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Rob AB Oostendorp,1– 4 JW Hans Elvers,5,6 Emiel van Trijffel,7,8 Geert M Rutten,9,10 Gwendolyne GM Scholten-Peeters,11 Marcel Heijmans,4 Erik Hendriks,12,13 Emilia Mikolajewska,14,15 Margot De Kooning,3,16 Marjan Laekeman,17,18 Jo Nijs,3,16,19 Nathalie Roussel,20 Han Samwel21 1Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; 2Department of Manual Therapy, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium; 3Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; 4Practice Physiotherapy and Manual Therapy, Heeswijk-Dinther, the Netherlands; 5Department of Public Health and Research, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; 6Department of Allied Health Care, Methodological Health-Skilled Institute, Beuningen, the Netherlands; 7Department of Master Education, SOMT University of Physiotherapy, Amersfoort, the Netherlands; 8Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; 9Institute of Health Studies, Faculty of Health and Social Studies, HAN University of Applied Science, Nijmegen, the Netherlands; 10Campus Venlo, Faculty of Science and Engineering, Maastricht University, Maastricht, the Netherlands; 11Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands; 12Department of Epidemiology, Center of Evidence Based Physiotherapy, Maastricht University, Maastricht, the Netherlands; 13Practice Physiotherapy ‘Maasstaete, Druten, the Netherlands; 14Department of Physiotherapy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland; 15Neurocognitive Laboratory, Centre for Modern Interdisciplinary Technologies, Nicolaus Copernicus University, Toruń, Poland; 16Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium; 17Department of Nursing Sciences, Ph.D.-Kolleg, Faculty of Health, University Witten/Herdecke, Witten, Germany; 18Department of Physiological Psychology, University of Bamberg, Bamberg, Germany; 19Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden; 20Department of Physiotherapy and Rehabilitation Sciences (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; 21Revalis Pain Rehabilitation Centre, S Hertogenbosch, the NetherlandsCorrespondence: Rob AB OostendorpScientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, p/a Oude Kleefsebaan 325, AT Berg En Dal 6572, Nijmegen, the NetherlandsTel +31 246423419Email oostendorp.rob@gmail.comBackground: Whiplash-associated disorders (WADs) constitute a state of health characterized by a wide diversity of symptoms as a result of impairments of functions, activity limitations, and participation restrictions. Patient-reported outcome measurements (PROMs) and patient-reported outcomes (PROs) seem appropriate when describing and evaluating the health status of patients with WAD.Aim: To measure the use of PROMs and PROs as quality indicators in clinical reasoning, and to analyze and evaluate pre- and post-treatment ‘pain intensity’ and ‘functioning’, and for ‘perceived improvement’ in patients with WAD in primary care physiotherapy practice by year of referral, with the phase after accident and prognostic health profile embedded in the clinical reasoning process.Materials and Methods: Data were collected over a period of 10 years. Pain intensity, functioning, and perceived improvement were measured using the Visual Analogue Scale for Pain (VAS-P), the Neck Disability Index (NDI) and the Global Perceived Effect scale (GPE). Pre- and post-treatment mean differences were tested for statistical significance and compared to minimal clinically important differences (MCID). Effect sizes were expressed as Cohen’s d. Multivariable regression analysis was performed to explore independent associations of year of referral, phase after the accident, and the patient’s prognostic health profile with post-treatment pain intensity and functioning.Results: A consecutive sample of 523 patients was included. Pre- and post-treatment mean differences on VAS-P and NDI were statistically significant (P< 0.000) and clinically relevant, with ‘large’ effect sizes for pain intensity and functioning. MCIDs were achieved by 80% for VAS-P and for 60% for NDI. Year of referral and phase after the accident were independently associated with worse post-treatment functioning. About half of the patients (n=241 [46.1%]) perceived themselves as improved.Conclusion: The PROMs and PROs pain intensity, functioning and perceived improvement were integrated as quality indicators in the physiotherapy clinical reasoning process for patients with WAD. Significant differences in pain intensity and functioning were found but were unrelated to year of referral, phase after whiplash-related injury or prognostic health profile. The MCID VAS-P scores did not differ depending on experienced pain.Keywords: whiplash-Associated Disorders, neck pain, physiotherapy, patient-reported outcomes measures, routinely collected data

