Recreating the future-Indigenous research paradigms in health professional education research.

INTRODUCTION: Health and self-determination are recognised as universal human rights. Health professional education research and practice hold the capacity to prioritise values, worldviews and agendas that envisage sustainable and equitable futures for the entire community served. This paper explores the need for the co-location of Indigenous research paradigms in health professional education research and teaching. Indigenous communities have a long history of science, research and sustainable living and are holders of ways of knowing, being and doing that can shape actions and priorities in health research that value equity and sustainability. DISCUSSION: Knowledge construction in health professional education research does not occur in isolation nor is it value neutral. A continued dominance of the biomedical approach to health creates a system of innovation that is unbalanced and unable to deliver health outcomes demanded by contemporary society. As power and hierarchies are embedded in health professional education research and praxis, transformative action is required to bring forth marginalised voices in research processes. Critical reflexivity regarding the ontological, epistemological, axiological and methodological positioning of researchers is an important step towards creating and sustaining research structures that effectively value and co-locate different perspectives in knowledge production and translation. CONCLUSION: Working towards more equitable and sustainable futures for Indigenous and non-Indigenous communities requires health care systems to be informed and guided by different knowledge paradigms. This can work to avoid the ongoing reproduction of inefficient biomedical structures and purposefully disrupt the status quo of health inequities. Realising this requires the effective co-location of Indigenous research paradigms and ways of working into health professional education research that centre relationality, wholism, interconnectedness and self-determination. This calls for a raising of the critical consciousness of health professional education research academies.

Racial Disparities Among Predicted Bronchopulmonary Dysplasia Risk Outcomes in Premature Infants Born <30 Weeks Gestation.

Background and Objective: There is extensive literature to support eliminating race-based risk stratification. The National Institute of Child Health and Human Development (NICHD) calculator, used to predict risk of bronchopulmonary dysplasia (BPD), includes race as a variable. We sought to investigate how utilizing race in determination of risk for BPD may lead to inequitable care. Methods: The study included a retrospective cohort of infants born <30 weeks gestation between January 2016 and February 2022. The primary outcome was the difference in predictive risk of BPD for non-Hispanic Black compared to non-Hispanic White infants. The secondary outcome was the disparity in theoretical administration of post-natal corticosteroids when the calculator was applied to the cohort. Analysis included paired T-tests and Chi-Square. Results: Of the 273 infants studied, 154 were non-Hispanic Black (56%). There was no difference between the groups in gestation or respiratory support on day of life (DOL) 14 or 28. The predicted risk of moderate or severe BPD in non-Hispanic White babies was greater than non-Hispanic Black babies on both DOL 14 and 28 (p<0.01). When applied retrospectively to the cohort, the calculator resulted in differences in corticosteroid administration (risk >40%-non-Hispanic White 51.3% vs. non-Hispanic Black 35.7%, p=0.010; risk >50%-non-Hispanic White 42.9% vs. non-Hispanic Black 29.9%, p=0.026). Conclusion: When applied to our study cohort, the calculator resulted in a reduction in the predicted risk of BPD in non-Hispanic Black infants. If utilized to guide treatment, the calculator can potentially lead to disparities in care for non-Hispanic Black infants.

The impact of the baby friendly hospital initiative on healthcare utilization among newborns insured by Medicaid in Delaware.

