Road traffic noise and hypertension--accounting for the location of rooms.

OBJECTIVE: The association between the exposure to road traffic noise and the prevalence of hypertension was assessed accounting for background air pollution and the location of rooms with respect to the road. METHODS: A cross-sectional study was carried out inviting all subjects aged 35-74 years for participation that lived on 7 major trunk roads in 3-4 storey terraced apartment buildings and in parallel side streets that were completely shielded from noise due to the rows of houses along the major roads. The study was performed on 1770 subjects that did not have a self-reported medical doctor diagnosis of hypertension before they moved into their current residence. Noise levels at the facade of the front and the rear side of the houses were drawn from available noise maps of the area. A large set of covariates were considered to adjust the results for confounding. RESULTS: Significant increases between road traffic noise and hypertension were found with respect to the 24h A-weighted average noise indicator L(DEN). The adjusted odds ratio (OR) per noise level increment of 10 dB(A) was 1.11 (95% confidence interval (CI): 1.00-1.23). Stronger significant estimates of the noise effect were found in subjects with long residence time (OR=1.20, CI=1.05-1.37), and with respect to the exposure of the living room during daytime (OR=1.24, CI=1.08-1.41) compared with the exposure of the bedroom during night-time (OR=0.91, CI=0.78-1.06). CONCLUSION: Chronic exposure to road traffic noise is associated with an increased risk of high blood pressure. Daytime noise exposure of the living room had a stronger impact on the association than night-time exposure of the bedroom.

Prediction of new-onset asthma and nasal allergy by skin prick test and RAST in a cohort of adults.

Limited information exists regarding the incidence and predictors of asthma and nasal allergy in adulthood. We determined the incidence rate of asthma and nasal allergy in adults and assessed the predictive value of skin prick tests (SPTs) and radioallergosorbent tests (RASTs) for these two outcomes. Two German centres involved in the European Community Respiratory Health Survey conducted a follow-up assessment in 2012 of the baseline participants (1185 adults aged 21-47 years assessed in 1990). The predictive value of SPTs and RASTs on new-onset asthma and nasal allergy was assessed by Cox regression and by calculating the positive or negative predictive value. During the 20 years between baseline and follow-up, 3.1 and 4.4 per 1000 person-years of new-onset asthma and nasal allergy cases were recorded, respectively. The hazard ratios for SPTs of any specific and of all aeroallergens combined were slightly higher than those of RASTs for asthma and nasal allergy. The negative predictive values of both the SPT and RAST were very high and similar (0.94-0.96), whereas the postive predictive values were low (0.09-0.20). Positive SPT results showed a better association with new onset asthma and nasal allergy than positive RAST either to any specific aeroallergens or to all combined.

Bronchial responsiveness, spirometry and mortality in a cohort of adults.

OBJECTIVE: Prospective population studies have reported that pulmonary function, measured by forced expiratory volume in one second (FEV(1)), is an independent predictor for mortality. Besides, several studies found that death from all causes is higher in asthmatics than in non-asthmatics. However, none of these studies examined whether bronchial hyperresponsiveness (BHR), one of the key features in asthma, can be used as a predictor for mortality. Thus, the aim of this study was to analyze the association between BHR, FEV(1), and all-cause mortality in a population-based cohort of adults. METHODS: Within the cross-sectional survey ECRHS-I Erfurt (1990-1992), 1162 adults aged 20-65 years performed lung function tests, including spirometry and BHR testing by methacholine inhalation up to a cumulative dose of 2 mg. BHR was assessed from the methacholine dose nebulized at ≥ 20% fall of FEV(1). After circa 20 years of follow-up, the association between baseline lung function, BHR, and mortality was investigated. RESULTS: A total of 85 individuals (7.3%) died during a mean follow-up period of 17.4 years (SD = 2.4). FEV(1), but not forced vital capacity (FVC), was a predictor for mortality. In men, BHR increased the mortality risk (OR = 2.6, 95% CI: 1.3-5.3; adjusted for age and BMI). Additional adjustment for asthma did not change the results (OR = 2.4, 95% CI: 1.2-5.0). However, after an additional adjustment for pack years of cigarette smoking or airway obstruction, the association was not statistically significant anymore (OR = 1.8, 95% CI: 0.8-4.0, OR = 1.9, 95% CI: 0.9-4.3, respectively). CONCLUSIONS: BHR was associated with an increased mortality risk in men. Potential explanatory factors for this association are cigarette smoking, chronic obstructive pulmonary disease (COPD), or asthma. Thus, BHR might be an indirect predictor for all-cause mortality. FEV(1) was an independent predictor for all-cause mortality.

