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Donaldson G, Seemungal TA, Bhowmik A, et al., 2002, Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease, Thorax, Vol: 57, Pages: 847-852, ISSN: 0040-6376
Patel IS, Seemungal TA, Wilks M, et al., 2002, Relationship between bacterial colonisation and the frequency, character, and severity of COPD exacerbations, Thorax, Vol: 57, Pages: 759-764, ISSN: 0040-6376
Keatinge W, Donaldson G, 2001, Winter deaths: worm housing is not enough, BRITISH MEDICAL JOURNAL, Vol: 323, Pages: 166-167, ISSN: 0959-535X
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Donaldson GC, Rintamäki H, Näyhä S, 2001, Outdoor clothing: its relationship to geography, climate, behaviour and cold-related mortality in Europe, Int J Biometeorol, Vol: 45, Pages: 45-51, ISSN: 0020-7128
It has been suggested, that the inhabitants of northern European regions, who experience little cold-related mortality, protect themselves outdoors by wearing more clothing, at the same temperature, than people living in southern regions where such mortality is high. Outdoor clothing data were collected in eight regions from 6583 people divided by sex and age group (50-59 and 65-74 years). Across Europe, the total clothing worn (as assessed by dry thermal insulation and numbers of items or layers) increased significantly with cold, wind, less physical activity and longer periods outdoors. Men wore 0.14 clo (1 clo = 0.115 m2 K W-1) more than women and the older people wore 0.05 clo more than the younger group (both P < 0.001). After allowance for these factors, regional differences in insulation and item number were correlated (r = -0.74, P = 0.037; r = -0.74, P = 0.036 respectively), but not those in clothing layers (r = -0.21; P = 0.61), with indices of cold-related mortality. Cold weather most increased the wearing of gloves, scarves and hats. The geographical variation in the wearing of these three together items more closely matched that in cold-related mortality (r = -0.89, P = 0.003). A possible explanation for this may be that they protect the head and hands, where stimulation by cold greatly increases peripheral vasoconstriction causing a rise in blood pressure that procedure haemoconcentration and raised cardiovascular risk.
Keatinge WR, Donaldson GC, 2001, Mortality related to cold and air pollution in London after allowance for effects of associated weather patterns, Environ Res, Vol: 86, Pages: 209-216, ISSN: 0013-9351
We looked for atypical weather patterns that could confound, and explain large inconsistencies in, conventional estimates of mortality due to SO(2), CO, and smoke. Using Greater London data for 1976-1995 in the linear temperature/mortality range 0-15 degrees C we determined weather patterns associated with pollutants (all deseasonalized) by single regressions of daily temperature, wind, rain, humidity, and sunshine at successive days advance and delay. Polluted days were colder (P<0.01 for SO(2), CO, and smoke) and less windy and rainy than usual, and this cold weather was more prolonged than usual with 50% maximum temperature depression 5.9 days (95% interval 4.0-7.7) before high SO(2), compared to 2.0 (1.6-2.3) days before average cold days. We also used multiple regression of mortality at 50+ years of age on all these weather factors and pollutants at 0-, 1-, 2- to 4-, 5- to 13-, and 14- to 24-day delays to allow for the atypical weather patterns. This showed cold weather associated with 2.77 excess deaths per million during 24 days following a 1 degrees C fall for 1 day, but no net excess deaths with SO(2) (mean 28.0 ppb) or CO (1.26 ppm). It suggested (P>0.05) some increase with smoke, perhaps acting as surrogate for PM(10), for which data were too scanty to analyze.