BACKGROUND: The Baby Friendly Hospital Initiative was created to enhance breastfeeding, although its impact on infant healthcare utilization is unclear. Breast feeding infants are vulnerable to readmission soon after birth secondary to dehydration and hyperbilirubinemia. Breastfeeding can also protect infants from unnecessary health care utilization later in life by preventing infection. The objective of this study was to examine the impact of the Baby Friendly Hospital Initiative on readmissions and emergency department utilization among Medicaid births in Delaware. METHODS: The study was a quasi-experimental design. Medicaid claims files were used to study births at five hospitals in Delaware born between January 1, 2014, and December 31, 2018, and covered under Medicaid at time of birth. Three hospitals were designated Baby Friendly, two were not and served as controls. Outcomes included Emergency Department (ED) utilization and readmissions within 30 days and one-year of birth hospitalization. Exposure to the Baby Friendly Hospital Initiative was determined by year and hospital of birth. Logistic regression and interrupted time series segmented regression analysis with controls were used to assess the effect of Baby Friendly Hospital Initiative on healthcare utilization. RESULTS: In total, 19,695 infants were born at five hospitals with 80% (15,939) born at hospitals that were designated Baby Friendly. ED utilization and readmissions over the 1st year of life for breastfeeding related diagnosis at the Baby Friendly hospitals occurred in 240 (1.5%) and 226 (1.4%) of infants, respectively. Exposure to the Baby Friendly Hospital Initiative was associated with increased odds of all cause 30-day readmission (AOR: 1.15; 95% CI: 1.03-1.28) but not readmissions over the 1st year of life. While 30-day ED visits did not change after BFHI, one-year ED visits were reduced (0.91, 95% CI 0.86-0.97). A significant negative trend was seen over time for ED utilization post BFHI compared to controls (B: -5.90, p < 0.01). CONCLUSION: There was a small observed increase in the odds of all cause 30-day readmissions with no change in one-year readmissions after BFHI in Delaware. Although there were no observed changes in 30-day ED utilization, there was a reduction in one-year ED utilization following the implementation of the Baby Friendly Hospital Initiative in Delaware birth hospitals. Our data help to inform policy and decision making for statewide systems of care that may be used to support breast feeding.

Institutional Variability in Representation of Women and Racial and Ethnic Minority Groups Among Medical School Faculty.

Importance: Bolstering the ranks of women and underrepresented groups in medicine (URM) among medical faculty can help address ongoing health care disparities and therefore constitutes a critical public health need. There are increasing proportions of URM faculty, but comparisons of these changes with shifts in regional populations are lacking. Objective: To quantify the representation of women and URM and assess changes and variability in representation by individual US medical schools. Design, Setting, and Participants: This retrospective cross-sectional study assessed US medical school faculty rosters for women and URM, including American Indian and Alaska Native, Black, Hispanic, and Native Hawaiian or other Pacific Islander faculty. US allopathic medical schools participating in the Association of American Medical Colleges (AAMC) Faculty Administrative Management Online User System from 1990 to 2019 (updated December 31 for each year), were included. Faculty data were analyzed from yearly cross-sections updated as of December 31 for each year from 1990 to 2019. For census data, decennial census data were used for years 1990, 2000, and 2010. Intercensal estimates were used for all other years from 1990 to 2019. Main Outcomes and Measures: Trends and variability in representation quotient (RQ), defined as representation of a group within an institution's faculty compared to its respective US county. Results: There were 121 AAMC member institutions (72 076 faculty) in 1990, which increased to 144 institutions (184 577 faculty) in 2019. The median RQ of women faculty increased from 0.42 (IQR, 0.37-0.46) to 0.80 (IQR, 0.74-0.89) (slope, +1.4% per year; P < .001). The median RQ of Black faculty increased from 0.10 (IQR, 0.06-0.22) to 0.22 (IQR, 0.14-0.41) (slope, +0.5% per year; P < .001), but remained low. In contrast, the median RQ of Hispanic faculty decreased from 0.44 (IQR, 0.19-1.22) to 0.34 (IQR, 0.23-0.62) (slope, -1.7% per year; P < .001) between 1990 and 2019. Absolute total change in RQ of URM showed an increase; however, the 30-year slope did not differ from zero (+0.1% per year; P = .052). Although RQ of women faculty increased for most institutions (127 [88.2%]), large variability in URM faculty trends were observed (57 institutions [39.6%] with increased RQ and 10 institutions [6.9%] with decreased RQ). Nearly one-quarter of institutions shifted from the top to bottom 50th percentile institutional ranking by URM RQ with county vs national comparisons. Conclusions and Relevance: The findings of this cross-sectional study suggest that representation of women in academic medicine improved with time, while URM overall experienced only modest increases with wide variability across institutions. Among URM, the Hispanic population has lost representational ground. County-based population comparisons provide new insights into institutional variation in representation among medical school faculty.

Habitat Imaging of Tumors Enables High Confidence Sub-Regional Assessment of Response to Therapy.

