Deep Learning-based Segmentation of Computed Tomography Scans Predicts Disease Progression and Mortality in Idiopathic Pulmonary Fibrosis.

Rationale: Despite evidence demonstrating a prognostic role for computed tomography (CT) scans in idiopathic pulmonary fibrosis (IPF), image-based biomarkers are not routinely used in clinical practice or trials. Objectives: To develop automated imaging biomarkers using deep learning-based segmentation of CT scans. Methods: We developed segmentation processes for four anatomical biomarkers, which were applied to a unique cohort of treatment-naive patients with IPF enrolled in the PROFILE (Prospective Observation of Fibrosis in the Lung Clinical Endpoints) study and tested against a further United Kingdom cohort. The relationships among CT biomarkers, lung function, disease progression, and mortality were assessed. Measurements and Main Results: Data from 446 PROFILE patients were analyzed. Median follow-up duration was 39.1 months (interquartile range, 18.1-66.4 mo), with a cumulative incidence of death of 277 (62.1%) over 5 years. Segmentation was successful on 97.8% of all scans, across multiple imaging vendors, at slice thicknesses of 0.5-5 mm. Of four segmentations, lung volume showed the strongest correlation with FVC (r = 0.82; P < 0.001). Lung, vascular, and fibrosis volumes were consistently associated across cohorts with differential 5-year survival, which persisted after adjustment for baseline gender, age, and physiology score. Lower lung volume (hazard ratio [HR], 0.98 [95% confidence interval (CI), 0.96-0.99]; P = 0.001), increased vascular volume (HR, 1.30 [95% CI, 1.12-1.51]; P = 0.001), and increased fibrosis volume (HR, 1.17 [95% CI, 1.12-1.22]; P < 0.001) were associated with reduced 2-year progression-free survival in the pooled PROFILE cohort. Longitudinally, decreasing lung volume (HR, 3.41 [95% CI, 1.36-8.54]; P = 0.009) and increasing fibrosis volume (HR, 2.23 [95% CI, 1.22-4.08]; P = 0.009) were associated with differential survival. Conclusions: Automated models can rapidly segment IPF CT scans, providing prognostic near and long-term information, which could be used in routine clinical practice or as key trial endpoints.

How Academic Medicine Can Help Confront the Opioid Crisis.

The United States is in the midst of a devastating overdose and addiction crisis involving opioids as well as other drugs. Yet, despite the existence of effective treatments for opioid use disorder, only a minority of people who need treatment for this or other substance use disorders receive it. Besides the terrible human and economic costs of overdose deaths and the other health consequences of addiction, untreated substance use has wide-ranging impacts across health care. Academic medicine can help address this crisis by increasing the preparedness of the current and future clinical workforce to detect and treat substance misuse and addiction through increased attention to these topics in medical and nursing schools and in residency programs. In this commentary, the authors explore the barriers to treatment for substance misuse and addiction and the role of academic medicine in improving treatment outcomes through training, clinical care, health service delivery, and research.

Functional respiratory imaging identifies redistribution of pulmonary blood flow in patients with COVID-19.

An increasing observation is that some patients with COVID-19 have normal lung compliance but significant hypoxaemia different from typical acute respiratory distress syndrome (ARDS). We hypothesised that changes in pulmonary blood distribution may be partially responsible and used functional respiratory imaging on CT scans to calculate pulmonary blood volume. We found that patients with COVID-19 had significantly reduced blood volume in the smaller calibre blood vessels (here defined as <5 mm2 cross-sectional area) compared with matched ARDS patients and healthy controls. This suggests that using high levels of PEEP may not alone be enough to oxygenate these patients and that additional management strategies may be needed.

Caffeine and energy drink use by combat arms soldiers in Afghanistan as a countermeasure for sleep loss and high operational demands.

