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The 2015/16 El Niño brought severe drought and record-breaking temperatures in the tropics. Here, using satellite-based L-band microwave vegetation optical depth, we mapped changes of above-ground biomass (AGB) during the drought and in subsequent years up to 2019. Over more than 60% of drought-affected intact forests, AGB reduced during the drought, except in the wettest part of the central Amazon, where it declined 1 y later. By the end of 2019, only 40% of AGB reduced intact forests had fully recovered to the predrought level. Using random-forest models, we found that the magnitude of AGB losses during the drought was mainly associated with regionally distinct patterns of soil water deficits and soil clay content. For the AGB recovery, we found strong influences of AGB losses during the drought and of γ. γ is a parameter related to canopy structure and is defined as the ratio of two relative height (RH) metrics of Geoscience Laser Altimeter System (GLAS) waveform data--RH25 (25% energy return height) and RH100 (100% energy return height; i.e., top canopy height). A high γ may reflect forests with a tall understory, thick and closed canopy, and/or without degradation. Such forests with a high γ (γ ≤ 0.3) appear to have a stronger capacity to recover than low-γ ones. Our results highlight the importance of forest structure when predicting the consequences of future drought stress in the tropics. [ABSTRACT FROM AUTHOR]

Healthcare decision makers who determine funding for new medical technologies depend on manufacturers to provide evidence of the technology''s efficacy, safety and cost-effectiveness. Constrained budgets and increasing reliance on formal health technology assessment (HTA) have created an abundance of external hurdles that manufacturers must navigate to ensure successful product commercialization. These demands have pushed pharmaceutical companies to adjust their internal structures to coordinate generation of appropriate evidence. In this article we summarize internal and external opportunities for manufacturers to establish a foundation of evidence for successful market access, starting in Phase I of development and continuing throughout the post-approval product lifecycle. [Copyright &y& Elsevier]

In summer 2018, Europe experienced a record drought, but it remains unknown how the drought affected ecosystem carbon dynamics. Using observations from 34 eddy covariance sites in different biomes across Europe, we studied the sensitivity of gross primary productivity (GPP) to environmental drivers during the summer drought of 2018 versus the reference summer of 2016. We found a greater drought-induced decline of summer GPP in grasslands (−38%) than in forests (−10%), which coincided with reduced evapotranspiration and soil water content (SWC). As compared to the 'normal year' of 2016, GPP in different ecosystems exhibited more negative sensitivity to summer air temperature (Ta) but stronger positive sensitivity to SWC during summer drought in 2018, that is, a stronger reduction of GPP with soil moisture deficit. We found larger negative effects of Ta and vapour pressure deficit (VPD) but a lower positive effect of photosynthetic photon flux density on GPP in 2018 compared to 2016, which contributed to reduced summer GPP in 2018. Our results demonstrate that high temperature-induced increases in VPD and decreases in SWC aggravated drought impacts on GPP. This article is part of the theme issue 'Impacts of the 2018 severe drought and heatwave in Europe: from site to continental scale'. [ABSTRACT FROM AUTHOR]

This article reports on a research project that uses two innovative heuristics to examine the changes that texts – produced to disseminate new scientific knowledge – undergo when they travel across space and time. A critical analysis of such transformations would enhance our understanding of the processes involved in knowledge dissemination and inform the practice of communicating scientific knowledge to a variety of audiences. Based on our study of 520 closely linked science and science-related sources collected over 12 months in 2016, we argue that when scientific knowledge is re-contextualized to be disseminated to different audiences, it is not simply rephrased or simplified to make it more accessible. Rather, it also undergoes transformational processes that involve issues of social power, authority and access that require new analytical tools to surface more clearly. We report on the methodology of the study with a particular focus on its heuristics, and the transformations that result from a critical analysis of the data collected. We finally discuss a number of theoretical and practical implications in relation to contemporary practices for re-entextualizing scientific knowledge. [ABSTRACT FROM AUTHOR]

