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BackgroundSocial media platforms provide new possibilities within health research. With Facebook being the largest social network in the world, it constitutes a potential platform for recruitment and data collection from women of reproductive age. Women in Denmark and in other Western countries postpone motherhood and risk infertility due to their advanced age when they try to conceive. To date, no study has explored Danish women’s reflections on the timing of motherhood within a social media setting. ObjectiveThe aim of this study was to explore the challenges and opportunities of using Facebook as a platform for qualitative health research in Danish women of reproductive age. MethodsThis study was a qualitative study based on 3 online focus groups on Facebook with 26 Danish women of reproductive age discussing the timing of motherhood in January 2020. ResultsConducting online focus groups on Facebook was successful in this study as the web-based approach was found suitable for developing qualitative data with women of reproductive age and made recruitment easy and free of charge. All participants found participating in an online focus group to be a positive experience. More than half of the women participating in the online focus groups found it advantageous to meet on Facebook instead of meeting face-to-face. ConclusionsConducting online focus groups on Facebook is a suitable method to access qualitative data from women of reproductive age. Participants were positive toward being a part of an online focus group. Online focus groups on social media have the potential to give women of reproductive age a voice in the debate of motherhood.

BACKGROUND AND AIMS: Falls among older people are associated with injury, functional decline, fear of falling, and depression. This study aims to evaluate the effect of multifactorial fall prevention on function, fear of falling, health-related quality of life and psychological well-being. METHODS: 392 older people >/=65 years sustaining a fall, leading to treatment in the emergency room or hospitalization, were included in a randomized, controlled intervention study on multifactorial fall prevention. The intervention consisted of systematic assessment and personalized treatment aimed at reducing risk factors for falls, and was performed at the geriatric outpatient department of a university hospital. The control group received usual care. Outcome measures were functional ability (Barthel Index and Frenchay Activity Index), fear of falling (Activities Balance Confidence Scale), health-related quality of life (SF- 36), and psychological well-being (SCL-92), and were recorded at interviews 6 and 12 months after inclusion. RESULTS: Only the physical function of SF-36 was slightly positively affected by the intervention (p=0.04). There were no effects on general health (p=0.49) or mental health (p=0.39) items, Barthel Index (p=0.10), Frenchay Activity Index (p=0.71), balance confidence (p=0.77), anxiety (p=0.92), depression (p=0.90) or somatization (p=0.13). CONCLUSIONS: This program of multifactorial fall prevention may have an effect on the physical function item of health-related quality of life in favor of the intervention group, but none on other measures of health-related quality of life, daily function, fear of falling or psychological well-being. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate whether follow-up services for stroke survivors could improve functional outcome and reduce readmission rate. In this paper results of functional outcome are reported. DESIGN: Randomized controlled trial allocating patients to one of three different types of aftercare: (1) follow-up home visits by a physician, (2) physiotherapist instruction in the patient's home, or (3) standard aftercare. SUBJECTS: Stroke patients with persisting impairment and disability who, after completing inpatient rehabilitation, were discharged to their homes. OUTCOME MEASURES: Six months after discharge, functional outcome was assessed with Functional Quality of Movement, Barthel Index, Frenchay Activity Index and Index of Extended Activites of Daily Living. RESULTS: One-hundred and fifty-five stroke patients were included in the study. Fifty-four received follow-up home visits by a physician, 53 were given instructions by a physiotherapist in their home and 48 received standard aftercare only. No statistically significant differences in functional outcome six months after discharge were demonstrated between the three groups. However, all measurements showed a tendency towards higher scores indicating better function in both interventions groups compared with the control group. CONCLUSION: Follow-up services after stroke may be a way of improving functional outcome. The results of the present study should be evaluated in future trials. More research in this field is needed, especially studies of how to support stroke survivors to resume social and leisure activities. [ABSTRACT FROM AUTHOR]

Background: Nursing students often face challenges reconciling theoretical concepts with clinical realities. This study examines a novel concept 'Communities of Reflection' designed and tested to enhance coherency between theory and practice. The concept involves reflection groups comprising students, preceptors, and faculty during clinical placements., Aim: To examine the meaning of 'Communities of Reflection' regarding the coherency between theory and practice as perceived by the involved participants., Method: A qualitative multi-methods approach involved nursing students, preceptors, and faculty members who participated in 'Communities of Reflection.' Data collection methods included interviews, focus groups, written reflections, and observations., Findings: The content analysis revealed that 'Communities of Reflection' facilitate a shared engagement in nursing, fostering a deeper level of reflection. Creating a safe space and embracing vulnerability are key aspects of this shared engagement., Conclusion: 'Communities of Reflection' offer a valuable framework for promoting coherency between theory and practice. It appears to be crucial to students' outcomes that a well-established, equitable theory-practice partnership is the solid foundation, acknowledging that emotions can serve as a catalyst for the development of professional expertise., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Bone and muscle impairment, named osteoporosis and sarcopenia, may co-occur with age, and patients with both disorders might exhibit physical frailty. One-hundred sixty-three patients were included. 14.2% had both disorders and presented more frequent with previous fall, reduced daily activity level, walk/balance challenges, and need of walking aid, indicating overall frailty., Purpose: In older adults, sarcopenia (muscle impairment) and physical frailty may accompany osteoporosis (bone brittleness), yet osteoporosis is typically assessed without evaluating these conditions, even though coexistence may contribute to exacerbated negative health outcomes. We aimed at evaluating the prevalence of sarcopenia and impaired muscle domains in osteoporotic patients and explore the risk of osteosarcopenia from markers of physical frailty., Methods: In Copenhagen, Denmark, osteoporotic patients aged 65 + were assessed cross-sectionally in 2018-2019. Evaluations included muscle mass, strength, and function; bone mineral density; and self-reported physical activity, fall, balance challenges, dizziness, and the need of walking aid. Low bone mass, low-energy fracture, or treatment with anti-osteoporotic medication defined patient with osteoporosis, and sarcopenia was defined by low muscle strength and mass. Osteosarcopenia was defined from the coexistence of both conditions., Results: One-hundred sixty-three patients with osteoporosis were included. Of those, 23 (14.2%) exhibited sarcopenia, hence osteosarcopenia. Hand-grip-strength, 30-s-chair-stand-test, relative-appendicular-lean-muscle-mass, and gait-speed were below cut-off levels in 21.0%, 30.9%, 28.8%, and 23.6% of the patients, respectively. Previous fall, activity level, walk and balance challenges, and need of walking aid were statistically (or borderline) significantly more often affected in the osteosarcopenic group compared with the solely osteoporotic. Logistic regression analysis, however, revealed that only the need for walking aid significantly increased the risk of an osteosarcopenia diagnosis (odds ratio 5.54, 95% CI (1.95-15.76), p < 0.01)., Conclusions: Sarcopenia and impaired muscle domains were frequent in osteoporotic patients, as were markers of physical frailty, indicating the need of thorough examination of osteoporotic patients., (© 2024. The Author(s).)

