Identifying and Reducing Insulin Errors in the Simulated Military Critical Care Air Transport Environment: A Human Factors Approach.

INTRODUCTION: During high-fidelity simulations in the Critical Care Air Transport (CCAT) Advanced course, we identified a high frequency of insulin medication errors and sought strategies to reduce them using a human factors approach. MATERIALS AND METHODS: Of 169 eligible CCAT simulations, 22 were randomly selected for retrospective audio-video review to establish a baseline frequency of insulin medication errors. Using the Human Factors Analysis Classification System, dosing errors, defined as a physician ordering an inappropriate dose, were categorized as decision-based; administration errors, defined as a clinician preparing and administering a dose different than ordered, were categorized as skill-based. Next, 3 a priori interventions were developed to decrease the frequency of insulin medication errors, and these were grouped into 2 study arms. Arm 1 included a didactic session reviewing a sliding-scale insulin (SSI) dosing protocol and a hands-on exercise requiring all CCAT teams to practice preparing 10 units of insulin including a 2-person check. Arm 2 contained arm 1 interventions and added an SSI cognitive aid available to students during simulation. Frequency and type of insulin medication errors were collected for both arms with 93 simulations for arm 1 (January-August 2021) and 139 for arm 2 (August 2021-July 2022). The frequency of decision-based and skill-based errors was compared across control and intervention arms. RESULTS: Baseline insulin medication error rates were as follows: decision-based error occurred in 6/22 (27.3%) simulations and skill-based error occurred in 6/22 (27.3%). Five of the 6 skill-based errors resulted in administration of a 10-fold higher dose than ordered. The post-intervention decision-based error rates were 9/93 (9.7%) and 23/139 (2.2%), respectively, for arms 1 and 2. Compared to baseline error rates, both arm 1 (P = .04) and arm 2 (P < .001) had a significantly lower rate of decision-based errors. Additionally, arm 2 had a significantly lower decision-based error rate compared to arm 1 (P = .015). For skill-based preparation errors, 1/93 (1.1%) occurred in arm 1 and 4/139 (2.9%) occurred in arm 2. Compared to baseline, this represents a significant decrease in skill-based error in both arm 1 (P < .001) and arm 2 (P < .001). There were no significant differences in skill-based error between arms 1 and 2. CONCLUSIONS: This study demonstrates the value of descriptive error analysis during high-fidelity simulation using audio-video review and effective risk mitigation using training and cognitive aids to reduce medication errors in CCAT. As demonstrated by post-intervention observations, a human factors approach successfully reduced decision-based error by using didactic training and cognitive aids and reduced skill-based error using hands-on training. We recommend the development of a Clinical Practice Guideline including an SSI protocol, guidelines for a 2-person check, and a cognitive aid for implementation with deployed CCAT teams. Furthermore, hands-on training for insulin preparation and administration should be incorporated into home station sustainment training to reduced medication errors in the operational environment.

Hypobaria During Aeromedical Evacuation and Systemic Inflammation after Porcine Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI)-related morbidity is caused largely by secondary injury resulting from hypoxia, excessive sympathetic drive, and uncontrolled inflammation. Aeromedical evacuation (AE) is utilized by the military for transport of wounded soldiers to higher levels of care. We hypothesized that the hypobaric, hypoxic conditions of AE may exacerbate uncontrolled inflammation following TBI that could contribute to more severe TBI-related secondary injury. STUDY DESIGN: Thirty-six female pigs were used to test TBI vs. TBI sham, hypoxia vs. normoxia, and hypobaria vs. ground conditions. TBI was induced by controlled cortical injury, hypobaric conditions of 12,000 feet were established in an altitude chamber, and hypoxic exposure was titrated to 85% SpO2 while at altitude. Serum cytokines, UCH-L1 and TBI biomarkers were analyzed via ELISA. Gross analysis and staining of cortex and hippocampus tissue was completed for glial fibrillary acidic protein (GFAP) and phosphorylated tau (p-tau). RESULTS: Serum IL-1b, IL-6, and TNFα were significantly elevated following TBI in pigs exposed to altitude-induced hypobaria/hypoxia, as well as hypobaria alone, compared to ground level/normoxia. No difference in TBI biomarkers following TBI or hypobaric, hypoxic exposure was noted. No difference in brain tissue GFAP or p-tau when comparing the most different conditions of sham TBI+ground/normoxia to the TBI+hypobaria/hypoxia group was noted. CONCLUSION: The hypobaric environment of AE induces systemic inflammation following TBI. Severe inflammation may play a role in exacerbating secondary injury associated with TBI and contribute to worse neurocognitive outcomes. Measures should be taken to minimize barometric and oxygenation changes during AE following TBI.

