Ambient air pollution and cause-specific risk of hospital admission in China: A nationwide time-series study


Autoři: Jiangshao Gu aff001;  Ying Shi aff004;  Yifang Zhu aff005;  Ning Chen aff001;  Haibo Wang aff004;  Zongjiu Zhang aff008;  Ting Chen aff001
Působiště autorů: Center for Big Data Research in Health and Medicine, Institute for Data Sciences, Tsinghua University, Beijing, China aff001;  Tsinghua-Fuzhou Institute of Digital Technology, Beijing National Research Center for Information Science and Technology, Tsinghua University, Beijing, China aff002;  Institute for Artificial Intelligence, State Key Lab of Intelligent Technology and Systems, Department of Computer Science and Technology, Tsinghua University, Beijing, China aff003;  China Standard Medical Information Research Center, Shenzhen, China aff004;  Department of Environmental Health Science, University of California at Los Angeles, Los Angeles, California, United States of America aff005;  Institute of the Environment and Sustainability, University of California at Los Angeles, Los Angeles, California, United States of America aff006;  Clinical Trial Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China aff007;  Bureau of Medical Administration, National Health Commission of the People’s Republic of China, Beijing, China aff008
Vyšlo v časopise: Ambient air pollution and cause-specific risk of hospital admission in China: A nationwide time-series study. PLoS Med 17(8): e32767. doi:10.1371/journal.pmed.1003188
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003188

Souhrn

Background

The impacts of air pollution on circulatory and respiratory systems have been extensively studied. However, the associations between air pollution exposure and the risk of noncommunicable diseases of other organ systems, including diseases of the digestive, musculoskeletal, and genitourinary systems, remain unclear or inconclusive. We aimed to systematically assess the associations between short-term exposure to main air pollutants (fine particulate matter [PM2.5] and ozone) and cause-specific risk of hospital admission in China over a wide spectrum of human diseases.

Methods and findings

Daily data on hospital admissions for primary diagnosis of 14 major and 188 minor disease categories in 252 Chinese cities (107 cities in North China and 145 cities in South China) from January 1, 2013, to December 31, 2017, were obtained from the Hospital Quality Monitoring System of China (covering 387 hospitals in North China and 614 hospitals in South China). We applied a 2-stage analytic approach to assess the associations between air pollution and daily hospital admissions. City-specific associations were estimated with quasi-Poisson regression models and then pooled by random-effects meta-analyses. Each disease category was analyzed separately, and the P values were adjusted for multiple comparisons. A total of 117,338,867 hospital admissions were recorded in the study period. Overall, 51.7% of the hospitalized cases were male, and 71.3% were aged <65 years. Robust positive associations were found between short-term PM2.5 exposure and hospital admissions for 7 major disease categories: (1) endocrine, nutritional, and metabolic diseases; (2) nervous diseases; (3) circulatory diseases; (4) respiratory diseases; (5) digestive diseases; (6) musculoskeletal and connective tissue diseases; and (7) genitourinary diseases. For example, a 10-μg/m3 increase in PM2.5 was associated with a 0.21% (95% CI 0.15% to 0.27%; adjusted P < 0.001) increase in hospital admissions for diseases of the digestive system on the same day in 2-pollutant models (adjusting for ozone). There were 35 minor disease categories significantly positively associated with same-day PM2.5 in both single- and 2-pollutant models, including diabetes mellitus, anemia, intestinal infection, liver diseases, gastrointestinal hemorrhage, renal failure, urinary tract calculus, chronic ulcer of skin, and back problems. The association between short-term ozone exposure and respiratory diseases was robust. No safety threshold in the exposure–response relationships between PM2.5 and hospital admissions was observed. The main limitations of the present study included the unavailability of data on personal air pollution exposures.

Conclusions

In the Chinese population during 2013–2017, short-term exposure to air pollution, especially PM2.5, was associated with increased risk of hospitalization for diseases of multiple organ systems, including certain diseases of the digestive, musculoskeletal, and genitourinary systems; many of these associations are important but still not fully recognized. The effect estimates and exposure–response relationships can inform policy making aimed at protecting public health from air pollution in China.

