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Background: Climate change is expected to elevate exposure to several environmental health risk factors, including extreme environmental temperatures, air pollution and airborne allergenic pollen. Given their interconnected effects on respiratory and cardiovascular diseases, it is crucial to evaluate these exposures simultaneously. Yet, comprehensive efforts to do so remain limited. This research aims to develop an approach using modelled data, in conjunction with health-based threshold values, to assess whether, where and when there is simultaneous threshold exceedance of heat, air pollution and airborne allergenic pollen in Europe., Methods: Hourly exposure data for the three stressors were sourced from three models (air pollution: LOTOS-EUROS, pollen: Copernicus Atmosphere Monitoring Service, meteorological conditions: ECMWF) for 2021 and 2022. Thresholds for each stressor that indicate the boundary of acceptable limits were based on officially established tresholds or literature recommendations. The result is a 0.1°x0.1° resolution grid (approximately 10 km x 10 km) for each stressor, with each cell representing whether exposure met or exceeded the threshold., Findings: Simultaneous threshold exceedance of air pollution and heat is occurring in various degrees throughout Europe. In the summer of 2022, the exceedances ranged from below 1% in large parts of Northern Europe to as much as 25% of the time in the Mediterranean area. An assessment of monthly threshold exceedance patterns shows a dynamic and changing co-exposure pattern across the year, which differs per region., Interpretation: This work lays out a robust approach to assess simultaneous threshold exceedances of multiple environmental health risk stressors. This approach can guide policy makers in pinpointing high-risk areas particularly vulnerable to simultaneous threshold exceedances, and develop mitigation strategies for those areas., Funding: Internal funding from TNO., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Purpose: The rising frequency of extreme heat events poses an escalating threat of heat-related illnesses and fatalities, placing an additional strain on global healthcare systems. Whether the risk of heat-related issues is sex specific, particularly among the elderly, remains uncertain., Methods: 16 men and 15 women of similar age (69 ± 5 years) were exposed to an air temperature of 39.1 ± 0.3 °C and a relative humidity (RH) of 25.1 ± 1.9%, during 20 min of seated rest and at least 40 min of low-intensity (10 W) cycling exercise. RH was gradually increased by 2% every 5 min starting at minute 30. We measured sweat rate, heart rate, thermal sensation, and the rise in gastrointestinal temperature (Tgi) and skin temperature (Tsk)., Results: Tgi consistently increased from minute 30 to 60, with no significant difference between females and males (0.012 ± 0.004 °C/min vs. 0.011 ± 0.005 °C/min; p = 0.64). Similarly, Tsk increase did not differ between females and males (0.044 ± 0.007 °C/min vs. 0.038 ± 0.011 °C/min; p = 0.07). Females exhibited lower sweat rates than males (0.29 ± 0.06 vs. 0.45 ± 0.14 mg/m 2 /min; p < 0.001) in particular at relative humidities exceeding 30%. No sex differences in heart rate and thermal sensation were observed., Conclusion: Elderly females exhibit significantly lower sweat rates than their male counterparts during low-intensity exercise at ambient temperatures of 39 °C when humidity exceeds 30%. However, both elderly males and females demonstrate a comparable rise in core temperature, skin temperature, and mean body temperature, indicating similar health-related risks associated with heat exposure., (© 2024. The Author(s).)

This study investigates how cognitive performance is affected by the combination of two stressors that are operationally relevant for helicopter pilots: heat load and hypobaric hypoxia. Fifteen participants were exposed to (1) no stressors, (2) heat load, (3) hypobaric hypoxia, and (4) combined heat load and hypobaric hypoxia. Hypobaric hypoxia (13,000 ft) was achieved in a hypobaric chamber. Heat load was induced by increasing ambient temperature to ∼28 °C. Cognitive performance was measured using two multitasks, and a vigilance task. Subjective and physiological data (oxygen saturation, heart rate, core- and skin temperature) were also collected. Mainly heat load caused cognitive performance decline. This can be explained by high subjective heat load and increased skin temperature, which takes away cognitive resources from the tasks. Only the arithmetic subtask was sensitive to hypobaric hypoxia, whereby hypobaric hypoxia caused a further performance decline in addition to the decline caused by heat load. Practitioner summary: Little is known about how multiple environmental stressors interact. This study investigates the combined effects of heat load and hypobaric hypoxia on cognitive performance. An additive effect of heat load and hypobaric hypoxia was found on a arithmetic task, which may be attributed to independent underlying mechanisms.

