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DAWN'S RAYS ARE creeping west across the Mojave, crawling up Joshua trees and barrel cacti, as a group of U.S. Special Operations warriors sit cross-legged, all lined up and scanning the dry horizon. These exquisitely tattooed, overmuscled rogues have descended upon this desert from across the nation. Alongside them are a handful of first responders and a few civilians. Chests slowly rise and fall as each person inhales and exhales the cool, dry air. One among their ranks breaks the silence. Ready? asks Alex Horton, a commander in the Joint Special Operations Command. All nod.

Im there anticipating some reenactment of Desert Storm. But what I get is closer to Desert Om. Close your eyes to begin this meditation, Horton says. I want you to focus on the sensation of the breath. When thoughts arise, notice them without judgment. And then she occasionally reminds the group to feel the breath or notice and let go, until after 15 minutes she announces, Times up.

Peter Bohler

Were at a weekend retreat held by SOFLETE, a fitness-content company owned by Special Operations personnel that isnt following the long-held narrative of how people in the military, first responders, and other active men and women should train, live, and do their jobs. Army Rangers and Green Berets, Marines, firefighters, police, and SWAT members, along with an accountant, an electrical lineman, a roughneck, and others: Most of the 25 people here have taken lives, saved lives, and undoubtedly seen some shit. Together this group is seeking something like enlightenment: zenning out, exploring the psychedelic landscape of Joshua Tree National Park, and speaking the capital-T truth about the state of being an elite serviceman or -woman in 2019.

Each of them landed in the Mojave after a bout of burnoutfrom too many stressful deployments or hours on duty or patrol; from military-style beatdown workouts and the nagging injuries that ensued; from the idea that those who keep us safe, or even civilians simply interested in military culture, must be part of a stoic, tougher-than-thou caste. The SOFLETE peeps are here doing something about that burnout. But they also know that the feeling extends far beyond the Mojave. Which is why theyre also scaling up their efforts on various media channels and through a training appto bring the next generation of Special Operations training and tactical thinking to the masses.

CALL IT THE military-fitness complexand its now at industrial scale. Its the thousands of books, podcast episodes, Instagram feeds, seminars, and fitness programs that promise to reveal the physical and mental magic that makes Special Operations warriors so tough. The space is dominated by testosterone-emboldened vets and brands whose messages are basically this: The answer to all your problems is to adopt a military mind-set, or mental toughness, which is loosely translated as grinding harder and longer than the next guy and never quitting or showing weakness.

SOFLETE PARTNER Doug Kiesewetter has served 14 years, mostly with the Army Special Forces, including a stint in Baghdad as an advisor to the Iraqi army in 2017.

There is, for instance, David Goggins, a retired Navy SEAL and ultra-endurance athlete who has roughly 2 million Instagram followers. A typical post features the participation-trophy-hating Goggins running while shouting into the camera about how growth requires suffering. He rails against soft bullshit like feeling pain, not exercising hard enough, and quitting. In his best-selling book, Cant Hurt Me, Goggins brags about breaking fellow SEALs with workouts that were punishing physically and how he would lose all respect for the men who questioned the efficacy of those injurious sessions. He thinks a lot of people are fucking pussies. Or theres Jocko Willink, a retired SEAL with some 850,000 Instagram followers as well as a popular podcast and books, who regularly posts photos of his 4:30 a.m. wakeup times, plus black-and-white shots of sweat puddles, overloaded barbells, and massive kettlebells, with captions like The Altar of Pain, Blunt force trauma, and Torture with [insert weight].

Then youve got groups of exSpecial Ops guys who host events that allow the average man to experience the hell of Hell Week. An event put on by SEALFit called Kokoro, for example, bills itself as the premier training event for forging mental toughness. About $2,500 buys you a 50-hour Hell Week physical and emotional thrashing that, like one of New Yorks hottest clubs in a deranged Stefon skit on Saturday Night Live, has everything: multiple ice baths, group log carries, heavy rucking, the CrossFit workout Murph, calisthenics in the frigid Pacific Ocean, and more!

If Instagram comment sections are a reliable measure, these messages and events seem to have motivated a wave of sedentary guys to get off the couch. Which is undoubtedly a good thing, what with 72 percent of Americans now overweight or obese. And theyve helped guys with soul-sucking office jobs find meaning by letting them feel the often-unknown bodily sensationslike cold, exhaustion, hunger, and painthat lie beyond a comfort zone.

There are plenty of companies out there who do hard for hards sake, says George Briones, 31, a Marine recon operator and a SOFLETE employee. Thats not what we do. Were often working against that mind-set. Most [military personnel] push too hard and work through an injury and make it worse.

SOFTLETE DIRECTOR and Army Green Beret Brian Hueske has served 12 years, deploying seven times: to Iraq, Jordan, Lebanon, Congo, and in 2013, Afghanistan.

As more troops and first responders have adopted these hard-line training and mind-set tactics, more and more of them have become mentally and physically beaten up and broken down. That can put them and their teams in dangerous positions, or just ruin their ability to live a healthy civilian life. The U.S. Army has publicly stated that injuries are a modern military epidemic, and a study funded by the U.S. Army Research Laboratory discovered that about 20 percent of its Spec Ops soldiers each year experience injuries that require medical attention. For every 100 soldiers, there are 25 annual injuries. The top cause of those injuries? Not bullets or IEDs. Exercise. Going too hard, too often. Team workouts consisting of ten-mile hikes while wearing 60-pound packs, followed by more pushups, situps, and flutter kicks than you can count, followed by whatever else a soldier does on his own in the gym, be it CrossFit, ultrarunning, or bodybuilding. In fact, the researchers say, 77 percent of these injuries could be avoided with improved injury-prevention programs.

Another problem, says Briones, is that many Special Operations guys are either bodybuilders, bodyweight ninjas, or pure endurance athletes. Theyre fitness specialists in a job that requires strength, speed, stamina, and mobilitythe capacity to drag a 200-plus-pound fallen comrade in full gear, sprint for cover during a firefight, ruck through the mountains to a mission point, or hold a covered-but-contorted shooting position in a sniper nest.

The military branches are fully aware that the way their personnel train isnt exactly optimal. And theyre working on itwith varying degrees of success. The Army says its on a bold mission to change its culture of fitness so that training transfers to combat more effectively, reduces the risk of injury, and improves soldier readiness and resiliency. Major General Lonnie Hibbard, who commands the U.S. Army Center for Initial Military Training, calls it holistic health and fitness. Its loosely described as physical fitness and performance enhancement, but also mental and spiritual fitness.

But whether the plan will make it out of the bureaucratic swamp and onto basesand then survive thereis anyones guess. In 2009, for instance, U.S. Special Operations Command funded the Armys creation of Thor3, a fitness program with its own facilities staffed by physical therapists, strength and conditioning coaches (poached from Team USA and elite sports programs), and sports nutritionists. It focused on optimizing the physical and mental conditioning of Special Forces operators and helping injured ones recover. It worked when it was implemented, improving fitness and reducing injuries, but it was slowly defunded and often neglected by untrained team leaders who didnt realize its value.

You also have the unseen scars, of course. The suicide rate among veterans is 50 percent greater than that of the general public, and police officers and firefighters are more likely to die by their own hand than in the line of duty. The New York Times recently reported that more than 45,000 veterans and active-duty service members have killed themselves in the past six years. That is more than 20 deaths a dayin other words, more suicides each year than the total American military deaths in Afghanistan and Iraq.

Peter Bohler

Mental toughness isnt just doing more reps or miles than the next guy or getting through a selection course; its using smarter-not-harder approaches to fitness, even if that means you wont be the strongest, fastest, fittest-looking guy in the gym. Its knowing when to back down and take a day to take care of yourself. Its checking your intentions, and even asking for help and recognizing your vulnerability. As the branches slowly trudge forwardthe new fitness assessment test, for example, has been in the works for years and wont be ready for rollout until late 2020SOFLETE is filling a gap.

Now heavily meditated, the group rises from the seated position. Next up at the Mojave retreat: yoga. Nope, these SOFLETE dudes are not what you might expect from top military personnel. Surfers, hippies, hipsters, and snowflakes...who also happen to have body counts is how they describe themselves. But they may be onto something. The company began in 2015 with the intention of providing fitness programming exclusively for Special Operations guys. For them, the stakes of military fitness are much higher than looking cool on the Gram. The wrong fitness program can prevent servicemen and -women from advancing past a Special Ops selection course, stalling their career, or, even worse, put them in harms way on the battlefield.

SOFLETE is rethinking warrior fitness with sane fitness programming served with a side of woo, which just may be what military men and women need to be better at their jobs. Yeah, I meditate. Yes, I do yoga. Yes, I do all these things that some people may associate with femininity or something, says Brian Hueske, 38, a career Green Beret whos built like a grizzly bear and who now also works for SOFLETE. But Im doing this stuff to maintain performance. At the end of the day, Im doing this stuff because it makes me better at killing bad people.