Klíčová slova:

Air pollution – Diagnostic medicine – Hospitals – China – Medical risk factors – Respiratory infections – Respiratory system – Cities


Zdroje

1. Dominici F, Peng RD, Bell ML, Pham L, McDermott A, Zeger SL, et al. Fine particulate air pollution and hospital admission for cardiovascular and respiratory diseases. JAMA. 2006;295(10):1127–34. doi: 10.1001/jama.295.10.1127 16522832

2. Lanzinger S, Schneider A, Breitner S, Stafoggia M, Erzen I, Dostal M, et al. Ultrafine and fine particles and hospital admissions in central Europe. Results from the UFIREG study. Am J Respir Crit Care Med. 2016;194(10):1233–41. doi: 10.1164/rccm.201510-2042OC 27224452

3. Di Q, Wang Y, Zanobetti A, Wang Y, Koutrakis P, Choirat C, et al. Air pollution and mortality in the Medicare population. N Engl J Med. 2017;376(26):2513–22. doi: 10.1056/NEJMoa1702747 28657878

4. Di Q, Dai L, Wang Y, Zanobetti A, Choirat C, Schwartz JD, et al. Association of short-term exposure to air pollution with mortality in older adults. JAMA. 2017;318(24):2446–56. doi: 10.1001/jama.2017.17923 29279932

5. Cohen AJ, Brauer M, Burnett R, Anderson HR, Frostad J, Estep K, et al. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015. Lancet. 2017;389(10082):1907–18. doi: 10.1016/S0140-6736(17)30505-6 28408086

6. Rajagopalan S, Al-Kindi SG, Brook RD. Air pollution and cardiovascular disease: JACC state-of-the-art review. J Am Coll Cardiol. 2018;72(17):2054–70. doi: 10.1016/j.jacc.2018.07.099 30336830

7. North CM, Rice MB, Ferkol T, Gozal D, Hui C, Jung SH, et al. Air pollution in the Asia-Pacific region. A joint Asian Pacific Society of Respirology/American Thoracic Society perspective. Am J Respir Crit Care Med. 2019;199(6):693–700. doi: 10.1164/rccm.201804-0673PP 30508489

8. Bowe B, Xie Y, Li T, Yan Y, Xian H, Al-Aly Z. The 2016 global and national burden of diabetes mellitus attributable to PM2.5 air pollution. Lancet Planet Health. 2018;2(7):e301–12. doi: 10.1016/S2542-5196(18)30140-2 30074893

9. Landrigan PJ, Fuller R, Acosta NJR, Adeyi O, Arnold R, Basu NN, et al. The Lancet Commission on pollution and health. Lancet. 2018;391(10119):462–512. doi: 10.1016/S0140-6736(17)32345-0 29056410

10. Tian L, Qiu H, Sun S, Tsang H, Chan KP, Leung WK. Association between emergency admission for peptic ulcer bleeding and air pollution: a case-crossover analysis in Hong Kong’s elderly population. Lancet Planet Health. 2017;1(2):e74–81. doi: 10.1016/S2542-5196(17)30021-9 29851584

11. Prada D, Zhong J, Colicino E, Zanobetti A, Schwartz J, Dagincourt N, et al. Association of air particulate pollution with bone loss over time and bone fracture risk: analysis of data from two independent studies. Lancet Planet Health. 2017;1(8):e337–47. doi: 10.1016/S2542-5196(17)30136-5 29527596

12. Bowe B, Xie Y, Li T, Yan Y, Xian H, Al-Aly Z. Particulate matter air pollution and the risk of incident CKD and progression to ESRD. J Am Soc Nephrol. 2018;29(1):218–30. doi: 10.1681/ASN.2017030253 28935655

13. Bowe B, Xie Y, Li T, Yan Y, Xian H, Al-Aly Z. Associations of ambient coarse particulate matter, nitrogen dioxide, and carbon monoxide with the risk of kidney disease: a cohort study. Lancet Planet Health. 2017;1(7):e267–76. doi: 10.1016/S2542-5196(17)30117-1 29851625

14. Chan TC, Zhang Z, Lin BC, Lin C, Deng HB, Chuang YC, et al. Long-term exposure to ambient fine particulate matter and chronic kidney disease: a cohort study. Environ Health Perspect. 2018;126(10):107002. doi: 10.1289/EHP3304 30392394