Vegetation optical depth (VOD) is seasonally sensitive to plant water content and aboveground biomass. This index has a strong penetrability within the vegetation canopy and is less impacted by atmosphere aerosol contamination effects, clouds and sun illumination than optical vegetation indices. VOD is thus increasingly applied in ecological applications, e.g. , carbon stock, phenology and vegetation monitoring. However, VOD retrieval over dense forests is subject to uncertainties caused by the thick canopy and complex multiple scattering effects. Thus, a comprehensive evaluation of VOD products over dense forests is needed for effective and accurate applications. This study evaluated the seasonal variations of eight recently developed/reprocessed VOD products at different frequencies (e.g. , Ku-, X-, C- and L-band) over Amazon intact forests, supported by the ORCHIDEE-CAN-NHA model-simulated vegetation water content. Furthermore, we also explored the potential causes of VOD retrieval issues, in terms of retrieval algorithm uncertainties. We first confirmed that soil water availability dominated seasonal dynamics of vegetation water content over Amazon intact forests. This was verified by model-simulated vegetation water content and by C-band radar backscatter observations. Generally, evening or midday vegetation water content shows higher correlations with soil moisture than morning or midnight vegetation water content. In terms of ability of morning or midnight VOD products to follow the seasonality of soil moisture, active microwave ASCAT-IB C-VOD (median seasonal correlation with soil moisture (R) ∼ 0.50) outperforms the passive microwave VOD products, followed by passive microwave AMSR2 X-VOD (R ∼ 0.26) and VODCA X-VOD (R ∼ 0.16). However, SMOS-IC L-VOD (R ∼ −0.15) and AMSR2 C1-VOD (R ∼ −0.20) show obviously negative seasonal correlations with soil moisture across most pixels. This implausible behavior is likely to be caused by the inappropriate setting of time-invariant scattering effects in the passive microwave VOD retrieval algorithms, which could lead to an overestimation of the VOD amplitude during dry seasons. Thus, we recommend that the seasonal scattering effects be considered in the passive microwave VOD retrieval algorithms. These findings can contribute to the improvement of VOD retrieval algorithms and help with the development of their ecological applications over Amazon dense forests. • A comprehensive evaluation of VOD products over Amazon is conducted • Soil water availability dominates seasonal variations in vegetation water content • ASCAT-IB VOD shows a high ability to capture the seasonality of plant water content • Seasonal scattering effects should be considered to retrieve VOD in Amazon [ABSTRACT FROM AUTHOR]

A long-standing debate looks at whether air or soil dryness is more limiting to vegetation water use and productivity. The answer has large implications for future ecosystem functioning, as atmospheric dryness is predicted to increase globally while changes in soil moisture are predicted to be far more variable. Here, I review the complexities that contribute to this debate, including the strong coupling between atmospheric and soil dryness, and the widespread heterogeneity in vegetation hydraulic traits, acclimations, and adaptations to water stress. I discuss solutions to improve understanding and modeling of vegetation sensitivity to dryness, including how different types of observational data can be used together to gain insight into vegetation response to water stress across spatial and temporal scales., (© 2024 The Author(s). New Phytologist © 2024 New Phytologist Foundation.)

The Australian Bragg Centre for Proton Therapy and Research (ABCPTR) established the Bragg Consumer Advisory Group (BCAG) in 2023. The ABCPTR, being the first of its kind in Australia, will offer proton therapy treatment for challenging solid tumours with the potential to reduce radiation-induced side effects. With over 110 Proton Beam Therapy (PBT) centres globally, Australian patients currently can apply to access government funded treatment overseas, however, international travel for treatment presents various, significant challenges. Consumer engagement in healthcare plays a pivotal role in navigating the multifaceted journey of cancer treatment and can complement cancer control strategies by ensuring the practicalities of the cancer journey are realised. The ABCPTR aims to involve consumers in decision-making processes, especially as it prepares to open Australia's first national proton therapy centre. The aim of this commentary is to highlight the importance of involving consumers in cancer care, and to demonstrate how this was done in Australia's first proton therapy centre. To establish a consumer engagement team, ABCPTR utilised existing clinical staff. The team's formation and upskilling were integral to the project's success. The engagement framework was developed based on the five stages of commitment by the Australian Health Research Alliance and Western Australian Health Translation Network. The ABCPTR consumer engagement team successfully created a community engagement framework and upskilled in consumer engagement principles over 9-12 months. An Expression of Interest (EOI) was launched, resulting in the formation of the BCAG comprising of 10 members with diverse backgrounds and experiences. The BCAG has been actively involved in decision-making processes, with a consumer-led chair and co-chair in place. The group's feedback is expected to influence key performance indicators for the centre. The establishment of the BCAG at the ABCPTR emphasises the importance of integrating patient and community perspectives into clinical initiatives. This proactive approach ensures that processes remain patient-centred. The ongoing multi-level consumer engagement strategy aims to shape a more inclusive approach to cancer care in Australia, especially concerning PBT., (© 2023 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.)