Modern-day Rambos with a softer side and no pretension to badassery? Could my experience in the desert have all been some strange hallucination? I needed to find out.

AND SO IT is that a few weeks later I find myself at SOFLETE headquarters in Durham, North Carolina. In the desert, I saw the restorative side of SOFLETE. Now Im about to experience how the company builds elite war fighters and glean insights into its special marketing sauce thats part rah-rah inspiration, part parody of bro science. That it took just four years for the company to go from a single workout shared by PDF to a 6,000-square-foot building and a reach of 2.5 million people each month speaks to the efficacy of SOFLETEs workouts and the thirst for military-themed merch.

There are eight of us performing a mobility warmup on the 50-foot strip of turf that runs through SOFLETE HQ, which is part no-expenses-spared CrossFit-style gym, part content-creation studio, and part office. By the 2010s, the SOFLETE brain trust had started to realize that the message of the military-fitness complex was all wrong. Between deployments, each of them was running an elite gym, all looking for the fitness sweet spot where a warrior is optimized to performat a moments notice, over an entire career. Special Operations guys never know when theyre going to have to go on a mission, says Doug Kiesewetter, 38, an Army Special Forces weapons sergeant and partner at SOFLETE. Any day could be the Super Bowl. So imagine Tom Brady doing a burner workout and endless miles of rucking with an 80-pound pack every day leading up to the Super Bowl. How would he play? Not great, right? But thats essentially what many other military-fitness companies were and still are asking from their users.

Peter Bohler

In 2011, Id spent the year doing a popular military athlete program, says Hueske as he adjusts the settings on a camera hell use to capture video that SOFLETE will post to its social-media channels and website, dieliving.com. The site covers fitnessy topics like how to avoid boot-camp injuries and how to eat for performance, as well as mind-set stuff like dealing with failure, the trials of coming home from deployment, and grappling with the badass identity that society forces on military guys. Every day, Id do an hour of 80-pound sandbag Turkish getups, followed by these crazy high-intensity workouts. I always felt crushed, but thats what I was told would work. It didnt.

We had a training mission to raid an enemy compound, and to do that we had to climb up this huge hill in full kit with all of our breaching equipment, which is like 90 or 100 pounds of gear, he says. By the time we reached the top, I was smokedand the actual mission hadnt even started.

Peter Bohler

For someone like a pro CrossFit athletewho can eat perfectly, sleep eight hours a night, get massages, and all thatregular all-in workouts can be effective. But military guys typically eat shitty food, get shitty sleep, and have shitty access to recovery practices (no ice baths in Tora Bora). Pounding away at balls-to-the-wall workouts eventually hurt Hueskes back. So then I was forced to recover, he says while snapping photos of the group performing the warmup routine that will mobilize our legs, hips, and shoulders, three areas that military personnel commonly injure. During Hueskes rehab, a colleague called him aside and, in the furtive tone you might use when confessing to another man that you like to sing along to Taylor Swift when youre driving to work, said, This training youre doing...I know you think its cool, but youre totally wrong. Heres what you need to do....

The guy began explaining that how hard youre dragging your skull across the dirt does not correlate with a workouts efficacy, says Hueske. It only sets you up for injury and crap performance. A military strength coach gave him some programming that ticked a lot of fitness boxes and pushed Hueskes limits but also stressed recovery and improving his mobility. I was working out less, Hueske says. I felt like I was sandbagging, but I stayed the course.

Soon after, he was sent on another training mission. It was a six- or seven-hour infiltration where we were carrying heavy gear through the woods slowly and deliberately, he says. When we arrived at our destination to start the mission, I still had 95 percent left in the tank. It was a meathead revelation. The other SOFLETE guys had similar come-to-fitness-Jesus moments. Briones was once involved in a four-hour firefight in Afghanistan when a burned-out team member went down with heatstroke in hour three, putting the entire team in danger as they tried to evacuate him.

I watched my peers break themselves from overtraining and spend years trying to rehab while still needing to go to war, says Kiesewetter. Running patrols in Afghanistan and Iraq, theyd walk with a hitch in their step, fail to turn on speed and power when they needed it most, and just generally move like dudes a decade older. Christian Hines, the SOFLETE employee who models many of the exercises in the app and who came from the Armys 82nd Airborne, watched as many of his teammates were removed from their daily duties and training because they injured themselves trying to one-up the next guy in some timed workout or deadlifting session.

Now warmed up, were moving on to a strength phase. Well do three sets each of back squats, box jumps, and bench presses. The squat-and-jump combo leverages a phenomenon called post-activation potentiation, which research shows may give you a boost in strength and power.

Two of the cofounders of SOFLETE, whom well call Bill and Greg (they wished not to be named due to their roles in the military), saw the same issue of overkill. The original idea for SOFLETE was inspired by a peer of mine, says Greg. He was perpetually hurt from military fitness programs, which is so common among SOF guys.

Peter Bohler

In 2014, Greg went on a deer-hunting retreat with a nonmilitary friend named Aron Woolman, a successful Wall Street trader then in his mid-30s. Theyd spent the weekend discussing the problems with military fitness programming, and after talking with Woolman, an astute business mind, Greg decided they should do something about it.

So Greg, Bill, and Woolman did. They saw an opportunity in fitness plans that prepare men and women for Special Operations selection camps, which have low pass rates. Most other programs mimicked the hell of selection, following the train how you fight mantra, says Greg. Think daily miles of heavy rucking and anything else that sounded militaryish and awful. But while they zigged, Greg and Bill zagged. If you throw on a 70-pound ruck and walk for 12 miles, you get tired pretty quick, says Greg. Then every step is sloppy, on uncontrolled terrain, while youre weighted down, so the potential to twist an ankle or knee is extremely high. If that happens, there go your chances of passing selection.

Gregs and Bills experiences at selection told them that a better strategy is to strengthen all the muscles involved in rucking and to build an aerobic base. If you can back-squat 400 pounds and run a respectable ten-mile time, youre going to do well in the ten-mile ruck run, says Greg. The three men put together a PDF of a selection-prep program, which included lots of military-specific strength and conditioning fundamentals but very little heavy rucking, and tossed a brand on the file: SOFLETE, a combination of SOF, the acronym for Special Operations Forces, and athlete. Then they uploaded it to the Internet.

The PDF took off, says Bill. It got a shocking number of guys through selection camps. We were running SOFLETE as a small passion project, but by October of 2015 we realized that we should focus on running it as a business, says Woolman, a laid-back type who acts as the CEO and mom of the company. The othersKiesewetter, Briones, and Huesketook notice, everyone started talking, and SOFLETE gained speed.

That initial PDF has evolved into more than 100 different programs based on your goalbuilding strength, endurance, or muscle, for example, or prepping for a huntall accessible on the SOFLETE app for $34 a month, making them easy to do on bases and in gyms around the world. They tick all the boxes a war fighter needsraw strength, explosive power, all-day endurance, and killer speedwhile sneaking in, through nutrition coaching and extended mobility warmups and cooldowns, the never-say-die durability that helps modern servicemen and -women survive deployment after deployment and thrive in kinetic modern warfare.

Peter Bohler

Durability is critical for todays Spec Ops personnel, as America increasingly leans on its elite war-fighting teams. Special Operations are now active in over 90 countries, and members of the House and Senate Armed Services Committees have even testified that the constant deployments are taking a physical and mental toll.

SOFLETE workouts are hard, and we encourage people not to flip the idiot switch, but the recovery components are key, says Kiesewetter, the funny brother of the group, who, thanks to his sleeves of military-style tattoos, appears in many SOFLETE videos. This idiot-switch-free approach to holistic fitness training is why this band of irreverent servicemen has amassed a hell of a following. The company has grown 2,000 percent since the end of 2015.

Each training program is like a symphony, every workout building to a larger goal. The 12-week Juggernaut program, for example, stresses developing muscle and power. It does this via compound lifts like the deadlift, back squat, and power clean. But it doesnt neglect durability and stamina. Juggernaut has plenty of mobility and accessory work, plus biweekly days featuring sessions such as eight sets of 400-meter runs at a slow pace. Harmonized programs are common in professional sports, but not every military-fitness company has caught on.

Each SOFLETE program goes through the meathead brain trust: six combat-experienced Special Operations personnel who have an alphabet soup of fitness credentials. This hive mind sets them apart. Many other military-style programs are written by a single guy. And that guy may be a fitness pro who has no military background, which oftentimes causes him to measure success by a servicemans numbers in the gym, rather than his performance at war.

Peter Bohler

That gym-based mind-set is dangerous. Because the more you push your performance limits, the greater the toll your training takes on your body. SOFLETE prioritizes durability over absolute performance, says Kiesewetter. Having enough fitness and durability is what allows you to stay out of harms way mission after mission. With SOFLETE programming, youre probably going to have to give up being the absolute biggest, fastest, strongest guy in your unit, says Hueske. But you will be third or fourth best in all those metrics over 20 years, while the guys who are number one keep rotating because they get injured.

