Psychological stress and fatal heart attack: the Athens (1981) earthquake natural experiment

Sleep quality and mental health differences following Syria-Turkey earthquakes: A cross-sectional study

BACKGROUND

This study explores the lasting mental health impact of the Syria-Turkey earthquakes in 2023 on a population affected by conflict and trauma. It analyzes pre- and post-event mental health and sleep quality differences, identifying predictors of outcomes.

AIMS

Studying the 2023 Syria-Turkey earthquakes' enduring mental health impact on conflict-affected individuals, this research informs better support and interventions for disaster survivors.

METHODS

This longitudinal, cross-sectional study examined the enduring mental health impact of the Syria-Turkey earthquakes. The present study involved N = 1,413 Syrian survivors, aged 18 years or older, who actively participated by contributing both pre- and post-earthquake data. A meticulously designed digital questionnaire with established metrics assessed sleep disturbances, depressive symptoms, and anxiety levels. Stratification variables (age, gender, education, marital status) were used for subgroup analysis. Arabic versions of PHQ-9, PSQI, and GAD-2 proved reliable for measuring depression, sleep quality, and anxiety.

RESULTS

The majority of participants were female (73.6%) with tertiary education (83.3%). Post-earthquake, a higher percentage reported poor sleep quality (67.7% vs. 59.7%, p < .001) and increased prevalence of MDE (66.1% vs. 56%, p < .001). GAD did not differ significantly. Post-earthquake, women had a higher likelihood of poor sleep quality (OR: 1.58, 95% CI [1.19, 2.10], p < .001) and MDE (OR: 1.55, 95% CI [1.18 to 2.04], p = .003). Predictors varied before and after earthquakes; age and education were significant predictors of poor sleep quality, MDE, and GAD.

CONCLUSION

This study reveals higher rates of poor sleep quality and major depressive episodes among earthquake-affected individuals, especially women. Age, education, and gender contribute to these outcomes. Targeted interventions and comprehensive mental health support are crucial for post-earthquake recovery.

Ascorbic acid prevents stress-induced hypercoagulability in overweight and obese individuals

Ascorbic acid (AA) may contribute to restoring hemostatic balance after mental stress (MS) in overweight/obese adults. We aimed to determine the effects of AA administration on hemostatic responses to MS in overweight/obese men. Fourteen overweight/obesity men (27 ± 7 years; BMI: 29.7 ± 2.6 kg m-2) performed the Stroop color-word stress task for 5 min after non-simultaneous infusion of placebo (PL, 0.9% NaCl) and AA (3 g). Blood was collected at baseline, during MS, and 60 min after MS to measure: activated partial thromboplastin time, prothrombin time, and fibrinogen concentration, by coagulometer; platelet-derived microvesicles (PMV, mv/μL), by flow cytometry; nitrite (μM), by chemiluminescence. In PL session, MS led to decreases in PTs (stress, p = 0.03; 60 min, p < 0.001), PT-INR (stress, p < 0.001; 60 min, p < 0.01), aPTTs (60 min, p = 0.03), aPTT ratio (60 min, p = 0.04) and fibrinogen (60 min, p = 0.04), while increased PT activity (60 min, p = 0.01) when compared to baseline. Furthermore, AA increased PTs (60 min, p < 0.001), PT-INR (60 min, p = 0.03) and decreased PT activity (60 min, p < 0.001) and fibrinogen (stress, p = 0.04) when compared to PL. Nitrite was increased in response to stress during AA session (p < 0.001 vs PL). There was no difference in PMV. Ascorbic acid prevented the impaired hemostatic profile and improved nitrite response to stress in the overweight and obese adults.

Endothelin Modulates Rhythm Disturbances and Autonomic Responses to Acute Emotional Stress in Rats

The ubiquitous peptide endothelin is currently under investigation as a modulatory factor of autonomic responses to acute emotional stress. Baseline plasma levels of endothelin alter blood pressure responses, but it remains unclear whether autonomic activity and arrhythmogenesis (i.e., brady- or tachyarrhythmias) are affected. We recorded sympathetic and vagal indices (derived from heart rate variability analysis), rhythm disturbances, voluntary motion, and systolic blood pressure after acute emotional stress in conscious rats with implanted telemetry devices. Two strains were compared, namely wild-type and ETB-deficient rats, the latter displaying elevated plasma endothelin. No differences in heart rate or blood pressure were evident, but sympathetic responses were blunted in ETB-deficient rats, contrasting prompt activation in wild-type rats. Vagal withdrawal was observed in both strains at the onset of stress, but vagal activity was subsequently restored in ETB-deficient rats, accompanied by low voluntary motion during recovery. Reflecting such distinct autonomic patterns, frequent premature ventricular contractions were recorded in wild-type rats, as opposed to sinus pauses in ETB-deficient rats. Thus, chronically elevated plasma endothelin levels blunt autonomic responses to acute emotional stress, resulting in vagal dominance and bradyarrhythmias. Our study provides further insights into the pathophysiology of stress-induced tachyarrhythmias and syncope.

Impact of Earthquake on Cardiovascular Health: What Should Cardiovascular Healthcare Providers Anticipate After the Devastating Earthquakes in Turkey and Syria?

Natural disasters like earthquakes have direct and indirect association with major adverse cardiac events. They can impact cardiovascular health by multiple mechanisms not to mention their impact on cardiovascular care and services. Besides the humanitarian tragedy that calls attention globally, we as part of cardiovascular community are concerned with the short and long outcomes of those who survived the recent Turkey and Syria earthquake tragedy. Therefore, in this review, we aimed to draw attention of cardiovascular healthcare providers to the anticipated cardiovascular issues that may arise in survivors on short- and long-term postearthquakes to ensure proper screening and earlier management of this population. With the anticipated increase in natural disasters in future considering climate changes, geological factors, and human activities, the cardiovascular healthcare providers as part of medical community should be aware of the high rate of cardiovascular disease burden that can occur among survivors of earthquakes and other natural disasters, so, they should act accordingly in terms of preparedness measures, adequate response planning starting from services re-allocation to personnel training and enhancing access to medical and cardiac care in both acute and chronic contexts, not to mention screening and risk-stratifying the patients to optimize their management.

Association between the extent of house collapse and urine sodium-to-potassium ratio of victims affected by the 2011 Great East Japan Earthquake and Tsunami: a cross-sectional study

People who experience natural disasters have a high risk of developing cardiovascular diseases. We investigated the association between the extent of house collapse and urine sodium-to-potassium (UNa/K) ratio of 2011 Great East Japan Earthquake victims. We used the baseline survey data of the Tohoku Medical Megabank Project Community-Based Cohort Study of 29 542 individuals (aged 20-74 years) residing in the affected areas. The UNa/K ratio was calculated using spot urinary electrolyte values. Analysis of covariance was used to calculate the multivariate-adjusted geometric means of the UNa/K ratio in the following groups stratified according to the self-reported extent of house collapse: total collapse (TC), half collapse (HC), partial collapse (PC), and no damage (ND). Multivariable-adjusted odds ratios (ORs) for a high UNa/K ratio were calculated using logistic regression. The TC, HC, PC, and ND groups comprised 5 359 (18.1%), 3 576 (12.1%), 7 331 (24.8%), and 13 276 (44.9%) participants, respectively. The TC (3.33; 95% confidence interval [CI], 3.28-3.38), HC (3.37; 3.30-3.43), and PC (3.32; 3.28-3.37) groups had significantly higher multivariate-adjusted geometric means of the UNa/K ratio than the ND (3.24; 3.21-3.27) group. The multivariable-adjusted ORs (95% CIs) for a high UNa/K ratio in the TC, HC, and PC groups vs. the ND group were 1.07 (0.99-1.15), 1.20 (1.11-1.31), and 1.20 (1.12-1.28), respectively. Similar associations between house collapse and UNa/K ratio were observed for both sexes. We report that victims of a natural disaster tend to have a diet with high sodium-to-potassium ratio.

