给编辑:
哮喘是全球重要的疾病,是医院入院,医疗咨询,处方和生活质量受损的主要原因。哮喘的确切原因(尽管在很大程度上未知)是多因素的,并且涉及遗传和环境因素的复杂相互作用。
尽管较低社会经济群体中的人们通常会增加医院入院率[1],几乎没有专门报道严重的哮喘(i.e.prolonged admissions and/or death within 30 days). Evidence about the effects of air pollutants on the occurrence of serious asthma is also unclear [2]。
We aimed to establish the hospital admission rate and case fatality for serious asthma, and whether admissions are associated more strongly with social deprivation or air pollutants.
我们使用f住院病人的医疗记录链接数据rom the Patient Episode Database for Wales (PEDW) and mortality data from the National Health Service (NHS) Welsh Administrative Register. PEDW covers inpatient admissions to all NHS hospitals across 22 local health authorities in Wales, UK (population three million) and has been used as the basis of many previous published studies.
我们纳入了从1999年4月1日至2007年3月31日的所有紧急入院,哮喘(ICD-10代码J45和J46)是出院时的主要诊断。所有年龄段的患者持续≥3天,或者在30天内死亡(因任何原因而死亡)被归类为“严重”病例。我们在研究期内包括了所有第一个“严重”入院,随后的认真入院,只要在认真入院后30天就发生了。
We measured social deprivation and its seven domains using the Welsh Index of Multiple Deprivation 2005 [3]。社会剥夺得分分配到威尔士的1,896个较低的超级产出区域(LSOA)(平均LSOA人口1,560)[3]。LSOA根据其社会剥夺得分进行排名,并将其分为五分之一(I:最少剥夺; V:最剥夺的)。
Data on the following eight air pollutants were provided by the AEA Energy and Environment Company (the official British air pollution monitoring agency) from 1999–2007: benzene, carbon monoxide, nitric oxide, nitrogen dioxide, ozone, particulate matter <10.0 μm·m−3和<2.5μm·m−3in diameter and sulfur dioxide [4]。空气污染物是基于年度测量的年平均值。在2007年(臭氧2005年),它们从23个地点插值到1 km的地理水平2[4]。
The main outcome measures were, first, hospitalised incidence of serious asthma per 100,000 population, standardised directly using the standard European population, and secondly, case fatality (all causes of death) at 30 days, standardised directly using the study population. Statistical methods include the Chi-square trend test, adjusted and unadjusted correlations between hospitalised incidence of serious asthma and, respectively, social deprivation and air pollutants. They were calculated at the LSOA level and derived through multiple linear regression using logged incidence rates. Correlations between serious asthma and social deprivation were adjusted for air pollutants, and反之亦然。尽管随着时间的流逝,许多空气污染物非常稳定[5], we also investigated trends by correlating monthly means of air pollutants over the 8-yr study period with corresponding monthly (logged) incidence of serious asthma to all hospitals in the local authority corresponding to each site. We also investigated correlations between the air pollutants and social deprivation at the LSOA level.
在9,986例不同的患者中,严重哮喘有12,740次入院(每100,000人口54.5次),平均值±sd年龄50.0±23.9岁。女性比男性年龄较大(p <0.001)(平均52.4相对45.0 yrs). There were 183 deaths within 30 days of admission (case fatality 1.4%), mostly (72%) among people aged ≥65 yrs.
在婴儿中(每100,000名90.6)和75-84岁(108)和≥85岁(131)的老年人(131)中,严重哮喘的住院病最高。女性的发病率高(72)高于男性(36)。男性婴儿的年龄特异性发病率高(p <0.001),男性和女性儿童类似,但在所有成年年龄段中,女性中的男女都高于男性。
Hospitalised incidence was 2.48-fold higher (95% CI 2.34–2.62) for the most deprived quintile V (77.0 per 100,000) compared with the least deprived quintile I (31.0). This increased risk was found across all age groups; <14 yrs (1.95 increased risk), 15–54 yrs (2.66) and ≥55 yrs (2.38). There was a significant (p<0.001) trend of increasing incidence across deprivation quintiles I to V.
