Continental Scale Hydrostratigraphy: Basin-Scale Testing of Alternative Data-Driven Approaches.

Integrated hydrological modeling is an effective method for understanding interactions between parts of the hydrologic cycle, quantifying water resources, and furthering knowledge of hydrologic processes. However, these models are dependent on robust and accurate datasets that physically represent spatial characteristics as model inputs. This study evaluates multiple data-driven approaches for estimating hydraulic conductivity and subsurface properties at the continental-scale, constructed from existing subsurface dataset components. Each subsurface configuration represents upper (unconfined) hydrogeology, lower (confined) hydrogeology, and the presence of a vertical flow barrier. Configurations are tested in two large-scale U.S. watersheds using an integrated model. Model results are compared to observed streamflow and steady state water table depth (WTD). We provide model results for a range of configurations and show that both WTD and surface water partitioning are important indicators of performance. We also show that geology data source, total subsurface depth, anisotropy, and inclusion of a vertical flow barrier are the most important considerations for subsurface configurations. While a range of configurations proved viable, we provide a recommended Selected National Configuration 1 km resolution subsurface dataset for use in distributed large-and continental-scale hydrologic modeling.

Continental Scale Hydrostratigraphy: Comparing Geologically Informed Data Products to Analytical Solutions.

This study synthesizes two different methods for estimating hydraulic conductivity (K) at large scales. We derive analytical approaches that estimate K and apply them to the contiguous United States. We then compare these analytical approaches to three-dimensional, national gridded K data products and three transmissivity (T) data products developed from publicly available sources. We evaluate these data products using multiple approaches: comparing their statistics qualitatively and quantitatively and with hydrologic model simulations. Some of these datasets were used as inputs for an integrated hydrologic model of the Upper Colorado River Basin and the comparison of the results with observations was used to further evaluate the K data products. Simulated average daily streamflow was compared to daily flow data from 10 USGS stream gages in the domain, and annually averaged simulated groundwater depths are compared to observations from nearly 2000 monitoring wells. We find streamflow predictions from analytically informed simulations to be similar in relative bias and Spearman's rho to the geologically informed simulations. R-squared values for groundwater depth predictions are close between the best performing analytically and geologically informed simulations at 0.68 and 0.70 respectively, with RMSE values under 10 m. We also show that the analytical approach derived by this study produces estimates of K that are similar in spatial distribution, standard deviation, mean value, and modeling performance to geologically-informed estimates. The results of this work are used to inform a follow-on study that tests additional data-driven approaches in multiple basins within the contiguous United States.

Water Table Depth Estimates over the Contiguous United States Using a Random Forest Model.

Water table depth (WTD) has a substantial impact on the connection between groundwater dynamics and land surface processes. Due to the scarcity of WTD observations, physically-based groundwater models are growing in their ability to map WTD at large scales; however, they are still challenged to represent simulated WTD compared to well observations. In this study, we develop a purely data-driven approach to estimating WTD at continental scale. We apply a random forest (RF) model to estimate WTD over most of the contiguous United States (CONUS) based on available WTD observations. The estimated WTD are in good agreement with well observations, with a Pearson correlation coefficient (r) of 0.96 (0.81 during testing), a Nash-Sutcliffe efficiency (NSE) of 0.93 (0.65 during testing), and a root mean square error (RMSE) of 6.87 m (15.31 m during testing). The location of each grid cell is rated as the most important feature in estimating WTD over most of the CONUS, which might be a surrogate for spatial information. In addition, the uncertainty of the RF model is quantified using quantile regression forests. High uncertainties are generally associated with locations having a shallow WTD. Our study demonstrates that the RF model can produce reasonable WTD estimates over most of the CONUS, providing an alternative to physics-based modeling for modeling large-scale freshwater resources. Since the CONUS covers many different hydrologic regimes, the RF model trained for the CONUS may be transferrable to other regions with a similar hydrologic regime and limited observations.