Association between personality and the risk of ischemic heart disease mortality before and after the Great East Japan Earthquake: Data from the Miyagi Cohort Study

BACKGROUND

The purpose of the present study was to investigate the association between personality and the risk of IHD mortality among Great East Japan Earthquake (GEJE) survivors, and to investigate whether personality traits affected the increase in IHD mortality observed after the GEJE.

METHODS

We analyzed data for 29,065 men and women in the Miyagi Cohort Study who were 40-64 years old at baseline. We divided the participants into quartiles based on scores for each of the four personality subscales (extraversion, neuroticism, psychoticism, and lie), using the Japanese version of the Eysenck Personality Questionnaire-Revised Short Form. We divided the eight years before and after the GEJE event (11 March 2011) into two period, and examined the relationship between personality traits and the risk of IHD mortality. Cox proportional hazards analysis was used to estimate the multivariate hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk of IHD mortality according to each personality subscale category.

RESULTS

In the four years before the GEJE, neuroticism was significantly associated with an increased risk of IHD mortality. Compared with the lowest category for neuroticism, the multivariate-adjusted HR (95% CI) for IHD mortality in the highest category was 2.19 (1.03-4.67) (p-trend = 0.12). In contrast, no statistically significant association between neuroticism and IHD mortality was observed in the four years after the GEJE.

CONCLUSION

This finding suggests that the observed increase in IHD mortality after the GEJE can be attributed to risk factors other than personality.

Longitudinal Trends in Blood Pressure Associated with The Changes in Living Environment Caused by the Great East Japan Earthquake: The Fukushima Health Management Survey

The Great East Japan Earthquake occurred on 11 March 2011, forcing Fukushima Prefecture residents to change their living environment. Such sudden changes possibly have long-term effects on cardiovascular-related diseases. We therefore sought to identify temporal relationships between living environment changes and blood pressure levels over three years following the earthquake. Participants included 14,941 men and 21,533 women aged 16 years or older who answered self-administered questionnaires, including questions on living environment changes at baseline (2012). Blood pressure levels were measured each year from 2012 to 2015. Linear mixed-effects models were used to analyze associations between living environment changes and blood pressure levels. Men with changes in living environment (i.e., those living in shelters or in temporary housing, rental apartments, relatives' houses, or others) showed significantly higher diastolic blood pressure levels than those who lived in their home at baseline (77.3 mmHg vs. 77.8 mmHg; p < 0.001). The time-dependent effect of diastolic blood pressure levels associated with living environment was not statistically significant, indicating a sustained difference in diastolic blood pressure associated with living environment changes at baseline after three years. The effect of living environment changes on diastolic blood pressure increment was also evident in men without antihypertensive medication use during the study period and in men who were current drinkers at baseline. There were no associations between living environment changes and diastolic blood pressure levels among women. Sudden changes in living environment due to the disaster had an impact on the long-term effects of higher diastolic blood pressure among middle-aged men.

Rapid Rise in Cardio-Ankle Vascular Index as a Predictor of Impending Cardiovascular Events -Smooth Muscle Cell Contraction Hypothesis for Plaque Rupture

Predictive factors for vascular events have not been established. The vasculature of the atheroma is supplied by penetration of the vasa vasorum through the smooth muscle cell layer from the adventitia. Smooth muscle cell contraction induces compression of the vasa vasorum, resulting in ischemia in intimal atheromatous lesions. Cardio-ankle vascular index (CAVI) has become known as an index of arterial stiffness of the arterial tree from the origin of the aorta to the ankle. CAVI reflects the progress of arteriosclerosis, and a rapid rise in CAVI indicates arterial smooth muscle cell contraction. We hypothesized that rapidly increased arterial stiffness evaluated by CAVI may be a predictor of impending cardiovascular events.

Impact of lifestyle and psychosocial factors on the onset of hypertension after the Great East Japan earthquake: a 7-year follow-up of the Fukushima Health Management Survey

Natural disasters force many evacuees to change several aspects of their lifestyles. This longitudinal study aimed to investigate whether factors such as living environment and lifestyle factors were related to new-onset hypertension in survivors of the Great East Japan Earthquake over a long-term follow-up of up to 7 years after the earthquake. The present study examined data collected from 29,025 Japanese participants aged 39-89 years, sourced from general health checkups and the Fukushima Mental Health and Lifestyle Survey, which was conducted in 13 communities between 2011 and 2018. A total of 10,861 participants received follow-up examinations. During a median follow-up of 4.3 years, 3744 participants (1588 men, 41.4%; 2,156 women, 30.7%) had newly developed hypertension. Heavy drinking (adjusted hazard ratio 1.38, 95% confidence interval 1.21-1.57, p < 0.001) and obesity (adjusted hazard ratio 1.27, 95% confidence interval 1.19-1.37, p < 0.001) were significantly associated with new-onset hypertension after the disaster in multivariate-adjusted analysis. Furthermore, experiencing evacuation after the disaster was also significantly associated with the risk of new-onset hypertension in men (adjusted hazard ratio 1.14, 95% confidence interval 1.02-1.27, p = 0.016). The present study indicated that lifestyle factors, such as drinking and obesity, and evacuation experience in men had significant effects on the risk of new-onset hypertension in the long term after the earthquake.

Psychological Stress and Heart Disease: Fact or Folklore?

For at least a few centuries, if not millennia, psychological stress has been popularly believed to contribute to heart disease. Does psychological stress really contribute to heart disease? Are anecdotal, patient, and lay press reports that angina, heart attack, and even cardiac death are caused by stress based on fact, or are they just folklore? In this review, the study data supporting associations between stress and cardiovascular risk, as well as potential mechanisms by which psychological stress might contribute to heart disease and precipitate myocardial ischemia and infarction, are critically reviewed and summarized.

The Omnipresence of Autonomic Modulation in Health and Disease

The Autonomic Nervous System (ANS) is a critical part of the homeostatic machinery with both central and peripheral components. However, little is known about the integration of these components and their joint role in the maintenance of health and in allostatic derailments leading to somatic and/or neuropsychiatric (co)morbidity. Based on a comprehensive literature search on the ANS neuroanatomy we dissect the complex integration of the ANS: (1) First we summarize Stress and Homeostatic Equilibrium - elucidating the responsivity of the ANS to stressors; (2) Second we describe the overall process of how the ANS is involved in Adaptation and Maladaptation to Stress; (3) In the third section the ANS is hierarchically partitioned into the peripheral/spinal, brainstem, subcortical and cortical components of the nervous system. We utilize this anatomical basis to define a model of autonomic integration. (4) Finally, we deploy the model to describe human ANS involvement in (a) Hypofunctional and (b) Hyperfunctional states providing examples in the healthy state and in clinical conditions.

