City-level vulnerability to temperature-related mortality in the USA and future projections: a geographically clustered meta-regression.

BACKGROUND: Extreme heat exposure can lead to premature death. Climate change is expected to increase the frequency, intensity, and duration of extreme heat events, resulting in many additional heat-related deaths globally, as well as changing the nature of extreme cold events. At the same time, vulnerability to extreme heat has decreased over time, probably due to a combination of physiological, behavioural, infrastructural, and technological adaptations. We aimed to account for these changes in vulnerability and avoid overstated projections for temperature-related mortality. We used the historical observed decrease in vulnerability to improve future mortality estimates. METHODS: We used historical mortality and temperature data from 208 US cities to quantify how observed changes in vulnerability from 1973 to 2013 affected projections of temperature-related mortality under various climate scenarios. We used geographically structured meta-regression to characterise the relationship between temperature and mortality for these urban populations over the specified time period. We then used the fitted relationships to project mortality under future climate conditions. FINDINGS: Between Oct 26, 2018, and March 9, 2020, we established that differences in vulnerability to temperature were geographically structured. Vulnerability decreased over time in most areas. US mortalities projected from a 2°C increase in mean temperature decreased by more than 97% when using 2003-13 data compared with 1973-82 data. However, these benefits declined with increasing temperatures, with a 6°C increase showing only an 84% decline in projected mortality based on 2003-13 data. INTERPRETATION: Even after accounting for adaptation, the projected effects of climate change on premature mortality constitute a substantial public health risk. Our work suggests large increases in temperature will require additional mitigation to avoid excess mortality from heat events, even in areas with high air conditioning coverage in place. FUNDING: The US Environmental Protection Agency and Abt Associates.

Longitudinal Community Assessment for Public Health Emergency Response to Wildfire, Bastrop County, Texas.

On September 4, 2011, a wildfire ignited in Bastrop County, Texas, resulting in losses of 34,068 acres of land and 1,645 homes and 2 deaths. At the request of the Texas Department of State Health Services Health Service Region 7 and the Bastrop County Office of Emergency Management, Community Assessments for Public Health Emergency Response (CASPER) were conducted in the weeks following the wildfire and again 3.5 years later to assess both the immediate and long-term public health and preparedness impacts of the wildfire. The objective of these assessments was to learn more about the trajectory of disaster recovery, including rebuilding, evacuation, household emergency planning, and mental and physical health outcomes among both adults and children. In 2015, households exposed to the 2011 wildfires were significantly more likely to have established a family meeting place and evacuation route, to have confidence in the local government's ability to respond to disaster, and to report symptoms of depression and higher stress. Longitudinal assessments using the CASPER method can provide actionable information for improved planning, preparedness, and recovery to public health and emergency management agencies and community residents.

Physiological adaptations to chronic stress in healthy humans - why might the sexes have evolved different energy utilisation strategies?

KEY POINTS: The human stress response activates the autonomic nervous system and endocrine systems to increase performance during environmental challenges. This response is usually beneficial, improving the chance of overcoming environmental challenges, but costs resources such as energy. Humans and other animals are known to adapt their responses to acute stress when they are stimulated chronically, presumably to optimise resource utilisation. Characterisation of these adaptations has been limited. Using advanced imaging techniques, we show that cardiovascular and endocrine physiology, reflective of energy utilisation during acute stress, and energy storage (fat) differ between the sexes when they are exposed to chronic stress. We examine possible evolutionary explanations for these differences, related to energy use, and point out how these physiological differences could underpin known disparities between the sexes in their risk of important cardiometabolic disorders such as obesity and cardiovascular disease. ABSTRACT: Obesity and associated diseases, such as cardiovascular disease, are the dominant human health problems in the modern era. Humans develop these conditions partly because they consume excess energy and exercise too little. Stress might be one of the factors contributing to these disease-promoting behaviours. We postulate that sex-specific primordial energy optimisation strategies exist, which developed to help cope with chronic stress but have become maladaptive in modern societies, worsening health. To demonstrate the existence of these energy optimisation strategies, we recruited 88 healthy adults with varying adiposity and chronic stress exposure. Cardiovascular physiology at rest and during acute stress (Montreal Imaging Stress Task), and body fat distribution were measured using advanced magnetic resonance imaging methods, together with endocrine function, cardiovascular energy use and cognitive performance. Potential confounders such as lifestyle, social class and employment were accounted for. We found that women exposed to chronic stress had lower adiposity, greater acute stress cardiovascular responses and better cognitive performance. Conversely, chronic stress-exposed men had greater adiposity and lower cardiovascular responses to acute stress. These results provide initial support for our hypothesis that differing sex-specific energy conservation strategies exist. We propose that these strategies have initially evolved to benefit humans but are now maladaptive and increase the risk of disorders such as obesity, especially in men exposed to chronic stress.

