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Objective Patient involvement in scientific research is becoming increasingly important to ensure a patient-centered approach to medicine. The objective of this study is twofold: firstly, to ascertain patients’ perspectives on adherence to therapy and secondly, to integrate this information into a systematic review (SR) on interventions to improve adherence in chronic obstructive pulmonary disease (COPD). Methods In parallel with the SR, two focus group interviews with a COPD self-help group were conducted using semi-structured interview guidelines. The interviews were analyzed using computer-assisted qualitative content analysis according to Kuckartz with the aim of complementing the results of the systematic literature review and to develop propositions for further scientific use. Results The first focus group interview comprising 321 codes included 14 (mean age 67.7 ± 6.8 years; 71.4% female) and the second interview comprising 139 codes included 10 (mean age 68,5 ± 8,2 years; 50% female) patients. Ten categories of the content analysis informed the logic models and the applicability analysis of the SR and six propositions representing the patient’s perspective were developed for further scientific use: Main themes were (I) Enhancement of patient’s self-efficacy (II) Access to trusted medical information (III) Patient-physician relationship (IV) Measures to improve adherence (V) Sociocultural/medical environment (VI) Methods to measure adherence. Conclusion The inclusion of the patient perspective in an SR can be successfully achieved by conducting focus group interviews. Multimodal measures aimed at enhancing patient’s self-efficacy helping them to achieve individual goals reinforces adherence to therapy from a patient’s perspective.

Background Non-invasive ventilation (NIV) is a well-established treatment for chronic hypercapnic respiratory failure (CHRF). While studies have demonstrated benefits for mortality, hospitalization rates, and health related quality of life (HRQL), evidence is particularly sparse regarding HRQL determinants in the older population. Methods In a prospective, monocentric observational study, HRQL was assessed using the established Severe Respiratory Insufficiency Questionnaire (SRI). The study was prospectively registered in the German Clinical Trials Register on 17 June 2015 under the registration number DRKS00008759. Patients were categorized into two age-based groups: older patients (≥ 65 years) and younger patients (< 65 years). Multiple linear regression analyses were used to analyze factors on HRQL, including SRI scores, anemia, autonomy impairment, exacerbation history and other factors. Results 237 Patients with COPD with CHRF receiving NIV therapy were included. The mean SRI summary score was 49.9 ± 16.8. with 23.2% ( N  = 55) suffering from anemia and 36.7% ( N  = 87) experiencing  ≥  2 exacerbations annually. Autonomy impairment was observed in 49.4% ( N  = 117) of patients. The updated Charlson Comorbidity Index (uCCI) was 2.2 ± 1.86. No significant differences were found in SRI Summary Scale scores between age groups ( p  = 0.581), but notable disparities were present in the uCCI ( p  = 0.014). Multiple regression analysis revealed a negative association of exacerbation history (Young group: -9.2; 95% CI = -14.8/ -3.55 vs. Older group: -6.17; 95% CI = -11.91/ -0.43) and level of autonomy impairment (e.g. Level of Care 2 Young group: -13.91; 95% CI = -21.4/ -6.43 vs. Older group: -14.94; 95% CI = -22.64/ -7.24) on SRI scores with age-related differences. Anemia only had a negative association on the SRI scores in younger patients with COPD (Young group: -7.9; 95% CI = -14.0/ -1.75 vs. Older group: -1.78; 95% CI = -9.21/ 5.65). Discussion Frequent exacerbations and a higher level of autonomy impairment had a negative association on HRQL across all ages. However only higher levels of impairment (≥ 2) have a detrimental impact on older patients. Anemia was a negative HRQL factor in younger patients, where it was more prevalent. Overall, HRQL was found to be comparably favorable in both older and younger patients, despite age-specific differences in influencing factors. Registration of the clinical trial The study from which the data were analyzed was prospectively registered in the German Clinical Trials Register (DRKS00008759) on June 17, 2015.

