Analysis of environmental risk factors for pulmonary embolism: A case-crossover study (2001-2013)

Pulmonary Embolism in a Young African American Male: A Diagnostic Challenge

This case report highlights the diagnostic challenges posed by pulmonary embolism (PE) in a young, otherwise healthy 33-year-old African American male with no apparent risk factors. The patient presented with penile pain, swelling, hematuria, flank pain, and rash, and was admitted for balanoposthitis and acute urinary retention. Despite prophylactic heparin, he suffered two cardiac arrests secondary to PE on the fifth day of hospitalization. Prompt thrombolytic therapy and heparin infusion were initiated, but his course was complicated by anuric acute kidney injury requiring hemodialysis, shock liver, and gastrointestinal bleeding. Imaging revealed a substantial thrombus burden in the pulmonary arteries. Notably, a hypercoagulable workup was negative. The absence of typical risk factors, negative hypercoagulable workup, and occurrence of PE despite prophylaxis underscore the importance of vigilance in recognizing atypical presentations. This case emphasizes the need for a high index of suspicion and comprehensive evaluation to diagnose PE in young patients without clear predisposing factors.

Low ambient temperature might trigger the symptom onset of pulmonary embolism: A nationwide case-crossover study at hourly level in China

BACKGROUND

Pulmonary embolism (PE) is an important cause of death and its seasonality has long been observed. Very few epidemiological studies have explored the potential role of ambient temperature in PE symptom onset, especially at the hourly level.

METHODS

We conducted a time-stratified case-crossover study among 17,903 PE patients with hourly onset of symptom from 1590 hospitals across China between January 2015 and September 2020. Conditional logistic regression model combined with distributed lag non-linear models were used to explore the associations between hourly ambient temperature and PE symptom onset. The attributable fractions due to non-optimum temperature were calculated.

RESULTS

The exposure-response relationship curve was inverse and almost linear. Lower temperature was significantly associated with higher risk of PE symptom onset when temperature was below 18 °C. This risk occurred immediately at the same hour, attenuated thereafter, and became nonsignificant at approximately 72 h after exposure. Compared with the referent temperature (P₉₉, 34.1 °C), the odds ratio of PE symptom onset associated with extremely low temperature (P₁, -16.1 °C) over lag 0-72 h was 1.63 (95%CI: 1.23, 2.16). Low temperature may account for 16.19 % of the symptom onset nationally with higher proportion in the south of China. The effects were stronger in older adults, males, and cold seasons.

CONCLUSIONS

We provided the first-hand robust evidence that transient exposure (at the hourly level) to low temperature might trigger the symptom onset of PE and constitute a considerable burden for PE patients. Targeted protections and health education are needed for susceptible populations.

Correlation of Air Pollution and Prevalence of Acute Pulmonary Embolism in Northern Thailand

BACKGROUND

The relationship between the level of air pollution and acute pulmonary embolism (APE) has had inconsistent results.

OBJECTIVE

This study aimed to analyze the relationship between the high level of air pollution exposure and APE.

METHODS

A ten-year retrospective cohort, single-center study was performed on patients diagnosed with APE from October 2010 to December 2020. The association between air pollution and monthly APE case diagnosis was analyzed.

RESULTS

A total number of 696 patients was included. The effect of every 10 µg/m³ increment of particulate matters with an aerodynamic diameter < 10 µm (PM₁₀) on total monthly APE cases (unprovoked PE and provoked PE) was increased significantly at lag 4, 5 and 6 months with adjusted RR (95% CI) of 1.06 (1.01, 1.12), p = 0.011, 1.07 (1.01, 1.13), p = 0.021 and 1.06 (1.01, 1.12), p = 0.030, respectively. Adjusted RR for APE was significantly increased for PM₁₀ in the second tertile ((adjusted RR (95% CI) 1.76 (1.12, 2.77)), p = 0.014.

CONCLUSIONS

We conclude that PM₁₀ is associated with an increased prevalence of APE cases. The policy for tighter control of air pollution in our country is needed to reduce the impact of air pollutants on people's health.

Air pollution increases the risk of pulmonary embolism: a meta-analysis

OBJECTIVES

Air pollution can lead to many cardiovascular and respiratory diseases, but the impact of air pollution on pulmonary embolism is still uncertain. We conducted a meta-analysis to assess the relationship between air pollution and pulmonary embolism.

CONTENT

We searched PubMed, EMBASE, Web of Science, and the Cochran Library for citations on air pollutants (carbon monoxide, sulfur dioxide, nitrogen dioxide, ozone and particulate matter) and pulmonary embolism. A total of nine citations met the inclusion criteria. There is no evidence of bias. CO, SO₂, PM₁₀ and PM_2.5 had no significant effect on the occurrence of pulmonary embolism. NO₂ and O₃ can increase the risk of pulmonary embolism to a small extent.