Rob AB Oostendorp, 1–4 JW Hans Elvers, 5, 6 Emiel van Trijffel, 7, 8 Geert M Rutten, 9, 10 Gwendolyne GM Scholten–Peeters, 11 Marcel Heijmans, 4 Erik Hendriks, 12, 13 Emilia Mikolajewska, 14, 15 Margot De Kooning, 3, 16 Marjan Laekeman, 17 Jo Nijs, 3, 16 Nathalie Roussel, 18 Han Samwel 19 1Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; 2Department of Manual Therapy, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium; 3Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; 4Practice Physiotherapy and Manual Therapy, Heeswijk-Dinther, the Netherlands; 5Department of Public Health and Research, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; 6Methodological Health-Skilled Institute, Beuningen, the Netherlands; 7SOMT University of Physiotherapy, Amersfoort, the Netherlands; 8Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; 9Institute of Health Studies, Faculty of Health and Social Studies, HAN University of Applied Science, Nijmegen, the Netherlands; 10Faculty of Science and Engineering, Maastricht University, Maastricht, the Netherlands; 11Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Free University Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands; 12Department of Epidemiology, Center of Evidence Based Physiotherapy, Maastricht University, Maastricht, the Netherlands; 13Practice Physiotherapy ‘Klepperheide’, Druten, the Netherlands; 14Department of Physiotherapy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus Univerisity, Toruń, Poland; 15Neurocognitive Laboratory, Centre for Modern Interdisciplinary Technologies, Nicolaus Copernicus University, Toruń, Poland; 16Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium; 17Department of Nursing Sciences, Ph.D.-Kolleg, Faculty of Health, University Witten/Herdecke, Witten, Germany; 18Department of Physiotherapy and Rehabilitation Sciences (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; 19Revalis Pain Rehabilitation Centre, ‘s Hertogenbosch, the NetherlandsCorrespondence: Rob AB OostendorpScientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, p/a Oude Kleefsebaan 325, Berg en Dal 6572 AT, the NetherlandsTel +31 2464234219Email oostendorp.rob@gmail.comBackground: Quality indicators (QIs) are measurable elements of practice performance and may relate to context, process, outcome and structure. A valid set of QIs have been developed, reflecting the clinical reasoning used in primary care physiotherapy for patients with whiplash-associated disorders (WAD). Donabedian’s model postulates relationships between the constructs of quality of care, acting in a virtuous circle.Aim: To explore the relative strengths of the relationships between context, process, and outcome indicators in the assessment of primary care physiotherapy in patients with WAD.Materials and Methods: Data on WAD patients (N=810) were collected over a period of 16 years in primary care physiotherapy practices by means of patients records. This routinely collected dataset (RCD-WAD) was classified in context, process, and outcome variables and analyzed retrospectively. Clinically relevant variables were selected based on expert consensus. Associations were expressed, using zero-order, as Spearman rank correlation coefficients (criterion: rs > 0.25 [minimum: fair]; α-value = 0.05).Results: In round 1, 62 of 85 (72.9%) variables were selected by an expert panel as relevant for clinical reasoning; in round 2, 34 of 62 (54.8%) (context variables 9 of 18 [50.0%]; process variables 18 of 34 [52.9]; outcome variables 8 of 10 [90.0%]) as highly relevant. Associations between the selected context and process variables ranged from 0.27 to 0.53 (p≤ 0.00), between selected context and outcome variables from 0.26 to 0.55 (p≤ 0.00), and between selected process and outcome variables from 0.29 to 0.59 (p≤ 0.00). Moderate associations (rs > 0.50; p≤ 0.00) were found between “pain coping” and “fear avoidance” as process variables, and “pain intensity” and “functioning” as outcome variables.Conclusion: The identified associations between selected context, process, and outcome variables were fair to moderate. Ongoing work may clarify some of these associations and provide guidance to physiotherapists on how best to improve the quality of clinical reasoning in terms of relationships between context, process, and outcome in the management of patients with WAD.Keywords: physiotherapy, whiplash injuries, outcome and process assessment, healthcare quality indicators, collected data