Background Previous studies have demonstrated the efficacy of rehabilitation after a cardiovascular procedure. Especially older and multimorbid patients benefit from rehabilitation after a cardiac procedure. Prehabilitation prior to cardiac procedures may also have positive effects on patients’ pre- and postoperative outcomes. Results of a current meta-analysis show that prehabilitation prior to cardiac procedures can improve perioperative outcomes and alleviate adverse effects. Germany currently lacks a structured cardiac prehabilitation program for older patients, which is coordinated across healthcare sectors. Methods In a randomized, controlled, two-arm parallel group, assessor-blinded multicenter intervention trial (PRECOVERY), we will randomize 422 patients aged 75 years or older scheduled for an elective cardiac procedure (e.g., coronary artery bypass graft surgery or transcatheter aortic valve replacement). In PRECOVERY, patients randomized to the intervention group participate in a 2-week multimodal prehabilitation intervention conducted in selected cardiac-specific rehabilitation facilities. The multimodal prehabilitation includes seven modules: exercise therapy, occupational therapy, cognitive training, psychosocial intervention, disease-specific education, education with relatives, and nutritional intervention. Participants in the control group receive standard medical care. The co-primary outcomes are quality of life (QoL) and mortality after 12 months. QoL will be measured by the EuroQol 5-dimensional questionnaire (EQ-5D-5L). A health economic evaluation using health insurance data will measure cost-effectiveness. A mixed-methods process evaluation will accompany the randomized, controlled trial to evaluate dose, reach, fidelity and adaptions of the intervention. Discussion In this study, we investigate whether a tailored prehabilitation program can improve long-term survival, QoL and functional capacity. Additionally, we will analyze whether the intervention is cost-effective. This is the largest cardiac prehabilitation trial targeting the wide implementation of a new form of care for geriatric cardiac patients. Trial registration German Clinical Trials Register (DRKS; http://www.drks.de ; DRKS00030526). Registered on 30 January 2023.

Despite several studies on decadal-scale solar influence on climate, a systematic analysis of the Sun's contribution to decadal surface climate predictability is still missing. Here, we disentangle the solar-cycle-induced climate response from internal variability and from other external forcings such as greenhouse gases. We utilize two 10-member ensemble simulations with a state-of-the-art chemistry–climate model, to date a unique dataset in chemistry–climate modeling. Using these model simulations, we quantify the potential predictability related to the solar cycle and demonstrate that the detectability of the solar influence on surface climate depends on the magnitude of the solar cycle. Further, we show that a strong solar cycle forcing organizes and synchronizes the decadal-scale component of the North Atlantic Oscillation, the dominant mode of climate variability in the North Atlantic region.

Southern Hemisphere lower-stratospheric ozone depletion has been shown to lead to a poleward shift of the tropospheric jet stream during austral summer, influencing surface atmosphere and ocean conditions, such as surface temperatures and sea ice extent. The characteristics of stratospheric and tropospheric responses to ozone depletion, however, differ among climate models depending on the representation of ozone in the models. The most appropriate way to represent ozone in a model is to calculate it interactively. However, due to computational costs, in particular for long-term coupled ocean–atmosphere model integrations, the more common way is to prescribe ozone from observations or calculated model fields. Here, we investigate the difference between an interactive and a specified chemistry version of the same atmospheric model in a fully coupled setup using a nine-member chemistry–climate model ensemble. In the specified chemistry version of the model the ozone fields are prescribed using the output from the interactive chemistry model version. We use daily resolved ozone fields in the specified chemistry simulations to achieve a very good comparability between the ozone forcing with and without interactive chemistry. We find that although the shortwave heating rate trend in response to ozone depletion is the same in the different chemistry settings, the interactive chemistry ensemble shows a stronger trend in polar cap stratospheric temperatures (by about 0.7 K decade−1) and circumpolar stratospheric zonal mean zonal winds (by about 1.6 m s−1 decade−1 as compared to the specified chemistry ensemble. This difference between interactive and specified chemistry in the stratospheric response to ozone depletion also affects the tropospheric response. However, an impact on the poleward shift of the tropospheric jet stream is not detected. We attribute part of the differences found in the experiments to the missing representation of feedbacks between chemistry and dynamics in the specified chemistry ensemble, which affect the dynamical heating rates, and part of it to the lack of spatial asymmetries in the prescribed ozone fields. This effect is investigated using a sensitivity ensemble that was forced by a three-dimensional instead of a two-dimensional ozone field. This study emphasizes the value of interactive chemistry for the representation of the Southern Hemisphere stratospheric-jet response to ozone depletion and infers that for periods with strong ozone variability (trends) the details of the ozone forcing could also have an influence on the representation of southern-hemispheric climate variability.