Introduction: Older patients with cancer range from fit to frail with various comorbidities and resilience to chemotherapy. Besides nausea and fatigue, a significant number of patients experience dizziness and impaired walking balance after chemotherapy, which can have great impact on their functional ability and health related quality of life. Symptoms are easily overlooked and therefore often underreported and managed, which is why symptoms could end up as long-lasting side effects. The aim of this study is to investigate the development of dizziness, decline in walking balance, and sarcopenia and the effect of a comprehensive geriatric assessment and 12 weeks of group-based exercise on these symptoms. The exercise intervention includes vestibular and balance exercises, and progressive resistance training, to counteract the symptoms in older patients with colorectal cancer treated with chemotherapy., Materials and Methods: This is a randomized controlled trial including patients ≥65 years initiating (neo)adjuvant or first-line palliative chemotherapy for colorectal cancer. Patients will undergo a comprehensive assessment program including measures of vestibular function, balance, muscle strength, mass, and endurance, peripheral and autonomic nerve function, and subjective measures of dizziness, concern of falling, and health related quality of life. Tests will be performed at baseline, 12, and 24 weeks. Patients will be placed in three different randomized controlled trials depending on chemotherapy regimen and randomized 1:1 to comprehensive geriatric assessment and exercise three times/week or control. Participants in both groups will continue with usual care, including standardized oncological treatment. In total, 150 patients are needed to assess the two primary outcomes of (1) maintenance of walking balance assessed with Dynamic Gait Index and (2) lower limb strength and endurance assessed with 30 Second Sit-to-Stand Test at 12 weeks. The primary outcomes will be analyzed using a mixed linear regression model investigating the between-group differences., Discussion: Trial enrollment began in April 2023 and is the first trial to evaluate reasons for dizziness, decline in walking balance, and sarcopenia in older patients receiving chemotherapy. The trial will provide new and valuable knowledge in how to assess, manage, and prevent dizziness, decline in walking balance, and sarcopenia in older patients with colorectal cancer., Trial Registration: The Regional Ethics Committee (j.nr. H-22064206). Danish Data Protection Agency (P-2023-86) and ClinicalTrials.gov (NCT05710809)., Competing Interests: Declaration of Competing Interest All authors declare that they have no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: To estimate the prevalence of bilateral vestibulopathy (BV) and evaluate the association with, and concurrent validity of the Dynamic Gait Index (DGI) and the Dizziness Handicap Inventory (DHI) in diagnosing BV based on video head impulse test (vHIT) among older adults ≥65 years referred to a geriatric falls clinic on suspicion of vestibular impairment., Materials and Methods: The vHIT was applied as a reference standard of BV to estimate diagnostic parameters for optimal cut-off scores of DGI and DHI applied separately and in combination., Results: Two-hundred medical records were reviewed (70% women, mean age 79.4 years). The prevalence of BV was 9%. DGI was weakly associated with BV: Odds Ratio (OR) 1.15 (95% confidence interval (CI): 1.01; 1.31), with a 93% sensitivity and 47% specificity of a cut-off score of 16. The total score of DHI showed no association with BV: OR 1.01 (95% CI: 0.98; 1.04). The concurrent validity for BV and DGI and/or DHI were found to be inadequate., Conclusions: A prevalence of 9% underlines the relevance for assessment of BV. Only a weak association between DGI and/or DHI and BV was found. Thus, vHIT remains the preferred test for detecting BV in geriatric fall assessments.IMPLICATIONS FOR REHABILITATIONBilateral vestibulopathy (BV) has numerous negative consequences for older adults and the prevalence is high among older adults referred to a geriatric falls clinic on suspicion of vestibular impairment.The Dynamic Gait Index (DGI) and the Dizziness Handicap Inventory (DHI) are not valid alternatives to the Video Head Impulse Test (vHIT) when assessing BV among geriatric outpatients.

In this paper, we investigate the potential gains in cost-effectiveness from changing the spatial scale at which nutrient reduction targets are set for the Baltic Sea, with particular focus on nutrient loadings from agriculture. The costs of achieving loading reductions are compared across five levels of spatial scale, namely the entire Baltic Sea; the marine basin level; the country level; the watershed level; and the grid square level. A novel highly-disaggregated model, which represents decreases in agricultural profits, changes in root zone N concentrations and transport to the Baltic Sea is used. The model includes 14 Baltic Sea marine basins, 14 countries, 117 watersheds and 19,023 10-by-10 km grid squares. The main result which emerges is that there is a large variation in the total cost of the program depending on the spatial scale of targeting: for example, for a 40% reduction in loads, the costs of a Baltic Sea-wide target is nearly three times lower than targets set at the smallest level of spatial scale (grid square). These results have important implications for both domestic and international policy design for achieving water quality improvements where non-point pollution is a key stressor of water quality., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

Excess nitrogen (N) losses from intensive agricultural production are a world-wide problem causing eutrophication in vulnerable aquatic ecosystems such as estuaries. Therefore, Denmark as one of the most intensively farmed countries in the world has enforced mandatory regulations on agricultural production since the late 1980s. We demonstrate the outcome of the regulations imposed on agriculture by analyzing decadal trends in nitrate (NO 3 - ) concentrations and loads in streams using 29 years of detailed monitoring data and survey information on agricultural practices at field level from five intensively cultivated headwater catchments. The analysis includes the importance of four main drivers (climate, land use, agricultural practices, and biogeophysical properties of catchments), each divided into different factors that may influence stream NO 3 - loads during three subperiods defined by the time of introduction of different mitigation measures: i) 1990-1998, ii) 1999-2007, and iii) 2008-2018. Significant correlations with annual flow-weighted stream NO 3 - concentrations and/or loads were found for factors representing all of the four main drivers including precipitation, large scale climate fluctuations, runoff, previous year's runoff, baseflow index, number of annual frost days, agricultural area, livestock density, field N surplus, catch crop cover, manure storage capacity, method and time of manure spreading, and time of soil tillage. Changes in the four drivers were reflected by the load-runoff (L-Q) relationships for each of the three subperiods within each of the five headwater catchments. The five catchments experienced large but catchment-specific downward shifts in the L-Q relationship attributable to changes in land use and agricultural management within the catchments. The documented large downward shifts in NO 3 - loads demonstrated for the five catchments (30-52%) as a consequence of mandatory regulation over a period of nearly three decades are a unique example of how agriculture can reduce its environmental impact., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Older patients admitted to the emergency departments represent a heterogeneous group, some are frail with reduced reserve capacity and without ability to compensate to acute illness. They often present with nonspecific complaints and atypical presentation and are at-risk of complications and adverse events. These patients need a fast comprehensive interdisciplinary and multicomponent assessment and intervention to reduce the risk of further functional decline and to optimize their overall health status, independency and quality of life. This is the purpose of acute geriatrics.

