Operationalization of a multidimensional sex/gender concept for quantitative environmental health research and implementation in the KORA study: Results of the collaborative research project INGER.

Background: In environmental health research, sex and gender are not yet adequately considered. There is a need to improve data collection in population-based environmental health studies by comprehensively surveying sex/gender-related aspects according to gender theoretical concepts. Thus, within the joint project INGER we developed a multidimensional sex/gender concept which we aimed to operationalize and to test the operationalization for feasibility. Methods: In an iterative process, we created questionnaire modules which quantitatively captured the requirements of the INGER sex/gender concept. We deployed it in the KORA cohort (Cooperative Health Research in the Region of Augsburg, Germany) in 2019 and evaluated response and missing rates. Results: The individual sex/gender self-concept was surveyed via a two-step approach that asked for sex assigned at birth and the current sex/gender identity. Additionally, we used existing tools to query internalized sex/gender roles and externalized sex/gender expressions. Adapted to the KORA population, we asked for discrimination experiences and care and household activities contributing to explain structural sex/gender relations. Further intersectionality-related social categories (e.g., socio-economic position), lifestyle and psychosocial factors were covered through data available in KORA. We could not identify appropriate tools to assess the true biological sex, sexual orientation and ethnic/cultural identity, which have yet to be developed or improved. The response-rate was 71%, the evaluation of 3,743 questionnaires showed a low missing rate. Prevalence of marginalized groups regarding sex/gender identity and definable by experiences of discrimination was very low. Conclusion: We have shown how the multidimensional INGER sex/gender concept can be operationalized according to an European and North American understanding of sex/gender for use in quantitative research. The questionnaire modules proved feasible in an epidemiologic cohort study. Being a balancing act between theoretical concepts and its quantitative implementation our operationalization paves the way for an adequate consideration of sex/gender in environmental health research.

Consideration of sex/gender in publications of quantitative health-related research: Development and application of an assessment matrix.

During the last years the need to integrate sex and gender in health-related research for better and fairer science became increasingly apparent. Various guidelines and checklists were developed to encourage and support researchers in considering the entangled dimensions of sex/gender in their research. However, a tool for the assessment of sex/gender consideration and its visualization is still missing. We aim to fill this gap by introducing an assessment matrix that can be used as a flexible instrument for comprehensively evaluating the sex/gender consideration in quantitative health-related research. The matrix was developed through an iterative and open process based on the interdisciplinary expertise represented in our research team and currently published guidelines. The final matrix consists of 14 different items covering the whole research process and the publication of results. Additionally, we introduced a method to graphically display this evaluation. By developing the matrix, we aim to provide users with a tool to systematically compare sex/gender consideration qualitatively between different publications and even different fields of study. This way, the assessment matrix represents a tool to identify research gaps and a basis for future research. In the long term, the implementation of this tool to evaluate the consideration of sex/gender should contribute to more sex/gender equitable health-related research.

Stability and predictors of somatic symptoms in men and women over 10 years: A real-world perspective from the prospective MONICA/KORA study.

OBJECTIVE: To assess the stability of somatic symptoms in community-dwelling participants. METHODS: The study included 2472 participants (1190 men, 1282 women; mean age 44.3 ± 10.9) from the prospective population-based MONICA-S3 cohort (1994/95) and the 10-year follow-up KORA-F3 cohort. Somatic symptoms were assessed by an adapted version of the Somatic Symptom Scale-8 (SSS-8a) with scores ranging from 0 to 24. Somatic symptom stability was assessed by weighted kappa values (κ). Generalized Estimating Equation models assessing symptom stability were adjusted for sociodemographic, lifestyle, clinical and psychosocial risk factors, as well as pre-existing medical conditions. RESULTS: The mean (±SD) SSS-8a was lower in men (S3: 6.88 ± 3.87, F3: 6.60 ± 3.86) than women (S3: 8.43 ± 4.0, F3: 8.31 ± 4.2) at both time points. However, somatic symptoms remained moderately stable in both genders over 10 years (κ =0.42 in men and κ = 0.48 in women), with the largest stability observed in trouble sleeping for men (κ =0.41) and pain in the joints for women (κ =0.41). Pre-existing somatic symptoms were significantly associated with increasing symptoms at follow-up [men: ß = 0.82 (SE 0.12), women: ß = 0.85 (SE 0.12)], followed by age and psychosocial factors, whereas higher education and recent health care utilization were inversely associated with increasing symptoms. Although hypertension and obesity were associated with increasing somatic symptoms in men, pre-existing medical conditions were not associated with increasing somatic symptoms in men nor women. CONCLUSIONS: The current findings indicate that somatic symptoms remain moderately stable in the general population during 10 years of follow-up, mainly driven by sociodemographic and psychosocial factors.