A Pilot Study on the 1H-NMR Serum Metabolic Profile of Takotsubo Patients Reveals Systemic Response to Oxidative Stress

Takotsubo syndrome (TTS) presents as an acute coronary syndrome characterized by severe left ventricular (LV) dysfunction and non-obstructive coronary artery disease that typically shows spontaneous recovery within days or weeks. The mechanisms behind TTS are mainly related to beta-adrenergic overstimulation and acute endogenous catecholamine surge, both of which could increase oxidative status that may induce further deterioration of cardiac function. Although several studies reported evidence of inflammation and oxidative stress overload in myocardial tissue of TTS models, systemic biochemical evidence of augmented oxidant activity in patients with TTS is lacking. In this study, serum samples of ten TTS patients and ten controls have been analyzed using ¹H-NMR spectroscopy. The results of this pilot study show a marked alteration in the systemic metabolic profile of TTS patients, mainly characterized by significant elevation of ketone bodies, 2-hydroxybutyrate, acetyl-L-carnitine, and glutamate levels, in contrast with a decrease of several amino acid levels. The overall metabolic fingerprint reflects a systemic response to oxidative stress caused by the stressor that triggered the syndrome’s onset.

Stress, the autonomic nervous system, and sudden death

The existence of an important relationship between stress, the autonomic nervous system, and sudden cardiac death (SCD) has been long recognized. In the present essay we review the large number of conditions, acting at individual or at population level, that have been causally associated to SCD and discuss the mechanistic and translational value of the studies exploring such associations. These conditions include external stressors (earthquakes, wars) and internal stressors (anger, fear, loss of a loved one) and emotions of even opposite sign. Most situations confirm the time-honored view that increases in sympathetic activity are proarrhythmic whereas increases in vagal activity are protective; however, we will also show and discuss a condition in which the culprit appears to be the excess of vagal activity. The physiologic rationale underlying the most typical situations is on one hand the profibrillatory effect of the increase in the heterogeneity of repolarization secondary to the release of norepinephrine, and on the other the combined effect of acetylcholine to lower heart rate and to antagonize the cardiac effects of norepinephrine at ventricular level. An interesting facet of this potentially lethal relationship is that the elements involved are by no means always exceptional, and they can actually represent part of our everyday life.

Prevalence Rate of Diabetes and Hypertension in Disaster-Exposed Populations: A Systematic Review and Meta-Analysis

Background

Non-communicable diseases (NCD) such as hypertension (HTN) and diabetes mellitus (DM) have been one of the major health problems in the world. The aim of this study was to evaluate the prevalence rate of DM and HTN following natural and man-made disasters that impose significant economic and psychological burdens on human communities.

Methods

In this systematic and meta-analysis review, all cross-sectional studies that at least one of their objectives was to measure the prevalence of HTN or DM in individuals affected by natural and man-made disasters were included. Literature review was done in international databases including PubMed, Scopus and Web of Science, from database inception to February 17, 2019. The extracted data included the bibliographic characteristics of the article, the age of the participants, number of participants, gender, sample size, outcome, duration of the follow-up, and prevalence of DM and HTN. Data were analyzed by STATA software (version 11) and random effect method and the I2 index were used to investigate heterogeneity between the articles.

Results

A total of 16 articles met the inclusion criteria. Based on the quality assessment, 11 papers were categorized as moderate and 5 paper were categorized as high quality. The prevalence of HTN and DM in disaster-exposed populations were 47.35 (CI 95%: 38.53–56.17) and 13.56 (CI 95%: 10.12–17.01), respectively.

Conclusion

The results of this study show a high prevalence of HTN and DM in survivors of major disasters, which is higher in comparison to the general population

Triangle of COVID, anxiety and menstrual cycle

This study aimed to examine whether the menstrual cycles of women with regular cycles have been affected by the COVID 19 pandemic. This cross-sectional online survey study evaluated the menstrual cycle characteristics of women in the reproductive phase of their lives during the COVID-19 pandemic in May 2020. Changes before and after COVID-19 were evaluated with a paired sample t-test and chi-square test. A Pearson correlation test was used to show the relationships between variables. The study was completed with 263 participants in total. The average age of the participants was 26.3 ± 6.9 (18-45). Participants' duration of period (p = .003) and pads used per day (p = .002) decreased compared to their experience before the COVID-19 outbreak. The mean total MSQ score was 3.1 ± 0.8 (0-4), mean STAI-1 score was 45.1 ± 9 (20-78) and mean STAI-II score was 43.3 ± 5.9 (30-69). It was found that STAI-I and STAI-II scores showed a positive correlation with MSQ-Somatic subgroup scores(r = 0.153, p = .013; 0.190, p = .002) and MSQ-Total scores (0.144, p = .020; 0.175, p = .004). With the COVID-19 pandemic, increased anxiety scores increased women's menstrual symptoms while the length of periods and the number of pads used decreased.Impact statementWhat is already known on this subject? The COVID 19 pandemic, has caused enormous psychological distress potentially resulting in the development of posttraumatic stress disorder. The menstrual cycle is a process that can be affected by psychological stress.What do the results of this study add? This is the first study to examine the relationship between stress caused by the COVID-19 pandemic and the menstrual cycle. The increases in the degree of anxiety and stress as a result of the COVID-19 outbreak was found to be high enough to affect the characteristics of the menstrual cycle in the women surveyed.What are the implications of these findings for clinical practice and/or further research? In a prospective study intended to be carried out after the outbreak ends in the future, it will be possible to evaluate whether the menstrual cycle parameters return to their former order and consequently this hypothesis will be able to be more definitively confirmed.

Association between Health Practice and Food Stockpiling for Disaster

In this study investigated the association between health practices and food stockpiling for disasters in predicted areas with a high risk of food shortage due to the Nankai Trough earthquake. A survey was conducted during 18-20 December 2019 using a self-administered web-based questionnaire. In total, 1200 individuals registered with an online survey company participated in the study. The association between health practices and food stockpiling status was analyzed (n = 998). 59.1% of participants had a poor Breslow's seven health practice scores (BHPS), 32.9% had a moderate score, and 8.0% had a good score. Multivariable logistic regression analysis revealed that higher BHPS had a significantly higher prevalence of food stockpiling. Additionally, the interrupted group had the highest percentage of participants with low BHPS. Lower BHPS was significantly associated with interrupted stockpiled in the adjusted models. Among the seven health practices, the odds ratio of the "eating breakfast" practice was high. There was a significant positive association between higher health practice scores and food stockpiling for disasters in areas with a high risk of food shortage due to the predicted earthquake. Particularly, it was clarified that individuals who had fewer good health practices were associated with ending up interrupting food stockpiling.

Ventricular arrhythmia burden during the coronavirus disease 2019 (COVID-19) pandemic

AIMS

Our objective was to determine the ventricular arrhythmia burden in implantable cardioverter-defibrillator (ICD) patients during COVID-19.

METHODS AND RESULTS

In this multicentre, observational, cohort study over a 100-day period during the COVID-19 pandemic in the USA, we assessed ventricular arrhythmias in ICD patients from 20 centres in 13 states, via remote monitoring. Comparison was via a 100-day control period (late 2019) and seasonal control period (early 2019). The primary outcome was the impact of COVID-19 on ventricular arrhythmia burden. The secondary outcome was correlation with COVID-19 incidence. During the COVID-19 period, 5963 ICD patients underwent remote monitoring, with 16 942 episodes of treated ventricular arrhythmias (2.8 events per 100 patient-days). Ventricular arrhythmia burden progressively declined during COVID-19 (P < 0.001). The proportion of patients with ventricular arrhythmias amongst the high COVID-19 incidence states was significantly reduced compared with those in low incidence states [odds ratio 0.61, 95% confidence interval (CI) 0.54-0.69, P < 0.001]. Comparing patients remotely monitored during both COVID-19 and control periods (n = 2458), significantly fewer ventricular arrhythmias occurred during COVID-19 [incident rate ratio (IRR) 0.68, 95% CI 0.58-0.79, P < 0.001]. This difference persisted when comparing the 1719 patients monitored during both the COVID-19 and seasonal control periods (IRR 0.69, 95% CI 0.56-0.85, P < 0.001).

