Showing papers by "Ulf Ekelund published in 2012"

Letter to the Editor: Standardized use of the terms "sedentary" and "sedentary behaviours"

Abstract: There has recently been an increase in research related to the health impact of sedentary behaviour (e.g., sitting) (Tremblay et al. 2010). Numerous studies suggest that those who engage in high amounts of sedentary behaviour can be at increased risk of morbidity and mortality regardless of their level of moderateto vigorous-intensity physical activity (MVPA) (Dunstan et al. 2010; Grøntved and Hu 2011; Katzmarzyk et al. 2009; Thorp et al. 2011; Wijndaele et al. 2011). Further, it has been noted that there is often little association between sedentary behaviour and MVPA (Biddle et al. 2004; Ekelund et al. 2006) and that it is possible for an individual to accumulate large amounts of both MVPA and sedentary behaviour in the course of a day (Healy et al. 2008; Katzmarzyk et al. 2009; Owen et al. 2010; Tremblay et al. 2010; Wong and Leatherdale 2008). Taken together, these findings suggest that too much sitting and too little MVPA represent separate and distinct risk factors for chronic, noncommunicable diseases (e.g., cardiovascular disease, diabetes, cancer). While research into the biology and health impact of sedentary behaviour represents an exciting new field of study, current inconsistencies in terminology are confusing for students, researchers, policymakers, and the general public. In short, the term “sedentary” currently has two separate and contradictory operational definitions. In this emerging field of research, sedentary behaviours are typically defined by both low energy expenditure (e.g., resting metabolic rate, typically ≤1.5 metabolic equivalents (METs)) and a sitting or reclining posture (Owen et al. 2010; Pate et al. 2008; Tremblay et al. 2010). In this context, a person may be described as sedentary if they engage in a large amount of sedentary behaviour. In contrast, in the sport and exercise literature the term sedentary is frequently used to describe the absence of some threshold of MVPA (Church et al. 2009; Melanson et al. 2009; Mullen et al. 2011; Sims et al. 2012; Smith et al. 2010). Thus, it is common for researchers in this field to describe a participant as sedentary because they are not meeting physical activity guidelines. Hence, many exercise studies include a “sedentary control group” or refer to their participants as coming from a “sedentary population” because of their lack of physical activity without actually measuring or assessing their level of sedentary behaviour. It is not difficult to see how these conflicting definitions of the term sedentary can easily lead to confusion. When reading the title or abstract of an article, it is often difficult to ascertain which definition of sedentary the authors have employed. If an article focuses on the health impact of a “sedentary lifestyle”, are they concerned with excessive sitting–lying down, the lack of physical activity, or both? Further, it is surprisingly common for articles within a given academic journal to oscillate between one definition and the other. To prevent further confusion, we propose that journal editors adopt a consistent definition of the term sedentary and require that all manuscripts published within their journal adhere to this common terminology. We suggest that journals formally define sedentary behaviour as any waking behaviour characterized by an energy expenditure ≤1.5 METs while in a sitting or reclining posture. In contrast, we suggest that authors use the term “inactive” to describe those who are performing insufficient amounts of MVPA (i.e., not meeting specified physical activity guidelines). The formal adoption of the above definitions by journal editors and reviewers would greatly improve the clarity of research and discussion related to these important health behaviours and help researchers searching for studies specific to sedentary behaviour or physical inactivity. We hope the research community will support these definitions and we look forward to further improvements in our understanding of the health impacts of sedentary behaviour and physical activity.

