The impact of short-term exposure to air pollutants on the onset of out-of-hospital cardiac arrest: A systematic review and meta-analysis

New evidence on the nephrotoxicity of fine particulate matter: Potential toxic components from different emission sources

Associations exist between fine particulate matter (PM2.5) exposure and impaired kidney function. However, the specific mechanisms and components causing renal damage remain unclear. PM2.5 was collected from an industrial and a rural area. Mice were categorized according to exposure, and biochemical, western blotting, histological, and immunohistochemical analyses were performed to evaluate the impact of PM2.5 constituents on their kidneys. To assess the impact of different PM2.5 components on inflammatory responses, a study was conducted by exposing the murine macrophage cell line (RAW 264.7). The study used a chelating resin to remove the influence of heavy metals from the water extract and employed a Toll-like receptor 4 (TLR4) antagonist to eliminate the effects of endotoxin, thereby evaluating the cellular inflammatory responses induced by various PM2.5 components. The major metallic elements at the industrial site were Fe, Mg, Zn, and Ca, whereas those at site Rural were Ca, K, and Mg. PM2.5 water extracts from both sites induced inflammatory cytokine upregulation in the lungs and kidneys, and inflammatory cell infiltration, antioxidant activity downregulation, and elevated levels of kidney injury molecule 1 in the kidneys. Exposure to PM2.5 water extract increased the mRNA levels of tumor necrosis factor-α, interleukin-6, and nitrite production in RAW264.7 macrophages. The inflammatory response and nitrite production induced by the industrial-site PM2.5 water extract were significantly suppressed after treatment with a chelating resin, whereas those from the rural area were suppressed by the Toll-like receptor 4 (TLR4) antagonist. These results suggest that heavy metals are crucial factors in PM2.5-induced cellular inflammatory responses in industrial areas, whereas endotoxin receptor--TLR4 mediated inflammatory pathways are the primary factor responsible for this response in rural areas. Furthermore, at equivalent dosages, the renal toxicity induced by the water-soluble components of rural-site PM2.5 may exceed that from industrial areas.

Impact of Extreme Temperature and Particulate Matter 2.5 on Outcomes of Out-of-Hospital Cardiac Arrest

BACKGROUND

Extreme temperature and particulate matter-2.5 (PM2.5) are known to affect the outcomes of out-of-hospital cardiac arrest (OHCA). However, studies that examine their effects at the exact time of OHCA occurrence are limited.

OBJECTIVE

This study aimed to investigate the impact of extreme cold, extreme heat, and PM2.5 on OHCA outcomes at the time of occurrence.

METHODS

We analyzed data from 82,497 OHCAs (aged > 18 years) in South Korea between January 2016 and December 2021. Extreme temperatures were defined as extreme cold (≤5th percentile) and extreme heat (≥95th percentile). PM2.5 refers to particulate matter ≤ 2.5 micrometers, with extreme PM2.5 defined as ≥95th percentile. The outcomes were survival to discharge and good neurological outcome, defined as a cerebral performance category of 1 or 2 at hospital discharge. We performed a multivariable logistic regression analysis to assess the impact of extreme temperature and PM2.5 on OHCA outcomes.

RESULTS

Extreme cold (-4.2°C to -20.2°C) showed no association with OHCA outcomes when compared to normal conditions (-0.9°C to 26.6°C). However, OHCAs during extreme heat (28.7°C to 39.3°C) showed a 15% significantly lower probability of survival to discharge (adjusted odds ratio [aOR]: 0.85, 95% confidence interval (CI): 0.74-0.98) compared to normal conditions. OHCAs during extreme PM2.5 (56 to 218 µg/m³) were associated with 14% lower probability of survival to discharge (aOR: 0.86, 95% CI: 0.75-0.99) compared to normal PM2.5 (0 to 43 µg/m³).

CONCLUSION

Extreme heat and PM2.5 were significantly associated with a decreased probability of survival to discharge in OHCA patients.

Effects of air pollution on global health: evidence from the global burden of disease study in the BRICS countries

PURPOSE

Considering the dynamic influence of environmental, social, economic, and political factors in the emergence and growth of the BRICS countries (Brazil, Russia, India, China, and South Africa) over the years and pre-existing differences, the adverse effects of air pollution on the health and well-being of the people have remained major areas of academic inquiry and policy interventions. The present study examines the global trend of deaths and Disability Adjusted Life Years (DALYs) attributable to air pollution with particular reference to the BRICS countries for the period 1990 to 2019.

METHODS

This study has used the global burden of disease estimates by using different rounds of the Global Burden of Disease (GBD) study report published by the Institute of Health Metrics Evaluation. This study has calculated the cause of death and DALYs due to environmental risk factors (i.e. Air pollution). Data analysis has been done by using the standard formula for the calculation of death (mortality) rate and DALYs rate. Similarly, we calculated the age and gender-wise death and DALYs rate by using the appropriate numerator and denominator.

RESULTS

The study discovered a significant shift in disease patterns over this period, as communicable diseases like respiratory infections and tuberculosis were replaced by non-communicable diseases such as ischemic heart disease (17.2 million), chronic obstructive pulmonary disease (14.59 million), and stroke (17.02 million) as the primary causes of air pollution-related deaths in 2019 at the global level. Additionally, the study identified a worrying increase in deaths linked to neonatal disorders and respiratory infections caused by ambient particulate matter pollution in South Africa, India, and Brazil. The impact of air pollution on public health is evident across different age groups and genders, with people aged 50-69 years, those aged 70 and above, and children under 5 years being more vulnerable. Furthermore, the male population is disproportionately affected by communicable and noncommunicable diseases caused by air pollution.

CONCLUSION

The study highlights the need for policymakers to implement evidence-based interventions to tackle this global health problem. The interventions should aim to reduce the emerging crisis of non-communicable diseases related to air pollution, particularly among vulnerable age groups and the male population, ultimately improving public health outcomes.

Air Pollution and Cardiac Arrest: A More Significant Intermediate Role of COPD than Cardiac Events

No prior studies have linked long-term air pollution exposure to incident sudden cardiac arrest (SCA) or its possible development trajectories. We aimed to investigate the association between long-term exposure to air pollution and SCA, as well as possible intermediate diseases. Based on the UK Biobank cohort, Cox proportional hazard model was applied to explore associations between air pollutants and SCA. Chronic obstructive pulmonary disease (COPD) and major adverse cardiovascular events (MACE) were selected as intermediate conditions, and multistate model was fitted for trajectory analysis. During a median follow-up of 13.7 years, 2884 participants developed SCA among 458 237 individuals. The hazard ratios (HRs) for SCA were 1.04-1.12 per interquartile range increment in concentrations of fine particulate matter, inhalable particulate matter, nitrogen dioxide, and nitrogen oxides. Most prominently, air pollutants could induce SCA through promoting transitions from baseline health to COPD (HRs: 1.06-1.24) and then to SCA (HRs: 1.16-1.27). Less importantly, SCA could be developed through transitions from baseline health to MACE (HRs: 1.02-1.07) and further to SCA (HRs: 1.12-1.16). This study provides novel and compelling evidence that long-term exposure to air pollution could promote the development of SCA, with COPD serving as a more important intermediate condition than MACE.

Does PM 2.5 and PM 10-associated heavy metals affect short-term and long-term survival after out-of-hospital cardiac arrest? Four-year study based on regional registry

BACKGROUND

This study aims to investigate the effect of arsenic (As), cadmium (Cd), nickel (Ni) and lead (Pb) suspended on particulate matters (PM) 2.5 and PM 10 taking into account clinical factors on 30-day and one-year survival after out-of-hospital cardiac arrest (OHCA).

METHODS

A retrospective 4-year study that involved patients hospitalized after OHCA. Patients' data were obtained from Emergency Medical Services dispatch cards and the National Health Fund. The concentration of air pollutants was measured by the Environmental Protection Inspectorate in Poland.

RESULTS

Among the 948 patients after OHCA, only 225 (23.7%) survived for 30 days, and 153 (16.1%) survived for 1 year. Survivors were more commonly affected by OHCA in urban areas (85 [55.6%] vs. 355 [44.7%]; P=0.013) and had slightly higher one-year mean concentration of As (0.78 vs. 0.77; P=0.01), Cd (0.34 vs. 0.34; P=0.012), and Pb (11.13 vs. 10.20; P=0.015) with no differences in daily mean concentration. Significant differences in mean concentrations of heavy metals and PM 2.5 and PM 10 were observed among different quarters. However, survival analysis revealed no differences in long-term survival between quarters. Heavy metals, PM 2.5, and PM 10 did not affect short-term and long-term survival in multivariable logistic regression.

CONCLUSIONS

The group of survivors showed slightly higher mean one-year concentrations of As, Cd and Pb, but they also experienced a higher incidence of OHCA in urban areas. There were no differences in long-term survival between patients who suffer OHCA in different quarters. Heavy metals did not independently affect survival.