We show that aerial tips are self-similar fractals of whole shrubs and present a field method that applies this fact to improves accuracy and precision of biomass estimates of tall-shrubs, defined here as those with diameter at root collar (DRC) ≥ 2.5 cm. Power function allometry of biomass to stem diameter generates a disproportionate prediction error that increases rapidly with diameter. Thus, biomass should be modeled as a single measure of stem diameter only if stem diameter is less than a threshold D max . When stem diameter exceeds D max , then the stem internode should be treated as a conic frustrum requiring two additional measures: a second, node-adjacent diameter and a length. If the second diameter is less than D max , then the power function allometry can be applied to the aerial tip; otherwise an additional internode is measured. This "two-component" allometry-internodes as frustra and aerial tips as shrubs-can reduce estimated biomass error propagated to the plot-level by as much as 50% or more where very large shrubs are present D max is any diameter such that the ratio of single-component to two-component uncertainty exceeds the ratio of two-component to single-component measurement time. Guidelines for estimating D max based on pilot field data are provided. Tall shrubs are increasing in abundance and distribution across Arctic, alpine, boreal, and dryland ecosystems. Estimating their biomass is important for both ecological studies and carbon accounting. Reducing field-sample prediction error increases precision in multi-stage modeling because additional measures efficiently improve plot-level biomass precision, reducing uncertainty for shrub biomass estimates., Competing Interests: As authors, we declare no conflict of interest in the publication of this study., (© 2021 The Authors. Ecology and Evolution published by John Wiley & Sons Ltd. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Aim: To describe lifeworld insights into the phenomenon of caring responsibility from the perspectives of persons aged 80+ years living alone with chronic illness, physical frailty and dependency on adult children., Design: A phenomenological inquiry inspired by Reflective Lifeworld Research., Method: Semi-structured lifeworld interviews with 11 persons aged 80+ years were conducted following their discharge. The interviews lasted 35-83 min, were audio-recorded and transcribed verbatim. Both interviews and the analysis followed the epistemological and methodological principles of Reflective Lifeworld Research., Findings: We identified the essential meaning 'It means everything' and four constituents illuminating different aspects inherent in the complex phenomenon of caring responsibility; 'A life-constraining transition,' 'Trusting the children to fill the gaps and be the glue,' 'Tacit responsibility, agreement and acceptance' and 'Depending on the children and knowing they are burdened by you.', Conclusions: Caring responsibility is based on a trusting relationship and tacit agreements indicating an understanding of interdependence and acceptance of dependence on adult children. However, a paradox appears when older persons express a deep-rooted perception of autonomy and independence as they have difficulties with their growing dependency and feelings of being burdensome. Older persons try to balance the continuum of autonomy, their existential self-image and actual capability. The practical part of caring responsibility seems to dominate and strongly affect the parent-child relationship because the child needs to take care of practical issues related to healthcare management and instrumental activities of daily living, leaving less time for meaningful togetherness., Implications for Practice: Older persons want their adult children to be involved and acknowledged when planning care and treatment because they often seem to serve as the 'glue' that makes it possible for the parent to remain in his/her own home., (© 2020 John Wiley & Sons Ltd.)

Climate change may affect stream ecosystems through flow regime alterations, which can be particularly complex in streams with a significant groundwater contribution. To quantify the impacts of climate change on hydrological regime and subsequently the stream biota, we linked SWAT-MODFLOW (A model coupling the Soil and Water Assessment Tool and the Modular Finite-difference Flow Model) with flow-biota empirical models that included indices for three key biological taxonomic identities (fish, macroinvertebrates and macrophytes) and applied the model-complex to a groundwater-dominated catchment in Denmark. Effects of predicted climate change towards the end of this century relative to the reference period (1996-2005) were tested with two contrasting climate change scenarios of different greenhouse gas emissions (Representative Concentration Pathway 2.6 (RCP 2.6) and RCP 8.5) and analysed for all subbasins grouped into streams of three size classes. The total water yield in the catchment did not change significantly (-1 ± 4 (SD) mm yr -1 ) from the baseline in the RCP2.6 scenario, while it increased by 9 ± 11 mm yr -1 in the RCP8.5 scenario. The three stream size classes underwent different alterations in flow regime and also demonstrated different biotic responses to climate change. All large and some small streams were impacted most heavily by the climate change, where fish and macrophyte indices decreased up to 14.4% and 11.2%, respectively, whereas these indices increased by up to 14.4% and 6.0%, respectively, in the medium and some small streams. The climate change effects were, as expected, larger in the RCP8.5 scenario than in the RCP2.6 scenario. Our study is the first to quantify the impacts of streamflow alterations induced by climate change on stream biota beyond specific species., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: As life expectancy increases, a growing percentage of older individuals with age-related diseases such as osteoporosis and sarcopenia are expected. Patients with both conditions, i.e. patient with osteosarcopenia, are suggested to have a higher risk of fall and fracture compared to individuals with either condition., Aim: To investigate the potential relationship between low bone mineral density (BMD) and muscle dysfunction in a Danish cohort of older home-dwelling individuals. Furthermore, to examine the prevalence of osteosarcopenia and alterations in prevalence depending on cut-off values chosen., Method: Measures of BMD, relative appendicular lean mass and hand grip strength were assessed in 529 individuals aged 65+ from the population-based cross-sectional Copenhagen Sarcopenia Study (CSS). Osteoporosis was diagnosed according to the World Health Organization guidelines. Sarcopenia was diagnosed in accordance with the guidelines from the European Working Group on Sarcopenia in Older People (EWGSOP2) with application of cut-off values from the EWGSOP2 paper compared to cut-off values derived from a local cohort (CSS)., Results: 19.2% had osteoporosis (66 women and 35 men), whereas 2.7% (6 women and 8 men) and 4.2% (7 women and 15 men) had sarcopenia with application of EWGSOP2 and CSS cut-off values, respectively. Using the EWGSOP2 cut-off values, 1.5% (4 women and 4 men) were diagnosed with osteosarcopenia compared to 1.4% (4 women and 3 men) using CSS cut-off values. In the osteoporosis sub-population, 8% (EWGSOP2) and 7% (CSS) had sarcopenia and within the sarcopenia sub-population, 61.5% (EWGSOP2) and 33.3% (CSS) had osteoporosis. At all sites, BMD was lower among individuals with sarcopenia and sarcopenia increased the risk of osteoporosis (odds ratios: EWGSOP2: 7.3 (p < 0.001) and CSS: 2.2 (ns))., Conclusion: Osteosarcopenia was present in 1.5% of a group of healthy home-dwelling older individuals. Notably, individuals with sarcopenia had lower BMD and a higher risk of osteoporosis, whereas the opposite (prevalence of sarcopenia in individuals with osteoporosis) was not as frequent. Our data indicate that screening for sarcopenia and osteoporosis should be performed simultaneously in older individuals at high risk of falls and fractures. However, further studies with outcome-related results are needed to identify optimal measures of osteosarcopenia and cut-off values for sarcopenia., Competing Interests: Declaration of competing interest None of the authors have any declaration of interests., (Copyright © 2020. Published by Elsevier Inc.)

This paper studies the relative importance of societal drivers and changing climate on anthropogenic nutrient inputs to the Baltic Sea. Shared Socioeconomic Pathways and Representative Concentration Pathways are extended at temporal and spatial scales relevant for the most contributing sectors. Extended socioeconomic and climate scenarios are then used as inputs for spatially and temporally detailed models for population and land use change, and their subsequent impact on nutrient loading is computed. According to the model simulations, several factors of varying influence may either increase or decrease total nutrient loads. In general, societal drivers outweigh the impacts of changing climate. Food demand is the most impactful driver, strongly affecting land use and nutrient loads from agricultural lands in the long run. In order to reach the good environmental status of the Baltic Sea, additional nutrient abatement efforts should focus on phosphorus rather than nitrogen. Agriculture is the most important sector to be addressed under the conditions of gradually increasing precipitation in the region and increasing global demand for food., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Climate and land-use change drive a suite of stressors that shape ecosystems and interact to yield complex ecological responses (that is, additive, antagonistic and synergistic effects). We know little about the spatial scales relevant for the outcomes of such interactions and little about effect sizes. These knowledge gaps need to be filled to underpin future land management decisions or climate mitigation interventions for protecting and restoring freshwater ecosystems. This study combines data across scales from 33 mesocosm experiments with those from 14 river basins and 22 cross-basin studies in Europe, producing 174 combinations of paired-stressor effects on a biological response variable. Generalized linear models showed that only one of the two stressors had a significant effect in 39% of the analysed cases, 28% of the paired-stressor combinations resulted in additive effects and 33% resulted in interactive (antagonistic, synergistic, opposing or reversal) effects. For lakes, the frequencies of additive and interactive effects were similar for all spatial scales addressed, while for rivers these frequencies increased with scale. Nutrient enrichment was the overriding stressor for lakes, with effects generally exceeding those of secondary stressors. For rivers, the effects of nutrient enrichment were dependent on the specific stressor combination and biological response variable. These results vindicate the traditional focus of lake restoration and management on nutrient stress, while highlighting that river management requires more bespoke management solutions.