Changes in deceleration capacity of heart rate and heart rate variability induced by ambient air pollution in individuals with coronary artery disease.

BACKGROUND AND OBJECTIVE: Exposure to ambient particles has been shown to be responsible for cardiovascular effects, especially in elderly with cardiovascular disease. The study assessed the association between deceleration capacity (DC) as well as heart rate variability (HRV) and ambient particulate matter (PM) in patients with coronary artery disease (CAD). METHODS: A prospective study with up to 12 repeated measurements was conducted in Erfurt, Germany, between October 2000 and April 2001 in 56 patients with physician-diagnosed ischemic heart disease, stable angina pectoris or prior myocardial infarction at an age of at least 50 years. Twenty-minute ECG recordings were obtained every two weeks and 24-hour ECG recordings every four weeks. Exposure to PM (size range from 10 nm to 2.5 µm), and elemental (EC) and organic (OC) carbon was measured. Additive mixed models were used to analyze the association between PM and ECG recordings. RESULTS: The short-term recordings showed decrements in the high-frequency component of HRV as well as in RMSSD (root-mean-square of successive differences of NN intervals) in association with increments in EC and OC 0-23 hours prior to the recordings. The long-term recordings revealed decreased RMSSD and pNN50 (% of adjacent NN intervals that differed more than 50 ms) in association with EC and OC 24-47 hours prior to the recordings. In addition, highly significant effects were found for DC which decreased in association with PM2.5, EC and OC concurrent with the ECG recordings as well as with a lag of up to 47 hours. CONCLUSIONS: The analysis showed significant effects of ambient particulate air pollution on DC and HRV parameters reflecting parasympathetic modulation of the heart in patients with CAD. An air pollution-related decrease in parasympathetic tone as well as impaired heart rate deceleration capacity may contribute to an increased risk for cardiac morbidity and sudden cardiac death in vulnerable populations.

The influence of improved air quality on mortality risks in Erfurt, Germany.

