Air pollution and emergency department visits for epistaxis

Air pollution and serious bleeding events in high-risk older adults

IMPORTANCE

Despite biological plausibility, very few epidemiologic studies have investigated the risks of clinically significant bleeding events due to particulate air pollution.

OBJECTIVE

To measure the independent and synergistic effects of PM2.5 exposure and anticoagulant use on serious bleeding events.

DESIGN

Retrospective cohort study (2008-2016).

SETTING

Nationwide Medicare population.

PARTICIPANTS

A 50% random sample of Medicare Part D-eligible Fee-for-Service beneficiaries at high risk for cardiovascular and thromboembolic events.

EXPOSURES

Fine particulate matter (PM2.5) and anticoagulant drugs (apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin).

MAIN OUTCOMES AND MEASURES

The outcomes were acute hospitalizations for gastrointestinal bleeding, intracranial bleeding, or epistaxis. Hazard ratios and 95% CIs for PM2.5 exposure were estimated by fitting inverse probability weighted marginal structural Cox proportional hazards models. The relative excess risk due to interaction was used to assess additive-scale interaction between PM2.5 exposure and anticoagulant use.

RESULTS

The study cohort included 1.86 million high-risk older adults (mean age 77, 60% male, 87% White, 8% Black, 30% anticoagulant users, mean PM2.5 exposure 8.81 μg/m3). A 10 μg/m3 increase in PM2.5 was associated with a 48% (95% CI: 45%-52%), 58% (95% CI: 49%-68%) and 55% (95% CI: 37%-76%) increased risk of gastrointestinal bleeding, intracranial bleeding, and epistaxis, respectively. Significant additive interaction between PM2.5 exposure and anticoagulant use was observed for gastrointestinal and intracranial bleeding.

CONCLUSIONS

Among older adults at high risk for cardiovascular and thromboembolic events, increasing PM2.5 exposure was significantly associated with increased risk of gastrointestinal bleeding, intracranial bleeding, and epistaxis. In addition, PM2.5 exposure and anticoagulant use may act together to increase risks of severe gastrointestinal and intracranial bleeding. Thus, clinicians may recommend that high-risk individuals limit their outdoor air pollution exposure during periods of increased PM2.5 concentrations. Our findings may inform environmental policies to protect the health of vulnerable populations.

Relationship Between Air Pollutants and the Incidence of Epistaxis in Yangzhou

Objectives: This project aims to explore the relationship between the air quality index (AQI), the concentration of 6 air pollutants, and the incidence of epistaxis in Yangzhou. Also, to provide reference information for the prevention and treatment of epistaxis. Methods: Data of patients with epistaxis admitted to the Northern Jiangsu People's Hospital Affiliated to Yangzhou University from January 2017 to December 2021 were collected. In addition, the local AQI and the concentrations of 6 air pollutants, namely particulate matter (PM2.5, PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), and ozone (O3), were analyzed at the time of onset. Furthermore, the correlation with the incidence of epistaxis has been analyzed. Results: From 2017 to 2021, there were 24,721 patients with epistaxis aged from 0 to 17 years old while male patients were more than females. The incidence was higher in April, May, and June. There was a statistically significant difference in the number of daily epistaxis in different months and under AQI conditions (P < .05). Spearman's correlation analysis showed that there was a positive correlation between the number of daily epistaxis and the concentrations of AQI, CO, NO2, O3, PM2.5, PM10, and SO2 in Yangzhou, in which O3, PM10, and SO2 were highly correlated with the average number of daily epistaxis, and there was no obvious time lag effect of air pollutants on epistaxis. Conclusion: Epistaxis in the Yangzhou area is more common in males, mostly occurs in 0 to 17 years old, with seasonal. There was also a positive correlation between the incidence of epistaxis and air pollutants in Yangzhou. Therefore, by reducing the AQI index in daily life, and reducing the concentration of environmental pollutants in the air, the occurrence of epistaxis could be prevented and reduced to a certain extent.

Influence of meteorological variables on the frequency of visits and hospital admission for epistaxis in a city with a cold semi-arid climate (Lorca, Spain)

BACKGROUND AND OBJECTIVES

Epistaxis is a common emergency for otorhinolaryngologists. Although the aetiological factors have been widely studied, they remain subject to debate. The role of meteorological variables has been discussed in recent years, but results have been inconsistent. Given a lack of prior data, the aim of our study was to identify the meteorological variables that influence the frequency of visits and hospital admission for epistaxis in a city with a cold semi-arid climate in Spain.

METHODS

Case-control study.