The group is cranking out the strength exercises before we move on to a stamina phase, which will entail doing as many rounds of 1,000-meter rows, 400-meter runs, and 400-meter farmers walks as possible in 13 minutes. Beyond the SOFLETE brain trust, theres John Warren, an Army sniper; Mike Crellin, a police officer in Houston; Nolan Bastien, a firefighter in Indianapolis; and Phil Sussman and Dave Ploch, of different wings of Army Special Operations. These men are the converted. SOFLETE programming helped with the back pain that Bastien, 39, had due to subpar exercising programs and overtraining. Thats made him, his team, and the public safer. Im a more functional part of my crew, he says.

The apps nutrition programming helped Crellin, 37, lose 80 pounds and Warren, 30, eat well consistently. The app calculates your carb, fat, and protein needs based on your size, goal, and activity level. Not into counting macronutrients? Cool. Who is? The app also spits out a days worth of recipes that fit exactly into your macros. The recipes are complexfor example, pork chop with veggie-loaded orzo or chicken with sweet-potato mash and roasted sproutsbut if youre kitchen-phobic, each week youll prep meals on Sunday and eat the same meals every other day.

When the workout ends, we form a sweaty circle around Sussman, who found yoga after an armored-vehicle accident sidelined him with pain and depression. He leads us through a series of poses that hit areas that tend to be particularly tight in war fighters and desk jockeys alike. Ploch digs the yoga part. He enlisted in 1996, has been deployed 14 times, and may be seeing more. I now know I have to work out smarter to keep mobile and flexible, he says. SOFLETE stuff is keeping me in the fight.

WE COMPLETE THE LIFTING part of the workout and now the gym is functioning as a full-fledged content studio, like Peloton but with less spandex and spinning. Im curious to finally learn what the heck the logowhich is stamped on everything from bumper plates and med balls to T-shirts and water bottlessymbolizes. First, though, Hueske has set up lighting and is interviewing Bastien for a series on how first responders have benefited from SOFLETE. Were trying to reach out to more guys with jobs like those, says Kiesewetter. And average guys. Theyll do that by holding more events like the one in Joshua Tree and by expanding the app.

SOFLETE is still a young company experiencing growing pains. The current version of the app, for example, offers a ton of programs, and its not clear how, say, one 80-plus-day strength program differs from the 14 other programs. In January, it plans to launch the app 2.0, which will include a more streamlined process of putting users into the programs they need. Youll be able to link it to an Apple watch, and your training, recovery, and nutrition will automatically scale based on recovery metrics from the watch. Anyone can comply with a three-month exercise program, says Kiesewetter. The challenge is how to make them comply with recovery practices as well.

Hueske, the brands media maven, elaborates. The word yoga has so long been synonymous with, like, leaf eating, he says. To get guys in my unit to do stuff like this, wed call it tactical stretching. So it is with SOFLETE, which often has to shape its message for testosterone-addled men who would perhaps rather not tread the same workout territory as their girlfriend.

We move off the turf to some couches. Im spent and feel like Ive put in hard work, but Im confident Ill be able to walk down the stairs tomorrow. I sip a shake of SOFLETE Fruit Hoops cereal-milk-flavored protein powder and water as the guys talk about SOFLETE products. We wanted a protein powder that tastes like the milk thats left after you eat a bowl of cereal, says Kiesewetter. They also sell a cinnabun-flavored protein powder and a melatonin, chamomile, and lavender nightcap called Teddy Bear Night Night.

Peter Bohler

Each guy is wearing some version of a SOFLETE T-shirt, which all feature the brands logo: a spade with a skull and two crossbones. The logo is also prominent in the brands dieliving.com stories. But what is it, exactly? An homage to the death cards that American troops would leave on Vietcong theyd killed in battle during the Vietnam War.

When that first PDF dropped, they shared it with friends and family on Facebook, says Woolman, where the logo and the mission caught the eyes of service personnel, law enforcement, first responders, and people interested in military fitness. We have just enough of the badass imagery to get people in the door, like the logo, and our military backgrounds probably help, says Kiesewetter. But then once people are in, its like, Hey, heres the yogawe give them the workouts and lifestyle advice they need.

The vernacular of the instruction is also uniquely direct. Take, for example, a recent Instagram video about correct pullup form. Caption: Were here to help if your pullups are hot garbage. Or the caption of a similar video about squats: If your front squat is jank as fuck you need to watch this video.

But sometimes that marketing humor borders on offensive. Take the description of a SOFLETE camo hat: Whether youre two steppin through Compton or playing IED hop scotch outside of Kabul, this snapback will drop every pair of panties within a six block radius. SOFLETE also once sold a cologne called Flex Offender. I spent two nights on the couch after my wife found out about that one, says Woolman.

While SOFLETE is making real progress with fitness, its not always as on point when it comes to helping break down the stereotype that military guys arent the most culturally sensitive creatures. Some of that is the brand trying to maintain authenticity, writing product descriptions that mimic how Spec Ops guys talk in a team room. And some of the blowback may be a consequence of a way-too-woke culture that has an amplified voice in social media. Woolman says SOFLETE is evolving and that the more offensive stuff is held over from the beginning of the brand. And I will say weve always been equal-opportunity offenders.

Peter Bohler

Its a theme Kiesewetter takes up. We all learned that that humor is a way to avoid uncomfortable situations, he says, speaking of the awkwardness that not only a trained killer but any person with a Y chromosome might feel opening up to the softer side of life. Hueske adds, And we just dont take ourselves too seriously. Lots of other militaryish companies do. They hope this makes SOFLETE videos and other content more accessible.

Theres an uncanny valley of how badass someone is in the military, says Hueske. In my career, Ive found that the most badass guys whove done the hardest stuff will never tell you about it. They never want to be recognized as badass. As we sit around laughing, Gogginss book, Cant Hurt Me, comes up, and its message doesnt resonate. Ploch (who, as a reminder, has deployed 14 times) smiles and says, You can get hurt in this job.

In 2017, a venture-capital firm approached SOFLETE. The team met a few Patagonia-vest-wearing finance types. Big money was on the lineenough to make SOFLETEs founders rich. They had just invested in another military brand, and they asked us, What are you guys against? says Woolman. We didnt understand the question. So they said, Well, are you against hipsters, liberals, people for gun control? What are you against? We said, Were not against anything. Were for helping people, for being authentic, and for pushing your personal boundaries and living your best life.

And then the SOFLETE guys all went to practice yoga.

More:
The Spec-Ops Guys Behind The App Transforming Military Fitness - menshealth.com

A brief from an unusual coalition of challengers, including the N.A.A.C.P., Microsoft and Princeton University, acknowledged that the Trump administration was free to make a different policy judgment than its predecessor had. But the termination, the brief said, was not based on a discretionary policy judgment.

Instead, the brief said, it was grounded in a legal determination by the attorney general that DACA is unlawful.

That approach, the brief continued, allowed the administration to tell the public that it could not permissibly maintain DACA, and that Congress and the courts, rather than the president, thus bore responsibility for the terminations human consequences. The government must now live with the consequences of claiming that its hands were tied.

The Trump administration argued that the program was an unlawful exercise of authority by the executive branch, relying on a ruling from the United States Court of Appeals for the Fifth Circuit, in New Orleans, concerning a related program. The Supreme Court deadlocked, 4 to 4, in an appeal of that ruling. Judges in the DACA cases said the two programs differed in important ways, undermining the administrations legal analysis.

Brad Smith, the president of Microsoft, which employs more than 60 DACA recipients, said there were lawful ways to shut down the program.

Our brief acknowledges very explicitly, based on the issues that weve raised, that were not suggesting that there would be no basis for a rescission of DACA, he said, using the legal term for ending the program. But if there is going to be a rescission of DACA, it has to be done in the right way and it has to be done for sound reasons.

The administration, by contrast, has argued that its determination that DACA is unlawful could not be second-guessed by the courts. Last year, the United States Court of Appeals for the Ninth Circuit, in San Francisco, rejected that view.

See the original post:
How the Trump Administration Eroded Its Own Legal Case on DACA - The New York Times

Cardiac rehab, known to be helpful after heart attacks, may also aid recovery from heart valve surgery, a study suggests.

Older adults who got cardiac rehabilitation after heart valve surgery were less likely to be hospitalized or die over the next year than those who didnt get this support, the study found.

Researchers examined data on 41,369 people insured by Medicare, the U.S. health program for individuals 65 and older, who had valve surgery in 2014. Overall, only 43% of them enrolled in medically supervised cardiac rehab programs focused on things like stress reduction, exercise, and heart-healthy living.

Compared to people who didnt go to cardiac rehab, those who did were 34% less likely to be hospitalized within one year of discharge after valve surgery, the study found. And rehab patients were also 61% less likely to die within one year of discharge.

To our knowledge, this is the first study to evaluate cardiac rehabilitation (CR) utilization among patients undergoing cardiac valve surgery at the national level in the United States, said Dr. Justin Bachmann, senior author of the study and medical director of the cardiopulmonary rehabilitation program at Vanderbilt University Medical Center in Nashville, Tennessee.

