chitu Z, Bojariu R, Velea L, Van Schaeybroeck B. Large sex differences in vulnerability to circulatory-system disease under current and future climate in Bucharest and its rural surroundings. ENVIRONMENTAL RESEARCH 2023; 234:116531. [PMID: 37394169 DOI: 10.1016/j.envres.2023.116531] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 07/04/2023]
Abstract
Circulatory-system diseases (CSDs) are responsible for 50-60% of all deaths in Romania. Due to its continental climate, with cold winters and very warm summers, there is a strong temperature dependence of the CSD mortality. Additionally, within its capital Bucharest, the urban heat island (UHI) is expected to enhance (reduce) heat (cold)-related mortality. Using distributed lag non-linear models, we establish the relation between temperature and CSD mortality in Bucharest and its surroundings. A striking finding is the strong temperature-related response to high urban temperatures of women in comparison with men from the total CSDs mortality. In the present climate, estimates of the CSDs attributable fraction (AF) of mortality at high temperatures is about 66% higher in Bucharest than in its rural surroundings for men, while it is about 100% times higher for women. Additionally, the AF in urban areas is also significantly higher for elderly people, and for those with hypertensive and cerebrovascular diseases than in the rural surroundings. On the other hand, in rural areas, men but especially women are currently more vulnerable with respect to low temperatures than in the urban environment. In order to project future thermal-related mortality, we have used five bias-corrected climate projections from regional circulation models under two climate-change scenarios, RCP4.5 and RCP8.5. Analysis of the temperature-mortality associations for future climate reveals the strongest signal under the scenario RCP8.5 for women, elderly people as well as for groups with hypertensive and cerebrovascular diseases. The net AF increase is much larger in urban agglomeration for women (8.2 times higher than in rural surroundings) and elderly people (8.5 times higher than in rural surroundings). However, our estimates of thermal attributable mortality are most likely underestimated due to the poor representation of UHI and future demography.
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Affiliation(s)
- Zenaida Chitu
- National Meteorological Administration, Bucharest, Romania
| | - Roxana Bojariu
- National Meteorological Administration, Bucharest, Romania.
| | - Liliana Velea
- National Meteorological Administration, Bucharest, Romania; University Ca' Foscari, Venice, Italy
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Vaičiulis V, Jaakkola JJK, Radišauskas R, Tamošiūnas A, Lukšienė D, Ryti NRI. Risk of ischemic and hemorrhagic stroke in relation to cold spells in four seasons. BMC Public Health 2023; 23:554. [PMID: 36959548 PMCID: PMC10037875 DOI: 10.1186/s12889-023-15459-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/16/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Cold winter weather increases the risk of stroke, but the evidence is scarce on whether the risk increases during season-specific cold weather in the other seasons. The objective of our study was to test the hypothesis of an association between personal cold spells and different types of stroke in the season-specific context, and to formally assess effect modification by age and sex. METHODS We conducted a case-crossover study of all 5396 confirmed 25-64 years old cases with stroke in the city of Kaunas, Lithuania, 2000-2015. We assigned to each case a one-week hazard period and 15 reference periods of the same calendar days of other study years. A personal cold day was defined for each case with a mean temperature below the fifth percentile of the frequency distribution of daily mean temperatures of the hazard and reference periods. Conditional logistic regression was applied to estimate odds ratios (OR) and 95% confidence intervals (95% CI) representing associations between time- and place-specific cold weather and stroke. RESULTS There were positive associations between cold weather and stroke in Kaunas, with each additional cold day during the week before the stroke increases the risk by 3% (OR 1.03; 95% CI 1.00-1.07). The association was present for ischemic stroke (OR 1.05; 95% CI 1.01-1.09) but not hemorrhagic stroke (OR 0.98; 95% CI 0.91-1.06). In the summer, the risk of stroke increased by 8% (OR 1.08; 95% CI 1.00-1.16) per each additional cold day during the hazard period. Age and sex did not modify the effect. CONCLUSIONS Our findings show that personal cold spells increase the risk of stroke, and this pertains to ischemic stroke specifically. Most importantly, cold weather in the summer season may be a previously unrecognized determinant of stroke.
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Affiliation(s)
- Vidmantas Vaičiulis
- Faculty of Public Health, Department of Environmental and Occupational Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Faculty of Public Health, Health Research Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jouni J K Jaakkola
- Center for Environmental and Respiratory Health Research (CERH), Research Unit of Population Health, Faculty of Medicine, University of Oulu, Oulu, Finland
- Biocenter Oulu, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
- Finnish Meteorological Institute, Helsinki, Finland
| | - Ričardas Radišauskas
- Faculty of Public Health, Department of Environmental and Occupational Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Laboratory of Population Studies, Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Abdonas Tamošiūnas
- Laboratory of Population Studies, Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Dalia Lukšienė
- Faculty of Public Health, Department of Environmental and Occupational Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Laboratory of Population Studies, Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Niilo R I Ryti
- Center for Environmental and Respiratory Health Research (CERH), Research Unit of Population Health, Faculty of Medicine, University of Oulu, Oulu, Finland.
- Biocenter Oulu, University of Oulu, Oulu, Finland.
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.
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6
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Koo GPY, Zheng H, Aik JCL, Tan BYQ, Sharma VK, Sia CH, Ong MEH, Ho AFW. Clustering of Environmental Parameters and the Risk of Acute Ischaemic Stroke. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4979. [PMID: 36981888 PMCID: PMC10049712 DOI: 10.3390/ijerph20064979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/05/2023] [Accepted: 03/08/2023] [Indexed: 06/18/2023]
Abstract
Acute ischaemic stroke (AIS) risk on days with similar environmental profiles remains unknown. We investigated the association between clusters of days with similar environmental parameters and AIS incidence in Singapore. We grouped calendar days from 2010 to 2015 with similar rainfall, temperature, wind speed, and Pollutant Standards Index (PSI) using k-means clustering. Three distinct clusters were formed 'Cluster 1' containing high wind speed, 'Cluster 2' having high rainfall, and 'Cluster 3' having high temperatures and PSI. We aggregated the number of AIS episodes over the same period with the clusters and analysed their association using a conditional Poisson regression in a time-stratified case-crossover design. Comparing the three clusters, Cluster 3 had the highest AIS occurrence (IRR 1.09; 95% confidence interval (CI) 1.05-1.13), with no significant difference between Clusters 1 and 2. Subgroup analyses in Cluster 3 showed that AIS risk was amplified in the elderly (≥65 years old), non-smokers, and those without a history of ischaemic heart disease/atrial fibrillation/vascular heart disease/peripheral vascular disease. In conclusion, we found that AIS incidence may be higher on days with higher temperatures and PSI. These findings have important public health implications for AIS prevention and health services delivery during at-risk days, such as during the seasonal transboundary haze.