Validation of Preload Assessment Technologies at Altitude in a Porcine Model of Hemorrhage.

INTRODUCTION: Dynamic preload assessment measures including pulse pressure variation (PPV), stroke volume variation (SVV), pleth variability index (PVI), and hypotension prediction index (HPI) have been utilized clinically to guide fluid management decisions in critically ill patients. These values aid in the balance of correcting hypotension while avoiding over-resuscitation leading to respiratory failure and increased mortality. However, these measures have not been previously validated at altitude or in those with temporary abdominal closure (TAC). METHODS: Forty-eight female swine (39 ± 2 kg) were separated into eight groups (n = 6) including all combinations of flight versus ground, hemorrhage versus no hemorrhage, and TAC versus no TAC. Flight animals underwent simulated aeromedical evacuation via an altitude chamber at 8000 ft. Hemorrhagic shock was induced via stepwise hemorrhage removing 10% blood volume in 15-min increments to a total blood loss of 40% or a mean arterial pressure of 35 mmHg. Animals were then stepwise transfused with citrated shed blood with 10% volume every 15 min back to full blood volume. PPV, SVV, PVI, and HPI were monitored every 15 min throughout the simulated aeromedical evacuation or ground control. Blood samples were collected and analyzed for serum levels of serum IL-1ß, IL-6, IL-8, and TNF-α. RESULTS: Hemorrhage groups demonstrated significant increases in PPV, SVV, PVI, and HPI at each step compared to nonhemorrhage groups. Flight increased PPV (P = 0.004) and SVV (P = 0.003) in hemorrhaged animals. TAC at ground level increased PPV (P < 0.0001), SVV (P = 0.0003), and PVI (P < 0.0001). When TAC was present during flight, PPV (P = 0.004), SVV (P = 0.003), and PVI (P < 0.0001) values were decreased suggesting a dependent effect between altitude and TAC. There were no significant differences in serum IL-1ß, IL-6, IL-8, or TNF-α concentration between injury groups. CONCLUSIONS: Based on our study, PPV and SVV are increased during flight and in the presence of TAC. Pleth variability index is slightly increased with TAC at ground level. Hypotension prediction index demonstrated no significant changes regardless of altitude or TAC status, however this measure was less reliable once the resuscitation phase was initiated. Pleth variability index may be the most useful predictor of preload during aeromedical evacuation as it is a noninvasive modality.

Predictive Value of Early Inflammatory Markers in Trauma Patients Based on Transfusion Status.

INTRODUCTION: Seven key inflammatory biomarkers were recently found to be associated with the risk of mortality in a multicenter study of massively transfused patients. The aim of this prospective single-center study was to determine which of these early inflammatory markers could predict 30-d mortality among all critically injured trauma patients. METHODS: Serum samples were collected at 6, 24, and 72 h from 238 consecutive patients admitted to the intensive care unit following traumatic injury. Inflammatory markers syndecan-1, eotaxin, IL-1ra, IL-6, IL-8, IL-10, IP-10, and MCP-1 were analyzed via multiplex enzyme-linked immunosorbent assay. Subgroup analysis was performed for patients undergoing massive transfusion (≥5 red blood cells), submassive transfusion (1-4 red blood cells), or no transfusion during the first 4 h postinjury. The primary outcome of 30-d survival was modeled as a function of each biomarker and confounders using repeat measures logistic regression. RESULTS: Patients had a median age of 51.3 y [33.7, 70.2], 70.6% were male, 17.4% experienced penetrating trauma, and had a median injury severity score of 22 [14, 33]. IL-1ra, IL-8, IL-10, and MCP-1 were significantly increased during the first 72 h in nonsurvivors (n = 31). Elevated IL-1ra, IL-8, IL-10, and MCP-1 at 6 h postinjury were associated with 30-d mortality. By contrast, serum syndecan-1 and eotaxin levels were not associated with mortality at any time point. IL-8 and lactate were increased at 6 h in 30-d nonsurvivors for patients receiving submassive transfusion (n = 78). CONCLUSIONS: Early evaluations of IL-1ra, IL-8, IL-10, and IP-10 within 6 h of injury are useful predictors of 30-d mortality. Subgroup analysis suggests that transfusion status does not significantly affect early inflammatory markers. LEVEL OF EVIDENCE: Level III, prognostic/epidemiological.

