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摘要:
目的 评估相邻日间温度变化(temperature changes between neighboring days, TCN)对缺血性脑卒中门诊就诊风险的影响。 方法 利用合肥市一所大型三甲医院缺血性脑卒中门诊就诊数据进行分析,采用分布滞后非线性模型结合泊松广义线性回归模型分析TCN与缺血性脑卒中门诊就诊人次之间的关系,对相关环境因素进行校正,并对不同性别和年龄的人群进行了分层分析。 结果 合肥市2014—2018年共有32 560例缺血性脑卒中患者,其中男性占57.2%,≥65岁的人群占49.7%,平均每日就诊人数为17.8人次。暴露-反应关系曲线显示TCN与缺血性脑卒中门诊就诊量相关。以TCN无变化(0)为参考,极端负TCN(P5,-3.9 ℃)的相对风险在累计滞后7 d达到最大(RR=1.796, 95% CI:1.150~2.805),而极端正TCN(P95,3.0 ℃)的相对风险在累计滞后6 d达到最大(RR=0.686, 95% CI:0.499~0.945)。亚组分析显示,男性和≥65岁缺血性脑卒中患者更易受负TCN的影响。 结论 合肥市TCN与缺血性脑卒中呈非线性关系; 负TCN增加缺血性脑卒中患者的门诊就诊风险,当气温骤降时注意缺血性脑卒中的发生; 正TCN降低缺血性脑卒中患者的门诊就诊风险,当气温升高时需要注意防暑降温,避免高温引起的其他健康问题。 Abstract:Objective To assess the effect of temperature changes between neighboring days on the risk of ischemic stroke outpatient visits. Methods A distributional lag nonlinear model combined with a Poisson generalised linear regression model was used to analyse the relationship between temperature changes between neighboring days and ischemic stroke outpatient visits at a large tertiary hospital in Hefei city, with corrections for relevant environmental factors and stratified by different gender and age groups. Results In this study, there were 32 560 ischemic stroke patients, with an average of 17.8 ischemic stroke visits per day. Exposure relationship curves show significant association between TCN and ischemic stroke outpatient visits. The relative risk over 0-7days Reached 1.796(95% CI: 1.150-2.805) for extreme negative temperature changes between neighboring days (5th percentile), whereas the relative risk of extreme positive temperature changes between neighboring days (95th percentile) was 0.686(95% CI: 0.499-0.945) and maximized at a cumulative lag of 6 days. Subgroup studies revealed that men and ischemic stroke patients over the age of 65 were more vulnerable to negative temperature changes between neighboring days. Conclusions Temperature changes between neighboring days and ischemic stroke are nonlinearly related in Hefei; with negative temperature changes between neighboring days increases the likelihood for ischemic stroke patients, watch for ischemic stroke when temperature drops suddenly; and positive temperature changes between neighboring days decreases the risk of ischemic stroke patients, who require protection from heat and other health concerns induced by rising temperature. -
图 1 合肥市TCN与缺血性脑卒中就诊的暴露-反应关系
TCN: 相邻日间温度变化;图A: TCN与缺血性脑卒中总体暴露-反应3D图;图B: TCN与缺血性脑卒中总体暴露-反应曲线图。
Figure 1. Exposure-response relationships between TCN and visits with ischemic stroke in Hefei City
TCN: temperature changes between neighboring days; Figure A: the 3D graph of the overall exposure response between TCN and ischemic stroke; Figure B: the overall exposure response curve of TCN and ischemic stroke.
图 2 合肥市各亚组缺血性脑卒中就诊者与TCN暴露-反应关系
TCN:相邻日间温度变化;A表示男性;B表示女性;C表示<65岁;D表示≥65岁。
Figure 2. Exposure-response relationships between ischemic stroke visits and TCN in a subgroup of patients, in Hefei City
TCN: temperature changes between neighboring days; A represents male; B represents female; C represents < 65 years old; D represents ≥ 65 years old.