Alternative cascade-testing protocols for identifying and managing patients with familial hypercholesterolaemia: systematic reviews, qualitative study and cost-effectiveness analysis.

Background: Cascade testing the relatives of people with familial hypercholesterolaemia is an efficient approach to identifying familial hypercholesterolaemia. The cascade-testing protocol starts with identifying an index patient with familial hypercholesterolaemia, followed by one of three approaches to contact other relatives: indirect approach, whereby index patients contact their relatives; direct approach, whereby the specialist contacts the relatives; or a combination of both direct and indirect approaches. However, it is unclear which protocol may be most effective. Objectives: The objectives were to determine the yield of cases from different cascade-testing protocols, treatment patterns, and short- and long-term outcomes for people with familial hypercholesterolaemia; to evaluate the cost-effectiveness of alternative protocols for familial hypercholesterolaemia cascade testing; and to qualitatively assess the acceptability of different cascade-testing protocols to individuals and families with familial hypercholesterolaemia, and to health-care providers. Design and methods: This study comprised systematic reviews and analysis of three data sets: PASS (PASS Software, Rijswijk, the Netherlands) hospital familial hypercholesterolaemia databases, the Clinical Practice Research Datalink (CPRD)-Hospital Episode Statistics (HES) linked primary-secondary care data set, and a specialist familial hypercholesterolaemia register. Cost-effectiveness modelling, incorporating preceding analyses, was undertaken. Acceptability was examined in interviews with patients, relatives and health-care professionals. Result: Systematic review of protocols: based on data from 4 of the 24 studies, the combined approach led to a slightly higher yield of relatives tested [40%, 95% confidence interval (CI) 37% to 42%] than the direct (33%, 95% CI 28% to 39%) or indirect approaches alone (34%, 95% CI 30% to 37%). The PASS databases identified that those contacted directly were more likely to complete cascade testing (p < 0.01); the CPRD-HES data set indicated that 70% did not achieve target treatment levels, and demonstrated increased cardiovascular disease risk among these individuals, compared with controls (hazard ratio 9.14, 95% CI 8.55 to 9.76). The specialist familial hypercholesterolaemia register confirmed excessive cardiovascular morbidity (standardised morbidity ratio 7.17, 95% CI 6.79 to 7.56). Cost-effectiveness modelling found a net health gain from diagnosis of -0.27 to 2.51 quality-adjusted life-years at the willingness-to-pay threshold of £15,000 per quality-adjusted life-year gained. The cost-effective protocols cascaded from genetically confirmed index cases by contacting first- and second-degree relatives simultaneously and directly. Interviews found a service-led direct-contact approach was more reliable, but combining direct and indirect approaches, guided by index patients and family relationships, may be more acceptable. Limitations: Systematic reviews were not used in the economic analysis, as relevant studies were lacking or of poor quality. As only a proportion of those with primary care-coded familial hypercholesterolaemia are likely to actually have familial hypercholesterolaemia, CPRD analyses are likely to underestimate the true effect. The cost-effectiveness analysis required assumptions related to the long-term cardiovascular disease risk, the effect of treatment on cholesterol and the generalisability of estimates from the data sets. Interview recruitment was limited to white English-speaking participants. Conclusions: Based on limited evidence, most cost-effective cascade-testing protocols, diagnosing most relatives, select index cases by genetic testing, with services directly contacting relatives, and contacting second-degree relatives even if first-degree relatives have not been tested. Combined approaches to contact relatives may be more suitable for some families. Future work: Establish a long-term familial hypercholesterolaemia cohort, measuring cholesterol levels, treatment and cardiovascular outcomes. Conduct a randomised study comparing different approaches to contact relatives. Study registration: This study is registered as PROSPERO CRD42018117445 and CRD42019125775. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 16. See the NIHR Journals Library website for further project information.

