Usability and feasibility of PreventS-MD web app for stroke prevention.

BACKGROUND: Most strokes and cardiovascular diseases (CVDs) are potentially preventable if their risk factors are identified and well controlled. Digital platforms, such as the PreventS-MD web app (PreventS-MD) may aid health care professionals (HCPs) in assessing and managing risk factors and promoting lifestyle changes for their patients. METHODS: This is a mixed-methods cross-sectional two-phase survey using a largely positivist (quantitative and qualitative) framework. During Phase 1, a prototype of PreventS-MD was tested internationally by 59 of 69 consenting HCPs of different backgrounds, age, sex, working experience, and specialties using hypothetical data. Collected comments/suggestions from the study HCPs in Phase 1 were reviewed and implemented. In Phase 2, a near-final version of PreventS-MD was developed and tested by 58 of 72 consenting HCPs using both hypothetical and real patient (n = 10) data. Qualitative semi-structured interviews with real patients (n = 10) were conducted, and 1 month adherence to the preventive recommendations was assessed by self-reporting. The four System Usability Scale (SUS) groups of scores (0-50 unacceptable; 51-68 poor; 68-80.3 good; >80.3 excellent) were used to determine usability of PreventS-MD. FINDINGS: Ninety-nine HCPs from 27 countries (45% from low- to middle-income countries) participated in the study, and out of them, 10 HCPs were involved in the development of PreventS before the study, and therefore were not involved in the survey. Of the remaining 89 HCPs, 69 consented to the first phase of the survey, and 59 of them completed the first phase of the survey (response rate 86%), and 58 completed the second phase of the survey (response rate 84%). The SUS scores supported good usability of the prototype (mean score = 80.2; 95% CI [77.0-84.0]) and excellent usability of the final version of PreventS-MD (mean score = 81.7; 95% CI [79.1-84.3]) in the field. Scores were not affected by the age, sex, working experience, or specialty of the HCPs. One-month follow-up of the patients confirmed the high level of satisfaction/acceptability of PreventS-MD and (100%) adherence to the recommendations. INTERPRETATION: The PreventS-MD web app has a high level of usability, feasibility, and satisfaction by HCPs and individuals at risk of stroke/CVD. Individuals at risk of stroke/CVD demonstrated a high level of confidence and motivation in following and adhering to preventive recommendations generated by PreventS-MD.

Patient and practice level factors associated with seasonal influenza vaccine uptake among at-risk adults in England, 2011 to 2016: An age-stratified retrospective cohort study.

We sought to gain insights into the determinants of seasonal influenza vaccine (SIV) uptake by conducting an age-stratified analysis (18-64 and 65+) of factors associated with SIV uptake among at-risk adults registered to English practices. Records for at-risk English adults between 2011 and 2016 were identified using the Clinical Practice Research Datalink database. SIV uptake was assessed annually. The associations of patient, practice, and seasonal characteristics with SIV uptake were assessed via cross-sectional and longitudinal analyses, using mixed-effects and general estimating equation logistic regression models. Overall SIV uptake was 35.3% and 74.0% for adults 18-64 and 65+, respectively. Relative to white patients, black patients were least likely to be vaccinated (OR18-64: 0.82 (95% CI: 0.80, 0.85); OR65+: 0.59 (95% CI: 0.56, 0.62)), while Asian patients among 18-64 year olds were most likely to be vaccinated (OR18-64: 1.10 (95% CI: 1.07, 1.13)). Females were more likely than males to be vaccinated among 18-64 year olds (OR18-64: 1.19 (95% CI: 1.18, 1.20)). Greater socioeconomic deprivation was associated with decreased odds of uptake among older patients (OR65+: 0.74 (95% CI: 0.71, 0.77)). For each additional at-risk condition, odds of uptake increased (OR18-64: 2.33 (95% CI: 2.31, 2.36); OR65+: 1.39 (95% CI: 1.38, 1.39)). Odds of uptake were highest among younger patients with diabetes (OR18-64: 4.25 (95% CI: 4.18, 4.32)) and older patients with chronic respiratory disease (OR65+: 1.60 (95% CI: 1.58, 1.63)), whereas they were lowest among morbidly obese patients of all ages (OR18-64: 0.68 (95% CI: 0.67, 0.70); OR65+: 0.97 (95% CI: 0.94, 0.99)). Prior influenza season severity and vaccine effectiveness were marginally predictive of uptake. Our age-stratified analysis uncovered SIV uptake disparities by ethnicity, sex, age, socioeconomic deprivation, and co-morbidities, warranting further attention by GPs and policymakers alike.