Rob AB Oostendorp,1–4 Hans Elvers,5,6 Emiel van Trijffel,7,8 Geert M Rutten,9,10 Gwendolyne GM Scholten–Peeters,11 Marcel Heijmans,4 Erik Hendriks,12,13 Emilia Mikolajewska,14,15 Margot De Kooning,3,8,16 Marjan Laekeman,17 Jo Nijs,3,8,16 Nathalie Roussel,18 Han Samwel191Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; 2Department of Manual Therapy, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium; 3Pain in Motion International Research Group, Free University Brussels, Brussels, Belgium; 4Practice Physiotherapy and Manual Therapy, Heeswijk-Dinther, the Netherlands; 5Department of Public Health and Research, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; 6Methodological Health-Skilled Institute, Beuningen, the Netherlands; 7SOMT University of Physiotherapy, Amersfoort, the Netherlands; 8Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Free University Brussels, Brussels, Belgium; 9Institute of Health Studies, Faculty of Health and Social Studies, HAN University of Applied Science, Nijmegen, the Netherlands; 10Faculty of Science and Engineering, University College Venlo, Maastricht University, Maastricht, the Netherlands; 11Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; 12Department of Epidemiology, Center of Evidence-Based Physiotherapy, Maastricht University, Maastricht, the Netherlands; 13Practice Physiotherapy ‘Klepperheide’, Druten, the Netherlands; 14Department of Physiotherapy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, Poland; 15Neurocognitive Laboratory, Centre for Modern Interdisciplinary Technologies, Nicolaus Copernicus University, Torun, Poland; 16Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium; 17Department of Nursing Sciences, Faculty of Health, University Witten/Herdecke, Witten, Germany; 18Department of Rehabilitation Sciences and Physiotherapy (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Belgium; 19Department of Medical Psychology, Canisius Wilhelmina Hospital, Nijmegen, the NetherlandsPurpose: To develop valid quality indicators (QIs) for physiotherapy care based on best available evidence, and to use these QIs to explore trends in the quality of physiotherapy care of patients with Whiplash-associated disorders (WAD) using guideline-based routinely collected data (RCD) gathered between 1996 and 2011.Materials and methods: The study consisted of two phases: 1) development of QIs and 2) analysis of patient records. A set of QIs was developed based on recommendations in the scientific literature and the Dutch Clinical Practice Guideline (CPG) “Physiotherapy Management and WAD”. QIs were expressed as percentages, allowing target performance levels to be defined (≥80% or ≤30% depending on whether desired performance required a high or low score on a QI). We then analyzed WAD patient data (N = 810) collected over a period of 16 years in two physiotherapy practices, separating patients into two groups defined as before (Group A 1996–2002; n = 353) and after (Group B 2003–2011; n = 457) implementation and transition to the Dutch CPG “Physiotherapy Management and WAD”.Results: Using an iterative process and input from both experts and users, 28 QIs were developed and subsequently classified per step of the clinical reasoning process for physiotherapy care. Based on 16 years of RCD, we found that the clinical reasoning process differed significantly (P ≤ 0.05) between the groups, in favor of Group B. Twelve of the 25 indicators (48.0%) in Group A and 19 of 26 indicators (73.1%) in Group B met predetermined performance targets. The number of target indicators also differed significantly between groups, favoring Group B (P ≤ 0.05).Conclusion: A preliminary set of novel QIs was developed. Using RCD and these QIs, we conclude that physiotherapy care in our study setting improved over the period 1996–2011. Furthermore, the QIs met the performance targets set for the clinical reasoning process after the transition to the Dutch CPG “Physiotherapy Management and WAD”. Keywords: quality of physiotherapy care, Whiplash-associated disorders, clinical guidelines, quality indicators, clinical reasoning process, routinely collected data