15. Chin MT. Basic mechanisms for adverse cardiovascular events associated with air pollution. Heart. 2015;101(4):253–6. doi: 10.1136/heartjnl-2014-306379 25552258

16. Li H, Cai J, Chen R, Zhao Z, Ying Z, Wang L, et al. Particulate matter exposure and stress hormone levels: a randomized, double-blind, crossover trial of air purification. circulation. 2017;136(7):618–27. doi: 10.1161/CIRCULATIONAHA.116.026796 28808144

17. Miller MR, Raftis JB, Langrish JP, McLean SG, Samutrtai P, Connell SP, et al. Inhaled nanoparticles accumulate at sites of vascular disease. ACS Nano. 2017;11(5):4542–52. doi: 10.1021/acsnano.6b08551 28443337

18. Maher BA, Ahmed IA, Karloukovski V, MacLaren DA, Foulds PG, Allsop D, et al. Magnetite pollution nanoparticles in the human brain. Proc Natl Acad Sci U S A. 2016;113(39):10797–801. doi: 10.1073/pnas.1605941113 27601646

19. Tian Y, Xiang X, Juan J, Sun K, Song J, Cao Y, et al. Fine particulate air pollution and hospital visits for asthma in Beijing, China. Environ Pollut. 2017;230:227–33. doi: 10.1016/j.envpol.2017.06.029 28654880

20. Tian Y, Liu H, Liang T, Xiang X, Li M, Juan J, et al. Fine particulate air pollution and adult hospital admissions in 200 Chinese cities: a time-series analysis. Int J Epidemiol. 2019;48(4):1142–51. doi: 10.1093/ije/dyz106 31157384

21. Meng Q, Mills A, Wang L, Han Q. What can we learn from China’s health system reform? BMJ. 2019;365:l2349. doi: 10.1136/bmj.l2349 31217222

22. World Health Organization. International statistical classification of diseases and related health problems, 10th revision. Geneva: World Health Organization; 2016 [cited 2020 Mar 15]. https://icd.who.int/browse10/2016/en.

23. Zhang L, Long J, Jiang W, Shi Y, He X, Zhou Z, et al. Trends in chronic kidney disease in China. N Engl J Med. 2016;375(9):905–6. doi: 10.1056/NEJMc1602469 27579659

24. Li J, Cui Z, Long J, Huang W, Wang J, Zhang H, et al. Primary glomerular nephropathy among hospitalized patients in a national database in China. Nephrol Dial Transplant. 2018;33(12):2173–81. doi: 10.1093/ndt/gfy022 29509919

25. Li J, Cui Z, Long JY, Huang W, Wang JW, Wang H, et al. The frequency of ANCA-associated vasculitis in a national database of hospitalized patients in China. Arthritis Res Ther. 2018;20(1):226. doi: 10.1186/s13075-018-1708-7 30286799

26. Healthcare Cost and Utilization Project. Clinical Classifications Software (CCS) for ICD-9-CM. Rockville (MD): Healthcare Cost and Utilization Project; 2017 [cited 2020 Mar 15]. https://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp.

27. Radley DC, Gottlieb DJ, Fisher ES, Tosteson AN. Comorbidity risk-adjustment strategies are comparable among persons with hip fracture. J Clin Epidemiol. 2008;61(6):580–7. doi: 10.1016/j.jclinepi.2007.08.001 18471662

28. Bobb JF, Obermeyer Z, Wang Y, Dominici F. Cause-specific risk of hospital admission related to extreme heat in older adults. JAMA. 2014;312(24):2659–67. doi: 10.1001/jama.2014.15715 25536257

29. Samet JM, Dominici F, Curriero FC, Coursac I, Zeger SL. Fine particulate air pollution and mortality in 20 U.S. cities, 1987–1994. N Engl J Med. 2000;343(24):1742–9. doi: 10.1056/NEJM200012143432401 11114312

30. Peng RD, Chang HH, Bell ML, McDermott A, Zeger SL, Samet JM, et al. Coarse particulate matter air pollution and hospital admissions for cardiovascular and respiratory diseases among Medicare patients. JAMA. 2008;299(18):2172–9. doi: 10.1001/jama.299.18.2172 18477784