Moderate to vigorous physical activity and sedentary time and cardiometabolic risk factors in children and adolescents

Abstract: I Brage finner du akseptert versjon av artikkelen, og den inneholder forskjeller fra forlagets pdf-versjon. Forlagets pdf-versjon finner du pa jama.jamanetwork.com: http://dx.doi.org/10.1001/jama.2012.156 / In Brage you'll find the accepted version of the article, and it contains differences from the journal's pdf version. The journal's pdf version is available at jama.jamanetwork.com: http://dx.doi.org/10.1001/jama.2012.156

A systematic review of reliability and objective criterion-related validity of physical activity questionnaires

Abstract: Physical inactivity is one of the four leading risk factors for global mortality. Accurate measurement of physical activity (PA) and in particular by physical activity questionnaires (PAQs) remains a challenge. The aim of this paper is to provide an updated systematic review of the reliability and validity characteristics of existing and more recently developed PAQs and to quantitatively compare the performance between existing and newly developed PAQs. A literature search of electronic databases was performed for studies assessing reliability and validity data of PAQs using an objective criterion measurement of PA between January 1997 and December 2011. Articles meeting the inclusion criteria were screened and data were extracted to provide a systematic overview of measurement properties. Due to differences in reported outcomes and criterion methods a quantitative meta-analysis was not possible. In total, 31 studies testing 34 newly developed PAQs, and 65 studies examining 96 existing PAQs were included. Very few PAQs showed good results on both reliability and validity. Median reliability correlation coefficients were 0.62–0.71 for existing, and 0.74–0.76 for new PAQs. Median validity coefficients ranged from 0.30–0.39 for existing, and from 0.25–0.41 for new PAQs. Although the majority of PAQs appear to have acceptable reliability, the validity is moderate at best. Newly developed PAQs do not appear to perform substantially better than existing PAQs in terms of reliability and validity. Future PAQ studies should include measures of absolute validity and the error structure of the instrument.

Prediction of childhood obesity by infancy weight gain: an individual-level meta-analysis

Abstract: To assess the predictive ability of infant weight gain on subsequent obesity we performed a meta-analysis of individual-level data on 47,661 participants from 10 cohort studies from the UK, France, Finland, Sweden, the US and Seychelles. For each individual, weight SD scores at birth and age 1 year were calculated using the same external reference (British 1990). Childhood obesity was defined by International Obesity Task Force criteria. Each +1 unit increase in weight SD scores between 0 and 1 year conferred a twofold higher risk of childhood obesity (odds ratio = 1.97 [95% confidence interval (CI) 1.83, 2.12]), and a 23% higher risk of adult obesity (odds ratio = 1.23 [1.16, 1.30]), adjusted for sex, age and birthweight. There was little heterogeneity between studies. A risk score for childhood obesity comprising weight gain 0-1 year, mother's body mass index, birthweight and sex was generated in a random 50% selection of individuals from general population cohorts with available information (n = 8236); this score showed moderate predictive ability in the remaining 50% sample (area under receiving operating curve = 77% [95% CI 74, 80%]). A separate risk score for childhood overweight showed similar predictive ability (area under receiving operating curve = 76% [73, 79%]). In conclusion, infant weight gain showed a consistent positive association with subsequent obesity. A risk score combining birthweight and infant weight gain (or simply infant weight), together with mother's body mass index and sex may allow early stratification of infants at risk of childhood obesity.

Assessing physical activity using wearable monitors: measures of physical activity.

Abstract: BackgroundPhysical activity may be defined broadly as “all bodily actions produced by the contraction of skeletal muscle that increase energy expenditure above basal level.” Physical activity is a complex construct that can be classified into major categories qualitatively, quantitatively, o

Validity of a short questionnaire to assess physical activity in 10 European countries

Abstract: To accurately examine associations of physical activity (PA) with disease outcomes, a valid method of assessing free-living activity is required. We examined the validity of a brief PA questionnair ...

Validity and Comparability of a Wrist-Worn Accelerometer in Children

Abstract: BACKGROUND: Wrist-worn accelerometers may provide an alternative to hip-worn monitors for assessing physical activity as they are easier to wear and may thus facilitate long-term recordings. The cu ...