The dry tropics occupy ~40% of the tropical land surface and play a dominant role in the trend and interannual variability of the global carbon cycle. Previous studies have reported considerable changes in the dry tropical precipitation seasonality due to climate change, however, the accompanied changes in the length of the vegetation growing season (LGS)-the key period of carbon sequestration-have not been examined. Here, we used long-term satellite observations along with in-situ flux measurements to investigate phenological changes in the dry tropics over the past 40 years. We found that only ~18% of the dry tropics show a significant (p ≤ .1) increasing trend in LGS, while ~13% show a significant decreasing trend. The direction of the LGS change depended not only on the direction of precipitation seasonality change but also on the vegetation water use strategy (i.e. isohydricity) as an adaptation to the long-term average precipitation seasonality (i.e. whether the most of LGS is in the wet season or dry season). Meanwhile, we found that the rate of LGS change was on average ~23% slower than that of precipitation seasonality, caused by a buffering effect from soil moisture. This study uncovers potential mechanisms driving phenological changes in the dry tropics, offering guidance for regional vegetation and carbon cycle studies., (© 2024 The Authors. Global Change Biology published by John Wiley & Sons Ltd.)

Uncovering the mechanisms that lead to Amazon forest resilience variations is crucial to predict the impact of future climatic and anthropogenic disturbances. Here, we apply a previously used empirical resilience metrics, lag-1 month temporal autocorrelation (TAC), to vegetation optical depth data in C-band (a good proxy of the whole canopy water content) in order to explore how forest resilience variations are impacted by human disturbances and environmental drivers in the Brazilian Amazon. We found that human disturbances significantly increase the risk of critical transitions, and that the median TAC value is ~2.4 times higher in human-disturbed forests than that in intact forests, suggesting a much lower resilience in disturbed forests. Additionally, human-disturbed forests are less resilient to land surface heat stress and atmospheric water stress than intact forests. Among human-disturbed forests, forests with a more closed and thicker canopy structure, which is linked to a higher forest cover and a lower disturbance fraction, are comparably more resilient. These results further emphasize the urgent need to limit deforestation and degradation through policy intervention to maintain the resilience of the Amazon rainforests., (© 2023 John Wiley & Sons Ltd.)

Proton Beam Therapy (PBT) has the potential to improve paediatric cancer care by reducing radiation exposure and thus long-term toxicities. Ethical concerns and debates surrounding the treatment, such as eligibility and accessibility, are ongoing in Australia. The Australian Bragg Centre for Proton Therapy and Research (ABCPTR) (named after Sir William Henry Bragg who described the Bragg peak in his laboratory at the University of Adelaide in 1903) aims to increase access to PBT in Australasia and offer a patient-centred care approach. Research is underway to assess PBT's safety and cost-effectiveness, using tools including Normal Tissue Complication Probability (NTCP) models. Collaborative efforts are focused on developing tailored survivorship clinics to enhance patient follow-up and quality of life. With the anticipated opening of the ABCPTR, Australia is preparing to take a significant step in radiation oncology, offering new research opportunities and creating a publicly funded treatment centre. The initiative aims to balance treatment efficacy with patient care, setting the stage for a future in which radiation therapy will reduce long-term side effects compared to the current standard of care. The implementation of PBT in Australia represents a complex and promising approach to paediatric oncology. This article provides an overview of the current landscape, highlighting the potential benefits and challenges of a treatment that could redefine the quality of survivorship and contribute to global research and best clinical practice., (© 2023 The Authors. Journal of Medical Imaging and Radiation Oncology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Radiologists.)