OBJECTIVES: Combat deployments are characterized by high operational demands with limited opportunities for sleep leading to fatigue and degraded cognitive and operational performance. Caffeine in moderate doses is recognized as an effective intervention for physical and cognitive decrements associated with sleep loss. METHODS: This report is based on data collected by two separate, independently conducted surveys administered in Afghanistan in 2011-2012. It assessed caffeine use and sleep disruption among U.S. Army combat soldiers (J-MHAT 8; n = 518) and among deployed soldiers with different military assignments (USARIEM Deployment Survey; n = 260). RESULTS: Daily caffeine intake assessed in the J-MHAT 8 survey averaged 404 ± 18 mg. In the USARIEM Deployment Survey, intake was 303 ± 29 mg and was significantly higher among combat arms soldiers (483 ± 100 mg) compared to combat service support personnel (235 ± 23 mg). In both surveys, over 55% of total caffeine intake was from energy drinks. Additional sources of caffeine included coffee, tea, sodas, gum, candy, and over-the-counter medications. Higher caffeine intake was not associated with ability to fall asleep at night or wake-up in the morning (J-MHAT 8 survey). Higher caffeine consumption was associated with disrupted sleep from high operational tempo and nighttime duties of combat operations. DISCUSSION: Overall caffeine consumption and energy drink use in Afghanistan was greater than among non-deployed soldiers and civilians. Caffeine was frequently used as a countermeasure during night operations to offset adverse effects of sleep loss on physical and cognitive function, consistent with current Department of the Army recommendations.

A review of caffeine's effects on cognitive, physical and occupational performance.

Caffeine is consumed by over 80% of U.S. adults. This review examines the effects caffeine has on cognitive and physical function, since most real-world activities require complex decision making, motor processing and movement. Caffeine exerts its effects by blocking adenosine receptors. Following low (∼40mg or ∼0.5mgkg-1) to moderate (∼300mg or 4mgkg-1) caffeine doses, alertness, vigilance, attention, reaction time and attention improve, but less consistent effects are observed on memory and higher-order executive function, such as judgment and decision making. Effects on physical performance on a vast array of physical performance metrics such as time-to-exhaustion, time-trial, muscle strength and endurance, and high-intensity sprints typical of team sports are evident following doses that exceed about 200mg (∼3mgkg-1). Many occupations, including military, first responders, transport workers and factory shift workers, require optimal physical and cognitive function to ensure success, workplace safety and productivity. In these circumstances, that may include restricted sleep, repeated administration of caffeine is an effective strategy to maintain physical and cognitive capabilities.

Longitudinal trends in use of dietary supplements by U.S. Army personnel differ from those of civilians.

Prevalence and patterns of dietary supplement (DS) use by U.S. Army soldiers differ from the civilian population. Longitudinal trends in use of DSs by civilians have been examined, but are unavailable in subpopulations such as military service members. The present study examined longitudinal changes in DS use by soldiers. A standardized questionnaire on DS use was administered in 2006-2007 (N = 989) and 2010-2011 (N = 1196) to convenience samples of active duty soldiers. Data were weighted for total population demographics of age, sex, and rank. Regular use of DSs by soldiers increased significantly (56% ± 1.6% vs. 64% ± 1.7%; p ≤ 0.001) over the 4 years primarily because of an increase of DS use among the youngest 18- to 24-year-old soldiers (43.0% ± 2.5% vs 62.3% ± 2.4%; p ≤ 0.01). Protein (22% ± 1.4% vs. 26% ± 1.5%; p ≤ 0.001) and combination (10.0% ± 1.0% vs. 24% ± 1.4%; p ≤ 0.001) product consumption also increased over the 4 years. Individual vitamin and mineral use - including iron, magnesium, selenium, and vitamins A, B6, B12, and D - significantly increased as well (p ≤ 0.05). In addition, expenditures on DSs by soldiers increased over time (p < 0.01). Reasons reported by soldiers for DS use suggest use increased to meet the occupational demands of military service. Educational interventions to minimize inappropriate use of DSs by soldiers are necessary to reduce adverse events resulting from unnecessary use of DSs and the financial burden associated with their use.

Protective clothing ensembles and physical employment standards.

Physical employment standards (PESs) exist for certain occupational groups that also require the use of protective clothing ensembles (PCEs) during their normal work. This review addresses whether these current PESs appropriately incorporate the physiological burden associated with wearing PCEs during respective tasks. Metabolic heat production increases because of wearing PCE; this increase is greater than that because of simply the weight of the clothing and can vary 2-fold among individuals. This variation negates a simple adjustment to the PES for the effect of the clothing on metabolic rate. As a result, PES testing that only simulates the weight of the clothing and protective equipment does not adequately accommodate this effect. The physiological heat strain associated with the use of PCEs is also not addressed with current PESs. Typically the selection tests of a PES lasts less than 20 min, whereas the requirement for use of PCE in the workplace may approach 1 h before cooling strategies can be employed. One option that might be considered is to construct a heat stress test that requires new recruits and incumbents to work for a predetermined duration while exposed to a warm environmental temperature while wearing the PCE.