The Biological Pump During the Last Glacial Maximum.

Much of the global cooling during ice ages arose from changes in ocean carbon storage that lowered atmospheric CO2. A slew of mechanisms, both physical and biological, have been proposed as key drivers of these changes. Here we discuss the current understanding of these mechanisms with a focus on how they altered the theoretically defined soft-tissue and biological disequilibrium carbon storage at the peak of the last ice age. Observations and models indicate a role for Antarctic sea ice through its influence on ocean circulation patterns, but other mechanisms, including changes in biological processes, must have been important as well, and may have been coordinated through links with global air temperature. Further research is required to better quantify the contributions of the various mechanisms, and there remains great potential to use the Last Glacial Maximum and the ensuing global warming as natural experiments from which to learn about climate-driven changes in the marine ecosystem.

Deep-water circulation changes lead North Atlantic climate during deglaciation.

Constraining the response time of the climate system to changes in North Atlantic Deep Water (NADW) formation is fundamental to improving climate and Atlantic Meridional Overturning Circulation predictability. Here we report a new synchronization of terrestrial, marine, and ice-core records, which allows the first quantitative determination of the response time of North Atlantic climate to changes in high-latitude NADW formation rate during the last deglaciation. Using a continuous record of deep water ventilation from the Nordic Seas, we identify a ∼400-year lead of changes in high-latitude NADW formation ahead of abrupt climate changes recorded in Greenland ice cores at the onset and end of the Younger Dryas stadial, which likely occurred in response to gradual changes in temperature- and wind-driven freshwater transport. We suggest that variations in Nordic Seas deep-water circulation are precursors to abrupt climate changes and that future model studies should address this phasing.

Transient hydrodynamic effects influence organic carbon signatures in marine sediments.

Ocean dynamics served an important role during past dramatic climate changes via impacts on deep-ocean carbon storage. Such changes are recorded in sedimentary proxies of hydrographic change on continental margins, which lie at the ocean-atmosphere-earth interface. However, interpretations of these records are challenging, given complex interplays among processes delivering particulate material to and from ocean margins. Here we report radiocarbon (14C) signatures measured for organic carbon in differing grain-size sediment fractions and foraminifera in a sediment core retrieved from the southwest Iberian margin, spanning the last ~25,000 yr. Variable differences of 0-5000 yr in radiocarbon age are apparent between organic carbon in differing grain-sizes and foraminifera of the same sediment layer. The magnitude of 14C differences co-varies with key paleoceanographic indices (e.g., proximal bottom-current density gradients), which we interpret as evidence of Atlantic-Mediterranean seawater exchange influencing grain-size specific carbon accumulation and translocation. These findings underscore an important link between regional hydrodynamics and interpretations of down-core sedimentary proxies.

Author Correction: Intensified summer monsoon and the urbanization of Indus Civilization in northwest India.

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Intensified summer monsoon and the urbanization of Indus Civilization in northwest India.

Today the desert margins of northwest India are dry and unable to support large populations, but were densely occupied by the populations of the Indus Civilization during the middle to late Holocene. The hydroclimatic conditions under which Indus urbanization took place, which was marked by a period of expanded settlement into the Thar Desert margins, remains poorly understood. We measured the isotopic values (δ18O and δD) of gypsum hydration water in paleolake Karsandi sediments in northern Rajasthan to infer past changes in lake hydrology, which is sensitive to changing amounts of precipitation and evaporation. Our record reveals that relatively wet conditions prevailed at the northern edge of Rajasthan from ~5.1 ± 0.2 ka BP, during the beginning of the agricultural-based Early Harappan phase of the Indus Civilization. Monsoon rainfall intensified further between 5.0 and 4.4 ka BP, during the period when Indus urban centres developed in the western Thar Desert margin and on the plains of Haryana to its north. Drier conditions set in sometime after 4.4 ka BP, and by ~3.9 ka BP an eastward shift of populations had occurred. Our findings provide evidence that climate change was associated with both the expansion and contraction of Indus urbanism along the desert margin in northwest India.

