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      Increased hospitalizations for decompensated heart failure and acute myocardial infarction during mild winters: A seven-year experience in the public health system of the largest city in Latin America

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          Abstract

          Background

          In high-income temperate countries, the number of hospitalizations for heart failure (HF) and acute myocardial infarction (AMI) increases during the winter. This finding has not been fully investigated in low- and middle-income countries with tropical and subtropical climates. We investigated the seasonality of hospitalizations for HF and AMI in Sao Paulo (Brazil), the largest city in Latin America.

          Methods

          This was a retrospective study using data for 76,474 hospitalizations for HF and 54,561 hospitalizations for AMI obtained from public hospitals, from January 2008 to April 2015. The average number of hospitalizations for HF and AMI per month during winter was compared to each of the other seasons. The autoregressive integrated moving average (ARIMA) model was used to test the association between temperature and hospitalization rates.

          Findings

          The highest average number of hospital admissions for HF and AMI per month occurred during winter, with an increase of up to 30% for HF and 16% for AMI when compared to summer, the season with lowest figures for both diseases (respectively, HF: 996 vs. 767 per month, p<0.001; and AMI: 678 vs. 586 per month, p<0.001). Monthly average temperatures were moderately lower during winter than other seasons and they were not associated with hospitalizations for HF and AMI.

          Interpretation

          The winter season was associated with a greater number of hospitalizations for both HF and AMI. This increase was not associated with seasonal oscillations in temperature, which were modest. Our study suggests that the prevention of cardiovascular disease decompensation should be emphasized during winter even in low to middle-income countries with tropical and subtropical climates.

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          Most cited references21

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          I Brazilian Registry of Heart Failure - Clinical Aspects, Care Quality and Hospitalization Outcomes

          Background Heart failure (HF) is one of the leading causes of hospitalization in adults in Brazil. However, most of the available data is limited to unicenter registries. The BREATHE registry is the first to include a large sample of hospitalized patients with decompensated HF from different regions in Brazil. Objective Describe the clinical characteristics, treatment and prognosis of hospitalized patients admitted with acute HF. Methods Observational registry study with longitudinal follow-up. The eligibility criteria included patients older than 18 years with a definitive diagnosis of HF, admitted to public or private hospitals. Assessed outcomes included the causes of decompensation, use of medications, care quality indicators, hemodynamic profile and intrahospital events. Results A total of 1,263 patients (64±16 years, 60% women) were included from 51 centers from different regions in Brazil. The most common comorbidities were hypertension (70.8%), dyslipidemia (36.7%) and diabetes (34%). Around 40% of the patients had normal left ventricular systolic function and most were admitted with a wet-warm clinical-hemodynamic profile. Vasodilators and intravenous inotropes were used in less than 15% of the studied cohort. Care quality indicators based on hospital discharge recommendations were reached in less than 65% of the patients. Intrahospital mortality affected 12.6% of all patients included. Conclusion The BREATHE study demonstrated the high intrahospital mortality of patients admitted with acute HF in Brazil, in addition to the low rate of prescription of drugs based on evidence.
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            Excess winter mortality in Europe: a cross country analysis identifying key risk factors.

            Much debate remains regarding why certain countries experience dramatically higher winter mortality. Potential causative factors other than cold exposure have rarely been analysed. Comparatively less research exists on excess winter deaths in southern Europe. Multiple time series data on a variety of risk factors are analysed against seasonal-mortality patterns in 14 European countries to identify key relations Subjects and setting: Excess winter deaths (all causes), 1988-97, EU-14. Coefficients of seasonal variation in mortality are calculated for EU-14 using monthly mortality data. Comparable, longitudinal datasets on risk factors pertaining to climate, macroeconomy, health care, lifestyle, socioeconomics, and housing were also obtained. Poisson regression identifies seasonality relations over time. Portugal suffers from the highest rates of excess winter mortality (28%, CI=25% to 31%) followed jointly by Spain (21%, CI=19% to 23%), and Ireland (21%, CI=18% to 24%). Cross country variations in mean winter environmental temperature (regression coefficient (beta)=0.27), mean winter relative humidity (beta=0.54), parity adjusted per capita national income (beta=1.08), per capita health expenditure (beta=-1.19), rates of income poverty (beta=-0.47), inequality (beta=0.97), deprivation (beta=0.11), and fuel poverty (beta=0.44), and several indicators of residential thermal standards are found to be significantly related to variations in relative excess winter mortality at the 5% level. The strong, positive relation with environmental temperature and strong negative relation with thermal efficiency indicate that housing standards in southern and western Europe play strong parts in such seasonality. High seasonal mortality in southern and western Europe could be reduced through improved protection from the cold indoors, increased public spending on health care, and improved socioeconomic circumstances resulting in more equitable income distribution.
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              Air pollution and mortality in elderly people: a time-series study in Sao Paulo, Brazil.

              The relationship between daily mortality of elderly (65+ y) persons and air pollution in the metropolitan area of Sao Paulo, Brazil, for the period May 1990 to April 1991 was evaluated by time series regression, controlling for season, weather, and other factors. Mortality was associated with respirable particles (PM10), nitrogen oxides (NOx), sulfur dioxide (SO2), and carbon monoxide (CO). The association with PM10 was most statistically significant, robust, and independent of other air pollutants. An increase in PM10 equal to 100 micrograms/m3 was associated with an increase in overall mortality equal to approximately 13%. This association was consistent across various model specifications and estimation techniques. The dose-response relationship between mortality and respirable particulate pollution was almost linear, with no evidence of a "safe" threshold level. The results were similar to those observed in London and several U.S. cities. The results were also supportive of recent animal studies that have observed adverse health outcomes in experimental animals exposed to air pollution in Sao Paulo.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: SupervisionRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: Project administrationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                4 January 2018
                2018
                : 13
                : 1
                : e0190733
                Affiliations
                [1 ] Hospital Israelita Albert Einstein, Sao Paulo, Sao Paulo, Brazil
                [2 ] Instituto de Estudos Avançados da Universidade de São Paulo, Sao Paulo, Sao Paulo, Brazil
                [3 ] Robert F. Wagner School of Public Service, New York University, New York, New York, United States of America
                Instituto de Cardiologia J F Cabral, ARGENTINA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0003-3133-4989
                Article
                PONE-D-17-14856
                10.1371/journal.pone.0190733
                5754126
                29300764
                1a8c4f48-c196-498e-a9d3-c68a1cc0843a
                © 2018 Levin et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 17 April 2017
                : 15 December 2017
                Page count
                Figures: 2, Tables: 3, Pages: 10
                Funding
                The authors received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Cardiology
                Heart Failure
                Earth Sciences
                Seasons
                Winter
                Earth Sciences
                Seasons
                Medicine and Health Sciences
                Health Care
                Health Care Facilities
                Hospitals
                Medicine and Health Sciences
                Cardiology
                Myocardial Infarction
                Medicine and Health Sciences
                Public and Occupational Health
                People and places
                Geographical locations
                South America
                Brazil
                Engineering and Technology
                Environmental Engineering
                Pollution
                Custom metadata
                Relevant data are available at: http://www2.datasus.gov.br/DATASUS/index.php?area=0203/.

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                Uncategorized

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