Integrating Sex/Gender into Environmental Health Research: Development of a Conceptual Framework.

There is a growing awareness about the need to comprehensively integrate sex and gender into health research in order to enhance the validity and significance of research results. An in-depth consideration of differential exposures and vulnerability is lacking, especially within environmental risk assessment. Thus, the interdisciplinary team of the collaborative research project INGER (integrating gender into environmental health research) aimed to develop a multidimensional sex/gender concept as a theoretically grounded starting point for the operationalization of sex and gender in quantitative (environmental) health research. The iterative development process was based on gender theoretical and health science approaches and was inspired by previously published concepts or models of sex- and gender-related dimensions. The INGER sex/gender concept fulfills the four theoretically established prerequisites for comprehensively investigating sex and gender aspects in population health research: multidimensionality, variety, embodiment, and intersectionality. The theoretical foundation of INGER's multidimensional sex/gender concept will be laid out, as well as recent sex/gender conceptualization developments in health sciences. In conclusion, by building upon the latest state of research of several disciplines, the conceptual framework will significantly contribute to integrating gender theoretical concepts into (environmental) health research, improving the validity of research and, thus, supporting the promotion of health equity in the long term.

Sex/Gender-Differences in the Health Effects of Environmental Noise Exposure on Hypertension and Ischemic Heart Disease-A Systematic Review.

Previous studies have demonstrated cardiovascular health effects of environmental noise exposure, partly showing different effect estimates for males and females. This cannot be explained by biological differences between males and females alone. It is assumed that health outcomes and exposure patterns also depend on gender, determined by social, economic, and cultural factors in society. This systematic review evaluated the current state of how sex/gender is integrated in studies on environmental noise associated with hypertension, blood pressure, and ischemic heart diseases. A systematic literature search was conducted in three different databases, identifying thirty studies published between 1 January 2000 and 2 February 2020. Effects varied, with no consistent findings for both males and females. All studies used a binary operationalization of sex/gender, assuming static differences between males and females. The differentiation between biological and social dimensions of sex/gender was not present in any of the studies and the terms "sex" and "gender" were used interchangeably. However, biological and social dimensions of sex/gender were unconsciously taken up in the discussion of the results. Integrating sex/gender-theoretical concepts into future studies offers great potential to increase the validity of research findings, thus making them more useful for prevention efforts, health promotion, and health care.

[Combined effects of different environmental factors on health: air pollution, temperature, green spaces, pollen, and noise]. / Kombinierte Effekte verschiedener Umweltfaktoren auf die Gesundheit: Luftschadstoffe, Temperatur, Grünflächen, Pollen und Lärm.

Environmental factors affect the health and wellbeing of urban residents. However, they do not act individually on humans, but instead show potential synergistic or antagonistic effects. Questions that arise from this are: How does a combination of air pollutants with other environmental factors impact health? How well are these associations evidenced? What methods can we use to look at them? In this article, methodical approaches regarding the effects of a combination of various environmental factors are first described. Environmental factors are then examined, which together with different air pollutants, have an impact on human health such as ambient temperature, noise, and pollen as well as the effect of green spaces. Physical activity and nutrition are addressed regarding the attenuation of health effects from air pollution.While there is often clear evidence of health effects of single environmental stressors, there are still open questions in terms of their interaction. The research methods required for this still need to be further developed. The interrelationship between the different environmental factors make it clear that (intervention) measures for reducing single indicators are also interlinked. Regarding traffic, switching from passive to active transport (e.g., due to safe cycle paths and other measures) leads to less air pollutants, smaller increases in temperature in the long term, and at the same time improved health of the individual. As a result, sensible planning of the built environment has great potential to reduce environmental stressors and improve people's health and wellbeing.

