A New Era in Cardiac Rehabilitation Delivery: Research Gaps, Questions, Strategies, and Priorities.

Cardiac rehabilitation (CR) is a guideline-recommended, multidisciplinary program of exercise training, risk factor management, and psychosocial counseling for people with cardiovascular disease (CVD) that is beneficial but underused and with substantial disparities in referral, access, and participation. The emergence of new virtual and remote delivery models has the potential to improve access to and participation in CR and ultimately improve outcomes for people with CVD. Although data suggest that new delivery models for CR have safety and efficacy similar to traditional in-person CR, questions remain regarding which participants are most likely to benefit from these models, how and where such programs should be delivered, and their effect on outcomes in diverse populations. In this review, we describe important gaps in evidence, identify relevant research questions, and propose strategies for addressing them. We highlight 4 research priorities: (1) including diverse populations in all CR research; (2) leveraging implementation methodologies to enhance equitable delivery of CR; (3) clarifying which populations are most likely to benefit from virtual and remote CR; and (4) comparing traditional in-person CR with virtual and remote CR in diverse populations using multicenter studies of important clinical, psychosocial, and cost-effectiveness outcomes that are relevant to patients, caregivers, providers, health systems, and payors. By framing these important questions, we hope to advance toward a goal of delivering high-quality CR to as many people as possible to improve outcomes in those with CVD.

"I Just Wanted Nothing More Than to Get in a Real Shower": Patient Experience of the Inpatient Wait for a Heart Transplant.

BACKGROUND: Patients waiting for heart transplant may be hospitalized for weeks to months before undergoing transplantation. This high-stress period is further complicated by restrictions of daily privileges including diet, rooming, access to the outdoors, and hygiene (eg, limited in ability to shower). However, there is a paucity of research on the experience of this waiting period. We sought to describe the inpatient experience among patients awaiting heart transplantation and to better understand the needs of inpatients waiting for heart transplant. METHODS AND RESULTS: We conducted in-depth, semistructured phone interviews with a purposeful sample of patients who received a heart transplant in the past 10 years and waited in the hospital for at least 2 weeks before surgery. Using the prior literature, the lived experience of the lead author, and input from qualitative experts, we developed an interview guide. Interviews were recorded, transcribed, and analyzed in an iterative process until theoretical saturation was achieved. A 3-person coding team identified, discussed, and reconciled emergent themes. We conducted interviews with 15 patients. Overarching themes included food, hygiene, relationship with health care professionals, living environment, and stressors. Patients reported that strong bonds were formed between the patients and the staff, and the overwhelming majority only had positive comments about these relationships. However, many expressed negative comments about the experience of the food and limitations in personal hygiene. Other stressors included the unknown length of the waiting period, lack of communication about position on the transplant list, worry about family, and concerns that their life must be saved by the death of another. Many participants described that they would benefit from more interaction with recent heart transplant recipients. CONCLUSIONS: Hospitals and care units have the opportunity to make small changes that could greatly benefit the experience of waiting for a heart transplant, as well as the experience of hospitalization more generally.

Effects of Exercise Testing and Cardiac Rehabilitation in Patients with Coronary Heart Disease on Fear and Self-Efficacy of Exercise: A Pilot Study.

BACKGROUND: Exercise fear and low exercise self-efficacy are common in patients attending cardiac rehabilitation (CR). This study tested whether exercise prescription methods influence exercise fear and exercise self-efficacy. We hypothesized that the use of graded exercise testing (GXT) with a target heart rate range exercise prescription, relative to standard exercise prescription using rating of perceived exertion (RPE), would produce greater reductions in exercise fear and increase self-efficacy during CR. METHOD: Patients in CR (N = 32) were randomized to an exercise prescription using either RPE or a target heart rate range. Exercise fear and self-efficacy were assessed with questionnaires at three time points: baseline; after the GXT in target heart rate range group; and at session 6 for the RPE group and CR completion. Items were scored on a five-point Likert-type scale with higher mean scores reflecting higher fear of exercise and higher self-efficacy. To analyze mean differences, a mixed effects analysis was run. RESULTS: There were no significant changes in exercise self-efficacy between baseline and discharge from CR; these were not statistically significant (mean differences baseline - 0.63; end - 0.27 (p = 0.13)). Similarly, there was no change in fear between groups (baseline 0.30; end 0.51 (p = 0.37)). CONCLUSION: Patients in the RPE and target heart rate groups had non-significant changes in exercise self-efficacy over the course of CR. Contrary to our hypothesis, the use of GXT and target heart rate range did not reduce fear, and we noted sustained or increases in fear of exercise among patients with elevated baseline fear. A more targeted psychological intervention seems warranted to reduce exercise fear and self-efficacy in CR.