Around the world, daily variations in ambient air pollution have been consistently associated with variations in daily mortality. The aim of the study presented here was to assess the effects of ambient air pollution on daily mortality during a period of tremendous changes in air quality in the city of Erfurt, in eastern Germany, from October 1991 to March 2002. Data on particle size distributions were obtained from September 1995 to March 2002 at a research monitoring station. For particles from 0.01 microm to 2.5 microm in diameter, number concentrations (NCs)* and mass concentrations (MCs) were calculated. Particles with diameters less than or equal to 0.10 microm are defined as ultrafine particles (UFP). Data on the gaseous pollutants NO2, CO, SO2, and O3 and on PM10 (particulate matter [PM] with aerodynamic diameter less than or equal to 10 microm) were obtained from a government air-monitoring station. Data on changes in energy consumption, car fleet composition, and population were collected from local authorities. Death certificates of persons living in and dying in Erfurt were abstracted, and daily mortality counts were calculated. Poisson regression models were used to analyze the data, applying penalized splines (also known as P-splines) to model nonlinear relationships in the confounders. Model selection was done without air pollutants in the models, based on a combination of goodness-of-fit criteria and avoidance of autocorrelation in error terms. Final models included P-splines of time trend, meteorologic data, and influenza epidemics as well as day of the week with an indicator variable. Results are presented as change per interquartile range (IQR), i.e., change in the relative risk of mortality associated with a change in the concentration from the 25th to the 75th percentile of a given pollutant. Air pollutants were considered both as linear terms and as P-splines to assess the exposure-response functions. Changes in effect estimates over time were calculated using fully Bayesian time-varying coefficient models. This method was selected over four other approaches tested in simulation studies. Air-pollution concentrations decreased substantially in Erfurt during the decade under observation. The strongest changes were observed for SO2, for which annual concentrations decreased from 64 microg/m3 in 1992 to 4 microg/m3 in 2001. Concentrations of PM10, PM2.5 (particulate matter with aerodynamic diameter less than or equal to 2.5 microm), and CO decreased by more than 50%. NO2, O3, and ultrafine particles also decreased, though to a lesser extent. Based on visual inspection of the data on the changes in ambient air-pollution concentrations during the study period, we defined three study subperiods: A first subperiod from 1991 to 1995; a second, transitional subperiod from 1995 to 1998; and a third subperiod from 1998 to 2002. Generally, air-pollution concentrations decreased substantially from the first subperiod to the second, and some additional decreases occurred from the second subperiod to the third. During the second, transitional subperiod, natural gas replaced coal as the main energy source in Erfurt. In addition, the number of cars with catalytic converters increased over time, as did the number of cars in general. To facilitate the interpretation of the results, we organized the air pollutants into four groups: (1) NO2, CO, and ultrafine particles, (2) PM10 and PM2.5, (3) SO2, and (4) O3. We observed a 1.6% increased risk for daily mortality (CI, -0.4% to 3.5%) for an increase of 19.7 microg/m3 in NO2 (lag day 3), a 1.9% increased risk (CI, 0.2%-3.6%) for an increase of 0.48 mg/m3 in CO (lag day 4), and a 2.9% increased risk (CI, 0.3%-5.5%) for an increase of 9743/cm3 in ultrafine particles (lag day 4). No consistent associations were observed for PM10, PM2.5, or SO2. For O3, a 4.6% increased risk for daily mortality (CI, 1.1%-8.3%) was associated with a 43.8 microg/m3 maximum 8-hr concentration of O3 per day (lag day 2). For all four pollutants, exposure-response functions suggested no deviation from linearity. However, in time-varying models the strongest associations were observed for NO2, CO, and ultrafine particles during the transition subperiod, from 1995 to 1998, when O3 concentrations were lowest. Changes in source characteristics or ambient air-pollution concentrations were not able to explain these observations in a straightforward manner. However, the observations suggested that changes such as the introduction of three-way catalytic converters in cars and the substitution natural gas for coal might have been beneficial. Overall we concluded that: 1. Economic and political changes and the adoption of new technologies in eastern Germany resulted in distinct improvements in ambient air quality; 2. Urban air pollution in Erfurt changed within one decade from the eastern mixture toward that of western Europe ("western mixture"), which is dominated by concentrations of NOx, O3, fine particles, and ultrafine particles with low concentrations of SO2; 3. There was an association between daily mortality and ultrafine particles and combustion-related gases (lag days 3 or 4); 4. Ultrafine particles seemed to be the best pollution indicator and to point to the role of local combustion in the pollution mixture; 5. Regression coefficients showed variation over time for NO2, CO, ultrafine particles, and O3 that could not be explained by nonlinearity in the exposure-response functions; 6. Mortality associated with pollution was lower at the end of the 1990s than during the 1990s, except for mortality associated with O3; and 7. Mortality associated with pollution was strongest in the second, transitional subperiod, from 1995 to 1998, when changes in source characteristics had taken place but the benefits of improved ambient air quality had not yet been completely achieved.

Short-term mortality rates during a decade of improved air quality in Erfurt, Germany.

BACKGROUND: Numerous studies have shown associations between ambient air pollution and daily mortality. OBJECTIVES: Our goal was to investigate the association of ambient air pollution and daily mortality in Erfurt, Germany, over a 10.5-year period after the German unification, when air quality improved. METHODS: We obtained daily mortality counts and data on mass concentrations of particulate matter (PM)<10 microm in aerodynamic diameter (PM10), gaseous pollutants, and meteorology in Erfurt between October 1991 and March 2002. We obtained ultrafine particle number concentrations (UFP) and mass concentrations of PM<2.5 microm in aerodynamic diameter (PM2.5) from September 1995 to March 2002. We analyzed the data using semiparametric Poisson regression models adjusting for trend, seasonality, influenza epidemics, day of the week, and meteorology. We evaluated cumulative associations between air pollution and mortality using polynomial distributed lag (PDL) models and multiday moving averages of air pollutants. We evaluated changes in the associations over time in time-varying coefficient models. RESULTS: Air pollution concentrations decreased over the study period. Cumulative exposure to UFP was associated with increased mortality. An interquartile range (IQR) increase in the 15-day cumulative mean UFP of 7,649 cm(-3) was associated with a relative risk (RR) of 1.060 [95% confidence interval (CI), 1.008-1.114] for PDL models and an RR/IQR of 1.055 (95% CI, 1.011-1.101) for moving averages. RRs decreased from the mid-1990s to the late 1990s. CONCLUSION: Results indicate an elevated mortality risk from short-term exposure to UFP. They further suggest that RRs for short-term associations of air pollution decreased as pollution control measures were implemented in Eastern Germany.