The effects of climate change on plants are particularly pronounced in the Arctic region. Warming relaxes the temperature and nutrients boundaries that limit tundra plant growth. Increased resource availability under future climate conditions may induce a shift from a conservative economic strategy to an acquisitive one. Following the leaf economics spectrum that hypothesizes a strategy gradient between survival, plant size and costs for the photosynthetic leaf area, light absorption of tundra plants may increase. We investigated climate change effects on light absorptance and the relationship between light absorptance (fraction of absorbed photosynthetically active radiation, FAPAR) and structural and nutritional leaf traits, performing a soil warming and surface soil fertilization experiment on two deciduous tundra shrub species. Our results show that fertilization and warming combined increase light absorptance in Arctic shrubs and that FAPAR is correlated with leaf nutrients but not with structural leaf traits. This indicates an economic strategy shift of shrubs from conservative to acquisitive induced by warming and fertilization combined. We found species‐specific differences: FAPAR was influenced by warming alone in Betula nana but not in Salix pulchra, and FAPAR was correlated with leaf phosphorus in B. nana but not in S. pulchra. We attribute this to water limitation of B. nana that generally grows in drier areas within the study site compared to S. pulchra. We conclude that FAPAR is a measure that opens up more possibilities to estimate nutritional leaf traits and nutrient cycles, plant economic strategies, and ecological feedbacks of the tundra ecosystem on broader scales. Plain Language Summary: The effects of climate change on plants are very strong in the Arctic. Tundra plants are usually limited by temperature and nutrients. Tundra plants usually have an energy saving strategy, with long lifespan and small leaves. A warmer environment with more nutrients may shift their strategy to faster growth, larger leaves, and more light absorption. We examined climate change effects on the light absorptance of two tundra shrubs. In order to do this, we made an experiment in which we warmed and fertilized the soil. We furthermore studied the relationship between light absorptance and plant traits. Our results show that fertilization and warming combined increase light absorptance in Arctic shrubs. Furthermore, we could show that light absorptance is strongly related to the concentration of nutrients in the leaves. We also found differences in light absorptance between the two shrub species. We believe that these differences are due to Betula nana growing in drier areas with less water compared to Salix pulchra. We think that light absorptance is a good measure for predicting changes in nutrient cycles and plant strategies in the tundra ecosystem. Key Points: Fertilization and warming combined increase light absorptance in two deciduous Arctic shrub species. This indicates an economic strategy shiftLight absorptance is correlated with leaf nutrients but not with structural leaf traits in Arctic shrubsThere are species‐specific differences between the shrub species in regard to light absorptance [ABSTRACT FROM AUTHOR]

Aims: To assess the intended intensity of Type 2 diabetes care and the factors associated with that intensity of care after the annual monitoring visit in which a new person‐centred diabetes consultation model including shared decision making was used. Methods: We conducted an observational study in 1284 people from 47 general practices and six hospital outpatient clinics. Intensity of care (more, no/minimal change, less) was based on monitoring frequency and referral to other care providers. We used multivariable analyses to determine the factors that were independently associated with intensity of care. Care providers also reported three factors which, in their opinion, determined the intensity of care. Results: After the consultation, 22.8% of people chose more intensive care, 70.6% chose no/minimal change and 6.6% chose less intensive care. Whether care became more intensive vs not/minimally changed was associated with a high educational level (odds ratio 1.65, CI 1.07 to 2.53; P=0.023), concern about illness (odds ratio 1.08; CI 1.00 to 1.17; P=0.045), goal‐setting (odds ratio 6.53, CI 3.79 to 11.27; P<0.001), comorbidities (odds ratio 1.12, CI 1.00 to 1.24; P=0.041) and use of oral blood glucose lowering medication (odds ratio 0.59, CI 0.39 to 0.89; P=0.011). Less intensive care vs no/minimal change was associated with lower diabetes distress levels (odds ratio 0.87, CI 0.79 to 0.97; P=0.009). According to care providers, quality of life, lifestyle, person's preferences and motivation, glycaemic control, and self‐management possibilities most frequently determined the intended care. Conclusions: In person‐centred diabetes care, the intended intensity of care was associated with both disease‐ and person‐related factors. What's new?: Diabetes care organizations often state that a person's preferences, needs, values and self‐management possibilities should be taken into account by care providers.After implementation of a person‐centred diabetes consultation model, which included shared decision‐making, the intended diabetes care for the upcoming year was heterogeneous and was associated with not only disease‐ but also person‐related factors, such as educational level, concern about illness, goal‐setting and diabetes distress.Care providers should consider both disease‐ and person‐related factors when making shared decisions regarding the intensity of the diabetes care. [ABSTRACT FROM AUTHOR]