Familial hypercholesterolaemia is an inherited condition that causes raised cholesterol levels from birth and increases risk of heart disease if left untreated. After someone in a family is found to have familial hypercholesterolaemia (called an index case), their close relatives need to be contacted and checked to see if they have familial hypercholesterolaemia, using genetic or cholesterol testing. This is called 'cascade testing'. We planned to find the most cost-effective and acceptable way to do this. The relatives could be contacted for testing by the index case (indirect approach), by a health-care professional (direct approach) or by a combination of both approaches. We found, based on looking at hospital records, that more relatives were tested if health-care professionals directly contacted relatives. In previous studies, slightly more relatives were tested for familial hypercholesterolaemia with a combination approach. Interviews with patients also suggested that the direct approach was the most effective, but the most acceptable and successful approach depends on family relationships: using one approach for some families and using both for other families. Furthermore, by looking at the health-care records of large numbers of patients, we confirmed that people with a recorded diagnosis of familial hypercholesterolaemia in general practice records have a much higher risk of heart disease than the general population, and this was especially so for those with previous heart disease and/or raised cholesterols levels when diagnosed. However, one-quarter of new patients with familial hypercholesterolaemia recorded in their records were not treated within 2 years, with less than one-third reaching recommended cholesterol levels. We used what we had learned to help us estimate the most cost-effective way to do cascade testing. This showed that if the health service directly contact all relatives simultaneously for further assessment, rather than the current approach whereby close (first-degree) relatives are contacted first, this was cost-effective and good value for money.

The evolution of dam induced river fragmentation in the United States.

It is established that dams decrease river connectivity; however, previous global scale studies of river fragmentation focused on a small subset of the largest dams. In the United States, mid-sized dams, which are too small for global databases, account for 96% of major anthropogenic structures and 48% of reservoir storage. We conduct a national evaluation of the evolution of anthropogenic river bifurcation over time that includes more than 50,000 nationally inventoried dams. Mid-sized dams account for 73% of anthropogenically created stream fragments nationally. They also contribute disproportionately to short fragments (less than 10 km), which is particularly troubling for aquatic habitats. Here we show that dam construction has essentially reversed natural fragmentation patterns in the United States. Prior to human development, smaller river fragments and less connected networks occurred in arid basins while today we show that humid basins are the most fragmented due to human structures.

Reducing Premature Coronary Artery Disease in Malaysia by Early Identification of Familial Hypercholesterolemia Using the Familial Hypercholesterolemia Case Ascertainment Tool (FAMCAT): Protocol for a Mixed Methods Evaluation Study.

BACKGROUND: Familial hypercholesterolemia (FH) is predominantly caused by mutations in the 4 FH candidate genes (FHCGs), namely, low-density lipoprotein receptor (LDLR), apolipoprotein B-100 (APOB-100), proprotein convertase subtilisin/kexin type 9 (PCSK9), and the LDL receptor adaptor protein 1 (LDLRAP1). It is characterized by elevated low-density lipoprotein cholesterol (LDL-c) levels leading to premature coronary artery disease. FH can be clinically diagnosed using established clinical criteria, namely, Simon Broome (SB) and Dutch Lipid Clinic Criteria (DLCC), and can be identified using the Familial Hypercholesterolemia Case Ascertainment Tool (FAMCAT), a primary care screening tool. OBJECTIVE: This study aims to (1) compare the detection rate of genetically confirmed FH and diagnostic accuracy between the FAMCAT, SB, and DLCC in the Malaysian primary care setting; (2) identify the genetic mutation profiles, including novel variants, in individuals with suspected FH in primary care; (3) explore the experience, concern, and expectation of individuals with suspected FH who have undergone genetic testing in primary care; and (4) evaluate the clinical utility of a web-based FH Identification Tool that includes the FAMCAT, SB, and DLCC in the Malaysian primary care setting. METHODS: This is a mixed methods evaluation study conducted in 11 Ministry of Health primary care clinics located at the central administrative region of Malaysia. In Work stream 1, the diagnostic accuracy study design is used to compare the detection rate and diagnostic accuracy of the FAMCAT, SB, and DLCC against molecular diagnosis as the gold standard. In Work stream 2, the targeted next-generation sequencing of the 4 FHCGs is used to identify the genetic mutation profiles among individuals with suspected FH. In Work stream 3a, a qualitative semistructured interview methodology is used to explore the experience, concern, and expectation of individuals with suspected FH who have undergone genetic testing. Lastly, in Work stream 3b, a qualitative real-time observation of primary care physicians using the "think-aloud" methodology is applied to evaluate the clinical utility of a web-based FH Identification Tool. RESULTS: The recruitment for Work stream 1, and blood sampling and genetic analysis for Work stream 2 were completed in February 2023. Data collection for Work stream 3 was completed in March 2023. Data analysis for Work streams 1, 2, 3a, and 3b is projected to be completed by June 2023, with the results of this study anticipated to be published by December 2023. CONCLUSIONS: This study will provide evidence on which clinical diagnostic criterion is the best to detect FH in the Malaysian primary care setting. The full spectrum of genetic mutations in the FHCGs including novel pathogenic variants will be identified. Patients' perspectives while undergoing genetic testing and the primary care physicians experience in utilizing the web-based tool will be established. These findings will have tremendous impact on the management of patients with FH in primary care and subsequently reduce their risk of premature coronary artery disease. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47911.

