Form and function in hillslope hydrology : in situ imaging and characterization of flow-relevant structures

Thanks to Elly Karle and the Engler-BunteInstitute, KIT, for the IC measurements of bromide. We are grateful to Selina Baldauf, Marcel Delock, Razije Fiden, Barbara Herbstritt, Lisei Köhn, Jonas Lanz, Francois Nyobeu, Marvin Reich and Begona Lorente Sistiaga for their support in the lab and during fieldwork, as well as Markus Morgner and Jean Francois Iffly for technical support and Britta Kattenstroth for hydrometeorological data acquisition. Laurent Pfister and Jean-Francois Iffly from the Luxembourg Institute of Science and Technology (LIST) are acknowledged for organizing the permissions for the experiments. Moreover, we thank Markus Weiler (University of Freiburg) for his strong support during the planning of the hillslope experiment and the preparation of the manuscript. This study is part of the DFG-funded CAOS project “From Catchments as Organised Systems to Models based on Dynamic Functional Units” (FOR 1598). The manuscript was substantially improved based on the critical and constructive comments of the anonymous reviewers, Christian Stamm and Alexander Zimmermann, and the editor Ross Woods during the open review process, which is highly appreciated.Peer reviewedPublisher PD

Form and function in hillslope hydrology : Characterization of subsurface ow based on response observations

Acknowledgements. We are grateful to Marcel Delock, Lisei Köhn, and Marvin Reich for their support during fieldwork, as well as Markus Morgner and Jean Francois Iffly for technical support, Britta Kattenstroth for hydrometeorological data acquisition and isotope sampling, and Barbara Herbstritt and Begoña Lorente Sistiaga for laboratory work. Laurent Pfister and Jean-Francois Iffly from the Luxembourg Institute of Science and Technology (LIST) are acknowledged for organizing the permissions for the experiments and providing discharge data for Weierbach 1 and Colpach. We also want to thank Frauke K. Barthold and the two anonymous reviewers, whose thorough remarks greatly helped to improve the manuscript. This study is part of DFG-funded CAOS project “From Catchments as Organised Systems to Models based on Dynamic Functional Units” (FOR 1598). The article processing charges for this open-access publication were covered by a Research Centre of the Helmholtz Association.Peer reviewedPublisher PD

Picturing and modeling catchments by representative hillslopes

This study explores the suitability of a single hillslope as a parsimonious representation of a catchment in a physically based model. We test this hypothesis by picturing two distinctly different catchments in perceptual models and translating these pictures into parametric setups of 2-D physically based hillslope models. The model parametrizations are based on a comprehensive field data set, expert knowledge and process-based reasoning. Evaluation against streamflow data highlights that both models predicted the annual pattern of streamflow generation as well as the hydrographs acceptably. However, a look beyond performance measures revealed deficiencies in streamflow simulations during the summer season and during individual rainfall–runoff events as well as a mismatch between observed and simulated soil water dynamics. Some of these shortcomings can be related to our perception of the systems and to the chosen hydrological model, while others point to limitations of the representative hillslope concept itself. Nevertheless, our results confirm that representative hillslope models are a suitable tool to assess the importance of different data sources as well as to challenge our perception of the dominant hydrological processes we want to represent therein. Consequently, these models are a promising step forward in the search for the optimal representation of catchments in physically based models

Picturing and modeling catchments by representative hillslopes

This study explores the suitability of a single hillslope as a parsimonious representation of a catchment in a physically based model. We test this hypothesis by picturing two distinctly different catchments in perceptual models and translating these pictures into parametric setups of 2-D physically based hillslope models. The model parametrizations are based on a comprehensive field data set, expert knowledge and process-based reasoning. Evaluation against streamflow data highlights that both models predicted the annual pattern of streamflow generation as well as the hydrographs acceptably. However, a look beyond performance measures revealed deficiencies in streamflow simulations during the summer season and during individual rainfall–runoff events as well as a mismatch between observed and simulated soil water dynamics. Some of these shortcomings can be related to our perception of the systems and to the chosen hydrological model, while others point to limitations of the representative hillslope concept itself. Nevertheless, our results confirm that representative hillslope models are a suitable tool to assess the importance of different data sources as well as to challenge our perception of the dominant hydrological processes we want to represent therein. Consequently, these models are a promising step forward in the search for the optimal representation of catchments in physically based models

