Short-term exposure to desert dust and the risk of acute myocardial infarction in Japan: a time-stratified case-crossover study

Association between dental procedures and periprosthetic joint infection: A case-crossover study

BACKGROUND

Although the risk of dental procedures as a cause of bacteremia has been recognized, evidence regarding the association between dental procedures and late periprosthetic joint infection (LPJI) is scarce. We sought to determine whether dental procedures are associated with an increased risk of LPJI.

METHODS

The study was conducted under a case-crossover design using a large claims database in Japan. We identified adult patients who had undergone dental procedures and were hospitalized for LPJI between April 2014 and September 2021. Exposure to dental procedures was assessed during a case period of 1-4 weeks, with two control periods of 9-12 weeks and 17-20 weeks, preceding LPJI hospital admission. Conditional logistic regression models were used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) of LPJI associated with dental procedures in the case period compared with the two control periods.

RESULTS

In total, 241 patients with LPJI were included in the case-crossover study. At least one dental procedure was performed in 46 patients (19.1%) in the hazard period and in 75 patients (31.1%) in the control periods. The OR for LPJI with dental procedures was 0.96 (95% CI, 0.61-1.53; p = 0.88). Findings were robust in several sensitivity analyses, including stratification by whether the dental procedure included antibiotic prophylaxis.

CONCLUSIONS

This study suggests that dental procedures are not associated with increased risk of LPJI, and will raise questions about the recommendation for antibiotic prophylaxis before dental procedures.

Association Between Asian Dust Exposure and Pneumonia Hospitalization in Western Japan: A Case-Crossover Study

Epidemiological studies have reported that Asian dust (AD), a type of desert dust, has harmful effects on human health. This study aimed to examine the association between AD exposure and hospitalization due to pneumonia. Data on patients in Western Japan admitted for pneumonia were included from a real-world database derived from electronic medical records. We used the meteorological observatory data of the most populous city in each prefecture, in which AD event was defined as a loss of visibility from a distance ≤10 km. A case-crossover design and conditional logistic regression model were used. Overall, 12 938 patients were included, and AD exposure events were observed for 557 days. Exposure to an AD event five days prior to hospitalization was significantly associated with hospitalization for pneumonia after adjusting for weather variables (odds ratio = 1.17; 95% confidence interval = [1.01, 1.36]). These findings suggest that AD exposure is associated with an increased rate of admission for pneumonia in Western Japan.

Climate Change and Cardiovascular Health: A Systematic Review

Importance

Climate change may increase the risk of adverse cardiovascular outcomes by causing direct physiologic changes, psychological distress, and disruption of health-related infrastructure. Yet, the association between numerous climate change-related environmental stressors and the incidence of adverse cardiovascular events has not been systematically reviewed.

Objective

To review the current evidence on the association between climate change-related environmental stressors and adverse cardiovascular outcomes.

Evidence Review

PubMed, Embase, Web of Science, and Cochrane Library were searched to identify peer-reviewed publications from January 1, 1970, through November 15, 2023, that evaluated associations between environmental exposures and cardiovascular mortality, acute cardiovascular events, and related health care utilization. Studies that examined only nonwildfire-sourced particulate air pollution were excluded. Two investigators independently screened 20 798 articles and selected 2564 for full-text review. Study quality was assessed using the Navigation Guide framework. Findings were qualitatively synthesized as substantial differences in study design precluded quantitative meta-analysis.

Findings

Of 492 observational studies that met inclusion criteria, 182 examined extreme temperature, 210 ground-level ozone, 45 wildfire smoke, and 63 extreme weather events, such as hurricanes, dust storms, and droughts. These studies presented findings from 30 high-income countries, 17 middle-income countries, and 1 low-income country. The strength of evidence was rated as sufficient for extreme temperature; ground-level ozone; tropical storms, hurricanes, and cyclones; and dust storms. Evidence was limited for wildfire smoke and inadequate for drought and mudslides. Exposure to extreme temperature was associated with increased cardiovascular mortality and morbidity, but the magnitude varied with temperature and duration of exposure. Ground-level ozone amplified the risk associated with higher temperatures and vice versa. Extreme weather events, such as hurricanes, were associated with increased cardiovascular risk that persisted for many months after the initial event. Some studies noted a small increase in cardiovascular mortality, out-of-hospital cardiac arrests, and hospitalizations for ischemic heart disease after exposure to wildfire smoke, while others found no association. Older adults, racial and ethnic minoritized populations, and lower-wealth communities were disproportionately affected.