[Nighttime transportation noise annoyance in Germany: personal and regional differences in the German National Cohort Study]. / Nächtliche Verkehrslärmbelästigung in Deutschland: individuelle und regionale Unterschiede in der NAKO Gesundheitsstudie.

BACKGROUND: Noise annoyance is associated with adverse health-related conditions and reduced wellbeing. Thereby, subjective noise annoyance depends on the objective noise exposure and is modified by personal and regional factors. OBJECTIVE: How many participants of the German National Cohort Study (GNC; NAKO Gesundheitsstudie) were annoyed by transportation noise during nighttime and what factors were associated with noise annoyance? MATERIALS AND METHODS: This cross-sectional analysis included 86,080 participants from 18 study centers, examined from 2014 to 2017. We used multinomial logistic regression to investigate associations of personal and regional factors to noise annoyance (slightly/moderately or strongly/extremely annoyed vs. not annoyed) mutually adjusting for all factors in the model. RESULTS: Two thirds of participants were not annoyed by transportation noise during nighttime and one in ten reported strong/extreme annoyance with highest percentages for the study centers Berlin-Mitte and Leipzig. The strongest associations were seen for factors related to the individual housing situation like the bedroom being positioned towards a major road (OR of being slightly/moderately annoyed: 4.26 [95% CI: 4.01;4.52]; OR of being strongly/extremely annoyed: 13.36 [95% CI: 12.47;14.32]) compared to a garden/inner courtyard. Participants aged 40-60 years and those in low- and medium-income groups reported greater noise annoyance compared to younger or older ones and those in the high-income group. CONCLUSION: In this study from Germany, transportation noise annoyance during nighttime varied by personal and regional factors.

[Integration of sex/gender into environmental health research. Results of the interdisciplinary research network Sex/Gender-Environment-Health (GeUmGe-NET)]. / Integration von Geschlecht in die Forschung zu umweltbezogener Gesundheit. Ergebnisse des interdisziplinären Forschungsnetzwerks Geschlecht ­ Umwelt ­ Gesundheit (GeUmGe-NET).

The comprehensive consideration of sex/gender in health research is essential to increase relevance and validity of research results. Contrary to other areas of health research, there is no systematic summary of the current state of research on the significance of sex/gender in environmental health. Within the interdisciplinary research network Sex/Gender-Environment-Health (GeUmGe-NET) the current state of integration of sex/gender aspects or, respectively, gender theoretical concepts into research was systematically assessed within selected topics of the research areas environmental toxicology, environmental medicine, environmental epidemiology and public health research on environment and health. Knowledge gaps and research needs were identified in all research areas. Furthermore, the potential for methodological advancements by using gender theoretical concepts was depicted. A dialogue between biomedical research, public health research, and gender studies was started with the research network GeUmGe-NET. This dialogue has to be continued particularly regarding a common testing of methodological innovations in data collection and data analysis. Insights of this interdisciplinary research are relevant for practice areas such as environmental health protection, health promotion, environmental justice, and environmental health monitoring.

Long-term associations of modeled and self-reported measures of exposure to air pollution and noise at residence on prevalent hypertension and blood pressure.