The Ability of Military Critical Care Air Transport Members to Visually Estimate Percent Systolic Pressure Variation.

INTRODUCTION: Inappropriate fluid management during patient transport may lead to casualty morbidity. Percent systolic pressure variation (%SPV) is one of several technologies that perform a dynamic assessment of fluid responsiveness (FT-DYN). Trained anesthesia providers can visually estimate and use %SPV to limit the incidence of erroneous volume management decisions to 1-4%. However, the accuracy of visually estimated %SPV by other specialties is unknown. The aim of this article is to determine the accuracy of estimated %SPV and the incidence of erroneous volume management decisions for Critical Care Air Transport (CCAT) team members before and after training to visually estimate and utilize %SPV. MATERIAL AND METHODS: In one sitting, CCAT team providers received didactics defining %SPV and indicators of fluid responsiveness and treatment with %SPV ≤7 and ≥14.5 defining a fluid nonresponsive and responsive patient, respectively; they were then shown ten 45-second training arterial waveforms on a simulated Propaq M portable monitor's screen. Study subjects were asked to visually estimate %SPV for each arterial waveform and queried whether they would treat with a fluid bolus. After each training simulation, they were told the true %SPV. Seven days post-training, the subjects were shown a different set of ten 45-second testing simulations and asked to estimate %SPV and choose to treat, or not. Nonparametric limits of agreement for differences between true and estimated %SPV were analyzed using Bland-Altman graphs. In addition, three errors were defined: (1) %SPV visual estimate errors that would label a volume responsive patient as nonresponsive, or vice versa; (2) incorrect treatment decisions based on estimated %SPV (algorithm application errors); and (3) incorrect treatment decisions based on true %SPV (clinically significant treatment errors). For the training and testing simulations, these error rates were compared between, and within, provider groups. RESULTS: Sixty-one physicians (MDs), 64 registered nurses (RNs), and 53 respiratory technicians (RTs) participated in the study. For testing simulations, the incidence and 95% CI for %SPV estimate errors with sufficient magnitude to result in a treatment error were 1.4% (0.5%, 3.2%), 1.6% (0.6%, 3.4%), and 4.1% (2.2%, 6.9%) for MDs, RNs, and RTs, respectively. However, clinically significant treatment errors were statistically more common for all provider types, occurring at a rate of 7%, 10%, and 23% (all P < .05). Finally, students did not show clinically relevant reductions in their errors between training and testing simulations. CONCLUSIONS: Although most practitioners correctly visually estimated %SPV and all students completed the training in interpreting and applying %SPV, all groups persisted in making clinically significant treatment errors with moderate to high frequency. This suggests that the treatment errors were more often driven by misapplying FT-DYN algorithms rather than by inaccurate visual estimation of %SPV. Furthermore, these errors were not responsive to training, suggesting that a decision-making cognitive aid may improve CCAT teams' ability to apply FT-DYN technologies.

Change in country-level COVID-19 lethality is associated with improved testing: no apparent role of medical care or disease-specific knowledge.