CONCLUSIONS

During COVID-19, there was a 32% reduction in ventricular arrhythmias needing device therapies, coinciding with measures of social isolation. There was a 39% reduction in the proportion of patients with ventricular arrhythmias in states with higher COVID-19 incidence. These findings highlight the potential role of real-life stressors in ventricular arrhythmia burden in individuals with ICDs.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry; URL: https://www.anzctr.org.au/; Unique Identifier: ACTRN12620000641998.

Rapid Rise of Cardio-Ankle Vascular Index May Be a Trigger of Cerebro-Cardiovascular Events: Proposal of Smooth Muscle Cell Contraction Theory for Plaque Rupture

Cardiovascular diseases have been recognized as the main cause of death all over the world. Recently, the established cardio-ankle vascular index (CAVI) has become known as an index of arterial stiffness of the arterial tree from the origin of the aorta to the ankle. CAVI reflects the progress of arteriosclerosis, and a rapid rise in CAVI indicates arterial smooth muscle cell contraction. Considering the vasculature of the atheroma where vasa vasorum penetrates the smooth muscle cell layer and supplies blood to the intimal atheromatous lesion, a rapid rise of CAVI means "choked" atheroma. Thus, we proposed a "smooth muscle cell contraction" hypothesis of plaque rupture.

Vestibular Function After the 2016 Kumamoto Earthquakes: A Retrospective Chart Review

This retrospective chart review aimed to examine both the vestibular function and causes of dizziness experienced by individuals following a series of major earthquakes and repetitive aftershocks. All patients with balance disorders who experienced the 2016 Kumamoto earthquakes and their aftershocks completed questionnaires relevant to balance disorders and were enrolled in this study after providing informed consent. There were 2.8 times more patients with balance disorders post the earthquake. Anxiety (P = 0.02), orthostatic dysregulation (P = 0.005), and motion sickness scores (P = 0.03) were all significantly higher after the earthquakes. A subset of participants underwent clinical equilibrium testing, showing significant deteriorations in the equilibrium test results (stabilometry: P = 0.01), cervical vestibular-evoked myogenic potentials (P = 0.04), and head-up tilt (P = 0.03) after the earthquake. The findings of this study also suggest that earthquake-induced disequilibrium may be further influenced by physical stressors, including sensory disruptions induced by earthquake vibrations, changes in the living conditions, and autonomic stress. This study increases our understanding of human equilibrium in response to natural disasters. Moreover, these findings will facilitate the management of dizziness experienced during or after such disasters. Future studies should identify strategies for mitigating autonomic dysfunction to prevent post-earthquake dizziness.

Five-year blood pressure trajectories of survivors of the tsunami following the Great East Japan Earthquake in Iwate

Whether tsunami survivors who suffered substantial damage experienced increases in blood pressure (BP) immediately after the disaster and in the medium to long term is unclear. We divided tsunami survivors into groups, those who relocated (substantial damage) and those who did not (little damage) and compared the BP trajectories between the groups over the first 5 years after the disaster. Of the 42,831 residents, 3914 were assessed from 2010 to 2015. Subgroup analysis was performed among the 2037 subjects with no information on antihypertensive medications between 2010 and 2015 (no antihypertensive medication group). The BP trajectories in the relocation and no relocation groups were compared using linear mixed models. The multivariate-adjusted mean systolic BP (SBP) values for all subjects significantly decreased after the disaster in both the group who relocated (2010: 130.6 mmHg, 2015: 124.8 mmHg) and the group who did not relocate (2010: 130.7 mmHg, 2015: 126.7 mmHg). The interaction between relocation and time points on SBP was significant (P = 0.017). In the no antihypertensive medication group, the SBP values in the subgroup who relocated were significantly lower in the second, third, and fifth years after the disaster than those in the subgroup who did not relocate. It was concluded that the SBP values of survivors of the tsunami caused by Great East Japan Earthquake decreased in the medium to long term after the disaster, and the group who relocated had a larger decrease in SBP than the group who did not relocate.

A Selective Review of Negative Control Methods in Epidemiology

PURPOSE OF REVIEW

Negative controls are a powerful tool to detect and adjust for bias in epidemiological research. This paper introduces negative controls to a broader audience and provides guidance on principled design and causal analysis based on a formal negative control framework.

RECENT FINDINGS

We review and summarize causal and statistical assumptions, practical strategies, and validation criteria that can be combined with subject-matter knowledge to perform negative control analyses. We also review existing statistical methodologies for the detection, reduction, and correction of confounding bias, and briefly discuss recent advances towards nonparametric identification of causal effects in a double-negative control design.

SUMMARY

There is great potential for valid and accurate causal inference leveraging contemporary healthcare data in which negative controls are routinely available. Design and analysis of observational data leveraging negative controls is an area of growing interest in health and social sciences. Despite these developments, further effort is needed to disseminate these novel methods to ensure they are adopted by practicing epidemiologists.

Takotsubo Syndrome: Finally Emerging From the Shadows?

It is now 30 years since Japanese investigators first described Takotsubo Syndrome (TTS) as a disorder occurring mainly in ageing women, ascribing it to the impact of multivessel coronary artery spasm. During the intervening period, it has become clear that TTS involves relatively transient vascular injury, followed by prolonged myocardial inflammatory and eventually fibrotic changes. Hence symptomatic recovery is generally slow, currently an under-recognised issue. It appears that TTS is induced by aberrant post-β₂-adrenoceptor signalling in the setting of "surge" release of catecholamines. Resultant activation of nitric oxide synthases and increased inflammatory vascular permeation lead to prolonged myocardial infiltration with macrophages and associated oedema formation. Initially, the diagnosis of TTS was made via exclusion of relevant coronary artery stenoses, plus the presence of regional left ventricular hypokinesis. However, detection of extensive myocardial oedema on cardiac MRI imaging offers a specific basis for diagnosis. No adequate methods are yet available for definitive diagnosis of TTS at hospital presentation. Other major challenges remaining in this area include understanding of the recently demonstrated association between TTS and antecedent cancer, the development of effective treatments to reduce risk of short-term (generally due to shock) and long-term mortality, and also to accelerate symptomatic recovery.

Short-term effect of stock volatility and cardiovascular mortality: a systematic review and meta-analysis

Background

Cardiovascular disease (CVD) and stroke are leading causes of death. It has several risk factors, including stress and pressure. Stock volatility can cause acute stress for stockholders so that it can cause CVD events. Recently, the spread of new coronaviruses worldwide has affected economic development greatly, leading to more severe stock market fluctuations, so we systematically quantify the short-term effect of stock volatility and CVD events.

Methods

Time-series analysis on the effect of stock volatility and cardiovascular events were concluded. We conducted a systematic literature search for studies published in PubMed, Embase, and Cochrane Data up to the date February 9, 2020. We assessed publication bias using Egger’s test. Overall analysis and sensitivity analysis were conducted separately.

Results

Four studies were finally included. Every 100-point increase in the stock market will bring about 1.01% increases in cardiovascular mortality [95% confidence intervals (CI), −0.18% to 2.21%]. The meta-analysis showed no statistical significance for cardiovascular mortality. Every 100-point increase in the stock market brought 1.01% increases in the cardiovascular mortality [95% CI, −0.18% to 2.21%]. In terms of stroke events, the estimated effect was 2.999% (95% CI, 0.325% to 5.673%). Different lag patterns also have effects on cardiovascular mortality. Every 100-point increase brought about 4.026% (95% CI, 1.516% to 6.536%) and 4.424% (95% CI, 1.145% to 7.703%) for lag 01 and 04 separately.