After more than 50 years of studying soldiers in the cold, we are well past the phase of defining the unique problems; the research requirements are known but the solutions have been slow in coming. This requires iterative testing of proposed lab-based solutions with soldiers in the real environment. Representing a renewed effort to produce and implement solutions to human biomedical challenges in Arctic operations, this journal supplement highlights presentations from a three-day NATO Human Factors and Medicine panel-sponsored symposium in Washington DC in October 2022. While technology can certainly aid soldiers in extreme environments, it is ultimately training that is the most important factor for ensuring optimal performance and survival. By investing in the development of specialized Arctic forces training and implementing new solutions to protect their health and performance, we can ensure success in the coldest and harshest of environments.

Purpose: For wheelchair users with a spinal cord injury, the lower body may be a more convenient cooling site than the upper body. However, it remains unknown if leg cooling reduces thermal strain in these individuals. We compared the impact of upper-body versus lower-body cooling on physiological and perceptual outcomes during submaximal arm-crank exercise under heat stress in individuals with paraplegia., Methods: Twelve male participants with paraplegia (T4-L2, 50% complete lesion) performed a maximal exercise test in temperate conditions, and three heat stress tests (32°C, 40% relative humidity) in which they received upper-body cooling (COOL-UB), lower-body cooling (COOL-LB), or no cooling (CON) in a randomized counterbalanced order. Each heat stress test consisted of four exercise blocks of 15 min at 50% of peak power output, with 3 min of rest in between. Cooling was applied using water-perfused pads, with 14.8-m tubing in both COOL-UB and COOL-LB., Results: Gastrointestinal temperature was 0.2°C (95% confidence interval (CI), 0.1°C to 0.3°C) lower during exercise in COOL-UB versus CON (37.5°C ± 0.4°C vs 37.7°C ± 0.3°C, P = 0.009), with no difference between COOL-LB and CON ( P = 1.0). Heart rate was lower in both COOL-UB (-7 bpm; 95% CI, -11 to -3 bpm; P = 0.01) and COOL-LB (-5 bpm; 95% CI, -9 to -1 bpm; P = 0.049) compared with CON. The skin temperature reduction at the cooled skin sites was larger in COOL-LB (-10.8°C ± 1.1°C) than in COOL-UB (-6.7°C ± 1.4°C, P < 0.001), which limited the cooling capacity in COOL-LB. Thermal sensation of the cooled skin sites was improved and overall thermal discomfort was lower in COOL-UB ( P = 0.01 and P = 0.04) but not in COOL-LB ( P = 0.17 and P = 0.59) compared with CON., Conclusions: Upper-body cooling more effectively reduced thermal strain than lower-body cooling in individuals with paraplegia, as it induced greater thermophysiological and perceptual benefits., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Sports Medicine.)

Exposure to extreme environmental heat or cold during military activities can impose severe thermal strain, leading to impairments in task performance and increasing the risk of exertional heat (including heat stroke) and cold injuries that can be life-threatening. Substantial individual variability in physiological tolerance to thermal stress necessitates an individualized approach to mitigate the deleterious effects of thermal stress, such as physiological monitoring of individual thermal strain. During heat exposure, measurements of deep-body (T c ) and skin temperatures and heart rate can provide some indication of thermal strain. Combining these physiological variables with biomechanical markers of gait (in)stability may provide further insight on central nervous system dysfunction - the key criterion of exertional heat stroke (EHS). Thermal strain in cold environments can be monitored with skin temperature (peripheral and proximal), shivering thermogenesis and T c . Non-invasive methods for real-time estimation of T c have been developed and some appear to be promising but require further validation. Decision-support tools provide useful information for planning activities and biomarkers can be used to improve their predictions, thus maximizing safety and performance during hot- and cold-weather operations. With better understanding on the etiology and pathophysiology of EHS, the microbiome and markers of the inflammatory responses have been identified as novel biomarkers of heat intolerance. This review aims to (i) discuss selected physiological and biomechanical markers of heat or cold strain, (ii) how biomarkers may be used to ensure operational readiness in hot and cold environments, and (iii) present novel molecular biomarkers (e.g., microbiome, inflammatory cytokines) for preventing EHS., Competing Interests: Declaration of interest statement The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

