Growing convergence research: Coproducing climate projections to inform proactive decisions for managing simultaneous wildfire risk.

We apply a convergence research approach to the urgent need for proactive management of long-term risk associated with wildfire in the United States. In this work we define convergence research in accordance with the US National Science Foundation-as a means of addressing a specific and compelling societal problem for which solutions require deep integration across disciplines and engagement of stakeholders. Our research team brings expertise in climate science, fire science, landscape ecology, and decision science to address the risk from simultaneous and impactful fires that compete for management resources, and leverages climate projections for decision support. In order to make progress toward convergence our team bridges spatial and temporal scale divides arising from differences in disciplinary and practice-based norms. We partner with stakeholders representing US governmental, tribal, and local decision contexts to coproduce a robust information base for support of decision making about wildfire preparedness and proactive land/fire management. Our approach ensures that coproduced information will be directly integrated into existing tools for application in operations and policy making. Coproduced visualizations and decision support information provide projections of the change in expected number of fires that compete for resources, the number of fire danger days per year relative to prior norms, and changes in the length and overlap of fire season in multiple US regions. Continuing phases of this work have been initiated both by stakeholder communities and by our research team, a demonstration of impact and value.

The importance of race, gender, and religion in naturalization adjudication in the United States.

This study presents an empirical investigation of naturalization adjudication in the United States using new administrative data on naturalization applications decided by the US Citizenship and Immigration Services between October 2014 and March 2018. We find significant group disparities in naturalization approvals based on applicants' race/ethnicity, gender, and religion, controlling for individual applicant characteristics, adjudication years, and variation between field offices. Non-White applicants and Hispanic applicants are less likely to be approved than non-Hispanic White applicants, male applicants are less likely to be approved than female applicants, and applicants from Muslim-majority countries are less likely to be approved than applicants from other countries. In addition, race/ethnicity, gender, and religion interact to produce a certain group hierarchy in naturalization approvals. For example, the probability of approval for Black males is 5 percentage points smaller than that of White females. The probability of approval for Blacks from Muslim-majority countries is 9 percentage points smaller than that of Whites from other countries. The probability of approval for females from Muslim-majority countries is 6 percentage points smaller than that of females from other countries. This study contributes to our understanding of the nature of inequalities present in agency decision-making in the naturalization process.

Prehabilitation Coming of Age: IMPLICATIONS FOR CARDIAC AND PULMONARY REHABILITATION.

While cardiac and pulmonary rehabilitation programs traditionally involve exercise therapy and risk management following an event (eg, myocardial infarction and stroke), or an intervention (eg, coronary artery bypass surgery and percutaneous coronary intervention), prehabilitation involves enhancing functional capacity and optimizing risk profile prior to a scheduled intervention. The concept of prehabilitation is based on the principle that patients with higher functional capabilities will better tolerate an intervention, and will have better pre- and post-surgical outcomes. In addition to improving fitness, prehabilitation has been extended to include multifactorial risk intervention prior to surgery, including psychosocial counseling, smoking cessation, diabetes control, nutrition counseling, and alcohol abstinence. A growing number of studies have shown that patients enrolled in prehabilitation programs have reduced post-operative complications and demonstrate better functional, psychosocial, and surgery-related outcomes. These studies have included interventions such as hepatic transplantation, lung cancer resection, and abdominal aortic aneurysm (repair, upper gastrointestinal surgery, bariatric surgery, and coronary artery bypass grafting). Studies have also suggested that incorporation of prehabilitation before an intervention in addition to traditional rehabilitation following an intervention further enhances physical function, lowers risk for adverse events, and better prepares a patient to resume normal activities, including return to work. In this overview, we discuss prehabilitation coming of age, including key elements related to optimizing pre-surgical fitness, factors to consider in developing a prehabilitation program, and exercise training strategies to improve pre-surgical fitness.

Benefits and Risks of High-Intensity Interval Training in Patients With Coronary Artery Disease.