Conclusions and Relevance

Several environmental stressors that are predicted to increase in frequency and intensity with climate change are associated with increased cardiovascular risk, but data on outcomes in low-income countries are lacking. Urgent action is needed to mitigate climate change-associated cardiovascular risk, particularly in vulnerable populations.

Are Dental Procedures Associated With Pyogenic Vertebral Osteomyelitis?

BACKGROUND

Dental procedures can lead to bacteremia and have been considered a potential risk factor for pyogenic vertebral osteomyelitis (PVO). However, data on the association between dental procedures and PVO are limited.

QUESTIONS/PURPOSES

(1) After controlling for relevant confounding variables, are dental procedures associated with an increased risk of PVO? (2) Does antibiotic prophylaxis before dental procedures effectively decrease the risk of PVO?

METHODS

A case-crossover study was conducted to investigate the association between dental procedures and PVO using a Japanese claims database. The advantage of this study design is that confounding factors that do not vary over time are automatically adjusted for, because cases act as their own controls. From April 2014 to September 2021, the database included 8414 patients who were hospitalized for PVO. Of these, 50% (4182 of 8414) were excluded because they had not undergone any dental procedures before the index date, a further 0.1% (10 of 8414) were excluded because they were younger than 18 years at the index date, and a further 7% (623 of 8414) were excluded because they did not have at least 20 weeks of continuous enrollment before the index date, leaving 43% (3599 of 8414) eligible for analysis here. The mean age was 77 ± 11 years, and 55% (1985 of 3599) were men. Sixty-five percent (2356 of 3599) of patients had a diagnosis of diabetes mellitus, and 42% (1519 of 3599) of patients had a diagnosis of osteoporosis. We compared the frequency of dental procedures between a 4-week hazard period before the admission date for PVO and two control periods, 9 to 12 weeks and 17 to 20 weeks before the admission date for PVO, within individuals. We calculated odds ratios and 95% confidence intervals using conditional logistic regression analysis.

RESULTS

Comparing the hazard and matched control periods within individuals demonstrated that dental procedures were not associated with an increased risk of PVO (OR 0.81 [95% CI 0.72 to 0.92]; p < 0.001). Additional analysis stratified by antibiotic prophylaxis use showed that antibiotic prophylaxis was not associated with a lower OR of developing PVO after dental procedures (with antibiotic prophylaxis: OR 1.11 [95% CI 0.93 to 1.32]; p < 0.26, without antibiotic prophylaxis: OR 0.72 [95% CI 0.63 to 0.83]; p < 0.001). Our sensitivity analyses, in which the exposure assessment interval was extended from 4 to 8 or 12 weeks and exposure was stratified by whether the dental procedure was invasive, demonstrated results that were consistent with our main analysis.

CONCLUSION

Dental procedures were not associated with an increased risk of subsequent PVO in this case-crossover study. The effectiveness of antibiotic prophylaxis was not demonstrated in the additional analysis that categorized exposure according to the use of antibiotic prophylaxis. Our results suggest that the association between dental procedures and PVO may have been overestimated. Maintaining good oral hygiene may be important in preventing the development of PVO. The indications for antibiotic prophylaxis before dental procedures should be reconsidered in view of the potential risk of adverse drug reactions to antibiotic prophylaxis and the emergence of drug-resistant pathogens. Larger randomized controlled trials are needed to confirm these findings and assess the role of antibiotic prophylaxis.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Association of air pollution exposure and increased coronary artery disease risk: the modifying effect of genetic susceptibility

BACKGROUND

Both genetic factors and air pollution are risk factors for coronary artery disease (CAD), but their combined effects on CAD are uncertain. The study aimed to comprehensively investigate their separate, combined and interaction effects on the onset of CAD.

METHODS

We utilized data from the UK Biobank with a recruitment of 487,507 participants who were free of CAD at baseline from 2006 to 2010. We explored the separate, combined effect or interaction association among genetic factors, air pollution and CAD with the polygenic risk score (PRS) and Cox proportional hazard models.