Over the past decades, vegetation has changed significantly along with climatic changes in the Arctic. Deciduous shrub cover is often assumed to expand in tundra landscapes, but more frequent abrupt permafrost thaw resulting in formation of thaw ponds could lead to vegetation shifts towards graminoid dominated wetland. Which mechanisms drive vegetation changes in the tundra ecosystem is still not sufficiently clear. In this study, the dynamic tundra vegetation model NUCOM-tundra was used to evaluate the consequences of climate change scenarios of warming and increasing precipitation for future tundra vegetation change, and to identify the mechanisms that drive these changes. The model includes three plant functional types (moss, graminoids and shrubs), carbon and nitrogen cycling, water and permafrost dynamics and a simple thaw pond module. Climate scenario simulations were performed for sixteen combinations of temperature and precipitation increases in five vegetation types representing a gradient from dry shrub dominated, to moist mixed and wet graminoid dominated sites. Vegetation composition dynamics in currently mixed vegetation sites was dependent on both temperature and precipitation changes, with warming favouring shrub dominance and increased precipitation favouring graminoid abundance. Climate change simulations based on greenhouse gas emission scenarios in which temperature and precipitation increases were combined showed initial increases in graminoid abundance followed by shrub expansion with further climate change. The simulations suggest that the shrubs are better light competitors, but their growth can be limited by very wet soil conditions and low nutrient supply. Graminoids have the advantage of being able to grow in a wide range of soil moisture conditions and having access to nutrients in deeper soil layers. Abrupt permafrost thaw initiating thaw pond formation led to complete domination of graminoids. However, due to increased drainage, shrubs could profit from such changes in adjacent areas. Both climate and thaw pond formation simulations suggest that a wetter tundra can be responsible for local shrub decline instead of shrub expansion. [ABSTRACT FROM AUTHOR]

Introduction: Knowledge about the natural clinical course is needed to improve understanding of recovery postsurgery as outcome is poor for some patients. Knowledge of the natural clinical course of symptoms and disability will inform optimal timing and the nature of rehabilitation intervention. The objective of this study is to provide first evidence synthesis investigating the natural clinical course of disability and pain in patients aged >16 years post primary lumbar discectomy. Methods and analysis: A systematic review and data synthesis will be conducted. Prospective cohorts that include a well-defined inception cohort (point of surgery) of adult participants who have undergone primary lumbar discectomy/microdiscectomy will be included. Outcomes will include measurements reported on 1 or more outcomes of disability and pain, with a baseline presurgery measurement. Following development of the search strategy, 2 reviewers will independently search information sources, assess identified studies for inclusion, extract data and assess risk of bias. A third reviewer will mediate on any disagreement at each stage. The search will employ sensitive topic-based strategies designed for each database from inception to 31 January 2016. There will be no language or geographical restrictions. Risk of bias will be assessed using a modified QUality In Prognostic Studies (QUIPS) tool . Data will be extracted for time points where follow-up was at least 80%. Means and 95% CIs will be plotted over time for pain and disability. All results will be reported in the context of study quality. Ethics and dissemination: This review will provide the first rigorous summary of the course of pain and disability across all published prospective cohorts. The findings will inform our understanding of when to offer and how to optimise rehabilitation following surgery. Results will be published in an open access journal. The study raises no ethical issues. PROSPERO registration number: CRD42015020806. [ABSTRACT FROM AUTHOR]

Peat bogs have accumulated more atmospheric carbon (C) than any other terrestrial ecosystem today. Most of this C is associated with peat moss ( Sphagnum) litter. Atmospheric nitrogen (N) deposition can decrease Sphagnum production, compromising the C sequestration capacity of peat bogs. The mechanisms underlying the reduced production are uncertain, necessitating multifactorial experiments., We investigated whether glasshouse experiments are reliable proxies for field experiments for assessing interactions between N deposition and environment as controls on Sphagnum N concentration and production. We performed a meta-analysis over 115 glasshouse experiments and 107 field experiments., We found that glasshouse and field experiments gave similar qualitative and quantitative estimates of changes in Sphagnum N concentration in response to N application. However, glasshouse-based estimates of changes in production - even qualitative assessments - diverged from field experiments owing to a stronger N effect on production response in absence of vascular plants in the glasshouse, and a weaker N effect on production response in presence of vascular plants compared to field experiments., Thus, although we need glasshouse experiments to study how interacting environmental factors affect the response of Sphagnum to increased N deposition, we need field experiments to properly quantify these effects. [ABSTRACT FROM AUTHOR]