Background: Pharmacogenomics (PGx) is an emerging field. Many drug-gene interactions are known but not yet routinely addressed in clinical practice. Therefore, there is a significant gap in care, necessitating development of implementation strategies., Objective: The objective of the study was to assess the impact of implementing a PGx practice model which incorporates comprehensive pharmacogenomic risk evaluation, testing and medication optimization administered by 7 PGx-certified ambulatory care pharmacists embedded across 30 primary care clinic sites., Methods: Pharmacogenomic services were implemented in 30 primary care clinics within the Cincinnati, Ohio area. Patients are identified for pharmacogenomic testing using a clinical decision support tool (CDST) that is fully integrated in the electronic medical record (EMR) or by provider designation (e.g., psychotropic drug failure). Pharmacogenomic testing is performed via buccal swab using standardized clinic processes. Discrete data results are returned directly into the EMR/CDST for review by PGx-certified ambulatory care pharmacists. Recommendations and prescriptive changes are then discussed and implemented as a collaborative effort between pharmacist, primary care provider, specialists, and patient., Results: A total of 422 unique interactions were assessed by the embedded ambulatory care PGx pharmacists (N = 7) during this interim analysis. About half (213) were pharmacogenomic interactions, and of these, 124 were actionable. When an intervention was actionable, 82% of the time a change in medication was recommended. The underlying reasons for recommending therapy alterations were most commonly ineffective therapy (43%), adverse drug reaction prevented (34%), or adverse drug reaction observed (13%)., Conclusion: Variations in drug metabolism, response, and tolerability can negatively impact patient outcomes across many disease states and treatment specialties. Incorporation of pharmacogenomic testing with accessible clinical decision support into the team-based care model allows for a truly comprehensive review and optimization of medications. Our initial analysis suggests that comprehensive PGx testing should be considered to enhance medication safety and efficacy in at-risk patients., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Over 80 monogenic causes of very early onset inflammatory bowel disease [VEOIBD] have been identified. Prior reports of the natural history of VEOIBD have not considered monogenic disease status. The objective of this study is to describe clinical phenotypes and outcomes in a large single-centre cohort of patients with VEOIBD and universal access to whole exome sequencing [WES]., Methods: Patients receiving IBD care at a single centre were prospectively enrolled in a longitudinal data repository starting in 2012. WES was offered with enrollment. Enrolled patients were filtered by age of diagnosis <6 years to comprise a VEOIBD cohort. Monogenic disease was identified by filtering proband variants for rare, loss-of-function, or missense variants in known VEOIBD genes inherited according to standard Mendelian inheritance patterns., Results: This analysis included 216 VEOIBD patients, followed for a median of 5.8 years. Seventeen patients [7.9%] had monogenic disease. Patients with monogenic IBD were younger at diagnosis and were more likely to have Crohn's disease phenotype with higher rates of stricturing and penetrating disease and extraintestinal manifestations. Patients with monogenic disease were also more likely to experience outcomes of intensive care unit [ICU] hospitalisation, gastrostomy tube, total parenteral nutrition use, stunting at 3-year follow-up, haematopoietic stem cell transplant, and death. A total of 41 patients [19.0%] had infantile-onset disease. After controlling for monogenic disease, patients with infantile-onset IBD did not have increased risk for most severity outcomes., Conclusions: Monogenic disease is an important driver of disease severity in VEOIBD. WES is a valuable tool in prognostication and management of VEOIBD., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The 2015/16 El Niño brought severe drought and record-breaking temperatures in the tropics. Here, using satellite-based L-band microwave vegetation optical depth, we mapped changes of above-ground biomass (AGB) during the drought and in subsequent years up to 2019. Over more than 60% of drought-affected intact forests, AGB reduced during the drought, except in the wettest part of the central Amazon, where it declined 1 y later. By the end of 2019, only 40% of AGB reduced intact forests had fully recovered to the predrought level. Using random-forest models, we found that the magnitude of AGB losses during the drought was mainly associated with regionally distinct patterns of soil water deficits and soil clay content. For the AGB recovery, we found strong influences of AGB losses during the drought and of [Formula: see text]. [Formula: see text] is a parameter related to canopy structure and is defined as the ratio of two relative height (RH) metrics of Geoscience Laser Altimeter System (GLAS) waveform data-RH25 (25% energy return height) and RH100 (100% energy return height; i.e., top canopy height). A high [Formula: see text] may reflect forests with a tall understory, thick and closed canopy, and/or without degradation. Such forests with a high [Formula: see text] ([Formula: see text] ≥ 0.3) appear to have a stronger capacity to recover than low-[Formula: see text] ones. Our results highlight the importance of forest structure when predicting the consequences of future drought stress in the tropics.