Cardiac rehab has previously been found effective for patients recovering from other types of procedures after heart attacks or procedures to place stents to prop open arteries, researchers note in JAMA Cardiology.

Cardiac rehab includes supervised exercise as well as dietary and smoking cessation counseling, Bachmann said by email. Management of cardiovascular risk factors (i.e., diet and stopping smoking) as well as improvements in cardiorespiratory fitness translate into improved health.

But not all patients in the study had equal access to cardiac rehab.

Compared to white patients, Asian and Hispanic patients were 64% less likely to get cardiac rehab, while black patients had 40% lower odds.

At the same time, people who had coronary artery bypass grafting in addition to valve surgery were 26% more likely to get cardiac rehab than those who only had valve procedures.

And people living in the Midwest were more than twice as likely to go to cardiac rehab as patients living in southern states. Half of the patients in the study were at least 73 years old.

One-year mortality rates, excluding people who died while hospitalized for the valve surgery or within 30 days of discharge, were 6.6% overall. Among patients who got cardiac rehab, one-year mortality was 2.2%.

The study wasnt designed to prove whether or how cardiac rehab might directly affect patient outcomes, nor did it examine why some patients might not have been offered cardiac rehab or chose not to enroll.

Even so, the results underscore the importance of discussing options for cardiac rehab, when possible before surgery so services will be lined up when theyre needed, said Dr. Randal Thomas, co-author of an editorial accompanying the study and medical director of cardiac rehabilitation at the Mayo Clinic in Rochester, Minnesota.

They will recover quicker, feel better, function better, and live longer as a result, Randal said by email. If a center-based program is not available near them, they should ask about the options for a home-based cardiac rehabilitation program that would be available to them instead.

2019 Thomson/Reuters. All rights reserved.

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Cardiac Rehab After Heart Valve Surgery Tied to Better Outcomes - Newsmax

By Dr. Rebecca KappusDepartment of Health and Exercise Science, Appalachian State University

The holiday season is here, and so is one of the unhealthiest times of the year for many of us: weight gain, added stress, unhealthy eating and little to no time for exercise, which results in strain on our cardiovascular system. Studies suggest increased cardiovascular disease risk during winter months, with a peak around the holidays.

There are a variety of ways we can protect our hearts during this holiday season and into the new year. Here are eight tips to help keep a happy, healthy heart:

Studies have shown people put off getting medical care until the holidays are over, which is a risk you shouldnt take. Visit your doctor especially before traveling. Be sure you know your numbers (blood pressure, blood sugar, cholesterol) and if you dont, have updated blood work completed, update and refill medications, and make a list of questions for your doctor about any health concerns you might have. Get a flu shot while youre there to prevent illness that can put extra strain on your heart.

Between the many parties to attend, meals to make, decorating, shopping (and financial strain) and family visits, the holidays are some of the most stressful times of the year. Before the holidays begin, consider your biggest stressors and make a plan on how you will handle them. Complete holiday shopping early. Cook meals in advance. Limit the parties you attend. Its OK to say no and its OK to ask for help. Better yet, check in on friends and family members who might be having a stressful time themselves.

Embrace the holiday fun! Social isolation increases your risk of heart issues. So, include time with loved ones and consider giving of yourself and your time at homeless shelters and soup kitchens, as volunteering promotes both physical and mental health.

Make sure youre eating plenty of fruits, vegetables and whole grains every day. Being satiated will help you say no to the endless holiday treats around every corner. Even better, avoid the places where you might be tempted to indulge: the office kitchen with homemade cookies, your evening route home past fast-food restaurants, and the supermarket when youre hungry.

This is a matter of planning your indulgences and making them count: a special treat only available around the holidays, a homemade dessert at a holiday party, etc. Make sure to stay well hydrated by keeping a water bottle close by and refilling it several times throughout the day. Limit alcohol intake. Weighing yourself regularly can lead to less weight gain.

Set an alarm on your phone to go off every hour so you can stand up and move around. Fit in extra activity in little ways: take the stairs, stand or pace while talking on the phone, or walk to complete your errands. Shoot for three or four 10-minute walks during the course of the day. Plan to get your exercise done early, first thing in the morning before the day gets busy. Exercise can help to relieve stress and help keep your weight in check.

Scheduling is key, and planning ahead will help you stick to a routine that promotes good health. Get a friend to hold you accountable, sign up for a weekly fitness class, or set daily alarms on your phone or computer to keep you in line. When days get busy, it is easy to forget to take medications, forgo a meal (and overeat later), and allow stress to overtake your day.

Research has shown that we lose willpower over the course of the day as we make more decisions, which may lead us to make poor choices by the end of the day. This is why we eat junk food at night and blow off our evening walk for a night in front of the TV. The most successful people reduce the amount of decisions they have to make: Facebook entrepreneur Mark Zuckerberg said he eats the same breakfast every morning and Apple CEO Steve Jobs wore the same outfit every day.

The holidays dont have to be a time of weight gain, high stress and low physical activity. And they definitely dont have to be a time of the year when we disregard our heart health. Try instilling some of these tips now, add a few more every week and carry them with you into the new year.

Share your feedback on this story.

March 8, 2013

Listening to music can be relaxing, invigorating or charged with emotions. Dr. Christine Leist, an assistant professor of music therapy at Appalachian State University, thinks music also can benefit women who have had or are at risk of heart attack.

Sep. 21, 2018

Appalachians Leon Levine Hall leads to innovative and collaborative learning for thousands, and more graduates prepared for the health sciences workforce. It is the first completed project of the Connect NC Bond referendum.

Feb. 21, 2014

A new grant program focused on creating a healthy, just and sustainable society supports a student's research measuring the health benefits of N.C. apples, among other projects.

The Department of Health and Exercise Science in Appalachian State Universitys Beaver College of Health Sciences delivers student-centered education that is accentuated by quality teaching, scholarly activity and service. The department includes two undergraduate academic disciplines: exercise science and public health. The department also offers two masters degrees: athletic training, which leads to professional licensure, and exercise science, which prepares students for advanced study in a variety of related fields as well as research. Learn more at https://hes.appstate.edu.

Appalachian's Beaver College of Health Sciences opened in 2010 as the result of a strategic university commitment to significantly enhance the health and quality of life for individuals, families and communities in North Carolina and beyond. In 2015, the college was named for an Appalachian alumnus and pioneer in the health care industry Donald C. Beaver 62 64 of Conover. The college offers nine undergraduate degree programs and seven graduate degree programs, which are organized into six departments: Communication Sciences and Disorders; Health and Exercise Science; Nursing; Nutrition and Health Care Management; Recreation Management and Physical Education; and Social Work. Learn more at https://healthsciences.appstate.edu.

As the premier public undergraduate institution in the state of North Carolina, Appalachian State University prepares students to lead purposeful lives as global citizens who understand and engage their responsibilities in creating a sustainable future for all. The Appalachian Experience promotes a spirit of inclusion that brings people together in inspiring ways to acquire and create knowledge, to grow holistically, to act with passion and determination, and to embrace diversity and difference. Located in the Blue Ridge Mountains, Appalachian is one of 17 campuses in the University of North Carolina System. Appalachian enrolls more than 19,000 students, has a low student-to-faculty ratio and offers more than 150 undergraduate and graduate majors.

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8 tips for a happy healthy heart during the holidays, from an Appalachian expert - Appalachian State University

Thats where things stood in late 2018, when Wilkowitzs son asked if shed heard the story of the Golden State Killer.

She hadnt, so he told her how earlier that year authorities charged a former police officer with a series of rapes and murders committed in California between 1974 and 1986.

That case, the first to use investigative genetic genealogy to solve a violent crime, sparked a wave of interest in the technique. Parabon, which did not work on the Golden State Killer case, has since helped police solve dozens of murders and rapes, led by the companys in-house genetic genealogist, CeCe Moore.

Wilkowitzs son suggested she contact Moore. She took the advice, asking Moore in a Facebook message to consider researching Eves killing. Moore responded that she wanted to help but could not, because New York wouldnt allow it. She promised to look into the case if Parabon was granted its permit.

Wilkowitz emailed a top official at the New York Department of Health, who confirmed what Moore told her.

New York regulates private companies performing DNA forensic testing to ensure that all testing is scientifically sound and performed with the appropriate controls in place, Anne Walsh, the head of the departments Forensic Identity Section, wrote to Wilkowitz.

Before doing the DNA work required for investigative genetic genealogy, a company must obtain a forensic identity permit from the New York State Department of Health. The agency requires the permit from all private laboratories looking to test materials derived from the human body for the purpose of forensic identification, to ensure that the testing is done properly, according to Jonah Bruno, an agency spokesman. Permits are issued for a variety of testing methods. The process of obtaining the permit is rigorous, requiring regular training, inspections and proficiency testing and the hiring of a qualified lab director.