Air pollution, traffic noise and noise annoyance are suggested to be associated with hypertension and blood pressure (BP); however, the evidence remains inconsistent. Our study examined the long-term associations of modeled and self-reported measures of air pollution and traffic noise on prevalent hypertension and BP. We analyzed cross-sectional data from 2552 participants aged 31-72years from the KORA F4 (2006-2008) study conducted in the region of Augsburg, Germany. Land-use regression models were used to estimate residential long-term exposure to particulate matter <2.5µm (PM2.5), soot content of PM2.5 (PM2.5abs) and nitrogen dioxide (NO2). Road traffic noise levels at the facade of the dwellings were estimated for the participants' residences. Participants filled-in a questionnaire on noise annoyance and heavy traffic passing their residence. Linear and logistic regression models adjusting for confounders were used to assess the association between exposure measures and hypertension and BP. An interquartile increase in annual mean PM2.5 (1µg/m3) was significantly associated with 15% higher prevalence of hypertension, without (95% CI: 2.5; 28.0%) and with (95% CI: 0.7; 30.8%) adjustment for traffic noise. Diastolic blood pressure (DBP) was associated with air pollutants and traffic noise with percent increases in mean of 0.7 (95% CI: 0.2; 1.2), 0.6 (95% CI: 0.1; 1.1) and 0.3 (95% CI: 0.0; 0.7) for an interquartile increase in PM2.5 (1µg/m3) and PM2.5abs (0.2∗10-5/m), and 5dB(A) increase in 24-hour road traffic noise, respectively. Associations of PM2.5abs and NO2 with hypertension or DBP were stronger in men and diabetic individuals. No clear associations were seen with systolic BP or noise annoyance. In conclusion, self-reported measures of air pollution or noise did not perform better than the objective measures. Our findings provide further evidence for a link between air pollution, noise and cardiovascular disease and indicate a stronger association for men and diabetic individuals.

Association of novel metrics of particulate matter with vascular markers of inflammation and coagulation in susceptible populations -results from a panel study.

BACKGROUND AND AIMS: Epidemiological studies have shown adverse effects of ambient air pollutants on health with inflammation and oxidative stress playing an important role. We examine the association between blood biomarkers of inflammation and coagulation and physical attributes of particulate matter which are not routinely measured such as particle length or surface area concentration and apparent density of PM. METHODS: Between 3/2007 and 12/2008 187 non-smoking individuals with type 2 diabetes mellitus (T2D) or impaired glucose tolerance (IGT) were examined within the framework of the KORA Study in Augsburg, Germany. In addition, we selected 87 participants with a potential genetic predisposition on detoxifying and inflammatory pathways. This was defined by the null polymorphism for glutathione S-transferase M1 in combination with a certain single nucleotide polymorphism on the C-reactive protein (CRP) gene (rs1205) or the fibrinogen gene (rs1800790). Participants had blood drawn up to seven different times, resulting in 1765 blood samples. Air pollutants were collected at a central measurement station and individual 24-h averages calculated. Associations between air pollutants and high sensitivity CRP, myeloperoxidase (MPO), interleukin (IL)-6 and fibrinogen were analysed using additive mixed models. RESULTS: For the panel with genetic susceptibility, increases were seen for CRP and MPO with most attributes, specifically particle length and active surface concentration. The %change of geometric mean and 95% confidence intervals for the 5-day average exposure for CRP and MPO were 34.6% [21.8;48.8] and 8.3% [3.2;13.6] per interquartile range increase of particle length concentration and 29.8% [15.9;45.3] and 10.4 [4.4;16.7] for active surface area. Results for the panel of T2D and IGT and the other blood biomarkers were less conclusive. CONCLUSIONS: Particle length concentration and active surface concentration showed strong positive associations with blood biomarkers reflecting inflammation. These air pollution metrics might reflect harmful aerosol properties better than particulate mass or number concentration. They might therefore be important for epidemiological studies.

Individual daytime noise exposure in different microenvironments.