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Affiliation(s)
| | - Huili Zheng
- National Registry of Diseases Officer, Health Promotion Board, Singapore 168937, Singapore
| | - Joel C. L. Aik
- Environmental Epidemiology and Toxicology Division, Environmental Health Institute, National Environment Agency, Singapore 228231, Singapore
- Pre-Hospital & Emergency Research Center, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Benjamin Y. Q. Tan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Vijay K. Sharma
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Ching Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Marcus E. H. Ong
- Health Services & Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
| | - Andrew F. W. Ho
- Pre-Hospital & Emergency Research Center, Duke-NUS Medical School, Singapore 169857, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
- Centre of Population Health Research and Implementation, SingHealth Regional Health System, Singapore 168753, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 117549, Singapore
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7
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Alahmad B, Khraishah H, Royé D, Vicedo-Cabrera AM, Guo Y, Papatheodorou SI, Achilleos S, Acquaotta F, Armstrong B, Bell ML, Pan SC, de Sousa Zanotti Stagliorio Coelho M, Colistro V, Dang TN, Van Dung D, De’ Donato FK, Entezari A, Guo YLL, Hashizume M, Honda Y, Indermitte E, Íñiguez C, Jaakkola JJ, Kim H, Lavigne E, Lee W, Li S, Madureira J, Mayvaneh F, Orru H, Overcenco A, Ragettli MS, Ryti NR, Saldiva PHN, Scovronick N, Seposo X, Sera F, Silva SP, Stafoggia M, Tobias A, Garshick E, Bernstein AS, Zanobetti A, Schwartz J, Gasparrini A, Koutrakis P. Associations Between Extreme Temperatures and Cardiovascular Cause-Specific Mortality: Results From 27 Countries. Circulation 2023; 147:35-46. [PMID: 36503273 PMCID: PMC9794133 DOI: 10.1161/circulationaha.122.061832] [Citation(s) in RCA: 75] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death worldwide. Existing studies on the association between temperatures and cardiovascular deaths have been limited in geographic zones and have generally considered associations with total cardiovascular deaths rather than cause-specific cardiovascular deaths. METHODS We used unified data collection protocols within the Multi-Country Multi-City Collaborative Network to assemble a database of daily counts of specific cardiovascular causes of death from 567 cities in 27 countries across 5 continents in overlapping periods ranging from 1979 to 2019. City-specific daily ambient temperatures were obtained from weather stations and climate reanalysis models. To investigate cardiovascular mortality associations with extreme hot and cold temperatures, we fit case-crossover models in each city and then used a mixed-effects meta-analytic framework to pool individual city estimates. Extreme temperature percentiles were compared with the minimum mortality temperature in each location. Excess deaths were calculated for a range of extreme temperature days. RESULTS The analyses included deaths from any cardiovascular cause (32 154 935), ischemic heart disease (11 745 880), stroke (9 351 312), heart failure (3 673 723), and arrhythmia (670 859). At extreme temperature percentiles, heat (99th percentile) and cold (1st percentile) were associated with higher risk of dying from any cardiovascular cause, ischemic heart disease, stroke, and heart failure as compared to the minimum mortality temperature, which is the temperature associated with least mortality. Across a range of extreme temperatures, hot days (above 97.5th percentile) and cold days (below 2.5th percentile) accounted for 2.2 (95% empirical CI [eCI], 2.1-2.3) and 9.1 (95% eCI, 8.9-9.2) excess deaths for every 1000 cardiovascular deaths, respectively. Heart failure was associated with the highest excess deaths proportion from extreme hot and cold days with 2.6 (95% eCI, 2.4-2.8) and 12.8 (95% eCI, 12.2-13.1) for every 1000 heart failure deaths, respectively. CONCLUSIONS Across a large, multinational sample, exposure to extreme hot and cold temperatures was associated with a greater risk of mortality from multiple common cardiovascular conditions. The intersections between extreme temperatures and cardiovascular health need to be thoroughly characterized in the present day-and especially under a changing climate.
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Affiliation(s)
- Barrak Alahmad
- Environmental Health Department (B.Alahmad, A.Z., J.S., P.K.), Harvard T.H. Chan School of Public Health, Boston, MA
- Environmental and Occupational Health Department, Faculty of Public Health, Kuwait University, Kuwait City (B.Alahmad)
| | - Haitham Khraishah
- Cardiology Division, University of Maryland Medical Center, University of Maryland, Baltimore (H.Khraishah)
| | - Dominic Royé
- Department of Geography, University of Santiago de Compostela, Spain (D.R.)
| | - Ana Maria Vicedo-Cabrera
- Institute of Social and Preventive Medicine (A.M.V-C.)
- Oeschger Center for Climate Change Research, University of Bern, Switzerland (A.M.V-C.)
- Department of Public Health Environments and Society (A.M.V-C., B.Armstrong), London School of Hygiene and Tropical Medicine, UK
| | - Yuming Guo
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (Y.G., S.L.)
| | | | - Souzana Achilleos
- School of Health Sciences, Cyprus University of Technology, Limassol (S.A.)
