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      Deprivation, winter season, and COPD exacerbations

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          Abstract

          COPD exacerbations are a major cause of hospital admissions, especially during the winter months. They are mainly attributed to the increase in respiratory viral infections, though clearly other factors must also play a part. Some patients with COPD have particular susceptibility to frequent exacerbations, and this patient group is especially at risk of hospital admissions, repeat admissions, co-morbidity and deaths. 1 The interesting paper by McAllister and colleagues in this issue of the PCRJ examines the additive effect of socio-economic deprivation on seasonal hospital admissions in COPD patients. 2 The authors found a greater number of winter admissions for COPD in the most deprived compared to the least deprived quintile of the Scottish population (39 versus 7 extra admissions per 10,000 patient years between summer and winter respectively). Previous studies in England and Wales have shown no difference in excess winter deaths between areas with greater or less deprivation or colder housing. 3–6 Indeed, excess winter mortality of working men aged between 50–59 years in the lowest social group (class 5) is lower than any other social class possibly because of their increased activity and that they take precautions against the cold during their manual occupations. 7 The findings by McAllister and colleagues can be explained by their unique approach to the question. They investigated whether the joint effect differs from the sum of the effects caused individually by temperature and deprivation. Thus, they found that patients with COPD are more likely to be admitted to hospital for an exacerbation beyond what one would expect because it is cold outside and they live in a deprived area. The cause of these extra admissions could be due to the synergistic effect of poor housing being more expensive to heat. The study does have implications, as the demands on community care systems will be greater because more of the COPD patients discharged from hospital will be from a socio-economically deprived background. Targeting help for these patients is more problematic; interventional studies have so far failed to show any reduction in mortality or morbidity due to housing and heating upgrades, though improvements have been seen in quality of life indices. 8 This may be due to the small sample size of these trials performed in the community for practical reasons. Targeting home improvement schemes just at elderly people is also politically difficult — inevitably those elderly people who live with their families will not be as high a priority. An important limitation of McAllister et al.'s study was the use of monthly data. There are fewer admissions to hospital over the weekend and the number of weekends in each month will differ. Also, fewer patients are admitted during Christmas and the New Year periods, and this will affect the hospital admission numbers on a monthly basis. 9 Cold weather also has a delayed effect on people, with peak mortality from respiratory disease occurring 12 days after peak cold. 10 Though this study showed a disproportionate effect of cold weather on the most deprived, Keatinge 11 reported that excess winter deaths in the general population were no different from able bodied elderly people, mainly women, living in warden controlled housing where the costs of heating did not depend on how much the resident used. However, inadequate home heating is not the only cause of winter mortality, and outdoor cold exposure is also important. 12 Wearing suitable protective clothing such as a hat and gloves in cold weather is beneficial but this advice is often neglected by patients. Other reasons are that COPD may be underdiagnosed in patients with socio-economic deprivation and thus this group is more likely to develop more severe exacerbations with a respiratory infection. McAllister and colleagues report that there were around 30% more hospitalised COPD exacerbations in the winter than in the summer months. 2 Large well designed public health interventional studies are now needed to investigate these observations further. It is likely that deprivation and season may also interact together to increase COPD exacerbations of mild to moderate severity. Therefore, it is possible that deprivation may contribute to under-reporting of exacerbations with less chance of treating these events. 13 Meanwhile, it is important to advise patients — especially those with a history of frequent exacerbations — to take advantage of home insulation grants and to wear warm clothes when going outside the home, as this should reduce winter hospital admissions for COPD exacerbations.

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          Most cited references8

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          Mechanisms and impact of the frequent exacerbator phenotype in chronic obstructive pulmonary disease

          Exacerbations of chronic obstructive pulmonary disease (COPD) are important events that carry significant consequences for patients. Some patients experience frequent exacerbations, and are now recognized as a distinct clinical subgroup, the ‘frequent exacerbator’ phenotype. This is relatively stable over time, occurs across disease severity, and is associated with poorer health outcomes. These patients are therefore a priority for research and treatment. The pathophysiology underlying the frequent exacerbator phenotype is complex, with increased airway and systemic inflammation, dynamic lung hyperinflation, changes in lower airway bacterial colonization and a possible increased susceptibility to viral infection. Frequent exacerbators are also at increased risk from comorbid extrapulmonary diseases including cardiovascular disease, gastroesophageal reflux, depression, osteoporosis and cognitive impairment. Overall these patients have poorer health status, accelerated forced expiratory volume over 1 s (FEV1) decline, worsened quality of life, and increased hospital admissions and mortality, contributing to increased exacerbation susceptibility and perpetuation of the frequent exacerbator phenotype. This review article sets out the definition and importance of the frequent exacerbator phenotype, with a detailed examination of its pathophysiology, impact and interaction with other comorbidities.
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            Temperature, housing, deprivation and their relationship to excess winter mortality in Great Britain, 1986-1996.