Air Pollution and Temperature: a Systematic Review of Ubiquitous Environmental Exposures and Sudden Cardiac Death

PURPOSE OF REVIEW

Environmental exposures have been associated with increased risk of cardiovascular mortality and acute coronary events, but their relationship with out-of-hospital cardiac arrest (OHCA) and sudden cardiac death (SCD) remains unclear. SCD is an important contributor to the global burden of cardiovascular disease worldwide.

RECENT FINDINGS

Current literature suggests a relationship between environmental exposures and cardiovascular disease, but their relationship with OHCA/SCD remains unclear. A literature search was conducted in PubMed, Embase, Web of Science, and Global Health. Of 5138 studies identified by our literature search, this review included 30 studies on air pollution, 42 studies on temperature, 6 studies on both air pollution and temperature, and 1 study on altitude exposure and OHCA/SCD. Particulate matter air pollution, ozone, and both hot and cold temperatures are associated with increased risk of OHCA/SCD. Pollution and other exposures related to climate change play an important role in OHCA/SCD incidence.

Antagonism between ambient ozone increase and urbanization-oriented population migration on Chinese cardiopulmonary mortality

Ever-increasing ambient ozone (O3) pollution in China has been exacerbating cardiopulmonary premature deaths. However, the urban-rural exposure inequity has seldom been explored. Here, we assess population-scale O3 exposure and mortality burdens between 1990 and 2019 based on integrated pollution tracking and epidemiological evidence. We find Chinese population have been suffering from climbing O3 exposure by 4.3 ± 2.8 ppb per decade as a result of rapid urbanization and growing prosperity of socioeconomic activities. Rural residents are broadly exposed to 9.8 ± 4.1 ppb higher ambient O3 than the adjacent urban citizens, and thus urbanization-oriented migration compromises the exposure-associated mortality on total population. Cardiopulmonary excess premature deaths attributable to long-term O3 exposure, 373,500 (95% uncertainty interval [UI]: 240,600-510,900) in 2019, is underestimated in previous studies due to ignorance of cardiovascular causes. Future O3 pollution policy should focus more on rural population who are facing an aggravating threat of mortality risks to ameliorate environmental health injustice.

Short-Term Ambient Air Pollution Exposure and Risk of Out-of-Hospital Cardiac Arrest in Sweden: A Nationwide Case-Crossover Study

Background Air pollution is one of the main risk factors for cardiovascular disease globally, but its association with out-of-hospital cardiac arrest at low air pollution levels is unclear. This nationwide study in Sweden aims to investigate if air pollution is associated with a higher risk of out-of-hospital cardiac arrest in an area with relatively low air pollution levels. Methods and Results This study was a nationwide time-stratified case-crossover study investigating the association between short-term air pollution exposures and out-of-hospital cardiac arrest using data from the SRCR (Swedish Registry for Cardiopulmonary Resuscitation) between 2009 and 2019. Daily air pollution levels were estimated in 1×1-km grids for all of Sweden using a satellite-based machine learning model. The association between daily air pollutant levels and out-of-hospital cardiac arrest was quantified using conditional logistic regression adjusted for daily air temperature. Particulate matter <2.5 μm exposure was associated with a higher risk of out-of-hospital cardiac arrest among a total of 29 604 cases. In a multipollutant model, the association was most pronounced for intermediate daily lags, with an increased relative risk of 6.2% (95% CI, 1.0-11.8) per 10 μg/m3 increase of particulate matter <2.5 μm 4 days before the event. A similar pattern of association was observed for particulate matter <10 μm. No clear association was observed for O3 and NO2. Conclusions Short-term exposure to air pollution was associated with higher risk of out-of-hospital cardiac arrest. The findings add to the evidence of an adverse effect of particulate matter on out-of-hospital cardiac arrest, even at very low levels below current regulatory standards.

Application of smart devices in investigating the effects of air pollution on atrial fibrillation onset

Few studies have examined the link between short-term exposure to air pollutants and atrial fibrillation (AF) episodes. This study aims to examine the association of hourly criteria air pollutants with AF episodes. We employ a smart device-based photoplethysmography technology to screen AF from 2018 to 2021. Hourly concentrations of six criteria air pollutants are matched to the onset hour of AF for each participant. We adopt a time-stratified case-crossover design to capture the acute effects of air pollutants on AF episodes, using conditional logistic regression models. Subgroup analyses are conducted by age, gender, and season. A total of 11,906 episodes of AF are identified in 2976 participants from 288 Chinese cities. Generally, the strongest associations of air pollutants are present at lag 18-24 h, with positive and linear exposure-response relationships. For an interquartile range increase in inhalable particles, fine particles, nitrogen dioxide, and carbon monoxide, the odds ratio (OR) of AF is 1.19 [95% confidential interval (CI): 1.03, 1.37], 1.38 (95%CI: 1.14, 1.67), 1.60 (95%CI: 1.16, 2.20) and 1.48 (95%CI: 1.19, 1.84), respectively. The estimates are robust to the adjustment of co-pollutants, and they are larger in females, older people, and in cold seasons. There are insignificant associations for sulfur dioxide and ozone. This nationwide case-crossover study demonstrates robust evidence of significant associations between hourly exposure to air pollutants and the onset of AF episodes, which underscores the importance of ongoing efforts to further improve air quality as an effective target for AF prevention.

Cell-free circulating mitochondrial DNA: An emerging biomarker for airborne particulate matter associated with cardiovascular diseases

The association of airborne particulate matter exposure with the deteriorating function of the cardiovascular system is fundamentally driven by the impairment of mitochondrial-nuclear crosstalk orchestrated by aberrant redox signaling. The loss of delicate balance in retrograde communication from mitochondria to the nucleus often culminates in the methylation of the newly synthesized strand of mitochondrial DNA (mtDNA) through DNA methyl transferases. In highly metabolic active tissues such as the heart, mtDNA's methylation state alteration impacts mitochondrial bioenergetics. It affects transcriptional regulatory processes involved in biogenesis, fission, and fusion, often accompanied by the integrated stress response. Previous studies have demonstrated a paradoxical role of mtDNA methylation in cardiovascular pathologies linked to air pollution. A pronounced alteration in mtDNA methylation contributes to systemic inflammation, an etiological determinant for several co-morbidities, including vascular endothelial dysfunction and myocardial injury. In the current article, we evaluate the state of evidence and examine the considerable promise of using cell-free circulating methylated mtDNA as a predictive biomarker to reduce the more significant burden of ambient air pollution on cardiovascular diseases.

The Effect of Sustained Poor Air Quality on EMS Call Volume and Characteristics: A Time-Stratified Case-Crossover Study

OBJECTIVES

As wildfires and air pollution become more common across the United States, it is increasingly important to understand the burden they place on public health. Previous studies have noted relationships between air quality and use of Emergency Medical Services (EMS), but until now, these studies have focused on day-to-day air quality. The goal of this study is to investigate the effect of sustained periods of poor air quality on EMS call characteristics and volume.

METHODS

Using a time-stratified case-crossover design, the effect of exposure to periods of poor air quality on number and type of EMS calls in California, USA from 2014-2019 was observed. Poor air quality periods greater than three days were identified at the United States Environmental Protection Agency's (EPA's) Air Quality Index (AQI) levels of Unhealthy for Sensitive Groups (AQI 100) and Unhealthy (AQI 150). Periods less than three days apart were combined. Each poor air quality period was matched with two one-week controls, the first being the closest preceding week that did not intersect a different case. The second control was the closest week at least three days after the case and not intersecting with a different case. Due to seasonal variation in EMS usage, from the initial cases, cases were used only if it was possible to identify controls within 28 days of the case. A conditional Poisson regression calculated risk ratios for EMS call volume.

RESULTS

Comparing the case periods to the controls, significant increases were found at AQI >100 for total number of calls, and the primary impressions categories of emotional state or behavior, level of consciousness, no patient complaint, other, respiratory, and abdominal. At an AQI >150, significance was found for the primary impressions categories of other, pain, respiratory, and digestive.

CONCLUSION

These data demonstrate increased EMS calls during sustained poor air quality, and that several EMS primary impression categories are disproportionately affected. This study is limited by the imprecision of the primary impression's classification provided by the EMS clinician responding to the EMS call. More research is needed to understand the effects of periods of poor air quality on the EMS system for more efficient deployment of resources.