SUMMARY

This meta-analysis suggests that some air pollutants are associated with an increased risk of pulmonary embolism.

OUTLOOK

Reducing air pollution and improving air quality can effectively reduce the risk of pulmonary embolism.

Climatic influences on cardiovascular diseases

Classical risk factors only partially account for variations in cardiovascular disease incidence; therefore, also other so far unknown features, among which meteorological factors, may influence heart diseases (mainly coronary heart diseases, but also heart failure, arrhythmias, aortic dissection and stroke) rates. The most studied phenomenon is ambient temperature. The relation between mortality, as well as cardiovascular diseases incidence, and temperature appears graphically as a ''U'' shape. Exposure to cold, heat and heat waves is associated with an increased risk of acute coronary syndromes. Other climatic variables, such as humidity, atmospheric pressure, sunlight hours, wind strength and direction and rain/snow precipitations have been hypothesized as related to fatal and non-fatal cardiovascular diseases incidence. Main limitation of these studies is the unavailability of data on individual exposure to weather parameters. Effects of weather may vary depending on other factors, such as population disease profile and age structure. Climatic stress may increase direct and indirect risks to human health via different, complex pathophysiological pathways and exogenous and endogenous mechanisms. These data have attracted growing interest because of the recent earth's climate change, with consequent increasing ambient temperatures and climatic fluctuations. This review evaluates the evidence base for cardiac health consequences of climate conditions, and it also explores potential further implications.

Association between exposure to air pollutants and the risk of hospitalization for pulmonary embolism in Beijing, China: A case-crossover design using a distributed lag nonlinear model

BACKGROUND

Pulmonary embolism (PE) is a life-threatening condition. Few studies have evaluated the relationship between air pollution and PE, and these results have been inconsistent. Therefore, our study aimed to investigate the association between air pollutant exposure and the risk of hospitalization due to PE.

MATERIALS AND METHODS

Daily PE admissions, meteorological data, and ambient pollution data from January 1, 2015, to December 31, 2018, were collected in Beijing. A quasi-Poisson regression model combined with time-stratified case-crossover design and a distributed lag nonlinear model was used to determine the effect of air pollutant exposure on PE admission. To examine the stability of air pollutants' effects, multi-pollutant analyses were performed. Stratified analyses by age and sex were further conducted.

RESULTS

There were 5060 PE admissions during the study period, with an estimated incidence of 6.5 per 100,000. PM_2.5, PM₁₀, SO₂, O₃ and CO exposures were significantly associated with elevated risk of PE hospitalization. The highest cumulative risks were observed at a lag of 0-28 days for PM_2.5 (relative risk [RR] = 1.056, 95% confidence intervals [CI]: 1.015-1.098), PM₁₀ (RR = 1.042, 95%CI: 1.010-1.075), and CO (RR = 1.466, 95%CI: 1.127-1.906), at a lag of 0-27 days for SO₂ (RR = 1.674, 95%CI: 1.200-2.335), and at a lag of 0-4 days for O₃ (RR = 1.019, 95%CI: 1.001-1.038). All associations mentioned above except O₃ remained significant in multi-pollutant models. Stratified analyses showed that women and those aged ≥65 years people were more sensitive to PM₁₀ and CO exposure than men and those aged <65 years. The effect of PM_2.5 exposure was statistically significant in all subgroups.

CONCLUSIONS

Exposure to PM_2.5, PM₁₀, SO₂, and CO showed a positive association with PE hospitalization. High-risk PE groups should take special precautions on days with poor air quality.

Association between air temperature, air pollution and hospital admissions for pulmonary embolism and venous thrombosis in Italy

BACKGROUND

Previous studies reported a link between short-term exposure to environmental stressors (air pollution and air temperature) and atherothrombotic cardiovascular diseases. However, only few of them reported consistent associations with venous thromboembolism (VTE). Our aim was to estimate the association between daily air temperature and particulate matter (PM) air pollution with hospital admissions for pulmonary embolism (PE) and venous thrombosis (VT) at national level in Italy.

METHODS

We collected daily hospital PE and VT admissions from the Italian Ministry of Health during 2006-2015 in all the 8,084 municipalities of Italy, and we merged them with air temperature and daily PM10 concentrations estimated by satellite-based spatiotemporal models. First, we applied multivariate Poisson regression models at province level. Then, we obtained national overall effects by random-effects meta-analysis.