表 1 合肥市缺血性脑卒中就诊人次、气象数据的统计资料
Table 1. Statistics on outpatient ischemic stroke visits, climate data in Hefei City
变量 Variable 总计 Total x±s P1 P5 P25 P50 P75 P95 P99 总就诊人次 Total population 32 560 17.80±11.10 0 2.0 8.0 17.0 26.0 38.0 45.0 男性 Male 18 645 10.20±6.80 0 1.0 4.0 10.0 15.0 22.0 28.0 女性 Female 13 915 7.60±5.20 0 0 3.0 7.0 11.0 17.0 22.0 年龄组/岁 Age group/years <65 16 377 9.00±6.00 0 1.0 4.0 8.0 13.0 19.0 25.0 ≥65 16 183 8.90±6.10 0 0 4.0 8.0 13.0 20.0 25.0 TCN/℃ 0.00±2.30 -6.4 -3.9 -1.1 0.2 1.4 3.0 4.2 平均温度/℃ Mean temperature/℃ 16.90±9.20 -1.1 2.0 8.9 17.9 24.6 30.5 33.0 最高温度/℃ Maxmum temperature/℃ 21.60±9.60 1.0 5.7 13.9 22.9 29.4 35.3 37.7 最低温度/℃ Minimum temperature/℃ 13.10±0.30 -5.2 -2.2 5.1 13.9 21.2 26.8 28.5 风速/(m·s-1) Wind speed/(m·s-1) 1.90±0.80 0.7 0.9 1.4 1.8 2.3 3.3 4.1 相对湿度/% Relative humidity/% 75.50±18.40 42.0 53.0 68.0 76.0 85.0 95.0 98.0 日照时数/h Sunlight hours/h 4.09±4.07 0 0 0 4.3 8.3 11.0 11.9 降雨量/mm Rainfall/mm 3.50±10.60 0 0 0 0 1.0 20.1 48.8 注:TCN, 相邻日间温度变化;P1,第1百分位数;P5,第5百分位数;P25,第25百分位数;P50,第50百分位数;P75,第75百分位数;P95,第95百分位数;P99,第99百分位数。
Note:TCN, temperature changes between neighboring days;P1, 1th percentile; P5, 5th percentile; P25, 25th percentile; P50, 50th percentile; P75, 75th percentile; P95, 95th percentile; P99, 99th percentile.表 2 合肥市气象因素间的Spearman相关系数
Table 2. Coefficients of spearman correlation between meteorological factors in Hefei City
变量 Variable 平均温度/℃ Mean temperature/℃ TCN/℃ 相对湿度/% Relative humidity/% 日照时数/h Sunlight hours/h 风速/(m·s-1) Wind speed/(m·s-1) 降雨量/mm Rainfall/mm 平均温度/℃ Mean temperature/℃ 1.00 TCN/℃ 0.09 ① 1.00 相对湿度/% Relative humidity/% 0.01 -0.22 ① 1.00 日照时数/h Sunlight hours/h 0.30 ① 0.38 ① -0.63 ① 1.00 风速/(m·s-1) Wind speed/(m·s-1) 0.03 -0.21 ① -0.02 -0.23 1.00 降雨量/mm Rainfall/mm -0.03 -0.39 ① 0.65 ① -0.60 ① 0.18 ① 1.00 注:TCN, 相邻日间温度变化。
① P<0.01。
Note:TCN, temperature changes between neighboring days.
