Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey

Cardiac rehabilitation (CR) programmes support patients to achieve professionally recommended cardiovascular prevention targets and thus good clinical status and improved quality of life and prognosis. Information on CR service delivery in Europe is sketchy.

Guidelines for the use and interpretation of assays for monitoring autophagy

In 2008 we published the first set of guidelines for standardizing research in autophagy. Since then, research on this topic has continued to accelerate, and many new scientists have entered the field. Our knowledge base and relevant new technologies have also been expanding. Accordingly, it is important to update these guidelines for monitoring autophagy in different organisms. Various reviews have described the range of assays that have been used for this purpose. Nevertheless, there continues to be confusion regarding acceptable methods to measure autophagy, especially in multicellular eukaryotes. A key point that needs to be emphasized is that there is a difference between measurements that monitor the numbers or volume of autophagic elements (e.g., autophagosomes or autolysosomes) at any stage of the autophagic process vs. those that measure flux through the autophagy pathway (i.e., the complete process); thus, a block in macroautophagy that results in autophagosome accumulation needs to be differentiated from stimuli that result in increased autophagic activity, defined as increased autophagy induction coupled with increased delivery to, and degradation within, lysosomes (in most higher eukaryotes and some protists such as Dictyostelium) or the vacuole (in plants and fungi). In other words, it is especially important that investigators new to the field understand that the appearance of more autophagosomes does not necessarily equate with more autophagy. In fact, in many cases, autophagosomes accumulate because of a block in trafficking to lysosomes without a concomitant change in autophagosome biogenesis, whereas an increase in autolysosomes may reflect a reduction in degradative activity. Here, we present a set of guidelines for the selection and interpretation of methods for use by investigators who aim to examine macroautophagy and related processes, as well as for reviewers who need to provide realistic and reasonable critiques of papers that are focused on these processes. These guidelines are not meant to be a formulaic set of rules, because the appropriate assays depend in part on the question being asked and the system being used. In addition, we emphasize that no individual assay is guaranteed to be the most appropriate one in every situation, and we strongly recommend the use of multiple assays to monitor autophagy. In these guidelines, we consider these various methods of assessing autophagy and what information can, or cannot, be obtained from them. Finally, by discussing the merits and limits of particular autophagy assays, we hope to encourage technical innovation in the field.

Can level of education, accreditation and use of databases in cardiac rehabilitation be improved? Results from the European Cardiac Rehabilitation Inventory Survey

Professional skills, education and accreditation, along with clinical outcome assessment, are considered important factors to achieve comprehensive delivery and quality of cardiac rehabilitation (CR). This study assessed professional educational programmes, accreditation and use of databases in CR across the European countries.

Impact of Holocene climate changes on alpine and treeline vegetation at Sanetsch Pass, Bernese Alps, Switzerland

In order to infer reactions of treeline and alpine vegetation to climatic change, past vegetation changes are reconstructed on the basis of pollen, macrofossil and charcoal analysis. The sampled sediment cores originate from the small pond Emines, located at the Sanetsch Pass (connecting the Valais and Bern, Switzerland) at an altitude of 2288 m a.s.l. Today's treeline is at ca. 2200 m a.s.l. in the area, though due to special pass (saddle) conditions it is locally depressed to ca. 2060 m a.s.l. Our results reveal that the area around Emines was covered by treeless alpine vegetation during most of the past 12,000 years. Single individuals of Betula, Larix decidua and possibly Pinus cembra occurred during the Holocene. Major centennial to millennial-scale responses of treeline vegetation to climatic changes are evident. However, alpine vegetation composition remained rather stable between 11,500 and 6000 cal. BP, showing that Holocene climatic changes of +/− 1 °C hardly influenced the local vegetation at Emines. The rapid warming of 3–4 °C at the Late Glacial/Holocene transition (11,600 cal. BP) caused significant altitudinal displacements of alpine species that were additionally affected by the rapid upward movement of trees and shrubs. Since the beginning of the Neolithic, vegetation changes at Sanetsch Pass resulted from a combination of climate change and human impact. Anthropogenic fire increase and land-use change combined with a natural change from subcontinental to more oceanic climate during the second half of the Holocene led to the disappearance of P. cembra in the study area, but favoured the occurrence of Picea abies and Alnus viridis. The mid- to late-Holocene decline of Abies alba was primarily a consequence of human impact, since this mesic species should have benefitted from a shift to more oceanic conditions. Future alpine vegetation changes will be a function of the amplitude and rapidity of global warming as well as human land use. Our results imply that alpine vegetation at our treeline pass site was never replaced by forests since the last ice-age. This may change in the future if anticipated climate change will induce upslope migration of trees. The results of this study emphasise the necessity of climate change mitigation in order to prevent biodiversity losses as a consequence of unprecedented community and species displacement in response to climatic change.