RESULTS

The hazard ratios (HRs) [95% confidence interval (CI)] of CAD for 10-µg/m3 increases in PM2.5, NO2 and NOx concentrations were 1.25 (1.09, 1.44), 1.03 (1.01, 1.05) and 1.01 (1.00, 1.02), respectively. Participants with high PRS and air pollution exposure had a higher risk of CAD than those with the low genetic risk and low air pollution exposure, and the HRs (95% CI) of CAD in the PM2.5, PM10, NO2 and NOx high joint exposure groups were 1.56 (1.48, 1.64), 1.55(1.48, 1.63), 1.57 (1.49, 1.65), and 1.57 (1.49, 1.65), respectively. Air pollution and genetic factors exerted significant additive effects on the development of CAD (relative excess risk due to the interaction [RERI]: 0.12 (0.05, 0.19) for PM2.5, 0.17 (0.10, 0.24) for PM10, 0.14 (0.07, 0.21) for NO2, and 0.17 (0.10, 0.24) for NOx; attributable proportion due to the interaction [AP]: 0.09 (0.04, 0.14) for PM2.5, 0.12 (0.07, 0.18) for PM10, 0.11 (0.06, 0.16) for NO2, and 0.13 (0.08, 0.18) for NOx).

CONCLUSION

Exposure to air pollution was significantly related to an increased CAD risk, which could be further strengthened by CAD gene susceptibility. Additionally, there were positive additive interactions between genetic factors and air pollution on the onset of CAD. This can provide a more comprehensive, precise and individualized scientific basis for the risk assessment, prevention and control of CAD.

PM2.5 exposure increases the risk of preterm birth in pre-pregnancy impaired fasting glucose women: A cohort study in a Southern province of China

Previous studies have indicated maternal exposure to particles with aerodynamic diameter <2.5 μm (PM_2.5) is associated with preterm birth (PTB). However, no study has investigated this effect in pre-pregnancy impaired fasting glucose (IFG) women. This study aimed to differentiate the effects of maternal PM_2.5 exposure on PTB between pre-pregnancy IFG and normoglycemia women, and to further identify the susceptible window. This cohort study was conducted between January 2014 and December 2017 in 21 Chinese cities. All the recruited women received pre-pregnancy fasting serum glucose (FSG) tests and were followed up for their delivery outcomes. The PM_2.5 exposures were estimated by the daily air pollution concentrations of the nearby monitors. Women with FSG below 7.0 mmol/L were included in the analysis. We employed the Cox proportional hazards models to examine whether PM_2.5 exposure was associated with PTB. 237957 women were included and 7055 (3.0%) of them were pre-pregnancy IFG. During the entire pregnancy, we found 24.1% (HR = 1.241; 95% CI: 1.069, 1.439), 61.8% (HR = 1.618; 95% CI: 1.311, 1.997) and 18.6% (HR = 1.186; 95% CI: 1.004, 1.402) of increases in risk for all PTB, early PTB (20-33 gestational weeks) and late PTB (34-36 gestational weeks) among the pre-pregnancy IFG women, and 15.9% (HR = 1.159; 95% CI: 1.127, 1.192), 33.9% (HR = 1.339; 95% CI: 1.255, 1.430) and 13.2% (HR = 1.132; 95% CI: 1.098, 1.168) of increases in risk for all PTB, early PTB and late PTB among the normoglycemia women, with each 10 μg/m³ increment of PM_2.5 exposure, respectively. Furthermore, PM_2.5 exposure had the strongest effect on all PTB during trimester 1 (0-12 gestational weeks) among the pre-pregnancy IFG women, compared with the less strong effect during trimester 1 among the normoglycemia women. In conclusion, pre-pregnancy IFG increases the risk of PTB attributed to PM_2.5, especially during trimester 1. Moreover, the effects of PM_2.5 are greater on early PTB than late PTB for both pre-pregnancy IFG and normoglycemia women.

Isa WYH. An Evaluation of the Role of Oxidative Stress in Non-Obstructive Coronary Artery Disease

Approximately half of all women presenting to the emergency department with angina chest pain do not have obstructive coronary artery disease (CAD) on coronary angiography. This condition is termed non-obstructive coronary artery disease (NOCAD), and includes ischemia with no obstructive coronary artery disease (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Oxidative stress has been reported to be involved in the development and progression of CAD. However, a scarcity of studies has assessed a correlation between oxidative stress and NOCAD. Thus, a literature review was performed of available reports on the role of oxidative stress in NOCAD. Possible mechanisms involved in oxidative stress that may contribute to NOCAD were identified and evaluated. A key finding of this literature review was that oxidative stress caused vasoconstriction and endothelial damage, and this results in coronary microvascular dysfunction and vasospasm, which, in turn, lead to the pathogenesis of NOCAD.