Conclusions

Though our study has a number of limitations due to the limited studies included, it suggested that stock volatility had a lagging effect on CVD mortality, which may last for several days. Also, it might increase the incidence of stroke.

The extended autonomic system, dyshomeostasis, and COVID-19

The pandemic viral illness COVID-19 is especially life-threatening in the elderly and in those with any of a variety of chronic medical conditions. This essay explores the possibility that the heightened risk may involve activation of the "extended autonomic system" (EAS). Traditionally, the autonomic nervous system has been viewed as consisting of the sympathetic nervous system, the parasympathetic nervous system, and the enteric nervous system. Over the past century, however, neuroendocrine and neuroimmune systems have come to the fore, justifying expansion of the meaning of "autonomic." Additional facets include the sympathetic adrenergic system, for which adrenaline is the key effector; the hypothalamic-pituitary-adrenocortical axis; arginine vasopressin (synonymous with anti-diuretic hormone); the renin-angiotensin-aldosterone system, with angiotensin II and aldosterone the main effectors; and cholinergic anti-inflammatory and sympathetic inflammasomal pathways. A hierarchical brain network-the "central autonomic network"-regulates these systems; embedded within it are components of the Chrousos/Gold "stress system." Acute, coordinated alterations in homeostatic settings (allostasis) can be crucial for surviving stressors such as traumatic hemorrhage, asphyxiation, and sepsis, which throughout human evolution have threatened homeostasis; however, intense or long-term EAS activation may cause harm. While required for appropriate responses in emergencies, EAS activation in the setting of chronically decreased homeostatic efficiencies (dyshomeostasis) may reduce thresholds for induction of destabilizing, lethal vicious cycles. Testable hypotheses derived from these concepts are that biomarkers of EAS activation correlate with clinical and pathophysiologic data and predict outcome in COVID-19 and that treatments targeting specific abnormalities identified in individual patients may be beneficial.

Trends in the Incidence of Sudden Deaths and Heart Diseases in Fukushima After the Great East Japan Earthquake

On March 11, 2011, a great earthquake, known as the Great East Japan Earthquake, hit northeastern Japan, resulting in a tsunami that caused a nuclear disaster, the Fukushima Daiichi Nuclear Power Plant accident, forcing about 160,000 people to evacuate. We, therefore, sought to examine the effects of this evacuation on the onset of cardiovascular diseases and sudden death (SD) in Fukushima Prefecture, three years after the earthquake. We divided the evacuation zone into two areas, whole evacuation zone (Area 1) and partial evacuation zone (Area 2), and we defined the north district of the prefecture as the control area (Area 3). We cross-referenced the death certificate data with data from the Fukushima Prefecture acute myocardial infarction registration survey. For each area, we tallied the number of people who fell into the SD, myocardial infarction (MI), and MI suspected groups. We calculated the age-adjusted incidence rates and analyzed the differences in the adjusted incidence rates across three years using a Poisson regression model. The age-adjusted death rate of the SD group was significantly higher in 2011 in all areas than in 2012 or 2013 (P < 0.05). The total death rate was higher in Area 1 in March 2011, just after the disaster, than in the other two areas. The rate of SD was also higher in Area 1 than in the other areas in March 2011. The incidence of sudden cardiac death might have increased just after the Great East Japan Earthquake in the evacuation area, but not in other areas in Fukushima Prefecture.

Lessons learned about stress and the heart after major earthquakes

There is evidence that certain stressors can trigger cardiovascular events. Several studies have now demonstrated an increase in major adverse cardiac events associated with natural disasters such as an earthquake. The purpose of this paper is to review the literature on earthquakes and cardiovascular events. Reports from 13 major quakes were reported. Earthquakes have been associated with a number of cardiac events including sudden cardiac death, fatal myocardial infarction (MI), myocardial infarction, stress cardiomyopathy, heart failure, stroke, arrhythmias, hypertension and pulmonary embolism. Most reports were associated with earthquakes of magnitude 6.0 or greater. Cardiac events were reported within hours of the quakes. In some reports there was a sharp spike in cardiac events followed by a decrease; but in other quakes the increases in cardiac events lasted weeks, months and even years. There often was an association between the cardiac events and amount of personal property loss. The Great East Japan Earthquake was an unusual event in that it was associated with a major tsunami and cardiac events appeared worse in inundated areas due to flooding. Some but not all reports suggested more MIs associated with early morning earthquakes that woke up the population. Hospitals in earthquake-prone areas should consider developing plans for handling increases in myocardial infarctions and other cardiac events that are associated with earthquakes.

Arrhythmic Risk in Elderly Patients Candidates to Transcatheter Aortic Valve Replacement: Predictive Role of Repolarization Temporal Dispersion

Background/Aim

Degenerative aortic valve stenosis (AS) is associated to ventricular arrhythmias and sudden cardiac death, as well as mental stress in specific patients. In such a context, substrate, autonomic imbalance as well as repolarization dispersion abnormalities play an undoubted role. Aim of the study was to evaluate the increase of premature ventricular contractions (PVC) and complex ventricular arrhythmias during mental stress in elderly patients candidate to the transcatheter aortic valve replacement (TAVR).

Methods

In eighty-one elderly patients with AS we calculated several short-period RR- and QT-derived variables at rest, during controlled breathing and during mild mental stress, the latter being represented by a mini-mental state evaluation (MMSE).

Results

All the myocardial repolarization dispersion markers worsened during mental stress (p < 0.05). Furthermore, during MMSE, low frequency component of the RR variability increased significantly both as absolute power (LF_RR) and normalized units (LF_{RRN U}) (p < 0.05) as well as the low-high frequency ratio (LF_RR/HF_RR) (p < 0.05). Eventually, twenty-four (30%) and twelve (15%) patients increased significantly PVC and, respectively, complex ventricular arrhythmias during the MMSE administration. At multivariate logistic regression analysis, the standard deviation of QTend (QTe_sd), obtained at rest, was predictive of increased PVC (odd ratio: 1.54, 95% CI 1.14-2.08; p = 0.005) and complex ventricular arrhythmias (odd ratio: 2.31, 95% CI 1.40-3.83; p = 0.001) during MMSE. The QTe_sd showed the widest sensitive-specificity area under the curve for the increase of PVC (AUC: 0.699, 95% CI: 0.576-0.822, p < 0.05) and complex ventricular arrhythmias (AUC: 0.801, 95% CI: 0.648-0.954, p < 0.05).

Conclusion

In elderly with AS ventricular arrhythmias worsened during a simple cognitive assessment, this events being a possible further burden on the outcome of TAVR. QTe_sd might be useful to identify those patients with the highest risk of ventricular arrhythmias. Whether the TAVR could led to a QTe_sd reduction and, hence, to a reduction of the arrhythmic burden in this setting of patients is worthy to be investigated.

Two major earthquakes in Christchurch were not associated with increased ventricular arrhythmias: Analysis of implanted defibrillator diagnostics

Aim

Christchurch, New Zealand, experienced two major earthquakes on 4^th September 2010 and 22^nd February 2011. Previous studies have demonstrated that earthquakes are associated with sudden cardiac deaths. Whilst myocardial ischemia would contribute to this, ventricular arrhythmia triggered by stress has also been suggested. We aim to study the impact of the two earthquakes on ventricular arrhythmia events.