The influence of concurrent disturbances on plant community dynamics in northern hemlock-hardwood forests

Throughout the Upper Great Lakes region, alterations to historic disturbance regimes have influenced plant community dynamics in hemlock-hardwood forests. Several important mesic forest species, eastern hemlock (Tsuga canadensis), yellow birch (Betula alleghaniensis), eastern white pine (Pinus strobus), and Canada yew (Taxus canadensis), are in decline due to exploitive logging practices used at the turn of the 20th century and the wave of intense fires that followed. Continued regeneration and recruitment failure is attributed to contemporary forest management practices and overbrowsing by white-tailed deer (Odocoileus virginianus). Therefore, I examined the influence of two concurrent disturbances, overstory removal and herbivory, on plant community dynamics in two hemlock-hardwood forests. I measured the post-disturbance regeneration response (herbaceous and woody species) inside and outside of deer exclosures in 20 artificial canopy gaps (50 – 450 m2) and monitored survival and growth for hundreds of planted seedlings. The results of this research show that interacting disturbances can play a large role in shaping plant community composition and structure in hemlock-hardwood forests. White-tailed deer herbivory homogenized the post-disturbance plant communities across the experimental gradient of gap areas, essentially making species compositions in small gaps “look like” those in large gaps. Deer browsing also influenced probability of survival for planted Canada yew cuttings; all else being equal an individual was nearly seven times more likely to survive if protected from herbivory (P < 0.001). In contrast, the ability of sugar maple (Acer saccharum) to persist under high levels of herbivory and respond rapidly to overstory release appears to be related to the presence of stem layering(i.e., portions of below-ground prostrate stem). Layering occurred in 52% of excavated saplings (n = 100) and was significantly associated with increased post-disturbance height growth. Understory light was also important to planted seedling establishment and height growth. Higher levels of direct under-canopy light negatively impacted survival for shade-tolerant hemlock and Canada yew, while an increase in diffuse light was linked to a higher probability of survival for yellow birch and height growth for hemlock and Canada yew. Increases in white pine height growth were also significantly associated with a decrease in canopy cover.

Promoting Biodiversity in Forest Ecosystems Using Ecological Forestry

A subset of forest management techniques, termed ecological forestry, have been developed in order to produce timber and maintain the ecological integrity of forest communities through practices that more closely mirror natural disturbance regimes. Even though alternative methods have been described and tested, these approaches still need to be established and analyzed in a variety of geographic regions in order to calibrate and measure effectiveness across different forest types. The primary objective of this research project was to assess whether group selection combined with legacy-tree retention could enhance mid-tolerant tree recruitment in a late-successional northern hardwood forest. In order to evaluate a novel alternative regeneration technique, 49 group-selection openings in three size classes were created in 2003 with a biological legacy tree retained in the center of each opening. Twenty reference sites, managed using single-tree selection, were also analyzed for comparison. The specific goals of the project were to: 1) determine the fate and persistence of the openings and legacy trees 2) assess the understory response of the group-selection openings versus the single-tree selection reference sites, and 3) evaluate the spatial patterns of yellow birch (Betula alleghaniensis Britt.) and eastern hemlock (Tsuga canadensis (L.) Carr.) in the group-selection openings. The results from 8-9 years post-study implementation and the changes that have occurred between 2004/5 and 2011/12 are discussed. The alternative regeneration technique developed and assessed in this study has the potential to enrich biodiversity in a range of forest types. Projected group-selection opening persistence rates ranged from 41-91 years. Openings from 500-1500 m2 are predicted to persist long enough for mid-tolerant tree recruitment. The legacy trees responded well to release and experienced a low mortality rate. Yellow birch (the primary shade mid-tolerant tree in the study area) densities increased with opening size. Maples surpassed all other species in abundance. In the sapling layer, sugar maple (Acer saccharum Marsh.) was 2 to over 300 times more abundant in the group-selection openings and 2 to 3 times more abundant in the references sites than all other species present. Red maple (Acer rubrum L.) was the second most abundant species present in the openings and reference sites. Spatial patterns of yellow birch and eastern hemlock in the openings were mostly aggregated. The southern edges of the largest openings contained the highest magnitude of yellow birch and eastern hemlock per unit area. Continued monitoring and additional treatments will likely be necessary in order to ensure underrepresented species successfully reach maturity.