Physical activity reduces the risk of incident type 2 diabetes in general and in abdominally lean and obese men and women: the EPIC-InterAct Study

Abstract: We examined the independent and combined associations of physical activity and obesity with incident type 2 diabetes in men and women. The InterAct case-cohort study consists of 12,403 incident type 2 diabetes cases and a randomly selected subcohort of 16,154 individuals, drawn from a total cohort of 340,234 participants with 3.99 million person-years of follow-up. Physical activity was assessed by a four-category index. Obesity was measured by BMI and waist circumference (WC). Associations between physical activity, obesity and case-ascertained incident type 2 diabetes were analysed by Cox regression after adjusting for educational level, smoking status, alcohol consumption and energy intake. In combined analyses, individuals were stratified according to physical activity level, BMI and WC. A one-category difference in physical activity (equivalent to approximately 460 and 365 kJ/day in men and women, respectively) was independently associated with a 13% (HR 0.87, 95% CI 0.80, 0.94) and 7% (HR 0.93, 95% CI 0.89, 0.98) relative reduction in the risk of type 2 diabetes in men and women, respectively. Lower levels of physical activity were associated with an increased risk of diabetes across all strata of BMI. Comparing inactive with active individuals, the HRs were 1.44 (95% CI 1.11, 1.87) and 1.38 (95% CI 1.17, 1.62) in abdominally lean and obese inactive men, respectively, and 1.57 (95% CI 1.19, 2.07) and 1.19 (95% CI 1.01, 1.39) in abdominally lean and obese inactive women, respectively. Physical activity is associated with a reduction in the risk of developing type 2 diabetes across BMI categories in men and women, as well as in abdominally lean and obese men and women.

Travel to School and Physical Activity Levels in 9–10 Year-Old UK Children of Different Ethnic Origin; Child Heart and Health Study in England (CHASE)

Abstract: Background Travel to school may offer a convenient way to increase physical activity levels in childhood. We examined the association between method of travel to school and physical activity levels in urban multi-ethnic children. Methods and Findings 2035 children (aged 9–10 years in 2006–7) provided data on their usual method of travel to school and wore an Actigraph-GT1M activity monitor during waking hours. Associations between method of travel and mean level of physical activity (counts per minute [CPM], steps, time spent in light, moderate or vigorous activity per day) were examined in models adjusted for confounding variables. 1393 children (69%) walked or cycled to school; 161 (8%) used public transport and 481 (24%) travelled by car. White European children were more likely to walk/cycle, black African Caribbeans to travel by public transport and South Asian children to travel by car. Children travelling by car spent less time in moderate to vigorous physical activity (−7 mins, 95%CI-9,-5), and had lower CPM (−32 CPM, 95%CI-44,-19) and steps per day (−813 steps, 95%CI,-1043,-582) than walkers/cyclists. Pupils travelling by public transport had similar activity levels to walkers/cyclists. Lower physical activity levels amongst car travellers' were especially marked at travelling times (school days between 8–9 am, 3–5 pm), but were also evident on weekdays at other times and at weekends; they did not differ by gender or ethnic group. Conclusion Active travel to school is associated with higher levels of objectively measured physical activity, particularly during periods of travel but also at other times. If children travelling by car were to achieve physical activity levels (steps) similar to children using active travel, they would increase their physical activity levels by 9%. However, the population increase would be a modest 2%, because of the low proportion of car travellers in this urban population.

Children younger than 7 years with type 1 diabetes are less physically active than healthy controls.

Abstract: Aim: To examine if children younger than 7 years with type 1 diabetes are less physically active and spend more time sedentary than healthy children. Methods: Using a repeated measures case-control study design, physical activity (PA) was measured by continuous combined accelerometer and heart rate registration for 7 days at two time points during 1 year (autumn and spring). PA data were expressed as time spent sedentary, in moderate and vigorous intensity PA and total PA. Differences between groups and gender were analysed with mixed linear regression models. In this study there were 24 children (12 girls) with type 1 diabetes mellitus and 26 (14 girls) healthy controls, all younger than 7 years at inclusion. Results: Children with diabetes were less active overall (p = 0.010) and spent 16 min less in moderate-to-vigorous PA (p = 0.006). The difference in sedentary time (21 min less) between groups was not significant (p = 0.21). Overall PA (12.1 counts/min per day, p = 0.004) and time in moderate and vigorous PA (16.0 min/day, p = 0.002) was significantly higher in boys than in girls. A significant effect of age was observed. Conclusion: Physical activity is significantly reduced in young children with type 1 diabetes.