Association between Initiation of Pulmonary Rehabilitation and Rehospitalizations in Patients Hospitalized with Chronic Obstructive Pulmonary Disease.

Rationale: Although clinical trials have found that pulmonary rehabilitation (PR) can reduce the risk of readmissions after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, less is known about PR's impact in routine clinical practice. Objectives: To evaluate the association between initiation of PR within 90 days of discharge and rehospitalization(s). Methods: We analyzed a retrospective cohort of Medicare beneficiaries (66 years of age or older) hospitalized for COPD in 2014 who survived at least 30 days after discharge. Measurements and Main Results: We used propensity score matching and estimated the risk of recurrent all-cause rehospitalizations at 1 year using a multistate model to account for the competing risk of death. Of 197,376 total patients hospitalized in 4,446 hospitals, 2,721 patients (1.5%) initiated PR within 90 days of discharge. Overall, 1,534 (56.4%) patients who initiated PR and 125,720 (64.6%) who did not were rehospitalized one or more times within 1 year of discharge. In the propensity-score-matched analysis, PR initiation was associated with a lower risk of readmission in the year after PR initiation (hazard ratio, 0.83; 95% confidence interval, 0.77-0.90). The mean cumulative number of rehospitalizations at 1 year was 0.95 for those who initiated PR within 90 days and 1.15 for those who did not (P < 0.001). Conclusions: After hospitalization for COPD, Medicare beneficiaries who initiated PR within 90 days of discharge experienced fewer rehospitalizations over 1 year. These results support findings from randomized controlled clinical trials and highlight the need to identify effective strategies to increase PR participation.

Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association.

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is associated with substantial morbidity, mortality, and healthcare use. Great strides have been made in stroke prevention and rhythm control strategies, yet reducing the incidence of AF has been slowed by the increasing incidence and prevalence of AF risk factors, including obesity, physical inactivity, sleep apnea, diabetes mellitus, hypertension, and other modifiable lifestyle-related factors. Fortunately, many of these AF drivers are potentially reversible, and emerging evidence supports that addressing these modifiable risks may be effective for primary and secondary AF prevention. A structured, protocol-driven multidisciplinary approach to integrate lifestyle and risk factor management as an integral part of AF management may help in the prevention and treatment of AF. However, this aspect of AF management is currently underrecognized, underused, and understudied. The purpose of this American Heart Association scientific statement is to review the association of modifiable risk factors with AF and the effects of risk factor intervention. Implementation strategies, care pathways, and educational links for achieving impactful weight reduction, increased physical activity, and risk factor modification are included. Implications for clinical practice, gaps in knowledge, and future directions for the research community are highlighted.

Multi-shot acquisitions for stimulus-evoked spinal cord BOLD fMRI.

PURPOSE: To demonstrate the feasibility of 3D multi-shot magnetic resonance imaging acquisitions for stimulus-evoked blood oxygenation level dependent (BOLD) functional magnetic resonance imaging (fMRI) in the human spinal cord in vivo. METHODS: Two fMRI studies were performed at 3T. The first study was a hypercapnic gas challenge where data were acquired from healthy volunteers using a multi-shot 3D fast field echo (FFE) sequence as well as single-shot multi-slice echo-planar imaging (EPI). In the second study, another cohort of healthy volunteers performed an upper extremity motor task while fMRI data were acquired using a 3D multi-shot acquisition. RESULTS: Both 2D-EPI and 3D-FFE were shown to be sensitive to BOLD signal changes in the cervical spinal cord, and had comparable contrast-to-noise ratios in gray matter. FFE exhibited much less signal drop-out and weaker geometric distortions compared to EPI. In the motor paradigm study, the mean number of active voxels was highest in the ventral gray matter horns ipsilateral to the side of the task and at the spinal level associated with innervation of finger extensors. CONCLUSIONS: Highly multi-shot acquisition sequences such as 3D-FFE are well suited for stimulus-evoked spinal cord BOLD fMRI.