BACKGROUND: Numerous studies showed that chronic noise exposure modeled through noise mapping is associated with adverse health effects. However, knowledge about real individual noise exposure, emitted by several sources, is limited. OBJECTIVES: To explain the variation in individual daytime noise exposure regarding different microenvironments, activities and individual characteristics. MATERIALS AND METHODS: In a repeated measures study in Augsburg, Germany (March 2007-December 2008), 109 individuals participated in 305 individual noise measurements with a mean duration of 5.5h. Whereabouts and activities were recorded in a diary. One-minute averages of A-weighted equivalent continuous sound pressure levels (Leq) were determined. We used mixed additive models to elucidate the variation of Leq by diary-based information, baseline characteristics and time-invariant variables like long-term noise exposure. RESULTS: Overall noise levels were highly variable (median: 64 dB(A); range: 37-105 dB(A)). Highest noise levels were measured in traffic during bicycling (69 dB(A); 49-97 dB(A)) and lowest while resting at home (54 dB(A); 37-94 dB(A)). Nearly all diary-based information as well as physical activity, sex and age-group had significant influences on individual noise. In an additional analysis restricted to times spent at the residences, long-term noise exposure did not improve the model fit. CONCLUSIONS: Individual exposures to day-time noise were moderate to high and showed high variations in different microenvironments except when being in traffic. Individual noise levels were greatly determined by personal activities but also seemed to depend on environmental noise levels.

Elevated particle number concentrations induce immediate changes in heart rate variability: a panel study in individuals with impaired glucose metabolism or diabetes.

BACKGROUND: The health effects of short-term exposure to ambient ultrafine particles in micro-environments are still under investigation. METHODS: Sixty-four individuals with type 2 diabetes and impaired glucose tolerance recorded ambulatory electrocardiograms over five to six hours on 191 occasions in a panel study in Augsburg, Germany. Personal exposure to particle number concentrations (PNC) was monitored for each individual on 5-minute basis concurrently and particulate matter with an aerodynamic diameter<2.5 µm (PM2.5) was acquired from a central monitoring site on an hourly basis. RESULTS: More than 11,000 5-minute intervals were available for heart rate and measures of heart rate variability including SDNN (standard deviation of NN intervals). A concurrent decrease in 5-minute SDNN of -0.56% (95% confidence limits (CI): -1.02%; -0.09%) and a 5-minute delayed increase in heart rate of 0.23 % (95% CI: 0.11%; 0.36%) was observed with an increase in personal PNC of 16,000 per cm3 in additive mixed models. Models evaluating the association of concurrent 5-minute personal PNC and of 1-hour PM2.5 showed independent effects on SDNN. CONCLUSION: The data suggest that freshly emitted ultrafine particles and aged fine particulate matter are both associated with changes in cardiac function in individuals with type 2 diabetes and impaired glucose tolerance in urban areas.

Personal day-time exposure to ultrafine particles in different microenvironments.

In order to assess the personal exposure to ultrafine particles (UFP) during individual day-time activities and to investigate the impact of different microenvironments on exposure, we measured personal exposure to particle number concentrations (PNC), a surrogate for UFP, among 112 non-smoking participants in Augsburg, Germany over a nearly two-year period from March 2007 to December 2008. We obtained 337 personal PNC measurements from 112 participants together with dairies of their activities and locations. The measurements lasted on average 5.5h and contained on average 330 observations. In addition, ambient PNC were measured at an urban background stationary monitoring site. Personal PNC were highly variable between measurements (IQR of mean: 11780-24650cm(-3)) and also within a single measurement. Outdoor personal PNC in traffic environments were about two times higher than in non-traffic environments. Higher indoor personal PNC were associated with activities like cooking, being in a bistro or exposure to passive smoking. Overall, personal and stationary PNC were weakly to moderately correlated (r<0.41). Personal PNC were much higher than stationary PNC in traffic (ratio: 1.5), when shopping (ratio: 2.4), and indoors with water vapor (ratio: 2.5). Additive mixed models were applied to predict personal PNC by participants' activities and locations. Traffic microenvironments were significant determinants for outdoor personal PNC. Being in a bistro, passive smoking, and cooking contributed significantly to an increased indoor personal PNC.

Associations between ambient air pollution and blood markers of inflammation and coagulation/fibrinolysis in susceptible populations.