① P<0.01.表 3 不同亚组中TCN对缺血性脑卒中就诊的单日滞后效应
Table 3. Single day lag effect of TCN on ischemic stroke visits in different subgroups
项目 Project 滞后天数 Lag days RR值 value(95% CI) Lag0 Lag1 Lag2 Lag3 总就诊人次 Total population P5(-3.9 ℃) 1.049(0.975~1.129) 1.040(0.979~1.105) 1.039(0.973~1.109) 1.048(0.977~1.123) P95(3.0 ℃) 0.934(0.862~1.103) 0.958(0.904~1.015) 0.972(0.922~1.024) 0.971(0.920~1.024) 男性 Male P5(-3.9 ℃) 1.082(0.999~1.173) 1.063(0.995~1.136) 1.054(0.981~1.132) 1.063(0.982~1.145) P95(3.0 ℃) 0.889(0.814~0.972) 0.926(0.870~0.987) 0.951(0.898~1.009) 0.958(0.902~1.016) 女性 Female P5(-3.9 ℃) 1.007(0.927~1.094) 1.010(0.944~1.081) 1.017(0.946~1.095) 1.030(0.953~1.114) P95(3.0 ℃) 0.996(0.910~1.090) 1.001(0.939~1.067) 0.999(0.942~1.059) 0.988(0.930~1.049) <65岁 years P5(-3.9 ℃) 1.037(0.954~1.126) 1.026(0.959~1.098) 1.024(0.902~1.102) 1.103(0.957~1.119) P95(3.0 ℃) 0.904(0.825~0.990) ① 0.946(0.887~1.009) 0.973(0.917~1.003) 0.978(0.921~1.039) ≥65岁 years P5(-3.9 ℃) 1.059(0.976~1.150) 1.053(0.984~1.127) 1.053(0.979~1.133) 1.061(0.981~1.148) P95(3.0 ℃) 0.963(0.880~1.053) 0.969(0.909~1.033) 0.970(0.915~1.030) 0.964(0.907~1.024) 项目 Project 滞后天数 Lag days RR值 value(95% CI) Lag4 Lag5 Lag6 Lag7 总就诊人次 Total population P5(-3.9 ℃) 1.066(0.995~1.141) 1.091(1.023~1.164) ① 1.122(1.052~1.197) ① 1.156(1.074~1.244) ① P95(3.0 ℃) 0.957(0.909~1.008) 0.935(0.890~0.980) ① 0.907(0.862~0.953) ① 0.877(0.825~0.932) ① 男性 Male P5(-3.9 ℃) 1.079(1.001~1.163) ① 1.107(1.032~1.188) ① 1.143(1.065~1.226) ① 1.183(1.092~1.283) ① P95(3.0 ℃) 0.947(0.895~1.003) 0.926(0.878~0.976) ① 0.897(0.848~0.948) ① 0.865(0.808~0.926) ① 女性 Female P5(-3.9 ℃) 1.048(0.971~1.132) 1.070(0.995~1.150) 1.095(1.018~1.177) ① 1.122(1.032~1.219) ① P95(3.0 ℃) 0.970(0.915~1.027) 0.946(0.896~0.999) ① 0.920(0.870~0.973) ① 0.893(0.834~0.955) ① <65岁 years P5(-3.9 ℃) 1.056(0.978~1.139) 1.085(1.010~1.116) ① 1.121(1.043~1.205) ① 1.161(1.069~1.261) ① P95(3.0 ℃) 0.963(0.909~1.021) 0.934(0.885~0.987) ① 0.898(0.847~0.951) ① 0.858(0.978~0.922) ① ≥65岁 years P5(-3.9 ℃) 1.077(0.997~1.162) 1.097(1.021~1.180) ① 1.122(1.004~1.207) ① 1.150(1.058~1.249) ① P95(3.0 ℃) 0.951(0.897~1.008) 0.934(0.885~0.986) ① 0.914(0.865~0.965) ① 0.893(0.836~0.953) ① 注:TCN, 相邻日间温度变化; P5,第5百分位数;P95,第95百分位数。
① P<0.05。
Note:TCN, temperature changes between neighboring days; P5, 5th percentile; P95, 95th percentile.