Criterion validity of a 10-category scale for ranking physical activity in Norwegian women

Abstract: Accurate measurement of physical activity (PA) is critical to establish dose-response relationships with various health outcomes. We compared the self-administered PA questionnaire from the Norwegian Women and Cancer Study (NOWAC) with a criterion method in middle-aged Norwegian women. A sample of 177 randomly recruited healthy women attended two clinical visits approximately 4-6 months apart. At each visit, the women completed the NOWAC PA questionnaire (NOPAQ), rating their overall PA level on a 10-category scale (1 being a "very low" and 10 being a "very high" PA level) and performed an 8-minute step-test to estimate aerobic fitness (VO2max). After each visit, the women wore a combined heart rate and movement sensor for 4 consecutive days of free-living. Measures of PA obtained from the combined heart rate and movement sensor, which were used as criterion, included individually calibrated PA energy expenditure (PAEE), acceleration, and hours/day of moderate-to-vigorous intensity PA (MVPA). These were averaged between visits and compared to NOPAQ scores at visit 2. Intra-class correlation coefficients for objective measures from both free-living periods were in the range of 0.65-0.87 (P < 0.001), compared to 0.62 (P < 0.001) for NOPAQ. There was a moderate but significant (P < 0.001) Spearman's rank correlation coefficient in the range of 0.36-0.46 between NOPAQ and objective measures of PA. Linear trends for the association between the NOPAQ rating scale with PAEE, hours/day of MVPA and VO2max (P < 0.001) were also demonstrated. Self-reported PA level measured on a 10-category scale appears valid to rank PA in a female Norwegian population.

Physical activity, calcium intake and childhood bone mineral: a population-based cross-sectional study.

Abstract: Summary In a free-living cohort of 4-year old children, mean daily time in moderate–vigorous physical activity and daily calcium intake at 3 years, were positively related to hip bone size and density. Relationships between physical activity and bone indices were stronger when calcium intake was above compared with below median (966 mg/day).

Bidirectional cross-sectional and prospective associations between physical activity and body composition in adolescence: birth cohort study.

Abstract: The aim of this study was to investigate the cross-sectional and prospective associations between physical activity and body composition in adolescence. This is a prospective study, including 4,103 adolescents belonging to the Pelotas (Brazil) 1993 birth cohort, who were followed up at the mean ages of 11.3 and 14.7 years. Subsample analyses included 511 individuals with accelerometry and deuterium dilution data at 13.3 years. Sum of skinfolds at age 11.3 years was highly correlated with skinfolds at age 14.7 years (rho = 0.74, P < 0.001). More than 85% of participants remained in the same quintile or changed by not more than one quintile during the 3.4 year period. Tracking of physical activity was considerably lower, although still significant; the correlation was 0.24 (P < 0.001) and 61.4% of the adolescents moved one or less quintiles. In fully-adjusted models, no significant cross-sectional or longitudinal associations were found between physical activity and body composition, neither in boy...

Evaluation of the Indian Migration Study Physical Activity Questionnaire (IMS-PAQ): a cross-sectional study