During the early stage of a fire, a process operator often acts as the first responder and may be exposed to high heat radiation levels. The present limit values of long- (>15 min) and short-term exposure (<5 min), 1.0 and 1.5 kW/m2, respectively, have been set using physiological models and manikin measurements. Since human validation is essentially lacking, this study investigated whether operators’ protective clothing offers sufficient protection during a short-term deployment. Twelve professional firefighters were exposed to three radiation levels (1.5, 2.0, and 2.5 kW/m2) when wearing certified protective clothing in front of a heat radiation panel in a climatic chamber (20 °C; 50% RH). The participants wore only briefs (male) or panties and a bra (female) and a T-shirt under the operators’ clothing. Skin temperatures were continuously measured at the chest, belly, forearm, thigh, and knee. The test persons had to stop if any skin temperature reached 43 °C, at their own request, or when 5 min of exposure was reached. The experiments showed that people in operators’ clothing can be safely exposed for 5 min to 1.5 kW/m2, up to 3 min to 2.0 kW/m2, and exposure to 2.5 kW/m2 or above must be avoided unless the clothing can maintain an air gap.

Objectives: To evaluate how separate and combined climatic parameters affect peak core temperature during exercise in the heat using computer simulations fed with individual data., Methods: The impact of eight environmental conditions on rectal temperature (T re ) was determined for exercise under heat stress using the Fiala-thermal-Physiology-and-Comfort simulation model. Variations in ambient temperature (T a ±6°C), relative humidity (RH±15%) and solar radiation (SR+921 W/m 2 ) were assessed in isolation and combination (worst-case/best-case scenarios) and compared with baseline (T a 32°C, RH 75%, SR 0 W/m 2 ). The simulation model was fed with personal, anthropometric and individual exercise characteristics., Results: 54 athletes exercised for 46±10 min at baseline conditions and achieved a peak core temperature of 38.9±0.5°C. Simulations at a higher T a (38°C) and SR (921 W/m 2 ) resulted in a higher peak T re compared with baseline (+0.6±0.3°C and +0.5±0.2°C, respectively), whereas a higher RH (90%) hardly affected peak T re (+0.1±0.1°C). A lower T a (26°C) and RH (60%) reduced peak T re by -0.4±0.2°C and a minor -0.1±0.1°C, respectively. The worst-case simulation yielded a 1.5±0.4°C higher T re than baseline and 2.0±0.7°C higher than the best-case condition., Conclusion: Combined unfavourable climatic conditions produce a greater increase in peak core temperature than the sum of its parts in elite athletes exercising in the heat., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Human tolerance to cold environments is extremely limited and responses between individuals is highly variable. Such physiological and morphological predispositions place them at high risk of developing cold weather injuries [CWI; including hypothermia and/or non-freezing (NFCI) and freezing cold injuries (FCI)]. The present manuscript highlights current knowledge on the vulnerability and variability of human cold responses and associated risks of developing CWI. This review 1) defines and categorizes cold stress and CWI, 2) presents cold defense mechanisms including biological adaptations, acute responses and acclimatization/acclimation and, 3) proposes mitigation strategies for CWI. This body of evidence clearly indicates that all humans are at risk of developing CWI without adequate knowledge and protective equipment. In addition, we show that while body mass plays a key role in mitigating risks of hypothermia between individuals and populations, NFCI and FCI depend mainly on changes in peripheral blood flow and associated decrease in skin temperature. Clearly, understanding the large interindividual variability in morphology, insulation, and metabolism is essential to reduce potential risks for CWI between and within populations., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 Her Majesty the Queen in Right of Canada (Department of National Defence).)

The combination of an exacerbated workload and impermeable nature of the personal protective equipment (PPE) worn by COVID-19 healthcare workers increases heat strain. We aimed to compare the prevalence of heat strain symptoms before (routine care without PPE) versus during the COVID-19 pandemic (COVID-19 care with PPE), identify risk factors associated with experiencing heat strain, and evaluate the access to and use of heat mitigation strategies. Dutch healthcare workers (n = 791) working at COVID-19 wards for ≥1 week, completed an online questionnaire to assess personal characteristics, heat strain symptoms before and during the COVID-19 pandemic, and the access to and use of heat mitigation strategies. Healthcare workers experienced ~25× more often heat strain symptoms during medical duties with PPE (93% of healthcare workers) compared to without PPE (30% of healthcare workers; OR = 25.57 (95% CI = 18.17-35.98)). Female healthcare workers and those with an age <40 years were most affected by heat strain, whereas exposure time and sports activity level were not significantly associated with heat strain prevalence. Cold drinks and ice slurry ingestion were the most frequently used heat mitigation strategies and were available in 63.5% and 30.1% of participants, respectively. Our findings indicate that heat strain is a major challenge for COVID-19 healthcare workers, and heat mitigations strategies are often used to counteract heat strain.