- Department of Primary Care and Population Health, University of Nicosia Medical School, Cyprus (S.A.)
| | | | - Ben Armstrong
- Department of Public Health Environments and Society (A.M.V-C., B.Armstrong), London School of Hygiene and Tropical Medicine, UK
| | - Michelle L. Bell
- School of the Environment, Yale University, New Haven, CT (M.L.B., W.L.)
| | - Shih-Chun Pan
- National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan (S-C.P., Y-L.L.G.)
| | | | - Valentina Colistro
- Department of Quantitative Methods, School of Medicine, University of the Republic, Montevideo, Uruguay (V.C.)
| | - Tran Ngoc Dang
- Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam (T.N.D., D.V.D.)
| | - Do Van Dung
- Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam (T.N.D., D.V.D.)
| | | | - Alireza Entezari
- Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran (A.E., F.M.)
| | - Yue-Liang Leon Guo
- National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan (S-C.P., Y-L.L.G.)
| | - Masahiro Hashizume
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Japan (M.H.)
| | - Yasushi Honda
- Center for Climate Change Adaptation, National Institute for Environmental Studies, Tsukuba, Japan (Y.H.)
| | - Ene Indermitte
- Department of Family Medicine and Public Health, University of Tartu, Estonia (E.I., H.O.)
| | - Carmen Íñiguez
- CIBER de Epidemiología y Salud Pública, Madrid, Spain (D.R., C.Í.)
- Department of Statistics and Computational Research, Universitat de València, Spain (C.Í.)
| | - Jouni J.K. Jaakkola
- Center for Environmental and Respiratory Health Research (J.J.K.J.), University of Oulu, Finland
- Medical Research Center Oulu (J.J.K.J.), University of Oulu, Finland
- Biocenter Oulu (N.R.I.R., J.J.K.J.), University of Oulu, Finland
| | - Ho Kim
- Graduate School of Public Health, Seoul National University, South Korea (H.Kim)
| | - Eric Lavigne
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Canada (E.L.)
| | - Whanhee Lee
- School of the Environment, Yale University, New Haven, CT (M.L.B., W.L.)
- School of Biomedical Engineering, College of Information and Biomedical Engineering, Pusan National University, Yangsan, South Korea (W.L.)
| | - Shanshan Li
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (Y.G., S.L.)
- Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (S.L.)
| | - Joana Madureira
- Department of Environmental Health, Instituto Nacional de Saúde Dr Ricardo Jorge, Porto, Portugal (J.M.)
- Epidemiology Research Unit (EPIUnit) (J.M.), Instituto de Saúde Pública, Universidade do Porto, Portugal
- Laboratory for Integrative and Translational Research in Population Health (J.M.), Instituto de Saúde Pública, Universidade do Porto, Portugal
| | - Fatemeh Mayvaneh
- Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran (A.E., F.M.)
| | - Hans Orru
- Department of Family Medicine and Public Health, University of Tartu, Estonia (E.I., H.O.)
| | - Ala Overcenco
- Laboratory of Management in Science and Public Health, National Agency for Public Health of the Ministry of Health, Chisinau, Moldova (A.O.)
| | - Martina S. Ragettli
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute (M.S.R.), Switzerland
- University of Basel (M.S.R.), Switzerland
| | - Niilo R.I. Ryti
- Biocenter Oulu (N.R.I.R., J.J.K.J.), University of Oulu, Finland
| | | | - Noah Scovronick
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA (N.S.)
| | - Xerxes Seposo
- School of Tropical Medicine and Global Health, Nagasaki University, Japan (X.S., A.T.)
| | - Francesco Sera
- Department of Statistics, Computer Science and Applications G. Parenti, University of Florence, Italy (F.S.)
| | - Susana Pereira Silva
- Department of Epidemiology, Instituto Nacional de Saúde Dr Ricardo Jorge, Lisboa, Portugal (S.P.S.)
| | - Massimo Stafoggia
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy (F.K.D’D., M.S.)
| | - Aurelio Tobias
- School of Tropical Medicine and Global Health, Nagasaki University, Japan (X.S., A.T.)
- Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research, Barcelona (A.T.)
| | - Eric Garshick
- Pulmonary, Allergy, Sleep and Critical Care Medicine Section, Department of Medicine, Veterans Affairs Boston Healthcare System, Harvard Medical School, West Roxbury, MA (E.G.)
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital (E.G.), Harvard Medical School, MA
| | - Aaron S. Bernstein
- Center for Climate, Health and the Global Environment (A.S.B.), Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Pediatrics, Boston Children’s Hospital (A.S.B.), Harvard Medical School, MA
| | - Antonella Zanobetti
- Environmental Health Department (B.Alahmad, A.Z., J.S., P.K.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Joel Schwartz
- Environmental Health Department (B.Alahmad, A.Z., J.S., P.K.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Antonio Gasparrini
- Centre for Statistical Methodology (A.G.), London School of Hygiene and Tropical Medicine, UK
- Centre on Climate Change and Planetary Health (A.G.), London School of Hygiene and Tropical Medicine, UK
| | - Petros Koutrakis
- Environmental Health Department (B.Alahmad, A.Z., J.S., P.K.), Harvard T.H. Chan School of Public Health, Boston, MA
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8
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Khraishah H, Alahmad B, Ostergard RL, AlAshqar A, Albaghdadi M, Vellanki N, Chowdhury MM, Al-Kindi SG, Zanobetti A, Gasparrini A, Rajagopalan S. Climate change and cardiovascular disease: implications for global health. Nat Rev Cardiol 2022; 19:798-812. [PMID: 35672485 DOI: 10.1038/s41569-022-00720-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 12/15/2022]
Abstract
Climate change is the greatest existential challenge to planetary and human health and is dictated by a shift in the Earth's weather and air conditions owing to anthropogenic activity. Climate change has resulted not only in extreme temperatures, but also in an increase in the frequency of droughts, wildfires, dust storms, coastal flooding, storm surges and hurricanes, as well as multiple compound and cascading events. The interactions between climate change and health outcomes are diverse and complex and include several exposure pathways that might promote the development of non-communicable diseases such as cardiovascular disease. A collaborative approach is needed to solve this climate crisis, whereby medical professionals, scientific researchers, public health officials and policymakers should work together to mitigate and limit the consequences of global warming. In this Review, we aim to provide an overview of the consequences of climate change on cardiovascular health, which result from direct exposure pathways, such as shifts in ambient temperature, air pollution, forest fires, desert (dust and sand) storms and extreme weather events. We also describe the populations that are most susceptible to the health effects caused by climate change and propose potential mitigation strategies, with an emphasis on collaboration at the scientific, governmental and policy levels.