31. Chen R, Yin P, Meng X, Liu C, Wang L, Xu X, et al. Fine particulate air pollution and daily mortality. a nationwide analysis in 272 Chinese cities. Am J Respir Crit Care Med. 2017;196(1):73–81. doi: 10.1164/rccm.201609-1862OC 28248546

32. Liu C, Yin P, Chen R, Meng X, Wang L, Niu Y, et al. Ambient carbon monoxide and cardiovascular mortality: a nationwide time-series analysis in 272 cities in China. Lancet Planet Health. 2018;2(1):e12–8. doi: 10.1016/S2542-5196(17)30181-X 29615203

33. Wang L, Liu C, Meng X, Niu Y, Lin Z, Liu Y, et al. Associations between short-term exposure to ambient sulfur dioxide and increased cause-specific mortality in 272 Chinese cities. Environ Int. 2018;117:33–9. doi: 10.1016/j.envint.2018.04.019 29715611

34. Kan H, London SJ, Chen G, Zhang Y, Song G, Zhao N, et al. Differentiating the effects of fine and coarse particles on daily mortality in Shanghai, China. Environ Int. 2007;33(3):376–84. doi: 10.1016/j.envint.2006.12.001 17229464

35. Xie W, Li G, Zhao D, Xie X, Wei Z, Wang W, et al. Relationship between fine particulate air pollution and ischaemic heart disease morbidity and mortality. Heart. 2015;101(4):257–63. doi: 10.1136/heartjnl-2014-306165 25341536

36. Tian Y, Liu H, Zhao Z, Xiang X, Li M, Juan J, et al. Association between ambient air pollution and daily hospital admissions for ischemic stroke: a nationwide time-series analysis. PLoS Med. 2018;15(10):e1002668. doi: 10.1371/journal.pmed.1002668 30286080

37. Tian Y, Liu H, Wu Y, Si Y, Song J, Cao Y, et al. Association between ambient fine particulate pollution and hospital admissions for cause specific cardiovascular disease: time series study in 184 major Chinese cities. BMJ. 2019;367:l6572. doi: 10.1136/bmj.l6572 31888884

38. Gu J, Shi Y, Chen N, Wang H, Chen T. Ambient fine particulate matter and hospital admissions for ischemic and hemorrhagic strokes and transient ischemic attack in 248 Chinese cities. Sci Total Environ. 2020;715:136896. doi: 10.1016/j.scitotenv.2020.136896 32007884

39. Yin P, He G, Fan M, Chiu KY, Fan M, Liu C, et al. Particulate air pollution and mortality in 38 of China’s largest cities: time series analysis. BMJ. 2017;356:j667. doi: 10.1136/bmj.j667 28292780

40. Benjamini Y, Hochberg Y. Controlling the false discovery rate—a practical and powerful approach to multiple testing. J R Stat Soc Series B Stat Methodol. 1995;57(1):289–300.

41. Ebenstein A, Fan M, Greenstone M, He G, Zhou M. New evidence on the impact of sustained exposure to air pollution on life expectancy from China’s Huai River Policy. Proc Natl Acad Sci U S A. 2017;114(39):10384–9. doi: 10.1073/pnas.1616784114 28893980

42. Samoli E, Analitis A, Touloumi G, Schwartz J, Anderson HR, Sunyer J, et al. Estimating the exposure-response relationships between particulate matter and mortality within the APHEA multicity project. Environ Health Perspect. 2005;113(1):88–95. doi: 10.1289/ehp.7387 15626653

43. Bell ML, Peng RD, Dominici F. The exposure-response curve for ozone and risk of mortality and the adequacy of current ozone regulations. Environ Health Perspect. 2006;114(4):532–6. doi: 10.1289/ehp.8816 16581541

44. Lipsitch M, Tchetgen Tchetgen E, Cohen T. Negative controls: a tool for detecting confounding and bias in observational studies. Epidemiology. 2010;21(3):383–8. doi: 10.1097/EDE.0b013e3181d61eeb 20335814