Impact of Air Pollution and COVID-19 Infection on Periprocedural Death in Patients with Acute Coronary Syndrome

Air pollution and COVID-19 infection affect the pathogenesis of cardiovascular disease. The impact of these factors on the course of ACS treatment is not well defined. The purpose of this study was to evaluate the effects of air pollution, COVID-19 infection, and selected clinical factors on the occurrence of perioperative death in patients with acute coronary syndrome (ACS) by developing a neural network model. This retrospective study included 53,076 patients with ACS from the ORPKI registry (National Registry of Invasive Cardiology Procedures) including 2395 COVID-19 (+) patients and 34,547 COVID-19 (-) patients. The neural network model developed included 57 variables, had high performance in predicting perioperative patient death, and had an error risk of 0.03%. Based on the analysis of the effect of permutation on the variable, the variables with the greatest impact on the prediction of perioperative death were identified to be vascular access, critical stenosis of the left main coronary artery (LMCA) or left anterior descending coronary artery (LAD). Air pollutants and COVID-19 had weaker effects on end-point prediction. The neural network model developed has high performance in predicting the occurrence of perioperative death. Although COVID-19 and air pollutants affect the prediction of perioperative death, the key predictors remain vascular access and critical LMCA or LAD stenosis.

Air Pollution and the Heart: Updated Evidence from Meta-analysis Studies

PURPOSE OF REVIEW

Although environmental exposure such as air pollution is detrimental to cardiovascular disease (CVD), the effects of different air pollutants on different CVD endpoints produced variable findings. We provide updated evidence between air pollutants and CVD outcomes including mitigation strategies with meta-analytic evidence.

RECENT FINDINGS

An increased exposure to any class of air pollutants including particulate matter (PM), gas, toxic metals, and disruptive chemicals has been associated with CVD events. Exposure to PM < 2.5 μm has been consistently associated with most heart diseases and stroke as well as CVDs among at-risk individuals. Despite this, there is no clinical approach available for systemic evaluation of air pollution exposure and management. A large number of epidemiological evidence clearly suggests the importance of air pollution prevention and control for reducing the risk of CVDs and mortality. Cost-effective and feasible strategies for air pollution monitoring, screening, and necessary interventions are urgently required among at-risk populations and those living or working, or frequently commuting in polluted areas.

Ambient air pollutants and respiratory health outcomes in Tabriz and Urmia, two metropolises of Iran

Polluted air affects human life and it is crucial to assess air pollutants to inform policy and protect human lives. In this study, we sought to assess the respiratory outcomes associated with PM₁₀, O₃, SO₂, and NO₂ in the Iranian population. The required data, which included concentrations of air pollutants, meteorology, and population size, were obtained from the department of environment and meteorological organizations. The validity of the data was evaluated, and appropriate calculations were conducted on the data to extract the required values and parameters for modeling (using the AirQ2.2.3). This study was conducted in two megacities of Iran (Tabriz and Urmia) with over 2 million population. The annual averages of SO₂, NO₂, and PM₁₀ concentrations were 9, 73, and 43 μg/m³ in Tabriz and 76, 29, and 76 μg/m³ in Urmia, respectively. Excess deaths from respiratory diseases associated with PM₁₀ and SO₂ were estimated to be 33.1 and 1.2 cases in Tabriz and 31.6 and 24.7 cases in Urmia, respectively. The proportions of hospitalizations for chronic obstructive pulmonary disease (COPD) attributable to SO₂ and NO₂ in Tabriz were 0.07% and 1.61%, respectively, whereas they were 2.84% and 0.48% in Urmia. O₃ had an annual average of 56 μg/m³ in Tabriz and with 44.5 excess respiratory deaths and 42.5 excess hospital admissions for COPD, it had the greatest health impacts among the pollutants studied. Findings from this study add to the growing literature, especially from developing countries, that provides insights to help authorities and decision-makers develop and implement effective interventions to curb air pollution and save lives.

Short-term effects of exposure to ambient PM1, PM2.5, and PM10 on ischemic and hemorrhagic stroke incidence in Shandong Province, China

BACKGROUND

Short-term exposure to ambient PM_2.5 and PM₁₀ is associated with increased risk of mortality and hospital admissions for stroke. However, there is less evidence regarding the effect of exposure to PM₁ on stroke incidence. We estimated the incidence risk of stroke and the attributable fractions related to short-term exposure to ambient PM₁, PM_2.5 and PM₁₀ in China.

METHODS

County-specific incidence of stroke was obtained from health statistics in years 2014-2019. We linked county-level mean daily concentrations of PM₁, PM_2.5 and PM₁₀ with stroke incidence. We used the time stratified case-crossover design to estimate the associations between stroke incidence and exposure to PM₁, PM_2.5 and PM₁₀. We also estimated the disease burden fractions attributable to PM₁, PM_2.5, and PM₁₀.

RESULTS

The study included a total of 2,193,954 stroke, from which 1,861,331 were ischemic and 332,623 were hemorrhagic stroke. PM₁, PM_2.5, and PM₁₀ levels were associated with increased risks of total stroke and ischemic stroke at when assessing the associations in exposure at lag0-4 days. The increase of 10 μg/m³ in PM₁, PM_2.5, and PM₁₀ was associated with total stroke, and the relative risks were 1.012 (95% confidence interval: 1.008, 1.015), 1.006 (1.004, 1.007) and 1.003 (1.002, 1.004), while the associations with ischemic stroke were 1.013 (1.010, 1.017), 1.006 (1.005, 1.008) and 1.003 (1.002, 1.004), respectively. There was no significant association between PM and risk of hemorrhagic stroke. The attributable fractions of total stroke were 6.9% (5.1%, 8.5%), 5.6% (4.2%, 6.8%) and 5.6% (3.9%, 7.1%) for PM₁, PM_2.5, and PM₁₀, respectively.

CONCLUSIONS

PM₁ showed a stronger association with stroke, with a larger attributable fraction of outcomes, than PM_2.5 and PM₁₀. Clean air policies should target the whole scope of PM, including PM₁.

Spatial Resolved Surface Ozone with Urban and Rural Differentiation during 1990-2019: A Space-Time Bayesian Neural Network Downscaler

Long-term exposure to ambient ozone (O₃) can lead to a series of chronic diseases and associated premature deaths, and thus population-level environmental health studies hanker after the high-resolution surface O₃ concentration database. In response to this demand, we innovatively construct a space-time Bayesian neural network parametric regressor to fuse TOAR historical observations, CMIP6 multimodel simulation ensemble, population distributions, land cover properties, and emission inventories altogether and downscale to 10 km × 10 km spatial resolution with high methodological reliability (R² = 0.89-0.97, RMSE = 1.97-3.42 ppbV), fair prediction accuracy (R² = 0.69-0.77, RMSE = 5.63-7.97 ppbV), and commendable spatiotemporal extrapolation capabilities (R² = 0.62-0.76, RMSE = 5.38-11.7 ppbV). Based on our predictions in 8-h maximum daily average metric, the rural-site surface O₃ are 15.1±7.4 ppbV higher than urban globally averaged across 30 historical years during 1990-2019, with developing countries being of the most evident differences. The globe-wide urban surface O₃ are climbing by 1.9±2.3 ppbV per decade, except for the decreasing trends in eastern United States. On the other hand, the global rural surface O₃ tend to be relatively stable, except for the rising tendencies in China and India. Using CMIP6 model simulations directly without urban-rural differentiation will lead to underestimations of population O₃ exposure by 2.0±0.8 ppbV averaged over each historical year. Our original Bayesian neural network framework contributes to the deep-learning-driven environmental studies methodologically by providing a brand-new feasible way to realize data fusion and downscaling, which maintains high interpretability by conforming to the principles of spatial statistics without compromising the prediction accuracy. Moreover, the 30-year highly spatial resolved monthly surface O₃ database with multiple metrics fills in the literature gap for long-term surface O₃ exposure tracing.

Ambient air pollution and cardiovascular diseases: An umbrella review of systematic reviews and meta-analyses

The available evidence on the effects of ambient air pollution on cardiovascular diseases (CVDs) has increased substantially. In this umbrella review, we summarized the current epidemiological evidence from systematic reviews and meta-analyses linking ambient air pollution and CVDs, with a focus on geographical differences and vulnerable subpopulations. We performed a search strategy through multiple databases including articles between 2010 and 31 January 2021. We performed a quality assessment and evaluated the strength of evidence. Of the 56 included reviews, the most studied outcomes were stroke (22 reviews), all-cause CVD mortality, and morbidity (19). The strongest evidence was found between higher short- and long-term ambient air pollution exposure and all-cause CVD mortality and morbidity, stroke, blood pressure, and ischemic heart diseases (IHD). Short-term exposures to particulate matter <2.5 μm (PM2.5 ), <10 μm (PM10 ), and nitrogen oxides (NOx ) were consistently associated with increased risks of hypertension and triggering of myocardial infarction (MI), and stroke (fatal and nonfatal). Long-term exposures of PM2.5 were largely associated with increased risk of atherosclerosis, incident MI, hypertension, and incident stroke and stroke mortality. Few reviews evaluated other CVD outcomes including arrhythmias, atrial fibrillation, or heart failure but they generally reported positive statistical associations. Stronger associations were found in Asian countries and vulnerable subpopulations, especially among the elderly, cardiac patients, and people with higher weight status. Consistent with experimental data, this comprehensive umbrella review found strong evidence that higher levels of ambient air pollution increase the risk of CVDs, especially all-cause CVD mortality, stroke, and IHD. These results emphasize the importance of reducing the alarming levels of air pollution across the globe, especially in Asia, and among vulnerable subpopulations.