Methods

We conducted a retrospective review of all patients resident in the earthquake zone with implantable defibrillators. Ventricular arrhythmia requiring therapy and non-sustained events were recorded from the period of 30 days before thru 30 days after the two earthquakes. Weekly event rates were calculated and compared using log rank analysis. Results are expressed as mean (range), significance was determined at the <0.05 level.

Results

For the 211 patients who were exposed to the 2010 earthquake, there was no difference in the proportion of patients free of therapy, either Shock or ATP (0.943 before and 0.933 after the earthquake, p = 0.85, ns). Similarly, there was no significant increase in events requiring therapy in the 236 patients exposed to the 2011 earthquake (0.957 before and 0.961 after the earthquake, p = 0.80, ns). We identified one patient who required multiple therapy for ventricular tachycardia immediately following both earthquakes.

Conclusion

The two Christchurch earthquakes were not associated with an increase in the event rate of either sustained or non-sustained ventricular arrhythmias in our patients. We identified only a single patient who had arrhythmic storms immediately following the earthquakes.

Ten Surprising Facts About Stressful Life Events and Disease Risk

After over 70 years of research on the association between stressful life events and health, it is generally accepted that we have a good understanding of the role of stressors in disease risk. In this review, we highlight that knowledge but also emphasize misunderstandings and weaknesses in this literature with the hope of triggering further theoretical and empirical development. We organize this review in a somewhat provocative manner, with each section focusing on an important issue in the literature where we feel that there has been some misunderstanding of the evidence and its implications. Issues that we address include the definition of a stressful event, characteristics of diseases that are impacted by events, differences in the effects of chronic and acute events, the cumulative effects of events, differences in events across the life course, differences in events for men and women, resilience to events, and methodological challenges in the literature.

Acute and Subacute Triggers of Cardiovascular Events

Inability to predict short-term cardiovascular (CV) events and take immediate preemptive actions has long been the Achilles heel of cardiology. However, certain triggers of these events have come to light. Although these triggers are nonspecific and are part of normal life, studying their temporal relationship with the onset of CV events provides an opportunity to alert high-risk atherosclerotic patients who may be most vulnerable to such triggers, the "vulnerable patient". Herein, we review the literature and shed light on the epidemiology and underlying pathophysiology of different triggers. We describe that certain adrenergic triggers can precipitate a CV event within minutes or hours; whereas triggers that elicit an immune or inflammatory response such as infections may tip an asymptomatic "vulnerable patient" to become symptomatic days and weeks later. In conclusion, healthcare providers should counsel high-risk CV patients (e.g., in secondary prevention clinics or those with coronary artery Calcium >75th percentile) on the topic, advise them to avoid such triggers, take protective measures once exposed, and seek emergency care immediately after becoming symptomatic after such triggers. Furthermore, clinical trials targeting triggers (prevention or intervention) are needed.

Acute stress and subsequent health outcomes: A systematic review

OBJECTIVE

To systematically review the relationship between acute posttraumatic stress symptoms (<1 month) and subsequent physical and mental health outcomes other than posttraumatic stress disorder (PTSD).

METHODS

A systematic search of electronic databases (PubMed, PsycINFO, CINAHL, and Web of Science) was conducted to identify longitudinal studies examining the link between acute posttraumatic stress and physical and mental health. Inclusion criteria required assessment of acute posttraumatic stress (<1 month post-event) and at least one follow-up assessment of a physical or mental health outcome (not PTSD).

RESULTS

1,051 articles were screened; 22 met inclusion criteria. Fourteen studies examined physical health outcomes and 12 examined non-PTSD mental health outcomes. Early psychological responses to trauma were associated with a variety of short- (<1 year) and long- (≥1 year) term physical and mental health outcomes. Physical health outcomes included poor general physical health, increased pain and disability, lower quality of life, and higher risk of all-cause mortality. Significant psychological outcomes included more cumulative psychiatric disorders, depression, and anxiety. Significant psychosocial outcomes included increased family conflict.

CONCLUSIONS

Methodologically rigorous longitudinal studies support the utility of measuring acute psychological responses to traumatic events as they may be an important marker of preventable trauma-related morbidity and mortality that warrants long-term monitoring and/or early intervention.

At the heart of programming: the role of micro-RNAs

Epidemiological and experimental observations tend to prove that environment, lifestyle or nutritional challenges influence heart functions together with genetic factors. Furthermore, when occurring during sensitive windows of heart development, these environmental challenges can induce an 'altered programming' of heart development and shape the future heart disease risk. In the etiology of heart diseases driven by environmental challenges, epigenetics has been highlighted as an underlying mechanism, constituting a bridge between environment and heart health. In particular, micro-RNAs which are involved in each step of heart development and functions seem to play a crucial role in the unfavorable programming of heart diseases. This review describes the latest advances in micro-RNA research in heart diseases driven by early exposure to challenges and discusses the use of micro-RNAs as potential targets in the reversal of the pathophysiology.

Impact of major earthquakes on the incidence of acute coronary syndromes - A systematic review of the literature

Natural disasters such as tsunami, hurricanes, and earthquakes may have a negative impact on cardiac health. The aim of our systematic review is to evaluate the impact of earthquakes on the incidence of acute coronary syndromes and cardiac mortality and to examine the impact of the time of earthquakes on the incidence of acute coronary syndromes. MEDLINE and Cochrane databases were searched for studies assessing the impact of earthquakes on acute coronary syndromes from inception until December 20, 2017. Reference lists of all included studies and relevant review studies were also searched. A total of 26 studies on 12 earthquake disasters were included in the systematic review. The existing data show a significant negative impact of the Great East Japan, Christchurch, Niigata-Chuetsu, Northridge, Great Hanshin-Awaji, Sichuan, Athens, Armenia, and Noto Peninsula earthquakes on the incidence of acute coronary syndromes. By contrast, studies on the Newcastle, Loma Prieta, and Thessaloniki earthquakes did not show a significant correlation with myocardial infarction and cardiac mortality. In conclusion, earthquakes may be associated with increased incidence of acute coronary syndromes and cardiovascular mortality. There are conflicting data about the impact of the timing of earthquakes on the occurrence of acute coronary syndromes. Preventive measures to promote the adjustment of healthcare systems to treat cardiovascular diseases after natural disasters should be immediately implemented particularly in high-risk regions.

Three-Year Follow-up After the Great East Japan Earthquake in the Incidence of Out-of-Hospital Cardiac Arrest With Cardiac Origin

BACKGROUND

We assessed whether the occurrence of out-of-hospital cardiac arrest (OHCA) with cardiac origin increased in the disaster areas during the 3-year period after the Great East Japan Earthquake (GEJE).Methods and Results:From the OHCA registry in Japan, yearly changes in occurrence after the GEJE were assessed by applying Poisson regression models. The risk ratio of the first year after the earthquake was significantly greater in both men and women, but the difference disappeared in the second and third years.

CONCLUSIONS

The GEJE significantly increased the occurrence of OHCA with cardiac origin in the first year after the earthquake.

Physical Activity and Anger or Emotional Upset as Triggers of Acute Myocardial Infarction: The INTERHEART Study

BACKGROUND

Physical exertion, anger, and emotional upset are reported to trigger acute myocardial infarction (AMI). In the INTERHEART study, we explored the triggering association of acute physical activity and anger or emotional upset with AMI to quantify the importance of these potential triggers in a large, international population.

METHODS

INTERHEART was a case-control study of first AMI in 52 countries. In this analysis, we included only cases of AMI and used a case-crossover approach to estimate odds ratios for AMI occurring within 1 hour of triggers.