Abstract: Socio-cultural differences for country-specific activities are rarely addressed in physical activity questionnaires. We examined the reliability and validity of the Indian Migration Study Physical Activity Questionnaire (IMS-PAQ) in urban and rural groups in India. A sub-sample of IMS participants (n = 479) was used to examine short term (≤1 month [n = 158]) and long term (> 1 month [n = 321]) IMS-PAQ reliability for levels of total, sedentary, light and moderate/vigorous activity (MVPA) intensity using intraclass correlation (ICC) and kappa coefficients (k). Criterion validity (n = 157) was examined by comparing the IMS-PAQ to a uniaxial accelerometer (ACC) worn ≥4 days, via Spearman's rank correlations (ρ) and k, using Bland-Altman plots to check for systematic bias. Construct validity (n = 7,000) was established using linear regression, comparing IMS-PAQ against theoretical constructs associated with physical activity (PA): BMI [kg/m2], percent body fat and pulse rate. IMS-PAQ reliability ranged from ICC 0.42-0.88 and k = 0.37-0.61 (≤1 month) and ICC 0.26 to 0.62; kappa 0.17 to 0.45 (> 1 month). Criterion validity was ρ = 0.18-0.48; k = 0.08-0.34. Light activity was underestimated and MVPA consistently and substantially overestimated for the IMS-PAQ vs. the accelerometer. Criterion validity was moderate for total activity and MVPA. Reliability and validity were comparable for urban and rural participants but lower in women than men. Increasing time spent in total activity or MVPA, and decreasing time in sedentary activity were associated with decreasing BMI, percent body fat and pulse rate, thereby demonstrating construct validity. IMS-PAQ reliability and validity is similar to comparable self-reported instruments. It is an appropriate tool for ranking PA of individuals in India. Some refinements may be required for sedentary populations and women in India.

Combined Impact of Lifestyle Factors on Prospective Change in Body Weight and Waist Circumference in Participants of the EPIC-PANACEA Study

Abstract: Background: The evidence that individual dietary and lifestyle factors influence a person’s weight and waist circumference is well established; however their combined impact is less well documented. Therefore, we investigated the combined effect of physical activity, nutrition and smoking status on prospective gain in body weight and waist circumference. Methods: We used data of the prospective EPIC-PANACEA study. Between 1992 and 2000, 325,537 participants (94,445 men and 231,092 women, aged between 25–70) were recruited from nine European countries. Participants were categorised into two groups (positive or negative health behaviours) for each of the following being physically active, adherent to a healthy (Mediterranean not including alcohol) diet, and never-smoking for a total score ranging from zero to three. Anthropometric measures were taken at baseline and were mainly self-reported after a medium follow-up time of 5 years. Results: Mixed-effects linear regression models adjusted for age, educational level, alcohol consumption, baseline body mass index and follow-up time showed that men and women who reported to be physically active, never-smoking and adherent to the Mediterranean diet gained over a 5-year period 537 (95% CI 2706, 2368) and 200 (2478, 287) gram less weight and 0.95 (21.27, 20.639) and 0.99 (21.29, 20.69) cm less waist circumference, respectively, compared to participants with zero healthy behaviours. Conclusion: The combination of positive health behaviours was associated with significantly lower weight and waist circumference gain.

No Interactions Between Previously Associated 2-Hour Glucose Gene Variants and Physical Activity or BMI on 2-Hour Glucose Levels

Abstract: Gene-lifestyle interactions have been suggested to contribute to the development of type 2 diabetes. Glucose levels 2 h after a standard 75-g glucose challenge are used to diagnose diabetes and are associated with both genetic and lifestyle factors. However, whether these factors interact to determine 2-h glucose levels is unknown. We meta-analyzed single nucleotide polymorphism (SNP) × BMI and SNP × physical activity (PA) interaction regression models for five SNPs previously associated with 2-h glucose levels from up to 22 studies comprising 54,884 individuals without diabetes. PA levels were dichotomized, with individuals below the first quintile classified as inactive (20%) and the remainder as active (80%). BMI was considered a continuous trait. Inactive individuals had higher 2-h glucose levels than active individuals (β = 0.22 mmol/L [95% CI 0.13-0.31], P = 1.63 × 10(-6)). All SNPs were associated with 2-h glucose (β = 0.06-0.12 mmol/allele, P ≤ 1.53 × 10(-7)), but no significant interactions were found with PA (P > 0.18) or BMI (P ≥ 0.04). In this large study of gene-lifestyle interaction, we observed no interactions between genetic and lifestyle factors, both of which were associated with 2-h glucose. It is perhaps unlikely that top loci from genome-wide association studies will exhibit strong subgroup-specific effects, and may not, therefore, make the best candidates for the study of interactions.