This paper describes the functional development of the ClimApp tool (available for free on iOS and Android devices), which combines current and 24 h weather forecasting with individual information to offer personalised guidance related to thermal exposure. Heat and cold stress assessments are based on ISO standards and thermal models where environmental settings and personal factors are integrated into the ClimApp index ranging from -4 (extremely cold) to +4 (extremely hot), while a range of -1 and +1 signifies low thermal stress. Advice for individuals or for groups is available, and the user can customise the model input according to their personal situation, including activity level, clothing, body characteristics, heat acclimatisation, indoor or outdoor situation, and geographical location. ClimApp output consists of a weather summary, a brief assessment of the thermal situation, and a thermal stress warning. Advice is provided via infographics and text depending on the user profile. ClimApp is available in 10 languages: English, Danish, Dutch, Swedish, Norwegian, Hellenic (Greek), Italian, German, Spanish and French. The tool also includes a research functionality providing a platform for worker and citizen science projects to collect individual data on physical thermal strain and the experienced thermal strain. The application may therefore improve the translation of heat and cold risk assessments and guidance for subpopulations. ClimApp provides the framework for personalising and downscaling weather reports, alerts and advice at the personal level, based on GPS location and adjustable input of individual factors.

Objectives: Soldier performance in the Arctic depends on planning and training, protective equipment, and human physiological limits. The purpose of this review was to highlight the span of current research on enhancing soldier effectiveness in extreme cold and austere environments., Methods: The practices of seasoned soldiers who train in the Arctic and cold-dwelling natives inform performance strategies. We provide examples of research and technology that build on these concepts., Results: Examples of current performance research include evaluation of equipment and tactics such as the bioenergetics of load carriage over snow in Norwegian exercises; Canadian field monitoring of hand temperatures and freezing cold injuries for better protection of manual dexterity; and Dutch predictive modeling of cold-wet work tolerances. Healthy young men can respond to cold with a substantial thermogenic response based on US and Canadian studies on brown adipose tissue and other mechanisms of non-shivering thermogenesis; the potential advantage of greater fat insulation is offset in obese unfit subjects by a smaller thermogenic response. Current physiological studies are addressing previously unanswered problems of cold acclimation procedures, thermogenic enhancement and regulation, and modulation of sympathetic activation, all of which may further enhance cold survival and expand the performance envelope., Conclusion: There is an inseparable behavioral component to soldier performance in the Arctic, and even the best equipment does not benefit soldiers who have not trained in the actual environment. Training inexperienced soldiers to performance limits may be helped with personal monitoring technologies and predictive models., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