45. Zanobetti A, Dominici F, Wang Y, Schwartz JD. A national case-crossover analysis of the short-term effect of PM2.5 on hospitalizations and mortality in subjects with diabetes and neurological disorders. Environ Health. 2014;13(1):38. doi: 10.1186/1476-069X-13-38 24886318

46. Lee H, Myung W, Kim DK, Kim SE, Kim CT, Kim H. Short-term air pollution exposure aggravates Parkinson’s disease in a population-based cohort. Sci Rep. 2017;7:44741. doi: 10.1038/srep44741 28300224

47. Kasdagli MI, Katsouyanni K, Dimakopoulou K, Samoli E. Air pollution and Parkinson’s disease: a systematic review and meta-analysis up to 2018. Int J Hyg Environ Health. 2019;222(3):402–9. doi: 10.1016/j.ijheh.2018.12.006 30606679

48. Orazzo F, Nespoli L, Ito K, Tassinari D, Giardina D, Funis M, et al. Air pollution, aeroallergens, and emergency room visits for acute respiratory diseases and gastroenteric disorders among young children in six Italian cities. Environ Health Perspect. 2009;117(11):1780–5. doi: 10.1289/ehp.0900599 20049132

49. Kaplan GG, Tanyingoh D, Dixon E, Johnson M, Wheeler AJ, Myers RP, et al. Ambient ozone concentrations and the risk of perforated and nonperforated appendicitis: a multicity case-crossover study. Environ Health Perspect. 2013;121(8):939–43. doi: 10.1289/ehp.1206085 23842601

50. Ananthakrishnan AN, Bernstein CN, Iliopoulos D, Macpherson A, Neurath MF, Ali RAR, et al. Environmental triggers in IBD: a review of progress and evidence. Nat Rev Gastroenterol Hepatol. 2018;15(1):39–49. doi: 10.1038/nrgastro.2017.136 29018271

51. Zheng Z, Xu X, Zhang X, Wang A, Zhang C, Huttemann M, et al. Exposure to ambient particulate matter induces a NASH-like phenotype and impairs hepatic glucose metabolism in an animal model. J Hepatol. 2013;58(1):148–54. doi: 10.1016/j.jhep.2012.08.009 22902548

52. Zheng Z, Zhang X, Wang J, Dandekar A, Kim H, Qiu Y, et al. Exposure to fine airborne particulate matters induces hepatic fibrosis in murine models. J Hepatol. 2015;63(6):1397–404. doi: 10.1016/j.jhep.2015.07.020 26220751

53. Xu X, Wang G, Chen N, Lu T, Nie S, Xu G, et al. Long-term exposure to air pollution and increased risk of membranous nephropathy in China. J Am Soc Nephrol. 2016;27(12):3739–46. doi: 10.1681/ASN.2016010093 27365535

54. Power MC, Kioumourtzoglou MA, Hart JE, Okereke OI, Laden F, Weisskopf MG. The relation between past exposure to fine particulate air pollution and prevalent anxiety: observational cohort study. BMJ. 2015;350:h1111. doi: 10.1136/bmj.h1111 25810495

55. Pun VC, Manjourides J, Suh H. Association of ambient air pollution with depressive and anxiety symptoms in older adults: results from the NSHAP study. Environ Health Perspect. 2017;125(3):342–8. doi: 10.1289/EHP494 27517877

56. Braithwaite I, Zhang S, Kirkbride JB, Osborn DPJ, Hayes JF. Air pollution (particulate matter) exposure and associations with depression, anxiety, bipolar, psychosis and suicide risk: a systematic review and meta-analysis. Environ Health Perspect. 2019;127(12):126002. doi: 10.1289/EHP4595 31850801

57. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789–858. doi: 10.1016/S0140-6736(18)32279-7 30496104

58. Yang G, Wang Y, Zeng Y, Gao GF, Liang X, Zhou M, et al. Rapid health transition in China, 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet. 2013;381(9882):1987–2015. doi: 10.1016/S0140-6736(13)61097-1 23746901

59. GBD 2017 Risk Factor Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1923–94. doi: 10.1016/S0140-6736(18)32225-6 30496105