Parabon began seeking a permit after the company got a warning in 2017 from the Department of Health for helping the New York City Police Department use a DNA analysis similar to whats used in genetic genealogy to develop leads on a murder suspect and the identity of a dead woman.

The company has been trying to meet the permit requirements for more than a year, according to Parabon CEO Steven Armentrout. I think were close, Armentrout said in an October email.

The delay has frustrated law enforcement authorities and some elected officials, including New York State Sen. Phil Boyle, a Republican who represents parts of Suffolk County and wants to eliminate bureaucratic obstacles to the use of investigative genetic genealogy.

It works, but for some reason the Department of Health is slow to get off the mark and were the only state that doesnt allow it, Boyle said.

Defense lawyers and privacy advocates said they are thankful for the restrictions in New York.

Genetic genealogy relies on the same kind of analysis used by direct-to-consumer DNA tests, revealing a lot about peoples lineage including adoptions and out-of-wedlock births and their predispositions to certain health conditions. Critics worry about the government misusing that information.

Critics also worry that people who have shared their profiles on public databases dont understand that they can be used to arrest a relative. And they worry about abuse of the technology by people who are unqualified or unscrupulous.

Its easy to be like, this is terrible, New Yorkers dont have access to justice and victims feel that way, said Erin Murphy, an NYU law professor who researches the expanding use of DNA testing in the criminal justice system. But the system is playing with fire by treating genetic genealogy like its no big deal, she added.

There are private companies and government agencies getting access to our genomic material, and we are moving blindly ahead. I understand the urgency, but we do need to pause, Murphy said.

Moore, of Parabon, said she was itching to work on the Wilkowitz case assuming there was enough DNA available from the suspect for the advanced analysis. She also said she understood the need for regulations. However, for a new technology like this, there has to be a way to get it expedited for approval so families arent waiting, Moore said. And its a matter of public safety.

Beyrer said that if investigative genetic genealogy became an option, the Wilkowitz case would be one of the first unsolved murders hed want to submit. It is the only cold case whose files he keeps in his office. Genetic genealogy is a huge advance and it could blow this case open, he said.

Wilkowitz is newly divorced, and her children have left Long Island. She recently moved to Rhode Island, where she works at a child-care center. The experience forced her to pare her possessions. In her temporary living space, at a friends home, she keeps a framed photograph of her and Eve standing at their doorstep in Oakdale, one of their last pictures together.

In a storage box, there is a portrait of her family long before the murder. There are snapshots of Eve at various ages, up until soon before she was killed. There is a baggie full of clothing tags with Eves name stitched on them, saved by their mother when they were young children.

These are the only keepsakes of her sister.

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Her sister was murdered in 1980. New DNA methods could crack the case, but NY won't allow it. - NBC News

Chicago Public Schools teachers collaborate during a professional development session.

In recent weeks, the nation turned its eyes to my hometown of Chicago, as 21,000 teachers walked out on strike. Its an image weve grown used to: Whether its Los Angeles, Oklahoma or West Virginia, teachers are making it clear they need additional support to do the job we ask of them.

Nationally, 44% of new teachers leave the field within five yearsa higher number than ever before. From 2011 to 2016, enrollment in teacher preparation programs fell by 35%. And as the workforce shrinks, those who stay shoulder additional burdens: Data suggests teachers spend an average of $459 of their own money a year on supplies, with teachers in high-poverty schools spending even more. Eighteen percent work a second job. For years now, weve asked our teachers to do more with less. Weve got to change that.

Within this backdrop, I think about teachers like Jennifer Fedrick. Jennifer teaches fifth grade at George Washington Elementary School on Chicagos East Side. Throughout her career, she has been widely recognized by colleagues and peers here as remarkablea teacher who truly cares about her students, and who makes the classroom a place to grow.

Two years ago, however, Jennifer was on the verge of enrolling in nursing school. After teaching 20 years, she was ready to abandon the profession.

Why? If you asked her, you would hear about being told what to do and when to do it; about not getting the space to try and fail; about kids forced to focus on the same content at the same time, even when their skills spanned multiple grades.

As Jennifer said to us recently: I didnt feel like I was making a difference anymore. I like to help people, and to me, nursing seemed like a better opportunity to help people.

For as much we talk about the negatives of a one-size-fits-all classroom model for students, we rarely cover how stressful and dissatisfying it is to teach within one. I dont think its a stretch to say that most teachers are like Jennifer: They enter the profession to make a difference. When we force educators to teach toward uniformity, we sap them of the motivation, passion and personal connection they need to drive strong learning experiences.

The one-size-fits-all model leads inevitably to a stale, constricting dynamic between teachers and administrators. In most schools across the country, teachers are not rewarded for the skillslike critical thinking, collaboration and creativitythat are increasingly valued in the broader world of work. We need them to foster these skills in our learners but we dont give them the opportunity to exercise them in their own careers. They arent given the space to innovate, or the autonomy to adapt to and engage individual learners. Instead, by the design of our traditional model, theyre forced to teach toward standardized tests and mythical average students.

The Illinois State Board of Education recently reported that there were more than 1,400 unfilled teaching positions in 2018, and projected that at least 20,000 more educators will be needed by 2020. Nationally its no better, with the Economic Policy Institute forecasting a national teacher shortage of at least 200,000 by 2025. The crisis is real, and growing.

Recent statistics from the Learning Policy Institute list poor job satisfaction as the number one reason teachers provide for leaving the professionahead of personal reasons, desire to pursue another career and the often-cited compensation issues. Salary, of course, is a major component of job satisfaction, but if were going to revitalize American education and avoid a full-blown teacher crisis, we will need to think bigger about the problem. In the traditional classroom model, educators like Jennifer are not supported to do what they set out to do, or treated like the leaders they can be.

Jennifer, however, changed her mind about leaving education after her school started thinking differently about teaching and learning. Starting in 2018, she and her colleagues at George Washington worked to deconstruct the factory-style model, piloting strategies and tools to help personalize instruction around individual students. The most successful shifts toward personalized learning work when teachers lead the change, and for Jennifer, the end of the traditional classroom came hand-in-hand with a fundamentally altered workplace dynamic. She was empowered to take risks, refine new ideas with colleagues and learn and apply learning science from research. In the process, she experienced a transformation of her teaching. With that came a renewed passion for her profession.

The reality is that we have already lost thousands of Jennifer Fedricks. The more-pressing reality is that if we dont act fast, were set to lose thousands more. As we consider how we attract and retain the talents of educators, we will need to think bigger than debates over class size, salary and school support staff. Fundamental transformation of the entire one-size-fits-all model is what will be required to develop a more powerful, satisfied professionone in which educators are enabled as design thinkers. If we dont give teachers the chance to exercise and build upon their talents, our kids will miss the same opportunity.

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To Curb The Teacher Shortage, We Need To Think Bigger About The Problem - Forbes

PURPOSE To assess the effect of a primary carebased community-links practitioner (CLP) intervention on patients quality of life and well-being.

METHODS Quasi-experimental cluster-randomized controlled trial in socioeconomically deprived areas of Glasgow, Scotland. Adult patients (aged 18 years or older) referred to CLPs in 7 intervention practices were compared with a random sample of adult patients from 8 comparison practices at baseline and 9 months. Primary outcome: health-related quality of life (EQ-5D-5L, a standardized measure of self-reported health-related quality of life that assesses 5 dimensions at 5 levels of severity). Secondary outcomes: well-being (Investigating Choice Experiments for the Preferences of Older People Capability Measure for Adults [ICECAP-A]), depression (Hospital Anxiety and Depression Scale, Depression [HADS-D]), anxiety (Hospital Anxiety and Depression Scale, Anxiety [HADS-A]), and self-reported exercise. Multilevel, multiregression analyses adjusted for baseline differences. Patients were not blinded to the intervention, but outcome analysis was masked.

RESULTS Data were collected on 288 and 214 (74.3%) patients in the intervention practices at baseline and follow-up, respectively, and on 612 and 561 (92%) patients in the comparison practices. Intention-to-treat analysis found no differences between the 2 groups for any outcome. In subgroup analyses, patients who saw the CLP on 3 or more occasions (45% of those referred) had significant improvements in EQ-5D-5L, HADS-D, HADS-A, and exercise levels. There was a high positive correlation between CLP consultation rates and patient uptake of suggested community resources.

CONCLUSIONS We were unable to prove the effectiveness of referral to CLPs based in primary care in deprived areas for improving patient outcomes. Future efforts to boost uptake and engagement could improve overall outcomes, although the apparent improvements in those who regularly saw the CLPs may be due to reverse causality. Further research is needed before wide-scale deployment of this approach.