Deciduous shrubs are expected to rapidly expand in the Arctic during the coming decades due to climate warming. A transition towards more shrub-dominated tundra may have large implications for the regional surface energy balance, permafrost stability and carbon storage capacity, with consequences for the global climate system. However, little information is available on the natural long-term shrub growth response to climatic variability. Our aim was to determine the climate factor and time period that are most important to annual shrub growth in our research site in NE- Siberia. Therefore, we determined annual radial growth rates in Salix pulchra and Betula nana shrubs by measuring ring widths. We constructed shrub ring width chronologies and compared growth rates to regional climate and re- motely sensed greenness data. Early summer temperature was the most important factor influencing ring width of S. pulchra (Pearson's r :-0.73, p < 0.001) and B. nana (Pearson's r :- 0.46, p < 0.001 ). No effect of winter precipitation on shrub growth was observed. In contrast, summer precipitation of the previous year correlated positively with B. nana ring width (Pearson's r = 0.42, p < 0.01), suggesting that wet summers facilitate shrub growth in the following growing season. S. pulchra ring width correlated positively with peak summer NDVI, despite the small coverage of S. pulchra shrubs (<5 % surface cover) in our research area. We provide the first climate-growth study on shrubs for Northeast Siberia, the largest tundra region in the world. We show that two deciduous shrub species with markedly different growth forms have a similar growth response to changes in climate The obtained shrub growth response to climate variability in the past increases our understanding of the mechanisms underlying current shrub expansion, which is required to predict future climate-driven tundra vegetation shifts. [ABSTRACT FROM AUTHOR]

Climate change is expected to cause extensive vegetation changes in the Arctic: deciduous shrubs are already expanding, in response to climate warming. The results from transect studies suggest that increasing shrub cover will impact significantly on the surface energy balance. However, little is known about the direct effects of shrub cover on permafrost thaw during summer. We experimentally quantified the influence of Betula nana cover on permafrost thaw in a moist tundra site in northeast Siberia with continuous permafrost. We measured the thaw depth of the soil, also called the active layer thickness (ALT), ground heat flux and net radiation in 10 m diameter plots with natural B. nana cover (control plots) and in plots in which B. nana was removed (removal plots). Removal of B. nana increased ALT by 9% on average late in the growing season, compared with control plots. Differences in ALT correlated well with differences in ground heat flux between the control plots and B. nana removal plots. In the undisturbed control plots, we found an inverse correlation between B. nana cover and late growing season ALT. These results suggest that the expected expansion of deciduous shrubs in the Arctic region, triggered by climate warming, may reduce summer permafrost thaw. Increased shrub growth may thus partially offset further permafrost degradation by future temperature increases. Permafrost models need to include a dynamic vegetation component to accurately predict future permafrost thaw. [ABSTRACT FROM AUTHOR]

Question: Can mixing ratio and species affect the use of substrate-derived CO2 by Sphagnum? Location: Poor fen in south Sweden and greenhouse in Wageningen, The Netherlands. Methods: Two mixing ratios of Sphagnum cuspidalum and S. magellanicum were exposed to two levels of CO2 by pumping CO2 enriched and non-enriched water through aquaria containing the species mixtures in the greenhouse. Results: Enhanced CO2 stimulated the production of S. cuspidatum, but only in aquaria co-dominated by S. magellanicum, coinciding with higher CO2 concentrations in the water layer. The denser growing S. magellanicum seemed to reduce gas escape from the water, resulting in accumulation of dissolved CO2. Adding CO2 did not affect species replacement. Conclusions: The use of substrate-derived CO2 for Sphagnum production depended on species identity and mixing ratio. The effect of mixing ratio on CO2 concentrations in the water layer suggests that species composition may affect both the efficiency with which substrate-derived CO2 is trapped and subsequently used. This could result in hitherto unexplored feedbacks between vegetation composition and gas exchange. [ABSTRACT FROM AUTHOR]

The present study explored illness perceptions of end stage renal disease (ESRD) patients on both haemodialysis (HD) and peritoneal dialysis (PD) treatment, and their associations with quality of life. Leventhal's self-regulation model (SRM) was used as a theoretical framework. Illness perceptions and quality of life were assessed with the IPQ-R and the SF-36 in 91 HD and 42 PD patients participating in the NECOSAD-study. Compared to HD patients, PD patients experienced more personal control and had a better understanding of the illness. Illness perceptions explained from 17 to 51% of the variance in quality of life scores. Perception of more symptoms, more consequences and lower personal control were associated with lower well-being. The concept of illness perceptions is useful in understanding the impact of ESRD and of dialysis treatment on quality of life. Interventions aimed at providing more knowledge about ESRD and dialysis, and provision of skills to coping with the illness and its consequences may improve quality of life in dialysis patients. [ABSTRACT FROM AUTHOR]