Cohort-based long-term ozone exposure-associated mortality risks with adjusted metrics: A systematic review and meta-analysis

Long-term ozone (O3) exposure may lead to non-communicable diseases and increase mortality risk. However, cohort-based studies are relatively rare, and inconsistent exposure metrics impair the credibility of epidemiological evidence synthetization. To provide more accurate meta-estimations, this study updates existing systematic reviews by including recent studies and summarizing the quantitative associations between O3 exposure and cause-specific mortality risks, based on unified exposure metrics. Cross-metric conversion factors were estimated linearly by decadal observations during 1990-2019. The Hunter-Schmidt random-effects estimator was applied to pool the relative risks. A total of 25 studies involving 226,453,067 participants (14 unique cohorts covering 99,855,611 participants) were included in the systematic review. After linearly unifying the inconsistent O3 exposure metrics , the pooled relative risks associated with every 10 nmol mol-1 (ppbV) incremental O3 exposure, by mean of the warm-season daily maximum 8-h average metric, were as follows: 1.014 with 95% confidence interval (CI) ranging 1.009-1.019 for all-cause mortality; 1.025 (95% CI: 1.010-1.040) for respiratory mortality; 1.056 (95% CI: 1.029-1.084) for COPD mortality; 1.019 (95% CI: 1.004-1.035) for cardiovascular mortality; and 1.074 (95% CI: 1.054-1.093) for congestive heart failure mortality. Insignificant mortality risk associations were found for ischemic heart disease, cerebrovascular diseases, and lung cancer. Adjustment for exposure metrics laid a solid foundation for multi-study meta-analysis, and widening coverage of surface O3 observations is expected to strengthen the cross-metric conversion in the future. Ever-growing numbers of epidemiological studies supported the evidence for considerable cardiopulmonary hazards and all-cause mortality risks from long-term O3 exposure. However, evidence of long-term O3 exposure-associated health effects was still scarce, so more relevant studies are needed to cover more populations with regional diversity.

Effect modification by sex for associations of fine particulate matter (PM2.5) with cardiovascular mortality, hospitalization, and emergency room visits: systematic review and meta-analysis

Particulate matter with aerodynamic diameter no larger than 2.5 μm (PM2.5) has been linked to cardiovascular diseases (CVDs) but evidence for vulnerability by sex remains unclear. We performed systematic review and meta-analysis to synthesize the state of scientific evidence on whether cardiovascular risks from PM2.5 differ for men compared to women. The databases Pubmed, Scopus, Embase, and GreenFILE were searched for studies published Jan. 1995 to Feb. 2020. Observational studies conducting subgroup analysis by sex for impacts of short-term or long-term exposure to PM2.5 on target CVDs were included. Data were independently extracted in duplicate and pooled with random-effects meta-regression. Risk ratios (RRs) for long-term exposure and percent changes in outcomes for short-term exposure were calculated per 10 μg/m3 PM2.5 increase. Quality of evidence of risk differences by sex was rated following Grading of Recommendations Assessment, Development and Evaluation (GRADE). A total of 12,502 articles were screened, with 61 meeting inclusion criteria. An additional 32 studies were added from citation chaining. RRs of all CVD mortality for long-term PM2.5 for men and women were the same (1.14; 95% CI: 1.09, 1.22) indicating no statistically different risks. Men and women did not have statistically different risks of daily CVD mortality, hospitalizations from all CVD, ischemic heart disease, cardiac arrest, acute myocardial infarction, and heart failure from short-term PM2.5 exposure (difference in % change in risk per 10 μg/m3 PM2.5: 0.04 (95% CI, -0.42 to 0.51); -0.05 (-0.47 to 0.38); 0.17 (-0.90, 1.24); 1.42 (-1.06, 3.97); 1.33 (-0.05, 2.73); and -0.48 (-1.94, 1.01), respectively). Analysis using GRADE found low or very low quality of evidence for sex differences for PM2.5-CVD risks. In conclusion, this meta-analysis and quality of evidence assessment of current observational studies found very limited evidence of the effect modification by sex for effects of PM2.5 on CVD outcomes in adults, which can inform clinical approaches and policies.

The influence of air pollution by PM2.5, PM10 and associated heavy metals on the parameters of out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA), defined as abrupt cessation of mechanical activity of the heart, is one of the most common causes of death in high-income countries. Cardiac arrest is most often a result of severe cardiovascular disease. New evidence shows that air pollutants such as heavy metals and atmospheric particulate matter have an impact on the pathophysiology of many cardiovascular diseases as well on incidences of OHCA. This retrospective analysis includes all OHCA cases that occurred in central Poland covering the area of 11.711 km² with the population density of 108 people per square kilometer. Among 2878 EMS-treated OHCA cases between 2013 and 2016, cardiopulmonary resuscitation (CPR) was attempted in 2076 (72%) patients. Concentrations of air pollutants were compared with temperature, humidity and clinical factors affecting the CPR. The study shows seasonal variation of PM 2.5 (p < 0.001), PM 10 (p < 0.001), As (p < 0.001) and Cd (p < 0.001) over the years. Air pollution has a significant effect on the parameters of pre-hospital evaluation in OHCA patients, especially with respect to the content of PM2.5/PM10 and heavy metals. Nickel exposure affects the incidence of initial shockable rhythm (IRR 0.92; p = 0.01) and effectiveness of CPR (IRR 0.94; p = 0.003). Arsenic has an impact on overall mortality (IRR 1.07; p = 0.01) and death upon the arrival of EMS team (IRR 1.15; p < 0.001). Overall mortality was also related to ambient levels of PM10 (IRR 1.004; p < 0.047).

Out-of-hospital cardiac arrest and ambient air pollution: A dose-effect relationship and an association with OHCA incidence

Background

Pollution has been suggested as a precipitating factor for cardiovascular diseases. However, data about the link between air pollution and the risk of out-of-hospital cardiac arrest (OHCA) are limited and controversial.

Methods

By collecting data both in the OHCA registry and in the database of the regional agency for environmental protection (ARPA) of the Lombardy region, all medical OHCAs and the mean daily concentration of pollutants including fine particulate matter (PM₁₀, PM_2.5), benzene (C₆H₆), carbon monoxide (CO), nitrogen dioxide (NO₂), sulphur dioxide (SO₂), and ozone (O₃) were considered from January 1^st to December 31^st, 2019 in the southern part of the Lombardy region (provinces of Pavia, Lodi, Cremona and Mantua; 7863 km2; about 1550000 inhabitants). Days were divided into high or low incidence of OHCA according to the median value. A Probit dose-response analysis and both uni- and multivariable logistic regression models were provided for each pollutant.

Results

The concentrations of all the pollutants were significantly higher in days with high incidence of OHCA except for O₃, which showed a significant countertrend. After correcting for temperature, a significant dose-response relationship was demonstrated for all the pollutants examined. All the pollutants were also strongly associated with high incidence of OHCA in multivariable analysis with correction for temperature, humidity, and day-to-day concentration changes.

Conclusions

Our results clarify the link between pollutants and the acute risk of cardiac arrest suggesting the need of both improving the air quality and integrating pollution data in future models for the organization of emergency medical services.

Significance between air pollutants, meteorological factors, and COVID-19 infections: probable evidences in India

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease represents the causative agent with a potentially fatal risk which is having great global human health concern. Earlier studies suggested that air pollutants and meteorological factors were considered as the risk factors for acute respiratory infection, which carries harmful pathogens and affects the immunity. The study intended to explore the correlation between air pollutants, meteorological factors, and the daily reported infected cases caused by novel coronavirus in India. The daily positive infected cases, concentrations of air pollutants, and meteorological factors in 288 districts were collected from January 30, 2020, to April 23, 2020, in India. Spearman's correlation and generalized additive model (GAM) were applied to investigate the correlations of four air pollutants (PM2.5, PM10, NO2, and SO2) and eight meteorological factors (Temp, DTR, RH, AH, AP, RF, WS, and WD) with COVID-19-infected cases. The study indicated that a 10 μg/m3 increase during (Lag0-14) in PM2.5, PM10, and NO2 resulted in 2.21% (95%CI: 1.13 to 3.29), 2.67% (95% CI: 0.33 to 5.01), and 4.56 (95% CI: 2.22 to 6.90) increase in daily counts of Coronavirus Disease 2019 (COVID 19)-infected cases respectively. However, only 1 unit increase in meteorological factor levels in case of daily mean temperature and DTR during (Lag0-14) associated with 3.78% (95%CI: 1.81 to 5.75) and 1.82% (95% CI: -1.74 to 5.38) rise of COVID-19-infected cases respectively. In addition, SO2 and relative humidity were negatively associated with COVID-19-infected cases at Lag0-14 with decrease of 7.23% (95% CI: -10.99 to -3.47) and 1.11% (95% CI: -3.45 to 1.23) for SO2 and for relative humidity respectively. The study recommended that there are significant correlations between air pollutants and meteorological factors with COVID-19-infected cases, which substantially explain the effect of national lockdown and suggested positive implications for control and prevention of the spread of SARS-CoV-2 disease.