Validity of Reporting Oxygen Uptake Efficiency Slope from Submaximal Exercise Using Respiratory Exchange Ratio as Secondary Criterion

Abstract: Background. Oxygen uptake efficiency slope (OUES) is a reproducible, objective marker of cardiopulmonary function. OUES is reported as being relatively independent of exercise intensity. Practical guidance and criteria for reporting OUES from submaximal tests has not been established. Objective. Evaluate the use of respiratory exchange ratio (RER) as a secondary criterion for reporting OUES. Design. 100 healthy volunteers (53 women) completed a ramped treadmill protocol to exhaustive exercise. OUES was calculated from data truncated to RER levels from 0.85 to 1.2 and compared to values generated from full test data. Results. Mean (sd) OUES from full test data and data truncated to RER 1.0 and RER 0.9 was 2814 (718), 2895 (730), and 2810 (789) mL/min per 10-fold increase in VE, respectively. Full test OUES was highly correlated with OUES from RER 1.0 (r = 0.9) and moderately correlated with OUES from RER 0.9 (r = 0.79). Conclusion. OUES values peaked in association with an RER level of 1.0. Sub-maximal OUES values are not independent of exercise intensity. There is a significant increase in OUES value as exercise moves from low to moderate intensity. RER can be used as a secondary criterion to define this transition.

Likelihood of acute coronary syndrome in emergency department chest pain patients varies with time of presentation

Abstract: There is a circadian and circaseptal (weekly) variation in the onset of acute coronary syndrome (ACS). The aim of this study was to elucidate whether the likelihood of ACS among emergency department (ED) chest pain patients varies with the time of presentation. All patients presenting to the Lund ED at Skane University Hospital with chest pain or discomfort during 2006 and 2007 were retrospectively included. Age, sex, arrival time at the ED and discharge diagnose (ACS or not) were obtained from the electronic medical records. There was a clear but moderate circadian variation in the likelihood of ACS among presenting chest pain patients, the likelihood between 8 and 10 am being almost twice as high as between 6 and 8 pm. This was mainly explained by a variation in the ACS likelihood in females and patients under 65 years, with no significant variation in males and patients over 65 years. There was no significant circaseptal variation in the ACS likelihood. Our results indicate that there is a circadian variation in the likelihood of ACS among ED chest pain patients, and suggest that physicians should consider the time of presentation to the ED when determining the likelihood of ACS.

Infancy and childhood growth and physical activity in adolescence: prospective birth cohort study from Brazil.

Abstract: Background The Developmental Origins of Health and Disease hypothesis suggests that intrauterine, infancy and early childhood variables play a key role at programming later health However, little is known on the programming of behavioral variables, because most studies so far focused on chronic disease-related and human capital outcomes The aim of the present study was to evaluate the effects of prenatal, infancy and childhood weight and length/height gains on objectively-measured physical activity (PA) in adolescence

The association of education with long-term weight change in the EPIC-PANACEA cohort