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Affiliation(s)
- Haitham Khraishah
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA. .,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Barrak Alahmad
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.,Environmental & Occupational Health Department, Faculty of Public Health, Kuwait University, Hawalli, Kuwait
| | | | - Abdelrahman AlAshqar
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Mazen Albaghdadi
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nirupama Vellanki
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mohammed M Chowdhury
- Department of Vascular and Endovascular Surgery, Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Sadeer G Al-Kindi
- University Hospitals, Harrington Heart & Vascular Institute, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Antonella Zanobetti
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Antonio Gasparrini
- Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, London, UK.,Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, London, UK.,Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Sanjay Rajagopalan
- University Hospitals, Harrington Heart & Vascular Institute, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
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9
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Lin CW, Chen PW, Liu WM, Hsu JY, Huang YL, Cheng Y, Liu AB. Dynamic Changes and Temporal Association with Ambient Temperatures: Nonlinear Analyses of Stroke Events from a National Health Insurance Database. J Clin Med 2021; 10:5041. [PMID: 34768561 PMCID: PMC8584505 DOI: 10.3390/jcm10215041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/24/2021] [Accepted: 10/27/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The associations between ambient temperatures and stroke are still uncertain, although they have been widely studied. Furthermore, the impact of latitudes or climate zones on these associations is still controversial. The Tropic of Cancer passes through the middle of Taiwan and divides it into subtropical and tropical areas. Therefore, the Taiwan National Health Insurance Database can be used to study the influence of latitudes on the association between ambient temperature and stroke events. METHODS In this study, we retrieved daily stroke events from 2010 to 2015 in the New Taipei and Taipei Cities (the subtropical areas) and Kaohsiung City (the tropical area) from the National Health Insurance Research Database. Overall, 70,338 and 125,163 stroke events, including ischemic stroke and intracerebral hemorrhage, in Kaohsiung City and the Taipei Area were retrieved from the database, respectively. We also collected daily mean temperatures from the Taipei and Kaohsiung weather stations during the same period. The data were decomposed by ensemble empirical mode decomposition (EEMD) into several intrinsic mode functions (IMFs). There were consistent 6-period IMFs with intervals around 360 days in most decomposed data. Spearman's rank correlation test showed moderate-to-strong correlations between the relevant IMFs of daily temperatures and events of stroke in both areas, which were higher in the northern area compared with those in the southern area. CONCLUSIONS EEMD is a useful tool to demonstrate the regularity of stroke events and their associations with dynamic changes of the ambient temperature. Our results clearly demonstrate the temporal association between the ambient temperature and daily events of ischemic stroke and intracranial hemorrhage. It will contribute to planning a healthcare system for stroke seasonally. Further well-designed prospective studies are needed to elucidate the meaning of these associations.
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Affiliation(s)
- Che-Wei Lin
- Department of Biomedical Engineering, College of Engineering, National Cheng Kung University, Tainan 701401, Taiwan;
- Medical Device Innovation Center, National Cheng Kung University, Tainan 704302, Taiwan
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan
| | - Po-Wei Chen
- Medical Department, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan;
| | - Wei-Min Liu
- Department of Computer Science and Information Engineering, National Chung Cheng University, Chiayi 621301, Taiwan;
| | - Jin-Yi Hsu
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan;
| | - Yu-Lun Huang
- Department of Medicine, School of Medicine, Tzu Chi University, Hualien 970374, Taiwan;
| | - Yu Cheng
- Department of Medical Education, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei 231405, Taiwan;
| | - An-Bang Liu
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien 970473, Taiwan
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10
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Yamamoto S, Koh M, Matsumura K, Hamazaki K, Inadera H, Kuroda S. Impact of Low Ambient Temperature on the Occurrence of Spontaneous Intracerebral Hemorrhage-Analysis of Population-Based Stroke Registry in Toyama, Japan. J Stroke Cerebrovasc Dis 2021; 31:106156. [PMID: 34735898 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 09/25/2021] [Accepted: 10/01/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Although several studies have reported that some meteorological factors such as ambient temperature and atmospheric pressure, affect the incidence of spontaneous intracerebral hemorrhage (ICH), the correlation remains unclear. This retrospective time-series analysis was aimed to clarify the effects of meteorological parameters on the incidence of ICH. MATERIALS AND METHODS Data of patients with ICH were obtained from a population-based survey of acute stroke patients between April 2016 and March 2019. All days during the study period were categorized into "no ICH day" when no ICHs occurred, "single ICH day" when only one ICH occurred, and "cluster day" when two or more ICHs occurred. Meteorological data were compared for among the three categories. RESULTS 1,691 ICH patients from 19 hospitals were registered. In a total of 1,095 days, 250 were categorized as no ICH days, 361 as single ICH days, and 484 as cluster days. Daily ambient temperature declined in parallel with the daily number of ICHs, and it was a significant predictor for single ICH days and cluster days. Furthermore, the incidence of ICH in patients aged 65 years or above, men, those who emerged at home, those with modified Rankin Scale 3-5; and those with hypertension; and ICHs in the basal ganglia, brain stem, and cerebellum were more likely to be affected by low ambient temperature. CONCLUSION Daily ambient temperature was significantly associated with ICH incidence. Patients' activity, history of hypertension, and location of hemorrhage were also related to the impact of low ambient temperature on the incidence of ICH.
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Affiliation(s)
- Shusuke Yamamoto
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan.
| | - Masaki Koh
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan.
| | - Kenta Matsumura
- Toyama Regional Center for Japan Environment and Children's Study, University of Toyama, Toyama, Japan.
| | - Kei Hamazaki
- Department of Public Health, Faculty of Medicine, University of Toyama, Toyama, Japan.
| | - Hidekuni Inadera
- Department of Public Health, Faculty of Medicine, University of Toyama, Toyama, Japan.
| | - Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan.