CASES

patients who attended the accident and emergency department of a secondary level hospital for epistaxis over a 9-year period (2011-2019). Controls were established by simple random sampling among emergency rooms visits in general (patients who attended the same centre over the same period of time). Sociodemographic, clinical and meteorological variables were all taken into account.

RESULTS

2749 patients in the epistaxis group and 2764 in the control group. There were significant differences in the epistaxis group, with a higher proportion of male (62.85%) and older patients. Univariate and multivariate analysis revealed that the daily minimum temperature and maximum wind speed were factors significantly associated with the onset of epistaxis. In addition, logistic regression analysis showed that decreases in minimum temperature and increases in maximum wind speed were associated with an increase in epistaxis (p < 0.01). No association was found between hospital admission and the weather conditions.

CONCLUSION

Our findings suggest that low minimum temperatures and high wind speeds are associated with the number of visits to hospital accident and emergency departments for epistaxis, but not with hospital admission.

Cold Climate Impact on Air-Pollution-Related Health Outcomes: A Scoping Review

In cold temperatures, vehicles idle more, have high cold-start emissions including greenhouse gases, and have less effective exhaust filtration systems, which can cause up to ten-fold more harmful vehicular emissions. Only a few vehicle technologies have been tested for emissions below -7 °C (20 °F). Four-hundred-million people living in cities with sub-zero temperatures may be impacted. We conducted a scoping review to identify the existing knowledge about air-pollution-related health outcomes in a cold climate, and pinpoint any research gaps. Of 1019 papers identified, 76 were selected for review. The papers described short-term health impacts associated with air pollutants. However, most papers removed the possible direct effect of temperature on pollution and health by adjusting for temperature. Only eight papers formally explored the modifying effect of temperatures. Five studies identified how extreme cold and warm temperatures aggravated mortality/morbidity associated with ozone, particles, and carbon-monoxide. The other three found no health associations with tested pollutants and temperature. Additionally, in most papers, emissions could not be attributed solely to traffic. In conclusion, evidence on the relationship between cold temperatures, traffic-related pollution, and related health outcomes is lacking. Therefore, targeted research is required to guide vehicle regulations, assess extreme weather-related risks in the context of climate change, and inform public health interventions.

Joint effect of heatwaves and air quality on emergency department attendances for vulnerable population in Perth, Western Australia, 2006 to 2015

BACKGROUND

As global warming and the frequency and intensity of heatwaves increases, health service utilization, including emergency department attendances (EDA) have correspondingly increased across the world. The impact of air quality on health adds to the complexity of the effects. Potential joint effects between heatwaves and air quality on EDA have been rarely reported in the literature, prompting this study.

OBJECTIVES

To investigate the potential joint effect of heatwaves and air quality on the EDA for vulnerable populations in the Perth metropolitan area, Western Australia.

METHODS

A time series design was used. Daily data on EDA, heatwaves (excess heat factor>0) and air pollutants (CO, SO₂, NO₂, O₃, PM₁₀ and PM_2.5) were collected for Perth, Western Australia from 2006 to 2015. Poisson regression modelling was used to assess the associations between heatwaves, air quality, and EDA. Risk assessments on age, gender, Aboriginality, socio-economic status (SES), and joint effect between heatwaves and air quality on EDA were conducted.

RESULTS

The EDA rate was higher in heatwave days (77.86/100,000/day) compared with non-heatwave days (73.90/100,000/day) with rate ratio of 1.053 (95% confidence interval 1.048, 1.058). The EDA rate was higher in males, people older than 60 years or younger than 15 years, Aboriginal people, and people with low SES. Exposure to CO, SO₂, O₃ and PM_2.5 increased risk on EDA and exposure to PM_2.5 showed joint effect with heatwave and increased risk of EDA by 6.6% after adjustment of all other risk factors.

CONCLUSIONS

EDA is an important indicator to evaluate heatwave related morbidity for emergency medical service as EDA rate increased during heatwaves with relative high concentrations of air pollutants. As all air pollutants measured in the study were lower than the Australian National Standards, the joint effect of heatwaves and air quality needs to be further examined when it exceeds the standards.

Pediatric Epistaxis and Its Correlation Between Air Pollutants in Beijing From 2014 to 2017

BACKGROUND

Epistaxis is a common symptom in children. The effect of air pollution on epistaxis is not yet clear.

OBJECTIVES

To explore the characteristics of pediatric epistaxis in Beijing and its correlation with air pollutants.

MATERIAL AND METHODS

Data were collected from 2014 to 2017 in Otolaryngology Department of Capital Institute of Pediatrics. Children diagnosed with epistaxis with relevant information with the same period of municipal air pollutants' concentration were compared.