RESULTS

This analysis was conducted on 219,952 PE and 275,506 VT hospitalizations. Meta-analytical results showed weak associations between the two exposures and the study outcomes in the full year analysis. During autumn and winter, PE hospital admissions increased by 1.07% (95% confidence intervals [CI]: 0.21%; 1.92%) and 0.96% (95% CI: 0.07%; 1.83%) respectively, per 1 °C decrement of air temperature in the previous 10 days (lag 0-10). In summer we observed adverse effects at high temperatures, with a 1% (95% CI: 0.10%; 1.91%) increasing risk per 1 °C increment. We found no association between VT and cold temperatures.

CONCLUSION

Results show a significant effect of air temperature on PE hospitalizations in the cold seasons and summer. No effect of particulate matter was detected.

COPD exacerbations are related to poor air quality in Innsbruck: A retrospective pilot study

BACKGROUND

Triggers of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are diverse, potentially including airborne pollutants.

OBJECTIVES

To analyze whether daily air pollution levels correlate with AECOPD frequency.

METHODS

In this retrospective pilot-study, AECOPD frequency was recorded between 2010 and 2016 at the University Hospital of Innsbruck's emergency department and correlated with daily air quality parameters. Data was compared to pulmonary embolism (PE) frequency, a disease not directly involving the airways.

RESULTS

In total, 669 AECOPD and 857 PE events were registered. Days with AECOPD revealed significantly higher concentrations of CO and SO₂, whereas days with PE displayed an elevation of NO. Higher frequencies of AECOPD during winter months correlated with higher CO and SO₂ levels, disclosing a seasonal trend, while no such pattern was observed for PE.

CONCLUSION

Air pollution is linked to AECOPD frequency, however, prospective studies are needed to confirm this possible, underrecognized trigger of AECOPD.

The effect of air-pollution and weather exposure on mortality and hospital admission and implications for further research: A systematic scoping review

BACKGROUND

Air-pollution and weather exposure beyond certain thresholds have serious effects on public health. Yet, there is lack of information on wider aspects including the role of some effect modifiers and the interaction between air-pollution and weather. This article aims at a comprehensive review and narrative summary of literature on the association of air-pollution and weather with mortality and hospital admissions; and to highlight literature gaps that require further research.

METHODS

We conducted a scoping literature review. The search on two databases (PubMed and Web-of-Science) from 2012 to 2020 using three conceptual categories of "environmental factors", "health outcomes", and "Geographical region" revealed a total of 951 records. The narrative synthesis included all original studies with time-series, cohort, or case cross-over design; with ambient air-pollution and/or weather exposure; and mortality and/or hospital admission outcomes.

RESULTS

The final review included 112 articles from which 70 involved mortality, 30 hospital admission, and 12 studies included both outcomes. Air-pollution was shown to act consistently as risk factor for all-causes, cardiovascular, respiratory, cerebrovascular and cancer mortality and hospital admissions. Hot and cold temperature was a risk factor for wide range of cardiovascular, respiratory, and psychiatric illness; yet, in few studies, the increase in temperature reduced the risk of hospital admissions for pulmonary embolism, angina pectoris, chest, and ischemic heart diseases. The role of effect modification in the included studies was investigated in terms of gender, age, and season but not in terms of ethnicity.

CONCLUSION

Air-pollution and weather exposure beyond certain thresholds affect human health negatively. Effect modification of important socio-demographics such as ethnicity and the interaction between air-pollution and weather is often missed in the literature. Our findings highlight the need of further research in the area of health behaviour and mortality in relation to air-pollution and weather, to guide effective environmental health precautionary measures planning.

Influence of weather and air pollution on the occurrence of idiopathic pulmonary embolism in the region of Sousse (Tunisia)

Pulmonary embolism (PE) is the most serious manifestation of thromboembolic conditions. Its incidence varies considerably between countries, suggesting its interaction with the external environment. To analyze the influence of climate and air pollution on the occurrence of idiopathic PE in the region of Sousse (Tunisia). A total of 142 patients with idiopathic PE at two academic hospitals in Sousse (Tunisia) were enrolled in the study over a 7-year period. An analysis of two time series (environmental data and PE cases) was performed. Climatic data were collected from the National Institute of Meteorology. Air pollution data were obtained from the modeling platform of the National Agency for Protection of the Environment. The year 2015 was marked by the occurrence of the highest number of cases (24.6%). A statistically significant decrease in PE risk of 41.9% was observed during the summer with an OR of 0.59 (95% CI [0.36-0.94] and p = 0.026), compared with other seasons. Poisson GLM regression showed a significant increased risk of PE of 3.3% for each 1 °C temperature drop. After multiple binary logistic regression, the elevation of PM₁₀ concentration was independently associated with an increased risk of PE (p < 10^-3, OR 79.55, 95% CI [42.28-149.6]). Some environmental parameters may predispose to the onset of idiopathic PE. Understanding their accurate influence may have preventive and curative implications.