在整个LSOA中,住院病的发病率与社会剥夺(0.45; P <0.001)以及所有七个剥夺组成部分显着相关(所有p <0.001;表格1)。与六个组成部分存在正相关;“收入”(0.45),“就业”(0.44),“教育”(0.40),“健康”(0.34),“住房”(0.15)(0.15)和“物理环境”(0.14)(0.14)和与地理位置的负相关性“访问”到服务”(-0.29)。
There were modest, significant positive correlations between hospitalised incidence and seven of the eight air pollutants ranging from 0.12 for sulfur dioxide to 0.18 for particulate matter <10.0 μm·m−3和<2.5μm·m−3,但与臭氧无关(0.005;表格1])。每月空气污染物平均值与严重哮喘的趋势之间的趋势之间的相关性也很弱(表格1)。调整了社会剥夺后,空气污染物与哮喘更为微弱(表格1)。However, after adjusting for the air pollutants, the correlations between social deprivation and asthma were not affected substantially (表格1)。
在整个LSOA中,空气污染物与社会剥夺之间存在适度的正相关,范围从0.07(臭氧)到0.19(苯;表格1)。There was a significant reduction over time in hospitalised incidence of serious asthma from 1999/2000 to 2006/2007 (p<0.001) by 1.6% per year (95% CI 0.9−2.3%), but no significant trend for case fatality (p=0.15).
A major strength of this study is its size, covering >12,000 hospital admissions in a geographically defined population of three million. It is based on record linkage of inpatient and mortality data, which enables repeat admissions for the same patients to be identified as well as deaths following hospital discharge. Study limitations are, first, that the asthma admissions and air pollutants covered 8 yrs from 1999 to 2007, but air pollutants were measured geographically to 1 km2仅在1年(2007年)中,在2005年衡量了社会剥夺。随着时间的流逝,社会剥夺措施是一致的,尽管随着时间的流逝,许多空气污染物都非常稳定[5],我们还调查了1999年至2007年从1999年到2007年的空气污染物的每月手段,以解释可能的趋势。其次,我们的数据缺乏有关疾病史,病理,医学观察,治疗和入院前死亡的详细信息,尽管这并不应大大降低有关发病率的主要研究结论。由于我们的研究涵盖了≥3天的严重哮喘住院治疗,因此粗略的临床判断引起的误诊应该是最小的。空气污染物是基于住宅而不是工作场所的,这也可能通过暴露于职业相关的尘埃,气体和气污染物来影响哮喘。
Our overall hospitalised incidence of serious asthma (54.5 per 100,000) compares with 138 for all asthma admissions in Wales in 2002 [6], which is among the highest in the world.
我们发现,严重哮喘的住院和八种空气污染物中的七个住院之间的相关性适中。这些相关性(全部<0.20)比社会剥夺方面的相关性要弱得多(0.45),包括“就业”,“收入”和“教育”(0.40-0.45)。调整剥夺时,空气污染物的相关性大大降低(<0.14)。此外,每月的空气污染物手段与“严重哮喘”的每月录取之间的相关性也大多是谦虚或弱,并且比社会剥夺和“严重哮喘”之间的相关性。我们的发现支持哮喘恶化和空气污染物趋势之间缺乏持续关系[2]。
Community studies internationally have often reported conflicting findings about the relationship between asthma prevalence and socioeconomic group, although one of the largest studies (across 15 European countries) reported higher asthma prevalence in lower socioeconomic groups [7]。大多数对哮喘入院的研究报告说,被剥夺群体之间的率高得多[1],这表明哮喘与社会经济群体之间的联系比在社区环境中更强。我们在贫困群体中导致“严重哮喘”发病率更高的可能原因包括健康寻求行为的差异,遵守医疗保健,可能的较低住院阈值以及较长的住院住宿(≥3天),这是由于社区的较低水平和自我支持而导致的。
更高的发病率serious asthma among the most deprived also reflects more frequent severe exacerbations, which could reflect differences in exposure. For example, deprived groups smoke more, which independently accelerates lung decline and worsens symptoms [8],虽然哮喘吸烟者拥有更多的入院,并且使用更多的医疗保健资源,而不是非吸烟者[9]。The modest associations between air pollutants and areas of social deprivation across Wales [10]进一步表明,与空气污染物相比。High levels of deeply inhaled pollutants from smoking are likely to overwhelm any effect of background air pollutants in causing acute asthma attacks.
尽管空气污染物可能会引起哮喘加剧,但其影响显得很小,而对社会剥夺的影响却少。对严重哮喘的社会不平等现象的进一步研究应集中在病毒感染中烟雾烟,天气,工作场所暴露和地理变异的可能混淆作用。
致谢
The authors are grateful to Caroline Brooks, Steven Macey, Alan Watkins and Wai-Yee Cheung, Swansea University, Swansea, UK for advice with the analysis. The authors are also grateful to the Health Information Research Unit (HIRU), College of Medicine, Swansea University, for preparing and providing access to the project specific linked datasets from the Secure Anonymised Information Linkage (SAIL) system, which is funded by the Wales Office of Research and Development.
脚注
利益声明
J.M. Hopkin和K.E.的感兴趣陈述刘易斯可以在www.www.qdcxjkg.com/site/misc/statement.xhtml
- ©ERS 2012