The pathophysiological pathways linking particulate air pollution to cardiovascular disease are still not fully understood. We examined the association between ambient air pollutants and blood markers of inflammation and coagulation/fibrinolysis in three potentially susceptible populations. Three panels of non-smoking individuals were examined between 3/2007 and 12/2008: 1) with type 2 diabetes mellitus (T2D, n=83), 2) with impaired glucose tolerance (IGT, n=104), and 3) with a potential genetic predisposition which could affect detoxifying and inflammatory pathways (n=87) defined by the null polymorphism for glutathione S-transferase M1 (GSTM1) in combination with a certain single nucleotide polymorphism on the C-reactive protein (CRP) or the fibrinogen gene. Study participants had blood drawn up to seven times every four to six weeks. In total, 1765 blood samples were analysed for CRP, interleukin (IL)-6, soluble CD40 ligand (sCD40L), fibrinogen, myeloperoxidase (MPO), and plasminogen activator inhibitor-1 (PAI-1). Hourly mean values of particulate air pollutants, particle number concentrations in different size ranges and gaseous pollutants were collected at fixed monitoring sites and individual 24hour averages calculated. Associations between air pollutants and blood markers were analysed for each panel separately and taking the T2D panel and the IGT panel together, using additive mixed models adjusted for long-term time trend and meteorology. For the panel with potential genetic susceptibility, CRP and MPO increased for most lags, especially with the 5-day average exposure (% change of geometric mean and 95% confidence interval: 22.9% [12.0;34.7] for CRP and 5.0% [0.3;9.9] for MPO per interquartile range of PM2.5). Small positive associations were seen for fibrinogen while sCD40L, PAI-1 and IL-6 mostly decreased in association with air pollution concentrations. Except for positive associations for fibrinogen we did not see significant results with the two other panels. Participants with potential genetic susceptibility showed a clear association between inflammatory blood biomarkers and ambient air pollutants. Our results support the hypothesis that air pollution increases systemic inflammation especially in susceptible populations which may aggravate atherosclerotic diseases and induce multi-organ damage.

Short-term effects of air temperature on blood pressure and pulse pressure in potentially susceptible individuals.

BACKGROUND: Only few epidemiological studies have investigated the association between air temperature and blood pressure (BP) or pulse pressure (PP), with inconsistent findings. We examined whether short-term changes in air temperature were associated with changes in BP or PP in three different populations. METHODS: Between March 2007 and December 2008, 371 systolic and diastolic BP measurements were collected in 30 individuals with type-2 diabetes mellitus (T2D), 30 persons with impaired glucose tolerance and 42 healthy individuals without a metabolic disorder from Augsburg, Germany. Hourly means of ambient meteorological data were obtained from a fixed measurement station. Personal temperature measurements were conducted using data loggers. Temperature effects were evaluated using additive mixed models adjusting for time trend and relative humidity. RESULTS: Decreases in air temperature were associated with an increase in systolic BP, diastolic BP and PP in individuals with T2D. For example, a 1°C decrease in ambient temperature was associated with an immediate increase in systolic BP of 1.0 mmHg (95%-confidence interval: [0.5;1.4]mmHg). Effects of personally measured air temperature were similar. Temperature effects were modified by age, body mass index, gender, antihypertensive medication and whereabouts, such as being indoors. CONCLUSIONS: We observed associations between decreases in air temperature and increases in BP as well as PP in persons with T2D indicating that these people might be potentially more susceptible to changes in air temperature. Our findings may provide a hypothesis for a mechanism between air temperature decreases and short-term increases of cardiovascular events.

Impact of personally measured pollutants on cardiac function.

Epidemiological studies have shown associations between ambient air pollution and changes in heart rate variability (HRV). However, studies using personal air pollution measurements, especially with exposure averages <24h, are still rare. Between February and March 2008 HRV data as well as personal exposure to particulate matter <2.5µm (PM2.5), and particle number concentrations (PNC) were collected in five volunteers for up to 8.3h on a 5min resolution. Information about the participant's whereabouts was also collected. Mixed models were used to analyze concurrent and up to 30min delayed effects of air pollutants as well as being in traffic on 5min-averages of heart rate (HR), high and low frequency power (HF and LF), standard deviation of all normal-to-normal intervals (SDNN), and the root mean square of successive interval differences (RMSSD). Results are presented as %-change from the mean per increase in interquartile range of air pollutant. In total, 474 5-min segments were available for analysis. We observed concurrent and delayed reductions in SDNN of about 0.8-1.0% in association with a 5.4µg/m(3) increase in PM2.5. However, being in traffic by car led to an increase of about 20% 10-14min and 15-19min later. An increase in PM2.5 or PNC was associated with lagged decreases for RMSSD and HF. We detected concurrent reductions in RMSSD (-17.6% [95%-confidence interval: 29.1; -4.3]) when being in traffic by bike/foot. Being in traffic by car was associated with an immediate reduction in LF while more delayed increases in LF were observed when being in traffic by bike/foot. Air pollution and traffic effects on HR were less consistent. These rapid changes in HRV within 30min might be mediated by the autonomic nervous system in response to direct reflexes from receptors in the lungs.