Imaging biomarkers are used in therapy development to identify and quantify therapeutic response. In oncology, use of MRI, PET and other imaging methods can be complicated by spatially complex and heterogeneous tumor micro-environments, non-Gaussian data and small sample sizes. Linear Poisson Modelling (LPM) enables analysis of complex data that is quantitative and can operate in small data domains. We performed experiments in 5 mouse models to evaluate the ability of LPM to identify responding tumor habitats across a range of radiation and targeted drug therapies. We tested if LPM could identify differential biological response rates. We calculated the theoretical sample size constraints for applying LPM to new data. We then performed a co-clinical trial using small data to test if LPM could detect multiple therapeutics with both improved power and reduced animal numbers compared to conventional t-test approaches. Our data showed that LPM greatly increased the amount of information extracted from diffusion-weighted imaging, compared to cohort t-tests. LPM distinguished biological response rates between Calu6 tumors treated with 3 different therapies and between Calu6 tumors and 4 other xenograft models treated with radiotherapy. A simulated co-clinical trial using real data detected high precision per-tumor treatment effects in as few as 3 mice per cohort, with p-values as low as 1 in 10,000. These findings provide a route to simultaneously improve the information derived from preclinical imaging while reducing and refining the use of animals in cancer research.

State-Level Social and Economic Policies and Their Association With Perinatal and Infant Outcomes.

Policy Points State-level social and economic policies that expand tax credits, increase paid parental leave, raise the minimum wage, and increase tobacco taxes have been demonstrated to reduce adverse perinatal and infant health outcomes. These findings can help prioritize evidence-based legislated policies to improve perinatal and infant outcomes in the United States. CONTEXT: Rates of preterm birth and infant mortality are alarmingly high in the United States. Legislated efforts may directly or indirectly reduce adverse perinatal and infant outcomes through the enactment of certain economic and social policies. METHODS: We conducted a narrative review to summarize the associations between perinatal and infant outcomes and four state-level US policies. We then used a latent profile analysis to create a social and economic policy profile for each state based on the observed policy indicators. FINDINGS: Of 27 articles identified, nine focused on tax credits, eight on paid parental leave, four on minimum wages, and six on tobacco taxes. In all but three studies, these policies were associated with improved perinatal or infant outcomes. Thirty-three states had tax credit laws, most commonly the earned income tax credit (n = 28, 56%). Eighteen states had parental leave laws. Two states had minimum wage laws lower than the federal minimum; 14 were equal to the federal minimum; 29 were above the federal minimum; and 5 did not have a state law. The average state tobacco tax was $1.76 (standard deviation = $1.08). The latent profile analysis revealed three policy profiles, with the most expansive policies in Western and Northeastern US states, and the least expansive policies in the US South. CONCLUSIONS: State-level social and economic policies have the potential to reduce adverse perinatal and infant health outcomes in the United States. Those states with the least expansive policies should therefore consider enacting these evidence-based policies, as they have shown a demonstratable benefit in other states.

Multi-parameter photon-by-photon hidden Markov modeling.

Single molecule Förster resonance energy transfer (smFRET) is a unique biophysical approach for studying conformational dynamics in biomacromolecules. Photon-by-photon hidden Markov modeling (H2MM) is an analysis tool that can quantify FRET dynamics of single biomolecules, even if they occur on the sub-millisecond timescale. However, dye photophysical transitions intertwined with FRET dynamics may cause artifacts. Here, we introduce multi-parameter H2MM (mpH2MM), which assists in identifying FRET dynamics based on simultaneous observation of multiple experimentally-derived parameters. We show the importance of using mpH2MM to decouple FRET dynamics caused by conformational changes from photophysical transitions in confocal-based smFRET measurements of a DNA hairpin, the maltose binding protein, MalE, and the type-III secretion system effector, YopO, from Yersinia species, all exhibiting conformational dynamics ranging from the sub-second to microsecond timescales. Overall, we show that using mpH2MM facilitates the identification and quantification of biomolecular sub-populations and their origin.

The role of governance in Indigenous medical education research.

CONTEXT: This article considers the role of governance in Indigenous medical education research through the lens of an Australian Aboriginal research project titled Healing Conversations. The Healing Conversations project is developing and testing a targeted educational framework for improved clinical communication between healthcare practitioners and Australian Aboriginal peoples in regional and urban locations. It is proposed that an effective governance approach can support Indigenous and non-Indigenous stakeholders to work together in decision-making structures to enable outcomes that promote and prioritise Indigenous worldviews and values in medical education research. ISSUE: The case study explored here puts forth the notion of effective governance as one practical way to decolonise medical education research structures in both the urban and regional setting. The importance of relationships between Indigenous and non-Indigenous stakeholders is supported in tailored governance structures, as knowledge translation efforts are situated in mainstream tertiary education structures that hold collective responsibility and accountability for change in this space. LESSONS LEARNT: Reflections from the Healing Conversations research case study are outlined for future consideration regarding sustainable and effective Indigenous governance initiatives in medical education and research structures. This includes the importance of an Indigenous governance structure within the research team and a strong understanding of the roles and contributions of each research team member, along with the required humanistic qualities to action effective governance in Indigenous medical education research. Collaborative governance structures are fundamental as the inclusion and prioritisation of Indigenous worldviews and values is a key step in redressing Indigenous healthcare disparities and providing culturally safe healthcare institutions.