AIM: Reductions in the case fatality rate of COVID-19 in the unvaccinated have been credited to improvements in medical care. Here I test whether either of these factors predicts reductions in the case fatality rate, and whether observed reductions are better explicable by improved ascertainment of mild cases. METHODS: Using weighted log-log regression, I compute the association between changes in the case fatality rate and test density between 3 July 2020 and 5 January 2021 in 162 countries; and check whether case fatality rate change is associated with either per capita medical spending (proxy for critical care access) or timing of the pandemic (proxy for COVID-specific knowledge). RESULTS: The median test density increased from 175 tests per thousand population to 1200, while the median case fatality rate dropped from 4.1% to 2.0%. While the case fatality rate was higher at both timepoints in Europe/North America than Africa / Asia, its association with test density was similar across countries. For each doubling in test density, the mean case fatality rate decreased by 18% (P<0.0001) with a median (interquartile rate) country-level decline of 20% (5-30) per doubling of test density. The rate of change of the case fatality rate was not associated with either medical care access or COVID-specific knowledge (all P>0.10). CONCLUSIONS: Declines in the case fatality rate were adequately explained by improved testing, with no effect of either medical knowledge or improvements in care. The true lethality of COVID-19 may not have changed much at the population level. Prevention should remain a priority.

Estimating total morbidity burden of COVID-19: relative importance of death and disability.

OBJECTIVE: Calculations of disease burden of COVID-19, used to allocate scarce resources, have historically considered only mortality. However, survivors often develop postinfectious 'long-COVID' similar to chronic fatigue syndrome; physical sequelae such as heart damage, or both. This paper quantifies relative contributions of acute case fatality, delayed case fatality, and disability to total morbidity per COVID-19 case. STUDY DESIGN AND SETTING: Healthy life years lost per COVID-19 case were computed as the sum of (incidence*disability weight*duration) for death and long-COVID by sex and 10-year age category in three plausible scenarios. RESULTS: In all models, acute mortality was only a small share of total morbidity. For lifelong moderate symptoms, healthy years lost per COVID-19 case ranged from 0.92 (male in his 30s) to 5.71 (girl under 10) and were 3.5 and 3.6 for the oldest females and males. At higher symptom severities, young people and females bore larger shares of morbidity; if survivors' later mortality increased, morbidity increased most in young people of both sexes. CONCLUSIONS: Under most conditions most COVID-19 morbidity was in survivors. Future research should investigate incidence, risk factors, and clinical course of long-COVID to elucidate total disease burden, and decisionmakers should allocate scarce resources to minimize total morbidity.

Cardioprotective effects of resistance training add to those of total activity in Americans.

BACKGROUND: Resistance training is cardioprotective independent of total activity in experimental research and is prescribed to clinical populations, but is often largely neglected at population scale. Here we determine whether these benefits are relevant to general practice. METHODS: A total of 6947 Americans over 20 years old (51% male) from NHANES 2003-2006 reported resistance training and objectively tracked 1-week total activity. Activity measures were modeled as five-level predictors of objectively measured binary heart-disease risks (hypertension, dyslipidemia, overweight, and diabetes) corrected for age, ethnicity, gender, and smoking. Significance was defined as Pfor trend less than .10 that the lowest activity category differed from the average of all others. If both activity measures predicted the same risk, mutually corrected models were run. RESULTS: Average total activity was 20 minutes/day (SD 24). About 30% of subjects had resistance trained in the past month, reporting up to 7 sessions/day. Prevalences of hypertension, dyslipidemia, overweight, and diabetes were 32%, 46%, 68%, and 7.2%, respectively. All significant associations for resistance training (but not total activity) exhibited a threshold in dose-response curve, with comparable benefits from any dose above "none." Resistance trainers had significantly lower odds of hypertension (ORs, 0.55-0.85), overweight (ORs, 0.55-0.74), and diabetes (ORs, 0.51-0.80), but not dyslipidemia (ORs, 0.55-0.74). For total activity there was no significant trend in risk of either hypertension or dyslipidemia, but there were for overweight (ORs for each quintile above the lowest 1.04, 0.89, 0.78, and 0.49) and diabetes (ORs, 0.83, 0.68, 0.50, and 0.23; all Pfor trend <.01). Associations of resistance training with diabetes and obesity attenuated only slightly after correction for total activity, and vice versa. CONCLUSIONS: Cardioprotective associations of resistance training were comparable to those of total activity and clinically relevant at low doses. Largest benefits accrued to those who combined any dose of resistance training with high total activity.

Role of Ascertainment Bias in Determining Case Fatality Rate of COVID-19.