Aim: To provide lifeworld insights into experiences of adult children with caring responsibility for an 80+-year-old chronically ill parent with frailty., Background: Informal care is common in Nordic welfare countries; however, little is known about adult children's experience of caring responsibility in this setting., Design: A phenomenological-hermeneutic study based on Reflective Lifeworld Research., Methods: Diaries and semi-structured interviews with 12 adult children., Results: Caring responsibility is identified as "a condition of life, filled with uncertainty." Three constituents contribute to this phenomenon: (a) balancing love, duty and reciprocity; (b) being the parent's advocate and manager; and (c) experiencing concerns and bodily strain., Conclusion: Adult children work hard to provide care and enhance the well-being of their parent. Heidegger's concept 'Fürsorge' may help us understand how by showing how caring responsibility means balancing different roles vis-à-vis the parent, one's own life and the health and social systems. Caring responsibility changes the relationship between parent and child., Competing Interests: The authors declare no conflict of interest., (© 2020 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Assessing the impacts of groundwater abstractions on stream ecosystems is crucial for developing water planning and regulations in lowland areas that are highly dependent on groundwater, such as Denmark. To assess the effects of groundwater abstractions on flow regime and stream biota in a lowland groundwater-dominant catchment, we combined the SWAT-MODFLOW model with flow-biota empirical models including indices for three key biological taxonomic identities (fish, macroinvertebrates, and macrophytes). We assessed the effects of the current level of abstractions and also ran a scenario for assessing the effect of extreme groundwater abstractions (pumping rates of the drinking water wells were increased by 20 times in one subbasin of the catchment). Three subbasin outlets representing stream segments of different sizes were used for this evaluation. Current groundwater abstraction level had only minor impacts on the flow regime and stream biotic indices at the three subbasin outlets. The extreme abstractions, however, led to significant impacts on the small stream but had comparatively minor effects on the larger streams. The fish index responded most negatively to the groundwater abstractions, followed by the macrophyte index, decreasing, respectively, by 23.5% and 11.2% in the small stream in the extreme groundwater abstraction scenario. No apparent impact was found on macroinvertebrates in any of the three subbasin outlets. We conclude that this novel approach of a combined modelling system is a useful tool to quantitatively assess the effects of groundwater abstractions on stream biota and thereby support water planning and regulations related to groundwater abstractions. We highlight the need for developing improved biotic models that target specifically small headwater streams, which are often most affected by water abstraction., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: Validation of the Danish version of the SARC-F (Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls) for hospitalized geriatric medical patients, compared against the original EWGSOP (European Working Group on Sarcopenia in Older People) and revised EWGSOP2 definition for sarcopenia. Additionally, investigation of the ability of SARC-F to individually identify low strength/function and muscle mass., Design: Cross-sectional analysis of data from an RCT., Setting: Hospital, Medical Department., Participants: 122 geriatric medical patients (65.6% women) ≥ 70 years of age with mixed medical conditions., Measurements: SARC-F screening, diagnostic assessment of sarcopenia (hand-grip strength, muscle mass measured by dual-frequency bio-impedance analysis, and 4-m usual gait speed)., Results: The prevalence of risk of sarcopenia (SARC-F ≥ 4) was 48.3%, while it was diagnosed in 65.8% and 21.7%, with EWGSOP and EWGSOP2, respectively. The sensitivity, specificity, positive predictive value, negative predictive value according to EWGSOP were 50.0 %, 53.7 %, 67.2% and 36.1%, while they were 53.8 %, 53.2 %, 24.1% and 80.6%, according to EWGSOP2 (all participants). The ability of SARC-F to predict reduced strength, function, and muscle mass was modest. There was a significant negative linear, yet weak, relationship between total SARC-F score and hand-grip strength (R2=0.033) and 4-m gait speed (R2=0.111), but not muscle mass (R2=0.004)., Conclusion: SARC-F does not seem to be a suitable screening tool for identifying and excluding non-sarcopenic geriatric patients. Furthermore, the SARC-F score was more strongly correlated with reduced muscle strength and physical function than with low muscle mass., Competing Interests: None of the authors declare any conflicts of interests

Sarcopenia (loss of muscle mass/strength) burdens many older adults - hospitalised older adults being particularly vulnerable. Treating the condition, protein supplementation (PrS) and resistance training (RT) may act synergistically. Therefore, this block-randomised, double-blind, multicentre intervention study, recruiting geriatric patients > 70 years from three medical departments, investigated the effect of PrS combined with RT during hospitalisation and 12 weeks after discharge. Participants were randomly allocated (1:1) to receive PrS (totally 27·5 g whey protein/d, about 2000 kJ/d) or isoenergetic placebo-products (< 1·5 g protein/d) divided into two servings per d to supplement the habitual diet. Both groups were engaged in a standardised, progressive low-intensity RT programme for the lower extremities (hospital: supervised daily/after discharge: self-training 4×/week). From April 2016 to September 2017, 2351 patients were screened, 462 were eligible, and 165 included. Fourteen were excluded and ten dropped out, leaving 141 participants in the intention-to-treat analysis. The average total protein intake during hospitalisation/after discharge was 1·0 (interquartile range (IQR) 0·8, 1·3)/1·1 (IQR 0·9, 1·3) g/kg per d (protein-group) and 0·6 (IQR 0·5, 0·8)/0·9 (IQR 0·6, 1·0) g/kg per d (placebo group). Both groups improved significantly for the primary and secondary endpoints of muscle mass/strength, functional measurements and quality of life, but no additional effect of PrS was seen for the primary endpoint (30-s chair stand test, repetitions, median changes from baseline: (standard test: 0 (IQR 0, 5) (protein group) v. 2 (IQR 0, 6) (placebo group) and modified test: 2 (IQR 0, 5) (protein group) v. 2 (IQR -1, 5) (placebo group)) or any secondary endpoints (Mann-Whitney U tests, P > 0·05). In conclusion, PrS increasing the total protein intake by 0·4 and 0·2 g/kg per d during hospitalisation and after discharge, respectively, does not seem to increase the adaptive response to low-intensity RT in geriatric medical patients.

In this study, quantitative models of the agricultural sector and nutrient transport and cycling are used to analyse the impacts in the Baltic Sea of replacing the current Greening measures of the EU's Common Agricultural Policy with a package of investments in manure handling. The investments aim at improving nutrient utilization and reducing nitrogen leaching, based on the assumption that lagging farms and regions can catch up with observed good practice. Our results indicate that such investments could reduce nitrogen surpluses in agriculture by 18% and nitrogen concentrations in the Baltic Sea by 1 to 9% depending on the basin. The Greening measures, in contrast, are found to actually increase nitrogen leaching.