Donaldson GC, Seemungal TAR, Wedzicha JA, 2000, Natural history of exacerbations in patients with chronic obstructive pulmonary disease., Publisher: BRITISH MED JOURNAL PUBL GROUP, Pages: A3-A3, ISSN: 0040-6376
Seemungal T, Donaldson GC, Wedzicha JA, 2000, Exacerbations and the risk hospitalisation in patients with COPD, Publisher: BRITISH MED JOURNAL PUBL GROUP, Pages: A44-A44, ISSN: 0040-6376
Jaques SCD, Wedzicha JA, Donaldson GC, 2000, Effect of exercise at-18 °C on expired nitric oxide in young men, Publisher: CAMBRIDGE UNIV PRESS, Pages: 222P-223P, ISSN: 0022-3751
Wedzicha JA, Seemungal TA, MacCallum PK, et al., 2000, Acute exacerbations of chronic obstructive pulmonary disease are accompanied by elevations of plasma fibrinogen and serum IL-6 levels, Thromb Haemost, Vol: 84, Pages: 210-215, ISSN: 0340-6245
Respiratory tract infections may acutely increase risk from coronary heart disease (CHD), though the mechanisms have not been defined. Patients with chronic obstructive pulmonary disease (COPD) are prone to repeated exacerbations that are often associated with respiratory infections. These patients also have increased cardiovascular morbidity and mortality. We hypothesized that transient acute increases in plasma fibrinogen, an independent risk factor for CHD, could occur at COPD exacerbation (mediated through a rise in IL6) and thereby provide a mechanism linking respiratory infection to risk of coronary heart disease.
Seemungal TA, Donaldson GC, Bhowmik A, et al., 2000, Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease, Am J Respir Crit Care Med, Vol: 161, Pages: 1608-1613, ISSN: 1073-449X
Although exacerbations of chronic obstructive pulmonary disease (COPD) are associated with symptomatic and physiological deterioration, little is known of the time course and duration of these changes. We have studied symptoms and lung function changes associated with COPD exacerbations to determine factors affecting recovery from exacerbation. A cohort of 101 patients with moderate to severe COPD (mean FEV(1) 41.9% predicted) were studied over a period of 2.5 yr and regularly followed when stable and during 504 exacerbations. Patients recorded daily morning peak expiratory flow rate (PEFR) and changes in respiratory symptoms on diary cards. A subgroup of 34 patients also recorded daily spirometry. Exacerbations were defined by major symptoms (increased dyspnea, increased sputum purulence, increased sputum volume) and minor symptoms. Before onset of exacerbation there was deterioration in the symptoms of dyspnea, sore throat, cough, and symptoms of a common cold (all p < 0.05), but not lung function. Larger falls in PEFR were associated with symptoms of increased dyspnea (p = 0.014), colds (p = 0.047), or increased wheeze (p = 0.009) at exacerbation. Median recovery times were 6 (interquartile range [IQR] 1 to 14) d for PEFR and 7 (IQR 4 to 14) d for daily total symptom score. Recovery of PEFR to baseline values was complete in only 75.2% of exacerbations at 35 d, whereas in 7.1% of exacerbations at 91 d PEFR recovery had not occurred. In the 404 exacerbations where recovery of PEFR to baseline values was complete at 91 d, increased dyspnea and colds at onset of exacerbation were associated with prolonged recovery times (p < 0.001 in both cases). Symptom changes during exacerbation do not closely reflect those of lung function, but their increase may predict exacerbation, with dyspnea or colds characterizing the more severe. Recovery is incomplete in a significant proportion of COPD exacerbations.
Keatinge WR, Donaldson GC, Cordioli E, et al., 2000, Heat related mortality in warm and cold regions of Europe: observational study, BMJ, Vol: 321, Pages: 670-673, ISSN: 0959-8138
To assess heat related mortalities in relation to climate within Europe.
Keatinge WR, Donaldson GC, Bucher K, et al., 2000, Winter mortality in relation to climate, Int J Circumpolar Health, Vol: 59, Pages: 154-159, ISSN: 1239-9736
We report further details of the Eurowinter survey of cold related mortalities and protective measures against cold in seven regions of Europe, and review these with other evidence on the relationship of winter mortality to climate. Data for the oldest subject group studied, aged 65-74, showed that in this vulnerable group, high levels of protection against indoor and outdoor cold at given outdoor temperatures were found mainly in countries with cold winters, and were associated with low levels of excess mortality at a given level of outdoor cold. Regions such as London that had poor protection against cold and/or high baseline mortalities had higher levels of winter excess mortality than expected for the coldness of their winters.