Current models may be overestimating the sequestration potential of forests.

Vegetation is a key component in the global carbon cycle as it stores ~450 GtC as biomass, and removes about a third of anthropogenic CO 2 emissions. However, in some regions, the rate of plant carbon uptake is beginning to slow, largely because of water stress. Here, we develop a new observation-based methodology to diagnose vegetation water stress and link it to environmental drivers. We used the ratio of remotely sensed land surface to near surface atmospheric temperatures (LST/T air ) to represent vegetation water stress, and built regression tree models (random forests) to assess the relationship between LST/T air and the main environmental drivers of surface energy fluxes in the tropical Americas. We further determined ecosystem traits associated with water stress and surface energy partitioning, pinpointed critical thresholds for water stress, and quantified changes in ecosystem carbon uptake associated with crossing these critical thresholds. We found that the top drivers of LST/T air , explaining over a quarter of its local variability in the study region, are (1) radiation, in 58% of the study region; (2) water supply from precipitation, in 30% of the study region; and (3) atmospheric water demand from vapor pressure deficits (VPD), in 22% of the study region. Regions in which LST/T air variation is driven by radiation are located in regions of high aboveground biomass or at high elevations, while regions in which LST/T air is driven by water supply from precipitation or atmospheric demand tend to have low species richness. Carbon uptake by photosynthesis can be reduced by up to 80% in water-limited regions when critical thresholds for precipitation and air dryness are exceeded simultaneously, that is, as compound events. Our results demonstrate that vegetation structure and diversity can be important for regulating surface energy and carbon fluxes over tropical regions., (© 2022 John Wiley & Sons Ltd.)

Both low soil water content (SWC) and high atmospheric dryness (vapor pressure deficit, VPD) can negatively affect terrestrial gross primary production (GPP). The sensitivity of GPP to soil versus atmospheric dryness is difficult to disentangle, however, because of their covariation. Using global eddy-covariance observations, here we show that a decrease in SWC is not universally associated with GPP reduction. GPP increases in response to decreasing SWC when SWC is high and decreases only when SWC is below a threshold. By contrast, the sensitivity of GPP to an increase of VPD is always negative across the full SWC range. We further find canopy conductance decreases with increasing VPD (irrespective of SWC), and with decreasing SWC on drier soils. Maximum photosynthetic assimilation rate has negative sensitivity to VPD, and a positive sensitivity to decreasing SWC when SWC is high. Earth System Models underestimate the negative effect of VPD and the positive effect of SWC on GPP such that they should underestimate the GPP reduction due to increasing VPD in future climates., (© 2022. The Author(s).)