Exercise-based cardiac rehabilitation is integral to secondary prevention in patients with coronary artery disease. Recently, the effectiveness and "superiority" of high-intensity interval training (HIIT) is a purported time-saving alternative to "traditional" moderate-intensity continuous training (MICT) in cardiac rehabilitation. The rationale for HIIT adoption is, however, not fully substantiated in the scientific literature. Established guidelines for exercise testing and training, when carefully adhered to, reduce the likelihood of triggering a cardiac event or inducing musculoskeletal injury. Clinicians should likewise consider patient risk stratification and introduce HIIT as an alternative to MICT only after patients exhibit stable and asymptomatic responses to vigorous exercise training. Although HIIT adherence appears comparable with MICT during outpatient rehabilitation, compliance drops dramatically for unsupervised exercise. Despite the enthusiasm surrounding HIIT, its main advantage over MICT appears to be short-term exercise performance outcomes and indices of vascular function. Regarding benefits to cardiovascular disease risk factor modification, management of vital signs, and measures of cardiac performance, current evidence indicates that HIIT does not outperform MICT. Long-term outcomes to HIIT are currently uncertain and logistical constraints to HIIT incorporation need additional clarification. Based on these limited findings, derived from facilities and clinicians at the forefront of cardiac rehabilitation, the routine adoption of HIIT should be viewed cautiously. In conclusion, the current review highlights numerous specific research directives that are needed before the safety and effectiveness of HIIT can be confirmed and widely adopted in patients with known or suspected coronary artery disease, especially in unsupervised, nonmedical settings.

Electrical Myostimulation (EMS) Improves Glucose Metabolism and Oxygen Uptake in Type 2 Diabetes Mellitus Patients--Results from the EMS Study.

AIMS: In patients with type 2 diabetes mellitus (T2DM) exercise training is recommended to improve glycemic control. Electrical myostimulation (EMS) of skeletal muscles is a new method to increase exercise capacity in patients with chronic heart failure. The aim of this study was to investigate the effects of EMS in T2DM on glucose metabolism, body composition, and exercise performance using a newly designed stimulation suit that involves trunk, leg, and arm muscles. SUBJECTS AND METHODS: Fifteen individuals (nine males; 61.7±14.8 years old) were trained for 10 weeks twice weekly for 20 min with EMS. Effects on glucose, glycosylated hemoglobin (HbA(1c)), oxygen consumption, and body composition were evaluated. RESULTS: There was a significant increase of oxygen uptake at the aerobic threshold from 12.3±0.8 to 13.3±0.7 mL/kg/min (P=0.003) and of maximal work capacity from 96.9±6.4 to 101.4±7.9 W (P=0.046), with a concomitant trend for improved maximal oxygen uptake (from 14.5±0.9 to 14.7±0.9 mL/kg/min [P=0.059]). Fasting blood glucose level decreased from 164.0±12.5 to 133.4±9.9 mg/dL (P=0.001), and HbA(1c) level decreased from 7.7±0.3% to 7.2±0.3% (P=0.041), whereas mean total weight (from 101.5±4.0 to 103.1±4.3 kg) and proportion of body fat (from 38.8±3.2% to 40.3±3.4%) remained statistically unchanged. CONCLUSIONS: EMS can improve glucose metabolism and functional performance in T2DM patients. These data suggest that EMS might emerge as a novel additional therapeutic mode of exercise training and might help patients to overcome their sedentary lifestyle.

Cardiac rehabilitation in Europe.

Cardiovascular disease (CVD) remains the main cause of death for men in most European countries, and in all for women. While mortality rates have been declining in most countries, hospital discharge for CVD has been stable since 2004, increasing the pool of patients eligible for cardiac rehabilitation (CR). The physical rehabilitation of patients with CVD has been practiced in Europe to varying degrees since the early 1970s with most countries now engaged in Phase I through Phase III programs. Funding for CR comes from a variety of sources including patient pay, private insurance, retirement and/or obligatory and governmental subsidy. CR is practiced based on best available evidence but participation rates range between 30-50% of eligible patients. Participation rates present one of several challenges and opportunities for future research in Europe, along with assessment of long-term CR outcomes and better extension to primary prevention.

Using a treadmill for the 6-minute walk test: reliability and validity.