Play-based interventions improve physical function for people with adult-acquired brain injury: a systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: To undertake a systematic review and meta-analysis of the effectiveness of play-based interventions compared to traditional therapy in rehabilitation of adults with adult-acquired brain injury. DATA SOURCES: The search was performed using Medline; Cinahl Plus; Health Source (Nursing/Academic Edition); Psychology and behavioural sciences collection; Biomedical reference collection (basic). REVIEW METHODS: Studies included were randomised controlled trials that investigated the effect of play-based interventions on physical function of adults with adult acquired brain injury. Two independent reviewers identified eligible studies and assessed methodological quality using a modified Downs and Black. Meta-analysis compared standardised differences in means, to determine effect sizes for grouped functional outcome measures. The GRADE scoring system was used to determine the level of clinical evidence. RESULTS: Thirty studies met the inclusion criteria, 13 were considered high quality and 17 moderate quality. Studies predominantly involved post-stroke participants, with only three studies including participants with traumatic brain injury. When compared to traditional therapy, dose-matched studies of play-based interventions showed a significant effect on independence (Effect size (ES) = 0.6) and physical performance (ES = 0.43), as measured using the Fugl -Meyer. For non-dose matched studies, play-based interventions showed a significant improvement for balance (ES = 0.76) compared with traditional therapy. In all studies that measured participant enjoyment, play-based therapy was rated as more enjoyable than traditional therapy. CONCLUSION: Play-based interventions for people with adult acquired brain injury are more effective in improving balance and independence, which may be due to them being more enjoyable than traditional therapy.

Biological and physical controls in the Southern Ocean on past millennial-scale atmospheric CO2 changes.

Millennial-scale climate changes during the last glacial period and deglaciation were accompanied by rapid changes in atmospheric CO2 that remain unexplained. While the role of the Southern Ocean as a 'control valve' on ocean-atmosphere CO2 exchange has been emphasized, the exact nature of this role, in particular the relative contributions of physical (for example, ocean dynamics and air-sea gas exchange) versus biological processes (for example, export productivity), remains poorly constrained. Here we combine reconstructions of bottom-water [O2], export production and (14)C ventilation ages in the sub-Antarctic Atlantic, and show that atmospheric CO2 pulses during the last glacial- and deglacial periods were consistently accompanied by decreases in the biological export of carbon and increases in deep-ocean ventilation via southern-sourced water masses. These findings demonstrate how the Southern Ocean's 'organic carbon pump' has exerted a tight control on atmospheric CO2, and thus global climate, specifically via a synergy of both physical and biological processes.

Evolution of South Atlantic density and chemical stratification across the last deglaciation.

Explanations of the glacial-interglacial variations in atmospheric pCO2 invoke a significant role for the deep ocean in the storage of CO2. Deep-ocean density stratification has been proposed as a mechanism to promote the storage of CO2 in the deep ocean during glacial times. A wealth of proxy data supports the presence of a "chemical divide" between intermediate and deep water in the glacial Atlantic Ocean, which indirectly points to an increase in deep-ocean density stratification. However, direct observational evidence of changes in the primary controls of ocean density stratification, i.e., temperature and salinity, remain scarce. Here, we use Mg/Ca-derived seawater temperature and salinity estimates determined from temperature-corrected δ(18)O measurements on the benthic foraminifer Uvigerina spp. from deep and intermediate water-depth marine sediment cores to reconstruct the changes in density of sub-Antarctic South Atlantic water masses over the last deglaciation (i.e., 22-2 ka before present). We find that a major breakdown in the physical density stratification significantly lags the breakdown of the deep-intermediate chemical divide, as indicated by the chemical tracers of benthic foraminifer δ(13)C and foraminifer/coral (14)C. Our results indicate that chemical destratification likely resulted in the first rise in atmospheric pCO2, whereas the density destratification of the deep South Atlantic lags the second rise in atmospheric pCO2 during the late deglacial period. Our findings emphasize that the physical and chemical destratification of the ocean are not as tightly coupled as generally assumed.