Public health impact of daily life triggers of sudden cardiac death: A systematic review and comparative risk assessment

BACKGROUND

Sudden cardiac death (SCD) may be triggered by daily circumstances and activities such as stressful psycho-emotional events, physical exertion or substance misuse. We calculated population attributable fractions (PAFs) to estimate the public health relevance of daily life triggers of SCD and to compare their population impacts.

METHODS

We searched PubMed, Scopus and the Web of Science citation databases to retrieve studies of triggers of SCD and cardiac arrest that would enable a computation of PAFs. When more studies investigated the same trigger, a meta-analytical pooled risk random-effect estimate was used.

RESULTS

Of the retrieved studies, eight provided data enabling computation of PAFs. The prevalence of exposure within population for SCD triggers in the control periods ranged from 1.06% for influenza infection to 8.73% for recent use of cannabis. Triggers ordered from the highest to the lowest risk increase were: physical exertion, recent cocaine use, episodic alcohol consumption, recent amphetamine use, episodic coffee consumption, psycho-emotional stress within the previous month, influenza infection, and recent cannabis use. The relative risk increase ranged from 1.10 to 4.98. By accounting for both the magnitude of the risk increase and the prevalence in the population, the present estimates of PAF assign 14.5% (95% confidence interval [CI] 4.9-28.5) of all SCDs to episodic alcohol consumption, 9.4% (95% CI 1.2-29.3) to physical exertion, 6.9% (95% CI 0.3-25.0) to cocaine, 6% (95% CI 1.2-14.6) to episodic coffee consumption, 3% (95% CI 0.4-6.8) to psycho-emotional stress in the previous month, 1.7% (95% CI -0.9 to 12.9) to amphetamines, 0.9% (95% CI -4.9 to 12.5) to cannabis, and 0.3% (95% CI 0.2-0.4) to influenza infections.

CONCLUSIONS

In addition to episodic alcohol consumption, a trigger with the greatest public health importance for SCD, episodic physical exertion, cocaine use and coffee consumption also show a considerable population impact.

Fine particulate matter and out-of-hospital cardiac arrest of respiratory origin

Exposure to ambient air pollution increases mortality and is a leading contributor to the global disease burden [1]. Epidemiological studies have elucidated a relationship between out-of-hospital cardiac arrests (OHCAs) and air pollutants, especially particulate matter (diameter ≤2.5 μm; PM_2.5) [2, 3]. The causes of OHCA are broadly categorised as cardiac and non-cardiac [4]. A 10 µg·m⁻³ increase in PM_2.5 exposure yielded a 1.6% increase in the incidence of cardiac origin OHCA [3, 5]. However, few studies on OHCAs of non-cardiac origin, including intrinsic respiratory diseases (COPD/pneumonia/asthma) are available. We examined the association between short-term exposure to PM_2.5 and bystander-witnessed respiratory origin OHCAs, including eventual prognosis. We also investigated differences between PM_2.5 exposure-related cardiac and respiratory origin OHCAs.

Particulate matter is a potential risk factor for out-of-hospital cardiac arrests (OHCAs) of respiratory origin. The percent increase in incidence of OHCA of respiratory origin is equivalent to that of PM_2.5 exposure-related OHCAs of cardiac origin.http://bit.ly/3tDXym0

Environmental Risk Factors and Health: An Umbrella Review of Meta-Analyses

Background: Environmental health is a growing area of knowledge, continually increasing and updating the body of evidence linking the environment to human health. Aim: This study summarizes the epidemiological evidence on environmental risk factors from meta-analyses through an umbrella review. Methods: An umbrella review was conducted on meta-analyses of cohort, case-control, case-crossover, and time-series studies that evaluated the associations between environmental risk factors and health outcomes defined as incidence, prevalence, and mortality. The specific search strategy was designed in PubMed using free text and Medical Subject Headings (MeSH) terms related to risk factors, environment, health outcomes, observational studies, and meta-analysis. The search was limited to English, Spanish, and French published articles and studies on humans. The search was conducted on September 20, 2020. Risk factors were defined as any attribute, characteristic, or exposure of an individual that increases the likelihood of developing a disease or death. The environment was defined as the external elements and conditions that surround, influence, and affect a human organism or population's life and development. The environment definition included the physical environment such as nature, built environment, or pollution, but not the social environment. We excluded occupational exposures, microorganisms, water, sanitation and hygiene (WASH), behavioral risk factors, and no-natural disasters. Results: This umbrella review found 197 associations among 69 environmental exposures and 83 diseases and death causes reported in 103 publications. The environmental factors found in this review were air pollution, environmental tobacco smoke, heavy metals, chemicals, ambient temperature, noise, radiation, and urban residential surroundings. Among these, we identified 65 environmental exposures defined as risk factors and 4 environmental protective factors. In terms of study design, 57 included cohort and/or case-control studies, and 46 included time-series and/or case-crossover studies. In terms of the study population, 21 included children, and the rest included adult population and both sexes. In this review, the largest body of evidence was found in air pollution (91 associations among 14 air pollution definitions and 34 diseases and mortality diagnoses), followed by environmental tobacco smoke with 24 associations. Chemicals (including pesticides) were the third larger group of environmental exposures found among the meta-analyses included, with 19 associations. Conclusion: Environmental exposures are an important health determinant. This review provides an overview of an evolving research area and should be used as a complementary tool to understand the connections between the environment and human health. The evidence presented by this review should help to design public health interventions and the implementation of health in all policies approach aiming to improve populational health.

Transient risk of ambient fine particulate matter on hourly cardiovascular events in Tainan City, Taiwan

BACKGROUND

The association between daily changes in ambient fine particulate matter (PM2.5) and cardiovascular diseases have been well established in mechanistic, epidemiologic and exposure studies. Only a few studies examined the effect of hourly variations in air pollution on triggering cardiovascular events. Whether the current PM2.5 standards can protect vulnerable individuals with chronic cardiovascular diseases remain uncertain.

METHODS

we conducted a time-stratified, case-crossover study to assess the associations between hourly changes in PM2.5 levels and the vascular disease onset in residents of Tainan City, Taiwan, visiting Emergency Room of Chi Mei Medical Center between January 2006 and December 2016. There were 26,749 cases including 10,310 females (38.5%) and 16,439 males (61.5%) identified. The time of emergency visit was identified as the onset for each case and control cases were selected as the same times on other days, on the same day of the week in the same month and year respectively. Residential address was used to identify the ambient air pollution exposure concentrations from the closest station. Conditional logistic regression with the stepwise selection method was used to estimate adjusted odds ratios (ORs) for the association.

RESULTS

When we only included cases occurring at PM2.5>10 μg/m3 and PM2.5>25 μg/m3, very significant ORs could be observed for 10 μg/m3 increases in PM2.5 at 0 and 1 hour, implying fine particulate exposure could promptly trigger vascular disease events. Moreover, a very clear increase in risk could be observed with cumulative exposure from 0 to 48 hours, especially in those cases where PM2.5>25 μg/m3.

CONCLUSIONS

Our study demonstrated that transient and low concentrations of ambient PM2.5 trigger adult vascular disease events, especially cerebrovascular disease, regardless of age, sex, and exposure timing. Warning and delivery systems should be setup to protect people from these prompt adverse health impacts.

A review of multivariate analysis: is there a relationship between airborne particulate matter and meteorological variables?

Among statistical tools for the study of atmospheric pollutants, trajectory regression analysis (TRA), cluster analysis (CA), and principal component analysis (PCA) can be highlighted. Therefore, this article presents a systematic review of such techniques based on (i) air mass influences on particulate matter (PM) and (ii) the study of the relationship between PM and meteorological variables. This article aims to review studies that use TRA and to review studies that adopt CA and/or PCA to identify the associations and relationship between meteorological variables and atmospheric pollutants. Papers published between 2006 and 2018 and indexed by five of the main scientific databases were considered (ScienceDirect, Web of Science, PubMed, SciELO, and Scopus databases). PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations supported this systematic review. From the resulting most relevant papers, eight studies analyzed the influence of air mass trajectories on PM using TRA and twenty-one studies searched for the relationship between meteorological variables and PM using CA and/or PCA. A combination of TRA and time series models was identified as the possibility of future works. Besides, studies that simultaneously combine the three techniques to identify both the influence of air masses on PM and its relationship with meteorological variables are a possibility of future papers, because it can lead to a better comprehension of such a phenomenon.