Dynamic Threshold Analysis of Daily Oxygen Saturation for Improved Management of COPD Patients.

This study presents a novel dynamic threshold algorithm that is applied to daily self-measured SpO2 data for management of chronic obstructive pulmonary disease (COPD) patients in remote patient monitoring to improve accuracy of detection of exacerbation. Conventional approaches based on a fixed threshold applied to a single SpO 2 reading to detect deterioration in patient condition are known to have poor accuracy and result in high false alarm rates. This study develops and evaluates use of a dynamic threshold algorithm to reduce false alarm rates. Daily data from four COPD patients with a record of clinical interventions during the period were selected for analysis. We model the SpO2 time-series data as a combination of a trend and a stochastic component (residual). We estimate the long-term trend using a locally weighed least-squares (low-pass) filter over a long-term processing window. Results show that the time evolution of the long-term trend indicated exacerbation with improved accuracy compared to a fixed threshold in our study population. Deterioration in the condition of a patient also resulted in an increase in the standard deviation of the residual (σres ), from 2% or less when the patient is in a healthy condition to 4% or more when condition deteriorates. Statistical analysis of the residuals showed they had a normal distribution when the condition of the patient was stable but had a long tail on the lower side during deterioration.

Development and validation of risk assessment models for diabetes-related complications based on the DCCT/EDIC data.

AIM: To derive and validate a set of computational models able to assess the risk of developing complications and experiencing adverse events for patients with diabetes. The models are developed on data from the Diabetes Control and Complications Trial (DCCT) and the Epidemiology of Diabetes Interventions and Complications (EDIC) studies, and are validated on an external, retrospectively collected cohort. METHODS: We selected fifty-one clinical parameters measured at baseline during the DCCT as potential risk factors for the following adverse outcomes: Cardiovascular Diseases (CVD), Hypoglycemia, Ketoacidosis, Microalbuminuria, Proteinuria, Neuropathy and Retinopathy. For each outcome we applied a data-mining analysis protocol in order to identify the best-performing signature, i.e., the smallest set of clinical parameters that, considered jointly, are maximally predictive for the selected outcome. The predictive models built on the selected signatures underwent both an interval validation on the DCCT/EDIC data and an external validation on a retrospective cohort of 393 diabetes patients (49 Type I and 344 Type II) from the Chorleywood Medical Center, UK. RESULTS: The selected predictive signatures contain five to fifteen risk factors, depending on the specific outcome. Internal validation performances, as measured by the Concordance Index (CI), range from 0.62 to 0.83, indicating good predictive power. The models achieved comparable performances for the Type I and, quite surprisingly, Type II external cohort. CONCLUSIONS: Data-mining analyses of the DCCT/EDIC data allow the identification of accurate predictive models for diabetes-related complications. We also present initial evidences that these models can be applied on a more recent, European population.

Habitual alcohol consumption is associated with lower cardiovascular stress responses--a novel explanation for the known cardiovascular benefits of alcohol?

In contrast to heavy alcohol consumption, which is harmful, light to moderate drinking has been linked to reduced cardiovascular morbidity and mortality. Effects on lipid status or clotting do not fully explain these benefits. Exaggerated cardiovascular responses to mental stress are detrimental to cardiovascular health. We hypothesized that habitual alcohol consumption might reduce these responses, with potential benefits. Advanced magnetic resonance techniques were used to accurately measure cardiovascular responses to an acute mental stressor (Montreal Imaging Stress Task) in 88 healthy adults (∼1:1 male:female). Salivary cortisol and task performance measures were used to assess endocrine and cognitive responses. Habitual alcohol consumption and confounding factors were assessed by questionnaire. Alcohol consumption was inversely related to responses of heart rate (HR) (r = -0.31, p = 0.01), cardiac output (CO) (r = -0.32, p = 0.01), vascular resistance (r = 0.25, p = 0.04) and mean blood pressure (r = -0.31, p = 0.01) provoked by stress, but not to stroke volume (SV), or arterial compliance changes. However, high alcohol consumers had greater cortisol stress responses, compared to moderate consumers (3.5 versus 0.7 nmol/L, p = 0.04). Cognitive measures did not differ. Findings were not explained by variations in age, sex, social class, ethnicity, physical activity, adrenocortical activity, adiposity, smoking, menstrual phase and chronic stress. Habitual alcohol consumption is associated with reduced cardiac responsiveness during mental stress, which has been linked to lower risk of hypertension and vascular disease. Consistent with established evidence, our findings suggest a mechanism by which moderate alcohol consumption might reduce cardiovascular disease, but not high consumption, where effects such as greater cortisol stress responses may negate any benefits.

Adiposity is associated with blunted cardiovascular, neuroendocrine and cognitive responses to acute mental stress.