This paper describes the recommended solar forcing dataset for CMIP6 and highlights changes with respect to CMIP5. The solar forcing is provided for radiative properties, namely total solar irradiance (TSI), solar spectral irradiance (SSI), and the F10.7 index as well as particle forcing, including geomagnetic indices Ap and Kp, and ionization rates to account for effects of solar protons, electrons, and galactic cosmic rays. This is the first time that a recommendation for solar-driven particle forcing has been provided for a CMIP exercise. The solar forcing datasets are provided at daily and monthly resolution separately for the CMIP6 preindustrial control, historical (1850–2014), and future (2015–2300) simulations. For the preindustrial control simulation, both constant and time-varying solar forcing components are provided, with the latter including variability on 11-year and shorter timescales but no long-term changes. For the future, we provide a realistic scenario of what solar behavior could be, as well as an additional extreme Maunder-minimum-like sensitivity scenario. This paper describes the forcing datasets and also provides detailed recommendations as to their implementation in current climate models.For the historical simulations, the TSI and SSI time series are defined as the average of two solar irradiance models that are adapted to CMIP6 needs: an empirical one (NRLTSI2–NRLSSI2) and a semi-empirical one (SATIRE). A new and lower TSI value is recommended: the contemporary solar-cycle average is now 1361.0 W m−2. The slight negative trend in TSI over the three most recent solar cycles in the CMIP6 dataset leads to only a small global radiative forcing of −0.04 W m−2. In the 200–400 nm wavelength range, which is important for ozone photochemistry, the CMIP6 solar forcing dataset shows a larger solar-cycle variability contribution to TSI than in CMIP5 (50 % compared to 35 %).We compare the climatic effects of the CMIP6 solar forcing dataset to its CMIP5 predecessor by using time-slice experiments of two chemistry–climate models and a reference radiative transfer model. The differences in the long-term mean SSI in the CMIP6 dataset, compared to CMIP5, impact on climatological stratospheric conditions (lower shortwave heating rates of −0.35 K day−1 at the stratopause), cooler stratospheric temperatures (−1.5 K in the upper stratosphere), lower ozone abundances in the lower stratosphere (−3 %), and higher ozone abundances (+1.5 % in the upper stratosphere and lower mesosphere). Between the maximum and minimum phases of the 11-year solar cycle, there is an increase in shortwave heating rates (+0.2 K day−1 at the stratopause), temperatures ( ∼  1 K at the stratopause), and ozone (+2.5 % in the upper stratosphere) in the tropical upper stratosphere using the CMIP6 forcing dataset. This solar-cycle response is slightly larger, but not statistically significantly different from that for the CMIP5 forcing dataset.CMIP6 models with a well-resolved shortwave radiation scheme are encouraged to prescribe SSI changes and include solar-induced stratospheric ozone variations, in order to better represent solar climate variability compared to models that only prescribe TSI and/or exclude the solar-ozone response. We show that monthly-mean solar-induced ozone variations are implicitly included in the SPARC/CCMI CMIP6 Ozone Database for historical simulations, which is derived from transient chemistry–climate model simulations and has been developed for climate models that do not calculate ozone interactively. CMIP6 models without chemistry that perform a preindustrial control simulation with time-varying solar forcing will need to use a modified version of the SPARC/CCMI Ozone Database that includes solar variability. CMIP6 models with interactive chemistry are also encouraged to use the particle forcing datasets, which will allow the potential long-term effects of particles to be addressed for the first time. The consideration of particle forcing has been shown to significantly improve the representation of reactive nitrogen and ozone variability in the polar middle atmosphere, eventually resulting in further improvements in the representation of solar climate variability in global models.