Introducing genetic testing with case finding for familial hypercholesterolaemia in primary care: qualitative study of patient and health professional experience.

BACKGROUND: Familial hypercholesterolaemia (FH) is a common inherited condition causing elevated cholesterol, premature heart disease, and early death. Although FH can be effectively treated, over 80% of people with FH remain undetected. AIM: To explore patient and health professional experiences of introducing genetic testing with case finding for FH in primary care. DESIGN AND SETTING: Qualitative study in UK general practice. METHOD: Semi-structured interviews with a purposeful sample of 41 participants (24 patients and 17 health professionals) from eight practices, using an electronic case-finding tool (FAMCAT) to identify patients with higher likelihood of having FH and who were then offered diagnostic genetic testing in primary care. Data were analysed thematically. RESULTS: While prior awareness of FH was low, patients were unsurprised to be identified as being at risk, and positive about being offered genetic testing by their practice. Patients not found to have FH were relieved, although some felt frustrated that their high cholesterol lacked a clear cause. Those confirmed to have FH largely expected and accepted this outcome. Practitioners saw detection of FH as an important new opportunity for preventive care. They found the case-finding tool easy to apply and noted patients' high uptake of genetic testing. While they were comfortable referring appropriate patients for further specialist management, GPs sought clearer definition about responsibility for identification and long- term care of FH in future care pathways. CONCLUSION: Introducing genetic testing with electronic case finding for FH in primary care was positively experienced by patients and practitioners. Further development of this approach could help improve detection of FH in the general population.

How do stroke survivors and their caregivers manage post-stroke fatigue? A qualitative study.

OBJECTIVES: The primary objective was to gain insight into the lived experiences of using day-to-day strategies to manage post-stroke fatigue. DESIGN: Qualitative, descriptive study. SETTING: Community telephone interviews. PARTICIPANTS: A purposive sample of 20 stroke survivors with current, or previous, post-stroke fatigue, and 8 caregivers, who provided informal care or support, were recruited. MAIN MEASURES: Semi-structured telephone interviews were undertaken. Data were analysed using a framework approach. RESULTS: Most participants had found their own ways of coping and their personal strategies included acceptance of having fatigue; 'pacing' (spreading activities out and interspersing with rest periods); keeping a diary in order to plan activities and to identify 'trigger' activities which induced fatigue; talking to (and educating) others about having fatigue; using relaxation; and accessing professional advice and support. The burden placed on caregivers was considerable and they often had to oversee the post-stroke fatigue management strategies used. CONCLUSIONS: Post-stroke fatigue is managed in different ways and there was not one particular strategy that seemed effective for everyone. Most people in our study had had to devise their own ways of coping practically. Given the scale of this problem, which profoundly impacts the lives of both stroke survivors and caregivers, the management of post-stroke fatigue merits more attention and evaluation. However, this must be directly informed by those with lived experience.