This paper analyzes the main weaknesses and key avenues for improvement of nutrient policies in the Baltic Sea region. HELCOM's Baltic Sea Action Plan (BSAP), accepted by the Baltic Sea countries in 2007, was based on an innovative ecological modeling of the Baltic Sea environment and addressed the impact of the combination of riverine loading and transfer of nutrients on the ecological status of the sea and its sub-basins. We argue, however, that the assigned country-specific targets of nutrient loading do not reach the same level of sophistication, because they are not based on careful economic and policy analysis. We show an increasing gap between the state-of-the-art policy alternatives and the existing command-and-control-based approaches to the protection of the Baltic Sea environment and outline the most important steps for a Baltic Sea Socioeconomic Action Plan. It is time to raise the socioeconomic design of nutrient policies to the same level of sophistication as the ecological foundations of the BSAP.

Non-point nitrogen discharges from agriculture are difficult to regulate, because of the diffuse nature of the pollution. Inflexible and uniform regulation policies have been the solution in many parts of the world. A more targeted and flexible regulation, adjusted to the heterogeneity of hydrological conditions and ambient water quality, as well as the heterogeneity in abatement costs between farms, has been challenging to develop and implement. One reason is the difficulties measuring the hydrological conditions on a detailed spatial scale. One of the most important hydrological factors, which co-determines the load reduction, is the retention (attenuation) of nitrogen in the catchment, from the root zone to the coast. It is therefore critical to understand how uncertainty in retention affects policy recommendations. In this paper, we use a spatial costs-minimization catchment model, TargetEconN, applied to the Danish catchment Limfjorden. The model includes retention, effects of measures and abatement costs at a detailed spatial scale. The model identifies optimal spatial allocation of nitrogen abatement measures at different load reduction targets to the fjord. We use the model to evaluate the sensitivity of the results to different forms of uncertainty in retention by running scenarios. For all scenarios, the total costs, the marginal costs and the distribution of measures are compared, and special emphasis is paid to how uncertainty on the retention affects the cost-effective allocation of abatement measures. The results indicate that taking spatial heterogeneity of retention into account is important to obtain cost-effective nitrogen abatement as this reduces the costs by approximately 25 percent. We assess the importance of uncertainty in the retention estimates by comparing baseline results with the results from model runs using 1) the mean retention estimate for all areas, 2) misspecification of the retention estimates by 10-20 percent in low and high retention areas, and 3) random misspecification of the retention across the catchment. The results indicate that this range of misspecification and uncertainty in retention, does not play a major role for the allocation of measures, nor for the total costs. We conclude that considering spatial heterogeneity in retention is important for cost-effectiveness, and that a policy where retention is included in the allocation of measures is relatively robust towards the uncertainty in the measurements of retention. Uncertainty and misspecification can lead to higher costs for individual farmers. However, for the agricultural community as a whole it is much more costly not to take differences in retention into account., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

There are infinite possible future scenarios reflecting the impacts of anthropogenic multiple stress on our planet. These impacts include changes in climate and land cover, to which aquatic ecosystems are especially vulnerable. To assess plausible developments of the future state of European surface waters, we considered two climate scenarios and three storylines describing land use, management and anthropogenic development ('Consensus', 'Techno' and 'Fragmented', which in terms of environmental protection represent best-, intermediate- and worst-case, respectively). Three lake and four river basins were selected, representing a spectrum of European conditions through a range of different human impacts and climatic, geographical and biological characteristics. Using process-based and empirical models, freshwater total nitrogen, total phosphorus and chlorophyll-a concentrations were projected for 2030 and 2060. Under current conditions, the water bodies mostly fail good ecological status. In future predictions for the Techno and Fragmented World, concentrations further increased, while concentrations generally declined for the Consensus World. Furthermore, impacts were more severe for rivers than for lakes. Main pressures identified were nutrient inputs from agriculture, land use change, inadequately managed water abstractions and climate change effects. While the basins in the Continental and Atlantic regions were primarily affected by land use changes, in the Mediterranean/Anatolian the main driver was climate change. The Boreal basins showed combined impacts of land use and climate change and clearly reflected the climate-induced future trend of agricultural activities shifting northward. The storylines showed positive effects on ecological status by classical mitigation measures in the Consensus World (e.g. riparian shading), technical improvements in the Techno World (e.g. increasing wastewater treatment efficiency) and agricultural extensification in the Fragmented World. Results emphasize the need for implementing targeted measures to reduce anthropogenic impacts and the importance of having differing levels of ambition for improving the future status of water bodies depending on the societal future to be expected., (Copyright © 2019 Elsevier B.V. All rights reserved.)

To analyse the potential future ecological state of estuaries located in the temperate climate (here exemplified with the Odense Fjord estuary, Denmark), we combined end-of-the-century climate change projections from four different climate models, four contrasting land use scenarios ("Agriculture for nature", "Extensive agriculture", "High-tech agriculture" and "Market driven agriculture") and two different eco-hydrological models. By decomposing the variance of the model-simulated output from all scenario and model combinations, we identified the key sources of uncertainties of these future projections. There was generally a decline in the ecological state of the estuary in scenarios with a warmer climate. Strikingly, even the most nature-friendly land use scenario, where a proportion of the intensive agricultural area was converted to forest, may not be enough to counteract the negative effects of a future warmer climate on the ecological state of the estuary. The different land use scenarios were the most significant sources of uncertainty in the projections of future ecological state, followed, in order, by eco-hydrological models and climate models, albeit all three sources caused high variability in the simulated outputs. Therefore, when projecting the future state of aquatic ecosystems in a global warming context, one should at the very least consider to evaluate an ensemble of land use scenarios (nutrient loads) but ideally also include multiple eco-hydrological models and climate change projections. Our study may set precedence for future attempts to predict and quantify uncertainties of model and model input ensembles, as this will likely be key elements in future tools for decision-making processes., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Changes in land use, climate and flow diversion are key drivers of river flow regime change that may eventually affect freshwater biodiversity and ecosystem functions. However, our knowledge is limited on how the functional features of stream organisms vary along the gradient of hydrological disturbance (i.e. flow regime changes) and how flow regimes mediate the functional features in lowland streams. We analyzed the functional traits of benthic diatoms (unicellular siliceous algae) that are most sensitive and tolerant to flow regime changes along a nationwide scale of 246 sites in Denmark. We combined RLQ and fourth-corner analyses to explore the co-variation between hydrological variables (R table) and species traits (Q table), constrained by the relative abundance of each species (L table) as observed in each of the sampling sites. Further, we examine the relationships between functional features (i.e., functional redundancy and diversity) and hydrological variables by multivariate statistical analyses. Results show that species turnover with displacement of sensitive species by tolerant species was the dominating process in benthic diatom communities during high flow disturbances. Functional features, as indicated by functional diversity and redundancy indices, were mediated mainly by high and low flow magnitude. Median daily flow magnitude shows a consistent positive relationship with functional redundancy and richness indices indicating that larger streams are more resilient to flow perturbations. In addition flow regime changes are less important than median daily flow magnitude and show inconsistent correlation to functional features likely due to the interaction of multiple environmental stressors. Our study highlights the robustness of trait-based approaches for identifying flow regime changes in streams, and strongly suggests that biodiversity conservation and water resource management should focus on protecting natural base flow in headwater streams and generally reduce flow regulation for sustaining stream ecosystems under future global changes., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Gathering information about forest variables is an expensive and arduous activity. As such, directly collecting the data required to produce high-resolution maps over large spatial domains is infeasible. Next generation collection initiatives of remotely sensed Light Detection and Ranging (LiDAR) data are specifically aimed at producing complete-coverage maps over large spatial domains. Given that LiDAR data and forest characteristics are often strongly correlated, it is possible to make use of the former to model, predict, and map forest variables over regions of interest. This entails dealing with the high-dimensional (~10 2 ) spatially dependent LiDAR outcomes over a large number of locations (~10 5 -10 6 ). With this in mind, we develop the Spatial Factor Nearest Neighbor Gaussian Process (SF-NNGP) model, and embed it in a two-stage approach that connects the spatial structure found in LiDAR signals with forest variables. We provide a simulation experiment that demonstrates inferential and predictive performance of the SF-NNGP, and use the two-stage modeling strategy to generate complete-coverage maps of forest variables with associated uncertainty over a large region of boreal forests in interior Alaska.