Testing telediagnostic thyroid ultrasound in Peru: a new horizon in expanding access to imaging in rural and underserved areas.

PURPOSE: Thyroid ultrasound is a key tool in the evaluation of the thyroid, but billions of people around the world lack access to ultrasound imaging. In this study, we tested an asynchronous telediagnostic ultrasound system operated by individuals without prior ultrasound training which may be used to effectively evaluate the thyroid and improve access to imaging worldwide. METHODS: The telediagnostic system in this study utilizes volume sweep imaging (VSI), an imaging technique in which the operator scans the target region with simple sweeps of the ultrasound probe based on external body landmarks. Sweeps are recorded and saved as video clips for later interpretation by an expert. Two operators without prior ultrasound experience underwent 8 h of training on the thyroid VSI protocol and the operation of the telemedicine platform. After training, the operators scanned patients at a health center in Lima. Telediagnostic examinations were sent to the United States for remote interpretation. Standard of care thyroid ultrasound was performed by an experienced radiologist at the time of VSI examination to serve as a reference standard. RESULTS: Novice operators scanned 121 subjects with the thyroid VSI protocol. Of these exams, 88% were rated of excellent image quality showing complete or near complete thyroid visualization. There was 98.3% agreement on thyroid nodule presence between VSI teleultrasound and standard of care ultrasound (Cohen's kappa 0.91, P < 0.0001). VSI measured the thyroid size, on average, within 5 mm compared to standard of care. Readers of VSI were also able to effectively characterize thyroid nodules, and there was no significant difference in measurement of thyroid nodule size (P = 0.74) between VSI and standard of care. CONCLUSION: Thyroid VSI telediagnostic ultrasound demonstrated both excellent visualization of the thyroid gland and agreement with standard of care thyroid ultrasound for nodules and thyroid size evaluation. This system could be deployed for evaluation of palpable thyroid abnormalities, nodule follow-up, and epidemiological studies to promote global health and improve the availability of diagnostic imaging in underserved communities.

Different brain profiles in children with prenatal alcohol exposure with or without early adverse exposures.

Prenatal alcohol exposure (PAE) can alter brain development and impact mental health outcomes, and often occurs in conjunction with postnatal adversity (e.g., maltreatment). However, it is unclear how postnatal adverse exposures may moderate mental health and brain outcomes in children with PAE. T1-weighted and diffusion magnetic resonance imaging were obtained from 66 participants aged 7-16 years. Twenty-one participants had PAE and adverse postnatal exposures (PAE+), 12 had PAE without adverse postnatal exposures (PAE-), and 33 were age- and gender-matched controls unexposed to either prenatal alcohol or postnatal adversity. Internalizing and externalizing mental health symptoms were assessed using the Behavioral Assessment System for Children II, Parent-Rating Scale. ANCOVAs were used to compare mental health symptoms, limbic and prefrontal cortical volumes, and diffusion parameters of cortico-limbic white matter tracts between groups, and to assess brain-mental health relationships. Both PAE groups had worse externalizing behavior (higher scores) than controls. The PAE- group had lower fractional anisotropy (FA) in the bilateral cingulum and left uncinate fasciculus, and smaller volumes in the left anterior cingulate cortex than controls and the PAE+ group. The PAE- group also had higher mean diffusivity (MD) in the left uncinate than the PAE+ group, and smaller right anterior cingulate and superior frontal gyrus volumes than controls. These findings show different brain structure and mental health symptom profiles in children with PAE with and without postnatal adversity, highlighting the need to consider adverse postnatal exposures in individuals with PAE.