ResOpsUS, a dataset of historical reservoir operations in the contiguous United States.

There are over 52,000 dams in the contiguous US ranging from 0.5 to 243 meters high that collectively hold 600,000 million cubic meters of water. These structures have dramatically affected the river dynamics of every major watershed in the country. While there are national datasets that document dam attributes, there is no national dataset of reservoir operations. Here we present a dataset of historical reservoir inflows, outflows and changes in storage for 679 major reservoirs across the US, called ResOpsUS. All of the data are provided at a daily temporal resolution. Temporal coverage varies by reservoir depending on construction date and digital data availability. Overall, the data spans from 1930 to 2020, although the best coverage is for the most recent years, particularly 1980 to 2020. The reservoirs included in our dataset cover more than half of the total storage of large reservoirs in the US (defined as reservoirs with storage greater 0.1 km3). We document the assembly process of this dataset as well as its contents. Historical operations are also compared to static reservoir attribute datasets for validation.

A hydrological simulation dataset of the Upper Colorado River Basin from 1983 to 2019.

This article presents a hydrological reconstruction of the Upper Colorado River Basin with an hourly temporal resolution, and 1-km spatial resolution from October 1982 to September 2019. The validated dataset includes a suite of hydrologic variables including streamflow, water table depth, snow water equivalent (SWE) and evapotranspiration (ET) simulated by an integrated hydrological model, ParFlow-CLM. The dataset was validated over the period with a combination of point observations and remotely sensed products. These datasets provide a long-term, natural-flow, simulation for one of the most over-allocated basins in the world.

Understanding the barriers and enablers of pharmacogenomic testing in primary care: a qualitative systematic review with meta-aggregation synthesis.

Introduction: Pharmacogenomic testing can indicate which drugs may have limited therapeutic action or lead to adverse effects, hence guiding rational and safe prescribing. However, in the UK and other countries, there are still significant barriers to implementation of testing in primary care. Objective: This systematic review presents the barriers and enablers to the implementation of pharmacogenomics in primary care setting. Materials & methods: MEDLINE, EMBASE, PsycINFO and CINAHL databases were searched through to July 2020 for studies that reported primary qualitative data of primary care professionals and patient views. Following screening, data extraction and quality assessment, data synthesis was undertaken using meta-aggregation based on the theoretical domain's framework (TDF). Confidence in the synthesized findings relating to credibility and dependability was established using CONQual. Eligible papers were categorized into six TDF domains - knowledge; social and professional roles; behavioral regulation; beliefs and consequences; environmental context and resources; and social influences. Results: From 1669 citations, eighteen eligible studies were identified across seven countries, with a sample size of 504 participants including both primary care professionals and patients. From the data, 15 synthesized statements, all with moderate CONQual rating emerged. These categories range from knowledge, awareness among Primary Care Physicians and patients, professional relationships, negative impact of PGx, belief that PGx can reduce adverse drug reactions, clinical evidence, cost-effectiveness, informatics, reporting issues and social issues. Conclusion: Through use of TDF, fifteen synthesized statements provide policymakers with valuable recommendations for the implementation of pharmacogenomics in primary care. In preparation, policymakers need to consider the introduction of effective educational strategies for both PCPs and patients to raise knowledge, awareness, and engagement. The actual introduction of PGx will require reorganization with decision support tools to aid use of PGx in primary care, with a clear delegation of roles and responsibilities between general professionals and pharmacists supplemented by a local pool of experts. Furthermore, policy makers need to address the cost effectiveness of pharmacogenomics and having appropriate infrastructure supporting testing and interpretation including informatic solutions for utilizing pharmacogenomic results.

Case-finding and genetic testing for familial hypercholesterolaemia in primary care.