Changes in biodiversity and vegetation composition in the central Swiss Alps during the transition from pristine forest to first farming

Aim: We investigate the response of vegetation composition and plant diversity to increasing land clearance, burning and agriculture at the Mesolithic–Neolithic transition (c. 6400–5000 bc) when first farming was introduced. Location: The Valais, a dry alpine valley in Switzerland. Methods: We combine high-resolution pollen, microscopic charcoal and sedimentological data to reconstruct past vegetation, fire and land use. Pollen evenness, rarefaction-based and accumulation-based palynological richness analyses were used to reconstruct past trends in plant diversity. Results: Our results show that from c. 5500 cal. yr bc, slash-and-burn activities created a more open landscape for agriculture, at the expense of Pinus and Betula forests. Land clearance by slash-and-burn promoted diverse grassland ecosystems, while on the long term it reduced woodland and forest diversity, affecting important tree species such as Ulmus and Tilia. Main conclusions: Understanding the resilience of Alpine ecosystems to past disturbance variability is relevant for future nature conservation plans. Our study suggests that forecasted land abandonment in the Alps will lead to pre-Neolithic conditions, with significant biodiversity losses in abandoned grassland ecosystems. Thus, management measures for biodiversity, such as ecological compensation areas, are needed in agricultural landscapes with a millennial history of human impact, such as the non-boreal European lowlands. Our study supports the hypothesis that species coexistence is maximized at an intermediate level of disturbances. For instance, species richness decreased when fire exceeded the quasi-natural variability observed during the Mesolithic times. Under a more natural disturbance regime, rather closed Pinus sylvestris and mixed oak forests would prevail.

Climatic and human impacts on mountain vegetation at Lauenensee (Bernese Alps, Switzerland) during the last 14,000 years

Lake sediments from Lauenensee (1381 m a.s.l.), a small lake in the Bernese Alps, were analysed to reconstruct the vegetation and fire history. The chronology is based on 11 calibrated radiocarbon dates on terrestrial plant macrofossils suggesting a basal age of 14,200 cal. BP. Pollen and macrofossil data imply that treeline never reached the lake catchment during the Bølling–Allerød interstadial. Treeline north of the Alps was depressed by c. 300 altitudinal meters, if compared with southern locations. We attribute this difference to colder temperatures and to unbuffered cold air excursions from the ice masses in northern Europe. Afforestation started after the Younger Dryas at 11,600 cal. BP. Early-Holocene tree-Betula and Pinus sylvestris forests were replaced by Abies alba forests around 7500 cal. BP. Continuous high-resolution pollen and macrofossil series allow quantitative assessments of vegetation dynamics at 5900–5200 cal. BP (first expansion of Picea abies, decline of Abies alba) and 4100–2900 cal. BP (first collapse of Abies alba). The first signs of human activity became noticeable during the late Neolithic c. 5700–5200 cal. BP. Cross-correlation analysis shows that the expansion of Alnus viridis and the replacement of Abies alba by Picea abies after c. 5500 cal. BP was most likely a consequence of human disturbance. Abies alba responded very sensitively to a combination of fire and grazing disturbance. Our results imply that the current dominance of Picea abies in the upper montane and subalpine belts is a consequence of anthropogenic activities through the millennia.

Die Vegetationsgeschichte der letzten 14 000 Jahre am Lauenensee

Sedimente des Lauenensees (Berner Oberland, 7381 m ü.M.) wurden untersucht, um mittels Pollen-, Pflanzenrest-und Holzkohleanalyse die regionale Vegetations-und Feuergeschichte zu rekonstruieren. Die Chronologie basiert auf elf kalibrierten Radiokarbondaten von terrestrischen Pflanzenresten und ergab ein Basisalter von 14 200 kal. Jahren vor heute (12 250 v. Chr.). Während des Bölling-Allerød lnterstadials war das Einzugsgebiet des Lauenensees noch nicht bewaldet. Somit lag die Waldgrenze in den Nordalpen tiefer als in den Zentral-und Südalpen. Die Wieder-bewaldung startete nach der Jüngeren Dryas vor 11 600 kal. Jahren (9650 v. Chr.). Diese frühen Birken-und Föhrenwälder (Betula und Pinus sylvestris) wurden vor rund 7500 kal. Jahren (5550 v. Chr.) durch Weisstannenwälder(Abies alba) ersetzt. Der erste menschliche Einfluss ist ab dem späten Neolithikum belegt (5700 bis 5200 kal. Jahre vor heute, 3750-3250 v. Chr.). Mit zwei hochaufgelösten Sequenzen wurde die Ausbreitung der Fichte (Picea abies) im Neolithikum (5700 bis 5200 kal. Jahre vor heute, 3750-3250 v. Chr.) und der Kollaps der Weisstanne in der Bronzezeit (4100 bis 2900 kal. Jahre vor heute, 2150-950 v. Chr.) untersucht. Die Resultate der Kreuzkorrelationen zeigen, dass die Ausbreitung der Grünerle (Ainus viridis) sowie der Wechsel von Weisstannen-zu Fichtenwäldern durch den Menschen ausgelöst wurde. Die Weisstanne reagiert nachweislich sehr sensibel auf Beweidung und Feuer, weshalb sich die heutige Fichtendominanz im oberen montanen und subalpinen Vegetationsgürtel aus der menschlichen Nutzung über die Jahrtausende ergeben haben muss.

Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery

Despite major improvements in diagnostics and interventional therapies, cardiovascular diseases remain a major health care and socio-economic burden both in western and developing countries, in which this burden is increasing in close correlation to economic growth. Health authorities and the general population have started to recognize that the fight against these diseases can only be won if their burden is faced by increasing our investment on interventions in lifestyle changes and prevention. There is an overwhelming evidence of the efficacy of secondary prevention initiatives including cardiac rehabilitation in terms of reduction in morbidity and mortality. However, secondary prevention is still too poorly implemented in clinical practice, often only on selected populations and over a limited period of time. The development of systematic and full comprehensive preventive programmes is warranted, integrated in the organization of national health systems. Furthermore, systematic monitoring of the process of delivery and outcomes is a necessity. Cardiology and secondary prevention, including cardiac rehabilitation, have evolved almost independently of each other and although each makes a unique contribution it is now time to join forces under the banner of preventive cardiology and create a comprehensive model that optimizes long term outcomes for patients and reduces the future burden on health care services. These are the aims that the Cardiac Rehabilitation Section of the European Association for Cardiovascular Prevention & Rehabilitation has foreseen to promote secondary preventive cardiology in clinical practice.

Holocene climate, fire and vegetation dynamics at the treeline in the Northwestern Swiss Alps

Treelines are expected to rise to higher elevations with climate warming; the rate and extent however are still largely unknown. Here we present the first multi-proxy palaeoecological study from the treeline in the Northwestern Swiss Alps that covers the entire Holocene. We reconstructed climate, fire and vegetation dynamics at Iffigsee, an alpine lake at 2,065 m a.s.l., by using seismic sedimentary surveys, loss on ignition, visible spectrum reflectance spectroscopy, pollen, spore, macrofossil and charcoal analyses. Afforestation with Larix decidua and tree Betula (probably B. pendula) started at ~9,800 cal. b.p., more than 1,000 years later than at similar elevations in the Central and Southern Alps, indicating cooler temperatures and/or a high seasonality. Highest biomass production and forest position of ~2,100–2,300 m a.s.l. are inferred during the Holocene Thermal Maximum from 7,000 to 5,000 cal. b.p. With the onset of pastoralism and transhumance at 6,800–6,500 cal. b.p., human impact became an important factor in the vegetation dynamics at Iffigsee. This early evidence of pastoralism is documented by the presence of grazing indicators (pollen, spores), as well as a wealth of archaeological finds at the nearby mountain pass of Schnidejoch. Human and fire impact during the Neolithic and Bronze Ages led to the establishment of pastures and facilitated the expansion of Picea abies and Alnus viridis. We expect that in mountain areas with land abandonment, the treeline will react quickly to future climate warming by shifting to higher elevations, causing drastic changes in species distribution and composition as well as severe biodiversity losses.

Tracing the origin of Arctic driftwood

Arctic environments, where surface temperatures increase and sea ice cover and permafrost depth decrease, are very sensitive to even slight climatic variations. Placing recent environmental change of the high-northern latitudes in a long-term context is, however, complicated by too short meteorological observations and too few proxy records. Driftwood may represent a unique cross-disciplinary archive at the interface of marine and terrestrial processes. Here, we introduce 1445 driftwood remains from coastal East Greenland and Svalbard. Macroscopy and microscopy were applied for wood anatomical classification; a multi-species subset was used for detecting fungi; and information on boreal vegetation patterns, circumpolar river systems, and ocean current dynamics was reviewed and evaluated. Four conifer (Pinus, Larix, Picea, and Abies) and three deciduous (Populus, Salix, and Betula) genera were differentiated. Species-specific identification also separated Pinus sylvestris and Pinus sibirica, which account for ~40% of all driftwood and predominantly originate from western and central Siberia. Larch and spruce from Siberia or North America represents ~26% and ~18% of all materials, respectively. Fungal colonization caused different levels of driftwood staining and/or decay. Our results demonstrate the importance of combining wood anatomical knowledge with insight on boreal forest composition for successfully tracing the origin of Arctic driftwood. To ultimately reconstruct spatiotemporal variations in ocean currents, and to better quantify postglacial uplift rates, we recommend consideration of dendrochronologically dated material from many more circumpolar sites.