Manuka honey chelates iron and impacts iron regulation in key bacterial pathogens.

AIM: The aim of this study was to test the hypothesis that Manuka honey (MH) chelates iron and promotes an iron-limiting environment, which contributes to its antimicrobial activity. METHODS AND RESULTS: Employing a ferrozine-based assay, we observed that MH is an iron chelator that depletes iron from solution. Siderophores are small molecules that bind ferric iron (III) with high affinity and their levels are upregulated by bacteria under iron-limiting conditions. We demonstrated by quantitating siderophore production that Escherichia coli and Pseudomonas aeruginosa treated with MH sub-minimum inhibitory concentrations (sub-MIC) experience an iron-limiting environment and increase siderophore production. In addition, supplementation with ferrous iron (II) significantly increased growth of E. coli, Staphylococcus aureus and P. aeruginosa cultured at their MH MIC above that observed in nonsupplemented controls. By contrast, supplementation with ferric iron (III) significantly increased growth for only E. coli and P. aeruginosa, above their nonsupplemented controls. CONCLUSIONS: Manuka honey chelates iron, thereby generating an iron-limiting environment for E. coli and P. aeruginosa, and to a lesser extent S. aureus, which contributes to its antimicrobial properties. SIGNIFICANCE AND IMPACT OF THE STUDY: Our work demonstrates that MH-induced iron chelation is an antimicrobial mechanism that differentially impacts the bacterial species tested here. Iron chelation affects multiple diverse physiological processes in bacteria and would contribute to the lack of bacterial resistance to MH. Iron metabolism is tightly regulated; bacteria require this essential nutrient for survival, but in excess it is toxic. Additional exploration of MH's iron chelation mechanism will facilitate its future use in mainstream medicine.

Association Between Initiation of Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival Among Medicare Beneficiaries.

Importance: Meta-analyses have suggested that initiating pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with improved survival, although the number of patients studied was small and heterogeneity was high. Current guidelines recommend that patients enroll in pulmonary rehabilitation after hospital discharge. Objective: To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival. Design, Setting, and Patients: This retrospective, inception cohort study used claims data from fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4446 acute care hospitals in the US. The final date of follow-up was December 31, 2015. Exposures: Initiation of pulmonary rehabilitation within 90 days of hospital discharge. Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. Time from discharge to death was modeled using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. Additional analyses evaluated the association between timing of pulmonary rehabilitation and mortality and between number of sessions completed and mortality. Results: Of 197 376 patients (mean age, 76.9 years; 115 690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38 302 (19.4%) died within 1 year of discharge, including 7.3% of patients who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all. Initiation within 90 days was significantly associated with lower risk of death over 1 year (absolute risk difference [ARD], -6.7% [95% CI, -7.9% to -5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P < .001). Initiation of pulmonary rehabilitation was significantly associated with lower mortality across start dates ranging from 30 days or less (ARD, -4.6% [95% CI, -5.9% to -3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P < .001) to 61 to 90 days after discharge (ARD, -11.1% [95% CI, -13.2% to -8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P < .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P = .01). Conclusions and Relevance: Among fee-for-service Medicare beneficiaries hospitalized for COPD, initiation of pulmonary rehabilitation within 3 months of discharge was significantly associated with lower risk of mortality at 1 year. These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed.

Punching above their weight: Large release of greenhouse gases from small agricultural dams.

Freshwater ecosystems play a major role in global carbon cycling through the breakdown of organic material and release of greenhouse gases (GHGs). Carbon dioxide (CO2 ) and methane (CH4 ) emissions from lakes, wetlands, reservoirs and small natural ponds have been well studied, however, the GHG emissions of highly abundant, small-scale (<0.01 km2 ) agricultural dams (small stream and run-off impoundments) are still unknown. Here, we measured the diffusive CO2 and CH4 flux of 77 small agricultural dams within south-east Australia. The GHG emissions from these waterbodies, which are currently unaccounted for in GHG inventories, amounted to 11.12 ± 2.59 g CO2 -equivalent m2 /day, a value 3.43 times higher than temperate reservoir emissions. Upscaling these results to the entire state of Victoria, Australia, resulted in a farm dam CO2 -equivalent/day emission rate of 4,853 tons, 3.1 times higher than state-wide reservoir emissions in spite of farm dams covering only 0.94 times the comparative area. We also show that CO2 and CH4 emission rates were both significantly positively correlated with dissolved nitrate concentrations, and significantly higher in livestock rearing farm dams when compared to cropping farm dams. The results from this study demonstrate that small agricultural farm dams can be a major source of greenhouse gas emissions, thereby justifying their inclusion in global carbon budgets.