RESULTS

Of 12 461 cases of AMI 13.6% (n=1650) engaged in physical activity and 14.4% (n=1752) were angry or emotionally upset in the case period (1 hour before symptom onset). Physical activity in the case period was associated with increased odds of AMI (odds ratio, 2.31; 99% confidence interval [CI], 1.96-2.72) with a population-attributable risk of 7.7% (99% CI, 6.3-8.8). Anger or emotional upset in the case period was associated with an increased odds of AMI (odds ratio, 2.44; 99% CI, 2.06-2.89) with a population-attributable risk of 8.5% (99% CI, 7.0-9.6). There was no effect modification by geographical region, prior cardiovascular disease, cardiovascular risk factor burden, cardiovascular prevention medications, or time of day or day of onset of AMI. Both physical activity and anger or emotional upset in the case period were associated with a further increase in the odds of AMI (odds ratio, 3.05; 99% CI, 2.29-4.07; P for interaction <0.001).

CONCLUSIONS

Physical exertion and anger or emotional upset are triggers associated with first AMI in all regions of the world, in men and women, and in all age groups, with no significant effect modifiers.

Long-term prognostic impact of the Great East Japan Earthquake in patients with cardiovascular disease - Report from the CHART-2 Study

BACKGROUND

We and others have previously reported that the Great East Japan Earthquake (GEJE) caused a significant but transient increase in cardiovascular diseases and deaths in the disaster area. However, it remains to be examined whether the GEJE had a long-term prognostic influence in large-scale cohort studies. This point is important when analyzing the data before and after the GEJE in the cohort studies in the disaster area.

METHODS

We examined 8676 patients registered in our Chronic Heart Failure Analysis and Registry in the Tohoku District-2 (CHART-2) Study (N=10,219) between 2006 and 2010 and were alive after March 10, 2011.

RESULTS

There were 48 GEJE-related deaths, causing a sharp and transient increase in all-cause death within a month after the GEJE. However, after excluding the GEJE-related deaths, the cubic polynomial spline smoothing showed no significant increase in all-cause death, heart failure admission, non-fetal acute myocardial infarction, or non-fetal stroke during the median 3-year follow-up after the GEJE. The extrapolation curves beyond the GEJE, which were obtained by the parametric survival models based on the survival data censored on the GEJE, were not significantly different from the Kaplan-Meier curves estimating the survival functions of deaths and cardiac events during the total follow-up period without considering the impacts of the GEJE. Furthermore, the multivariate Cox proportional hazard model applied to the matched cohort of the baseline data and the data after the GEJE showed no significant differences in the impacts of prognostic factors on all-cause mortality before and after the GEJE.

CONCLUSIONS

These results indicate that the GEJE had no significant long-term prognostic impact after the earthquake in cardiovascular patients in the disaster area.

Gender Differences in Post-Traumatic Stress

Acute stress can trigger cardiovascular events and disease. The earthquake is an "ideal" natural experiment for acute and chronic stress, with impact mainly on the cardiovascular system. On May 20th and 29th, 2012, two earthquakes of magnitude 5.9° to 6.4° on the Richter scale, hit the province of Modena and Reggio Emilia, an area of the north-center of Italy never considered at seismic risk. The purpose of our study was to assess whether there were gender-specific differences in stress-induced incidence of cardiovascular events and age of patients who arrived at the Emergency Departments (ED) of the three main teaching hospitals of the University of Modena and Reggio Emilia. Global access of patients, divided in relation to age, gender, and diagnosis was compared with that one detected in the same departments and in the same interval of time in 2010. The data collected were relative to consecutive cases derived by retrospective chart and acute cardiovascular events were classified according to ICD-9 (International Classification of Diseases, ninth revision). A total of 1,401 accesses were recorded in the year of earthquake versus 530 in 2010 (p ≤ 0.05), with no statistically significant differences in number of cases and mean age in relation to gender, despite the number of women exceeded that of men in 2012 (730 vs. 671); the opposite occurred, in 2010 (328 vs. 202). The gender analysis of 2012 showed a prevalence of acute coronary syndromes (ACSs 177 vs. 73, p ≤ 0.03) in men, whereas women presented more strokes and transient ischemic attacks (TIAs) (90 vs. 94, p ≤ 0.05), atrial fibrillation (120 vs. 49, p ≤ 0.05), deep venous thrombosis and pulmonary embolism (DVT/PE; 64 vs. 9, p ≤ 0.05), panic attacks (124 vs. 26, p ≤ 0.03), aspecific chest pain (122 vs. 18, p ≤ 0.05), TakoTsubo cardiomyopathy (10 vs. 0, p ≤ 0.05), and DVT/PE (61 vs. 3, p ≤ 0.03). The gender analysis of 2010 showed no difference in number of accesses and age, with higher incidence of ACS in men (130 vs. 34, p ≤ 0.05) and aspecific chest pain in women (42 vs. 5, p ≤ 0.05). The analysis between 2012 and the standard period (2010) showed women recurring to ED in larger number with more panic attacks (124 vs. 3, p ≤ 0.01), more atrial fibrillation (120 vs. 40, p ≤ 0.01) and, as a possible consequence, more TIAs and strokes (190 vs. 25, p ≤ 0.005), more TakoTsubo (10 vs. 0, p ≤ 0.05), DVT/PE (61 vs. 3, p ≤ 0.05), and aspecific chest pain (122 vs. 5, p ≤ 0.01). The difference between men's accesses to ED was less striking, but in 2012 men reported more panic attacks (26 vs. none, p ≤ 0.05), more atrial fibrillations, TIAs, and strokes (49 vs. 13, p ≤ 0.05 and 94 vs. 18, p ≤ 0.03). In conclusion, clinical (stress induced) events recorded during and immediately after the 2012 earthquakes were quite different between women and men, although the pathophysiological mechanism was probably the same, consisting acute sympathetic nervous activation, with elevation of blood pressure and heart rate, endothelial dysfunction, platelet and hemostatic activation, increased blood viscosity, and hypercoagulation. Women, in our observation, appeared to be more sensitive and responsive to acute stress, although men also appeared to suffer from stress effects when compared with a standard period, which, nevertheless, reflects in our population the most common epidemiology of gender difference in ED accesses for cardiovascular events.

Prevalence of Hypertension among Patients Attending Mobile Medical Clinics in the Philippines after Typhoon Haiyan

Introduction: On November 8, 2013, Super Typhoon Haiyan struck the Philippines, causing a humanitarian emergency. According to the World Health Organization, non-communicable diseases (NCDs), also known as chronic diseases, are the leading cause of death and disability around the world. NCDs kill 38 million people each year.  Sixteen million NCD deaths occur before the age of 70; 82% of which occurred in low- and middle-income countries.  NCDs are further exacerbated during a crisis, and addressing them should be a concern of any medical disaster response.

Methods: We conducted a retrospective observational study to determine the prevalence of hypertension among patients seeking medical care at mobile medical clinics after Typhoon Haiyan in the Philippines.

Results: A total of 3,730 adults were evaluated at the mobile medical clinics. Analysis of the medical records revealed that the overall prevalence of hypertension among adult patients was 47%. Approximately 24% of adult females and 27% of adult males were classified with stage 2 Hypertension.

Conclusions: Evidence-based guidelines on the management of hypertension and other NCDs (diabetes mellitus, cardiovascular disease, chronic lung disease and mental health) during humanitarian emergencies are limited. Clinical care of victims of humanitarian emergencies suffering with NCDs should be a critical part of disaster relief and recovery efforts.  We therefore recommend the development of best practices and evidence based management guidelines of hypertension and other NCDs in post-disaster settings.