We consider alternate formulations of recently proposed hierarchical Nearest Neighbor Gaussian Process (NNGP) models (Datta et al., 2016a) for improved convergence, faster computing time, and more robust and reproducible Bayesian inference. Algorithms are defined that improve CPU memory management and exploit existing high-performance numerical linear algebra libraries. Computational and inferential benefits are assessed for alternate NNGP specifications using simulated datasets and remotely sensed light detection and ranging (LiDAR) data collected over the US Forest Service Tanana Inventory Unit (TIU) in a remote portion of Interior Alaska. The resulting data product is the first statistically robust map of forest canopy for the TIU.

Background: Successful treatment of latent tuberculosis infection (LTBI) is essential to reduce tuberculosis (TB) incidence rates in low-burden countries. This study measures treatment completion and determinants of non-completion of LTBI treatment in Norway in 2016., Methods: This prospective cohort study included all individuals notified with LTBI treatment to the Norwegian Surveillance System for Infectious Diseases (MSIS) in 2016. We obtained data from MSIS and from a standardized form that was sent to health care providers at the time of patient notification to MSIS. We determined completion rates. Pearson's chi squared test was used to study associations between pairs of categorical variables and separate crude and multivariable logistic regression models were used to identify factors associated with treatment completion and adverse drug effects., Results: We obtained information on treatment completion from 719 of the 726 individuals notified for LTBI treatment in 2016. Overall, 91% completed treatment. Treatment completion was highest in the foreign-born group [foreign-born, n = 562 (92%) vs Norwegian-born, n = 115 (85%), p = 0.007]. Treatment completion did not differ significantly between prescribed regimens (p = 0.124). Adverse events were the most common reason for incomplete treatment. We found no significant differences in adverse events when comparing weekly rifapentine (3RPH) with three months daily isoniazid and rifampicin (3RH). However, there were significantly fewer adverse events with 3RPH compared to other regimens (p = 0.037). Age over 35 years was significantly associated with adverse events irrespective of regimen (p = 0.024), whereas immunosuppression was not significantly associated with adverse events after adjusting for other variables (p = 0.306). Treatment under direct observation had a significant effect on treatment completion for foreign-born (multivariate Wald p-value = 0.017), but not for Norwegian-born (multivariate Wald p-value = 0.408) individuals., Conclusions: We report a very high treatment completion rate, especially among individuals from countries with high TB incidence. The follow-up from tuberculosis-coordinators and the frequent use of directly observed treatment probably contributes to this. Few severe adverse events were reported, even with increased age and in individuals that are more susceptible. While these results are promising, issues of cost-effectiveness and targeting treatment to individuals at highest risk of TB are important components of public health impact.

Background: Age-related loss of muscle and bone (sarcopenia and osteoporosis), increases the risk of falls and fractures and consequently leads to a substantial economic burden for the society. The combined condition, osteosarcopenia, may identify patients at a higher risk of those outcomes and could be relevant for assessment and treatment in clinical practice., Aim: To evaluate the current knowledge of the prevalence of osteosarcopenia and the fracture risk in older people., Method: A systematic literature review was conducted until 10th March 2018. A total of 1105 papers were detected, whereof 1049 and 29 were excluded by title/abstracts and full-text assessment, respectively. Twenty-seven original papers were included in the systematic review, whereof 17 were suitable for meta-analysis., Results: The prevalence of osteosarcopenia varied (5-37%) depending on the classification of sarcopenia and whether participants were classified initially according to sarcopenia or osteoporosis. In patients with low-energy osteoporotic fractures, sarcopenia was present in 7.8-58% and 1.3-96.3% of the cases, women and men, respectively. The meta-analysis of prevalence of sarcopenia in patients with low-energy fracture (n = 9) was 46% (95% CI 44, 48; p < 0.001). The relative risk of fracture (sarcopenic versus non-sarcopenic) in meta-analysis of four studies was 1.37 (95% CI 1.18, 1.59; p < 0.001). Mean bone mineral density (n = 5) and T-score (n = 3) of femoral neck was significantly lower in sarcopenic participants [- 0.07 g/cm 2 (95% CI 0.08, 0.06) and - 0.34 (95% CI - 0.46, - 0.23), respectively]., Conclusion: Osteosarcopenia is frequent and the relative risk of fracture is higher among sarcopenic patients. A standard and strict classification of sarcopenia is needed to assess its true relationship and consequences., (© 2018. European Geriatric Medicine Society.)

Groundwater and surface water are often closely coupled and are both under the influence of multiple stressors. Stressed groundwater systems may lead to a poor ecological status of surface waters but to date no conceptual framework to analyse linked multi-stressed groundwater - surface water systems has been developed. In this paper, a framework is proposed showing the effect of groundwater on surface waters in multiple stressed systems. This framework will be illustrated by applying it to four European catchments, the Odense, Denmark, the Regge and Dinkel, Netherlands, and the Thames, UK, and by assessing its utility in analysing the propagation or buffering of multi-stressors through groundwater to surface waters in these catchments. It is shown that groundwater affects surface water flow, nutrients and temperature, and can both propagate stressors towards surface waters and buffer the effect of stressors in space and time. The effect of groundwater on drivers and states depends on catchment characteristics, stressor combinations, scale and management practises. The proposed framework shows how groundwater in lowland catchments acts as a bridge between stressors and their effects within surface waters. It shows water managers how their management areas might be influenced by groundwater, and helps them to include this important, but often overlooked part of the water cycle in their basin management plans. The analysis of the study catchments also revealed a lack of data on the temperature of both groundwater and surface water, while it is an important parameter considering future climate warming., (Copyright © 2018. Published by Elsevier B.V.)

The boreal biome represents approximately one third of the world's forested area and plays an important role in global biogeochemical and energy cycles. Numerous studies in boreal Alaska have concluded that growth of black and white spruce is declining as a result of temperature-induced drought stress. The combined evidence of declining spruce growth and changes in the fire regime that favor establishment of deciduous tree species has led some investigators to suggest the region may be transitioning from dominance by spruce to dominance by deciduous forests and/or grasslands. Although spruce growth trends have been extensively investigated, few studies have evaluated long-term radial growth trends of the dominant deciduous species (Alaska paper birch and trembling aspen) and their sensitivity to moisture availability. We used a large and spatially extensive sample of tree cores from interior Alaska to compare long-term growth trends among contrasting tree species (white and black spruce vs. birch and aspen). All species showed a growth peak in the mid-1940s, although growth following the peak varied strongly across species. Following an initial decline from the peak, growth of white spruce showed little evidence of a trend, while black spruce and birch growth showed slight growth declines from ~1970 to present. Aspen growth was much more variable than the other species and showed a steep decline from ~1970 to present. Growth of birch, black and white spruce was sensitive to moisture availability throughout most of the tree-ring chronologies, as evidenced by negative correlations with air temperature and positive correlations with precipitation. However, a positive correlation between previous July precipitation and aspen growth disappeared in recent decades, corresponding with a rise in the population of the aspen leaf miner (Phyllocnistis populiella), an herbivorous moth, which may have driven growth to a level not seen since the early 20th century. Our results provide important historical context for recent growth and raise questions regarding competitive interactions among the dominant tree species and exchanges of carbon and energy in the warming climate of interior Alaska., (© 2018 by the Ecological Society of America.)