① P<0.05.表 4 不同亚组中TCN对缺血性脑卒中就诊的累积滞后效应
Table 4. Cumulative lag effect of TCN on ischemic stroke visits in different subgroups
项目 Project 滞后天数 Lag days RR值 value(95% CI) Lag0 Lag0~1 Lag0~2 Lag0~3 总就诊人次 Total population P5(-3.9 ℃) 1.049(0.975~1.129) 1.091(0.960~1.241) 1.134(0.947~1.358) 1.189(0.938~1.506) P95(3.0 ℃) 0.934(0.862~1.103) 0.895(0.783~1.024) 0.870(0.731~1.037) 0.845(0.684~1.045) 男性 Male P5(-3.9 ℃) 1.082(0.999~1.173) 1.151(1.000~1.325) 1.214(0.996~1.479) 1.288(0.997~1.669) P95(3.0 ℃) 0.889(0.814~0.972) ① 0.825(0.711~0.956) ① 0.785(0.648~0.952) ① 0.752(0.595~0.950) ① 女性 Female P5(-3.9 ℃) 1.007(0.927~1.094) 1.018(0.881~1.176) 1.036(0.846~1.394) 1.068(0.818~1.394) P95(3.0 ℃) 0.996(0.910~1.090) 0.997(0.858~1.159) 0.996(0.820~1.211) 0.985(0.777~1.248) <65岁 years P5(-3.9 ℃) 1.037(0.954~1.126) 1.064(0.921~1.126) 1.090(0.891~1.335 1.129(0.866~1.471) P95(3.0 ℃) 0.904(0.825~0.990) ① 0.856(0.973~0.995) 0.833(0.684~1.014) 0.815(0.642~1.035) ≥65岁years P5(-3.9 ℃) 1.059(0.976~1.150) 1.117(0.967~1.289) 1.177(0.961~1.440) 1.250(0.958~1.629) P95(3.0 ℃) 0.963(0.880~1.053) 0.933(0.803~1.084) 0.906(0.746~1.101) 0.874(0.689~1.108) 项目 Project 滞后天数 Lag days RR值 value(95% CI) Lag0~4 Lag0~5 Lag0~6 Lag0~7 总就诊人次 Total population P5(-3.9 ℃) 1.268(0.944~1.701) 1.384(0.976~1.961) 1.553(1.043~2.313) ① 1.796(1.150~2.805) ① P95(3.0 ℃) 0.809(0.630~1.039) 0.757(0.569~1.007) 0.686(0.499~0.945) ① 0.602(0.423~0.858) ① 男性 Male P5(-3.9 ℃) 1.390(1.007~1.919) ① 1.540(1.051~2.256) ① 1.760(1.138~2.724) ① 2.084(1.279~3.396) ① P95(3.0 ℃) 0.713(0.541~0.939) ① 0.660(0.482~0.905) ① 0.592(0.417~0.842) ① 0.513(0.347~0.757) ① 女性 Female P5(-3.9 ℃) 1.120(0.805~1.559) 1.199(0.810~1.775) 1.314(0.840~2.056) 1.474(0.893~2.434) P95(3.0 ℃) 0.955(0.722~1.262) 0.904(0.657~1.244) 0.832(1.583~1.188) 0.743(0.501~1.103) <65岁 years P5(-3.9 ℃) 1.192(0.858~1.657) 1.294(0.876~1.912) 1.452(0.930~2.664) 1.686(1.024~2.776) ① P95(3.0 ℃) 0.785(0.593~1.040) 0.734(0.532~1.012) 0.659(0.460~0.944) ① 0.566(0.379~0.845) ① ≥65岁 years P5(-3.9 ℃) 1.134(0.967~1.873) 1.478(0.999~2.816) 1.659(1.061~2.595) ① 1.908(1.156~3.418) ① P95(3.0 ℃) 0.832(0.629~1.099) 0.777(0.565~1.069) 0.711(0.498~1.014) 0.635(0.428~0.940) ① 注:TCN, 相邻日间温度变化; P5,第5百分位数;P95,第95百分位数。
① P<0.05。
Note:TCN, temperature changes between neighboring days; P5, 5th percentile; P95, 95th percentile.
① P<0.05. -
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