Chlorinated Paraffins in Car Tires Recycled to Rubber Granulates and Playground Tiles.

Chlorinated paraffins (CPs) are used in various products to improve their physicochemical characteristics. Due to recycling, CPs may end up in "new" recycled products. In this study we investigated CPs present in end-of-life car tires that are recycled to rubber granulates used on artificial soccer fields, and playground tiles. The ∑CP(C10-C30) concentrations ranged from 1.5 to 67 µg/g in car tires, 13-67 µg/g in rubber granulates, and 16-74 µg/g in playground tiles. MCCPs were the dominant CP group with an average contribution of 72%. LCCPs up to C30, were detected for the first time in car tires, rubber granulates, and playground tiles. The CPs application in tires is unclear, the low CP concentrations found in this study (<0.007%) could possibly indicate contamination during the manufacturing process. The presence of CPs in the granulates and tiles, in addition to the multiple chemicals already detected, emphasizes the need to further investigate the migration and leaching behavior, in order to assess potential risks of CPs for humans and the environment. The presence of CPs in car tires may be another source of CPs for the environment. The CP volume brought into the environment by tire wear particles (TWP) from car tires in the European Union, is estimated at 2.0-89 tons annually.

3D Engineering of Ocular Tissues for Disease Modeling and Drug Testing.

The success rate from investigational new drug filing to drug approval has remained low for decades despite major scientific and technological advances, and a steady increase of funding and investment. The failure to demonstrate drug efficacy has been the major reason that drug development does not progress beyond phase II and III clinical trials. The combination of two-dimensional (2D) cellular in vitro and animal models has been the gold standard for basic science research and preclinical drug development studies. However, most findings from these systems fail to translate into human trials because these models only partly recapitulate human physiology and pathology. The lack of a dynamic three-dimensional microenvironment in 2D cellular models reduces the physiological relevance, and for these reasons, 3D and microfluidic model systems are now being developed as more native-like biological assay platforms. 3D cellular in vitro systems, microfluidics, self-organized organoids, and 3D biofabrication are the most promising technologies to mimic human physiology because they provide mechanical cues and a 3D microenvironment to the multicellular components. With the advent of human-induced pluripotent stem cell (iPSC) technology, the 3D dynamic in vitro systems further enable extensive access to human-like tissue models. As increasingly complex 3D cellular systems are produced, the use of current visualization technologies is limited due to the thickness and opaqueness of 3D tissues. Tissue-clearing techniques improve light penetration deep into tissues by matching refractive indices among the 3D components. 3D segmentation enables quantitative measurements based on 3D tissue images. Using these state-of-the-art technologies, high-throughput screening (HTS) of thousands of drug compounds in 3D tissue models is slowly becoming a reality. In order to screen thousands of compounds, machine learning will need to be applied to help maximize outcomes from the use of cheminformatics and phenotypic approaches to drug screening. In this chapter, we discuss the current 3D ocular models recapitulating physiology and pathology of the back of the eye and further discuss visualization and quantification techniques that can be implemented for drug screening in ocular diseases.

Beach-cast seagrass wrack contributes substantially to global greenhouse gas emissions.