The assumption that disease-related stressors are exclusive for particular diagnoses characterizes many studies of chronically ill patients. In this study the perceptions of 1305 patients from 10 different chronic disease categories were compared with respect to a number of important stressors. Differences were found in the amount and type of stressors experienced, but these differences could not solely be explained by type of disease. Personal characteristics such as age, sex, education level, living situation, and illness duration were also important in determining the degree and type of stress experienced. The implications of these findings for stress/coping research as well as the clinical implications are discussed. [ABSTRACT FROM AUTHOR]

To study the relationships between groups of organisms and the degree to which these relationships are consistent across major climatic gradients, we analysed the testate amoebae (Protozoa) communities, vegetation and water chemistry of one peatland in five countries: Switzerland, The Netherlands, Great Britain, Sweden and Finland as part of the BERI (Bog Ecosystem Research Initiative) project. The relationship between different data sets and subsets were investigated by means of detrended correspondence analysis, canonical correspondence analysis and Mantel permutation tests. The comparison of data on vegetation and testate amoebae showed that inter-site differences are more pronounced for the vegetation than for the testate amoebae species assemblage. Testate amoebae are a useful tool in multi-site studies and in environmental monitoring of peatlands because: (1) the number of species in Sphagnum-dominated peatlands is much higher than for mosses or vascular plants; (2) most peatland species are cosmopolitan in their distributions and therefore less affected than plants by biogeographical distribution patterns, thus differences in testate amoeba assemblages cab be interpreted primarily in terms of ecology; (3) they are closely related to the ecological characteristics of the exact spot where they live, therefore they can be used to analyse small-scale gradients that play a major role in the functioning of peatland ecosystems. This study revealed the existence of small-scale vertical gradients within the vegetation and life-form niche separation in response to water chemistry. The deep-rooted plants such as Corex spp. and Eriophorum spp are related to the chemistry of water sampled at ot near the ground water table, whereas the mosses are not. Testate amoebae were shown to be ecologically more closely related to the chemistry of water sampled at or near the water table level and to the mosses than to the deep-rooted plants. [ABSTRACT FROM AUTHOR]

Abstract Background The American short form Patient Activation Measure (PAM) is a 13-item instrument which assesses patient (or consumer) self-reported knowledge, skills and confidence for self-management of one’s health or chronic condition. In this study the PAM was translated into a Dutch version; psychometric properties of the Dutch version were established and the instrument was validated in a panel of chronically ill patients. Methods The translation was done according to WHO guidelines. The PAM 13-Dutch was sent to 4178 members of the Dutch National Panel of people with Chronic illness or Disability (NPCD) in April 2010 (study A) and again to a sub sample of this group (N = 973) in June 2010 (study B). Internal consistency, test-retest reliability and cross-validation with the SBSQ-D (a measure for Health literacy) were computed. The Dutch results were compared to similar Danish and American data. Results The psychometric properties of the PAM 13-Dutch were generally good. The level of internal consistency is good (α = 0.88) and item-rest correlations are moderate to strong. The Dutch mean PAM score (61.3) is comparable to the American (61.9) and lower than the Danish (64.2). The test-retest reliability was moderate. The association with Health literacy was weak to moderate. Conclusions The PAM-13 Dutch is a reliable instrument to measure patient activation. More research is needed into the validity of the Patient Activation Measure, especially with respect to a more comprehensive measure of Health literacy.

Abstract Background Compared to healthy people, patients with chronic kidney disease (CKD) participate less in paid jobs and social activities. The aim of the study was to examine a) the perceived autonomy, self-esteem and labor participation of patients in the pre-dialysis phase, b) pre-dialysis patients' illness perceptions and treatment perceptions, and c) the association of these perceptions with autonomy, self-esteem and labor participation. Methods Patients (N = 109) completed questionnaires at home. Data were analysed using bivariate and multivariate analyses. Results The results showed that the average autonomy levels were not very high, but the average level of self-esteem was rather high, and that drop out of the labor market already occurs during the pre-dialysis phase. Positive illness and treatment beliefs were associated with higher autonomy and self-esteem levels, but not with employment. Multiple regression analyses revealed that illness and treatment perceptions explained a substantial amount of variance in autonomy (17%) and self-esteem (26%). The perception of less treatment disruption was an important predictor. Conclusions Patient education on possibilities to combine CKD and its treatment with activities, including paid work, might stimulate positive (realistic) beliefs and prevent or challenge negative beliefs. Interventions focusing on these aspects may assist patients to adjust to CKD, and ultimately prevent unnecessary drop out of the labor market.