Case fatality rate (CFR) is used to calculate mortality burden of COVID-19 under different scenarios, thus informing risk-benefit balance of interventions both pharmaceutical and nonpharmaceutical. However, observed CFR is driven by testing: as more low-risk cases are identified, observed CFR will decline. This report quantifies test bias by modeling observed CFR as log-log-linear function of test density (tests per population) in 163 countries. CFR declined almost 20% (e.g. from 5% to 4%) for each doubling of test density (p < 0.0001); this association did not vary by continent (interaction p > 0.10) although at any given test density CFR was higher in Europe or North America than in Asia or Africa. This effect of test density on observed CFR is adequate to hide all but the largest true differences in case survivorship. Published estimates of CFR should specify test density, and comparisons should correct for it such as by applying the provided model.

Phylogenetic relationships and diversity of bat-associated Leptospira and the histopathological evaluation of these infections in bats from Grenada, West Indies.

Bats can harbor zoonotic pathogens, but their status as reservoir hosts for Leptospira bacteria is unclear. During 2015-2017, kidneys from 47 of 173 bats captured in Grenada, West Indies, tested PCR-positive for Leptospira. Sequence analysis of the Leptospira rpoB gene from 31 of the positive samples showed 87-91% similarity to known Leptospira species. Pairwise and phylogenetic analysis of sequences indicate that bats from Grenada harbor as many as eight undescribed Leptospira genotypes that are most similar to known pathogenic Leptospira, including known zoonotic serovars. Warthin-Starry staining revealed leptospiral organisms colonizing the renal tubules in 70% of the PCR-positive bats examined. Mild inflammatory lesions in liver and kidney observed in some bats were not significantly correlated with renal Leptospira PCR-positivity. Our findings suggest that Grenada bats are asymptomatically infected with novel and diverse Leptospira genotypes phylogenetically related to known pathogenic strains, supporting the hypothesis that bats may be reservoirs for zoonotic Leptospira.

Better lung function with increased handgrip strength, as well as maximum oxygen uptake, in congenital heart disease across the lifespan.

BACKGROUND: The respiratory benefits of muscle strength are well-known in heart-healthy populations, but recommendations and research often focus instead on aerobic fitness (peak oxygen uptake) or total activity. Independent benefits of strength thus may be underestimated, especially in congenital heart disease where perceived dangers of certain types of exercise may outweigh perceived benefits. To assess whether it is plausible that pulmonary benefits of strength in heart-healthy populations also apply in congenital heart disease, we simultaneously correlated these patients' lung function with fitness, strength, and cardiac diagnosis. METHODS: Lung function (forced expiratory volume in one second percentage predicted (FEV1%pred)) was modeled as function of handgrip strength, congenital heart disease diagnosis, peak oxygen uptake and the interactions of handgrip with sex and diagnosis in 538 Germans (58% male, ages 6-82 years) in linear models corrected for age, sex, height and weight. Congenital heart disease diagnoses were: complex cyanotic; Fallot/Truncus arteriosus communis (common arterial trunk) (TAC); shunts; transposition of the great arteries (TGA); left heart; and other/none. RESULTS: Each kg of handgrip was associated with 0.74% higher FEV1%pred ( p < 0.001) and handgrip explained almost 10% of variance in FEV1%pred. While some groups had higher FEV1%pred than others ( p for global null <0.0001), all experienced similar associations with strength ( p for interaction with handgrip >0.10 for both sex and diagnosis.) Correction for peak oxygen uptake eliminated the association with congenital heart disease, but not handgrip. CONCLUSION: Strength was associated with better lung function in all ages even after correction for peak oxygen uptake, regardless of sex and congenital heart disease. This suggests that strength may be at least as important for lung function as aerobic fitness. Heart-safe strength training may improve pulmonary function in congenital heart disease.

Uni- and triaxial accelerometric signals agree during daily routine, but show differences between sports.