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11
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Khan K, Tanaka-Mizuno S, Turin TC, Takashima N, Kadota A, Ueshima H, Miura K, Kita Y. Relationship of Ambient Temperature Parameters to Stroke Incidence in a Japanese Population - Takashima Stroke Registry, Japan, 1988-2010. Circ J 2021; 85:2215-2221. [PMID: 34321376 DOI: 10.1253/circj.cj-21-0325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Using a population-based stroke registry system, we evaluated the relationship between ambient temperature parameters and stroke incidence in a Japanese population.Methods and Results:We analyzed data from the Takashima Stroke Registry, which records all stroke occurrences in Takashima City, Japan. The study period of 8,401 days was divided into quintiles of daily weather parameters, and the middle quintile was used as the reference category. Incidence rates (IR per 100,000 person-years) were calculated across the quintiles. Poisson regression analysis was used to calculate the effect of temperature parameters on stroke incidence. There were 2,405 first-ever strokes (1,294 men), including 1,625 ischemic, 545 cerebral hemorrhages, 213 subarachnoid hemorrhages, and 22 unclassified strokes. The stroke IR was higher in the middle quintile of average temperature, 357.3 (328.4-388.8), and for other parameters. After adjustment for age and sex, for all stroke, the incidence rate ratio (IRR) in the highest (Q5: IRR 0.81, 95% confidence interval (CI) 0.71-0.92) and the second-highest (Q4: IRR 0.80, 95% CI 0.71-0.91) quintile was lower than that in the middle quintile (Q3: Reference). Analogous results were observed for the minimum, maximum, and lag-days temperatures, also in the subtypes and across ≥65 years of age, also in females. CONCLUSIONS Higher temperatures, irrespective of the parameter (average, minimum, or maximum), had a protective effect against stroke occurrence in Japan.
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Affiliation(s)
- Kawser Khan
- Department of Public Health, Shiga University of Medical Science.,National Heart Foundation Hospital and Research Institute
| | - Sachiko Tanaka-Mizuno
- Department of Medical Statistics, Shiga University of Medical Science.,Department of Digital Health and Epidemiology, Kyoto University
| | - Tanvir C Turin
- Department of Family Medicine, Cumming School of Medicine, University of Calgary
| | - Naoyuki Takashima
- Department of Public Health, Shiga University of Medical Science.,Department of Public Health, Kindai University, Faculty of Medicine
| | - Aya Kadota
- Department of Public Health, Shiga University of Medical Science.,NCD Epidemiology Research Center, Shiga University of Medical Science
| | - Hirotsugu Ueshima
- Department of Public Health, Shiga University of Medical Science.,NCD Epidemiology Research Center, Shiga University of Medical Science
| | - Katsuyuki Miura
- Department of Public Health, Shiga University of Medical Science.,NCD Epidemiology Research Center, Shiga University of Medical Science
| | - Yoshikuni Kita
- Department of Public Health, Shiga University of Medical Science.,Tsuruga Nursing University
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12
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Vasquez HE, Prasad L, Moscote-Salazar LR, Agrawal A. Atmospheric variables and subarachnoid hemorrhage: narrative review. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00102-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023] Open
Abstract
Abstract
Background
Stroke is a neurological emergency that tends to be the first cause of death in many countries. Atmospheric variables are strongly associated with stroke, in which subarachnoid hemorrhage (SAH) has been associated in many studies to meteorological risk factors such as air pollution, air pressure, weather changes, and ambient temperature. These characteristics may influence the brain circulation and cause SAH, being diagnosed as idiopathic SAH or SAH with unknown cause.
Objective
The main objective of this review is to present the most relevant meteorological risk factors that may develop subarachnoid hemorrhage according to the current evidence that supports the strong association.
Conclusion
Brain vessel circulation may be influenced by atmospheric variables such as air pollution and weather changes, generating intrinsic changes in the intima of the vessels which leads to vasospasm and with comorbidities associated may develop SAH.
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13
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Helsper M, Agarwal A, Aker A, Herten A, Darkwah-Oppong M, Gembruch O, Deuschl C, Forsting M, Dammann P, Pierscianek D, Jabbarli R, Sure U, Wrede KH. The Subarachnoid Hemorrhage-Weather Myth: A Long-Term Big Data and Deep Learning Analysis. Front Neurol 2021; 12:653483. [PMID: 34025556 PMCID: PMC8131675 DOI: 10.3389/fneur.2021.653483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/22/2021] [Indexed: 12/12/2022] Open
Abstract
Objective: The frequency of aneurysmal subarachnoid hemorrhage (aSAH) presents complex fluctuations that have been attributed to weather and climate changes in the past. In the present long-term big data and deep learning analysis, we have addressed this long-held myth. Methods: Bleeding dates and basic demographic data for all consecutive patients (n = 1,271) admitted to our vascular center for treatment of aSAH between January 2003 and May 2020 (6,334 days) were collected from our continuously maintained database. The meteorological data of the local weather station, including 13 different weather and climate parameters, were retrieved from Germany's National Meteorological Service for the same period. Six different deep learning models were programmed using the Keras framework and were trained for aSAH event prediction with meteorological data from January 2003 to June 2017, with 10% of this dataset applied for data validation and model improvement. The dataset from July 2017 to May 2020 was tested for aSAH event prediction accuracy for all six models using the area under the receiver operating characteristic curve (AUROC) as the metric. Results: The study group comprised of 422 (33.2%) male and 849 (66.8%) female patients with an average age of 55 ± 14 years. None of the models showed an AUROC larger than 60.2. From the presented data, the influence of weather and climate on the occurrence of aSAH events is extremely unlikely. Conclusion: The myth of special weather conditions influencing the frequency of aSAH is disenchanted by this long-term big data and deep learning analysis.