Soldier use of dietary supplements, including protein and body building supplements, in a combat zone is different than use in garrison.

United States Army personnel in garrison who are not deployed to combat theater report using dietary supplements (DSs) to promote health, increase physical and mental strength, and improve energy levels. Given the substantial physical and cognitive demands of combat, DS use may increase during deployment. This study compared DS use by garrison soldiers with DS use by personnel deployed to a combat theater in Afghanistan. Prevalence and patterns of DS use, demographic factors, and health behaviors were assessed by survey (deployed n = 221; garrison n = 1001). Eighty-two percent of deployed and 74% of garrison soldiers used DSs ≥ 1 time·week(-1). Logistic regression analyses, adjusted for significant demographic and health predictors of DS use, showed deployed personnel were more likely than garrison soldiers to use protein, amino acids, and combination products. Deployed females were more likely to use protein supplements and deployed males were more likely to use multivitamins, combination products, protein, and body building supplements than garrison respondents. Significantly more deployed (17%) than garrison (10%) personnel spent more than $50∙month(-1) on DSs. Higher protein supplement use among deployed personnel was associated with higher frequency of strength training and lower amounts of aerobic exercise for males but similar amounts of strength training and aerobic exercise for females. Protein supplements and combination products are used more frequently by deployed than garrison soldiers with the intent of enhancing strength and energy.

Caffeine improves reaction time, vigilance and logical reasoning during extended periods with restricted opportunities for sleep.

RATIONALE: Various occupational groups are required to maintain optimal physical and cognitive function during overnight periods of wakefulness, often with less than optimal sleep. Strategies are required to help mitigate the impairments in cognitive function to help sustain workplace safety and productivity. OBJECTIVES: To test the effectiveness of repeated 200 mg doses of caffeine on cognitive function and live-fire marksmanship with soldiers during three successive nights of sustained wakefulness followed by 4-h afternoon sleep periods. METHODS: Twenty Special Forces personnel (28.6 ± 4.7 years, 177.6 ± 7.5 cm and 81.2 ± 8.0 kg) were randomly assigned to receive four 200-mg doses of caffeine (n = 10) or placebo (n = 10) during the late evening and early morning hours during three successive days. An afternoon 4-h sleep period followed. The psychomotor (PVT) and field (FVT) vigilance, logical reasoning (LRT) tests and a vigilance monitor assessed cognitive function throughout the study. Live-fire marksmanship requiring friend-foe discrimination was assessed. RESULTS: Caffeine maintained speed on the PVT (p < 0.02), improved detection of events during FVT (p < 0.001), increased number of correct responses to stimuli as assessed by the vigilance monitor (p < 0.001) and increased response speed during the LRT (p < 0.001) throughout the three overnight testing periods. Live-fire marksmanship was not altered by caffeine. CONCLUSIONS: A total daily dose of 800 mg caffeine during successive overnight periods of wakefulness is an effective strategy to maintain cognitive function when optimal sleep periods during the day are not available.

The effects of protein supplements on muscle mass, strength, and aerobic and anaerobic power in healthy adults: a systematic review.