Seagrass ecosystems have received a great deal of attention recently for their ability to capture and store carbon, thereby helping to mitigate climate change. However, their carbon-sink capacity could be offset somewhat if exported plant material - which accounts for ∼90% of total leaf production - undergoes microbial breakdown and is emitted into the atmosphere as a greenhouse gas. Here we measured emissions (CO2 and CH4) from the breakdown of exported seagrass plant material, focusing on beach-cast 'wrack'. We tested two seagrass species; Zostera nigricaulis and Amphibolis antarctica, which have contrasting morphologies and chemistries. We found that both species of wrack were substantial sources of CO2, but not CH4, during the decomposition process. Biomass loss and the coinciding CO2 emissions occurred over the 30-day experiment, and the pattern of CO2 emissions over this time followed a double exponential model (R2 > 0.92). The initial flux rate was relatively high, most likely due to rapid leaching of labile compounds, then decreased substantially within the 2-9 days, and stabilizing at < 3 µmol g-1 d-1 during the remaining decomposition period. Additionally, seagrass wrack cast high up on beaches that remained dry had 72% lower emissions than wrack that was subjected to repeated wetting in the intertidal zone. This implies that relocation of seagrass wrack by coastal resource managers (e.g. from water's edge to drier dune areas) could help to reduce atmospheric CO2 emissions. Scaling up, we estimate the annual CO2-C flux from seagrass wrack globally is between 1.31 and 19.04 Tg C yr-1, which is equivalent to annual emissions of 0.63-9.19 million Chinese citizens. With climate change and increasing coastal development expected to accelerate the rate of wrack accumulation on beaches, this study provides timely information for developing coastal carbon budgets.

Participation in cardiac rehabilitation and survival after coronary artery bypass graft surgery: a community-based study.

BACKGROUND: Cardiac rehabilitation (CR) is recommended for all patients after coronary artery bypass surgery, yet little is known about the long-term mortality effects of CR in this population. METHODS AND RESULTS: We performed a community-based analysis on residents of Olmsted County, Minnesota, who underwent coronary artery bypass surgery between 1996 and 2007. We assessed the association between subsequent outpatient CR attendance and long-term survival. Propensity analysis was performed. Cox proportional hazards regression was then used to assess the association between CR attendance and all-cause mortality adjusted for the propensity to attend CR. We identified 846 eligible patients (age 66±11 years, 76% men, and 96% non-Hispanic whites) who survived at least 6 months after surgery, of whom 582 (69%) attended CR. During a mean (±SD) follow-up of 9.0±3.7 years, the 10-year all-cause Kaplan-Meier mortality rate was 28% (193 deaths). Adjusted for the propensity to attend CR, participation in CR was associated with a 10-year relative risk reduction in all-cause mortality of 46% (hazard ratio, 0.54; 95% confidence interval, 0.40-0.74; P<0.001) and a 10-year absolute risk reduction of 12.7% (number needed to treat=8). There was no evidence of a differential effect of CR on mortality with respect to age (≥65 versus <65 years), sex, diabetes, or prior myocardial infarction. CONCLUSIONS: CR attendance is associated with a significant reduction in 10-year all-cause mortality after coronary artery bypass surgery. Our results strongly support national standards that recommend CR for this patient group.

An early appointment to outpatient cardiac rehabilitation at hospital discharge improves attendance at orientation: a randomized, single-blind, controlled trial.

BACKGROUND: Outpatient cardiac rehabilitation (CR) decreases mortality rates but is underutilized. Current median time from hospital discharge to enrollment is 35 days. We hypothesized that an appointment within 10 days would improve attendance at CR orientation. METHODS AND RESULTS: At hospital discharge, 148 patients with a nonsurgical qualifying diagnosis for CR were randomized to receive a CR orientation appointment either within 10 days (early) or at 35 days (standard). The primary end point was attendance at CR orientation. Secondary outcome measures were attendance at ≥1 exercise session, the total number of exercise sessions attended, completion of CR, and change in exercise training workload while in CR. Average age was 60±12 years; 56% of participants were male and 49% were black, with balanced baseline characteristics between groups. Median time (95% confidence interval) to orientation was 8.5 (7-13) versus 42 (35 to NA [not applicable]) days for the early and standard appointment groups, respectively (P<0.001). Attendance rates at the orientation session were 77% (57/74) versus 59% (44/74) in the early and standard appointment groups, respectively, which demonstrates a significant 18% absolute and 56% relative improvement (relative risk, 1.56; 95% confidence interval, 1.03-2.37; P=0.022). The number needed to treat was 5.7. There was no difference (P>0.05) in any of the secondary outcome measures, but statistical power for these end points was low. Safety analysis demonstrated no difference between groups in CR-related adverse events. CONCLUSIONS: Early appointments for CR significantly improve attendance at orientation. This simple technique could potentially increase initial CR participation nationwide. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01596036.