Individual daytime noise exposure during routine activities and heart rate variability in adults: a repeated measures study.

BACKGROUND: Epidemiological studies have demonstrated associations between noise exposure and cardiovascular events. However, there have been few studies of possible underlying mechanisms. OBJECTIVES: We examined the association between individual daytime noise exposure and heart rate variability (HRV). METHODS: In a prospective panel study in Augsburg, Germany (March 2007-December 2008), 110 individuals participated in 326 electrocardiogram recordings with a mean duration of 6 hr. Five-minute averages of heart rate (HR) and HRV parameters were determined. Individual noise exposure was measured as A-weighted equivalent continuous sound pressure levels (L(eq)). Effects were estimated using additive mixed models adjusted for long- and short-term time trends and physical activity. Due to nonlinear exposure-response functions, we performed piecewise linear analyses with a cut-off point at 65 dB(A). RESULTS: Concurrent increases of 5 dB(A) in L(eq) < 65 dB(A) were associated with increases in HR (percent change of mean value: 1.48%; 95% CI: 1.37, 1.60%) and the ratio of low-frequency (LF) to high-frequency (HF) power (4.89%; 95% CI: 3.48, 6.32%), and with decreases in LF (-3.77%; 95% CI: -5.49, -2.02%) and HF (-8.56%; 95% CI: -10.31, -6.78%) power. Standard deviation of normal-to-normal intervals (SDNN) was positively associated with concurrent noise < 65 dB(A) (5.74%; 95% CI: 5.13, 6.36) but negatively associated with noise lagged by 5-15 min (-0.53% to -0.69%). Associations with cardiac function were less pronounced for noise ≥ 65 dB(A), with some in opposite directions from associations with noise < 65 dB(A). Concurrent associations were modified by sex and age. CONCLUSIONS: Individual daytime noise exposure was associated with immediate changes in HRV, suggesting a possible mechanism linking noise to cardiovascular risk. Noise at lower levels may have health consequences beyond those resulting from "fight-or-flight" responses to high levels of noise.

Short-term effects of air temperature on blood markers of coagulation and inflammation in potentially susceptible individuals.

OBJECTIVES: Changes in air temperature are associated with an increase in cardiovascular events, but the role of procoagulant and proinflammatory blood markers is still poorly understood. The authors investigated the association between air temperature and fibrinogen, plasminogen activator inhibitor type 1, interleukin-6 and high-sensitivity C reactive protein in two potentially susceptible groups. METHODS: This prospective panel study was conducted between March 2007 and December 2008 in Augsburg, Germany. The study population comprised 187 participants with type 2 diabetes mellitus or impaired glucose tolerance and 87 participants with genetic polymorphisms on the detoxification and inflammation pathways. Overall, 1766 repeated blood measurements were collected. Hourly meteorology data were available from a central measurement site. The association between temperature and blood markers was analysed with additive mixed models. RESULTS: For type 2 diabetes mellitus and impaired glucose tolerance participants, the authors observed immediate, lagged and cumulative increases in fibrinogen (range of percentage changes in geometric mean: 0.6%-0.8%) and plasminogen activator inhibitor type 1 (6.0%-10.1%) in association with a 5°C temperature decrement. Participants with a body mass index above 30 kg/m(2) as well as females showed particularly strong fibrinogen effects. In participants with the special genetic background, 5°C decreases in the 5-day average of temperature led to a change of 8.0% (95% CI 0.5% to 16.2%) in interleukin-6 and of -8.4% (95% CI -15.8% to -0.3%) in high-sensitivity C reactive protein, the latter driven by physically active individuals. CONCLUSIONS: The authors observed different temperature effects on blood markers in two potentially susceptible groups probably indicating varying underlying biological mechanisms. This study results might provide a link between temperature and cardiovascular events.