BACKGROUND: Protein supplements are frequently consumed by athletes and recreationally active adults to achieve greater gains in muscle mass and strength and improve physical performance. OBJECTIVE: This review provides a systematic and comprehensive analysis of the literature that tested the hypothesis that protein supplements accelerate gains in muscle mass and strength resulting in improvements in aerobic and anaerobic power. Evidence statements were created based on an accepted strength of recommendation taxonomy. DATA SOURCES: English language articles were searched through PubMed and Google Scholar using protein and supplements together with performance, exercise, strength, and muscle, alone or in combination as keywords. Additional articles were retrieved from reference lists found in these papers. STUDY SELECTION: Studies recruiting healthy adults between 18 and 50 years of age that evaluated the effects of protein supplements alone or in combination with carbohydrate on a performance metric (e.g., one repetition maximum or isometric or isokinetic muscle strength), metrics of body composition, or measures of aerobic or anaerobic power were included in this review. The literature search identified 32 articles which incorporated test metrics that dealt exclusively with changes in muscle mass and strength, 5 articles that implemented combined resistance and aerobic training or followed participants during their normal sport training programs, and 1 article that evaluated changes in muscle oxidative enzymes and maximal aerobic power. STUDY APPRAISAL AND SYNTHESIS METHODS: All papers were read in detail, and examined for experimental design confounders such as dietary monitoring, history of physical training (i.e., trained and untrained), and the number of participants studied. Studies were also evaluated based on the intensity, frequency, and duration of training, the type and timing of protein supplementation, and the sensitivity of the test metrics. RESULTS: For untrained individuals, consuming supplemental protein likely has no impact on lean mass and muscle strength during the initial weeks of resistance training. However, as the duration, frequency, and volume of resistance training increase, protein supplementation may promote muscle hypertrophy and enhance gains in muscle strength in both untrained and trained individuals. Evidence also suggests that protein supplementation may accelerate gains in both aerobic and anaerobic power. LIMITATIONS: To demonstrate measureable gains in strength and performance with exercise training and protein supplementation, many of the studies reviewed recruited untrained participants. Since skeletal muscle responses to exercise and protein supplementation differ between trained and untrained individuals, findings are not easily generalized for all consumers who may be considering the use of protein supplements. CONCLUSIONS: This review suggests that protein supplementation may enhance muscle mass and performance when the training stimulus is adequate (e.g., frequency, volume, duration), and dietary intake is consistent with recommendations for physically active individuals.

Moderate-intensity intermittent work in the heat results in similar low-level dehydration in young and older males.

Older individuals may be more susceptible to the negative thermal and cardiovascular consequences of dehydration during intermittent work in the heat. This study examined the hydration, thermal, and cardiovascular responses to intermittent exercise in the heat in 14 Young (Y, Mean ± SE; 25.8 ± 0.8 years), Middle-age (MA, 43.6 ± 0.9 years), and Older (O, 57.2 ± 1.5 years) healthy, non-heat acclimated males matched for height, mass, body surface area, and percent body fat. Rectal temperature (Tre), heart rate (HR), local sweat rate (LSR), and hydration indices were measured during 4 × 15-min moderate to heavy cycling bouts at 400 W heat production, each followed by a 15-min rest period, in Warm/Dry (35°C, 20% relative humidity [RH]) and Warm/Humid (35°C, 60% RH) heat. No differences were observed between the age groups for Tre, Tre change, HR, LSR, mass change, urine specific gravity, and plasma protein concentration in either condition, irrespective of the greater level of thermal and cardiovascular strain experienced in the Warm/Humid environment. Plasma volume changes (Dry Y: -5.4 ± 0.7, MA: -6.2 ± 0.9, O: -5.7 ± 0.9%, Humid Y: -7.3 ± 1.0, MA: -7.9 ± 0.8, O: -8.4 ± 1.0%) were similar between groups, as were urine specific gravity and plasma protein concentrations. Thus, physically active Young, Middle-age, and Older males demonstrate similar hydration, thermal, and cardiovascular responses during moderate- to high-intensity intermittent exercise in the heat.

Inflammatory responses of older firefighters to intermittent exercise in the heat.

PURPOSE: Repeated strenuous work in the heat may predispose firefighters to augmented immune responses and inflammation. This study examined the immune responses in 12 older Firefighters (FF) and 12 older Non-Firefighters (Non-FF), and a group of 6 young FF and 6 young Non-FF, following intermittent exercise in the heat. METHODS: The participants, matched for age, body surface area, body composition, and VO(2peak), cycled 4 × 15 min at moderate-to-high heat production (400 W), each followed by 15-min rest, in dry [10-20% relative humidity (RH)] and humid (60% RH) heat (35 °C). Rectal temperature (T(re)) and heart rate (HR) were measured continuously, and blood samples at baseline (PRE) and following 60-min recovery (POST) were analyzed for Interleukin (IL)-6, Tumor Necrosis Factor (TNF-α), C-reactive protein (CRP), platelet count (PLT), and mean platelet volume (MPV). RESULTS: No differences were observed for T(re), HR, TNF-α, CRP, or PLT between the FF and Non-FF in either condition. The Non-FF had greater changes in IL-6 (Warm/Dry = +1.10 ± 0.18, Warm/Humid = +2.94 ± 0.74 pg mL(-1)), compared to the FF (Warm/Dry = +0.67 ± 0.17, Warm/Humid = +0.70 ± 0.33 pg mL(-1)), and MPV at PRE/POST compared to the FF. Between the young and older FF and Non-FF, no differences in T(re), HR, PLT, or MPV were observed, however, elevated CRP (Warm/Dry) in the older FF, and IL-6 (Warm/Dry) and TNF-α (both conditions) in the older Non-FF, were observed. CONCLUSIONS: The elevated IL-6 in the Non-FF is potentially indicative of increased strain in the Non-FF and/or adaptive changes in the FF due to the occupational demands.