Background: Adults who deteriorate outside the ICU have high mortality. Most rapid response systems (RRSs) have employed manual detection processes that rapid response teams (RRTs) use to identify patients at risk. This project piloted the use of an automated early warning system (EWS), based on a very large database, that provides RRTs with 12 hours lead time to mount a response. Results from a 2-hospital pilot were encouraging, so leadership decided to deploy the Advance Alert Monitor (AAM) program in 19 more hospitals., Challenge: How can one deploy an RRS using an automated EWS at scale?, Solution: EWS displays were removed from frontline clinicians' hospital electronic dashboards, and a Virtual Quality Team (VQT) RN was interposed between the EWS and the RRT. VQT RNs monitor the EWS remotely-when alerts are issued, they conduct a preliminary chart review and contact hospital RRT RNs. VQT and RRT RNs review the cases jointly. The RRT RNs then consult with hospitalists regarding clinical rescue and/or palliative care workflows. Subsequently, VQT RNs monitor patient charts, ensuring adherence to RRS practice standards. To enable this process, the project team developed a governance structure, clinical workflows, palliative care workflows, and documentation standards., Results: The AAM Program now functions in 21 Kaiser Permanente Northern California hospitals. VQT RNs monitor EWS alerts 24 hours a day, 7 days a week. The AAM Program handles ∼16,000 alerts per year. Its implementation has resulted in standardization of RRT staffing, clinical rescue workflows, and in-hospital palliative care., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Sleep problems are widely prevalent and associated with various comorbidities including anxiety. Valerian ( Valeriana officinalis L.) is a popular herbal medicine used as a sleep aid, however the outcomes of previous clinical studies are inconsistent. This study was conducted to update and re-evaluate the available data in order to understand the reason behind the inconsistent outcomes and to provide a broader view of the use of valerian for associated disorders. PubMed, ScienceDirect, and Cochrane Library were searched to retrieve publications relevant to the effectiveness of valerian as a treatment of sleep problems and associated disorders. A total of 60 studies (n=6,894) were included in this review, and meta-analyses were performed to evaluate the effectiveness to improve subjective sleep quality (10 studies, n=1,065) and to reduce anxiety (8 studies, n=535). Results suggested that inconsistent outcomes were possibly due to the variable quality of herbal extracts and that more reliable effects could be expected from the whole root/rhizome. In addition, therapeutic benefits could be optimized when it was combined with appropriate herbal partners. There were no severe adverse events associated with valerian intake in subjects aged between 7 and 80 years. In conclusion, valerian could be a safe and effective herb to promote sleep and prevent associated disorders. However, due to the presence of multiple active constituents and relatively unstable nature of some of the active constituents, it may be necessary to revise the quality control processes, including standardization methods and shelf life.

Although the terrestrial biosphere absorbs about 25 per cent of anthropogenic carbon dioxide (CO 2 ) emissions, the rate of land carbon uptake remains highly uncertain, leading to uncertainties in climate projections 1,2 . Understanding the factors that limit or drive land carbon storage is therefore important for improving climate predictions. One potential limiting factor for land carbon uptake is soil moisture, which can reduce gross primary production through ecosystem water stress 3,4 , cause vegetation mortality 5 and further exacerbate climate extremes due to land-atmosphere feedbacks 6 . Previous work has explored the impact of soil-moisture availability on past carbon-flux variability 3,7,8 . However, the influence of soil-moisture variability and trends on the long-term carbon sink and the mechanisms responsible for associated carbon losses remain uncertain. Here we use the data output from four Earth system models 9 from a series of experiments to analyse the responses of terrestrial net biome productivity to soil-moisture changes, and find that soil-moisture variability and trends induce large CO 2 fluxes (about two to three gigatons of carbon per year; comparable with the land carbon sink itself 1 ) throughout the twenty-first century. Subseasonal and interannual soil-moisture variability generate CO 2 as a result of the nonlinear response of photosynthesis and net ecosystem exchange to soil-water availability and of the increased temperature and vapour pressure deficit caused by land-atmosphere interactions. Soil-moisture variability reduces the present land carbon sink, and its increase and drying trends in several regions are expected to reduce it further. Our results emphasize that the capacity of continents to act as a future carbon sink critically depends on the nonlinear response of carbon fluxes to soil moisture and on land-atmosphere interactions. This suggests that the increasing trend in carbon uptake rate may not be sustained past the middle of the century and could result in accelerated atmospheric CO 2 growth.

The terrestrial biosphere and atmosphere interact through a series of feedback loops. Variability in terrestrial vegetation growth and phenology can modulate fluxes of water and energy to the atmosphere, and thus affect the climatic conditions that in turn regulate vegetation dynamics. Here we analyze satellite observations of solar-induced fluorescence, precipitation, and radiation using a multivariate statistical technique. We find that biosphere-atmosphere feedbacks are globally widespread and regionally strong: they explain up to 30% of precipitation and surface radiation variance. Substantial biosphere-precipitation feedbacks are often found in regions that are transitional between energy and water limitation, such as semi-arid or monsoonal regions. Substantial biosphere-radiation feedbacks are often present in several moderately wet regions and in the Mediterranean, where precipitation and radiation increase vegetation growth. Enhancement of latent and sensible heat transfer from vegetation accompanies this growth, which increases boundary layer height and convection, affecting cloudiness, and consequently incident surface radiation. Enhanced evapotranspiration can increase moist convection, leading to increased precipitation. Earth system models underestimate these precipitation and radiation feedbacks mainly because they underestimate the biosphere response to radiation and water availability. We conclude that biosphere-atmosphere feedbacks cluster in specific climatic regions that help determine the net CO 2 balance of the biosphere., Competing Interests: Competing financial interests The authors declare no competing financial interests.