RESULTS

The annual visits of epistaxis showed a bimodal trend. The incidence of epistaxis in infants was low, increased with age, reached the peak between the ages of 4 to 5, and then gradually decreased with age. In different age groups, male patients were more than females. From 2014 to 2017 in Beijing, particulate matter less than 2.5 μm in diameter (PM2.5), particulate matter less than 10 μm in diameter (PM10), sulfur dioxide (SO₂), nitrogen dioxide (NO₂), and carbon monoxide (CO) showed a downtrend, lower in summer than in the other 3 seasons. Ozone (O₃) was significantly higher in 2016 and 2017, showed an increase trend in summer. The incidence of epistaxis was negatively correlated with PM2.5, PM10, SO₂, NO₂ and CO, which was positively correlated with O₃ (P < .05).

CONCLUSIONS

Pediatric epistaxis in Beijing changes with age and has obvious seasonal variation. There are some correlations between air pollutants and the incidence of epistaxis in children.

The role of meteorologic factors and air pollution on the frequency of pediatric epistaxis

Fluctuations in atmospheric temperature, humidity, and air pollution are associated with the incidence of epistaxis. To date, no study in the literature has evaluated the effect of air pollution and meteorologic conditions on the pediatric population. We aimed to evaluate the effect of meteorologic factors and air pollution on the frequency of epistaxis in children. Children presenting to an outpatient clinical setting at a tertiary care hospital during a 5-year period (July 1, 2009, to June 30, 2014) and diagnosed with epistaxis formed the study population. Daily temperature and humidity parameters and average daily atmospheric water vapor pressure, average daily concentration of particulate matter <10 μm in diameter, and sulfur dioxide readings were obtained. The distribution of daily parameters was analyzed. Of the 1,559 children with the primary diagnosis of epistaxis, data from 1,330 children were analyzed after excluding patients with coexisting pathologies. Positive correlations were found between the frequency of epistaxis and both the average daily temperature and the difference between the maximum and minimum daily temperature. There was a negative correlation between the epistaxis frequency and the average daily humidity, the difference between the maximum and minimum daily humidity, the average daily concentration of particulate matter, and the sulfur dioxide levels. Our findings suggest that epistaxis in children is related to high temperatures and low humidity.

Considering spatial heterogeneity in the distributed lag non-linear model when analyzing spatiotemporal data

The distributed lag non-linear (DLNM) model has been frequently used in time series environmental health research. However, its functionality for assessing spatial heterogeneity is still restricted, especially in analyzing spatiotemporal data. This study proposed a solution to take a spatial function into account in the DLNM, and compared the influence with and without considering spatial heterogeneity in a case study. This research applied the DLNM to investigate non-linear lag effect up to 7 days in a case study about the spatiotemporal impact of fine particulate matter (PM_2.5) on preschool children's acute respiratory infection in 41 districts of northern Taiwan during 2005 to 2007. We applied two spatiotemporal methods to impute missing air pollutant data, and included the Markov random fields to analyze district boundary data in the DLNM. When analyzing the original data without a spatial function, the overall PM_2.5 effect accumulated from all lag-specific effects had a slight variation at smaller PM_2.5 measurements, but eventually decreased to relative risk significantly <1 when PM_2.5 increased. While analyzing spatiotemporal imputed data without a spatial function, the overall PM_2.5 effect did not decrease but increased in monotone as PM_2.5 increased over 20 μg/m³. After adding a spatial function in the DLNM, spatiotemporal imputed data conducted similar results compared with the overall effect from the original data. Moreover, the spatial function showed a clear and uneven pattern in Taipei, revealing that preschool children living in 31 districts of Taipei were vulnerable to acute respiratory infection. Our findings suggest the necessity of including a spatial function in the DLNM to make a spatiotemporal analysis available and to conduct more reliable and explainable research. This study also revealed the analytical impact if spatial heterogeneity is ignored.

Socioeconomic status and anterior epistaxis in adult population

Objective

Little was known about the role of socioeconomic status as a risk factor for epistaxis in adult population. The objective of this study was to determine whether socioeconomic status influences the presentation to emergency department for anterior epistaxis in an adult population.

Methods

Retrospective review of emergency department visits from January 2012 to May 2014. The setting is in an emergency department of a Canadian tertiary care centre. Adult patients with primary diagnosis of anterior epistaxis in the emergency department were included in this study. The main outcome was emergency department visits for anterior epistaxis visits.