Intermittent claudication in the Erfurt Male Cohort (ERFORT) Study: its determinants and the impact on mortality. A population-based prospective cohort study with 30 years of follow-up.

AIMS: Intermittent claudication (IC) is the most common symptom of peripheral arterial disease and is associated with an increased mortality. Within the Erfurt Male Cohort (ERFORT) Study, one of the most long-lasting population-based prospective cohort studies in Europe, we investigated (i) which variables predict the development of incident IC determined by the WHO Rose questionnaire over a period of 15 years and (ii) if IC is predictive for 30 years all-cause mortality. METHODS: The baseline survey examined a random population-based sample of 1160 males aged 40-59 years with three follow-up examinations 5, 10 and 15 years after enrollment using each time the Rose questionnaire. RESULTS: An adjusted Cox regression analysis revealed smoking (HR (95% CI), 2.20 (1.24-3.92), p=0.01), diabetes mellitus (HR (95% CI), 4.68 (1.61-13.63), p=0.01) and coronary heart disease (HR (95% CI), 2.74 (1.08-6.96), p=0.03) to be significantly associated with incident IC. Participants with an IC had an significantly increased age-adjusted 30 years all-cause mortality (HR (95% CI), 1.56 (1.16-2.10), p=0.003). This association remained still significantly predictive after adjustment for other cardiovascular risk factors. CONCLUSIONS: Mainly smoking and diabetes mellitus are associated with incident IC. A positive Rose questionnaire is a strong predictor for all-cause mortality over 30 years. The simplicity of their use makes questionnaires highly attractive for identification of high-risk patients in primary health care.

Erfurt Male cohort Study (ERFORT Study). Study design and descriptive results.

OBJECTIVES: The main objective of ERFORT Study is to investigate cardiovascular risk factors, life-style related factors and psychosocial factors with regard to total and cause-specific mortality and morbidity. This paper describes the study design, frequency data on cardiovascular and psychosocial factors at baseline survey, and findings of three 5 year follow-up medical examinations. Life status was followed for 30 years. METHODS: The Erfurt Male Cohort Study (ERFORT Study) is a population-based prospective cohort study and has its origin in the WHO initiated feasibility study to acquire experience in multi-factorial intervention programs. The baseline survey in 1973-75 examined a random population-based sample of 1,160 males aged 35-61 years (brutto response rate 74.6%) from the city of Erfurt, East Germany. RESULTS: Standardized and mostly validated methods were applied for a collection of data on cardiovascular risk factors, lifestyle-related and psychosocial factors, blood tests and ECG. Three consecutive follow-up examinations yielded datasets of 907, 740 and 609 subjects' re-examination in 1978-79, 1983-85 and 1988-90. Cardiovascular diseases such as myocardial infarction, angina pectoris, and claudication intermittent approximately doubled within a 15-year follow-up. Prevalence of diabetes strongly increases from 2.8% at baseline to 12.0% at the 15-years follow up. High blood pressure (> or = 160/95 mm Hg) only slightly increased, whereas the antihypertensive treatment increased from 8.7% to 33.6%. CONCLUSIONS: This data set of a German cohort followed for several decades is an outstanding database to answer questions about long-term associations between biological and psychosocial factors and mortality in men.

Daily mortality and particulate matter in different size classes in Erfurt, Germany.

The link between elevated concentrations of ambient particulate matter (PM) and increased mortality has been investigated in numerous studies. Here we analyzed the role of different particle size fractions with respect to total and cardio-respiratory mortality in Erfurt, Germany, between 1995 and 2001. Number concentrations (NC) of PM were measured using an aerosol spectrometer consisting of a Differential Mobility Particle Sizer and a Laser Aerosol Spectrometer to characterize particles between 0.01 and 0.5 and between 0.1 and 2.5 microm, respectively. We derived daily means of particle NC for ultrafine (0.01-0.1 microm) and for fine particles (0.01-2.5 microm). Assuming spherical particles of a constant density, we estimated the mass concentrations (MC) of particles in these size ranges. Concurrently, data on daily total and cardio-respiratory death counts were obtained from local health authorities. The data were analyzed using Poisson Generalized Additive Models adjusting for trend, seasonality, influenza epidemics, day of the week, and meteorology using smooth functions or indicator variables. We found statistically significant associations between elevated ultrafine particle (UFP; diameter: 0.01-0.1 microm) NC and total as well as cardio-respiratory mortality, each with a 4 days lag. The relative mortality risk (RR) for a 9748 cm(-3) increase in UFP NC was RR=1.029 and its 95% confidence interval (CI)=1.003-1.055 for total mortality. For cardio-respiratory mortality we found: RR=1.031, 95% CI: 1.003-1.060. No association between fine particle MC and mortality was found. This study shows that UFP, representing fresh combustion particles, may be an important component of urban air pollution associated with health effects.