Accelerometers objectively monitor physical activity, and ongoing research suggests they can also detect patterns of body movement. However, different types of signal (uniaxial, captured by older studies, vs. the newer triaxial) and or/device (validated Actigraph used by older studies, vs. others) may lead to incomparability of results from different time periods. Standardization is desirable. We establish whether uniaxial signals adequately monitor routine activity, and whether triaxial accelerometry can detect sport-specific variations in movement pattern. 1402 adolescents wore triaxial Actigraphs (GT3X) for one week and diaried sport. Uni- and triaxial counts per minute were compared across the week and between over 30 different sports. Across the whole recording period 95% of variance in triaxial counts was explained by the vertical axis (5th percentile for R2, 91%). Sport made up a small fraction of daily routine, but differences were visible: even when total acceleration was comparable, little was vertical in horizontal movements, such as ice skating (uniaxial counts 41% of triaxial) compared to complex movements (taekwondo, 55%) or ambulation (soccer, 69%). Triaxial accelerometry captured differences in movement pattern between sports, but so little time was spent in sport that, across the whole day, uni- and triaxial signals correlated closely. This indicates that, with certain limitations, uniaxial accelerometric measures of routine activity from older studies can be feasibly compared to triaxial measures from newer studies. Comparison of new studies based on raw accelerations to older studies based on proprietary devices and measures (epochs, counts) will require additional efforts which are not addressed in this paper.

Accelerometric estimates of physical activity vary unstably with data handling.

BACKGROUND: Because of unreliable self-report, accelerometry is increasingly used to objectively monitor physical activity (PA). However, results of accelerometric studies vary depending on the chosen cutpoints between activity intensities. Population-specific activity patterns likely affect the size of these differences. To establish their size and stability we apply three sets of cutpoints, including two calibrated to a single reference, to our accelerometric data and compare PA estimates. METHODS: 1402 German adolescents from the GINIplus and LISAplus cohorts wore triaxial accelerometers (Actigraph GT3x) for one week (mean 6.23 days, 14.7 hours per day) at the hip. After validation of wear, we applied three sets of cutpoints for youth, including the most common standard (Freedson, 2005) and two calibrated to a single reference, (Romanzini uni- and triaxial, from Romanzini, 2014) to these data, estimating daily sedentary, light, moderate, vigorous and moderate-to-vigorous PA (MPA, VPA, MVPA). Stability of differences was assessed by comparing Romanzini's two sets of cutpoints. RESULTS: Relative agreement between cutpoints was closer for activity of lower intensities (largest difference for sedentary behaviour 9%) but increased for higher intensities (largest difference for light activity 40%, MPA 102%, VPA 88%; all p<0.01). Romanzini's uniaxial and triaxial cutpoints agreed no more closely with each other than with Freedson's. CONCLUSIONS: Estimated PA differed significantly between different sets of cutpoints, even when those cutpoints agreed perfectly on another dataset (i.e. Romanzini's.) This suggests that the detected differences in estimated PA depend on population-specific activity patterns, which cannot be easily corrected for: converting activity estimates from one set of cutpoints to another may require access to raw data. This limits the utility of accelerometry for comparing populations in place and time. We suggest that accelerometric research adopt a standard for data processing, and apply and present the results of this standard in addition to those from any other method.

Physical activity, subjective sleep quality and time in bed do not vary by moon phase in German adolescents.

Lunar periodicity in human biology and behaviour, particularly sleep, has been reported. However, estimated relationships vary in direction (more or less sleep with full moon) if they exist at all, and studies tend to be so small that there is potential for confounding by weekly or monthly cycles. Lunar variation in physical activity has been posited as a driver of this relationship, but is likewise not well studied. We explore the association between lunar cycle, sleep and physical activity in a population-based sample of 1411 Germans age 14-17 years (46% male). Physical activity (daily minutes moderate-to-vigorous activity) was objectively assessed by accelerometry for a total of 8832 days between 2011 and 2014. At the same time, time in bed (h) and subjective sleep quality (1-6) were diaried each morning. In models corrected for confounding, we found that lunar phase was not significantly associated with physical activity, subjective sleep quality or time in bed in either sex, regardless of season. Observed relationships varied randomly in direction between models, suggesting artefact. Thus, this large, objectively-measured and well-controlled population of adolescents displayed no lunar periodicity in objective physical activity, subjective sleep quality or time in bed.

Asthma and Rhinitis Are Associated with Less Objectively-Measured Moderate and Vigorous Physical Activity, but Similar Sport Participation, in Adolescent German Boys: GINIplus and LISAplus Cohorts.