Seemungal T, Donaldson GC, Bhowmik A, et al., 1999, Lung function lags behind symptoms at COPD exacerbation, Publisher: AMER LUNG ASSOC, Pages: A211-A211, ISSN: 1073-449X
Donaldson GC, Seemungal T, Jeffries DJ, et al., 1999, Effect of temperature on lung function and symptoms in chronic obstructive pulmonary disease, Eur Respir J, Vol: 13, Pages: 844-849, ISSN: 0903-1936
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.
Seemungal T, Bhowmik A, Donaldson GC, et al., 1998, Unreported exacerbations have a similar health burden to reported exacerbations, Thorax, Vol: 53, ISSN: 0040-6376
We have shown previously that up to 50% of exacerbations (E) may be unreported (Seemungal et al, Am J Respir Crit Care Med 1998; 157:1418-1422) however reported (RE) and unreported exacerbations (UE) do not differ significantly in symptoms and lung function though there may be health burden differences related to reporting. 53 patients (39M, 14F) with COPD [mean (sd) age 66.0 (8.2) years, FEV1 1.10 (0.42) 1, FEV1 % 41 (16.0) %, FVC 2.53 (0.89) 1, PaO2 8.98 (0.96) kPa, PaCO2 5.92 (0.80) kPa] were followed over 7 months from December, 1997. There were 92 exacerbations (range 1-4 /patient) of which 58 (63%) were reported and 34 (37%) unreported. In 3 unreported E no details of treatment were available. In 6 (19%) of the remaining 31 unreported exacerbations the patients did not realise that there was a problem or could not be bothered to report. In 3 (10 %) they self medicated with antibiotics and in 18 (58%) they saw their GP or were treated at the Outpatients Department of another hospital. In the remaining 13% of cases the GP came to the home (1), or the patient was admitted to hospital (2) or the patient was treated for another problem (1). Criteria for scoring the health burden of each E, modified from Nicholson (BMJ 1997; 315:1060-4) were, no change in activity (0), decreased ability to go out (1), decreased ability to self-care (2), bed bound (3), hospital admission without upgrade in social service support (4) and hospital admission with upgrade in social service support (5). Burden 0 1 2 3 4 Total RE (58) 15.6 53.5 29.4 0 1.7 100% p = 0.6 UE(31) 29.0 29.0 19.3 16.1 6.5 100% There was no significant difference in disease burden between reported and unreported exacerbations and this is consistent with our observation that there is no significant difference between reported and unreported exacerbations.
Donaldson GC, Brown JM, Herring R, et al., 1998, Effect of damp housing on patients with chronic obstructive pulmonary disease, Thorax, Vol: 53, ISSN: 0040-6376
This study examined whether damp housing was associated with increased frequency of COPD exacerbation or prevalence of chronic symptoms. 80 COPD patients (59 M, 21F; mean age ± SEM, 66.0 ± 8.6 years; FEV1 0.89 ± 0.45 1 and FVC 1.74 ± 0.84, PEFR 160 ± 81) were interviewed at home between 22 Jan and 17 Feb 1998. Measurements were made of spirometry, and of temperature and relative humidity in the room they considered coldest (61 bedrooms, 5 kitchen, 7 bathroom and 7 living room) . 26 of the 80 homes were considered damp by the occupant, and associated independently with greater humidity and lower temperatures (both p<0.05) Exacerbation as diagnosed using the criteria of Anthonisen (Ann Intern Med 106:196-204, 1987) from increase in symptoms recorded on daily diary cards. Their annual rate was calculated over either one or two whole years since Nov. 1995, rates were not available for 24 patients who had not recorded 200 days data in any 12 months. Exacerbation frequency was predicted as 3.2 per year (95% CI: 3.3 to 4.2; p=0.026; generalised linear modelling for poisson distribution) for patients living in damp homes, compared to 2.1 (1.7 to 2.5) for those in dry homes. Exacerbation frequency was unrelated to the number of occupants or people met during the day, or to pet ownership. Dampness was not related to living on the ground floor, nor to spirometry or other chronic symptoms, although only those homes that were damp had signs of mould.