HESS Opinions: Functional units: a novel framework to explore the link between spatial organization and hydrological functioning of intermediate scale catchments

This opinion paper proposes a novel framework for exploring how spatial organization alongside with spatial heterogeneity controls functioning of intermediate scale catchments of organized complexity. Key idea is that spatial organization in landscapes implies that functioning of intermediate scale catchments is controlled by a hierarchy of functional units: hillslope scale lead topologies and embedded elementary functional units (EFUs). We argue that similar soils and vegetation communities and thus also soil structures "co-developed" within EFUs in an adaptive, self-organizing manner as they have been exposed to similar flows of energy, water and nutrients from the past to the present. Class members of the same EFU (class) are thus deemed to belong to the same ensemble with respect to controls of the energy balance and related vertical flows of capillary bounded soil water and heat. Class members of superordinate lead topologies are characterized by the same spatially organized arrangement of EFUs along the gradient driving lateral flows of free water as well as a similar surface and bedrock topography. We hence postulate that they belong to the same ensemble with respect to controls on rainfall runoff transformation and related vertical and lateral fluxes of free water. We expect class members of these functional units to have a distinct way how their architecture controls the interplay of state dynamics and integral flows, which is typical for all members of one class but dissimilar among the classes. This implies that we might infer on the typical dynamic behavior of the most important classes of EFU and lead topologies in a catchment, by thoroughly characterizing a few members of each class. A major asset of the proposed framework, which steps beyond the concept of hydrological response units, is that it can be tested experimentally. In this respect, we reflect on suitable strategies based on stratified observations drawing from process hydrology, soil physics, geophysics, ecology and remote sensing which are currently conducted in replicates of candidate functional units in the Attert basin (Luxembourg), to search for typical and similar functional and structural characteristics. A second asset of this framework is that it blueprints a way towards a structurally more adequate model concept for water and energy cycles in intermediate scale catchments, which balances necessary complexity with falsifiability. This is because EFU and lead topologies are deemed to mark a hierarchy of "scale breaks" where simplicity with respect to the energy balance and stream flow generation emerges from spatially organized process-structure interactions. This offers the opportunity for simplified descriptions of these processes that are nevertheless physically and thermodynamically consistent. In this respect we reflect on a candidate model structure that (a) may accommodate distributed observations of states and especially terrestrial controls on driving gradients to constrain the space of feasible model structures and (b) allows testing the possible added value of organizing principles to understand the role of spatial organization from an optimality perspective

Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial.