Health inequalities are a global problem, resulting from a fundamental inequity in the distribution of income, power, and wealth. This inequity limits opportunities across the life course, including access to education, housing, jobs, and health care.1,2 In addition, people of low socioeconomic status experience multiple health problems and a concentration of risk factors,3 exacerbated by poor access to resources to manage them.4

A common policy response to health inequalities in recent years has been the introduction of various social prescribing programs. Social prescribing aims to link patients to nonmedical sources of support within a community, thus expanding options and resources beyond those traditionally provided in primary health care.5 In principle, social prescribing interventions should enable a more holistic response to patients needs. By providing access to community-based services and support, they can reduce social isolation, promote behavior change (such as joining a walking group), and mitigate some of the effects of poverty through welfare advice or employment opportunities, for example.6 The evidence base for the effectiveness of social prescribing is extremely limited, however.79

The Scottish government has recently supported social prescribing in areas of high socioeconomic deprivation. The Glasgow Deep End Links Worker Programme (LWP) aims to help people in areas of deprivation to live well in their communities by providing an attached community-links practitioner (CLP) to general practices.10 Here, we report the quantitative findings on patient outcomes of this program. Our aim was to test the hypothesis that the intervention would lead to improvements in patients quality of life and other aspects of well-being.

We conducted a quasi-experimental cluster-randomized controlled trial (RCT) of the Glasgow Deep End LWP.11 Practices were eligible for the program if they were located in Glasgow and in the 100 practices in Scotland (which has approximately 1,000 practices) serving the most-deprived patients (based on the percentage of registered patients in practices living in the 15% most-deprived postcodes in Scotland). Fifteen general practices serving patients living in very deprived areas (out of 76 eligible practices in Glasgow) took part. Funding from the Scottish government financed 7 practices to implement the intervention. The remaining 8 practices acted as a comparison group. Patients who participated in the evaluation provided written informed consent. The study was approved by the University of Glasgow College of Medical Veterinary and Life Sciences Ethics Committee (200140077) and registered prospectively with International Standard Randomized Controlled Trials (ISRCTN80842457), and the protocol was published.11

Fourteen practices expressed an interest in joining the LWP, in addition to the practice of the programs clinical lead. Of these, 6 were randomly selected to join the intervention arm of the trial, along with the clinical leads practice. The remaining 8 were designated comparator practices.11

Adult patients who were registered with an intervention practice and were referred to a CLP during the study recruitment period were eligible. Full details of the recruitment procedure have been published.11 In brief, the health care cliniciansgeneral practitioners (GPs) and practice nurses (PNs)were briefed to give adult patients (aged 18 years or older) the study information and to seek permission to pass on their contact details to the research team at the time of referral to a CLP. When this permission was received, a member of the research team contacted patients to explain the study and, if patients expressed interest in taking part, mailed them the study consent form and baseline questionnaire to complete and return to the study office. If there was no response within 10 days, patients were telephoned and given additional options for completing the questionnaire, either during a face-to-face meeting or over the telephone with the study researcher. We aimed to collect baseline data before the start of the CLP intervention whenever possible, although the researchers had no control over when the CLP would arrange to see the patient.

Because the characteristics of patients seen by a CLP were unknown in advance (any patient deemed suitable for referral to the CLP by the practice was eligible), it was not possible to select matched control patients from the comparator practices at the time of recruitment and baseline data collection. Therefore, 1,000 adult patients (aged 18 years or older) registered with a comparator practice were randomly selected for invitation to participate in the evaluation. A senior GP in each practice reviewed the list to remove patients they considered inappropriate for health or social reasons (such as terminal illness or family or other social crisis).11 The practice then mailed the study invitation pack to the patients included.

The practice-level intervention had 2 key components: a funded full-time CLP in each practice and a practice development fund. Table 1 describes the key features of the program. Its core functions were as follows:

CLPs established links between the practice and local community organizations, helped by the practice development fund used to buy out practice staff time to spend improving systems and building relationships.

General practices developed referral systems through which GPs and PNs referred patients they believed likely to benefit from seeing a CLP.

Description of the Glasgow Deep End Links Worker Program Using the TIDieR Framework12

Each CLP met the referred patient as many times as both thought appropriate, identified the patients most pressing problems, and supported referral to and ongoing contact with local community resources. The theory of change that underpinned the evaluation is shown in Supplemental Table 1, available at http://www.AnnFamMed.org/content/17/6/518/suppl/DC1/. Comparison practices were not allocated a CLP or a practice development fund.

The primary patient outcome was health-related quality of life, measured at baseline and at 9 months follow-up by the EQ-5D-5L, a standardized measure of self-reported health-related quality of life that assesses 5 dimensions at 5 levels of severity.15

Secondary patient outcome measures at baseline and follow-up at 9 months included the Investigating Choice Experiments for the Preferences of Older People Capability Measure for Adults (ICECAP-A,16 a capability-based measure of well-being in adults), the Hospital Anxiety and Depression Scale (HADS),17 the Work and Social Adjustment Scale,18 burden of multimorbidity,19 and self-reported lifestyle activities (smoking, alcohol, exercise). At baseline, data were collected on sociodemographic measures (age, sex, education, ethnicity, and work status) and deprivation status based on postcode by using the Scottish Index of Multiple Deprivation (the Scottish governments small-area index, which integrates 7 domains of deprivation to give an overall score).20

It was not possible to mask participants or health care professionals to the group allocation of their practice. It was also not feasible to blind members of the core study team collecting the data (B.F., L.G.), but the statisticians carrying out the primary analyses (A.M., A.B., G.J.-R.) and all other coauthors were blinded to the allocation. The statistical analysis plan was written before unblinded data analysis.

The minimum target sample sizes of 286 patients for intervention and 484 patients for comparator practices was calculated to have 80% power to detect a minimally important effect size of 0.274 standard deviations (SDs) in the EQ-5D-5L with a 95% degree of confidence, assuming an intraclass correlation of 0.01 and a 50% follow-up rate. This sample size would provide 90% power to detect an effect size of 0.316 SDs under the same assumptions.

Primary analysis was on an intention-to-treat basis (all patients referred to a CLP) using all available data. Subgroup analysis was conducted on patients who actually attended a CLP face-to-face consultation. Differences between groups were tested with appropriate mixed-effects linear or generalized linear regression models, allowing clustering by practice. Because the comparator patients were respondents from a randomly selected sample, it was expected that there would be differences in patient characteristics and outcome measures at baseline compared with the intervention patients. The statistical model used retained the standard adjustments (baseline outcome value, age, sex, deprivation, and multimorbidity) plus any other variables that differed at baseline and were significant predictors of outcome in the regression model.

Of 980 adult patients referred to a CLP during the study period (March-December 2015), 559 (57%) were referred to the research team for potential recruitment to the study. Of these, 288 (52%) were recruited (Supplemental Figure 1a, available at http://www.AnnFamMed.org/content/17/6/518/suppl/DC1/). Patients recruited into the study were representative of all CLP patient referrals in terms of sex, number and type of referral problems, and deprivation level but were slightly older (mean 46.4 years vs 48.3 years for all CLP referrals vs CLP study recruits, respectively, P = 0.018). (Supplemental Table 1, available at http://www.AnnFamMed.org/content/17/6/518/suppl/DC1/.) In comparison practices, a random sample of 7,942 yielded 612 (8%) returned completed baseline questionnaires (Supplemental Figure 1b, available at http://www.AnnFamMed.org/content/17/6/518/suppl/DC1/).

Of the 288 patients recruited to the study in the intervention group, 214 (74.3%) completed the follow-up questionnaire 9 months later. Of the 612 patients recruited into the study in the comparison group, 561 (92%) completed the follow-up questionnaire.

In both the intervention and comparison groups, English was the predominant first language (98%), and 60% of participants were female (Table 2). Patients in the intervention group were younger, of lower socioeconomic status, and more likely to be living alone than patients in the comparison group. They also had more medical and social problems, poorer quality of life, and poorer mental health (Table 2). The prevalence of individual medical conditions and social problems is shown in the supplementary file (Supplemental Tables 2 and 3, available at http://www.AnnFamMed.org/content/17/6/518/suppl/DC1/). Almost one-half (45%) of the intervention group smoked, and 58% reported that they did not exercise regularly.

Patient Characteristics at Baseline

Although we endeavored to collect baseline patient questionnaires before the patient first consulted with the CLP, this was possible in only 159/288 (55%) of patients. However, the baseline outcome and demographic measures of patients who completed the questionnaire before or after the first CLP appointment did not differ significantly (Supplemental Tables 4 and 5, available at http://www.AnnFamMed.org/content/17/6/518/suppl/DC1/). This finding suggests that seeing the CLP once before completing the baseline questionnaire did not affect the baseline outcome scores (further supported by our findings below).

Of the 288 patients in the study who were referred to the CLP, 26 (9.0%) did not engage at all. Of the 262 who engaged, 41.4% had 1 face-to face consultation with the CLP, 13.4% had 2, 12.1% had 3, and 33.5% had 4 or more, with the mean number being 3.1 (SD 4.59). Uptake of community resources by patients increased with increasing number of CLP contacts (Spearmans = 0.684, P <.001), although it declined somewhat above 4 consultations (Figure 1).

Relationship between number of times seen by CLP and patient contact with suggested community resource.

CLP = community-links practitioner.