Vegetation responses to rapid warming and to minor climatic fluctuations during the Late-Glacial Interstadial (GI-1) at Gerzensee (Switzerland)

High-resolution pollen analyses made on the same samples on which the ratios of oxygen isotopes were measured that provided the time scale and a temperature proxy after correlation to NorthGRIP. (1) A primary succession: The vegetation responded to the rapid rise of temperatures around 14,685 yr BP, with a primary succession on a decadal to centennial time scale. The succession between ca 15,600 and 13,000 yr BP included: (1.1.) The replacement of shrub-tundra by woodland of Juniperus and tree birch (around 14,665 yr BP) (1.2.) The response of Juniperus pollen to the shift in oxygen isotopes in less than 20 yr, (1.3.) A sequence of population increases of Hippophaë rhamnoides (ca 14,600 yr BP), Salix spp. (ca 14,600 yr BP), Betula trees (ca.14,480 yr BP), Populus cf. tremula (ca. 14,300 yr BP), and Pinus cf. sylvestris (ca. 13,830 yr BP). (2) Biological processes: Plants responded to the rapid increase of summer temperatures on all organisational levels: (2.1) Individuals may have produced more pollen (e.g. Juniperus); (2.2) Populations increased or decreased (e.g. Juniperus, Betula, later Pinus), and (2.3) Populations changed their biogeographical range and may show migrational lags. (2.4) Plant communities changed in their composition because the species pools changed through immigration and (local) extinction. Some plant communities may have been without modern analogue.These mechanisms require increasing amounts of time. (2.5) Processes on the level of ecosystems, with species interactions, may involve various time scales. Besides competition and facilitation, nitrogen fixation is discussed. (3) The minor fluctuations of temperature during the Late-Glacial Interstadial, which are recorded in δ18O, resulted in only very minor changes in pollen during the Aegelsee Oscillation (Older Dryas biozone, GI-1d) and the Gerzensee Oscillation (GI-1b). (4) Biodiversity: The afforestation at the onset of Bølling coincided with a gradual increase of taxonomic diversity up to the time of the major Pinus expansion.

Response of subfossil Cladocera in Gerzensee (Swiss Plateau) to early Late Glacial environmental change

Sub-fossil Cladocera were studied in a core from Gerzensee (Swiss Plateau) for the late-glacial periods of Oldest Dryas, Bølling, and Allerød. Cladocera assemblages were dominated by cold-tolerant littoral taxa Chydorus sphaericus, Acroperus harpae, Alonella nana, Alona affinis, and Alonella excisa. The rapid warming at the beginning of the Bølling (GI-1e) ca. 14,650 yr before present (BP: before AD 1950) was indicated by an abrupt 2‰ shift in carbonate δ18O and a clear change in pollen assemblages. Cladocera assemblages, in contrast, changed more gradually. C. sphaericus and A. harpae are the most cold-tolerant, and their abundance was highest in the earliest part of the record. Only 150–200 years after the beginning of the Bølling warming we observed an increase in less cold-tolerant A. excisa and A. affinis. The establishment of Alona guttata, A. guttata var. tuberculata, and Pleuroxus unicatus was delayed by ca. 350, 770, and 800 years respectively after the onset of the Bølling. The development of the Cladocera assemblages suggests increasing water temperatures during the Bølling/Allerød, which agrees with the interpretation by von Grafenstein et al. (2013-this issue) that decreasing δ18O values in carbonates in this period reflect increasing summer water temperatures at the sediment–water interface. Other processes also affected the Cladocera community, including the development and diversification of aquatic vegetation favourable for Cladocera. The record is clearly dominated by Chydoridae, as expected for a littoral core. Yet, the planktonic Eubosmina-group occurred throughout the core, with the exception of a period at ca. 13,760–13,420 yr BP. Lake levels reconstructed for this period are relatively low, indicating that the littoral location might have become too shallow for Eubosmina in that period.

Psychosocial aspects in cardiac rehabilitation: From theory to practice. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology

A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQoL) and prognosis in patients with established CHD. PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews. Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQoL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counselling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counselling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team.