Seemungal TAR, Donaldson GC, Paul EA, et al., 1998, Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease, AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, Vol: 157, Pages: 1418-1422, ISSN: 1073-449X
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Donaldson GC, Ermakov SP, Komarov YM, et al., 1998, Cold related mortalities and protection against cold in Yakutsk, eastern Siberia: observation and interview study, BMJ, Vol: 317, Pages: 978-982, ISSN: 0959-8138
To assess how effectively measures adopted in extreme cold in Yakutsk control winter mortality.
Donaldson GC, Tchernjavskii VE, Ermakov SP, et al., 1998, Winter mortality and cold stress in Yekaterinburg, Russia: interview survey, BMJ, Vol: 316, Pages: 514-518, ISSN: 0959-8138
To evaluate how mortality and protective measures against exposure to cold change as temperatures fall between October and March in a region of Russia with a mean winter temperature below -6 degrees C.
Seemungal TA, Donaldson GC, Paul EA, et al., 1998, Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease, Am J Respir Crit Care Med, Vol: 157, Pages: 1418-1422, ISSN: 1073-449X
Exacerbations occur commonly in patients with moderate or severe chronic obstructive pulmonary disease (COPD) but factors affecting their severity and frequency or effects on quality of life are unknown. We measured daily peak expiratory flow rate (PEFR) and daily respiratory symptoms for 1 yr in 70 COPD patients (52 male, 18 female, mean age [+/- SD] 67.5 +/- 8.3 yr, FEV1 1.06 +/- 0.45 L, FVC 2.48 +/- 0.82 L, FEV1/FVC 44 +/- 15%, FEV1 reversibility 6.7 +/- 9.1%, PaO2 8.8 +/- 1.1 kPa). Quality of life was measured by the St. George's Respiratory Questionnaire (SGRQ). Exacerbations (E) were assessed at acute visit (reported exacerbation) or from diary card data each month (unreported exacerbation). In 61 (87%) patients there were 190 exacerbations (median 3; range, 1 to 8) of which 93 (51%) were reported. There were no differences in major symptoms (increase in dyspnea, sputum volume, or purulence) or physiological parameters between reported and unreported exacerbations. At exacerbation, median peak flow fell by an average of 6.6 L/min (p = 0.0003). Using the median number of exacerbations as the cutoff point, patients were classified as infrequent exacerbators (E = 0 to 2) or frequent exacerbators (E = 3 to 8). The SGRQ Total and component scores were significantly worse in the group that had frequent exacerbations: SGRQ Total score (mean difference = 14.8, p < 0.001), Symptoms (23.1, p < 0.001), Activities (12.2, p = 0.003), Impacts (13.9, p = 0.002). However there was no difference between frequent and infrequent exacerbators in the fall in peak flow at exacerbation. Factors predictive of frequent exacerbations were daily cough (p = 0.018), daily wheeze (p = 0.011), and daily cough and sputum (p = 0.009) and frequent exacerbations in the previous year (p = 0.001). These findings suggest that patient quality of life is related to COPD exacerbation frequency.