The environmental conditions during the Tokyo Olympic and Paralympic Games are expected to be challenging, which increases the risk for participating athletes to develop heat-related illnesses and experience performance loss. To allow safe and optimal exercise performance of Dutch elite athletes, the Thermo Tokyo study aimed to determine thermoregulatory responses and performance loss among elite athletes during exercise in the heat, and to identify personal, sports-related, and environmental factors that contribute to the magnitude of these outcomes. For this purpose, Dutch Olympic and Paralympic athletes performed two personalized incremental exercise tests in simulated control (15°C, relative humidity (RH) 50%) and Tokyo (32°C, RH 75%) conditions, during which exercise performance and (thermo)physiological parameters were obtained. Thereafter, athletes were invited for an additional visit to conduct anthropometric, dual-energy X-ray absorptiometry (DXA), and 3D scan measurements. Collected data also served as input for a thermophysiological computer simulation model to estimate the impact of a wider range of environmental conditions on thermoregulatory responses. Findings of this study can be used to inform elite athletes and their coaches on how heat impacts their individual (thermo)physiological responses and, based on these data, advise which personalized countermeasures (i.e. heat acclimation, cooling interventions, rehydration plan) can be taken to allow safe and maximal performance in the challenging environmental conditions of the Tokyo 2020 Olympic and Paralympic Games., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Cooling vests alleviate heat strain. We quantified the perceptual and physiological heat strain and assessed the effects of wearing a 21°C phase change material cooling vest on these measures during work shifts of COVID-19 nurses wearing personal protective equipment (PPE). Seventeen nurses were monitored on two working days, consisting of a control (PPE only) and a cooling vest day (PPE + cooling vest). Sub-PPE air temperature, gastrointestinal temperature (T gi ), and heart rate (HR) were measured continuously. Thermal comfort (2 [1-4] versus 1 [1-2], p condtition  < 0.001) and thermal sensation (5 [4-7] versus 4 [2-7], p condition  < 0.001) improved in the cooling vest versus control condition. Only 18% of nurses reported thermal discomfort and 36% a (slightly) warm thermal sensation in the cooling vest condition versus 81% and 94% in the control condition (OR (95%CI) 0.05 (0.01-0.29) and 0.04 (<0.01-0.35), respectively). Accordingly, perceptual strain index was lower in the cooling vest versus control condition (5.7 ± 1.5 versus 4.3 ± 1.7, p condition  < 0.001, respectively). No differences were observed for the physiological heat strain index T gi and rating of perceived exertion across conditions. Average HR was slightly lower in the cooling vest versus the control condition (85 ± 12 versus 87 ± 11, p condition  = 0.025). Although the physiological heat strain among nurses using PPE was limited, substantial perceptual heat strain was experienced. A 21°C phase change material cooling vest can successfully alleviate the perceptual heat strain encountered by nurses wearing PPE., Competing Interests: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. We give full disclosure of any relationship or conflict of interest with the industry. The local Medical Ethical Committee approved the study (#2020-6379), and participants gave written informed consent prior to study participation. The manuscript has not been published and is not being considered for publication elsewhere in whole or part in any language. All authors have read and approved the manuscript. We agree to be accountable for all aspects of the work., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Purpose: Ventilated vests are developed to reduce thermal stress by enhancing convective and evaporative cooling from skin tissue underneath the vest. The purpose of this study is to investigate whether thermal stress is equal when a ventilated vest is worn compared to a no-vest situation with similar dry thermal resistance., Methods: Nine healthy males walked on a treadmill (7 km h -1 ) for 45 min in a desert climate (34 °C, 20% relative humidity) with and without ventilated vest. Gastrointestinal temperature (T gi ), heart rate (HR), and skin temperature (T sk ) were continuously monitored. Local sweat rate (LSR) was assessed two times on six skin locations. Subjective ratings were assessed every 10 min., Results: Final T gi (37.6 ± 0.1 °C for vest and 37.6 ± 0.1 °C for no-vest), HR (133 ± 7 bpm and 133 ± 9 bpm) and mean T sk (34.8 ± 0.7 °C and 34.9 ± 0.6 °C) were not different between conditions (p ≥ 0.163). Scapula skin temperature (T scapula ) under the vest tended to be lower (baseline to final: ΔT scapula  = 0.35 ± 0.37 °C) than without vest (ΔT scapula  = 0.74 ± 0.62 °C, p = 0.096). LSR at locations outside the vest did not differ with and without vest (p ≥ 0.271). Likewise, subjective responses did not differ between conditions (χ 2  ≥ 0.143)., Conclusions: We conclude that two systems with similar dry thermal resistance and, therefore, similar required evaporation, resulted in similar thermal stress during paced walking in a hot-dry environment. Local ventilation did not alter the sweating response on locations outside the vest.

This study investigates the hypotheses that during passive heat stress, the change in perception of time and change in accuracy of a timed decision task relate to changes in thermophysiological variables gastrointestinal temperature and heart rate (HR), as well as subjective measures of cognitive load and thermal perception. Young adult males (N = 29) participated in two 60-min head-out water immersion conditions (36.5°C-neutral and 38.0°C-warm). Cognitive task measurements included accuracy (judgment task), response time (judgment ask), and time estimation (interval timing task). Physiological measurements included gastrointestinal temperature and heart rate. Subjective measurements included cognitive task load (NASA-TLX), rate of perceived exertion, thermal sensation, and thermal comfort. Gastrointestinal temperature and HR were significantly higher in warm versus neutral condition (gastrointestinal temperature: 38.4 ± 0.2°C vs. 37.2 ± 0.2°C, p < 0.01; HR: 105 ± 8 BPM vs. 83 ± 9 BPM, p < 0.01). The change in accuracy was significantly associated with the change in gastrointestinal temperature, and attenuated by change in thermal sensation and change in HR (r2=0.40, p< 0.01). Change in response time was significantly associated with the change in gastrointestinal temperature (r2=0.26, p< 0.002), and change in time estimation was best explained by a change in thermal discomfort (r2=0.18, p< 0.01). Changes in cognitive performance during passive thermal stress are significantly associated with changes in thermophysiological variables and thermal perception. Although explained variance is low (<50%), decreased accuracy is attributed to increased gastrointestinal temperature, yet is attenuated by increased arousal (expressed as increased HR and warmth thermal sensation)., Competing Interests: No potential conflict of interest was reported by the authors., (© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