In the intention-to-treat analysis, referral to a CLP had no significant effect on the primary outcome (health-related quality of life) at 9 months compared with the comparison group in the adjusted analyses (Table 3). This was also the case for all secondary outcomes (Table 3). Subgroup analyses of the patients who consulted face to face with a CLP showed significant improvements in health-related quality of life among those who consulted 3 or more times (Table 4). Similar significant improvements were also observed for anxiety, depression, and self-reported exercise levels (Table 4). No effects were seen on work and social adjustment (Table 4), nor on smoking rates or self-reported alcohol intake (results not shown). The standardized effect sizes of these significant changes in quality of life, anxiety, depression, and exercise levels were generally small (Figure 2).

Effect of Referral to a Community-Links Practitioner on Patient Outcomes

Effect of Seeing a Community-Links Practitioner on Patient Outcomes

Effect sizes of frequency of seeing a community-links practitioner on patient outcomes.

CLP = community-links practitioner; EQ-5D-5L = a standardized measure of self-reported health-related quality of life that assesses 5 dimensions at 5 levels of severity; HADS-A = Hospital Anxiety and Depression Scale, Anxiety; HADS-D = Hospital Anxiety and Depression Scale, Depression.

Because of the high correlation between the number of times patients consulted a CLP and the uptake of suggested community resources (Figure 1), it was not possible in the regression analysis to isolate the effects of consulting a CLP from the effects of attending a community resource.

This quasi-experimental cluster RCT evaluated the effects of a social prescribing initiative, the Glasgow Deep End LWP, in 15 general practices located in areas of high socioeconomic deprivation in Scotland. We were unable to prove that intervention was effective overall (intention-to-treat analysis). Subgroup analysis found significant improvements in the primary outcome and some secondary outcomes in patients who saw the CLP several times. However, this amounted to less than one-half of the patients referred. Caution is warranted in the interpretation of such subgroup analysis because of the possibility of reverse causality.21

Despite the increasing popularity of social prescribing approaches, there is a limited evidence base on its effectiveness.5,79 Recent reviews have found few studies that have included a control group or used a randomized design. The RCT by Grant et al22 was the most similar to the current study in that it targeted patients with psychosocial problems (as identified by GPs), but the sample size was small, patients were generally not of low socioeconomic status (only 10% were in lowest 2 social classes), and follow-up was shorter (4 months) than in our study (9 months). They reported significant improvements in anxiety, depression, and overall general health. A more recent study of a link-worker intervention (with a matched control group), also conducted in a high-deprivation inner-city setting, found no effects of the intervention on anxiety, depression, or general health at 8 months follow-up.23 Similarly, another RCT in an older group, with a 3-year follow-up, found no effects of a link-worker approach.24 Our results, based on the intention-to-treat analysis, are thus in line with these other studies and add to the growing caution about the widely assumed benefits of such approaches.9

Qualitative studies have found that patients who engage with social prescribing initiatives generally find it a positive experience,23,25 but these studies also report that services are often not used to their full extent.23 Other barriers can include lack of buy-in from some GPs or funding for the third sector in a context of social care cuts.26 Our group recently published a qualitative evaluation of the views of the community organizations and the CLPs in the present study, which also concluded that such approaches may not achieve their potential because of ongoing economic austerity and lack of funding for the third sector.27

This is the largest study to date on the effects of social prescribing in deprived areas and one of only a few with a comparison group and cluster randomization. The study had adequate statistical power, with the achieved sample size being larger than the power calculation. The choice of quality of life as the primary outcome was appropriate, given that the intervention was generic rather than aimed at a particular problem or condition. We also included a wide range of validated secondary outcome measures relating to well-being.

Weaknesses of the study included its quasi-experimental design and the fact that it was not possible to have a matched comparison group at baseline. The fact that the research team was not involved in the design of the intervention (which was a service development) was unfortunate, because we could have contributed in terms of underpinning theory and evidence-based development. A longer duration of follow-up (beyond 9 months) would have been desirable, but this was not possible because of the funding limit. It was also not possible to include a cost-effectiveness analysis or access routine data on prescribing and health care utilization because the estimated costs for these data were not accepted by the funder. In addition, we did not have the information to link individual patients with the number and type of community resources used, and thus we cannot say whether some resources were more useful than others. With regard to self-reported exercise level, we used a short, simple measure rather than a better-validated questionnaire (such as the International Physical Activity Questionnaire28) in order to limit questionnaire length in the deprived population under study.

The management of patients with multiple complex health and social problems is a major global challenge with a limited evidence base.29 This type of complex multimorbidity is much more common in deprived than in affluent areas.30 Primary care clinicians and patients in deprived areas struggle to cope with such complexity.31,32 Given the ongoing existence of the inverse care law in deprived areas4,33,34 and the current shortage of GPs in the United Kingdom,35 social prescribing is an attractive option for policy makers as a potential way to reduce health inequalities. The findings of the present study question the effectiveness of this approach, however, with no benefits found in any measured outcome overall and possible benefit found only in those who repeatedly saw the CLP (which was less than one-half of those referred and which may be a spurious finding). Finding ways to improve the uptake and engagement rates of the intervention may lead to better overall outcomes, but further research is needed. Wide-scale deployment of social prescribing initiatives to reduce or mitigate health inequalities seems inappropriate until such research is conducted.

We are grateful to the practice staff and patients who took part in the study. Members of the evaluation advisory group, Andrea Williamson, Anne Ludbrook, Peter Craig, Jill Mutrie, Jane Ford, and Diane Stockton, gave helpful comments on the conduct of the evaluation. Peter Cawston, Mark Kelvin, and Chris Gourley facilitated data collection.

Conflicts of interest: authors report none.

To read or post commentaries in response to this article, see it online at http://www.AnnFamMed.org/content/17/6/518.

Author contributions: S.W.M. and S.W. were the principal investigators, and together with B.F. and C.O. they conceptualized and planned the study. All authors contributed to protocol development, and B.F. and S.W.M. liaised with practices and coordinated recruitment of patients. B.F. coordinated the trial. A.M. led the statistical analyses, which were undertaken by A.B. and G.J.-R. S.W.M. and S.W. wrote the first draft of the manuscript; all authors reviewed the manuscript for intellectual input, and all authors were involved in revisions, including the final revision.

Funding support: This study was funded by the NHS Health Scotland (contract 66450/1, 13/08/2014). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the funder.

Supplementary materials: Available at http://www.AnnFamMed.org/content/17/6/518/suppl/DC1/.

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Effectiveness of Community-Links Practitioners in Areas of High Socioeconomic Deprivation - Annals of Family Medicine

Common Pleas Judge Scott Washam of Columbiana County, Ohio has reportedly sealed votes on a referendum that could possibly ban profitable but unpopular speeding cameras from the town of East Liverpool.

According to The Newspaper, the 2019 election marks the second time that citizens of East Liverpool, Ohio have cast votes on whether to dissolve the city's speeding camera program. The initial campaign in favor of removing the cameras took place in 2017. East Liverpool officials, however, reportedly said that the petition was invalid because it was filed under the wrong law, and took the argument to the Ohio Seventh District Court of Appeals, which ruled in its favor.

Citizens attempted to get a revised, law-abiding version of the petition back on the ballot last year, reports Salem News, but the petition was reportedly submitted too late to make last year's vote, and instead appeared on this year's ballot. Judge Washam, however, has reportedly stepped in to prevent the votes from being counted and instead wishes to first resolve a lawsuit between the city and the Columbiana County Board of Elections. The latter takes no issue with the petition, whereas the former reportedly insists the year-old petition is untimely and wants it retroactively removed from the ballot via a reprint at the cost of $5,000.

"Sadly the votes for our issue have been sealed and won't be released until Judge Washam rules on the lawsuit filed by the city of East Liverpool against us and the Board of Elections," said East Liverpool Citizens Against Traffic Cameras. "This all could have been avoided had city officials simply allowed us to vote, but, regardless, this is the reality of the situation."

The Board's assistant prosecuting attorney Krista Peddicord reportedly pointed out that the city was not authorized to pay to reprint absentee ballots with public funds, and also noted that there is no legal precedent nationwide for a court to nullify votes on speed camera programs once cast.

"It is well settled that, 'provisions for municipal initiative or referendum should be liberally construed in favor of the power reserved so as to permit rather than preclude the exercise of such power, and the object sought to be attained should be promoted rather than prevented or obstructed,'" said Peddicord.

It's unclear how much the city profits from the active speed cams located throughout the town, but it's clearly enough to send local residents through a maze of red tape with the hopes that they give up.

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Ohio Judge Suppresses Votes of Election Aiming to Ban Speed Cameras - The Drive

For others, they find themselves at a crossroads, facing high school graduation, and going to college, entering the workforce, taking a gap year and joining the military are four of the most commonly chosen paths by American teenagers.

Whether military service is in their futures often depends on personal decisions, medical history and a desire to defend freedom, but it can also stem from a love of a program they found in high school, JROTC.

This familiar acronym stands for Junior Reserve Officers Training Corps, a program that stemmed from The National Defense Act of 1916, which established these programs at public and private educational institutions.