Introduction: The prevalence of sarcopenia varies extensively depending on the definitions and studied populations. The aim of this study was to assess the prevalence of sarcopenia in a Danish geriatric out-patient population using criteria from the European Working Group on Sarcopenia (EWGSOP)., Methods: Patients referred to a geriatric out-patientclinic were included. Using the EWGSOP´s recommendations, appendicular skeletal muscle mass (ASM), hand-grip strength (HGS) and gait speed (ten-meter walk (GS)) were assessed. Skeletal muscle mass index (SMI) was calculated by ASM/height2 (kg/m2), and patients were classified with: no sarcopenia (normal SMI), pre-sarcopenia (reduced SMI, normal HGS and GS), sarcopenia (reduced SMI and reduced HGS or GS) or severe sarcopenia (reduced SMI, HGS and GS)., Results: A total of 189 patients were screened, 80 were included. In all, 12 (15%) had severe sarcopenia, nine (11%) sarcopenia, eight (10%) pre-sarcopenia and 51 (64%) no sarcopenia. Mean age was significantly higher in the SARC- group (sarcopenia and severe sarcopenia) than in the NOSARC-group (pre-sarcopenia and no sarcopenia) (p = 0.009), and BMI was significantly lower in the SARC-group (p < 0.0001). No difference was found in gender distribution (p = 0.729)., Conclusions: 26% of patients in a geriatric out-patient population had sarcopenia, which highlights that this is a common condition. Standard assessments can identify functional limitations, but not sarcopenia. The EWGSOP's recommendations are feasible, and we suggest that they should form part of the standard clinical comprehensive geriatric assessment., Funding: none., Trial Registration: not relevant., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Water pollution and water scarcity are among the main environmental challenges faced by the European Union, and multiple stressors compromise the integrity of water resources and ecosystems. Particularly in lowland areas of northern Europe, high population density, flood protection and, especially, intensive agriculture, are important drivers of water quality degradation. In addition, future climate and land use changes may interact, with uncertain consequences for water resources. Modelling approaches have become essential to address water issues and to evaluate ecosystem management. In this work, three multi-stressor future storylines combining climatic and socio-economic changes, defined at European level, have been downscaled for the Odense Fjord catchment (Denmark), giving three scenarios: High-Tech agriculture (HT), Agriculture for Nature (AN) and Market-Driven agriculture (MD). The impacts of these scenarios on water discharge and inorganic and organic nutrient loads to the streams have been simulated using the Soil and Water Assessment Tool (SWAT). The results revealed that the scenario-specific climate inputs were most important when simulating hydrology, increasing river discharge in the HT and MD scenarios (which followed the high emission 8.5 representative concentration pathway, RCP), while remaining stable in the AN scenario (RCP 4.5). Moreover, discharge was the main driver of changes in organic nutrients and inorganic phosphorus loads that consequently increased in a high emission scenario. Nevertheless, both land use (via inputs of fertilizer) and climate changes affected the nitrate transport. Different levels of fertilization yielded a decrease in the nitrate load in AN and an increase in MD. In HT, however, nitrate losses remained stable because the fertilization decrease was counteracted by a flow increase. Thus, our results suggest that N loads will ultimately depend on future land use and management in an interaction with climate changes, and this knowledge is of utmost importance for the achievement of European environmental policy goals., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Inter- and intra-annual water level fluctuations and changes in water flow regime are intrinsic characteristics of Mediterranean lakes. Additionally, considering climate change projections for the water-limited Mediterranean region, increased air temperatures and decreased precipitation are anticipated, leading to dramatic declines in lake water levels as well as severe water scarcity problems. The study site, Lake Beyşehir, the largest freshwater lake in the Mediterranean basin, is - like other Mediterranean lakes - threatened by climatic changes and over-abstraction of water for irrigated crop farming. Therefore, implementation of strict water level management policies is required. In this study, an integrated modeling approach was used to predict the future water levels of Lake Beyşehir in response to potential future changes in climate and land use. Water level estimation was performed by linking the catchment model Soil and Water Assessment Tool (SWAT) with a Support Vector Regression model (ε-SVR). The projected increase in temperature and decrease in precipitation based on the climate change models led to an enhanced potential evapotranspiration and reduced total runoff. On the other hand, the effects of various land use scenarios within the catchment appeared to be comparatively insignificant. According to the ε-SVR model results, changes in hydrological processes caused a water level reduction for all scenarios. Moreover, the MPI-ESM-MR General Circulation Model outputs produced the most dramatic results by predicting that Lake Beyşehir may dry out by the 2040s with the current outflow regime. The results indicate that shallow Mediterranean lakes may face a severe risk of drying out and losing their ecosystem values in the near future if the current intensity of water abstraction is not reduced. In addition, the results also demonstrate that outflow management and sustainable use of water sources are vital to sustain lake ecosystems in water-limited regions., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Aim: The number of older adults will increase worldwide in the next 30 years, with many expected to develop chronic diseases and consequently require additional medical assessments and adequate care. The aim of this study was to describe how a group of older adults who need geriatric assessment experience growing older., Methodology: A qualitative study was performed. The empirical data consisted of qualitative in-depth interviews with eight older persons referred to geriatric assessment (median age 76, range 65-86). The interviews were analysed based on Giorgi's descriptive phenomenological methodology., Results: The results led to an overall essence and five themes. The five themes were identified: (i) considerations to avoid weakness, (ii) compensation for the inability to perform certain activities, (iii) aides - a symbol of freedom or limitation, (iv) lifestyle considered being particularly significant and (v) considerations about the end of life as a component of growing older. The essence was defined as: illness essential for the experience of growing older and pointed to the experience of growing older that highlighted that experiencing illnesses and limitations served as reminders of their advancing age., Conclusion: Growing older while in need of comprehensive geriatric assessment led to participants feeling they were no longer able to do the same things, they used to do. Consequently, compensation became an essential part of adaption to the altered situation. Aides that helped to overcome limitations in every daily life had the status of either creating freedom or being limiting in things they wished to do. Considerations about lifestyle were focused on housing and change of dwelling. This also led to thoughts about the future and end of life. Additional research regarding accommodations in older age is warranted to offer the best solutions for older people., (© 2015 Nordic College of Caring Science.)

We investigated leaching of dissolved phosphorus (P) from 45 tile-drains representing animal husbandry farms in all regions of Denmark. Leaching of P via tile-drains exhibits a high degree of spatial heterogeneity with a low concentration in the majority of tile-drains and few tile-drains (15% in our investigation) having high to very high concentration of dissolved P. The share of dissolved organic P (DOP) was high (up to 96%). Leaching of DOP has hitherto been a somewhat overlooked P loss pathway in Danish soils and the mechanisms of mobilization and transport of DOP needs more investigation. We found a high correlation between Olsen-P and water extractable P. Water extractable P is regarded as an indicator of risk of loss of dissolved P. Our findings indicate that Olsen-P, which is measured routinely in Danish agricultural soils, may be a useful proxy for the P leaching potential of soils. However, we found no straight-forward correlation between leaching potential of the top soil layer (expressed as either degree of P saturation, Olsen-P or water extractable P) and the measured concentration of dissolved P in the tile-drain. This underlines that not only the source of P but also the P loss pathway must be taken into account when evaluating the risk of P loss.