Association between ambient air pollution and out-of-hospital cardiac arrest: are there potentially susceptible groups?

This study aimed to examine the association between air pollution and out-of-hospital cardiac arrest (OHCA), and the effects of underlying diseases. Between January 2015 and December 2016, data on particulate matter (PM)_2.5 and other air pollutants in Kaohsiung City were collected, and an emergency medical service database was used for information on patients who experienced OHCA. Overall, 3566 patients were analyzed and subgroup analyses by sex, age, and preexisting morbidities were performed. Interquartile increments in PM_2.5, PM₁₀, and O₃ levels on lag 1 and NO₂ level on lag 3 were associated with increments of 10.8%, 11.3%, 6.2%, and 1.7% in OHCA incidence, respectively. Subgroup analyses showed that patients with diabetes (1.363; interaction p = 0.009), heart disease (1.612; interaction p = 0.001), and advanced age (≥70 years, 1.297; interaction p = 0.003) were more susceptible to NO₂ on lag 3. Moreover, patients were more susceptible to O₃ during the cold season (1.194; interaction p = 0.001). We found that PM_2.5, PM₁₀, NO₂, and O₃ may play an important role in OHCA events, and the effects vary by underlying condition, age and season.

Effect of meteorological factors and air pollutants on out-of-hospital cardiac arrests: a time series analysis

OBJECTIVES

We aimed to investigate the effects of meteorological factors and air pollutants on out-of-hospital cardiac arrest (OHCA) according to seasonal variations because the roles of these factors remain controversial to date.

METHODS

A total of 38 928 OHCAs of cardiac origin that occurred within eight metropolitan areas between 2012 and 2016 were identified from the Korean nationwide emergency medical service database. A time series multilevel approach based on Poisson analysis following a Granger causality test was used to analyse the influence of air pollution and 13 meteorological variables on OHCA occurrence.

RESULTS

Particulate matter (PM) ≤2.5 µm (PM_2.5), average temperature, daily temperature range and humidity were significantly associated with a higher daily OHCA risk (PM_2.5: 1.59%; 95% CI: 1.51% to 1.66% per 10µg/m³, average temperature 0.73%, 95% CI: 0.63% to 0.84% per 1°C, daily temperature range: 1.05%, 95% CI: 0.63% to 1.48% per 1°C, humidity -0.48, 95% CI: -0.40 to -0.56 per 1%) on lag day 1. In terms of the impact of these four risk factors in different seasons, average temperature and daily temperature range were highly associated with OHCA in the summer and winter, respectively. However, only PM_2.5 elevation (to varying extents) was an independent and consistent OHCA risk factor irrespective of the season.

CONCLUSIONS

PM_2.5, average temperature, daily temperature range and humidity were independently associated with OHCA occurrence in a season-dependent manner. Importantly, PM_2.5 was the only independent risk factor for OHCA occurrence irrespective of seasonal changes.

Association of Fine Particulate Matter Exposure With Bystander-Witnessed Out-of-Hospital Cardiac Arrest of Cardiac Origin in Japan

IMPORTANCE

Out-of-hospital cardiac arrests (OHCAs) are a major public health concern and a leading cause of death worldwide. Exposure to ambient air pollution is associated with increases in morbidity and mortality and has been recognized as a leading contributor to global disease burden.

OBJECTIVE

To examine the association between short-term exposure to particulate matter with a diameter of 2.5 μm or smaller (PM2.5) and the incidence of OHCAs of cardiac origin and with the development of initial cardiac arrest rhythm.

DESIGN, SETTING, AND PARTICIPANTS

This case-control study used data from cases registered between January 1, 2005, and December 31, 2016, in the All-Japan Utstein Registry, a prospective, nationwide, population-based database for OHCAs across all 47 Japanese prefectures. These OHCA cases included patients who had bystander-witnessed OHCAs and for whom emergency medical services responders initiated resuscitation before hospital transfer. A case-crossover design was employed for the study analyses. A prefecture-specific, conditional logistic regression model to estimate odds ratios was applied, and a random-effects meta-analysis was used to obtain prefecture-specific pooled estimates. All analyses were performed from May 7, 2019, to January 23, 2020.

MAIN OUTCOMES AND MEASURES

The main outcome was the association of short-term PM2.5 exposure with the incidence of bystander-witnessed OHCAs of cardiac origin. The differences in the distribution of initial cardiac arrest rhythm in OHCAs among those with exposure to PM2.5 were also examined.

RESULTS

In total, 103 189 OHCAs witnessed by bystanders were included in the final analysis. Among the patients who experienced such OHCAs, the mean (SD) age was 75 (15.5) years, and 62 795 (60.9%) were men. Point estimates of the percentage increase for a 10-μg/m3 increase in PM2.5 at lag0-1 (difference in mean PM2.5 concentrations measured on the case day and 1 day before) demonstrated a statistically significantly higher incidence of OHCA across most of the 47 prefectures, without significant heterogeneity (I2 = 20.1%; P = .12). A stratified analysis found an association between PM2.5 exposure and OHCAs (% increase, 1.6; 95% CI, 0.1%-3.1%). An initial shockable rhythm, such as ventricular fibrillation or pulseless ventricular tachycardia (% increase, 0.6; 95% CI, -2.0% to 3.2%), was not associated with PM2.5 exposure. However, an initial nonshockable rhythm, such as pulseless electrical activity and asystole, was associated with PM2.5 exposure (% increase, 1.4; 95% CI, 0.1%-2.7%).

CONCLUSIONS AND RELEVANCE

Findings from this study suggest that increased PM2.5 concentration is associated with bystander-witnessed OHCA of cardiac origin that commonly presents with nonshockable rhythm. The results support measures to reduce PM2.5 exposure to prevent OHCAs of cardiac origin.

Gasoline Vapor Emissions During Vehicle Refueling Events in a Vehicle Fleet Saturated With Onboard Refueling Vapor Recovery Systems: Need for an Exposure Assessment

Background: Gasoline contains large proportions of harmful chemicals, which can be released during vehicle refueling. Onboard Refueling Vapor Recovery (ORVR) can reduce these emissions, but there is limited research on the system's efficacy over time in an actual vehicle fleet. The aims of this study are: (1) determine the feasibility of using an infrared camera to view vapor emissions from refueling; (2) examine the magnitude of refueling-related emissions in an ORVR-saturated fleet, to determine need for an exposure-assessment. Methods: Using an infrared camera optimized for optical gas imaging of volatile organic chemicals, refueling was recorded for 16 vehicles at six gas stations. Pumps were inspected for damage, refueling shut-off valve functioning, and presence of Stage II Vapor Recovery. Vehicle make/model and age were recorded or estimated. Results: Vapor emissions were observed for 14 of 16 vehicles at each station, with severity varying substantially by vehicle make/model and age. Use of an infrared camera allowed for identification of vapor sources and timing of release, and for visualizing vapor trajectories. Discussion: Notably emissions occurred not only at the beginning and end of refueling but also throughout, in contrast to a prior study which did not detect increases in atmospheric hydrocarbon levels mid-refueling. Future studies are vitally needed to determine the risk to individuals during typical refueling in an ORVR saturated vehicle fleet. We recommend comprehensive exposure-assessment including real-time monitoring of emitted volatile organic compounds paired with infrared gas-imaging and measurement of internal dose and health effects of gas station customers.

A case-crossover analysis of the relationship of air pollution with out-of-hospital sudden unexpected death in Wake County, North Carolina (2013-2015)

Out-of-hospital sudden unexpected deaths are non-accidental deaths that occur without obvious underlying causes and may account for 10% of natural deaths before age 65. Short-term exposure to ambient air pollution is associated with all-cause (non-accidental) and cause-specific (e.g., cardiovascular) mortality, and with immediate exposures often yielding the highest magnitude risk estimates. Few studies have focused on short-term exposure to air pollution and sudden unexpected deaths. Using the University of North Carolina Sudden Unexpected Death in North Carolina population, we examine associations between short-term criteria air pollutant exposures with sudden unexpected deaths using a time-stratified case-crossover design, with data on criteria air pollutants from the Environmental Protection Agency's Air Quality System. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using conditional logistic regression with air pollutant exposures scaled to roughly inter-quartile ranges; models were adjusted for average temperature and relative humidity on event day and preceding 3 days. Potential for confounding by co-pollutants were examined in two pollutant models. ORs for PM_2.5 at lag day 1 were elevated (adjusted OR for 5 μg/m³ increase: 1.17 (0.98, 1.40)), and were robust to co-pollutant adjustment. Elevated odds were observed for SO₂ at lag day 0, and reduced odds for O₃ at lag day 0; however, these associations were somewhat attenuated toward the null (SO₂) or were not robust (O₃) to co-pollutant adjustment. This analysis in a racially and socioeconomically diverse cohort, with a more inclusive definition of sudden unexpected death than is typically employed offers evidence that PM_2.5 may be a clinically relevant trigger of sudden unexpected deaths in susceptible individuals.