Resources for cardiovascular healthcare associated with 30-day mortality in acute myocardial infarction with cardiogenic shock

Aims

Although primary percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS), such as extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pumping (IABP), have been widely used for acute myocardial infarction (AMI) patients with cardiogenic shock (AMICS), their in-hospital mortality remains high. This study aimed to investigate the association of cardiovascular healthcare resources with 30-day mortality in AMICS.

Methods and results

This was an observational study using a Japanese nationwide administrative data (JROAD-DPC) of 260 543 AMI patients between April 2012 and March 2018. Of these, 45 836 AMICS patients were divided into three categories based on MCS use: with MCS (ECMO with/without IABP), IABP only, or without MCS. Certified hospital density and number of board-certified cardiologists were used as a metric of cardiovascular healthcare resources. We estimated the association of MCS use, cardiovascular healthcare resources, and 30-day mortality. The 30-day mortality was 71.2% for the MCS, 23.9% for IABP only, and 37.8% for the group without MCS. The propensity score-matched and inverse probability-weighted Cox frailty models showed that primary PCI was associated with a low risk for mortality. Higher hospital density and larger number of cardiologists in the responsible hospitals were associated with a lower risk for mortality.

Conclusion

Although the 30-day mortality remained extremely high in AMICS, indication of primary PCI and improvement in providing cardiovascular healthcare resources associated with the short-term prognosis of AMICS.

Higher ambient nitrogen dioxide is associated with an elevated risk of hospital-acquired acute kidney injury

BACKGROUND

Previous studies have suggested that long-term exposure to air pollution increases the risk of chronic kidney disease and its progression. However, the effect of air pollution on the risk of acute kidney injury (AKI) has not been studied. We aim to evaluate the transient effect of air pollution on the risk of hospital-acquired AKI (HA-AKI).

METHODS

We selected from the Epidemiology of AKI in Chinese Hospitalized patients cohort AKI cases in which the onset date could be unambiguously determined. We obtained city-specific daily averages of the ambient level of particulate matter (2.5 μm and 10 μm), carbon monoxide, nitrogen dioxide (NO₂), sulfur dioxide (SO₂) and ozone (O₃) from the Ministry of Environmental Protection of China. We used the time-stratified case-crossover approach to examine the association between the ambient level of air pollutants and the risk of HA-AKI in the selected cases.

RESULTS

A total of 11 293 AKI cases that met the inclusion and exclusion criteria were selected. In univariable analysis, the ambient levels of NO₂ and SO₂ were significantly associated with the risk of HA-AKI. In the multivariable analysis that incorporated all six pollutants in the same model, NO₂ was the sole pollutant whose level remained associated with the risk of AKI (P < 0.001). The relationship between the level of NO₂ and the risk of HA-AKI appeared to be linear, with an estimated odds ratio of 1.063 (95% confidence interval 1.026-1.101) for each increment of 1 median absolute deviation in the exposure. The association was consistent across the subgroups stratified by age, gender, baseline estimated glomerular filtration rate, AKI severity, need for intensive care and season.

CONCLUSIONS

Higher ambient levels of NO₂ are associated with an increased risk of HA-AKI in hospitalized adults in China.

Association of short term exposure to Asian dust with increased blood pressure

Air pollution causes hypertension, cardiovascular disease, and mortality. Asian dust (AD) reportedly induces asthma or acute myocardial infarction along with air pollution, but its impact on blood pressure (BP) is unknown. We investigated the association between short-term AD exposure and BP fluctuations in 300,952 individuals whose BP was measured during April 2005–March 2015 and divided them into AD and non-AD groups based on visitation for AD-related events. AD’s occurrence, air pollutants’ concentration (suspended particulate matter, SO₂, NO₂, photochemical oxidants), and meteorological variables (mean ambient temperature, relative humidity) were obtained from a monitoring station; AD events correlated with decreased visibility (< 10 km). We observed 61 AD days, with 3897 participants undergoing medical check-ups. Short-term AD exposure at lag day-0 was significantly associated with higher systolic BP (SBP), diastolic BP (DBP), and pulse rate (PR) risk (β = 1.85, 95% confidence interval (CI) 1.35–2.35 for SBP, β = 2.24, 95% CI 1.88–2.61 for DBP, β = 0.52, 95% CI 0.14–0.91 for PR) using multi-pollutant model. Population-attributable fractions exposed to AD were 11.5% for those with elevated SBP (SBP ≥ 120 mmHg) and 23.7% for those with hypertension (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg). This study showed a strong association between short-term AD exposure and increased SBP and DBP.