PURPOSE: The 6-minute walk test (6MWT) is used to predict aerobic capacity, evaluate functional performance, and assess the risk of mortality and morbidity of several chronic conditions. The purpose of this study was to determine the validity and reliability of the 6MWT on a treadmill, thus increasing the clinical use of the 6MWT. PARTICIPANTS: Participants comprised 20 able-bodied persons (9 men, 11 women, 29.5 +/- 9.7 years, 1.73 +/- 1.0 m, 72.76 +/- 18.92 kg). All participants reported being nonsmokers and without any known cardiopulmonary, neurological, or orthopedic conditions. METHODS: Participants took part in 3 repeated treadmill 6MWTs (T6MWTs) and a graded cycle ergometer test to determine maximum oxygen consumption (VO2max). RESULTS: No statistically significant differences were found between the 3 T6MWTs for distance, rating of perceived exertion, or heart rate (HR) (P = .17, .47, and .44, respectively) using both a repeated measures 1-way analysis of variance and an intraclass correlation coefficient (model 2, 1). The reliability was best between the second and third T6MWTs for distance and HR (0.88 and 0.86, respectively). A predictive equation from the stepwise linear multiple regression was used: VO2max (L/min) = -1.732 + (weight [kg] x 0.049) + (distance [m] x 0.005) + (HR [beats/min] x [-0.015]), r = 0.869, SEE = 0.399. The Bland-Altman plot found 95% of the data points within the limits of agreement. CONCLUSIONS: The T6MWT protocol was found to be reliable for measuring distance and HR. It can reasonably predict absolute VO2max in a healthy adult population and should be validated in those with established chronic disease.

Prognostic ability of VE/VCO2 slope calculations using different exercise test time intervals in subjects with heart failure.

BACKGROUND: The minute ventilation-carbon dioxide production (VE/VCO2) slope, obtained during exercise testing, possesses prognostic value in heart failure (HF). The VE-VCO2 relationship is generally linear thereby hypothetically producing similar slope values regardless of the exercise-test time interval used for calculation. DESIGN: This study assesses the ability of the VE/VCO2 slope, calculated at different time intervals throughout a progressive exercise test, to predict 1-year cardiac-related hospitalization and mortality in subjects with HF. METHODS: Seventy-two subjects underwent symptom-limited exercise testing with ventilatory expired gas analysis. Mean age and left ventricular ejection fraction for 44 male and 28 female subjects were 51.2 years (+/-13.0) and 27.0% (+/-12.3) respectively. The VE/VCO2 slope was calculated from time 0 to 25, 50, 75 and 100% of exercise time and subsequently used to create five randomly selected VE/VCO2 slope categories. RESULTS: (The intraclass correlation coefficient found calculation of the VE/VCO2 slope, when divided into quartiles, to be a reliable measure (alpha=0.94, P<0.0001). Univariate Cox regression analysis revealed all VE/VCO2 slope categories (25-100% and random selections) were significant predictors of cardiac-related hospitalization and mortality over a 1-year period. Multivariate Cox regression analysis revealed all VE/VCO2 slope categories outperformed peak oxygen consumption (VO2) in predicting hospitalization and mortality at 1 year. CONCLUSIONS: Although the different classification schemes were not identical, these results suggest VE/VCO2 slope maintains prognostic significance regardless of exercise-test time interval. Calculation of VE/VCO2 slope may therefore still be valuable in subjects putting forth a sub-maximal effort while effort-dependent measures, such as peak VO2, are not.

Predicting peak oxygen consumption during a conservative ramping protocol: implications for the heart failure population.

PURPOSE: A significant discrepancy between measured oxygen consumption (VO(2)) (via ventilatory expired gas analysis) and estimated VO(2) (via the imposed workload) frequently is reported in the heart failure (HF) population during symptom-limited exercise testing. The purpose of this investigation was to examine the difference between measured and estimated VO(2) (VO(2) discrepancy) during a highly conservative ramping protocol. METHODS: For this study, 28 subjects with compensated HF (20 men and 8 women; age, 51.1 +/- 14.6 years) and 19 healthy control subjects (age-, gender-, and activity-matched to an HF subgroup) underwent symptom-limited exercise testing (treadmill) with ventilatory expired gas analysis. RESULTS: Peak estimated and measured VO(2) values were significantly higher in the age-, gender-, and activity-matched control group than in the HF group, but the change in measured VO(2) per change in estimated VO(2) (Deltameasured/Deltaestimated VO(2) slope) and the VO(2) discrepancy did not reach statistical significance. Peak estimated VO(2) was a significant predictor of peak measured VO(2) in the overall HF group (R2 = 0.90; P <.001). CONCLUSIONS: Although estimated VO(2) is not considered a replacement for measured VO(2), these results indicate that a highly conservative exercise protocol may allow for a more accurate prediction of peak measured VO(2) via the estimated oxygen cost for a given workload in patients with compensated HF.

Comparison of oxygen uptake on-kinetic calculations in heart failure.