The impact of air pollutants on ambulance dispatches: A systematic review and meta-analysis of acute effects

A number of systematic reviews have investigated the association between air pollutants and health impacts, these mostly focus on morbidity and mortality from hospital data. Previously, no reviews focused solely on ambulance dispatch data. These data sets have excellent potential for environmental health research. For this review, publications up to April 2019 were identified using three main search categories covering: ambulance services including dispatches; air pollutants; and health outcomes. From 308 studies initially identified, 275 were excluded as they did not relate to ambulance service dispatches, did not report the air pollutant association, and/or did not study ambient air pollution. The main health outcomes in the remaining 33 studies were cardiac arrest (n = 14), cardiovascular (n = 11) and respiratory (n = 10) dispatches. Meta-analyses were performed to summarise pooled relative risk (RR) of pollutants: particulate matter less than 2.5 and 10 μm (PM_2.5, PM₁₀), the fraction between PM₁₀ and PM_2.5 (coarse) and suspended particulate matter (SPM) per 10 μg/m³ increase, carbon monoxide (CO) per 1 ppm increase and of sulphur dioxide (SO₂), nitrogen dioxide (NO₂), and ozone (O₃) per 10 ppb increment and ambulance dispatches. Statistically significant associations were found for ambulance dispatch data for all-respiratory and PM_2.5 at 1.03 (95% CI:1.02-1.04) and at 1.10 (95% CI:1.00-1.21) for asthma and NO₂ associations. For dispatches with subsequent paramedic assessment for cardiac arrest with PM_2.5, CO and coarse dispatches at 1.05 (95% CI:1.03-1.08), 1.10 (95% CI:1.02-1.18) and 1.04 (95% CI:1.01-1.06) respectively. For dispatches with subsequent physician diagnosis for all-respiratory and PM_2.5 at 1.02 (95% CI:1.01-1.03). In conclusion, air pollution was significantly associated with an increase in ambulance dispatch data, including those for cardiac arrest, all-respiratory, and asthma dispatches. Ambulance services should plan accordingly during pollution events. Furthermore, efforts to improve air quality should lead to decreases in ambulance dispatches.

Short-term exposure to particulate matters is associated with septic emboli in infective endocarditis

This survey was to investigate the short-term effect of particulate matters (PMs) exposure on clinical and microbiological variables, especially septic emboli, in infective endocarditis (IE). The study analyzed 138 IE patients in Far Eastern Memorial Hospital from 2005 to 2015 and clinical variables were retrospectively requested. The data of air quality were recorded and collected by a network of 26 monitoring stations spreading in Northern part of Taiwan. We found that IE patients with septic emboli were found to be exposed to a significantly higher level of PM2.5 (32.01 ± 15.89 vs. 21.70 ± 13.05 μg/m, P < .001) and PM10 (54.57 ± 24.43 vs 40.98 ± 24.81 μg/m, P = .002) on lag 0 day when compared to those without. Furthermore, multivariate regression analysis revealed that that ambient exposure to PM2.5 (odds ratio: 3.87, 95% confidence interval: 1.31-8.31; P = .001) and PM10 (odds ratio: 4.58, 95% confidence interval: 2.03-10.32; P < .001) significantly increased risk of septic emboli in IE patients. To our knowledge, this is the first study demonstrating that short-term exposure to PMs was associated with septic emboli in IE.

Novel evidence for a greater burden of ambient air pollution on cardiovascular disease

Ambient and household air pollution is a major health problem worldwide, contributing annually to approximately seven million of all-cause avoidable deaths, shorter life expectancy, and significant direct and indirect costs for the community. Air pollution is a complex mixture of gaseous and particulate materials that vary depending on their source and physicochemical features. Each material has detrimental effects on human health, but a number of experimental and clinical studies have shown a strong impact for fine particulate matter (PM_2.5). In particular, there is more and more evidence that PM_2.5 exerts adverse effects particularly on the cardiovascular system, contributing substantially (mainly through mechanisms of atherosclerosis, thrombosis and inflammation) to coronary artery and cerebrovascular disease, but also to heart failure, hypertension, diabetes and cardiac arrhythmias. In this review, we summarize knowledge on the mechanisms and magnitude of the cardiovascular adverse effects of short-and long-term exposure to ambient air pollution, particularly for the PM_2.5 size fraction. We also emphasize that very recent data indicate that the global mortality and morbidity burden of cardiovascular disease associated with this air pollutant is dramatically greater than what has been thought up to now.

Does Particulate Matter Modify the Short-Term Association between Heat Waves and Hospital Admissions for Cardiovascular Diseases in Greater Sydney, Australia?

Little is known about the potential interactive effects of heat waves and ambient particulate matter on cardiovascular morbidity. A time-stratified case-crossover design was used to examine whether particulate matter (PM₁₀) modifies the association between heat waves and emergency hospital admissions for six cardiovascular diseases in Greater Sydney, Australia during the warm season for 2001–2013. We estimated and compared the effect of heat waves on high- and low-level PM₁₀ days at lag₀–lag₂, adjusting for dew-point temperature, ambient ozone, ambient nitrogen dioxide, and public holidays. We also investigated the susceptibility of both younger (0–64 years) and older populations (65 years and above), and tested the sensitivity of three heat wave definitions. Stronger heat wave effects were observed on high- compared to low-level PM₁₀ days for emergency hospital admissions for cardiac arrest for all ages combined, 0–64 years and 65 years and above; conduction disorders for 0–64 years; and hypertensive diseases for all ages combined and 0–64 years. Overall, we found some evidence to suggest that PM₁₀ may modify the association between heat waves and hospital admissions for certain cardiovascular diseases, although our findings largely differed across disease, age group, lag, and heat wave definition.

Exposure to outdoor air pollution and its human health outcomes: A scoping review

Despite considerable air pollution prevention and control measures that have been put into practice in recent years, outdoor air pollution remains one of the most important risk factors for health outcomes. To identify the potential research gaps, we conducted a scoping review focused on health outcomes affected by outdoor air pollution across the broad research area. Of the 5759 potentially relevant studies, 799 were included in the final analysis. The included studies showed an increasing publication trend from 1992 to 2008, and most of the studies were conducted in Asia, Europe, and North America. Among the eight categorized health outcomes, asthma (category: respiratory diseases) and mortality (category: health records) were the most common ones. Adverse health outcomes involving respiratory diseases among children accounted for the largest group. Out of the total included studies, 95.2% reported at least one statistically positive result, and only 0.4% showed ambiguous results. Based on our study, we suggest that the time frame of the included studies, their disease definitions, and the measurement of personal exposure to outdoor air pollution should be taken into consideration in any future research. The main limitation of this study is its potential language bias, since only English publications were included. In conclusion, this scoping review provides researchers and policy decision makers with evidence taken from multiple disciplines to show the increasing prevalence of outdoor air pollution and its adverse effects on health outcomes.

Wood stove use and other determinants of personal and indoor exposures to particulate air pollution and ozone among elderly persons in a Northern Suburb

A six-month winter-spring study was conducted in a suburb of the northern European city of Kuopio, Finland, to identify and quantify factors determining daily personal exposure and home indoor levels of fine particulate matter (PM_2.5 , diameter <2.5 µm) and its light absorption coefficient (PM_2.5abs ), a proxy for combustion-derived black carbon. Moreover, determinants of home indoor ozone (O₃ ) concentration were examined. Local central site outdoor, home indoor, and personal daily levels of pollutants were monitored in this suburb among 37 elderly residents. Outdoor concentrations of the pollutants were significant determinants of their levels in home indoor air and personal exposures. Natural ventilation in the detached and row houses increased personal exposure to PM_2.5 , but not to PM_2.5abs , when compared with mechanical ventilation. Only cooking out of the recorded household activities increased indoor PM_2.5 . The use of a wood stove room heater or wood-fired sauna stove was associated with elevated concentrations of personal PM_2.5 and PM_2.5abs , and indoor PM_2.5abs . Candle burning increased daily indoor and personal PM_2.5abs , and it was also a determinant of indoor ozone level. In conclusion, relatively short-lasting wood and candle burning of a few hours increased residents' daily exposure to potentially hazardous, combustion-derived carbonaceous particulate matter.

Effects of meteorological factor and air pollution on sudden sensorineural hearing loss using the health claims data in Busan, Republic of Korea

PURPOSE

Specific meteorological factors, including air pollution in the form of particulate matter (PM), affect the development of otologic disease and have adverse effects on the cardiovascular and respiratory systems. This study investigated relationships between the development of sudden sensorineural hearing loss(SSNHL) and meteorological factor with air pollution including PM.

MATERIALS AND METHODS

The daily patient number in 2015 admitted to the hospital with SSNHL were extracted from the Health Insurance Review and Assessment Service Bigdata in Busan. The meteorological factors and air pollution data of Busan area were obtained from meteorological stations in Busan. The relationship between the number of hospitalizations and the climatic factors was checked.