Seemungal T, Donaldson GC, Paul EA, et al., 1997, Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease, Thorax, Vol: 52, ISSN: 0040-6376
Exacerbations occur commonly in patients with moderate or severe COPD though effects on quality of life are unknown. 70 COPD patients (52M, 18F, mean(sd) age 67.5(8.3) yrs, FEV1 1.07(0.44) 1, FVC 2.50(0.80) 1, FEV1 reversibility 6.6 (9.6)%, PaO2 8.8 (1.1) kPa measured daily PEFR and daily respiratory symptoms for one year. Health - related quality of life was measured with the St. George's Respiratory Questionnaire (SGRQ). In 61(87%) patients there were 190 exacerbations, mean 2.7(1.5) exacerbations per patient per year. Over the 2 days prior to onset of exacerbation peak flow fell by a median(IQR) of - 6.6 (-16.7,0) 1/min (p < 0.001) per patient for mean(SD) 11.1(6.1) days. SGRQ scores were Total 57.1(16.6), Symptoms 66.3(19.9), Activities 74.9(17.6), Impacts 44.0(18.8) and these were related to the frequency of exacerbations (p): total score (p<0.001), symptoms (p<0.001), activities (p = 0.002), impacts (p = 0.001) but not to fall in PEFR nor to duration of fall in PEFR at exacerbation (p > 0.45). Factors predisposing to frequent exacerbations were past exacerbations(PE), daily cough(C), daily wheeze (W), and combination of daily cough and sputum, (CS) and these were also correlated with SGRQ scores (r values): SGRQ Score PE C W CS Total 0.33** 0.123 0.39** 0.13 Symptoms 0.54** 0.20 0.39** 0.25* Activities 0.27* 0.05 0.16 0.07 Impacts 0.24* 0.13 0.42** 0.10 **p<0.01 *p<0.05 COPD exacerbations and their predisposing factors affect quality of life. Reduction of exacerbation frequency may be expected to improve health status in COPD.
Donaldson GC, Seemungal T, Evans C, et al., 1997, Effect of cold exposure on lung function in COPD patients with exacerbation, Thorax, Vol: 52, ISSN: 0040-6376
Patients with COPD deteriorate in the winter, although the effect of cold exposure on lung function during stability and exacerbation are unknown. Nine COPD patients (8 M, 1F; mean age ± SEM, 67.6 ± 2.7 years; PaO2 9.48 ± 0.18 kPa, FEV1 0.71 ± 0.06 1 and reversibility 10.0 ± 4.5%) were exposed, seated, wearing outdoor clothing, to cold still air at 4.1 ± 0.6 °C for 30 min in a climatic chamber on two occasions, once when clinically stable and once when experiencing an exacerbation, as diagnosed using the criteria of Anthonisen (Ann Intern Med 106:196-204, 1987). On average the two occasions were 170 ± 40 days apart; barometric pressure was not significantly different. FEV1 and FVC were measured twice before entering the climatic chamber (at 22.3 ± 0.5 °C) and then after 30 min using a bellows type spirometer (Vitalograph) at ATPS, which previous studies show give valid results under similar conditions (Perks et al. Thorax 38: 592-594 1983; Cramer et al. Thorax 39: 771-774, 1984). When stable, FEV1 fell from 0.71 ± 0.06 1 to 0.61 ± 0.08 1 (P=0.031; paired t-test) and FVC by 2.10 ± 0.21 1 to 1.86 ± 0.27 1 (P=0.087). With exacerbation, 5.1 ± 1.2 days after onset, FEV1 fell from 0.63 ± 0.04 1 to 0.59 ± 0.04 1 (P=0.046) and FVC by 2.03 ± 0.23 1 to 1.87 ± 0.18 1 (P=0.122). Falls in FEV1 (as % of FEV1 at room temperature, to adjust for lower FEV1 at exacerbation) were 16.4 ±. 6.4% (without) and 6.3 ± 2.7 % (with exacerbation) (P=0.048). These results suggest that cold air has an immediate detrimental effect on FEV1 , which is more pronounced when the patient is free from exacerbation; possibly because the ability of the airways to constrict is reduced.