OBJECTIVE: Familial hypercholesterolaemia (FH) is a common inherited disorder that remains mostly undetected in the general population. Through FH case-finding and direct access to genetic testing in primary care, this intervention study described the genetic and lipid profile of patients found at increased risk of FH and the outcomes in those with positive genetic test results. METHODS: In 14 Central England general practices, a novel case-finding tool (Familial Hypercholetserolaemia Case Ascertainment Tool, FAMCAT1) was applied to the electronic health records of 86 219 patients with cholesterol readings (44.5% of total practices' population), identifying 3375 at increased risk of FH. Of these, a cohort of 336 consenting to completing Family History Questionnaire and detailed review of their clinical data, were offered FH genetic testing in primary care. RESULTS: Genetic testing was completed by 283 patients, newly identifying 16 with genetically confirmed FH and 10 with variants of unknown significance. All 26 (9%) were recommended for referral and 19 attended specialist assessment. In a further 153 (54%) patients, the test suggested polygenic hypercholesterolaemia who were managed in primary care. Total cholesterol and low-density lipoprotein-cholesterol levels were higher in those patients with FH-causing variants than those with other genetic test results (p=0.010 and p=0.002). CONCLUSION: Electronic case-finding and genetic testing in primary care could improve identification of FH; and the better targeting of patients for specialist assessment. A significant proportion of patients identified at risk of FH are likely to have polygenic hypercholesterolaemia. There needs to be a clearer management plan for these individuals in primary care. TRIAL REGISTRATION NUMBER: NCT03934320.

Disordered eating behaviours, body image and social networking in a type 1 diabetes population.

The purpose of this study was twofold: to examine predictors of disordered eating behaviours and body image dissatisfaction, including social networking, among type 1 diabetes population, and to qualitatively explore the relationship between type 1 diabetes management and body image. A convenience sample of 121 type 1 diabetes patients (F = 106; Mage = 36 ± 6.5) was collected via online questionnaires, of which 98 patients responded to two open-ended questions. Young age and negative body image explained 58.8 per cent of disordered eating variance, while body weight and social networking negatively contributed to poor body image (29.9%). Qualitative analysis revealed three themes: no control over body weight, limitation in clothing options and discomfort towards medical equipment.

A scoping review of psychoeducational interventions for people after transient ischemic attack and minor stroke.

BACKGROUND: Psychoeducation can provide information and support to cope with the physical and emotional effects of a health condition. This scoping review aimed to identify the evidence regarding psychoeducational interventions for people after a Transient Ischemic Attack (TIA) and minor stroke. METHODS: This review was conducted in accordance with the PRISMA Extension for Scoping Reviews. Three electronic databases (MEDLINE, Embase, PsycINFO) were searched for articles on interventions related to psychoeducational support post-TIA and minor/mild stroke. Search retrieved 3722 articles. Three reviewers independently screened titles, abstracts, full-texts, and extracted data for included studies. Study quality was assessed using the JADAD scale. TIDieR checklist was used to describe interventions. RESULTS: Fifteen RCTs were included. Twelve studies were of high quality (JADAD score ≥2), two were of low quality. A total of 1500 participants were recruited across studies. Definition of TIA and minor stroke was unclear, leading to the exclusion of several studies. Various interventions were included, including education/psychoeducation (n = 4); exercise and lifestyle advice (n = 3); telephone-based education/counseling (n = 3); secondary prevention education (n = 1); motivational interviewing (n = 2); self-management (n = 2). Interventions were inconsistently described, with information missing about who delivered it and tailoring. CONCLUSIONS: Definitions of stroke severity are not adequately reported. There are a variety of interventions including education about a range of stroke-specific topics. Many interventions are not adequately described, thus making it difficult to determine if the aim was to provide information or support post-TIA/minor stroke. There is a need for an in-depth systematic review to develop a clear definition of psychoeducation.

Psychotherapy versus treatment as usual and other control interventions in children and adolescents with overweight and obesity: a protocol for systematic review with meta-analysis and Trial Sequential Analysis.

