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The early part of the last deglaciation is characterised by a ~40 ppm atmospheric CO 2 rise occurring in two abrupt phases. The underlying mechanisms driving these increases remain a subject of intense debate. Here, we successfully reproduce changes in CO 2 , δ 13 C and Δ 14 C as recorded by paleo-records during Heinrich stadial 1 (HS1). We show that HS1 CO 2 increase can be explained by enhanced Southern Ocean upwelling of carbon-rich Pacific deep and intermediate waters, resulting from intensified Southern Ocean convection and Southern Hemisphere (SH) westerlies. While enhanced Antarctic Bottom Water formation leads to a millennial CO 2 outgassing, intensified SH westerlies induce a multi-decadal atmospheric CO 2 rise. A strengthening of SH westerlies in a global eddy-permitting ocean model further supports a multi-decadal CO 2 outgassing from the Southern Ocean. Our results highlight the crucial role of SH westerlies in the global climate and carbon cycle system with important implications for future climate projections. Despite decades of research, the sequence of events leading to the deglacial atmospheric CO 2 rise remains unclear. Menviel et al. show that Southern Ocean convection driven by intensified Southern Hemisphere westerlies during Heinrich stadial 1 can explain the abrupt p CO 2 rise and changes in atmosphere and ocean carbon isotopes.

Multimillennial simulations with a fully coupled climate–carbon cycle model are examined to assess the persistence of the climatic impacts of anthropogenic CO₂ emissions. It is found that the time required to absorb anthropogenic CO₂ strongly depends on the total amount of emissions; for emissions similar to known fossil fuel reserves, the time to absorb 50% of the CO₂ is more than 2000 yr. The long-term climate response appears to be independent of the rate at which CO₂ is emitted over the next few centuries. Results further suggest that the lifetime of the surface air temperature anomaly might be as much as 60% longer than the lifetime of anthropogenic CO₂ and that two-thirds of the maximum temperature anomaly will persist for longer than 10 000 yr. This suggests that the consequences of anthropogenic CO₂ emissions will persist for many millennia.

Background A growing body of evidence suggests that healthcare practitioners who enhance how they express empathy can improve patient health, and reduce medico-legal risk. However we do not know how consistently healthcare practitioners express adequate empathy. In this study, we addressed this gap by investigating patient rankings of practitioner empathy. Methods We conducted a systematic review and meta-analysis of studies that asked patients to rate their practitioners’ empathy using the Consultation and Relational Empathy (CARE) measure. CARE is emerging as the most common and best-validated patient rating of practitioner empathy. We searched: MEDLINE, Embase, PsycINFO, Cinahl, Science & Social Science Citation Indexes, the Cochrane Library and PubMed from database inception to March 2016. We excluded studies that did not use the CARE measure. Two reviewers independently screened titles and extracted data on average CARE scores, demographic data for patients and practitioners, and type of healthcare practitioners. Results Sixty-four independent studies within 51 publications had sufficient data to pool. The average CARE score was 40.48 (95% CI, 39.24 to 41.72). This rank s in the bottom 5th percentile in comparison with scores collected by CARE developers. Longer consultations ( n  = 13) scored 15% higher (42.60, 95% CI 40.66 to 44.54) than shorter ( n  = 9) consultations (34.93, 95% CI 32.63 to 37.24). Studies with mostly (>50%) female practitioners ( n  = 6) showed 16% higher empathy scores (42.77, 95% CI 38.98 to 46.56) than those with mostly (>50%) male ( n  = 6) practitioners (34.84, 95% CI 30.98 to 38.71). There were statistically significant ( P =  0.032) differences between types of providers (allied health professionals, medical students, physicians, and traditional Chinese doctors). Allied Health Professionals ( n  = 6) scored the highest (45.29, 95% CI 41.38 to 49.20), and physicians ( n  = 39) scored the lowest (39.68, 95% CI 38.29 to 41.08). Patients in Australia, the USA, and the UK reported highest empathy ratings (>43 average CARE), with lowest scores (<35 average CARE scores) in Hong Kong. Conclusions Patient rankings of practitioner empathy are highly variable, with female practitioners expressing empathy to patients more effectively than male practitioners. The high variability of patient rating of practitioner empathy is likely to be associated with variable patient health outcomes. Limitations included frequent failure to report response rates introducing a risk of response bias. Future work is warranted to investigate ways to reduce the variability in practitioner empathy.