In human sport science, the acute:chronic workload (ACWR) ratio is used to monitor an athlete's preparedness for competition and to assess injury risks. The aim of this study was to investigate whether acute and chronic workload calculations for external and internal loads (e.g. high-speed work distance and associated exertional effort) were associated with injury risk in elite eventing horses and to identify workloads performed by horses competing in different competition and at different fitness levels. Training load and injury data were collected from 58 international eventing horses (CCI2*-CCI5* level) over 1-3 years. A total of 94 individual competition seasons were monitored. During this period, heart rate (HR; beat/min) and GPS data were collected of all their conditional training sessions and competitions. External load was determined as the distance (m) covered at high speed (HS 1 ; velocity between 6.6 and 9.5 m/s), and sprint speed (SS 2 ; velocity>9.5 m/s). Internal load was calculated for HS and SS, using individualized training impulses (TRIMP 3 ;AU). For internal and external workload HS and SS the acute (1-week) and chronic (4-week) workloads were calculated and ACWR 4 determined. The injury data in relation to ACWR was modelled with a multilevel logistic regression. Akaike's information criterion was used for model reduction. Sixty-four soft tissue injuries were registered from a total of 2300 training sessions and competitions. External and internal workload at HS and SS were significantly affected by the year and fitness level of horses. Competition level and year significantly affected the distances covered at SS. The ACWR of high-speed distance of the present week (OR; 0.133, 95 % CI; 0.032, 0.484) and the previous week (OR 3.951, 95 % CI; 1.390, 12.498) were significantly associated with injury risk. Competition level and chronic workload had no significant effect on injuries. In agreement with findings in human athletes, acute spikes of workload in eventing horses increased the risk of injury. Evaluation of horses' workload can be used to design and effectively monitor training programs and can help to improve equine welfare by reducing injury risk., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Existing heat-health warning systems focus on warning vulnerable groups in order to reduce mortality. However, human health and performance are affected at much lower environmental heat strain levels than those directly associated with higher mortality. Moreover, workers are at elevated health risks when exposed to prolonged heat. This study describes the multilingual "HEAT-SHIELD occupational warning system" platform (https://heatshield.zonalab.it/) operating for Europe and developed within the framework of the HEAT-SHIELD project. This system is based on probabilistic medium-range forecasts calibrated on approximately 1800 meteorological stations in Europe and provides the ensemble forecast of the daily maximum heat stress. The platform provides a non-customized output represented by a map showing the weekly maximum probability of exceeding a specific heat stress condition, for each of the four upcoming weeks. Customized output allows the forecast of the personalized local heat-stress-risk based on workers' physical, clothing and behavioral characteristics and the work environment (outdoors in the sun or shade), also taking into account heat acclimatization. Personal daily heat stress risk levels and behavioral suggestions (hydration and work breaks recommended) to be taken into consideration in the short term (5 days) are provided together with long-term heat risk forecasts (up to 46 days), all which are useful for planning work activities. The HEAT-SHIELD platform provides adaptation strategies for "managing" the impact of global warming.