INTRODUCTION: The prevalence of children with overweight and obesity is increasing worldwide. Multicomponent interventions incorporating diet, physical activity and behavioural change have shown limited improvement to body mass index (BMI). However, the impact of psychotherapy is poorly explored. This systematic review aims to assess the effects of psychotherapeutic approaches for children with all degrees of overweight. METHODS AND ANALYSIS: We will include randomised clinical trials involving children and adolescents between 0 and 18 years with overweight and obesity, irrespective of publication type, year, status or language up to April 2020. Psychotherapy will be compared with no intervention; wait list control; treatment as usual; sham psychotherapy or pharmaceutical placebo. The following databases will be searched: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, Embase, PsycINFO, PubMed, Web of Science, CINAHL and LILACS. Primary outcomes will be BMI z-score, quality of life measured by a validated scale and proportion of patients with serious adverse events. Secondary outcomes will be body weight, self-esteem, anxiety, depression and proportion of patients with non-serious adverse events. Exploratory outcomes will be body fat, muscle mass and serious adverse events. Study inclusion, data extraction and bias risk assessments will be conducted independently by at least two authors. We will assess risk of bias according to Cochrane guidelines and the Cochrane Effective Practice and Organisation of Care guidance. We will use meta-analysis and control risks of random errors with Trial Sequential Analysis. The quality of the evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation Tool. The systematic review will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane guidelines. ETHICS AND DISSEMINATION: As individual patient data will not be included, we do not require ethics approval. This review will be published in a peer review journal. PROSPERO REGISTRATION NUMBER: CRD42018086458.

Biopsychosocial intervention for stroke carers (BISC): results of a feasibility randomised controlled trial and nested qualitative interview study.

OBJECTIVE: To determine the feasibility of recruiting to and delivering a biopsychosocial intervention for carers of stroke survivors. DESIGN: Feasibility randomised controlled study with nested qualitative interview study. SETTING: The intervention was delivered in the community in either a group or one-to-one format. SUBJECTS: Carers and stroke survivors within one year of stroke onset. INTERVENTIONS: A carer targeted intervention delivered by a research psychologist in six structured two-hour sessions or usual care control. The intervention combined education about the biological, psychological and social effects of stroke with strategies and techniques focussing on adjustment to stroke and caregiving. Stroke survivors in both groups received baseline and follow-up assessment but no intervention. MAIN OUTCOME: Recruitment rate, study attrition, fidelity of intervention delivery, acceptability and sensitivity of outcome measures used (health related quality of life, anxiety and depression and carer burden six months after randomisation). RESULTS: Of the 257 carers approached, 41 consented. Six withdrew before randomisation. Eighteen participants were randomised to receive the intervention and 17 to usual care. Attendance at sessions was greater when treated one-to-one. Feedback interviews suggested that participants found the intervention acceptable and peer support particularly helpful in normalising their feelings. Thirty participants were assessed at follow-up with improvements from baseline on all health measures for both groups. CONCLUSIONS: Our results suggest that a biopsychosocial intervention was acceptable to carers and can be delivered in group and one-to-one formats. Timing of approach and mode of intervention delivery is critical and requires tailoring to the carers individual needs.

Simulating Groundwater-Streamflow Connections in the Upper Colorado River Basin.

In mountain, snow driven catchments, snowmelt is supposed to be the primary contribution to river streamflows during spring. In these catchments the contribution of groundwater is not well documented because of the difficulty to monitor groundwater in such complex environment with deep aquifers. In this study we use an integrated hydrologic model to conduct numerical experiments that help quantify the effect of lateral groundwater flow on total annual and peak streamflow in predevelopment conditions. Our simulations focus on the Upper Colorado River Basin (UCRB; 2.8 × 105 km2 ) a well-documented mountain catchment for which both streamflow and water table measurements are available for several important sub-basins. For the simulated water year, our results suggest an increase in peak flow of up to 57% when lateral groundwater flow processes are included-an unexpected result for flood conditions generally assumed independent of groundwater. Additionally, inclusion of lateral groundwater flow moderately improved the model match to observations. The correlation coefficient for mean annual flows improved from 0.84 for the no lateral groundwater flow simulation to 0.98 for the lateral groundwater flow one. Spatially we see more pronounced differences between lateral and no lateral groundwater flow cases in areas of the domain with steeper topography. We also found distinct differences in the magnitude and spatial distribution of streamflow changes with and without lateral groundwater flow between Upper Colorado River Sub-basins. A sensitivity test that scaled hydraulic conductivity over two orders of magnitude was conducted for the lateral groundwater flow simulations. These results show that the impact of lateral groundwater flow is as large or larger than an order of magnitude change in hydraulic conductivity. While our results focus on the UCRB, we feel that these simulations have relevance to other headwaters systems worldwide.