Correlation between short-term air pollution exposure and unprovoked lung embolism. Prospective observational (Contamina-TEP Group)

BACKGROUND

The aim was to analyze the temporal relationship between short-term air pollution exposure and acute symptomatic unprovoked pulmonary embolism (PE).

PATIENTS/METHODS

We performed a prospective, multicenter study in consecutive patients diagnosed with acute symptomatic unprovoked PE from February 2012 to January 2013. We analyzed demographic and clinical data, patients' addresses, meteorological and air pollutants data (PM₁₀, SO₂, CO, NO₂, ozone emission data). We considered the number of days the patient had symptoms, and the study period constituted the previous 30 days. Likewise, the mean annual data of the reference season were calculated as well as the data of the 30-day study period corresponding to the same dates in the previous 3 years in order to obtain the monthly mean of the different pollutants for each period.

RESULTS

A total of 162 patients with acute symptomatic PE were recruited (43.2% unprovoked PE). The air pollutants could be determined in 50% of the patients with unprovoked PE, and a final analysis was performed in 35 patients. In the multiple comparison analysis to verify a possible correlation between the study period and the annual median, only NO₂ showed a statistically significant association (p = 0.009). When comparing the study period with the previous 3 years, only NO₂ maintained a statistically significant association for the 3 study periods.

CONCLUSIONS

We found a relationship between short-term exposure to NO₂ and the presence of unprovoked PE.

Seasonal variation in the frequency of venous thromboembolism: An updated result of a meta-analysis and systemic review

Objective

Venous thromboembolism, including deep vein thrombosis and pulmonary embolism, is likely to cause the death of both medical and surgical patients. Despite some evidence of seasonal variation in the incidence of venous thromboembolism, the existing studies obtain contradictory results. A temporal pattern for pulmonary embolism is known, but data on deep vein thrombosis are inconclusive. The purpose of this study is to make a meta-analysis and systematically review the literature about seasonal variations of pulmonary embolism and/or deep vein thrombosis in order to objectively diagnose venous thromboembolism.

Methods

According to dichotomous data, risk ratios (RRs) and 95% confidence intervals (CIs) were used to compare the incidence of venous thromboembolism in different seasons. The research was classified according to pulmonary embolism mortality, pulmonary embolism/deep vein thrombosis incidence, latitude/elevation/climatic types, and monthly incidence for four subgroup comparisons. There were a total of 23 eligible studies, in which 40,309 patients with venous thromboembolism were compared.

Results

The pooled total venous thromboembolism incidence was 27.2% in winter, 23.1% in spring, 24.6% in summer, and 25.1% in autumn. According to the results of pooled analysis, the incidence of venous thromboembolism in winter was much higher than that in summer (RR = 1.12, 95% CI: 1.01–1.24, adjusted P = .04), especially deep vein thrombosis. Moreover, the incidence of venous thromboembolism in summer and autumn was lower than that in winter in low-latitude (<200 m) areas and median low-latitude (0–50°-N) areas. Interestingly, the frequency of pulmonary embolism mortality was the largest in spring and smallest in summer (spring > winter ≈ autumn > summer). For monthly data, a statistically significantly lower incidence of venous thromboembolism was observed in May and July than in October.

Conclusions

The study revealed a significantly higher incidence of venous thromboembolism and deep vein thrombosis in winter than in summer. Pulmonary embolism mortality occurred more frequently in spring than during other seasons. A statistically significantly lower incidence of venous thromboembolism was observed in May and July compared with that in October.

Homocysteine injures vascular endothelial cells by inhibiting mitochondrial activity

The aim of the present study was to investigate the role of homocysteine (Hcy) in the pathogenesis of pulmonary embolism (PE) and the associated molecular mechanisms in human umbilical vein endothelial cells (HUVECs). Hcy contents were detected with high-performance liquid chromatography. Apoptosis was detected by flow cytometry using Annexin-V staining. Cytochrome c oxidase (COX) activity was assessed with an enzyme activity assay, and the expression levels of COX 17 were determined by western blot analysis. Intracellular reactive oxygen species levels were measured using a microplate reader with a fluorescence probe. The results demonstrated that, compared with the control group, the serum Hcy levels were significantly elevated in the PE group, suggesting that Hcy may be an indicator for PE. Following treatment with Hcy, the apoptosis rate was markedly elevated in HUVECs. Moreover, Hcy decreased COX activity and downregulated the expression of COX 17 in HUVECs. Furthermore, Hcy increased the ROS levels in these endothelial cells. However, all the above-mentioned physiopathological changes induced by Hcy in HUVECs could be restored by folic acid. In conclusion, the results of the present study demonstrated that Hcy inhibited COX activity, downregulated COX 17 expression, increased intracellular ROS levels and enhanced apoptosis in endothelial cells.