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      Increased vulnerability of COPD patient groups to urban climate in view of global warming

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          Patients with COPD show an increase in acute exacerbations (AECOPD) during the cold season as well as during heat waves in the summer months. Due to global climate changes, extreme weather conditions are likely to occur more frequently in the future. The goal of this study was to identify patient groups most at risk of exacerbations during the four seasons of the year and to determine at which temperature threshold the daily hospital admissions due to AECOPD increase during the summer.

          Patients and methods

          We analyzed retrospective demographic and medical data of 990 patients, who were hospitalized for AECOPD in Berlin, Germany. The cases were grouped into the following cohorts: “spring” (admission between March and May), “summer” (June – August), “autumn” (September – November), and “winter” (December – February). AECOPD hospital admissions from 2006 and 2010 were grouped into a “hot summer” cohort and cases from 2011 and 2012 into a “cold summer” data-set. Climate data were obtained from the German Meteorological Office.


          Patients hospitalized for a COPD exacerbation during winter were significantly older than summertime patients ( P=0.040) and also thinner than patients exacerbating in spring ( P=0.042). COPD exacerbations during hot summer periods happened more often to patients with a history of myocardial infarction ( P=0.014) or active smokers ( P=0.011). An AECOPD during colder summers occurred in patients with a higher Charlson index, who suffered in increased numbers from peripheral vascular diseases ( P=0.016) or tumors ( P=0.004). Summertime hospital admissions increased above a daily minimum temperature of 18.3°C ( P=0.006).


          The identification of COPD patient groups most at risk for climate related exacerbations enables climate-adapted prevention through patient guidance and treatment. In view of global climate changes, discovering vulnerabilities and implementing adaptive measures will be of growing importance.

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          Most cited references 18

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          Cardiovascular function in the heat-stressed human.

          Heat stress, whether passive (i.e. exposure to elevated environmental temperatures) or via exercise, results in pronounced cardiovascular adjustments that are necessary for adequate temperature regulation as well as perfusion of the exercising muscle, heart and brain. The available data suggest that generally during passive heat stress baroreflex control of heart rate and sympathetic nerve activity are unchanged, while baroreflex control of systemic vascular resistance may be impaired perhaps due to attenuated vasoconstrictor responsiveness of the cutaneous circulation. Heat stress improves left ventricular systolic function, evidenced by increased cardiac contractility, thereby maintaining stroke volume despite large reductions in ventricular filling pressures. Heat stress-induced reductions in cerebral perfusion likely contribute to the recognized effect of this thermal condition in reducing orthostatic tolerance, although the mechanism(s) by which this occurs is not completely understood. The combination of intense whole-body exercise and environmental heat stress or dehydration-induced hyperthermia results in significant cardiovascular strain prior to exhaustion, which is characterized by reductions in cardiac output, stroke volume, arterial pressure and blood flow to the brain, skin and exercising muscle. These alterations in cardiovascular function and regulation late in heat stress/dehydration exercise might involve the interplay of both local and central reflexes, the contribution of which is presently unresolved.
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            Effect of temperature on lung function and symptoms in chronic obstructive pulmonary disease.

            The present study investigated whether falls in environmental temperature increase morbidity from chronic obstructive pulmonary disease (COPD). Daily lung function and symptom data were collected over 12 months from 76 COPD patients living in East London and related to outdoor and bedroom temperature. Questionnaires were administered which asked primarily about the nature of night-time heating. A fall in outdoor or bedroom temperature was associated with increased frequency of exacerbation, and decline in lung function, irrespective of whether periods of exacerbation were excluded. Forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) fell markedly by a median of 45 mL (95% percentile range: -113-229 mL) and 74 mL (-454-991 mL), respectively, between the warmest and coolest week of the study. The questionnaire revealed that 10% had bedrooms <13 degrees C for 25% of the year, possibly because only 21% heated their bedrooms and 48% kept their windows open in November. Temperature-related reduction in lung function, and increase in exacerbations may contribute to the high level of cold-related morbidity from chronic obstructive pulmonary disease.
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              Heat-related emergency hospitalizations for respiratory diseases in the Medicare population.

              The heat-related risk of hospitalization for respiratory diseases among the elderly has not been quantified in the United States on a national scale. With climate change predictions of more frequent and more intense heat waves, it is of paramount importance to quantify the health risks related to heat, especially for the most vulnerable. To estimate the risk of hospitalization for respiratory diseases associated with outdoor heat in the U.S. elderly. An observational study of approximately 12.5 million Medicare beneficiaries in 213 United States counties, January 1, 1999 to December 31, 2008. We estimate a national average relative risk of hospitalization for each 10°F (5.6°C) increase in daily outdoor temperature using Bayesian hierarchical models. We obtained daily county-level rates of Medicare emergency respiratory hospitalizations (International Classification of Diseases, Ninth Revision, 464-466, 480-487, 490-492) in 213 U.S. counties from 1999 through 2008. Overall, each 10°F increase in daily temperature was associated with a 4.3% increase in same-day emergency hospitalizations for respiratory diseases (95% posterior interval, 3.8, 4.8%). Counties' relative risks were significantly higher in counties with cooler average summer temperatures. We found strong evidence of an association between outdoor heat and respiratory hospitalizations in the largest population of elderly studied to date. Given projections of increasing temperatures from climate change and the increasing global prevalence of chronic pulmonary disease, the relationship between heat and respiratory morbidity is a growing concern.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                23 October 2018
                : 13
                : 3493-3501
                [1 ]Division of Ambulatory Pneumology, Charité – Universitätsmedizin Berlin, Berlin, Germany, christina.hoffmann2@
                [2 ]Division of Pneumology and Infectiology – Thoracic Center, Vivantes Klinikum Neukölln, Berlin, Germany
                [3 ]Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
                Author notes
                Correspondence: Christina Hoffmann, Division of Ambulatory Pneumology, Charité – Universitätsmedizin Berlin, CC12 Arbeitsbereich Ambulante Pneumologie, Charitéplatz 1, 10117 Berlin, Germany, Tel +49 30 4 5066 9034, Email christina.hoffmann2@
                © 2018 Hoffmann et al. This work is published by Dove Medical Press Limited, and licensed under a Creative Commons Attribution License

                The full terms of the License are available at The license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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