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Affiliation(s)
- Moritz Helsper
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Aashish Agarwal
- Department of Computer Science and Applied Cognitive Science, University of Duisburg-Essen, Duisburg, Germany
| | - Ahmet Aker
- Department of Computer Science and Applied Cognitive Science, University of Duisburg-Essen, Duisburg, Germany
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Marvin Darkwah-Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Oliver Gembruch
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University of Duisburg-Essen, Essen, Germany
| | - Michael Forsting
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University of Duisburg-Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karsten Henning Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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14
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Fitchett JM. Perspectives on biometeorological research on the African continent. INTERNATIONAL JOURNAL OF BIOMETEOROLOGY 2021; 65:133-147. [PMID: 32997273 DOI: 10.1007/s00484-020-02020-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 06/11/2023]
Abstract
Since the first issue of the International Journal of Biometeorology in 1957, a total of 135 papers have reported on research in or of African countries. The majority of these have been on topics of animal biometeorology (36%), and the greatest proportion (24%) are situated in Nigeria. There has been a considerable increase in papers on African biometeorology since 2011, with those from this past decade accounting for 58% of all African papers in the journal. This occurs concurrent to an increase in the total number of papers published in the journal, driven by a move to the Editorial Manager system. While 66% of the papers on African biometeorology in the journal are authored by at least one person with an affiliation in the African continent, only 15 African countries are represented in the total authorship. As much of the African continent is projected to experience climatic changes exceeding the global mean, as much of the region is involved in animal and plant farming, and as seasonally-fluctuating and climatically affected diseases are common place, this low representation of work in Africa is surprising. This points to the need for greater awareness among African researchers of the discipline of biometeorology, greater involvement of African biometeorologists in International Society of Biometeorology and Commission meetings, and the inclusion of a greater number of African academics in the review process. This would be beneficial to the Society in increasing diversity and encouraging a more cosmopolitan engagement, and to the recognition of scientific development in African countries.
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Affiliation(s)
- Jennifer M Fitchett
- School of Geography, Archaeology and Environmental Studies, University of the Witwatersrand, Johannesburg, South Africa.
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15
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Ravljen M, Bajrović F, Vavpotič D. A time series analysis of the relationship between ambient temperature and ischaemic stroke in the Ljubljana area: immediate, delayed and cumulative effects. BMC Neurol 2021; 21:23. [PMID: 33446129 PMCID: PMC7807497 DOI: 10.1186/s12883-021-02044-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 01/01/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Stroke is a major health problem around the world. Several studies have examine the influence of ambient temperature on incidence of stoke, but they reported different results for different types of stroke and different geographical regions. Hence, effect of ambient temperature is still much of interest, when focusing on ischemic stroke (IS) in regions that have not been examined yet. The aim of our study is to analyse association between IS incidences and short, delayed and cumulative effect of average daily ambient temperature, humidity and pressure in central Europe. To the best of our knowledge, this is the first IS study conducted between 45° and 50° latitude where large part of Central European population resides. METHODS We linked daily hospitals' admission data for whole population and separately for two specific age groups with ambient temperature data. We considered patients coming from Ljubljana basin and its immediate surrounding. Data were gathered daily from January 2012 to December 2017. To measure the effect of average ambient temperature, humidity and pressure we used generalized linear model with a log-link-function and a Poisson distribution. RESULTS The results of our study show a statistically significant immediate, delayed and cumulative effects of ambient temperatures on IS incidence for the whole population and the population older than 65 years. Specifically, 1 °C reduction in ambient temperature on a given day (Lag 0) increases the IS risk for approximately 5‰ (all population) or 6‰ (population older than 65 years). Similar effects were found for lags from 1 to 6. Analysis of time windows from 0 to 1 days up to 0-28 days also show statistically significant cumulative effect for the same two age groups. IS incidence was not found to be significantly related to pressure or humidity in any group. CONCLUSION The findings of this study may help healthcare authorities in central Europe improve existing stroke prevention measures and raise public awareness.
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Affiliation(s)
- Mirjam Ravljen
- University of Ljubljana, Faculty of Health Sciences, Zdravstvena pot 5, Ljubljana, Slovenia.
| | - Fajko Bajrović
- University Medical Centre Ljubljana, Neurology Clinic, Department of Vascular Neurology and Neurological Intensive Care, Zaloška cesta 2, Ljubljana, Slovenia
| | - Damjan Vavpotič
- University of Ljubljana, Faculty of Computer and Information Science, Information Systems Laboratory, Večna pot 113, Ljubljana, Slovenia
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16
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Vencloviene J, Radisauskas R, Kranciukaite-Butylkiniene D, Tamosiunas A, Vaiciulis V, Rastenyte D. Association between stroke occurrence and changes in atmospheric circulation. BMC Public Health 2021; 21:42. [PMID: 33407282 PMCID: PMC7789358 DOI: 10.1186/s12889-020-10052-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 12/10/2020] [Indexed: 11/10/2022] Open
Abstract
Background The impact of weather on morbidity from stroke has been analysed in previous studies. As the risk of stroke was mostly associated with changing weather, the changes in the daily stroke occurrence may be associated with changes in atmospheric circulation. The aim of our study was to detect and evaluate the association between daily numbers of ischaemic strokes (ISs) and haemorrhagic strokes (HSs) and the teleconnection pattern. Methods The study was performed in Kaunas, Lithuania, from 2000 to 2010. The daily numbers of ISs, subarachnoid haemorrhages (SAHs), and intracerebral haemorrhages (ICHs) were obtained from the Kaunas Stroke Register. We evaluated the association between these types of stroke and the teleconnection pattern by applying Poisson regression and adjusting for the linear trend, month, and other weather variables. Results During the study period, we analysed 4038 cases (2226 men and 1812 women) of stroke. Of these, 3245 (80.4%) cases were ISs, 533 (13.2%) cases were ICHs, and 260 (6.4%) cases were SAHs. An increased risk of SAH was associated with a change in mean daily atmospheric pressure over 3.9 hPa (RR = 1.49, 95% CI 1.14–1.96), and a stronger El Niño event had a protective effect against SAHs (RR = 0.34, 95% CI 0.16–0.69). The risk of HS was positively associated with East Atlantic/West Russia indices (RR = 1.13, 95% CI 1.04–1.23). The risk of IS was negatively associated with the Arctic Oscillation index on the same day and on the previous day (RR = 0.97, p < 0.033). During November–March, the risk of HS was associated with a positive North Atlantic Oscillation (NAO) (RR = 1.29, 95% CI 1.03–1.62), and the risk of IS was negatively associated with the NAO index (RR = 0.92, 95% CI 0.85–0.99). Conclusions The results of our study provide new evidence that the North Atlantic Oscillation, Arctic Oscillation, East Atlantic/West Russia, and El Niño-Southern Oscillation pattern may affect the risk of stroke. The impact of these teleconnections is not identical for various types of stroke. Emergency services should be aware that specific weather conditions are more likely to prompt calls for more severe strokes.