Evaluating the Health Outcomes of the Healthy Women Healthy Babies Program in Delaware.

OBJECTIVES: The Delaware Healthy Women Healthy Babies Program (HWHB) was developed in response to increasing rates of infant mortality (IMR) and widening racial disparity. The primary aim of this study was to examine birth outcomes of enrolled and non-enrolled black and Hispanic women in the program whose payer was Medicaid. METHODS: We utilized a retrospective cohort of linked birth certificate and HWHB program participant data during 2011-2015. Our primary outcome variables (dependent variables) of interest included cigarette use, low birth weight, preterm birth and neonatal mortality. We utilized inverse probability of treatment weighting (IPTW) and estimated crude odds ratios (COR) and adjusted odds ratio (AOR) with 95% confidence intervals (CI) using IPTW as a weight variable. RESULTS: HWHB enrolled women were 10% less likely to smoke during pregnancy COR 0.89 (95% CI 0.82-0.96); were 9% less likely to deliver a low birth weight infant (AOR 0.91; 95% CI 0.84-0.99; p = 0.023); were 15% less likely to deliver a preterm infant (AOR 0.85; 0.78-0.92; p < .0001) as compared with non-HWHB women. Infants delivered by HWHB enrolled women had 27% less likelihood (AOR 0.73; 95% CI 0.54-0.98; p = 0.035) of experiencing a neonatal death (i.e., < 28 days) as compared with infants of non-enrolled HWHB women. CONCLUSION: The primary goal of this evaluation was to assess the effectiveness of the HWHB program on modifiable risk factors of IMR among HWHB enrolled and non-enrolled women. We found that HWHB program is a promising practice in improving the outcomes of infants born to participating black and Hispanic mothers.

Two-eyed seeing: A useful gaze in Indigenous medical education research.

CONTEXT: Medical education has a role in preparing future health care practitioners to have the skills to meaningfully address health disparities while providing effective clinical care considerate of diversity in our societies. This calls for medical education researchers to approach their craft in ways that prioritise and value inputs from a broader range of perspectives and worldviews in an effort to redress the negative impacts of social, political and structural forces on health outcomes. METHODS: Given the entrenched health inequities experienced by Indigenous populations across the globe, this paper details an approach to medical education research put forward by Canadian Mi'kmaw Elders Murdena and Albert Marshall and named 'two-eyed seeing'. This approach provides the opportunity for medical education researchers to address the ongoing impacts of colonisation, racism and marginalisation on health outcomes by prioritising Indigenous worldviews in medical curricula. The need for researchers and medical academies to critically consider Indigenous governance and processes of respectful knowledge sharing within the wider institutional and societal contexts is addressed. CONCLUSIONS: The benefits of two-eyed seeing in the context of better preparing the future workforce to effectively meet the needs of those most vulnerable, and to action change against health inequities, situate it as a promising research approach in medical education.

The Growing Problem of Hepatitis C Virus Infection: The Case of West Virginia.

Hepatitis C virus (HCV) is one of the most significant public health problems currently facing the United States, especially in West Virginia. If it is undetected and left untreated, the likelihood of sustaining a treatment response decreases. While early identification has been identified as a critical focus in trying to obtain better health outcomes, new drug treatments appear promising, if somewhat expensive. West Virginia is a predominantly rural state, where the incidence of HCV is 9 times the national average and Medicaid costs for treatment amounted to more than $27 million from 2014 to 2016. The purpose of this study was to conduct a systematic review of the effects of early identification and treatment for patients infected with HCV as it relates to West Virginia. A comprehensive systematic review was limited to 58 articles published from 2008 to 2018 and were in English. Findings from this review identified early detection as the first line of a preventive strategy to help reduce the evolving epidemic and that oral medications could reduce the risk of liver cancer and death. The cost associated with hospitalization of HCV more than tripled from $20 963 in 2005 to $64 867 in 2011 with the average charge per hospitalization at $53 626 due to HVC. The lack of adequate treatment options has led to increasing (and even more expensive) hospital care for untreated HCV. These facts suggest that this state might be facing an expected financial health care crisis due to its increasingly drug-related HCV-infected population.