Seemungal T, Donaldson GC, Bhowmik A, et al., 1997, Monitoring and reporting of COPD exacerbations in the community, Thorax, Vol: 52, ISSN: 0040-6376
Exacerbations are an important outcome measure in COPD patients. As patients are accustomed to chronic disability, they may under-report exacerbations to doctors. We have studied all exacerbations over 1 year, including reported and unreported ones to assess any differences. Between October 1995 and September 1996, a group of 70 COPD patients (52M, 18F, mean(sd) age 67.5(8.3) yrs, FEV1 1.07(0.44) 1, FVC 2.50(0.80) 1, FEV1 reversibility 6.6 (9.6)%, PaO2 8.8 (1.1) kPa, PaCO2 6.1(1.0) kPa COPD patients recorded on diary cards, daily peak flow rate(PEFR) and changes in respiratory symptoms. A sub-cohort of 26 also recorded daily FEV1 and FVC. Diagnosis of exacerbation(E) was made using criteria based on Anthonisen et al (Ann Intern Med. 1987:106; 196-204): Type 1 - all 3 major symptoms (increase in dyspnoea, sputum purulence and increased sputum volume); Type 2 - two of above; Type 3 - one above, with one minor symptom. 61 patients had 190 E (median 3, range 1-8) of which 93 were reported and 91 unreported (symptom data absent for 7). 183 exacerbations were classified into type 1 (n = 30), type2 (n = 73), and type 3 (n = 80). Over the 2 days prior to onset of exacerbation peak flow fell by a median(IQR) of -4.0 (-20,0) l/min (p < 0.001). There were no differences between reported and unreported exacerbations for the major symptoms of increased dyspnoea (p=0.15) and sputum volume and purulence(p>0.5 for both), type of exacerbation (p = 0.17), number of exacerbations recorded (p = 0.86), PEFR change (p = 0.66) or duration of that change (p = 0.34). For the minor symptoms, reported exacerbations were associated with increased cough (p=0.02), but a lower incidence of increased wheeze (p=0.03). There were no major differences between reported and unreported exacerbations. However exacerbations associated with increased cough were more frequently reported. Diary card monitoring of exacerbation by symptom, PEFR and FEV1 provides accurate documentation of exacerbation occ
MacKenzie MA, 1997, Cold exposure and winter mortality in Europe, LANCET, Vol: 350, Pages: 590-591, ISSN: 0140-6736
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Donaldson GC, Robinson D, Allaway SL, 1997, An analysis of arterial disease mortality and BUPA health screening data in men, in relation to outdoor temperature, Clin Sci (Lond), Vol: 92, Pages: 261-268, ISSN: 0143-5221
1. Laboratory studies have shown that cold exposure causes an increase in blood pressure, cholesterol and erythrocyte count. However, whether the mild cold exposures received during everyday life are sufficient to cause such changes is unclear. 2. To test this, outdoor temperatures in central London between 1986 and 1992 were related to both haematological and blood pressure data on 50-69-year-old men attending BUPA health screening examinations in London, and to mortality in South-East England. Since any association with temperature may be an artifact due to common, temperature-independent, annual rhythms in the parameters, these data were also analysed after removal of these circannual components by digital filtering. 3. It was found that short-term falls in temperature produced significant increases in Hb, erythrocyte count, packed cell volume, mean corpuscular Hb concentration, serum albumin, systolic and diastolic blood pressure, and significant decreases in mean corpuscular volume and erythrocyte sedimentation rate. Mean corpuscular Hb, leucocyte count, platelet count and serum cholesterol concentrations were unchanged. Time-series analysis showed that these changes occurred almost immediately in response to a fall in temperature, but persisted for longer intervals of up to 1-2 days. 4. Mortalities from ischaemic heart disease and cerebrovascular disease were also significantly increased by short-term falls in temperature. 5. These finding indicate that in the general population the cold exposures of normal life are sufficient to induce significant and prolonged haemoconcentration and hypertension, which may explain why deaths from arterial disease are more prevalent in the winter.