Results

A total of 351 cases of anterior epistaxis were included. The mean age was 70 years and 51% of patients were male. The patients were stratified into two groups based on whether their age was equal to and above, or below 75 years. Our analysis indicated that those 75 years or older in higher income quintiles have an increased risk of anterior epistaxis compared to the subjects in the lower income quintiles (P < 0.05). This association did not hold true for those younger than 75 years or for all age groups combined.

Conclusion

There is an association between higher socioeconomic status and the presentation to the emergency department with anterior epistaxis in the population older than 75 years but not in younger patients.

Associations of PM2.5 and Black Carbon with Hospital Emergency Room Visits during Heavy Haze Events: A Case Study in Beijing, China

In January 2013, severe haze events over northeastern China sparked substantial health concerns. This study explores the associations of fine particulate matter less than 2.5 μm (PM_2.5) and black carbon (BC) with hospital emergency room visits (ERVs) during a haze season in Beijing. During that period, daily counts of ERVs for respiratory, cardiovascular and ocular diseases were obtained from a Level-3A hospital in Beijing from 1 December 2012 to 28 February 2013, and associations of which with PM_2.5 and BC were estimated by time-stratified case-crossover analysis in single- and two-pollutant models. We found a 27.5% (95% confidence interval (CI): 13.0, 43.9%) increase in respiratory ERV (lag02), a 19.4% (95% CI: 2.5, 39.0%) increase in cardiovascular ERV (lag0), and a 12.6% (95% CI: 0.0, 26.7%) increase in ocular ERV (lag0) along with an interquartile range (IQR) increase in the PM_2.5. An IQR increase of BC was associated with 27.6% (95% CI: 9.6, 48.6%) (lag02), 18.8% (95% CI: 1.4, 39.2%) (lag0) and 11.8% (95% CI: −1.4, 26.8%) (lag0) increases for changes in these same health outcomes respectively. Estimated associations were consistent after adjusting SO₂ or NO₂ in two-pollutant models. This study provides evidence that improving air quality and reducing haze days would greatly benefit the population health.

Lethal Epistaxis

Epistaxis or nosebleed refers to bleeding from the nostrils, nasal cavity, or nasopharynx. Occasional cases may present with torrential lethal hemorrhage. Three cases are reported to demonstrate particular features: Case 1: A 51-year-old woman with lethal epistaxis with no obvious bleeding source; Case 2: A 77-year-old man with treated nasopharyngeal carcinoma who died from epistaxis arising from a markedly neovascularized tumor bed; Case 3: A 2-year-old boy with hemophilia B who died from epistaxis with airway obstruction in addition to gastrointestinal bleeding. Epistaxis may be associated with trauma, tumors, vascular malformations, bleeding diatheses, infections, pregnancy, endometriosis, and a variety of different drugs. Careful dissection of the nasal cavity is required to locate the site of hemorrhage and to identify any predisposing conditions. This may be guided by postmortem computerized tomographic angiography (PCTA). Despite careful dissection, however, a source of bleeding may never be identified.

The air quality health index and emergency department visits for urticaria in Windsor, Canada

Ambient air pollution exposure has been associated with several health conditions, limited not only to respiratory and cardiovascular systems but also to cutaneous tissues. However, few epidemiological studies examined pollution exposure on skin problems. Basically, the common mechanism by which pollution may affect skin physiology is by induction of oxidative stress and inflammation. Urticaria is among the skin pathologies that have been associated with pollution. Based on the combined effects of three ambient air pollutants, ozone (O₃), nitrogen dioxide (NO₂), and fine particulate matter (PM) with a median aerodynamic diameter of less than 2.5 μm (PM(2.5)), on mortality, the Air Quality Health Index (AQHI) in Canada was developed. The aim of this study was to examine the associations of short-term changes in AQHI with emergency department (ED) visits for urticaria in Windsor-area hospitals in Canada. Diagnosed ED visits were retrieved from the National Ambulatory Care Reporting System (NACRS). A time-stratified case-crossover design was applied to 2905 ED visits (males = 1215; females = 1690) for urticaria from April 2004 through December 2010. Odds ratios (OR) and their corresponding 95% confidence intervals (95%CI) for ED visits associated with increase by one unit of risk index were calculated employing conditional logistic regression. Positive and significant results were observed between AQHI levels and OR for ED visits for urticaria in Windsor for lags 2 and 3 days. A distributed lag nonlinear model technique was applied to daily counts of ED visits for lags 0 to 10 and significant results were obtained from lag 2 to lag 5 and for lag 9. These findings demonstrated associations between ambient air pollution and urticarial confirming that air pollution affects skin conditions.