Effects of protein supplements on muscle damage, soreness and recovery of muscle function and physical performance: a systematic review.

BACKGROUND: Protein supplements are frequently consumed by athletes and recreationally-active individuals, although the decision to purchase and consume protein supplements is often based on marketing claims rather than evidence-based research. OBJECTIVE: To provide a systematic and comprehensive analysis of literature examining the hypothesis that protein supplements enhance recovery of muscle function and physical performance by attenuating muscle damage and soreness following a previous bout of exercise. DATA SOURCES: English language articles were searched with PubMed and Google Scholar using protein and supplements together with performance, exercise, competition and muscle, alone or in combination as keywords. STUDY SELECTION: Inclusion criteria required studies to recruit healthy adults less than 50 years of age and to evaluate the effects of protein supplements alone or in combination with carbohydrate on performance metrics including time-to-exhaustion, time-trial or isometric or isokinetic muscle strength and markers of muscle damage and soreness. Twenty-seven articles were identified of which 18 dealt exclusively with ingestion of protein supplements to reduce muscle damage and soreness and improve recovery of muscle function following exercise, whereas the remaining 9 articles assessed muscle damage as well as performance metrics during single or repeat bouts of exercise. STUDY APPRAISAL AND SYNTHESIS METHODS: Papers were evaluated based on experimental design and examined for confounders that explain discrepancies between studies such as dietary control, training state of participants, sample size, direct or surrogate measures of muscle damage, and sensitivity of the performance metric. RESULTS: High quality and consistent data demonstrated there is no apparent relationship between recovery of muscle function and ratings of muscle soreness and surrogate markers of muscle damage when protein supplements are consumed prior to, during or after a bout of endurance or resistance exercise. There also appears to be insufficient experimental data demonstrating ingestion of a protein supplement following a bout of exercise attenuates muscle soreness and/or lowers markers of muscle damage. However, beneficial effects such as reduced muscle soreness and markers of muscle damage become more evident when supplemental protein is consumed after daily training sessions. Furthermore, the data suggest potential ergogenic effects associated with protein supplementation are greatest if participants are in negative nitrogen and/or energy balance. LIMITATIONS: Small sample numbers and lack of dietary control limited the effectiveness of several investigations. In addition, studies did not measure the effects of protein supplementation on direct indices of muscle damage such as myofibrillar disruption and various measures of protein signaling indicative of a change in rates of protein synthesis and degradation. As a result, the interpretation of the data was often limited. CONCLUSIONS: Overwhelmingly, studies have consistently demonstrated the acute benefits of protein supplementation on post-exercise muscle anabolism, which, in theory, may facilitate the recovery of muscle function and performance. However, to date, when protein supplements are provided, acute changes in post-exercise protein synthesis and anabolic intracellular signaling have not resulted in measureable reductions in muscle damage and enhanced recovery of muscle function. Limitations in study designs together with the large variability in surrogate markers of muscle damage reduced the strength of the evidence-base.

Are circulating cytokine responses to exercise in the heat augmented in older men?