Increased reservoir ages and poorly ventilated deep waters inferred in the glacial Eastern Equatorial Pacific.

Consistent evidence for a poorly ventilated deep Pacific Ocean that could have released its radiocarbon-depleted carbon stock to the atmosphere during the last deglaciation has long been sought. Such evidence remains lacking, in part due to a paucity of surface reservoir age reconstructions required for accurate deep-ocean ventilation age estimates. Here we combine new radiocarbon data from the Eastern Equatorial Pacific (EEP) with chronostratigraphic calendar age constraints to estimate shallow sub-surface reservoir age variability, and thus provide estimates of deep-ocean ventilation ages. Both shallow- and deep-water ventilation ages drop across the last deglaciation, consistent with similar reconstructions from the South Pacific and Southern Ocean. The observed regional fingerprint linking the Southern Ocean and the EEP is consistent with a dominant southern source for EEP thermocline waters and suggests relatively invariant ocean interior transport pathways but significantly reduced air-sea gas exchange in the glacial southern high latitudes.

Radiocarbon evidence for alternating northern and southern sources of ventilation of the deep Atlantic carbon pool during the last deglaciation.

Recent theories for glacial-interglacial climate transitions call on millennial climate perturbations that purged the deep sea of sequestered carbon dioxide via a "bipolar ventilation seesaw." However, the viability of this hypothesis has been contested, and robust evidence in its support is lacking. Here we present a record of North Atlantic deep-water radiocarbon ventilation, which we compare with similar data from the Southern Ocean. A striking coherence in ventilation changes is found, with extremely high ventilation ages prevailing across the deep Atlantic during the last glacial period. The data also reveal two reversals in the ventilation gradient between the deep North Atlantic and Southern Ocean during Heinrich Stadial 1 and the Younger Dryas. These coincided with periods of sustained atmospheric CO2 rise and appear to have been driven by enhanced ocean-atmosphere exchange, primarily in the Southern Ocean. These results confirm the operation of a bipolar ventilation seesaw during deglaciation and underline the contribution of abrupt regional climate anomalies to longer-term global climate transitions.

800,000 years of abrupt climate variability.

We constructed an 800,000-year synthetic record of Greenland climate variability based on the thermal bipolar seesaw model. Our Greenland analog reproduces much of the variability seen in the Greenland ice cores over the past 100,000 years. The synthetic record shows strong similarity with the absolutely dated speleothem record from China, allowing us to place ice core records within an absolute timeframe for the past 400,000 years. Hence, it provides both a stratigraphic reference and a conceptual basis for assessing the long-term evolution of millennial-scale variability and its potential role in climate change at longer time scales. Indeed, we provide evidence for a ubiquitous association between bipolar seesaw oscillations and glacial terminations throughout the Middle to Late Pleistocene.

Facing future climate change: is the past relevant?

From a socio-economic perspective, the 'sharp end' of climate research is very much about looking forward in time. As far as possible, we need to know what to expect and approximately when to expect it. However, it is argued here that our approach to climate change (including its scientific basis and its policy implications) is firmly linked to our understanding of the past. This is mainly due to the role played by palaeoclimate reconstructions in shaping our expectations of the climate system, in particular via their ability to test the accuracy of our climate models. Importantly, this includes the intuitive models that each of us carries around in our mind, as well as the more complex numerical models hiding inside supercomputers. It is through such models that palaeoclimate insights may affect the scientific and political judgements that we must make in the face of persistent and ultimately irreducible predictive uncertainty. Already we can demonstrate a great deal of confidence in our current understanding of the global climate system based specifically on insights from the geological record. If further advances are to be made effectively, climate models should take advantage of both past and present constraints on their behaviour, and should be given added credence to the extent that they are compatible with an increasingly rich tapestry of past climatic phenomena. Furthermore, palaeoclimate data should be accompanied by clearly defined uncertainties, and organized in arrays that are capable of speaking directly to numerical models, and their limitations in particular.