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Affiliation(s)
- Jone Vencloviene
- Department of Environmental Sciences, Vytautas Magnus University, Donelaicio St. 58, LT-44248, Kaunas, Lithuania. .,Institute of Cardiology, Lithuanian University of Health Sciences, Sukileliu St. 15, LT-50103, Kaunas, Lithuania.
| | - Ricardas Radisauskas
- Institute of Cardiology, Lithuanian University of Health Sciences, Sukileliu St. 15, LT-50103, Kaunas, Lithuania.,Department of Environmental and Occupational Medicine, Lithuanian University of Health Sciences, Tilzes St. 18, LT-47181, Kaunas, Lithuania
| | - Daina Kranciukaite-Butylkiniene
- Institute of Cardiology, Lithuanian University of Health Sciences, Sukileliu St. 15, LT-50103, Kaunas, Lithuania.,Department of Family Medicine, Lithuanian University of Health Sciences, Eiveniu St. 2, LT-50009, Kaunas, Lithuania
| | - Abdonas Tamosiunas
- Institute of Cardiology, Lithuanian University of Health Sciences, Sukileliu St. 15, LT-50103, Kaunas, Lithuania.,Department of Preventive Medicine, Lithuanian University of Health Sciences, Tilzes St. 18, LT-47181, Kaunas, Lithuania
| | - Vidmantas Vaiciulis
- Department of Environmental and Occupational Medicine, Lithuanian University of Health Sciences, Tilzes St. 18, LT-47181, Kaunas, Lithuania.,Health Research Institute, Lithuanian University of Health Sciences, Tilzes St. 18, LT-47181, Kaunas, Lithuania
| | - Daiva Rastenyte
- Department of Neurology, Lithuanian University of Health Sciences, Eiveniu St. 2, LT-50009, Kaunas, Lithuania
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Sherratt S. What are the implications of climate change for speech and language therapists? INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2021; 56:215-227. [PMID: 33258529 DOI: 10.1111/1460-6984.12587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND The emerging global issue of climate change has large-scale effects on health and well-being, including communication disorders. The broad range of the speech and language therapy profession's scope of practice incorporates prevention, advocacy and equality in service delivery. These act as a springboard for involvement in climate change and health. AIMS This is an appeal to speech and language therapists (SLTs) to focus and take action on this issue and its considerable effects on communication and swallowing disorders. METHODS & PROCEDURES This article discusses the importance of taking a public health position on prevention and equality of services to manage environmental determinants of communication and swallowing disorders. It also describes the extent to which climate change affects these disorders and exacerbates the inequality of healthcare services in low- and middle-income countries. MAIN CONTRIBUTION Five strategies are provided for action on fulfilling therapists' roles in reducing the incidence, development and exacerbation of climate-related communication and swallowing disorders, as well as the role of SLTs in acting as advocates. The case is made for expanding the scope of services to focus on prevention and service equality so as to best meet the needs of the wider community. CONCLUSIONS & IMPLICATIONS Despite other challenges currently facing SLTs, climate change and its increasing effects on communication disorders and dysphagia is difficult to ignore. SLTs owe it to their clients, the wider community, low- and middle-income countries, the economy, and the future to take action. What this paper adds What is already known on the subject Multiple studies published in peer-reviewed scientific journals show that climate change is extremely likely to be due to human activities. The global effects will be higher temperatures, changes in precipitation, more droughts and heatwaves, stronger and more intense hurricanes, and a rising sea level which directly threaten the health of entire populations. Other health professions are beginning to take climate change into account in training and practice. What this paper adds to existing knowledge Many disorders of communication and swallowing are caused or exacerbated by the effects of climate change. Increasing temperatures, extremes of precipitation, population displacement and air pollution contribute to cardiovascular and cerebrovascular events, respiratory disease, malnutrition, premature birth, air- and water-borne diseases, and mental illness. These may affect the communication and swallowing abilities across the lifespan, but particularly those of children and older adults. What are the potential or actual clinical implications of this work? SLTs' roles in prevention, advocacy and education act as a starting point for involvement in climate change and health. Three practical strategies for action include educating SLTs and other health professionals on climate change and its effects on communication and swallowing, promoting awareness with clients and their families, and gathering and disseminating reliable data.
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Affiliation(s)
- Sue Sherratt
- Communication Research Australia, Rankin Park, NSW, Australia
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Lorking N, Wood AD, Tiamkao S, Clark AB, Kongbunkiat K, Bettencourt-Silva JH, Sawanyawisuth K, Kasemsap N, Mamas MA, Myint PK. Seasonality of stroke: Winter admissions and mortality excess: A Thailand National Stroke population database study. Clin Neurol Neurosurg 2020; 199:106261. [PMID: 33096427 DOI: 10.1016/j.clineuro.2020.106261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 09/27/2020] [Accepted: 09/29/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We examined the existence and potential burden of seasonality of stroke admissions and mortality within a tropical climate using cohort data collected between 1 st November 2003 and 31 st October 2012. PATIENTS AND METHODS In a prospective cohort of hospitalised stroke patients from the catchment of ∼75 % of the Thai population (n = 569,307; mean SD age = 64(14.5)), incident stroke admissions, in-hospital mortality, prolonged hospitalisations, and stroke related complications by season were determined. Rates of incident stroke admissions by month and season were plotted. Winter excess indexes for study outcomes expressed as a percentage were calculated. Using logistic regression we examined the association between winter admission and in-hospital mortality (non-winter admission as reference) adjusting for age, sex, stroke type, year of admission, and presence of pre-existing comorbidities. RESULTS We observed a winter excess in mortality during hospitalisation (+10.3 %) and prolonged length of stay (+7.3 %). Respective winter excess indexes for dyslipidaemias, arrhythmias, anaemia, and alcohol related disorders in patients that died during hospitalisation were +1.4 %, +6.2 %, +0.2 %, +1.5 %. In these patients, respective winter excess indexes for post-stroke complications of pneumonia and sepsis were +6.7 % and +3.2 %. In fully adjusted analyses, winter admission (compared to non-winter admission) was associated with increased odds of in-hospital mortality (OR (95 % CI) = 1.023 (1.006-1.040)). CONCLUSIONS We provide robust evidence for the existence of an excess in winter stroke admissions and subsequent in-hospital deaths within a tropical region.