Sustained Increase in the Incidence of Acute Decompensated Heart Failure After the 2011 Japan Earthquake and Tsunami

This study investigated the long-term impact of the 2011 Japan earthquake and tsunami on the incidence of acute decompensated heart failure (HF) in the disaster area. This was a population-based study using comprehensive registration for all hospitals within the study area. The standardized incidence ratio (SIR) and 95% confidence interval (CI) for new onset of HF during the disaster year (2011) and postdisaster years (2012 to 2014) were determined. When SIR were compared between the low- and high-impact areas, as defined by the extent of tsunami inundation in residential areas, SIR showed a significant increase in high-impact areas in 2011 (1.67, 95% CI 1.45 to 1.88) and tended to return to baseline in 2012, the first postdisaster year (1.25, 95% CI 1.06 to 1.43). The rate again increased in 2013 (1.38, 95% CI 1.18 to 1.57) and 2014 (1.55, 95% CI 1.35 to 1.75). In low-impact areas, no such increase was apparent during either the disaster year or the postdisaster years. Mean postdisaster period SIR for municipalities significantly correlated with the percentage of tsunami flooding in residential areas (r = 0.52, p <0.05) and with the percentage of refugees within the population (r = 0.74, p <0.01). There was no significant relation between maximum seismic intensity and mean SIR in these municipalities. In conclusion, these results suggest that the catastrophic tsunami but not the earthquake per se resulted in a prolonged increase in the incidence of HF among the general population living in tsunami-stricken areas.

Modifying the Interagency Emergency Health Kit to include treatment for non-communicable diseases in natural disasters and complex emergencies

The Interagency Emergency Health Kit (IEHK) provides a standard package of medicines and simple medical devices for aid agencies to use in emergencies such as disasters and armed conflicts. Despite the increasing burden of non-communicable diseases (NCDs) in such settings, the IEHK includes few drugs and devices for management of NCDs. Using published data to model the population burden of acute and chronic presentations of NCDs in emergency-prone regions, we estimated the quantity of medications and devices that should be included in the IEHK. NCDs considered were cardiovascular diseases, diabetes, hypertension and chronic respiratory disease. In scenario 1 (the primary scenario), we assumed that resources in the IEHK would only include those needed to manage acute life-threatening conditions. In scenario 2, we included resources required to manage both acute and chronic presentations of NCDs. Drugs and devices that might be required included amlodipine, aspirin, atenolol, beclomethasone, dextrose 50%, enalapril, furosemide, glibenclamide, glyceryl trinitrate, heparin, hydralazine, hydrochlorothiazide, insulin, metformin, prednisone, salbutamol and simvastatin. For scenario 1, the number of units required ranged from 12 (phials of hydralazine) to ∼15 000 (tablets of enalapril). Space and weight requirements were modest and total cost for all drugs and devices was approximately US$2078. As expected, resources required for scenario 2 were much greater. Space and cost requirements increased proportionately: estimated total cost of scenario 2 was $22 208. The resources required to treat acute NCD presentations appear modest, and their inclusion in the IEHK seems feasible.

Short-Term Public Health Impact of the July 22, 2011, Terrorist Attacks in Norway: A Nationwide Register-Based Study

OBJECTIVES

To examine increases in several health outcomes after the July 22, 2011 terrorist attacks in Norway.

METHODS

Retrospective analysis of nationwide registers (n = 4,953,000) where incidences of schizophrenia/psychosis hospitalizations, suicides, acute myocardial infarctions, and preterm births after the terrorist attacks were compared with corresponding periods the previous 3 years.

RESULTS

Compared with the same period the preceding 3 years, the observed number of hospitalizations from schizophrenia/psychosis was 14% higher during the first 4 weeks after the terrorist attack (incidence ratio [IR] = 1.14, 95% confidence interval [CI] = 1.07-1.21). The corresponding IRs for the first 3 days and the first week were 1.26 (95% CI = 0.99-1.58) and 1.10 (95% CI = 0.96-1.24). The observed number of suicides was increased by 45% the first 4 weeks (IR = 1.45, 95% CI = 1.12-1.86), 163% the first 3 days (IR = 2.63, 95% CI = 1.15-5.20), and 105% the first week (IR = 2.05, 95% CI = 1.14-3.42). For acute myocardial infarction, there was an increase of 5% the first 4 weeks. There were also more births the 4 weeks (IR = 1.04, 95% CI = 1.01-1.07, but this increase was not seen in preterm births of less than 37 weeks of gestation (IR = 0.93, 95% CI = 0.83-1.04).

CONCLUSIONS

We observed a general nationwide increase of health outcomes investigated in this study the first 4 weeks after the terrorist attacks. These results may contribute to the growing body of evidence on the adverse health outcomes that may accompany national stressors.

Laughter is the Best Medicine? A Cross-Sectional Study of Cardiovascular Disease Among Older Japanese Adults

Background

We sought to evaluate the associations between frequency of daily laughter with heart disease and stroke among community-dwelling older Japanese women and men.

Methods

We analyzed cross-sectional data in 20 934 individuals (10 206 men and 10 728 women) aged 65 years or older, who participated in the Japan Gerontological Evaluation Study in 2013. In the mail-in survey, participants provided information on daily frequency of laughter, as well as body mass index, demographic and lifestyle factors, and diagnoses of cardiovascular disease, hyperlipidemia, hypertension, and depression.

Results

Even after adjustment for hyperlipidemia, hypertension, depression, body mass index, and other risk factors, the prevalence of heart diseases among those who never or almost never laughed was 1.21 (95% CI, −1.03–1.41) times higher than those who reported laughing every day. The adjusted prevalence ratio for stroke was 1.60 (95% CI, 1.24–2.06).

Conclusions

Daily frequency of laughter is associated with lower prevalence of cardiovascular diseases. The association could not be explained by confounding factors, such as depressive symptoms.

Impact of Prostate Cancer Diagnosis on Noncancer Hospitalizations Among Elderly Medicare Beneficiaries With Incident Prostate Cancer

OBJECTIVES

The purpose of this study was to analyze the impact of cancer diagnosis on noncancer hospitalizations (NCHs) by comparing these hospitalizations between the precancer and postcancer periods in a cohort of fee-for-service Medicare beneficiaries with incident prostate cancer.

METHODS

A population-based retrospective cohort study was conducted using the SEER-Medicare linked database for 2000 through 2010. The study cohort consisted of 57,489 elderly men (aged ≥ 67 years) with incident prostate cancer. NCHs were identified in 6 periods (t1-t6) before and after the incidence of prostate cancer. Each period consisted of 120 days. For each period, NCHs were defined as inpatient admissions with primary diagnosis codes not related to prostate cancer, prostate cancer-related procedures, or bowel, sexual, and urinary dysfunction. Bivariate and multivariate comparisons on rates of NCHs between the precancer and postcancer periods accounted for the repeated measures design.

RESULTS

The rate of NCHs was higher during the postcancer period (5.1%) compared with the precancer period (3.2%). In both unadjusted and adjusted models, elderly men were 37% (odds ratio [OR], 1.37; 95% CI, 1.32, 1.41) and 38% (adjusted OR, 1.38; 95% CI, 1.33, 1.46) more likely to have any NCHs during the postcancer period compared with the precancer period.

CONCLUSIONS

Elderly men with prostate cancer had a significant increase in the risk of NCHs after the diagnosis of prostate cancer. This study highlights the need to design interventions for reducing the excess NCHs after prostate cancer diagnosis among elderly men.