PURPOSE: The analysis of oxygen (O(2)) uptake on-kinetics during steady-rate is gaining interest in the heart failure (HF) population. The rate change in O(2) at the initiation of exercise can be assessed via nonlinear regression time constant (TC) or an algebraic equation (mean response time [MRT]). These calculations are presumed to be interchangeable, but research supporting this claim is limited. This investigation compares and contrasts two of the more commonly used O(2) uptake on-kinetic calculations. METHOD: Twenty-eight subjects diagnosed with compensated HF and 19 age, sex, and activity-matched controls underwent a symptom-limited exercise test and a steady-rate exercise session (6 min). Peak O(2) uptake, O(2) uptake at ventilatory threshold, the O(2) uptake TC (TC), and the O(2) uptake mean response time (MRT) were calculated for each subject. RESULTS: O(2) uptake on-kinetics was significantly faster for the control group ( < 0.05) regardless of calculation method. There was a significant difference between the O(2) uptake TC and MRT for the HF group. All O(2) uptake on-kinetic calculations were significantly correlated with aerobic capacity. CONCLUSIONS: O(2) uptake TC and MRT values may not be interchangeable in the HF population. All O(2) uptake on-kinetic calculations did produce a significant difference between experimental and control groups and correlated with indicators of aerobic capacity. The 10-s O(2) uptake on-kinetic calculations may be preferable secondary to expired gas fluctuations associated with breath-by-breath measures. Further work is, however, needed to determine which averaged O(2) uptake on-kinetic expression is optimal given the significant difference between TC and MRT. A mechanism for this difference may be the oscillatory ventilatory expired gas pattern demonstrated by some patients with HF.

Relationship between the Minnesota Living With Heart Failure Questionnaire and key ventilatory expired gas measures during exercise testing in patients with heart failure.

PURPOSE: This study assessed the relationship between the Minnesota Living With Heart Failure Questionnaire (MLWHFQ) and key ventilatory expired gas measures during a symptom-limited exercise test in the heart failure (HF) population. Specifically, is there evidence to indicate that perceived quality of life (QOL) influences exercise performance independent of physiologic function in the HF population? METHODS: Thirty-one subjects (21 male/10 female), diagnosed with compensated HF, underwent exercise testing and completed the MLWHFQ. Mean age and left ventricular ejection fraction were 52.8 years and 27.2%, respectively. Partial correlation, controlling for age and sex, assessed the relationship between MLWHFQ (overall and subscores) and key ventilatory expired gas measures. Intraclass correlation coefficient (ICC) analysis was used to determine reliability of the MLWHFQ. RESULTS: MLWHQ overall score (mean = 38.9, median = 36.0), physical subscore (mean = 14.8, median = 16.0), and psychosocial/symptomatology subscore (mean = 24.1, median = 19.0), were significantly correlated (P < or =.05) with peak oxygen consumption (VO2). The relationship between MLWHFQ and the minute ventilation-carbon dioxide production (VE/VCO2) slope was, however, not significant. ICC analysis revealed high reliability (0.95) for the MLWHFQ. CONCLUSIONS: The MLWHFQ demonstrates a significant relationship with peak VO2, a measure whose validity is dependent upon subject effort. VE/VCO2 slope, which is independent of subject effort and therefore potentially a better predictor of true physiologic function, does not appear to have a relationship with perceived QOL. These findings have implications for how the MLWHFQ is assessed, related to an exercise test, and used during clinical practice.

Comparison of ventilatory expired gas parameters used to predict hospitalization in patients with heart failure.

BACKGROUND: Several ventilatory expired gas measures obtained during exercise testing demonstrate prognostic value in the heart failure (HF) population. Comparison of prognostic efficacy between pertinent measures is sparse. METHODS: The ability of various expressions of peak oxygen consumption (VO2), the relationship between minute ventilation (VE) and carbon dioxide production (VCO2), and the partial pressure of end-tidal carbon dioxide (P(ET)CO2) were assessed to determine which measure(s) best predicted cardiac-related hospitalization over a 1-year period in subjects diagnosed with HF. RESULTS: Univariate Cox regression analysis found that several expressions of peak VO 2, VE-VCO2 relationship, and P(ET)CO2 were significant predictors of hospitalization. Multivariate Cox regression analysis revealed that the VE/VCO2 slope significantly predicted hospitalization (chi2 = 29.1, P <.00001). Peak VO 2 and P(ET)CO2 did not provide additional predictive value. CONCLUSIONS: The prognostic superiority of the VE/VCO2 slope over peak VO2 may be a result of the latter measure's partial dependence on subject effort and skeletal muscle function.