Abstract. In the last decades, a global warming trend was observed. Along with the temperature increase, modifications in the humidity and wind regime amplify the regional and local impacts on livestock husbandry. Direct impacts include the occurrence of climatic stress conditions. In Europe, cows are economically highly relevant and are mainly kept in naturally ventilated buildings that are most susceptible to climate change. The high-yielding cows are particularly vulnerable to heat stress. Modifications in housing management are the main measures taken to improve the ability of livestock to cope with these conditions. Measures are typically taken in direct reaction to uncomfortable conditions instead of in anticipation of a long-term risk for climatic stress. Measures that balance welfare, environmental and economic issues are barely investigated in the context of climate change and are thus almost not available for commercial farms. Quantitative analysis of the climate change impacts on animal welfare and linked economic and environmental factors is rare. Therefore, we used a numerical modeling approach to estimate the future heat stress risk in such dairy cattle husbandry systems. The indoor climate was monitored inside three reference barns in central Europe and the Mediterranean regions. An artificial neuronal network (ANN) was trained to relate the outdoor weather conditions provided by official meteorological weather stations to the measured indoor microclimate. Subsequently, this ANN model was driven by an ensemble of regional climate model projections with three different greenhouse gas concentration scenarios. For the evaluation of the heat stress risk, we considered the number and duration of heat stress events. Based on the changes in the heat stress events, various economic and environmental impacts were estimated. The impacts of the projected increase in heat stress risk varied among the barns due to different locations and designs as well as the anticipated climate change (considering different climate models and future greenhouse gas concentrations). There was an overall increasing trend in number and duration of heat stress events. At the end of the century, the number of annual stress events can be expected to increase by up to 2000, while the average duration of the events increases by up to 22 h compared to the end of the last century. This implies strong impacts on economics, environment and animal welfare and an urgent need for mid-term adaptation strategies. We anticipated that up to one-tenth of all hours of a year, correspondingly one-third of all days, will be classified as critical heat stress conditions. Due to heat stress, milk yield may decrease by about 2.8 % relative to the present European milk yield, and farmers may expect financial losses in the summer season of about 5.4 % of their monthly income. In addition, an increasing demand for emission reduction measures must be expected, as an emission increase of about 16 Gg of ammonia and 0.1 Gg of methane per year can be expected under the anticipated heat stress conditions. The cattle respiration rate increases by up to 60 %, and the standing time may be prolonged by 1 h. This causes health issues and increases the probability of medical treatments. The various impacts imply feedback loops in the climate system which are presently underexplored. Hence, future in-depth studies on the different impacts and adaptation options at different stress levels are highly recommended.

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In-Person, Hybrid, and Virtual Cardiac Rehabilitation 1 C ardiac rehabilitation (CR) reduces hospitalizations and mortality and improves functional status and quality of life for patients with cardiovascular disease. [1][2][3][4][5][6][7][8][9][10] Despite its benefits, only 24% of eligible patients participate in CR. [11][12][13] Indeed, on a global level, CR is only offered in roughly 50% of countries. 14 Root causes of low participation include patient financial and logistic barriers, bias in referrals, and limited program capacity, among others. [15][16][17][18][19] Up to 14% of adults live in an area without a CR center, and even if all CR centers operated at 110% capacity, only 40% of eligible patients could be served. 20 Cardiac rehabilitation holds tremendous promise but is underutilized and, often, unavailable.In an effort to make CR more accessible, the delivery of CR has evolved to include both traditional in-person sessions and newer virtual sessions. [21][22][23][24][25][26][27] Programs may offer virtual sessions only or a hybrid of in-person and virtual sessions. 28 Evidence continues to build that virtual and hybrid CR offer similar safety and efficacy compared with in-person CR. 9,[29][30][31][32][33][34][35][36] The COVID-19 pandemic has accelerated the adoption of virtual and hybrid CR in response to limited or suspended in-person services. 37 Nonetheless, there have been few studies that compare outcomes among in-person, hybrid, and virtual CR in clinical practice, representing a real-world setting. At the University of California, San Francisco (UCSF), the COVID-19 public health emergency necessitated the creation of a CR program that gave patients the choice to limit in-person CR visits and receive much, or all, of their CR virtually. This presented a unique opportunity to compare clinical outcomes between in-person, hybrid, and virtual CR at a single academic center.Our primary objective was to compare, in UCSF CR patients, the association of in-person, hybrid, and virtual CR with change in functional capacity between enrollment and completion, measured by distance completed on the 6-min walk test (6MWT). We hypothesized that change in the 6MWT would be similar between the in-person, hybrid, and virtual CR cohorts. In addition, we compared attainment of blood pressure (BP) control, change in waistto-hip ratio, depressive symptoms, anxiety symptoms, and cardiac self-efficacy. We also described completion rates, adverse events, and patient and staff qualitative perceptions of CR. METHODSThis cohort study included all patients who enrolled in CR at the UCSF between October 22, 2019, and May 10, 2021. All subjects were ≥18 yr men and women, and all races, ethnicities, and spoken languages were included. There were no specific inclusion or exclusion criteria related to education, literacy, or technology use. The study was reviewed and approved by the UCSF Institutional Review Board . Quantitative data were collected from electronic health records collected for patient care purposes, and written ...

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