Donaldson GC, Keatinge WR, 1997, Mortality related to cold weather in elderly people in southeast England, 1979-94, BMJ, Vol: 315, Pages: 1055-1056, ISSN: 0959-8138
Group TE, 1997, Cold exposure and winter mortality from ischaemic heart disease, cerebrovascular disease, respiratory disease, and all causes in warm and cold regions of Europe. The Eurowinter Group, Lancet, Vol: 349, Pages: 1341-1346, ISSN: 0140-6736
BACKGROUND: Differences in baseline mortality, age structure, and influenza epidemics confound comparisons of cold-related increases in mortality between regions with different climates. The Eurowinter study aimed to assess whether increases in mortality per 1 degree C fall in temperature differ in various European regions and to relate any differences to usual winter climate and measures to protect against cold. METHODS: Percentage increases in deaths per day per 1 degree C fall in temperature below 18 degrees C (indices of cold-related mortality) were estimated by generalised linear modelling. We assessed protective factors by surveys and adjusted by regression to 7 degrees C outdoor temperature. Cause-specific data gathered from 1988 to 1992 were analysed by multiple regression for men and women aged 50-59 and 65-74 in north Finland, south Finland, Baden-Wurttemburg, the Netherlands, London, and north Italy (24 groups). We used a similar method to analyse 1992 data in Athens and Palermo. FINDINGS: The percentage increases in all-cause mortality per 1 degree C fall in temperature below 18 degrees C were greater in warmer regions than in colder regions (eg, Athens 2.15% [95% CI 1.20-3.10] vs south Finland 0.27% [0.15-0.40]). At an outdoor temperature of 7 degrees C, the mean living-room temperature was 19.2 degrees C in Athens and 21.7 degrees C in south Finland; 13% and 72% of people in these regions, respectively, wore hats when outdoors at 7 degrees C. Multiple regression analyses (with allowance for sex and age, in the six regions with full data) showed that high indices of cold-related mortality were associated with high mean winter temperatures, low living-room temperatures, limited bedroom heating, low proportions of people wearing hats, gloves, and anoraks, and inactivity and shivering when outdoors at 7 degrees C (p < 0.01 for all-cause mortality and respiratory mortality; p > 0.05 for mortality from ischaemic heart disease and cerebrovascular diseas
Donaldson GC, Keatinge WR, 1997, Early increases in ischaemic heart disease mortality dissociated from and later changes associated with respiratory mortality after cold weather in south east England, J Epidemiol Community Health, Vol: 51, Pages: 643-648, ISSN: 0143-005X
STUDY OBJECTIVE: To identify the time courses and magnitude of ischaemic heart (IHD), respiratory (RES), and all cause mortality associated with common 20-30 day patterns of cold weather in order to assess links between cold exposure and mortality. DESIGN: Daily temperatures and daily mortality on successive days before and after a reference day were regressed on the temperature of the reference day using high pass filtered data in which changes with a cycle length < 80 days were unaffected (< 2%), but slower cyclical changes and trends were partly or completely suppressed. This provided the short term patterns of both temperature and mortality associated with a one day displacement of temperature. The results were compared with simple regressions of unfiltered mortality on temperature at successive delays. STUDY POPULATION AND SETTING: Population of south east England, including London, over 50 years of age from 1976-92. MAIN RESULTS: Colder than average days in the linear range 15 to 0 degrees C were associated with a "run up" of cold weather for 10-15 days beforehand and a "run down" for 10-15 days afterwards. The increases in deaths were maximal at 3 days after the peak in cold for IHD, at 12 days for RES, and at 3 days for all cause mortality. The increase lasted approximately 40 days after the peak in cold. RES deaths were significantly delayed compared with IHD deaths. Excess deaths per million associated with these short term temperature displacements were 7.3 for IHD, 5.8 for RES, and 24.7 for all cause, per one day fall of 1 degree C. These were greater by 52% for IHD, 17% for RES, and 37% for all cause mortality than the overall increases in daily mortality per degree C fall, at optimal delays, indicated by regressions using unfiltered data. Similar analyses of data at 0 to -6.7 degrees C showed an immediate rise in IHD mortality after cold, followed by a fall in both IHD and RES mortality rates which peaked 17 and 20 days respec