IntroductionPlacebo research investigated the underlying mechanisms of placebo effects, but they are rarely used to optimize treatments. Ethical and legal concerns have been raised, but research demonstrated that placebo mechanisms can be used without patients’ deception: Experimental studies showed that half of drugs in treatment of attention-deficit/hyperactivity disorder (ADHD) combined with open-label placebos could be as effective as standard medication to reduce ADHD symptoms.ObjectivesTo estimate the health economic advantages of harnessing the combination of open-label placebos with standard medication in ADHD.MethodsFor preliminary estimation of the mean treatment costs, the 12-months prevalence of ADHD in children and adolescents aged 5 to 14 years as well as the percentage of medication treatments were extracted from the literature. Mean treatment costs per patient and year were calculated for four treatment plans (different drugs and dosages) with both treatment with standard medication and half of drugs in combination with placebos.ResultsA 12-months prevalence of 4.3% equals around 260,000 children and adolescents with a compulsory health insurance in Germany. Of those, around 40-50% are equally treated with two standard drugs and two different dosages. Full standard drug treatments cost around 119 million EUR, and treatment with half of drugs in combination with placebos cost around 66 million EUR.ConclusionsThe combination of open-label placebos with half of standard medication could considerably reduce health costs. Reduction of side effects still must be considered. However, current studies are of experimental nature and lasted for no longer than two weeks.

Species richness and spatial variation in community composition (i.e., beta diversity) are key measures of biodiversity. They are largely determined by natural factors, but also increasingly affected by anthropogenic factors. Thus, there is a need for a clear understanding of the human impact on species richness and beta diversity, the underlying mechanisms, and whether human-induced changes can override natural patterns. Here, we dissect the patterns of species richness, community composition and beta diversity in relation to different environmental factors as well as human impact in one framework: aquatic macrophytes in 66 boreal lakes in Eastern Finland. The lakes had been classified as having high, good or moderate status (according to ecological classification of surface waters in Finland) reflecting multifaceted human impact. We used generalized least square models to study the association between different environmental variables (Secchi depth, irregularity of the shoreline, total phosphorus, pH, alkalinity, conductivity) and species richness. We tested the null hypothesis that the observed community composition can be explained by random distribution of species. We used multivariate distance matrix regression to test the effect of each environmental variable on community composition, and distance-based test for homogeneity of multivariate dispersion to test whether lakes classified as high, good or moderate status have different beta diversity. We showed that environmental drivers of species richness and community composition were largely similar, although dependent on the particular life-form group studied. The most important ones were characteristics of water quality (pH, alkalinity, conductivity) and irregularity of the shoreline. Differences in community composition were related to environmental variables independently of species richness. Species richness was higher in lakes with higher levels of human impact. Lakes with different levels of human impact had different community composition. Between-lake beta diversity did not differ in high, good or moderate status groups. However, the variation in environmental variables shaping community composition was larger in lakes with moderate status compared to other lakes. Hence, beta diversity in lakes with moderate status was smaller than what could be expected on the basis of these environmental characteristics. This could be interpreted as homogenization.

