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Objective The purpose of this study was to investigate the effects of adding virtual reality (VR) to maintenance cardiac rehabilitation (CR); it was hypothesized to increase adherence, motivation, and engagement. Methods This study was a randomized, 1:1 concealed-allocation, single-blinded, 2 parallel-arm crossover trial. Blinded assessments were undertaken at baseline (mid-program), 12 weeks, and 24 weeks after baseline. The setting was a single CR program of unlimited duration in Brazil. Participants were patients with cardiovascular diseases or risk factors who had been in the program for ≥3 months. The CR program consisted of 3 supervised exercise sessions per week. In the VR arm, participants had 1 VR session of the 3 per week during the initial 12 weeks of the trial; this was withdrawn the subsequent 12 weeks. Measures were: program adherence (% of 3 sessions/week over 12 weeks; ascertained in all participants), motivation (Behavioral Regulation in Exercise Questionnaire 3), and engagement (User Engagement Scale, adapted; vigor, dedication, and absorption subscales); all 3 were primary outcomes. Results Sixty-one (83.6%) patients were randomized (n = 30 to CR + VR); 54 (88.5%) were retained at 12 and 24 weeks. At baseline, participants had been in CR on average 7 years and had high engagement and motivation. CR + VR resulted in a significant increase in adherence at 12 weeks (baseline = 72.87%; 12 weeks = 82.80%), with significant reductions at 24 weeks when VR was withdrawn (65.48%); in the usual CR care arm, there were no changes over time. There was a significant effect for arm, with significantly higher adherence in the CR + VR arm than usual CR at 12 weeks (73.51%). Motivation decreased significantly from baseline to 12 weeks (4.32 [SD = 0.37] vs 4.02 [SD = 0.76]) and significantly increased from 12 to 24 weeks in the CR + VR arm (4.37 [SD = 0.36]). Absorption was significantly lower at 12 weeks in the CR + VR arm (6.79 [SD = 0.37] vs 6.20 [SD = 1.01]). Conclusion Although VR increased program adherence, interspersing it with usual CR sessions actually decreased patient motivation and absorption. Impact Supplementing a maintenance CR program with VR using “exergames” resulted in significantly greater adherence (8% increase or 3/36 sessions), and this was quite a robust effect given it was extinguished with the removal of VR. However, contrary to hypotheses, offering 1 session of VR per week and 2 of usual CR exercise was related to lower motivation and absorption, which has implications for how clinicians design programs for this patient population.

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In a global society, in which geotechnical projects are increasingly designed in a country other than the one where construction takes place, geotechnical risk management must be extended to cover infrastructure works, which are smaller than dams and tunnels, for example, since there is a significant impact on works budget imponderables. Therefore, a risk management methodology based on the likelihood of the occurrence of certain events and their economic consequences is proposed, which is applicable to bored piles (Kelly drilled) in coarse soils, easy to use, and simple to implement since the initial stage of construction. Of 12 case studies of construction works involving bored piles (Kelly drilled) carried out in Luanda (Angola), two selected examples involving the proposed risk methodology on sandy soil layers with interbedded clays are discussed. Subsequently, whether the overall foundation contract budget is affected by assessed risk is determined, and what influence it has on the budget in the light of mitigating factors and associated real costs. This method intended to encourage the adaptation of sustainable risk management in bored piles construction by the site project managers, involving risk analysis concurrently with budgetary review. Though the level of assessed technical risk may be acceptable, overall costs associated with the contract in question may not be acceptable.