A new global estimate of surface turbulent fluxes, latent heat flux (LE) and sensible heat flux (H), and gross primary production (GPP) is developed using a machine learning approach informed by novel remotely sensed Solar-Induced Fluorescence (SIF) and other radiative and meteorological variables. This is the first study to jointly retrieve LE, H and GPP using SIF observations. The approach uses an artificial neural network (ANN) with a target dataset generated from three independent data sources, weighted based on triple collocation (TC) algorithm. The new retrieval, named Water, Energy, and Carbon with Artificial Neural Networks (WECANN), provides estimates of LE, H and GPP from 2007 to 2015 at 1° × 1° spatial resolution and on monthly time resolution. The quality of ANN training is assessed using the target data, and the WECANN retrievals are evaluated using eddy covariance tower estimates from FLUXNET network across various climates and conditions. When compared to eddy covariance estimates, WECANN typically outperforms other products, particularly for sensible and latent heat fluxes. Analysing WECANN retrievals across three extreme drought and heatwave events demonstrates the capability of the retrievals in capturing the extent of these events. Uncertainty estimates of the retrievals are analysed and the inter-annual variability in average global and regional fluxes show the impact of distinct climatic events - such as the 2015 El Niño - on surface turbulent fluxes and GPP., Competing Interests: Competing Interests The authors declare that they have no conflict of interest.

Purpose: The US Food and Drug Administration recently approved the first 4th-generation HIV test. This study evaluated the cost-effectiveness of the 4th-generation assay versus a 3rd-generation test in screening for HIV infections in the United States., Methods: An exploratory microsimulation model was developed that follows hypothetical individuals and simulates the course of HIV/AIDS, treatment with highly active antiretroviral therapy, and transmissions., Results: With a 1% HIV prevalence, screening 1.5 million individuals with the 4th- versus 3rd-generation assay resulted in detection of 266 additional HIV cases at an incremental cost per additional HIV case detected of $63,763, an additional 489 life years and 395 quality-adjusted life years (QALYs), and 26 HIV transmissions prevented. Although lifetime costs were increased by $33.6 million, the incremental cost/QALY gained was $85,206. The 4th-generation test was more cost-effective in high incidence settings. The number needed to screen to detect one additional HIV case was 5,635., Conclusions: Screening using the 4th-generation assay may be cost-effective for HIV detection in appropriate settings, resulting in increased case identification, fewer transmissions, extended life, and increased quality of life. With early and accurate detection, this 4th-generation test may provide a suitable alternative to current 3rd-generation tests.

Objectives: To assess the effectiveness of professional herbal practice in the treatment of menopausal symptoms. To generate pilot data for future sample size calculations., Methods: A pilot prospective, randomized, waiting list controlled trial was conducted in primary care at one urban UK GP practice. Participants were 45 women aged 46-59, experiencing self-defined menopausal symptoms and no menstrual bleeding for 3 months. Exclusion criteria included use of hormone replacement therapy. Participants were block randomized into a treatment group (n = 15) who received a course of individualized treatment from one of three herbal practitioners, and control group (n = 30) offered treatment after waiting 4 months. Treatment was six consultations over 5 months including discussion of nutrition, lifestyle and individualized herbal prescription. Change in menopausal symptoms was measured in both groups using the validated Greene Climacteric Scale. Measure Yourself Medical Outcome Profile recorded changes in self-defined most troublesome symptoms., Results: Forty-four participants completed the study. The treatment group demonstrated a statistically and clinically significant reduction in menopausal symptoms compared to the control group. Total scores for menopausal symptoms reduced for both groups. Reduction for the treated group was 9.05 points greater than that for the control group, CI 5.08-13.03, as were changes in vasomotor scores (mean 1.81, CI 1.00-2.62). Libido increased (mean 0.69, CI 0.38-0.99) in the group receiving herbal treatment., Conclusion: The treatment package from herbal practitioners improved menopausal symptoms, particularly hot flushes and low libido. This offers evidence to support herbal medicine as a treatment choice during the menopause.