Abstract: BACKGROUND/OBJECTIVES: Cross-sectionally, educational attainment is strongly associated with the prevalence of obesity, but this association is less clear for weight change during adult life. The objective of this study is to examine the association between educational attainment and weight change during adult life in the European Prospective Investigation into Cancer and Nutrition (EPIC). SUBJECTS/METHODS: EPIC is a cohort study with 361 467 participants and up to 10 years of follow-up. Educational attainment was categorized according to the highest obtained school level (primary school or less, vocational secondary training, other secondary education and university). Multivariate mixed-effects linear regression models were used to study education in relation to weight at age 20 years (self-reported), to annual change in weight between age 20 years and measured weight at recruitment, and to annual change in weight during follow-up time. RESULTS: Higher educational attainment was associated with on average a lower body mass index (BMI) at age 20 years and a lower increase in weight up to recruitment (highest vs lowest educational attainment in men: -60 g per year (95% confidence interval (CI) -80; -40), women -110 g per year (95% CI -130; -80)). Although during follow-up after recruitment an increase in body weight was observed in all educational levels, gain was lowest in men and women with a university degree (high vs low education -120 g per year (95% CI -150; -90) and -70 g per year (95% CI -90; -60), respectively). CONCLUSIONS: Existing differences in BMI between higher and lower educated individuals at early adulthood became more pronounced during lifetime, which possibly impacts on obesity-related chronic disease risk in persons with lower educational attainment.

Determinants of non- response to a second assessment of lifestyle factors and body weight in the EPIC-PANACEA study

Abstract: Background: This paper discusses whether baseline demographic, socio-economic, health variables, length of follow-up and method of contacting the participants predict non-response to the invitation for a second assessment of lifestyle factors and body weight in the European multi-center EPIC-PANACEA study. Methods: Over 500.000 participants from several centers in ten European countries recruited between 1992 and 2000 were contacted 2–11 years later to update data on lifestyle and body weight. Length of follow-up as well as the method of approaching differed between the collaborating study centers. Non-responders were compared with responders using multivariate logistic regression analyses. Results: Overall response for the second assessment was high (81.6%). Compared to postal surveys, centers where the participants completed the questionnaire by phone attained a higher response. Response was also high in centers with a short follow-up period. Non-response was higher in participants who were male (odds ratio 1.09 (confidence interval 1.07; 1.11), aged under 40 years (1.96 (1.90; 2.02), living alone (1.40 (1.37; 1.43), less educated (1.35 (1.12; 1.19), of poorer health (1.33 (1.27; 1.39), reporting an unhealthy lifestyle and who had either a low ( 25, 1.08 (1.06; 1.10); especially ≥30 kg/m2, 1.26 (1.23; 1.29)). Conclusions: Cohort studies may enhance cohort maintenance by paying particular attention to the subgroups that are most unlikely to respond and by an active recruitment strategy using telephone interviews.

An artificial neural network to safely reduce the number of ambulance ECGs transmitted for physician assessment in a system with prehospital detection of ST elevation myocardial infarction.

Abstract: Pre-hospital electrocardiogram (ECG) transmission to an expert for interpretation and triage reduces time to acute percutaneous coronary intervention (PCI) in patients with ST elevation Myocardial Infarction (STEMI). In order to detect all STEMI patients, the ECG should be transmitted in all cases of suspected acute cardiac ischemia. The aim of this study was to examine the ability of an artificial neural network (ANN) to safely reduce the number of ECGs transmitted by identifying patients without STEMI and patients not needing acute PCI. Five hundred and sixty ambulance ECGs transmitted to the coronary care unit (CCU) in routine care were prospectively collected. The ECG interpretation by the ANN was compared with the diagnosis (STEMI or not) and the need for an acute PCI (or not) as determined from the Swedish coronary angiography and angioplasty register. The CCU physician's real time ECG interpretation (STEMI or not) and triage decision (acute PCI or not) were registered for comparison. The ANN sensitivity, specificity, positive and negative predictive values for STEMI was 95%, 68%, 18% and 99%, respectively, and for a need of acute PCI it was 97%, 68%, 17% and 100%. The area under the ANN's receiver operating characteristics curve for STEMI detection was 0.93 (95% CI 0.89-0.96) and for predicting the need of acute PCI 0.94 (95% CI 0.90-0.97). If ECGs where the ANN did not identify a STEMI or a need of acute PCI were theoretically to be withheld from transmission, the number of ECGs sent to the CCU could have been reduced by 64% without missing any case with STEMI or a need of immediate PCI. Our ANN had an excellent ability to predict STEMI and the need of acute PCI in ambulance ECGs, and has a potential to safely reduce the number of ECG transmitted to the CCU by almost two thirds.