Age-related chronic low-grade inflammation may render older individuals more susceptible to heat illnesses. The purpose of this study was to examine the influence of intermittent work in the heat on the circulating cytokine responses of older workers. Fourteen young (aged 25.6 ± 0.7 years) and older (aged 57.7 ± 1.5 years) males, matched for body surface area, cycled for 4 × 15 min (separated by 15-min rest) at moderate to heavy intensity (400 W heat production) in warm/dry (35 °C, 20% relative humidity (RH)) and warm/humid (35 °C, 60% RH) conditions. Rectal (Tre) and mean skin (MTsk) temperatures and heart rate were measured continuously, ratings of perceived exertion and thermal sensation recorded at the end of each exercise bout, and blood samples at baseline (PRE) and following the final 60-min recovery (POST) were analyzed for interleukin (IL)-6, tumor necrosis factor (TNF)-α, and percent changes in blood (BV) and plasma (PV) volumes. No differences were observed between the age groups for Tre, MTsk, heart rate, perceptual strain, or percentage of changes in BV, PV, or ΔTNF-α. Under both conditions, the older males had elevated IL-6 and TNF-α (PRE, POST) compared with the young males. ΔIL-6 tended to be greater in the warm/humid condition (+2.53 ± 0.49 and +1.52 ± 0.41 pg·mL(-1)) compared with the warm/dry condition (+1.02 ± 0.13 and +0.68 ± 0.18 pg·mL(-1)) for older but not young males, respectively. Young and older males experienced similar thermal, cardiovascular, and perceptual strain within the warm/dry and warm/humid conditions.

Effects of protein in combination with carbohydrate supplements on acute or repeat endurance exercise performance: a systematic review.

BACKGROUND: Protein supplements are consumed frequently by athletes and recreationally active adults for various reasons, including improved exercise performance and recovery after exercise. Yet, far too often, the decision to purchase and consume protein supplements is based on marketing claims rather than available evidence-based research. OBJECTIVE: The purpose of this review was to provide a systematic and comprehensive analysis of the literature that tested the hypothesis that protein supplements, when combined with carbohydrate, directly enhance endurance performance by sparing muscle glycogen during exercise and increasing the rate of glycogen restoration during recovery. The analysis was used to create evidence statements based on an accepted strength of recommendation taxonomy. DATA SOURCES: English language articles were searched with PubMed and Google Scholar using protein and supplements together with performance, exercise, competition, and muscle, alone or in combination as keywords. Additional articles were retrieved from reference lists found in these papers. STUDY SELECTION: Inclusion criteria specified recruiting healthy active adults less than 50 years of age and evaluating the effects of protein supplements in combination with carbohydrate on endurance performance metrics such as time-to-exhaustion, time-trial, or total power output during sprint intervals. The literature search identified 28 articles, of which 26 incorporated test metrics that permitted exclusive categorization into one of the following sections: ingestion during an acute bout of exercise (n = 11) and ingestion during and after exercise to affect subsequent endurance performance (n = 15). The remaining two articles contained performance metrics that spanned both categories. STUDY APPRAISAL AND SYNTHESIS METHODS: All papers were read in detail and searched for experimental design confounders such as energy content of the supplements, dietary control, use of trained or untrained participants, number of subjects recruited, direct measures of muscle glycogen utilization and restoration, and the sensitivity of the test metrics to explain the discrepant findings. RESULTS: Our evidence statements assert that when carbohydrate supplementation was delivered at optimal rates during or after exercise, protein supplements provided no further ergogenic effect, regardless of the performance metric used. In addition, the limited data available suggested recovery of muscle glycogen stores together with subsequent rate of utilization during exercise is not related to the potential ergogenic effect of protein supplements. LIMITATIONS: Many studies lacked ability to measure direct effects of protein supplementation on muscle metabolism through determination of muscle glycogen, kinetic assessments of protein turnover, or changes in key signaling proteins, and therefore could not substantiate changes in rates of synthesis or degradation of protein. As a result, the interpretation of their data was often biased and inconclusive since they lacked ability to test the proposed underlying mechanism of action. CONCLUSIONS: When carbohydrate is delivered at optimal rates during or after endurance exercise, protein supplements appear to have no direct endurance performance enhancing effect.

Do older firefighters show long-term adaptations to work in the heat?