Modeling Yield Losses and Fungicide Profitability for Managing Fusarium Head Blight in Brazilian Spring Wheat.

Fusarium head blight (FHB) and wheat yield data were gathered from fungicide trials to explore their relationship. Thirty-seven studies over 9 years and 11 locations met the criteria for inclusion in the analysis: FHB index in the untreated check ≥ 5% and the range of index in a trial ≥ 4 percentage points. These studies were grouped into two baseline yields, low (Yl ≤ 3,631 kg ha-1) or high (Yh > 3,631 kg ha-1), defined based on the median of maximum yields across trials. Attainable (disease-free) yields and FHB index were predicted using a wheat crop and a disease model, respectively, in 280 simulated trials (10 planting dates in a 28-year period, 1980 to 2007) for the Passo Fundo location. The damage coefficient was then used to calculate FHB-induced yield loss (penalizing attainable yield) for each experiment. Losses were compared between periods defined as before and after FHB resurge during the early 1990s. Disease reduction from the use of one or two sprays of a triazole fungicide (tebuconazole) was also simulated, based on previous meta-analytic estimates, and the response in yield was used in a profitability analysis. Population-average intercepts but not the slopes differed significantly between Yl (2,883.6 kg ha-1) and Yh (4,419.5 kg ha-1) baseline yields and the damage coefficients were 1.60%-1 and 1.05%-1, respectively. The magnitudes and trends of simulated yield losses were in general agreement with literature reports. The risk of not offsetting the costs of one or two fungicide sprays was generally higher (>0.75) prior to FHB resurgence but fungicide profitability tended to increase in recent years, depending on the year. Our simulations allowed us to reproduce trends in historical losses, and may be further adjusted to test the effect and profitability of different control measures (host resistance, other fungicides, etc.) on quality parameters such as test weight and mycotoxin contamination, should the information become available.

Assessment of physical rehabilitation movements through dimensionality reduction and statistical modeling.

The article proposes a method for evaluation of the consistency of human movements within the context of physical therapy and rehabilitation. Captured movement data in the form of joint angular displacements in a skeletal human model is considered in this work. The proposed approach employs an autoencoder neural network to project the high-dimensional motion trajectories into a low-dimensional manifold. Afterwards, a Gaussian mixture model is used to derive a parametric probabilistic model of the density of the movements. The resulting probabilistic model is employed for evaluation of the consistency of unseen motion sequences based on the likelihood of the data being drawn from the model. The approach is validated on two physical rehabilitation movements.

An assessment of the impact of green tea extract on palbociclib pharmacokinetics using a validated UHPLC-QTOF-MS method.

Green tea extracts (GTE) has been reported to be a kinase inhibitor and modulator for various drug metabolizing enzymes. It may give synergetic antioncogenic effect, but with a possibility of pharmacokinetic interactions with various co-administered anticancer agents like palbociclib (PAL), a selective inhibitor of CDK-4/6 primarily metabolized by CYP3A enzyme. To explore the impact of GTE on PAL pharmacokinetics in Sprague-Dawley rats, a rapid and sensitive UHPLC-QTOF-MS method was established. Chromatographic separation was carried out on an Acquity UPLC BEH C18 (100 × 2.1 mm, 1.7 µm) column using a gradient mobile phase system consisting of 0.1% formic acid and acetonitrile. Sample preparation was based on a simple protein precipitation method. Estimation of target ions [M + H]+ at m/z 448.2455 for PAL and m/z 441.2044 for ibrutinib (IS) was performed in selective ion mode ESI-HRMS. Good sensitivity (1.0 ng/mL) and linearity over a wide concentration range of 1-2000 ng/mL was exhibited by the method. The results indicated that the administration of GTE resulted in decreased oral bioavailability of PAL in both short- and long-term conditions. However, when both conditions were compared, the variation was less for the peak concentration and area under the concentration-time curve level of PAL.

Educating for Indigenous Health Equity: An International Consensus Statement.