Permafrost warming has the potential to amplify global climate change, because when frozen sediments thaw it unlocks soil organic carbon. Yet to date, no globally consistent assessment of permafrost temperature change has been compiled. Here we use a global data set of permafrost temperature time series from the Global Terrestrial Network for Permafrost to evaluate temperature change across permafrost regions for the period since the International Polar Year (2007–2009). During the reference decade between 2007 and 2016, ground temperature near the depth of zero annual amplitude in the continuous permafrost zone increased by 0.39 ± 0.15 °C. Over the same period, discontinuous permafrost warmed by 0.20 ± 0.10 °C. Permafrost in mountains warmed by 0.19 ± 0.05 °C and in Antarctica by 0.37 ± 0.10 °C. Globally, permafrost temperature increased by 0.29 ± 0.12 °C. The observed trend follows the Arctic amplification of air temperature increase in the Northern Hemisphere. In the discontinuous zone, however, ground warming occurred due to increased snow thickness while air temperature remained statistically unchanged. Climate change strongly impacts regions in high latitudes and altitudes that store high amounts of carbon in yet frozen ground. Here the authors show that the consequence of these changes is global warming of permafrost at depths greater than 10 m in the Northern Hemisphere, in mountains, and in Antarctica.

Variations in the solar spectral irradiance (SSI) with the 11-year sunspot cycle have been shown to have a significant impact on temperatures and the mixing ratios of atmospheric constituents in the stratosphere and mesosphere. Uncertainties in modelling the effects of SSI variations arise from uncertainties in the empirical models reconstructing the prescribed SSI data set as well as from uncertainties in the chemistry–climate model (CCM) formulation. In this study CCM simulations with the ECHAM/MESSy Atmospheric Chemistry (EMAC) model and the Community Earth System Model 1 (CESM1)–Whole Atmosphere Chemistry Climate Model (WACCM) have been performed to quantify the uncertainties of the solar responses in chemistry and dynamics that are due to the usage of five different SSI data sets or the two CCMs. We apply a two-way analysis of variance (ANOVA) to separate the influence of the SSI data sets and the CCMs on the variability of the solar response in shortwave heating rates, temperature, and ozone. The solar response is derived from climatological differences of time slice simulations prescribing SSI for the solar maximum in 1989 and near the solar minimum in 1994. The SSI values for the solar maximum of each SSI data set are created by adding the SSI differences between November 1994 and November 1989 to a common SSI reference spectrum for near-solar-minimum conditions based on ATLAS-3 (Atmospheric Laboratory of Applications and Science-3). The ANOVA identifies the SSI data set with the strongest influence on the variability of the solar response in shortwave heating rates in the upper mesosphere and in the upper stratosphere–lower mesosphere. The strongest influence on the variability of the solar response in ozone and temperature is identified in the upper stratosphere–lower mesosphere. However, in the region of the largest ozone mixing ratio, in the stratosphere from 50 to 10 hPa, the SSI data sets do not contribute much to the variability of the solar response when the Spectral And Total Irradiance REconstructions-T (SATIRE-T) SSI data set is omitted. The largest influence of the CCMs on variability of the solar responses can be identified in the upper mesosphere. The solar response in the lower stratosphere also depends on the CCM used, especially in the tropics and northern hemispheric subtropics and mid-latitudes, where the model dynamics modulate the solar responses. Apart from the upper mesosphere, there are also regions where the largest fraction of the variability of the solar response is explained by randomness, especially for the solar response in temperature.