The quality of local skin temperature prediction by thermophysiological models depends on the local skin blood flow (SBF) control functions. These equations were derived for low activity levels (0.8-1met) and mostly in sitting or supine position. This study validates and discusses the prediction of foot SBF during activities of 1-3met in male and females, and the effect on the foot skin temperature prediction (ΔT skin,foot ) using the thermophysiological simulation model ThermoSEM. The SBF at the foot was measured for ten male and ten female human subjects at baseline and during three activities (sitting, walking at 1km/h, preferred walking around 3km/h). Additional measurements included the energy expenditure, local skin temperatures (T skin,loc ), environmental conditions and body composition. Measured, normalized foot SBF is 2-8 times higher than the simulated SBF during walking sessions. Also, SBF increases are significantly higher in females vs. males (preferred walking: 4.8±1.5 versus 2.7±1.4, P < 0.05). The quality of ΔT skin,foot using the simulated foot SBF is poor (median deviation is -4.8°C, maximumumdeviationis-6°C). Using the measured SBF in ThermoSEM results in an improved local skin temperature prediction (new maximum deviation is -3.3°C). From these data a new SBF model was developed that includes the walking activity level and gender, and improves SBF prediction and ΔT skin,foot of the thermophysiological model. Accurate SBF and local skin temperature predictions are beneficial in optimizing thermal comfort simulations in the built environment, and might also be applied in sport science or patient's temperature management., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Evidence suggests that human timing ability is compromised by heat. In particular, some studies suggest that increasing body temperature speeds up an internal clock, resulting in faster time perception. However, the consequences of this speed-up for other cognitive processes remain unknown. In the current study, we rigorously tested the speed-up hypothesis by inducing passive hyperthermia through immersion of participants in warm water. In addition, we tested how a change in time perception affects performance in decision making under deadline stress. We found that participants underestimate a prelearned temporal interval when body temperature increases, and that their performance in a two-alternative forced-choice task displays signatures of increased time pressure. These results show not only that timing plays an important role in decision-making, but also that this relationship is mediated by temperature. The consequences for decision-making in job environments that are demanding due to changes in body temperature may be considerable.

The Tokyo Olympics and Paralympic games in 2020 will be held in hot and humid conditions. Heat acclimation (in a climatic chamber) or heat acclimatization (natural environment) is essential to prepare the (endurance) athletes and reduce the performance loss associated with work in the heat. Based on the 1990-2018 hourly meteorological data of Tokyo and the derived wet bulb globe temperature (WBGT) (Liljegren method), Heat Index and Humidex, it is shown that the circumstances prior to the games are likely not sufficiently hot to fully adapt to the heat. For instance, the WBGT 2 weeks prior to the games at the hottest moment of the day (13:00 h) is 26.4 ± 2.9°C and 28.6 ± 2.8°C during the games. These values include correction for global warming. The daily variation in thermal strain indices during the Tokyo Olympics (WBGT varying by 4°C between the early morning and the early afternoon) implies that the time of day of the event has a considerable impact on heat strain. The Paralympics heat strain is about 1.5°C WBGT lower than the Olympics, but may still impose considerable heat strain since the Paralympic athletes often have a reduced ability to thermoregulate. It is therefore recommended to acclimate about 1 month prior to the Olympics under controlled conditions set to the worst-case Tokyo climate and re-acclimatize in Japan or surroundings just prior to the Olympics.

Background & Aims: Many COPD patients have a reduced exercise capacity and mechanical efficiency and are at increased cardiometabolic risk. This study aimed to assess acute and 7-days effects of dietary nitrate on mechanical efficiency, exercise performance and cardiac biomarkers in patients with COPD., Methods: This double-blind, randomized cross-over placebo controlled trial included 20 mild-to-moderate COPD patients (66.6 ± 7.5 years) with moderate exercise impairments and decreased mechanical efficiency, normal BMI (26 ± 3 kg/m 2 ) but high prevalence of abdominal obesity (83.3%). Subjects were randomly allocated to the treatment order of 7 days sodium nitrate ingestion (∼8 mmol/day) and 7 days placebo (NaCl solution) or vice versa, separated by a washout period. Before (Day-1) and after (Day-7) both intervention periods resting metabolic rate and the metabolic response during submaximal cycle ergometry, cycling endurance time, plasma nitrate and nitrite levels, cardiac plasma biomarkers (e.g. cardiac troponin T, Nt-proBNP and creatinine kinase) and blood pressure were measured. Subsequently, gross, net and delta mechanical efficiency were calculated., Results: Plasma nitrate and nitrite concentrations increased at Day-1 and Day-7 after sodium nitrate but not after placebo ingestion. Systolic and diastolic blood pressure did not change following nitrate ingestion. Furthermore, no differences were observed in gross, net, and delta mechanical efficiency during submaximal exercise, cycling endurance time and cardiac biomarkers between nitrate and placebo on Day-1 and Day-7. Meta-analysis of all available studies in COPD also showed no beneficial effect of beetroot juice on systolic and diastolic blood pressure., Conclusion: Acute as well as 7-days sodium nitrate supplementation does not modulate mechanical efficiency, blood pressure or cardiac biomarkers in mild-to-moderate COPD patients., (Copyright © 2017 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Understanding the drivers leading to individual differences in human thermal perception has become increasingly important, amongst other things due to challenges such as climate change and an ageing society. This review summarizes existing knowledge related to physiological, psychological, and context-related drivers of diversity in thermal perception. Furthermore, the current state of knowledge is discussed in terms of its applicability in thermal comfort models, by combining modelling approaches of the thermoneutral zone (TNZ) and adaptive thermal heat balance model (ATHB). In conclusion, the results of this review show the clear contribution of some physiological and psychological factors, such as body composition, metabolic rate, adaptation to certain thermal environments and perceived control, to differences in thermal perception. However, the role of other potential diversity-causing parameters, such as age and sex, remain uncertain. Further research is suggested, especially regarding the interaction of different diversity-driving factors with each other, both physiological and psychological, to help establishing a holistic picture.