            To examine the associations between temperature, housing, deprivation and excess winter mortality using census variables as proxies for housing conditions. Small area ecological study at electoral ward level. Setting Great Britain between 1986 and 1996. Men and women aged 65 and over. Deaths from all causes (International Classification of Diseases, Ninth Revision [ICD-9] codes 0-999), coronary heart disease (ICD-9 410-414), stroke (ICD-9 430-438) and respiratory diseases (ICD-9 460-519). Odds of death occurring in winter period of the four months December to March compared to the rest of the year. During the study period (excluding the influenza epidemic year of 1989/90), a total of 1,682,687 deaths occurred in winter and 2,825,223 deaths occurred during the rest of the year among people aged > or =65 (around 30,000 excess winter deaths per year). A trend of higher excess winter mortality with age was apparent across all disease categories (P < 0.01). There was a significant association between winter mortality and temperature with a 1.5% higher odds of dying in winter for every 1 degrees C reduction in 24-h mean winter temperature. The amount of rain, wind and hours of sunshine were inversely associated with excess winter mortality. Selected housing variables derived from the English House Condition Survey showed little agreement with census-derived variables at electoral ward level. For all-cause mortality there was little association between deprivation and excess winter mortality, although lack of central heating was associated with a higher risk of dying in winter (odds ratio [OR] = 1.016, 95% CI : 1.009-1.022). Excess winter mortality continues to be an important public health problem in Great Britain. There was a strong inverse association with temperature. Lack of central heating was associated with higher excess winter mortality. Further work is needed to disentangle the complex relationships between different indicators of housing quality and other measures of socioeconomic deprivation and their relationship to the high number of excess winter deaths in Great Britain.
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              Early increases in ischaemic heart disease mortality dissociated from and later changes associated with respiratory mortality after cold weather in south east England.

              To identify the time courses and magnitude of ischaemic heart (IHD), respiratory (RES), and all cause mortality associated with common 20-30 day patterns of cold weather in order to assess links between cold exposure and mortality. Daily temperatures and daily mortality on successive days before and after a reference day were regressed on the temperature of the reference day using high pass filtered data in which changes with a cycle length < 80 days were unaffected (< 2%), but slower cyclical changes and trends were partly or completely suppressed. This provided the short term patterns of both temperature and mortality associated with a one day displacement of temperature. The results were compared with simple regressions of unfiltered mortality on temperature at successive delays. Population of south east England, including London, over 50 years of age from 1976-92. Colder than average days in the linear range 15 to 0 degrees C were associated with a "run up" of cold weather for 10-15 days beforehand and a "run down" for 10-15 days afterwards. The increases in deaths were maximal at 3 days after the peak in cold for IHD, at 12 days for RES, and at 3 days for all cause mortality. The increase lasted approximately 40 days after the peak in cold. RES deaths were significantly delayed compared with IHD deaths. Excess deaths per million associated with these short term temperature displacements were 7.3 for IHD, 5.8 for RES, and 24.7 for all cause, per one day fall of 1 degree C. These were greater by 52% for IHD, 17% for RES, and 37% for all cause mortality than the overall increases in daily mortality per degree C fall, at optimal delays, indicated by regressions using unfiltered data. Similar analyses of data at 0 to -6.7 degrees C showed an immediate rise in IHD mortality after cold, followed by a fall in both IHD and RES mortality rates which peaked 17 and 20 days respectively after a peak in cold. Twenty to 30 day patterns of cold weather below 15 degrees C were followed:(1) rapidly by IHD deaths, consistent with known thrombogenic and reflex consequences of personal cold exposure; and (2) by delayed increases in RES and associated IHD deaths in the range 0 to 15 degrees C, which were reversed for a few degrees below 0 degree C, and were probably multifactorial in cause. These patterns provide evidence that personal exposure to cold has a large role in the excess mortality of winter.
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                Author and article information

                Journal
                Prim Care Respir J
                Prim Care Respir J
                Primary Care Respiratory Journal: Journal of the General Practice Airways Group
                Nature Publishing Group
                1471-4418
                1475-1534
                September 2013
                19 August 2013
                : 22
                : 3
                : 264-265
                Affiliations
                [1 ]Centre for Respiratory Medicine, Royal Free Campus, University College London , London, UK
                Author notes
                [* ]Professor of Respiratory Medicine, Centre for Respiratory Medicine, Royal Free Campus, University College London , Rowland Hill Street, Hampstead, London, NW3 2PF, UK Tel: +44 (0)207 317 7517 Fax: +44 (0)207 472 6141 E-mail: w.wedzicha@ 123456ucl.ac.uk
                Article
                pcrj201378
                10.4104/pcrj.2013.00078
                6442833
                23959046
                b38ff9a9-8b40-4734-9521-cc35b5793471
                Copyright © 2013 Primary Care Respiratory Society UK
                History
                : 10 August 2013
                Categories
                Editorial

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