Lung cancer risk among former uranium miners of the WISMUT Company in Germany.

UNLABELLED: After 1946, the WISMUT Company developed the third-largest uranium-mining province in the world in the German Democratic Republic. METHODS: A case-control study among former WISMUT miners was conducted to investigate the lung cancer risk in relation to attained age, time since exposure, exposure duration, and exposure rate. It consisted of 505 patients with lung cancer and 1,073 controls matched to cases according to the year of birth. The cumulative exposure to radon and radon decay products was calculated as the sum of yearly exposures and expressed in Working Level Months (WLM). Cases had a mean cumulative exposure of 552 WLM compared to 420 WLM in controls. RESULTS: There was a statistically significant increase in lung cancer risk for cumulative exposures above 800 WLM. Under the assumption of a linear risk model, there was a significant increase in the relative risk of 0.10 per 100 WLM after adjusting for smoking and asbestos exposure. For current smokers the increase in relative risk was lower (0.05 per 100 WLM), whereas it was higher (0.20 per 100 WLM) among nonsmokers and longtime ex-smokers. After correcting in a sensitivity analysis for the fact that the controls of this study had a higher average exposure than the population of WISMUT workers they were recruited from, the adjusted ERR increased to 0.24 per 100 WLM. Lung cancer risk declined with time since exposure, except for exposures received 45 or more years ago. No inverse dose rate effect was observed.

Postload plasma glucose and 30-year mortality among nondiabetic middle-aged men from the general population: the ERFORT Study.

PURPOSE: The purpose of the study is to examine for the first time the association between 1-hour postload plasma glucose levels and known diabetes and 30-year total mortality. METHODS: The population-based Erfurt Male Cohort Study of 1160 men aged 40 to 59 years was carried out between September 1973 and August 1975. A 1-hour postload venous blood sample was obtained after an oral glucose tolerance test in all nondiabetic subjects. Mortality follow-up continued until death or September 30, 2003. RESULTS: Only 25 subjects were lost to follow-up, but 595 study participants (51.3%) died. Survival curves for persons with diabetes, subjects with postload glucose levels greater than 200 mg/dL, and those with not elevated levels already start to diverge after 2 years in persons with diabetes, but only after 5 years in subjects with high postload glucose levels. After 30 years of follow-up, men with diabetes had an almost twofold risk for death (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.26-2.97) and men with a postload plasma glucose level greater than 200 mg/dL had a 1.5-fold increased risk for death (HR, 1.49; 95% CI, 1.17-1.88) compared with men in the lower-glucose-level group, even after multivariable adjustment. CONCLUSIONS: Postload hyperglycemia is a long-term predictor for all-cause mortality in middle-aged men without diabetes from the general population.

Effects of particulate air pollution on blood pressure and heart rate in subjects with cardiovascular disease: a multicenter approach.

Given the hypothesis that air pollution is associated with elevated blood pressure and heart rate, the effect of daily concentrations of air pollution on blood pressure and heart rate was assessed in 131 adults with coronary heart disease in Helsinki, Finland; Erfurt, Germany; and Amsterdam, the Netherlands. Blood pressure was measured by a digital monitor, and heart rate was calculated as beats per minute from an electrocardiogram recording with the patient in supine position. Particle concentrations were measured at central measuring sites. Linear regression was used to model the association between 24-hr mean concentrations of particles and blood pressure and heart rate. Estimates were adjusted for trend, day of week, temperature, barometric pressure, relative humidity, and medication use. Pooled effect estimates showed a small significant decrease in diastolic and systolic blood pressure in association with particulate air pollution; a slight decrease in heart rate was found. Of the three centers, Erfurt revealed the most consistent particle effects. The results do not support findings from previous studies that had shown an increase in blood pressure and heart rate in healthy individuals in association with particles. However, particle effects might differ in cardiac patients because of medication intake and disease status, both affecting the autonomic control of the heart.