INTRODUCTION: Physical activity (PA) protects against most noncommunicable diseases and has been associated with decreased risk of allergic phenotype, which is increasing worldwide. However, the association is not always present; furthermore it is not clear whether it is strongest for asthma, rhinitis, symptoms of these, or atopic sensitization; which sex is most affected; or whether it can be explained by either avoidance of sport or exacerbation of symptoms by exercise. Interventions are thus difficult to target. METHODS: PA was measured by one-week accelerometry in 1137 Germans (mean age 15.6 years, 47% boys) from the GINIplus and LISAplus birth cohorts, and modeled as a correlate of allergic symptoms, sensitization, or reported doctor-diagnosed asthma or rhinitis. RESULTS: 8.3% of children had asthma, of the remainder 7.9% had rhinitis, and of the remainder 32% were sensitized to aero-allergens (atopic). 52% were lung-healthy controls. Lung-healthy boys and girls averaged 46.4 min and 37.8 min moderate-to-vigorous PA per day, of which 14.6 and 11.4 min was vigorous. PA in allergic girls was not altered, but boys with asthma got 13% less moderate and 29% less vigorous PA, and those with rhinitis with 13% less moderate PA, than lung-healthy boys. Both sexes participated comparably in sport (70 to 84%). Adolescents with wheezing (up to 68%, in asthma) and/or nose/eye symptoms (up to 88%, in rhinitis) were no less active. CONCLUSIONS: We found that asthma and rhinitis, but not atopy, were independently associated with low PA in boys, but not in girls. These results indicate that allergic boys remain a high-risk group for physical inactivity even if they participate comparably in sport. Research into the link between PA and allergy should consider population-specific and sex-specific effects, and clinicians, parents, and designers of PA interventions should specifically address PA in allergic boys to ensure full participation.

What is the impact of different spirometric criteria on the prevalence of spirometrically defined COPD and its comorbidities? Results from the population-based KORA study.

BACKGROUND: There is an ongoing debate about the appropriate spirometric criterion for airway obstruction to detect COPD. Furthermore, the association of different criteria with comorbidity prevalence and inflammatory biomarkers in advanced age is unclear. MATERIALS AND METHODS: Spirometry was performed in a population-based study (n=2,256) covering an age range of 41-90 years. COPD was spirometrically determined either by a fixed ratio (FR) of <0.7 for forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) or by FEV1/FVC below the lower limit of normal (LLN). Comorbidity prevalences and circulating biomarker levels (C-reactive protein [CRP], interleukin [IL]-6) were compared between subjects with or without COPD by the two criteria using logistic and multiple regression models, adjusting for sex and age. RESULTS: The prevalence of spirometrically defined COPD by FR increased with age from 10% in subjects aged <65 years to 26% in subjects aged ≥75 years. For LLN-defined COPD, it remained below 10% for all age groups. Overall, COPD diagnosis was not associated with specific comorbidities, except for a lower prevalence of obesity in both FR- and LLN-defined cases. Both CRP and IL-6 tended to be higher in cases by both criteria. CONCLUSION: In a population-based cohort of adults up to the age of 90 years, the prevalence of spirometrically defined COPD was higher for the FR criterion than for the LLN criterion. This difference increased with age. Neither prevalences of common comorbidities nor levels of the biomarkers, CRP or IL-6, were conclusively associated with the selection of the COPD criterion. Results have to be considered in light of the predominantly mild cases of airway obstruction in the examined study population.

Physical activity is not associated with spirometric indices in lung-healthy German youth.