RESULTS

SSNHL patient group showed more common in women, and the highest rates were observed in patients in their 50s. The daily mean patient numbers were 2.27. The number of SSNHL patients in spring was statistically significantly higher than that in summer. The mean daily PM10 and PM2.5 concentrations were 48.0 and 29.4 μg/m³, respectively. The mean wind speed, maximum wind speed and daily atmospheric pressure range was weakly positively associated with SSNHL patient number. There were weak negative correlations between maximum PM2.5 and SSNHL admissions. The mean temperature and wind chill index showed non-significantly negative relationships with SSNHL admissions.

CONCLUSIONS

In Busan area, statistically significant weak relationships were detected between the daily numbers of patients admitted to the hospital with SSNHL and meteorological data, including PM level. Further investigation of these associations is required.

Interactive effects of changing stratospheric ozone and climate on tropospheric composition and air quality, and the consequences for human and ecosystem health

The composition of the air we breathe is determined by emissions, weather, and photochemical transformations induced by solar UV radiation. Photochemical reactions of many emitted chemical compounds can generate important (secondary) pollutants including ground-level ozone (O₃) and some particulate matter, known to be detrimental to human health and ecosystems. Poor air quality is the major environmental cause of premature deaths globally, and even a small decrease in air quality can translate into a large increase in the number of deaths. In many regions of the globe, changes in emissions of pollutants have caused significant changes in air quality. Short-term variability in the weather as well as long-term climatic trends can affect ground-level pollution through several mechanisms. These include large-scale changes in the transport of O₃ from the stratosphere to the troposphere, winds, clouds, and patterns of precipitation. Long-term trends in UV radiation, particularly related to the depletion and recovery of stratospheric ozone, are also expected to result in changes in air quality as well as the self-cleaning capacity of the global atmosphere. The increased use of substitutes for ozone-depleting substances, in response to the Montreal Protocol, does not currently pose a significant risk to the environment. This includes both the direct emissions of substitutes during use and their atmospheric degradation products (e.g. trifluoroacetic acid, TFA).

Environmental justice screening tools: Implications for nursing

Environmental justice (EJ) means socially and economically disadvantaged communities and citizens are entitled to an equally clean environment and resources to enjoy. EJ communities are mostly located close to polluters such as Superfund sites, coal-fired power plants and landfills and are more likely to be exposed to higher levels of environmental hazards than the U.S. population on average. It is often a difficult task to identify EJ communities and the environmental hazards in the communities without using specific EJ screening tools. Therefore, the goal of this manuscript is to introduce public health nurses to map-based EJ screening tools. This will help public health nurses to identify EJ communities and take appropriate actions. Public Health Nurses can also use other relevant web sites, such as the U.S. Environmental Protection Agency (EPA), National Institute of Environmental Health Sciences (NIEHS) and Toxicology Data Network (TOXNET) as resources concerning potential health effects of pollutants. Using the provided tools in this paper, nurses should be able to identify EJ communities and be united to recognize barriers of EJ communities and become promoters for EJ advocacy in practice, leadership and education.

Ozone and cardiac arrest: The role of previous hospitalizations

BACKGROUND

Several studies have reported associations between exposure to particulate matter and incidence of out-of-hospital cardiac arrest (OHCA) and some have observed associations with ozone (O₃). There are no studies investigating susceptibility based on previous disease history to short-term O₃ exposure and the risk of OHCA.

AIM

To investigate the role of previous cardiovascular-related hospitalizations in modifying the associations between the risk of OHCA and short-term increase in O₃ concentrations.

METHODS

A time-stratified case-crossover analysis of 11,923 OHCA registered in the Swedish Register for Cardiopulmonary Resuscitation from 2006 to 2014 was performed. Using personal identification numbers, OHCA were linked to all previous hospitalizations in Sweden since 1987 to create susceptible groups based on the principal diagnosis code at discharge. Susceptibility was based on hospitalization for i) acute myocardial infarction; ii) heart failure; iii) arrhythmias; iv) diabetes; v) hypertension; and vi) stroke. Moving 2 and 24-h averages for O₃, PM_2.5, PM₁₀, and NO₂ were constructed from hourly averages.

RESULTS

A 10 μg/m³ higher 2-h average O₃ concentration was associated with a 2% higher risk of OHCA (95% CI, 0% 3%). Associations were similar for 24-h average O₃ and in individuals with or without hospitalizations for AMI, heart failure, diabetes, hypertension or stroke. Individuals with previous hospitalizations for arrhythmias had a lower risk of OHCA with higher O₃. No associations were observed for other pollutants.

CONCLUSIONS

Short-term exposure to O₃ was associated with an elevated risk of OHCA, however, previous hospitalizations for cardiovascular diseases were not associated with additionally augmented risks.

[Impact of the Air Quality on Health - Analysis of the activity of a SAMU-Center 15 in Paris area - the IQUASS Study]

INTRODUCTION

The atmospheric pollution is a growing public health problem. The highly urbanized regions such as Paris area seem particularly exposed. However, the overall health impact is poorly documented.

OBJECTIVE

To investigate the influence of air quality degradation on the demand for primary care.

METHOD

Site: medical dispatching center SAMU 93-Center 15. Related population: 1.6 million inhabitants.

DATA

daily number of medical regulation records (DRM) and daily air quality index (AQI) using the Airparif^® database from January 2014 to February 2017. The AQI is classified into five levels. Level 4 corresponds to the threshold of information and recommendations to reduce certain sources of polluting emissions and level 5 to the alert threshold setting up measures of restriction or suspension of the activities contributing to the pollution including vehicles circulation.

RESULTS

The analysis covered 1134 consecutive days and a total of 639,576 DRM. Average daily DRM number: 564 (507-643). IQA≥4 for 56 (5%) days and≥5 for 4 (0.4%) days. The number of DRM was very closely correlated with the IQA (R²=0.91); the daily median varied from 502 (494-621) for an IQA of level 1 to 650 (540-704) for an IQA≥4.

CONCLUSION

Degradation of air quality was significantly correlated with demand for primary care. The environmental alert is also a health alert. The impact was major (DRM +30%) considering all pathologies, all the pollutants on a departmental scale.

The Relationship Between Ambient Air Pollution and Acute Ischemic Stroke: A Time-Stratified Case-Crossover Study in a City-State With Seasonal Exposure to the Southeast Asian Haze Problem

STUDY OBJECTIVE

Studies are divided on the short-term association of air pollution with stroke. Singapore is exposed to seasonal transboundary haze. We aim to investigate the association between air pollution and stroke incidence in Singapore.

METHODS

We performed a time-stratified case-crossover analysis on all ischemic stroke cases reported to the Singapore Stroke Registry from 2010 to 2015. Exposure on days was compared with control days on which exposure did not occur. Control days were chosen on the same day of the week earlier and later in the same month in the same year. We fitted a conditional Poisson regression model to daily stroke incidence that included Pollutant Standards Index and environmental confounders. The index was categorized according to established classification (0 to 50=good, 51 to 100=moderate, and ≥101=unhealthy). We assessed the relationship between stroke incidence and Pollutant Standards Index in the entire cohort and in predetermined subgroups of individual-level characteristics.

RESULTS

There were 29,384 ischemic stroke cases. Moderate and unhealthy Pollutant Standards Index levels showed association with stroke occurrence, with incidence risk ratio 1.10 (95% confidence interval 1.06 to 1.13) and 1.14 (95% confidence interval 1.03 to 1.25), respectively. Subgroup analyses showed generally significant association, except in Indians and nonhypertensive patients. The association was significant in subgroups aged 65 years or older, women, Chinese, nonsmokers and those with history of diabetes, hypertension, and hyperlipidemia. Stratified by age and smoking, the risk diminished in smokers of all ages. Risk remained elevated for 5 days after exposure.

CONCLUSION

We found a short-term elevated risk of ischemic stroke after exposure to air pollution. These findings have public health implications for stroke prevention and emergency health services delivery.

APPROACHES TO PERSONALIZED THERAPY

Approaches to personalized therapy based on practical work of physicians are discussed. Personalized treatment considers patient’s interests and position, mechanisms of symptoms, somatic and mental comorbidities, chrono medicine, environment, genetics, and prognosis. Personalized treatment may be more effective, safe and inexpensive in compare with of traditional standardized care based on randomized controlled trials and clinical practice guidelines. Limitations and weaknesses of medical guidelines of authoritative professional societies are also discussed. Recommendations of clinical guidelines are based on randomized controlled trials with strict selection of patients without severe comorbid diseases. Accordingly, trials and guidelines conclusions cannot be applied for patients with heavy comorbidity. This justifies the need for organizational solutions and computer programs for support personalized treatment of patients. It is important to develop institute of primary care physicians and to train specialists in field of comorbid somatic diseases and mental disorders.