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Affiliation(s)
- Nicole Lorking
- Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, AB252ZD, UK
| | - Adrian D Wood
- Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, AB252ZD, UK
| | - Somsak Tiamkao
- Neurology Division, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand; North-eastern Stroke Research Group, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Allan B Clark
- Norwich Medical School, University of East Anglia, Norwich, NR47TJ, UK
| | - Kannikar Kongbunkiat
- North-eastern Stroke Research Group, Khon Kaen University, Khon Kaen, 40002, Thailand; Ambulatory Medicine Division, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | | | - Kittisak Sawanyawisuth
- Ambulatory Medicine Division, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Narongrit Kasemsap
- North-eastern Stroke Research Group, Khon Kaen University, Khon Kaen, 40002, Thailand; Ambulatory Medicine Division, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, ST55BG, UK
| | - Phyo K Myint
- Ageing Clinical and Experimental Research Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, AB252ZD, UK.
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Vered S, Paz S, Negev M, Tanne D, Zucker I, Weinstein G. High ambient temperature in summer and risk of stroke or transient ischemic attack: A national study in Israel. ENVIRONMENTAL RESEARCH 2020; 187:109678. [PMID: 32474306 DOI: 10.1016/j.envres.2020.109678] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To examine whether high ambient temperature and diurnal temperature range during the summer are associated with risk of stroke/transient ischemic attack (TIA). METHODS A time-stratified case-crossover study design was conducted. The study sample comprised all individuals aged ≥50 years who had a stroke/TIA reported to the Israeli National Stroke Registry between 2014 and 2016 during the summer season. Daily temperature data were retrieved from the Israel Meteorological Service. Conditional logistic regression models were used with relative humidity and air pollution as covariates. RESULTS The sample included 15,123 individuals who had a stroke/TIA during the summer season (mean age 73 ± 12 years; 54% males). High ambient temperature was associated with stroke/TIA risk starting from the day before the stroke event, and increasing in strength over a six-day lag (OR = 1.10 95%CI 1.09-1.12). Moreover, a larger diurnal temperature range prior to stroke/TIA occurrence was associated with decreased stroke/TIA risk (OR = 0.96 95%CI 0.95-0.97 for a six-day lag). CONCLUSIONS High ambient temperature may be linked to increased risk of cerebrovascular events in subsequent days. However, relief from the heat during the night may attenuate this risk.
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Affiliation(s)
- Shiraz Vered
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Shlomit Paz
- Department of Geography and Environmental Studies, University of Haifa, Haifa, Israel
| | - Maya Negev
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - David Tanne
- Stroke and Cognition Institute, Rambam Health Care Campus, Haifa, Israel
| | - Inbar Zucker
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Israel Center for Disease Control, Israel Ministry of Health, Ramat-Gan, Israel
| | - Galit Weinstein
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel.
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[Influence of extreme weather conditions on the deployment volume of emergency medical services]. Med Klin Intensivmed Notfmed 2019; 116:154-160. [PMID: 31802135 DOI: 10.1007/s00063-019-00641-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/08/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Due to global warming a worldwide increase in the frequency and intensity of heat waves have been forecast. In the context of the overall increasing number of emergency service calls, weather-induced effects on the number of calls are highly relevant. We evaluated the influence of extreme temperatures on emergency medical services. MATERIALS AND METHODS The study was conducted in Bochum, Germany. The authors examined the data from 16,767 emergency calls. In addition, the daily updated temperature data were collected for each emergency doctor call. Data were collected from 01 January 2014 until 31 December 2015. The primary question was the influence of extremes of the perceived temperature (PT; on the day of the call and the three previous days) on the diagnosis group of cardiovascular diseases. A secondary question was the influence of extremes of the temperature parameters (air temperature, PT, physiological equivalent temperature [PET]) on the day of call and the three previous days. RESULTS A total of 16,767 calls were assessed. The threshold values (upper and lower 5%) were -8.7 and 32.5 °C for PT and -0.7 and 26.7 °C for air temperature. Examination of the PT indicated a significantly increased rate of calls for cold spells on the day of the call (RR = 1.14; p = 0.033) as well as a lag effect of 3 days (RR = 1.1; p = 0.049). CONCLUSION The present study shows that during cold spells there is an increased rate of calls for cardiovascular diseases. This effect is not only observable on the extreme day itself but also 3 days later.
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Lavados PM, Olavarría VV, Hoffmeister L. Ambient Temperature and Stroke Risk. Stroke 2018; 49:255-261. [DOI: 10.1161/strokeaha.117.017838] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/30/2017] [Accepted: 11/09/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Pablo M. Lavados
- From the Departamento de Neurología y Psiquiatría (P.M.L., V.V.O.) y Departamento de Paciente Crítico (V.V.O.), Unidad de Neurología Vascular, Servicio de Neurología, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Chile; Departamento de Ciencias Neurológicas, Universidad de Chile, Santiago (P.M.L.); and Escuela de Salud Pública, Facultad de Ciencias, Universidad Mayor, Santiago, Chile (L.H.)
| | - Verónica V. Olavarría
- From the Departamento de Neurología y Psiquiatría (P.M.L., V.V.O.) y Departamento de Paciente Crítico (V.V.O.), Unidad de Neurología Vascular, Servicio de Neurología, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Chile; Departamento de Ciencias Neurológicas, Universidad de Chile, Santiago (P.M.L.); and Escuela de Salud Pública, Facultad de Ciencias, Universidad Mayor, Santiago, Chile (L.H.)
| | - Lorena Hoffmeister
- From the Departamento de Neurología y Psiquiatría (P.M.L., V.V.O.) y Departamento de Paciente Crítico (V.V.O.), Unidad de Neurología Vascular, Servicio de Neurología, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Chile; Departamento de Ciencias Neurológicas, Universidad de Chile, Santiago (P.M.L.); and Escuela de Salud Pública, Facultad de Ciencias, Universidad Mayor, Santiago, Chile (L.H.)
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