Immediate ozone effects on heart rate and repolarisation parameters in potentially susceptible individuals.

OBJECTIVES: Elevated ozone levels have been associated with cardiovascular morbidity and mortality. We investigated the effects of ozone on heart rate (HR) and repolarisation parameters in potentially susceptible populations. METHODS: Between March 2007 and December 2008, 363 ECG recordings including >2000 1 h intervals were measured in 64 individuals with type 2 diabetes or impaired glucose tolerance and in 46 healthy individuals with a potential genetic predisposition on the detoxification pathways from Augsburg, Germany. Associations between 1 h averages of ozone and HR, Bazett-corrected QT-interval (QTc), T-wave amplitude and T-wave complexity were analysed using additive mixed models. A variable indicating season and participants' location during the 1 h ECG recordings (summer and outdoors vs winter or indoors) was used as a potential ozone effect modifier. RESULTS: We observed concurrent and 1-4 h lagged increases in HR of 0.5-0.7% for each 20 µg/m(3) increase in ozone. These effects were stronger (1.0-1.2%) when participants were outdoors during the summer. We detected in all participants a concurrent (-1.31%; 95% CI -2.19% to -0.42%) and 1 h lagged (-1.32%; -2.19% to -0.45%) T-wave flattening. Elevated ozone levels were associated with 1 h (2.12%; 0.81 to 3.52) and 2 h lagged (1.89%; 0.55% to 3.26%) increases in T-wave complexity. However, no effects were seen for QTc. Ozone effects were generally more pronounced in individuals with metabolic disorders than a potential genetic predisposition. CONCLUSIONS: Changes in repolarisation might contribute to underlying pathophysiological changes associated with the link between elevated ozone levels and reported adverse cardiovascular outcomes.

Acute air pollution effects on heart rate variability are modified by SNPs involved in cardiac rhythm in individuals with diabetes or impaired glucose tolerance.

BACKGROUND: Epidemiological studies have shown associations between particulate matter (PM) and heart rate variability (HRV). OBJECTIVES: We investigated the effects of air pollution on the root mean square of successive differences (RMSSD) and the standard deviation of normal-to-normal intervals (SDNN) and effect modifications by single nucleotide polymorphisms (SNP). METHODS: Between March 2007 and December 2008 207 ECG recordings comprising 1153 1 h-intervals were measured in 61 individuals with type 2 diabetes or impaired glucose tolerance (IGT) from Augsburg, Germany. Associations between 1 h-averages of air pollutants (PM, sulphate, black carbon, and ultrafine particles) and ECG parameters were analyzed using additive mixed models. Genotypes of 139 SNPs supposed to be involved in cardiac rhythm were identified in the literature. Using regression trees for longitudinal data, SNPs associated with ECG parameters were determined and included as potential air pollution effect modifiers. RESULTS: We observed concurrent and lagged decreases in SDNN by about 2-5% in association with all air pollutants, especially in participants with at least one minor allele of rs332229. Increases in PM<2.5 µm (PM(2.5)) were associated with 4 h-lagged decreases of -6.6% [95%-confidence interval:-10.6;-2.6%] and -13.0% [-20.7;-5.1%] in SDNN in individuals with one or two minor alleles. We observed a -7.2% [-12.2;-1.8%] reduction in RMSSD associated with concurrent increases in PM(2.5.) Individuals with at least one minor allele of rs2096767 or at most one minor allele of rs2745967 exhibited stronger PM(2.5) effects. CONCLUSIONS: We identified a genetic predisposition in persons with diabetes or IGT making them potentially more susceptible to air pollutants with regard to changes in HRV.