60. Schraufnagel DE, Balmes JR, Cowl CT, De Matteis S, Jung SH, Mortimer K, et al. Air pollution and noncommunicable diseases: a review by the Forum of International Respiratory Societies’ Environmental Committee, part 1: the damaging effects of air pollution. Chest. 2019;155(2):409–16. doi: 10.1016/j.chest.2018.10.042 30419235

61. Schraufnagel DE, Balmes JR, Cowl CT, De Matteis S, Jung SH, Mortimer K, et al. Air pollution and noncommunicable diseases: a review by the Forum of International Respiratory Societies’ Environmental Committee, part 2: air pollution and organ systems. Chest. 2019;155(2):417–26. doi: 10.1016/j.chest.2018.10.041 30419237

62. Chen Z, Salam MT, Toledo-Corral C, Watanabe RM, Xiang AH, Buchanan TA, et al. Ambient air pollutants have adverse effects on insulin and glucose homeostasis in Mexican Americans. Diabetes Care. 2016;39(4):547–54. doi: 10.2337/dc15-1795 26868440

63. Mutlu EA, Engen PA, Soberanes S, Urich D, Forsyth CB, Nigdelioglu R, et al. Particulate matter air pollution causes oxidant-mediated increase in gut permeability in mice. Part Fibre Toxicol. 2011;8:19. doi: 10.1186/1743-8977-8-19 21658250

64. Kish L, Hotte N, Kaplan GG, Vincent R, Tso R, Ganzle M, et al. Environmental particulate matter induces murine intestinal inflammatory responses and alters the gut microbiome. PLoS ONE. 2013;8(4):e62220. doi: 10.1371/journal.pone.0062220 23638009

65. Wang C, Zhu G, Zhang L, Chen K. Particulate matter pollution and hospital outpatient visits for endocrine, digestive, urological, and dermatological diseases in Nanjing, China. Environ Pollut. 2020;261:114205. doi: 10.1016/j.envpol.2020.114205 32113107

66. Yang YR, Chen YM, Chen SY, Chan CC. Associations between long-term particulate matter exposure and adult renal function in the Taipei metropolis. Environ Health Perspect. 2017;125(4):602–7. doi: 10.1289/EHP302 27713105

67. Li W, Wilker EH, Dorans KS, Rice MB, Schwartz J, Coull BA, et al. Short-term exposure to air pollution and biomarkers of oxidative stress: the Framingham Heart Study. J Am Heart Assoc. 2016;5(5):e002742. doi: 10.1161/JAHA.115.002742 27126478

68. Yan Q, Liew Z, Uppal K, Cui X, Ling C, Heck JE, et al. Maternal serum metabolome and traffic-related air pollution exposure in pregnancy. Environ Int. 2019;130:104872. doi: 10.1016/j.envint.2019.05.066 31228787

69. Huang W, Wang G, Lu SE, Kipen H, Wang Y, Hu M, et al. Inflammatory and oxidative stress responses of healthy young adults to changes in air quality during the Beijing Olympics. Am J Respir Crit Care Med. 2012;186(11):1150–9. doi: 10.1164/rccm.201205-0850OC 22936356

70. Havet A, Zerimech F, Sanchez M, Siroux V, Le Moual N, Brunekreef B, et al. Outdoor air pollution, exhaled 8-isoprostane and current asthma in adults: the EGEA study. Eur Respir J. 2018;51(4):1702036. doi: 10.1183/13993003.02036-2017 29618600

71. Zeger SL, Thomas D, Dominici F, Samet JM, Schwartz J, Dockery D, et al. Exposure measurement error in time-series studies of air pollution: concepts and consequences. Environ Health Perspect. 2000;108(5):419–26. doi: 10.1289/ehp.00108419 10811568


Článek vyšel v časopise

PLOS Medicine


2020 Číslo 8

Nejčtenější v tomto čísle

Tomuto tématu se dále věnují…


Kurzy Doporučená témata Časopisy
Přihlášení
Zapomenuté heslo

Nemáte účet?  Registrujte se

Zapomenuté heslo

Zadejte e-mailovou adresu se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.

Přihlášení

Nemáte účet?  Registrujte se

VIRTUÁLNÍ ČEKÁRNA ČR Jste praktický lékař nebo pediatr? Zapojte se! Jste praktik nebo pediatr? Zapojte se!

×