Older experienced firefighters may show signs of heat adaptation, and thus reduced physiological strain, due to repeated occupational heat stress exposure. The aim was to examine physiological and perceptual strain, and hydration, responses to intermittent exercise in the heat in 12 older Non-Firefighter (Non-FF) and experienced Firefighter (FF) males, pair matched for age (Group mean ± SE: Non-FF = 51.7 ± 1.5, FF = 49.8 ± 1.1 years), VO(2peak) (Non-FF = 39.4 ± 2.2, FF = 40.7 ± 1.8 mL·kg(-1)·min(-1)), body surface area (Non-FF = 1.94 ± 0.04, FF = 2.03 ± 0.03 m(2)), and percent body fat (Non-FF = 24.4 ± 2.3, FF = 19.3 ± 1.8%). Rectal (Tre) and mean skin (MT(sk)) temperatures, heart rate (HR), local sweat rate (LSR), hydration indices, and ratings of thermal sensation and perceived exertion were measured during 4 ×15-min (rest 15-min) moderate-to-heavy cycling bouts (400 W heat production) in Dry and Humid heat (35°C, ∼20 and ∼60% relative humidity, respectively). No differences were observed between the Non-FF and FF for T(re), T(re) change, MT(sk), HR,% max HR, LSR, physiological strain index (PhSI), or % plasma volume change. Plasma protein concentration was reduced at baseline for the Non-FF (7.6 ± 0.1 g·100 mL(-1)) than FF (8.0 ± 0.1 g·100 mL(-1)). The Perceptual Strain Index overestimated PhSI for Non-FF and FF in both thermal conditions. At the end of exercise, the Non-FF showed a greater Tre difference between thermal conditions (0.27 ± 0.05°C) compared to the FF (0.10 ± 0.09°C). Although the Non-Firefighters and Firefighters demonstrate similar cardiovascular and hydration responses during moderate-to-heavy intensity exercise within each of the thermal conditions, the attenuated thermal effects between the two heat stress conditions in the Firefighters suggests a protective adaptation.

Protein supplementation for military personnel: a review of the mechanisms and performance outcomes.

Protein supplement use is common among athletes, active adults, and military personnel. This review provides a summary of the evidence base that either supports or refutes the ergogenic effects associated with different mechanisms that have been proposed to support protein supplementation. It was clear that if carbohydrate delivery was optimal either during or after an acute bout of exercise that additional protein will not increase exercise capacity. Evidence was also weak to substantiate use of protein supplements to slow the increase in brain serotonin and onset of central fatigue. It was also evident that additional research is warranted to test whether the benefits of protein supplements for enhancing recovery of fluid balance after exercise will affect subsequent work in the heat. In contrast, with repeated exercise, use of protein supplementation was associated with reductions in muscle soreness and often a faster recovery of muscle function due to reductions in protein degradation. There was also good supportive evidence for long-term benefits of protein supplementation for gains in muscle mass and strength through accelerated rates of protein synthesis, as long as the training stimulus was of sufficient intensity, frequency, and duration. However, studies have not examined the impact of protein supplements under the combined stress of a military environment that includes repeated bouts of exercise with little opportunity for feeding and recovery, lack of sleep, and exposure to extreme environments. Both additional laboratory and field research is warranted to help provide evidence-based guidance for the choice of protein supplements to enhance soldier performance.

Encapsulated environment.

In many occupational settings, clothing must be worn to protect individuals from hazards in their work environment. However, personal protective clothing (PPC) restricts heat exchange with the environment due to high thermal resistance and low water vapor permeability. As a consequence, individuals who wear PPC often work in uncompensable heat stress conditions where body heat storage continues to rise and the risk of heat injury is greatly enhanced. Tolerance time while wearing PPC is influenced by three factors: (i) initial core temperature (Tc), affected by heat acclimation, precooling, hydration, aerobic fitness, circadian rhythm, and menstrual cycle (ii) Tc tolerated at exhaustion, influenced by state of encapsulation, hydration, and aerobic fitness; and (iii) the rate of increase in Tc from beginning to end of the heat-stress exposure, which is dependent on the clothing characteristics, thermal environment, work rate, and individual factors like body composition and economy of movement. Methods to reduce heat strain in PPC include increasing clothing permeability for air, adjusting pacing strategy, including work/rest schedules, physical training, and cooling interventions, although the additional weight and bulk of some personal cooling systems offset their intended advantage. Individuals with low body fatness who perform regular aerobic exercise have tolerance times in PPC that exceed those of their sedentary counterparts by as much as 100% due to lower resting Tc, the higher Tc tolerated at exhaustion and a slower increase in Tc during exercise. However, questions remain about the importance of activity levels, exercise intensity, cold water ingestion, and plasma volume expansion for thermotolerance.