Multivariate meta-analysis: a method to summarize non-linear associations.

Multivariate meta-analysis represents a promising statistical tool in several research areas. Here, we provide a brief overview of the application of this methodology to combining complex multi-parameterized relationships, such as non-linear or delayed associations, in multi-site studies. The discussion focuses on the advantages over simpler univariate methods, estimation and computational issues and directions for further research

Mortality impacts of sulphur concetrations in 20 European cities in the APHEKOM Project

The implementation of three EU directives to reduce sulphur content in fuel was assessed for mortality impacts in 20 European cities, between 1990 and 2007 in the APHEKOM project. This specific study aimed to examine whether different lag structures apply to the relationships between cardiovascular and respiratory events and SO2 concentrations, which will therefore result in differences in mortality impacts from regulation implementation. Prior evidence has shown that cardiovascular mortality is more likely to be affected by SO2 concentrations on the same or the previous day of the event, while respiratory mortality more likely to show a delayed effect of exposure to the same pollutant

Profiling SO2 air pollution patterns in 9 EU Aphekom cities: The Aphekom Project

A detailed analysis of hourly pollutant concentrations mainly focusing on SO2 data obtained from 9 centres involved in the Aphekom project was conducted. This involved the generation of individual diurnal SO2 profiles in order to: (i) identify city specific patterns including source apportionment and quantification, (ii) track changes over time, (iii) analyse the changes in SO2 concentrations from different emission sources, i.e. traffic, heating, shipping and industrial sources, overtime

The assessment of the implementation of fuel related legislations and their impact on air quality and public health

The main focus of Work Package 6 of the Aphekom project was: to develop innovative methods to analyse the decrease in air pollution levels following implementation of an European regulation to reduce the sulphur content in liquid fuels; to follow the evolution of health risks over time; to track related effect modifiers; and to quantify the monetary costs of health impacts of the implemented regulation

The APHEKOM Project: A literature review of air pollution interventions and their impact of public health

Intervention studies play an important role in supporting and complementing scientific validation of results of epidemiological non-intervention studies linking air pollution and health. In this paper a collection of existing published intervention studies is reviewed with the aim to give a summarized overview spanning a variety of approaches regarding the type of the intervention and findings with the main focus on studies that assessed interventions that improved air quality and the associated positive impact on public health. Air pollution interventions were defined as events aimed at reducing air pollution and also events where air pollution reductions occurred as a side effect

Associations between environmental factors and hospital admissions for sickle cell disease

Sickle cell disease (SCD) is an increasing global health burden. This inherited disease is characterised by a remarkable phenotypic heterogeneity, which can only partly be explained by genetic factors. Environmental factors are likely to play an important role but studies of their impact on disease severity are limited and their results are often inconsistent. This study investigated associations between a range of environmental factors and hospital admissions of young patients with SCD in London and in Paris between 2008 and 2012. Specific analyses were conducted for sub-groups of patients with different genotypes and for the main reasons of admissions. Generalized additive models and distributed lag non-linear models were used to assess the magnitude of the associations and to calculate relative risks. Some environmental factors significantly influence the numbers of hospital admissions of children with SCD, although the associations identified are complicated. Our study suggests that meteorological factors are more likely to be associated with hospital admissions for SCD than air pollutants. It confirms previous reports of risks associated with wind speed (RR: 1.06/SD [95% confidence interval (CI): 1.00-1.12]) and also with rainfall (RR: 1.06/SD [95%CI: 1.01-1.12]). Maximum atmospheric pressure was found to be a protective factor (RR: 0.93/SD [95%CI: 0.88-0.99]). Weak or no associations were found with temperature. Divergent associations were identified for different genotypes or reasons of admissions, which could partly explain the lack of consistency in earlier studies. Advice to patients with SCD usually includes avoiding a range of environmental conditions that are believed to trigger acute complications, including extreme temperatures and high altitudes. Scientific evidence to support such advice is limited and sometimes confusing. This study shows that environmental factors do explain some of the variations in rates of admission to hospital with acute symptoms in SCD, but the associations are complex, and likely to be specific to different environments and the individual's exposure to them. Furthermore, this study highlights the need for prospective studies with large numbers of patients and standardised protocols across Europe

Effects of Cold Weather on Mortality: Results From 15 European Cities Within the PHEWE Project

Weather-related health effects have attracted renewed interest because of the observed and predicted climate change. The authors studied the short-term effects of cold weather on mortality in 15 European cities. The effects of minimum apparent temperature on cause- and age-specific daily mortality were assessed for the cold season (October-March) by using data from 1990-2000. For city-specific analysis, the authors used Poisson regression and distributed lag models, controlling for potential confounders. Meta-regression models summarized the results and explored heterogeneity. A 1 degrees C decrease in temperature was associated with a 1.35% (95% confidence interval (CI): 1.16, 1.53) increase in the daily number of total natural deaths and a 1.72% (95% CI: 1.44, 2.01), 3.30% (95% CI: 2.61, 3.99), and 1.25% (95% CI: 0.77, 1.73) increase in cardiovascular, respiratory, and cerebrovascular deaths, respectively. The increase was greater for the older age groups. The cold effect was found to be greater in warmer (southern) cities and persisted up to 23 days, with no evidence of mortality displacement. Cold-related mortality is an important public health problem across Europe. It should not be underestimated by public health authorities because of the recent focus on heat-wave episodes