Neutral thermal sensation is expected for a human body in heat balance in near-steady-state thermal environments. The physiological thermoneutral zone (TNZ) is defined as the range of operative temperatures where the body can maintain such heat balance by actively adjusting body tissue insulation, but without regulatory increases in metabolic rate or sweating. These basic principles led to the hypothesis that thermal sensation relates to the operative temperature distance from the thermoneutral centroid (dTNZ op ). This hypothesis was confirmed by data from respiratory climate chamber experiments. This paper explores the potential of such biophysical model for the prediction of thermal sensation under increased contextual variance. Data (798 votes, 47 participants) from a controlled office environment were used to analyze the predictive performance of the dTNZ op model. The results showed a similar relationship between dTNZ op and thermal sensation between the dataset used here and the previously used dataset. The predictive performance had the same magnitude as that of the PMV model; however, potential benefits of using a biophysical model are discussed. In conclusion, these findings confirm the potential of the biophysical model with regard to the understanding and prediction of human thermal sensation. Further work remains to make benefit of its full potential., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Passive mild heat acclimation (PMHA) reflects realistic temperature challenges encountered in everyday life. Active heat acclimation, combining heat exposure and exercise, influences several important thermophysiological parameters; for example, it decreases core temperature and enhances heat exchange via the skin. However, it is unclear whether PMHA elicits comparable adaptations. Therefore, this study investigated the effect of PMHA on thermophysiological parameters. Participants were exposed to slightly increased temperatures (∼33°C/22% RH) for 6 h/d over 7 consecutive days. To study physiologic responses before and after PMHA, participants underwent a temperature ramp (UP), where ambient temperature increased from a thermoneutral value (28.8 ± 0.3°C) to 37.5 ± 0.6°C. During UP, core and skin temperature, water loss, cardiovascular parameters, skin blood flow and energy expenditure were measured. Three intervals were selected to compare data before and after PMHA: baseline (minutes 30-55: 28.44 ± 0.21°C), T1 (minutes 105-115: 33.29 ± 0.4°C) and T2 (minutes 130-140: 35.68 ± 0.61°C). After 7 d of PMHA, core (T1: -0.13 ± 0.13°C, P = 0.011; T2: -0.14 ± 0.15°C, P = 0.026) and proximal skin temperature (T1: -0.22 ± 0.29°C, P = 0.029) were lower during UP, whereas distal skin temperature was higher in a thermoneutral state (baseline: +0.74 ± 0.77°C, P = 0.009) and during UP (T1: +0.49 ± 0.76°C, P = .057 (not significant), T2:+0.51 ± 0.63°C, P = .022). Moreover, water loss was reduced (-30.5 ± 33.3 ml, P = 0.012) and both systolic (-7.7 ± 7.7 mmHg, P = 0.015) and diastolic (-4.4 ± 4.8 mmHg, P = 0.001) blood pressures were lowered in a thermoneutral state. During UP, only systolic blood pressure was decreased (T2: -6.1 ± 4.4 mmHg, P = 0.003). Skin blood flow was significantly decreased at T1 (-28.35 ± 38.96%, P = 0.037), yet energy expenditure remained unchanged. In conclusion, despite the mild heat stimulus, we show that PMHA induces distinct thermophysiological adaptations leading to increased resilience to heat.