The act came only a year before the United States involvement in World War I, a conflict that spanned from 1914 to 1918.

This military-regulated high school program instills the values of citizenship, service to the United States, personal responsibility and a sense of accomplishment, according to documents from the U.S. Army Junior ROTC.

That program operates in more than 1,700 public and private high schools, military institutions and correctional centers throughout the U.S. and overseas. Approximately 40% of JROTC programs are in inner-city schools, serving a student population of 50% minorities.

Each year, about 314,000 JROTC cadets are taught by nearly 4,000 instructors who are retired from active duty, reserve duty or National Guard Army.

At Magna Vista High School in Ridgeway, students who sign up for the program experience JROTC in a variety of ways, from the classroom to the field, for competitions both in and out of state.

According to Magna Vistas website, that JROTC program is regarded as one of the best on the East Coast. Students perform community-service projects, handle color guard duties and learn leadership skills.

Sgt. 1st Class John Truini leads that program. To receive instruction from real-life military men and women gives cadets nationwide a glimpse into life in the service.

It gives them an idea of what military life will be like, in a sense, said Marlon McNair, a junior at Magna Vista.

Lessons for students

Female cadets make up 40% of the overall cadet population.

Seniors Autumn Willard, Kaitlyn Silvers and Kimberly Rodriguez-Barajas, a sophomore, are three of them at MVHS.

Willard expressed that, although the program teaches discipline, integrity and leadership for students planning to join the military, there are also applications cadets glean for civilian life.

Students learn how to be responsible for the real world, she said.

Rodriguez-Barajas said she also gathers knowledge from the program that she applies to her daily life.

The best skill JROTC has taught me is leadership and taking initiative, she said. I feel like they played a role for me to become a better person.

Students learn many valuable lessons and life skills while having a one-of-a-kind experience in JROTC.

For Silvers, learning leadership skills, participating in team-building exercised and learning to exercise the proper way rounded out three of her favorite aspects of the program.

Although some choose to go into the military or follow another path out of high school, Magna Vista cadets expressed trust in the skills they learned in the classroom.

The JROTC programs give high school students an opportunity to take a look into a military branch and see what they do while getting the leadership, education and training, Rodriguez-Barajas said.

Future options

Kolby Quigg, a senior, serves as the cadets student commander at Magna Vista. He also competes in the Warrior Raiders traveling competition team.

Quigg said that the best skill he learned from his years in the JROTC experience was leadership, but he also noted other positive qualities.

Henry County Public Schools JROTC programs prepare students for service in the military by teaching cadets necessary traits that will be used in the military, Quigg said. It keeps the cadets well prepared and trained.

Whether students decide to join the military following high school which approximately 15% of them do students in Magna Vistas JROTC program spoke positively about the career choice.

The military is a good option because it teaches young adults how to be trustworthy, have technical skills and gain money, Willard said.

Quigg said that joining the military could create a successful life path and instill important qualities in young adults but also noted benefits of the JROTC program outside of a military career.

No matter if you are going into the military or not, the benefits that students receive from being a part of JROTC are of a wide array, Quigg said. It teaches basic life skills that can even be used by an unemployed citizen. The lessons that are learned are endless.

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VETERANS: JROTC teaches lessons beyond simply the service members of the future - Martinsville Bulletin

A sudden pain, starting in your chest and radiating down your left arm. Pressure, as if an elephant suddenly sat upon your upper torso. Shortness of breath. Cold sweats. These are the classic signs of a heart attack for men. But what about women? Are the symptoms the same? Join us as we talk to a heart health expert at Norton Heart & Vascular Institute, to find out common heart attack signs and how men and women differ. Well also hear the stories of two women who survived unexpected heart problems and lead healthier, more active lives today.

First, a little background information: The term heart disease refers to several different heart conditions. In the United States, it usually means coronary artery disease, which affects the flow of blood to the heart. A heart attack happens when a part of the heart muscle doesnt get enough blood. Heart disease, left untreated, can cause a heart attack.

One in every five deaths in women is caused by a heart attack.

Current statistics from the Centers for Disease Control and Prevention and the American Heart Association show:

Although heart disease is the leading cause of death for women, heart attacks and heart disease have traditionally been perceived as a mens health issue. In fact, says cardiologist Dr. Janet Smith, that is why the so-called classic symptoms are typically symptoms men experience. For years, all the studies focused on men, so the symptoms they listed were what everyone came to recognize as symptoms of all heart attacks, explains Dr. Smith, who specializes in internal medicine and cardiovascular disease at Norton Healthcare.

Women can present the classic signs of a heart attack, she continues. Chest pressure or pain is the most common symptom for both men and women. But women are more likely than men to feel some of the other symptoms like shortness of breath, nausea, and fatigue. Many describe to me a feeling that something is very wrong, almost a feeling of impending doom.

Women should seek medical attention immediately if they notice*:

Some women may have no symptoms, or may not recognize them until too late. Brenda Burney was 63, healthy, active, and working when a stress test sent her reeling. Formerly in the military, Brenda has always known the importance of exercise, though she switched from running her miles to walking. A single mother of two grown sons, she relishes her role as Grammy to four granddaughters. And as a hospital chaplain, she is always busy. The job was (and is) stressful, however, and her doctor had become concerned about her blood pressure. I took a routine stress test on August 19, 2018, says Brenda. The doctors realized that something was wrong and sent me immediately to Norton Audubon Hospital where I was diagnosed with heart disease. Three days later, I had triple bypass surgery.

Looking back, Brenda says the warning signs were there. She has a family history of heart disease; her father had triple bypass surgery, her mother underwent a quadruple bypass. High blood pressure is another indicator. Brenda recalls experiencing a burning feeling in her chest when she exercised, a strange grabbing pain across her back, and fatigue. What does she want women to know? You are in control of your bodies. Listen to your body and allow it to tell the story of how you are.

Brenda was not aware she had heart disease until she took a stress test. She later underwent triple bypass surgery to improve her heart health.

Brenda attributes her survival to the quick intervention of her health providers and the support of her family. They were just as shocked as I was, but my extended family became my primary caregivers. They met to figure out a schedule and took off work to be with me.

Today Brenda is back at work as a palliative care chaplain. She eats well and continues to exercise, even introducing a Lets Move line dance group for seniors at her church. Most importantly to her, shes become a champion of womens heart health, sharing her story with others, promoting healthy diet and exercise, and actively participating in a support group at Norton.

After an event, its all about lifestyle, Dr. Smith explains. Making necessary changes is critical. Eating a heart-healthy diet, getting regular exercise, maintaining an optimal weight, not smoking, and taking prescribed medication are all important factors to recovery a lesson it took Chloe McClure two heart attacks to learn.

One of five daughters, Chloe has lost two sisters to colon cancer. One sibling had to have a colon resection, one sister is a breast cancer survivor, and her father died of a stroke in 1956. Her only brother died of a heart attack, but with so much cancer in her familys health history, Chloe says heart health was not really on her radar.

Single with two grown daughters, Chloe was a year from retirement as an administrative assistant when she had her first heart attack in January 2011. Like Brenda, Chloe also experienced intense fatigue, sometimes falling asleep in her work clothes right when she got home and sleeping until morning, but she chalked it up to her job. When her heart attack happened, it was sudden and surprising.

I leaned over to put paper in the copier and felt a huge, heavy weight in my chest, she says. It passed long enough for me to get help. I had an angioplasty with a stent at Norton and then I went right back to my same lifestyle. I didnt pay attention to diet or start exercising. My attitude was, Im fixed, so Ill just get on with my job.

Chloe has survived two heart attacks, and now appreciates the importance of leading a healthy, active life.

Two weeks after her April 2012 retirement, Chloe had her second heart attack.

I was having my morning coffee and noticed my shoulder bothering me. At first, I thought Id slept on it wrong, but then my jaw began hurting, almost like I had a toothache. I began to feel faint, then had chills and nausea. I realized what was happening so I called my daughter and she got me to the hospital quickly. The EKG showed I was having another heart attack. I had a second angioplasty with a stent.

She paid more attention to what her cardiologist told her this time. I started walking, she says. I participated in a mini-marathon this spring, I do Pilates, yoga, and water aerobics.

An ovarian cancer survivor, Chloe knows the importance of support groups. She also participates in the monthly group offered by Norton Healthcare and is on the Norton Patient and Family Advisory Council. She is an active volunteer in her community and with cancer support groups. Her best advice? Do not ignore what the doctor tells you!

Both Brenda and Chloe found help within Norton Healthcare, which provides some amazing preventative and after-care programs to help women get healthy and stay that way:

And lastly, what do cardiologists want women to know? Dr. Smiths parting advice echoes both Brendas and Chloes:

*Source: Norton Healthcare

To learn more about Nortons heart health programs and to find a physician, visit nortonhealthcare.com.

This article is sponsored by Norton Healthcare.

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The Most Important Things Women Should Know About Heart Health - StyleBlueprint

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