The association of cold weather and all-cause and cause-specific mortality in the island of Ireland between 1984 and 2007

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.This article has been made available through the Brunel Open Access Publishing Fund.Background This study aimed to assess the relationship between cold temperature and daily mortality in the Republic of Ireland (ROI) and Northern Ireland (NI), and to explore any differences in the population responses between the two jurisdictions. Methods A time-stratified case-crossover approach was used to examine this relationship in two adult national populations, between 1984 and 2007. Daily mortality risk was examined in association with exposure to daily maximum temperatures on the same day and up to 6 weeks preceding death, during the winter (December-February) and cold period (October-March), using distributed lag models. Model stratification by age and gender assessed for modification of the cold weather-mortality relationship. Results In the ROI, the impact of cold weather in winter persisted up to 35 days, with a cumulative mortality increase for all-causes of 6.4% (95%CI=4.8%-7.9%) in relation to every 1oC drop in daily maximum temperature, similar increases for cardiovascular disease (CVD) and stroke, and twice as much for respiratory causes. In NI, these associations were less pronounced for CVD causes, and overall extended up to 28 days. Effects of cold weather on mortality increased with age in both jurisdictions, and some suggestive gender differences were observed. Conclusions The study findings indicated strong cold weather-mortality associations in the island of Ireland; these effects were less persistent, and for CVD mortality, smaller in NI than in the ROI. Together with suggestive differences in associations by age and gender between the two Irish jurisdictions, the findings suggest potential contribution of underlying societal differences, and require further exploration. The evidence provided here will hope to contribute to the current efforts to modify fuel policy and reduce winter mortality in Ireland

The Effect of High Ambient Temperature on the Elderly Population in Three Regions of Sweden

The short-term effects of high temperatures are a serious concern in the context of climate change. In areas that today have mild climates the research activity has been rather limited, despite the fact that differences in temperature susceptibility will play a fundamental role in understanding the exposure, acclimatization, adaptation and health risks of a changing climate. In addition, many studies employ biometeorological indexes without careful investigation of the regional heterogeneity in the impact of relative humidity. We aimed to investigate the effects of summer temperature and relative humidity and regional differences in three regions of Sweden allowing for heterogeneity of the effect over the scale of summer temperature. To do so, we collected mortality data for ages 65+ from Stockholm, Göteborg and Skåne from the Swedish National Board of Health and Welfare and the Swedish Meteorological and Hydrological Institute for the years 1998 through 2005. In Stockholm and Skåne on average 22 deaths per day occurred, while in Göteborg the mean frequency of daily deaths was 10. We fitted time-series regression models to estimate relative risks of high ambient temperatures on daily mortality using smooth functions to control for confounders, and estimated non-linear effects of exposure while allowing for auto-regressive correlation of observations within summers. The effect of temperature on mortality was found distributed over the same or following day, with statistically significant cumulative combined relative risk of about 5.1% (CI = 0.3, 10.1) per °C above the 90th percentile of summer temperature. The effect of high relative humidity was statistically significant in only one of the regions, as was the effect of relative humidity (above 80th percentile) and temperature (above 90th percentile). In the southernmost region studied there appeared to be a significant increase in mortality with decreasing low summer temperatures that was not apparent in the two more northerly situated regions. The effects of warm temperatures on the elderly population in Sweden are rather strong and consistent across different regions after adjustment for mortality displacement. The impact of relative humidity appears to be different in regions, and may be a more important predictor of mortality in some areas

Estimating the Exposure–Response Relationships between Particulate Matter and Mortality within the APHEA Multicity Project

Several studies have reported significant health effects of air pollution even at low levels of air pollutants, but in most of theses studies linear nonthreshold relations were assumed. We investigated the exposure–response association between ambient particles and mortality in the 22 European cities participating in the APHEA (Air Pollution and Health—A European Approach) project, which is the largest available European database. We estimated the exposure–response curves using regression spline models with two knots and then combined the individual city estimates of the spline to get an overall exposure–response relationship. To further explore the heterogeneity in the observed city-specific exposure–response associations, we investigated several city descriptive variables as potential effect modifiers that could alter the shape of the curve. We conclude that the association between ambient particles and mortality in the cities included in the present analysis, and in the range of the pollutant common in all analyzed cities, could be adequately estimated using the linear model. Our results confirm those previously reported in Europe and the United States. The heterogeneity found in the different city-specific relations reflects real effect modification, which can be explained partly by factors characterizing the air pollution mix, climate, and the health of the population