Independent and combined association of muscle strength and cardiorespiratory fitness in youth with insuline resistance and beta-cell function in young adulthood

Abstract: OBJECTIVE To examine the independent and combined association of isometric muscle strength of the abdomen and back and cardiorespiratory fitness (CRF) in youth with indices of glucose metabolism in young adulthood among boys and girls from the European Youth Heart Study. RESEARCH DESIGN AND METHODS We used data from a population-based prospective cohort study among youth followed up for up to 12 years (n = 317). In youth, maximal voluntary contractions during isometric back extension and abdominal flexion were determined using a strain-gauge dynamometer and CRF was obtained from a maximal cycle ergometer test. Insulin resistance (homeostasis model assessment of insulin resistance [HOMA-IR]) and β-cell function (homeostasis model assessment of β-cell function [HOMA-B]) were estimated from fasting serum insulin and glucose that were obtained in youth and at follow-up in young adulthood. RESULTS For each 1-SD difference in isometric muscle strength (0.16 N/kg) in youth, fasting insulin, HOMA-IR, and HOMA-B in young adulthood changed by −11.3% (95% CI −17.0 to −5.2), −12.2% (−18.2 to −5.7), and −8.9% (−14.4 to −3.0), respectively, in young adulthood after adjustment for CRF and personal lifestyle and demographic factors. Results for CRF were very similar in magnitude, and the magnitude of associations for both exposures was unchanged with additional adjustment for general or abdominal adiposity in youth. Combined associations of muscle strength and CRF with fasting insulin, HOMA-IR, and HOMA-B were additive, and adolescents in the highest sex-specific tertile for both isometric muscle strength and CRF had the lowest levels of these glucose metabolism outcomes. CONCLUSIONS Increasing muscle strength and CRF should be targets in youth primordial prevention strategies of insulin resistance and β-cell dysfunction.

Ability of risk scores to predict a low complication risk in patients admitted for suspected acute coronary syndrome

Abstract: Background When acute coronary syndrome (ACS) cannot be ruled out, emergency department (ED) patients with chest pain are admitted for in-hospital observation because of the risk of complications such as arrhythmia and acute heart failure. A study was undertaken to compare the ability of three risk prediction models to identify patients at a very low risk of complications. Methods 559 consecutive patients with chest pain presenting to the ED and admitted for a suspicion of ACS were prospectively included. Predefined in-hospital complications were recorded and the risk predictions of the Global Registry of Acute Coronary Events (GRACE) risk score, the Freedom-from-Events (FFE) risk score and the Goldman rule were compared using receiver operating characteristics (ROC) curves. Results Of the 559 patients, 140 had ACS and 32 had at least one complication. The GRACE score was superior to the FFE score in predicting the risk of complications (area under ROC curve 0.76 (95% CI 0.68 to 0.85) vs 0.69 (95% CI 0.60 to 0.79), p=0.021) whereas the Goldman rule (area under ROC curve 0.60; 95% CI 0.49 to 0.72) was inferior to both the GRACE and FFE scores. With the GRACE score set to a negative predictive value of 100% (95% CI 96% to 100%), 108 patients (19.3%) at almost no risk of complications could have been correctly identified in the ED. Conclusion The GRACE and FFE scores are able to predict low complication risks in patients with chest pain admitted for suspected ACS, but only the GRACE score may be able to identify a significant number of patients at almost no risk of complications. A larger multicentre study is needed to confirm the possibility of using the GRACE score to identify patients suitable for assessment without monitoring.

The implementation of a fast-track care pathway for hip fracture patients

Abstract: Background On April 1, 2007, a clinical pathway for hip fracture patients was introduced at Lund University Hospital, Sweden. In this pathway, the emergency department was bypassed and the patient taken directly to the ward via X-ray. In 2009, a similar pathway was implemented at the nearby Helsingborg County Hospital.