A Mobile Phone Intervention to Improve Obesity-Related Health Behaviors of Adolescents Across Europe: Iterative Co-Design and Feasibility Study.

BACKGROUND: Promotion of physical activity, healthy eating, adequate sleep, and reduced sedentary behavior in adolescents is a major priority globally given the current increase in population health challenges of noncommunicable diseases and risk factors such as obesity. Adolescents are highly engaged with mobile technology, but the challenge is to engage them with mobile health (mHealth) technology. Recent innovations in mobile technology provide opportunities to promote a healthy lifestyle in adolescents. An increasingly utilized approach to facilitate increased engagement with mHealth technology is to involve potential users in the creation of the technology. OBJECTIVE: This study aimed to describe the process of and findings from co-designing and prototyping components of the PEGASO Fit for Future (F4F) mHealth intervention for adolescents from different cultural backgrounds. METHODS: A total of 74 adolescents aged 13 to 16 years from Spain, Italy, and the United Kingdom participated in the co-design of the PEGASO F4F technology. In 3 iterative cycles over 12 months, participants were involved in the co-design, refinement, and feasibility testing of a system consisting of diverse mobile apps with a variety of functions and facilities to encourage healthy weight-promoting behaviors. In the first iteration, participants attended a single workshop session and were presented with mock-ups or early-version prototypes of different apps for user requirements assessment and review. During the second iteration, prototypes of all apps were tested by participants for 1 week at home or school. In the third iteration, further developed prototypes were tested for 2 weeks. Participants' user experience feedback and development ideas were collected through focus groups and completion of questionnaires. RESULTS: For the PEGASO F4F technology to be motivating and engaging, participants suggested that it should (1) allow personalization of the interface, (2) have age-appropriate and easy-to-understand language (of icons, labels, instructions, and notifications), (3) provide easily accessible tutorials on how to use the app or navigate through a game, (4) present a clear purpose and end goal, (5) have an appealing and self-explanatory reward system, (6) offer variation in gamified activities within apps and the serious game, and (7) allow to seek peer support and connect with peers for competitive activities within the technology. CONCLUSIONS: Incorporating adolescents' preferences, the PEGASO F4F technology combines the functions of a self-monitoring, entertainment, advisory, and social support tool. This was the first study demonstrating that it is possible to develop a complex mobile phone-based technological system applying the principles of co-design to mHealth technology with adolescents across 3 countries. The findings from this study informed the development of an mHealth system for healthy weight promotion to be tested in a controlled multinational pilot trial.

Evapotranspiration depletes groundwater under warming over the contiguous United States.

A warmer climate increases evaporative demand. However, response to warming depends on water availability. Existing earth system models represent soil moisture but simplify groundwater connections, a primary control on soil moisture. Here we apply an integrated surface-groundwater hydrologic model to evaluate the sensitivity of shallow groundwater to warming across the majority of the US. We show that as warming shifts the balance between water supply and demand, shallow groundwater storage can buffer plant water stress; but only where shallow groundwater connections are present, and not indefinitely. As warming persists, storage can be depleted and connections lost. Similarly, in the arid western US warming does not result in significant groundwater changes because this area is already largely water limited. The direct response of shallow groundwater storage to warming demonstrates the strong and early effect that low to moderate warming may have on groundwater storage and evapotranspiration.