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education's influence-for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role and, in fact, may be complicit in perpetuating inequities.This article seeks to examine the factors underpinning medical education's role in Indigenous health inequity, to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity.The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. To contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions' responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership.

Healing Conversations: Developing a Practical Framework for Clinical Communication Between Aboriginal Communities and Healthcare Practitioners.

In recognition of the ongoing health disparities experienced by Aboriginal and Torres Strait Islander peoples (hereafter Aboriginal), this scoping review explores the role and impact of the clinical communication process on Aboriginal healthcare provision. A medical education lens is applied, looking at the utility of a tailored clinical communication framework to assist health practitioners work more effectively with Aboriginal peoples and communities. The initial framework, building on existing communication guides, proposes four domains: content, process, relational and environmental. It places emphasis on critical self-reflection of the health practitioner's own cultural identity and will be guided by collective Aboriginal worldviews in select Australian settings. Using a two-eyed seeing approach the framework will be developed and tested in health professional education. The aim of this research journey is to enable health practitioners to have more effective healthcare conversations with Aboriginal peoples, working toward more socially just and equitable healthcare interactions and outcomes.

The Relationships Between Depressive Symptoms, Functional Health Status, Physical Activity, and the Availability of Recreational Facilities: a Rural-Urban Comparison in Middle-Aged and Older Chinese Adults.

PURPOSE: This study drew upon the ecological system theory to demonstrate rural-urban differences in the relationships between the availability of recreational facilities, physical activity (PA), functional health status, and depressive symptoms in middle-aged and older Chinese adults. METHODS: Nationally representative data (n = 5949) from the Chinese Health and Retirement Longitudinal Study (CHARLS, 2011-2013) were examined using the multigroup structural equation modeling approach. RESULTS: The results suggest that higher availability of recreational facilities in the urban communities was associated with higher levels of leisure time physical activity (LTPA), better functional capacity, and less occurrence of depressive symptoms among urban participants. In contrast, LTPA engagement among rural participants was low and had negligible mitigating effects on functional decline and depressive symptoms. The findings also show that functional health status mediated the association between total PA and depressive symptoms in both rural and urban participants. However, high levels of total PA were directly associated with elevated depressive symptoms, suggesting that the context of PA and related socioeconomic factors might explain this association after the non-LTPA components were included. CONCLUSIONS: The findings highlight how complex patterns of intrapersonal, behavioral, and environmental correlates influence depressive symptoms in middle-aged and older Chinese adults. The context of PA should be considered when creating targeted strategies to prevent depressive symptoms. As an inactive lifestyle evolves with China's rapid urbanization, joint efforts from public health and urban planning should be made to promote LTPA and develop active living communities for achieving optimal health in later life.

Understanding the Nature of Measurement Error When Estimating Energy Expenditure and Physical Activity via Physical Activity Recall.

BACKGROUND: The National Health and Nutrition Examination Survey physical activity questionnaire (PAQ) is used to estimate activity energy expenditure (AEE) and moderate to vigorous physical activity (MVPA). Bias and variance in estimates of AEE and MVPA from the PAQ have not been described, nor the impact of measurement error when utilizing the PAQ to predict biomarkers and categorize individuals. METHODS: The PAQ was administered to 385 adults to estimate AEE (AEE:PAQ) and MVPA (MVPA:PAQ), while simultaneously measuring AEE with doubly labeled water (DLW; AEE:DLW) and MVPA with an accelerometer (MVPA:A). RESULTS: Although AEE:PAQ [3.4 (2.2) MJ·d-1] was not significantly different from AEE:DLW [3.6 (1.6) MJ·d-1; P > .14], MVPA:PAQ [36.2 (24.4) min·d-1] was significantly higher than MVPA:A [8.0 (10.4) min·d-1; P < .0001]. AEE:PAQ regressed on AEE:DLW and MVPA:PAQ regressed on MVPA:A yielded not only significant positive relationships but also large residual variances. The relationships between AEE and MVPA, and 10 of the 12 biomarkers were underestimated by the PAQ. When compared with accelerometers, the PAQ overestimated the number of participants who met the Physical Activity Guidelines for Americans. CONCLUSIONS: Group-level bias in AEE:PAQ was small, but large for MVPA:PAQ. Poor within-participant estimates of AEE:PAQ and MVPA:PAQ lead to attenuated relationships with biomarkers and misclassifications of participants who met or who did not meet the Physical Activity Guidelines for Americans.