A new Earth system model, the Flexible Ocean and Climate Infrastructure (FOCI), is introduced. A first version of FOCI consists of a global high-top atmosphere (European Centre Hamburg general circulation model; ECHAM6.3) and an ocean model (Nucleus for European Modelling of the Ocean v3.6; NEMO3.6) as well as sea-ice (Louvain-la-Neuve sea Ice Model version 2; LIM2) and land surface model components (Jena Scheme for Biosphere Atmosphere Coupling in Hamburg; JSBACH), which are coupled through the OASIS3-MCT software package. FOCI includes a number of optional modules which can be activated depending on the scientific question of interest. In the atmosphere, interactive stratospheric chemistry can be used (ECHAM6-HAMMOZ) to study, for example, the effects of the ozone hole on the climate system. In the ocean, a biogeochemistry model (Model of Oceanic Pelagic Stoichiometry; MOPS) is available to study the global carbon cycle. A unique feature of FOCI is the ability to explicitly resolve mesoscale ocean eddies in specific regions. This is realized in the ocean through nesting; first examples for the Agulhas Current and the Gulf Stream systems are described here. FOCI therefore bridges the gap between coarse-resolution climate models and global high-resolution weather prediction and ocean-only models. It allows to study the evolution of the climate system on regional and seasonal to (multi)decadal scales.The development of FOCI resulted from a combination of the long-standing expertise in ocean and climate modeling in several research units and divisions at the Helmholtz Centre for Ocean Research Kiel (GEOMAR). FOCI will thus be used to complement and interpret long-term observations in the Atlantic, enhance the process understanding of the role of mesoscale oceanic eddies for large-scale oceanic and atmospheric circulation patterns, study feedback mechanisms with stratospheric processes, estimate future ocean acidification, and improve the simulation of the Atlantic Meridional Overturning Circulation changes and their influence on climate, ocean chemistry and biology.In this paper, we present both the scientific vision for the development of FOCI as well as some technical details. This includes a first validation of the different model components using several configurations of FOCI. Results show that the model in its basic configuration runs stably under pre-industrial control as well as under historical forcing and produces a mean climate and variability which compares well with observations, reanalysis products and other climate models. The nested configurations reduce some long-standing biases in climate models and are an important step forward to include the atmospheric response in multidecadal eddy-rich configurations.

Infections acquired in hospital are an important cause of morbidity and mortality in very preterm infants. Several small trials have suggested that supplementing the enteral diet of very preterm infants with lactoferrin, an antimicrobial protein processed from cow's milk, prevents infections and associated complications. The aim of this large randomised controlled trial was to collect data to enhance the validity and applicability of the evidence from previous trials to inform practice. In this randomised placebo-controlled trial, we recruited very preterm infants born before 32 weeks' gestation in 37 UK hospitals and younger than 72 h at randomisation. Exclusion criteria were presence of a severe congenital anomaly, anticipated enteral fasting for longer than 14 days, or no realistic prospect of survival. Eligible infants were randomly assigned (1:1) to receive either enteral bovine lactoferrin (150 mg/kg per day; maximum 300 mg/day; lactoferrin group) or sucrose (same dose; control group) once daily until 34 weeks' postmenstrual age. Web-based randomisation minimised for recruitment site, gestation (completed weeks), sex, and single versus multifetal pregnancy. Parents, caregivers, and outcome assessors were unaware of group assignment. The primary outcome was microbiologically confirmed or clinically suspected late-onset infection (occurring >72 h after birth), which was assessed in all participants for whom primary outcome data was available by calculating the relative risk ratio with 95% CI between the two groups. The trial is registered with the International Standard Randomised Controlled Trial Number 88261002. We recruited 2203 participants between May 7, 2014, and Sept 28, 2017, of whom 1099 were assigned to the lactoferrin group and 1104 to the control group. Four infants had consent withdrawn or unconfirmed, leaving 1098 infants in the lactoferrin group and 1101 in the sucrose group. Primary outcome data for 2182 infants (1093 [99·5%] of 1098 in the lactoferrin group and 1089 [99·0] of 1101 in the control group) were available for inclusion in the modified intention-to-treat analyses. 316 (29%) of 1093 infants in the intervention group acquired a late-onset infection versus 334 (31%) of 1089 in the control group. The risk ratio adjusted for minimisation factors was 0·95 (95% CI 0·86–1·04; p=0·233). During the trial there were 16 serious adverse events for infants in the lactoferrin group and 10 for infants in the control group. Two events in the lactoferrin group (one case of blood in stool and one death after intestinal perforation) were assessed as being possibly related to the trial intervention. Enteral supplementation with bovine lactoferrin does not reduce the risk of late-onset infection in very preterm infants. These data do not support its routine use to prevent late-onset infection and associated morbidity or mortality in very preterm infants. UK National Institute for Health Research Health Technology Assessment programme (10/57/49).