Past climate records reveal many instances of rapid climate change that are often coincident with fast changes in atmospheric greenhouse gas concentrations, suggesting links and positive feedbacks between the carbon cycle and the physical climate system. The carbon reservoirs that might have played an important role during these past episodes of rapid change include near-surface soil and peatland carbon, permafrost, carbon stored in vegetation, methane hydrates in deep-sea sediments, volcanism, and carbon stored in parts of the ocean that are easily ventilated through changes in circulation. To determine whether similar changes might lie in store in our future, we must gain a better understanding of the physics, biogeochemistry, dynamics, and feedbacks involved in such events. Specifically, we need to ascertain the main natural sources of atmospheric carbon dioxide and methane linked to rapid climate events in the paleoclimate record, and understand the mechanisms, triggers, thresholds, and feedbacks that were involved. Our review contributes to this focus issue by synthesizing results from nine studies covering a broad range of past time episodes. Studies are categorized into (a) episodes of massive carbon release millions of years ago; (b) the transition from the last glacial to the current interglacial 19 000–11 000 years ago; and (c) the current era. We conclude with a discussion on major remaining research challenges and implications for future projections and risk assessment.

The first results of the UVic Earth System Model coupled to a land surface scheme and a dynamic global vegetation model are presented in this study. In the first part the present day climate simulation is discussed and compared to observations. We then compare a simulation of an ice age inception (forced with 116 ka BP orbital parameters and an atmospheric CO^sub 2^ concentration of 240 ppm) with a preindustrial run (present day orbital parameters, atmospheric [CO^sub 2^] = 280 ppm). Emphasis is placed on the vegetation's response to the combined changes in solar radiation and atmospheric CO^sub 2^ level. A southward shift of the northern treeline as well as a global decrease in vegetation carbon is observed in the ice age inception run. In tropical regions, up to 88% of broadleaf trees are replaced by shrubs and C^sub 4^ grasses. These changes in vegetation cover have a remarkable effect on the global climate: land related feedbacks double the atmospheric cooling during the ice age inception as well as the reduction of the meridional overturning in the North Atlantic. The introduction of vegetation related feedbacks also increases the surface area with perennial snow significantly.[PUBLICATION ABSTRACT]

This study explores natural and anthropogenic influences on the climate system, with an emphasis on the biogeophysical and biogeochemical effects of historical land cover change. The biogeophysical effect of land cover change is first subjected to a detailed sensitivity analysis in the context of the UVic Earth System Climate Model, a global climate model of intermediate complexity. Results show a global cooling in the range of -0.06 to -0.22 °C, though this effect is not found to be detectable in observed temperature trends. We then include the effects of natural forcings (volcanic aerosols, solar insolation variability and orbital changes) and other anthropogenic forcings (greenhouse gases and sulfate aerosols). Transient model runs from the year 1700 to 2000 are presented for each forcing individually as well as for combinations of forcings. We find that the UVic Model reproduces well the global temperature data when all forcings are included. These transient experiments are repeated using a dynamic vegetation model coupled interactively to the UVic Model. We find that dynamic vegetation acts as a positive feedback in the climate system for both the all-forcings and land cover change only model runs. Finally, the biogeochemical effect of land cover change is explored using a dynamically coupled inorganic ocean and terrestrial carbon cycle model. The carbon emissions from land cover change are found to enhance global temperatures by an amount that exceeds the biogeophysical cooling. The net effect of historical land cover change over this period is to increase global temperature by 0.15 °C.[PUBLICATION ABSTRACT]

One-third of the world’s coral reefs have disappeared over the last 30 years, and a further third is under threat today from various stress factors. The main global stress factors on coral reefs have been identified as changes in sea surface temperature (SST) and changes in surface seawater aragonite saturation (Ω arag ). Here, we use a climate model of intermediate complexity, which includes an ocean general circulation model and a fully coupled carbon cycle, in conjunction with present-day observations of inter-annual SST variability to investigate three IPCC representative concentration pathways (RCP 3PD, RCP 4.5, and RCP 8.5), and their impact on the environmental stressors of coral reefs related to open ocean SST and open ocean Ω arag over the next 400 years. Our simulations show that for the RCP 4.5 and 8.5 scenarios, the threshold of 3.3 for zonal and annual mean Ω arag would be crossed in the first half of this century. By year 2030, 66–85% of the reef locations considered in this study would experience severe bleaching events at least once every 10 years. Regardless of the concentration pathway, virtually every reef considered in this study (>97%) would experience severe thermal stress by year 2050. In all our simulations, changes in surface seawater aragonite saturation lead changes in temperatures.