Donaldson GC, Seemungal T, Evans C, et al., 1996, Effect of outdoor temperature on daily lung function and exacerbations in patients with COPD patients, Thorax, Vol: 51, ISSN: 0040-6376
Pulmonary function worsens and exacerbations increae in COPD patients during winter, but the role of outdoor temperature is controversial. Between October 1995 and March 1996, 71 COPD patients (52 M, 19F; mean age (SD) 67.1 ± 10.1 years; paO2 8.88 ± 1.08 kPa, FEV1 1.06 ± 0.43 1, FVC 2.46 ± 0.81 1) recorded at home morning peak flow and symptoms on monthly diary cards. Exacerbation was determined by one physician. In 25 patients (22M, 3F, mean age 66.1 ±9.1 years; ;paO2 8.79 ± 1.23 kPa, FEV1 1.12 ± 0.44 1, FVC 2.46 ± 0.64 1) daily FEV1 and FVC were also recorded. Central-London temperature data were obtained from the Meterological Office. For each subject, regression coefficients were separately calculated for FEV1, FVC and peak flow on same-day mean temperature, with Cochrane-Orcutt allowance for serial correlation and day number included as an independent variable to account for annual decline in lung function. Logit regression with allowance for serial correlation was used to analyse the relationship between symptoms and temperature. Median coefficients were 0.35* (ml/min/°C)for peak flow, 2.60* (ml/°C) FEV1, 3.11* (ml/°C) FVC, -0.061** shortness of breath , -0.109* increased sputum colour, -0.112*** increased sputum amount, -0.059* cold, -0.055* increased wheeze, -0.087** sore throat, -0.124*** increased cough, -0.081** exacerbation; * P<0.05, ** P<0.01, *** P<0.001; Wilcoxon signed-rank test that median =0. These decreases in FEV1 and FVC with fall in temperature may be sufficient to compromise patients with chronic respiratory disability. The mechanisms may involve changes in airway resistance, increased respiratory infection or changes in intra-thoracic blood volume.
Seemungal T, Paul EA, Donaldson GC, et al., 1996, Factors predisposing to exacerbations in patients with COPD, Thorax, Vol: 51, ISSN: 0040-6376
Exacerbations of COPD occur commonly in patients with moderate or severe disease but factors affecting frequency are not well known. Between October 1995 and May 1996, 88 COPD patients (60M, 28F, mean(SD) age 68.1(10.3) yrs, FEV1 1.02(0.43) 1, FVC 2.40(0.81) 1, FEV1/FVC 44%(14), PO2 8.84 (1.12) kPa,) from East London were given diary cards on which they recorded various parameters including daily peak flow and respiratory symptoms. Diagnosis of exacerbation was based on Anthonisen et al (Ann Intern Med. 1987:106; 196-204), incorporating primary symptoms (dyspnoea and sputum) and various secondary symptoms. This was determined by the same physician when patients were reviewed monthly from diary card data (unreported exacerbation) or at acute visit (reported exacerbation). In 66(75%) of these patients there were 166 exacerbations of which 96(58%) were reported. The mean fall in FEV1 to first reported exacerbation was 0.035(0.18) 1. The frequency of exacerbations was compared with possible predisposing factors (p-value), sex (0.67), chronic sinusitis or rhinitis (0.17), cardiac failure (0.72), number of lower respiratory tract infections in the previous year (0.04), currently smoking (0.34), smoking pack years (0.41), daily cough (0.57), daily dyspnoea (0.50), daily wheeze (0.04), daily sputum (0.16), inhaled steroid dose (0.49), oral steroid dose (0.49), long term oxygen therapy (0.58), hypoxia PaO2 < 8 kPa (0.37), PaC02 > 6.5 kPa (0.23), FEV1 < 0.8 1 (0.94). Thus patients with a number of previous exacerbations and daily reported wheeze are at greater risk of exacerbation. This supports the classification of COPD patients into "exacerbators" and "non-exacerbators".
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