In lung disease, physical activity improves lung function and reduces morbidity. However, healthy populations are not well studied. We estimate the relationship between spirometric indices and accelerometric physical activity in lung-healthy adolescents.895 nonsmoking German adolescents without chronic lung disease (45% male, mean±sd age 15.2±0.26 years) from the GINIplus and LISAplus cohorts completed questionnaires, spirometry, 7-day accelerometry and an activity diary. Physical activity was measured as minutes, quintiles and regularity of daily moderate, vigorous and moderate-to-vigorous physical activity (MVPA), participation in sport and active commuting to school. Primary outcomes were forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC and forced expiratory flow at 25-75% of FVC; they were separately correlated with physical activity and adjusted for confounders of respiratory function, including early-life exposures.Adolescents averaged 40 min MVPA per day, typical for European youth. 79% participated in sports and 51% commuted actively. An association was suggested between 3% higher FVC (∼100 mL) and either extreme MVPA quintile or percentage of days with >30 min MVPA (p<0.05). However, after Bonferroni correction all associations between spirometry, active lifestyle and physical activity were nonsignificant.Spirometric indices were not significantly associated with active lifestyle or measures of activity in lung-healthy adolescents after adjustment for confounding and multiple-comparison artefacts.

Physical Activity Levels and Domains Assessed by Accelerometry in German Adolescents from GINIplus and LISAplus.

BACKGROUND: Physical activity (PA) is a well-known and underused protective factor for numerous health outcomes, and interventions are hampered by lack of objective data. We combined accelerometers with diaries to estimate the contributions to total activity from different domains throughout the day and week in adolescents. METHODS: Accelerometric and diary data from 1403 adolescents (45% male, mean age 15.6 ± 0.5 years) were combined to evaluate daily levels and domains of sedentary, light, and moderate-to-vigorous activity (MVPA) during a typical week. Freedson's cutoff points were applied to determine levels of activity. Total activity was broken down into school physical education (PE), school outside PE, transportation to school, sport, and other time. RESULTS: About 2/3 of adolescents' time was spent sedentary, 1/3 in light activity, and about 5% in MVPA. Boys and girls averaged 46 (SD 22) and 38 (23) minutes MVPA per day. Adolescents were most active during leisure sport, spending about 30% of it in MVPA, followed by PE (about 20%) transport to school (14%) and either school class time or other time (3%). PE provided 5% of total MVPA, while leisure sport provided 16% and transportation to school 8%. School was the most sedentary part of the day with over 75% of time outside PE spent sedentary. CONCLUSIONS: These German adolescents were typical of Europeans in showing low levels of physical activity, with significant contributions from leisure sport, transportation and school PE. Leisure sport was the most active part of the day, and participation did not vary significantly by sex, study center (region of Germany) or BMI. Transportation to school was frequent and thus accounted for a significant fraction of total MVPA. This indicates that even in a population with good access to dedicated sporting activities, frequent active transportation can add significantly to total MVPA.

Neighbourhood and physical activity in German adolescents: GINIplus and LISAplus.

INTRODUCTION: Impact of neighbourhood on physical activity (PA) is under-investigated in European adolescents, and few studies have used objective data on both exposures and outcomes. Therefore we investigated the association between objectively measured neighbourhood characteristics and PA in 15-year-old German adolescents. METHODS: Study populations comprised of 688 adolescents residing in the urban Munich area and 504 from the rural Wesel area from the GINIplus and LISAplus birth cohorts. Neighbourhood was defined as a circular 500-m buffer around the residence. Greenness was calculated 1) as the mean Normalized Difference Vegetation Index (NDVI), and 2) as percent tree cover. Neighbourhood green spaces and sport and leisure facilities were defined as present or absent in a neighbourhood (data only available for Munich). Data on PA were collected from one-week triaxial accelerometry (hip-worn ActiGraph GT3X). Minutes of PA were classified into moderate-to-vigorous (MVPA), light and sedentary using Romanzini's et al. triaxial cutoffs, and averaged over the recording period. Activity diaries were used for differentiation between school and leisure (total minus school) PA. Area-specific associations were assessed by adjusted negative binomial regressions. RESULTS: In the Wesel area, residing in a neighbourhood with higher NDVI was associated with 9% more leisure MVPA among females and with 8% more leisure MVPA in rural dwellers. In the Munich area, residing in a neighbourhood with sport facilities was associated with 9% more leisure MVPA. The latter association was only significant in urban dwellers while neighbourhood leisure facilities increased MVPA in rural dwellers. Estimates were very similar when total MVPA was considered rather than solely leisure. CONCLUSION: There is indication that neighbourhood features could be associated with MVPA in German adolescents. However, different features seem to be important across sexes and in rural/urban settings, which need to be specifically addressed in future studies.