Obesity and mental stress are potent risk factors for cardiovascular disease but their relationship with each other is unclear. Resilience to stress may differ according to adiposity. Early studies that addressed this are difficult to interpret due to conflicting findings and limited methods. Recent advances in assessment of cardiovascular stress responses and of fat distribution allow accurate assessment of associations between adiposity and stress responsiveness. We measured responses to the Montreal Imaging Stress Task in healthy men (N = 43) and women (N = 45) with a wide range of BMIs. Heart rate (HR) and blood pressure (BP) measures were used with novel magnetic resonance measures of stroke volume (SV), cardiac output (CO), total peripheral resistance (TPR) and arterial compliance to assess cardiovascular responses. Salivary cortisol and the number and speed of answers to mathematics problems in the task were used to assess neuroendocrine and cognitive responses, respectively. Visceral and subcutaneous fat was measured using T(2) (*)-IDEAL. Greater BMI was associated with generalised blunting of cardiovascular (HR:ß = -0.50 bpm x unit(-1), P = 0.009; SV:ß = -0.33 mL x unit(-1), P = 0.01; CO:ß = -61 mL x min(-1) x unit(-1), P = 0.002; systolic BP:ß = -0.41 mmHg x unit(-1), P = 0.01; TPR:ß = 0.11 WU x unit(-1), P = 0.02), cognitive (correct answers: r = -0.28, P = 0.01; time to answer: r = 0.26, P = 0.02) and endocrine responses (cortisol: r = -0.25, P = 0.04) to stress. These associations were largely determined by visceral adiposity except for those related to cognitive performance, which were determined by both visceral and subcutaneous adiposity. Our findings suggest that adiposity is associated with centrally reduced stress responsiveness. Although this may mitigate some long-term health risks of stress responsiveness, reduced performance under stress may be a more immediate negative consequence.

Early experiences of the use of remote patient monitoring for the long term management of chronic disease.

We describe our experiences of using remote patient monitoring to support the long term management and clinical intervention in patients with chronic disease. Within the project we developed new algorithms to determine from vital signs collected on a daily basis, those patients requiring clinical investigation for their condition. Our aim was for patients to achieve and sustain clinically recommended values for parameters. In our study, the telemonitoring prompted clinical intervention in 37% of patients. Our approach proved particularly effective for the newly diagnosed, and for those with long term issues of management.

An e-Health approach to managing vascular surgical patients.

The objective of this study was to investigate an e-health approach to managing patients presenting with vascular-type symptoms. A pilot study of a prospective cohort of patients referred from a single general practitioner practice of 5700 patients using electronic referral, assessment by a practice nurse, and teleconferencing facilities as an adjunct to normal referral and management practice was designed and conducted. Thirty-eight patients aged 30-93 years old (median 72 years) were enrolled in the study between March 2001 and July 2004. Twelve patients had leg ulceration and 12 complained of leg pain. The remainder had a range of symptoms potentially vascular in nature. All but 1 patient had an initial teleconsultation. This initial teleconsultation lasted a median of 11 minutes (interquartile range 9 minutes (min) 59 seconds (sec)-12 min 43 sec). For 10 patients this was their only contact with the hospital. One patient had teleconsultation follow-up only, 26 patients attended the hospital for vascular laboratory studies or angiography, and 8 of these went on to have radiological and/or surgical intervention. Three patients attended the outpatient department for follow up; all other follow-ups were managed via the teleclinic. Overall, 57 standard outpatient attendances in these patients were replaced by teleconsultations. Common vascular-type symptoms can be satisfactorily evaluated across a telelink with the aid of a practice nurse and baseline patient data transmitted electronically. Decisions can be made regarding the need for further investigation and attendance in outpatient clinic can be largely eliminated.

A Technology-assisted approach to integrating healthcare in the community.

The fragmentary nature of healthcare provision in the United Kingdom presents particular problems for many patients with vascular disease. The management and organization of this disease are also costly for the National Health Service (NHS). Hence, so any attempt to keep hospital visits to the minimum while at the same time aiding effective treatment is to be welcomed. Information in the current NHS is stored in various places and access to it is restricted. There is no central, complete, patient record that is accessible to all healthcare professionals at the various levels of care. There is also no mechanism that allows the patient to interact with his or her local nurse and/or doctor/general practitioner (at primary-care level) involving the specialist/consultant (at secondary-care level). The concept and conduct of an ulcer care program for such patients are described in this paper. Nurse-led, this novel approach uses an innovative information technology system to bring together the isolated 'islands' of knowledge and information held by both the patient and healthcare professionals involved in their care. The technology described here combines both store and forward and real-time video. Informal feedback from patients, community nurses, doctors/general practitioners, and specialists/consultants suggests that such an approach is well received. However, we conclude with a discussion of the complexities involved in the interaction between technology and people and the implications for the management of healthcare.