At Department of Nursing, University College Lillebaelt in Denmark we use an experiential technique called sculpting in our simulation program. Sculpting is a kind of non-verbal role play in which participants are given a certain character and create a 'sculpture' by arranging family members, social circles and professionals in ways which reflect the quality of the relationships of the people involved. The aim of this study is to further describe the sculpting exercise and present a small scale evaluation study using a qualitative descriptive design. An evaluation sheet was formulated by the authors and filled out by 114 Danish third-year nursing students. The results show that sculpting is experienced as emotionally demanding, but in a good way. It is experienced as an eye-opener that helps to identify the possible complex and emotional dynamics in a family experiencing critical illness and impending death. Sculpting seems to increase nursing students' personal knowing related to palliative care. An experiential learning technique like sculpting can be introduced in other parts of nursing education to raise students' awareness of what they themselves bring into a situation and how this may affect their clinical judgments., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The Baltic Sea Action Plan (BSAP) requires tools to simulate effects and costs of various nutrient abatement strategies. Hierarchically connected databases and models of the entire catchment have been created to allow decision makers to view scenarios via the decision support system NEST. Increased intensity in agriculture in transient countries would result in increased nutrient loads to the Baltic Sea, particularly from Poland, the Baltic States, and Russia. Nutrient retentions are high, which means that the nutrient reduction goals of 135 000 tons N and 15 000 tons P, as formulated in the BSAP from 2007, correspond to a reduction in nutrient loadings to watersheds by 675 000 tons N and 158 000 tons P. A cost-minimization model was used to allocate nutrient reductions to measures and countries where the costs for reducing loads are low. The minimum annual cost to meet BSAP basin targets is estimated to 4.7 billion Euro.

Sediment transport is important for ecology and water quality in receiving waters. Physically based channel erosion methods were implemented in the Soil and Water Assessment Tool version 2009 (SWAT2009) to improve sediment concentration (SS) results. In the study, the default simplified Bagnold sediment routing method (EQN-0) and the physically based simplified Bagnold sediment routing method (EQN-1) were compared with Pareto fronts from multiobjective calibration. Two SWAT models using EQN-0 and EQN-1 were set up for a small agricultural Danish catchment and calibrated with multiobjective calibration on daily and weekly flow-weighted SS (WF SS). Results showed that the Pareto front of EQN-1 was slightly closer to the optimal point than EQN-0 in the objective space. Trade-off between WF SS and daily flow in EQN-1 was smaller than in EQN-0. The EQN-0 method generated more surface erosion to improve WF SS. The EQN-1 method generated more base flow to improve WF SS. The EQN-1 method was less dependent on surface erosion and simulated peak and low values of WF SS better than EQN-0. Therefore, EQN-1 is more suitable than EQN-0 in modeling SS in small lowland catchments., (Copyright © by the American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America, Inc.)

Dizziness is a common complaint in geriatric patients. Age-related changes in organs of balance control make the elderly more susceptible to diseases affecting the same system causing symptoms as dizziness, balance disturbance, fall and syncope. Work-up should be multifactorial and is feasible in geriatric outpatient clinics. Evidence-based interventions are available. New studies have found high frequency of vestibular dysfunction among old fall patients and suggest an association between vestibular dysfunction and orthostatic hypotension. Further research in this area is needed.

Setting: Despite a steep increase in the number of individuals treated for latent tuberculous infection (LTBI), few data are available on how treatment is implemented., Objective: To obtain baseline information on initiation and completion of treatment for LTBI in Norway in 2009., Design: A descriptive cross-sectional study., Results: All 721 patients treated for LTBI in 2009 in Norway were included, of whom 607 (84%) completed treatment. The treatment regimen generally consisted of 3 months of rifampicin and isoniazid. The three main reasons for starting treatment were: 1) countries of origin with high tuberculosis (TB) prevalence, 2) a positive tuberculin skin test, and 3) a positive interferon gamma release assay. The use of directly observed treatment varied by health region and age. The majority of the 34 medical specialists interviewed saw a need for new national guidelines to improve the selection of high-risk patients with LTBI., Conclusions: Management of LTBI is in accordance with current guidelines, with a high completion rate. More targeted selection of which patients should be offered preventive treatment is required, and new guidelines and tools to enhance risk assessment are necessary.

Increasing human impact on stream ecosystems has resulted in a growing need for tools helping managers to develop conservations strategies, and environmental monitoring is crucial for this development. This paper describes the development of models predicting the presence of fish assemblages in lowland streams using solely cost-effective GIS-derived land use variables. Three hundred thirty-five stream sites were separated into two groups based on size. Within each group, fish abundance data and cluster analysis were used to determine the composition of fish assemblages. The occurrence of assemblages was predicted using a dataset containing land use variables at three spatial scales (50 m riparian corridor, 500 m riparian corridor and the entire catchment) supplemented by a dataset on in-stream variables. The overall classification success varied between 66.1-81.1% and was only marginally better when using in-stream variables than when applying only GIS variables. Also, the prediction power of a model combining GIS and in-stream variables was only slightly better than prediction based solely on GIS variables. The possibility of obtaining precise predictions without using costly in-stream variables offers great potential in the design of monitoring programmes as the distribution of monitoring sites along a gradient in ecological quality can be done at a low cost.

Objectives: To address the external validity of a trial of multifactorial fall prevention through an analysis of differences between participants and nonparticipants regarding socioeconomic and morbidity variables., Design: Analysis of nonresponse in a randomized clinical trial., Setting: Geriatric outpatient department., Participants: One thousand one hundred five community-dwelling adults aged 65 and older who had sustained at least one injurious fall., Measurements: Marital status, housing tenure, income, comorbidity, hospitalization, fractures, and drug use before invitation to participate in the trial. Fractures, hospitalization and death were measured for 6 months of follow-up., Results: Four hundred forty-seven responding nonparticipants and 266 nonresponding nonparticipants were compared with 392 participants in the trial. Lower income (odds ratio (OR)=2.38, 95% confidence interval (CI)=1.28-4.28) and more days of hospitalization during the previous 5 years (OR=1.96, 95% CI=1.15-3.33) predicted responding nonparticipation; independent predictors of being a nonresponding nonparticipant were unmarried status (OR=2.0, 95% CI=1.36-2.94), lower income (OR=4.74, 95% CI=2.30-9.78), more days of hospitalization (OR=3.49, 95% CI=1.99-6.11), and prior fractures (OR=1.56, 95% CI=1.02-2.38). Nonresponding nonparticipants were significantly more likely to die (OR=12.99, 95% CI=1.6-105.6) or be hospitalized (OR=2.66, 95% CI=1.7-4.1) than participants during 6 months of follow-up., Conclusion: Nonresponding nonparticipants of a trial of multifactorial fall prevention differed significantly from participants in terms of socioeconomic and morbidity variables and were more likely to be hospitalized or die during 6 months of follow-up. Because of the differences between the two populations, it is questionable whether results from this randomized trial can be generalized to people potentially eligible for participation.