County-Level Cardiac Rehabilitation and Broadband Availability: Opportunities for Hybrid Care in the United States.

PURPOSE: Cardiac rehabilitation (CR) improves patient outcomes and quality of life and can be provided virtually through hybrid CR. However, little is known about CR availability in conjunction with broadband access, a requirement for hybrid CR. This study examined the intersection of CR and broadband availability at the county level, nationwide. METHODS: Data were gathered and analyzed in 2022 from the 2019 American Community Survey, the Centers for Medicare & Medicaid Services, and the Federal Communications Commission. Spatially adaptive floating catchments were used to calculate county-level percent CR availability among Medicare fee-for-service beneficiaries. Counties were categorized: by CR availability, whether lowest (ie, CR deserts), medium, or highest; and by broadband availability, whether CR deserts with majority-available broadband, or dual deserts. Results were stratified by state. County-level characteristics were examined for statistical significance by CR availability category. RESULTS: Almost half of US adults (n = 116 325 976, 47.2%) lived in CR desert counties (1691 counties). Among adults in CR desert counties, 96.8% were in CR deserts with majority-available broadband (112 626 906). By state, the percentage of the adult population living in CR desert counties ranged from 3.2% (New Hampshire) to 100% (Hawaii and Washington, DC). Statistically significant differences in county CR availability existed by race/ethnicity, education, and income. CONCLUSIONS: Almost half of US adults live in CR deserts. Given that up to 97% of adults living in CR deserts may have broadband access, implementation of hybrid CR programs that include a telehealth component could expand CR availability to as many as 113 million US adults.

Experimental evidence for asymmetric mate preference and aggression: behavioral interactions in a woodrat (Neotoma) hybrid zone.

BACKGROUND: Female mate preferences may be under strong selection in zones of contact between closely related species because of greater variation in available mates and the potential costs of hybridization. We studied female mate preferences experimentally in a zone of secondary contact between Desert and Bryant's Woodrat (Neotoma lepida and N. bryanti) in the southern foothills of the Sierra Nevada of California. We tested female preference for conspecific versus heterospecific males in paired choice trials in which females could interact freely with males, but males could not interact directly with each other. We compared preferences of females from both allopatric and sympatric sites. RESULTS: We did not find evidence of the process of reinforcement as assortative preferences were not stronger in sympatry than in allopatry. Mate preferences, however, were asymmetric, with N. lepida females mating preferentially with conspecifics and N. bryanti females showing no preference by species. Sympatric females were less likely to mate than allopatric females, due in part to an increase in aggressive interactions. However, even in the absence of aggression, courtship led to mating less often in sympatric females, suggesting they were choosier or had lower sexual motivation than allopatric females. CONCLUSIONS: Patterns of mate choice in this woodrat system appear to be strongly impacted by body size and aggressive behavior. In particular, females of the smaller-bodied species rarely interact with the relatively large heterospecific males. In contrast females of the larger-bodied species accept the relatively small heterospecific males. For sympatric animals, rates of aggression were markedly higher than for allopatric animals and reduced affiliative and reproductive behavior in our trials. Sympatric animals are larger and more aggressive, traits that are likely under strong ecological selection across the sharp resource gradient that characterizes the contact zone. However, our results suggest that these traits that are likely favored in competitive interactions between the species also impact reproductive interactions. Combined with our previous findings of post-zygotic isolation in this system, this study suggests that multiple isolating mechanisms contribute to the rate of genetic exchange between these species when they come into contact, and that these mechanisms are the result of selection on traits that are important in a range of ecological and reproductive interactions.