BACKGROUND: Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency. METHODS: In this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544. FINDINGS: Between Jan 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardised medical care (n=186) or standardised medical care alone (n=182); of whom 313 had primary outcome data at 12 months (156 [84%] of 186 patients in the CBT plus standardised medical care group and 157 [86%] of 182 patients in the standardised medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median 4 seizures [IQR 0-20] in the CBT plus standardised medical care group vs 7 seizures [1-35] in the standardised medical care group; estimated incidence rate ratio [IRR] 0·78 [95% CI 0·56-1·09]; p=0·144). Dissociative seizures were rated as less bothersome in the CBT plus standardised medical care group than the standardised medical care group (estimated mean difference -0·53 [95% CI -0·97 to -0·08]; p=0·020). The CBT plus standardised medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR 1·64 [95% CI 1·22 to 2·20]; p=0·001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analogue scale (estimated mean difference 6·16 [95% CI 1·48 to 10·84]; p=0·010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference -4·12 [95% CI -6·35 to -1·89]; p<0·001), less overall psychological distress than the standardised medical care group on the Clinical Outcomes in Routine Evaluation-10 scale (estimated mean difference -1·65 [95% CI -2·96 to -0·35]; p=0·013), and fewer somatic symptoms on the modified Patient Health Questionnaire-15 scale (estimated mean difference -1·67 [95% CI -2·90 to -0·44]; p=0·008). Clinical improvement at 12 months was greater in the CBT plus standardised medical care group than the standardised medical care alone group as reported by patients (estimated mean difference 0·66 [95% CI 0·26 to 1·04]; p=0·001) and by clinicians (estimated mean difference 0·47 [95% CI 0·21 to 0·73]; p<0·001), and the CBT plus standardised medical care group had greater satisfaction with treatment than did the standardised medical care group (estimated mean difference 0·90 [95% CI 0·48 to 1·31]; p<0·001). No significant differences in patient-reported seizure severity (estimated mean difference -0·11 [95% CI -0·50 to 0·29]; p=0·593) or seizure freedom in the last 3 months of the study (estimated odds ratio [OR] 1·77 [95% CI 0·93 to 3·37]; p=0·083) were identified between the groups. Furthermore, no significant differences were identified in the proportion of patients who had a more than 50% reduction in dissociative seizure frequency compared with baseline (OR 1·27 [95% CI 0·80 to 2·02]; p=0·313). Additionally, the 12-item Short Form survey-version 2 scores (estimated mean difference for the Physical Component Summary score 1·78 [95% CI -0·37 to 3·92]; p=0·105; estimated mean difference for the Mental Component Summary score 2·22 [95% CI -0·30 to 4·75]; p=0·084), the Generalised Anxiety Disorder-7 scale score (estimated mean difference -1·09 [95% CI -2·27 to 0·09]; p=0·069), and the Patient Health Questionnaire-9 scale depression score (estimated mean difference -1·10 [95% CI -2·41 to 0·21]; p=0·099) did not differ significantly between groups. Changes in dissociative seizures (rated by others) could not be assessed due to insufficient data. During the 12-month period, the number of adverse events was similar between the groups: 57 (31%) of 186 participants in the CBT plus standardised medical care group reported 97 adverse events and 53 (29%) of 182 participants in the standardised medical care group reported 79 adverse events. INTERPRETATION: CBT plus standardised medical care had no statistically significant advantage compared with standardised medical care alone for the reduction of monthly seizures. However, improvements were observed in a number of clinically relevant secondary outcomes following CBT plus standardised medical care when compared with standardised medical care alone. Thus, adults with dissociative seizures might benefit from the addition of dissociative seizure-specific CBT to specialist care from neurologists and psychiatrists. Future work is needed to identify patients who would benefit most from a dissociative seizure-specific CBT approach. FUNDING: National Institute for Health Research, Health Technology Assessment programme

Inflammatory arthritis in HIV positive patients: A practical guide

Background: Musculoskeletal manifestations of the human immunodeficiency virus (HIV) have been described since the outset of the global HIV epidemic. Articular syndromes that have been described in association with HIV include HIV-associated arthropathy, seronegative spondyloarthropathies (SPA) (reactive arthritis, psoriatic arthritis (PsA) and undifferentiated SPA), rheumatoid arthritis (RA) and painful articular syndrome. Methods: We carried out a computer-assisted search of PubMed for the medical literature from January 1981 to January 2015 using the keywords HIV, acquired immune-deficiency syndrome, rheumatic manifestations, arthritis, spondyloarthropathy, anti-TNF and disease modifying antirheumatic drugs. Only English language literature was included and only studies involving adult human subjects were assessed. Results: There are challenges in the management of inflammatory arthritis in patients who are HIV-positive, including difficulties in the assessment of disease activity and limited information on the safety of immunosuppressive drugs in these individuals. Conclusions: This review focuses on the clinical characteristics of the inflammatory articular syndromes that have been described in association with HIV infection and discusses the therapeutic options for these patients

Structural and non-coding variants increase the diagnostic yield of clinical whole genome sequencing for rare diseases

BACKGROUND: Whole genome sequencing is increasingly being used for the diagnosis of patients with rare diseases. However, the diagnostic yields of many studies, particularly those conducted in a healthcare setting, are often disappointingly low, at 25–30%. This is in part because although entire genomes are sequenced, analysis is often confined to in silico gene panels or coding regions of the genome. METHODS: We undertook WGS on a cohort of 122 unrelated rare disease patients and their relatives (300 genomes) who had been pre-screened by gene panels or arrays. Patients were recruited from a broad spectrum of clinical specialties. We applied a bioinformatics pipeline that would allow comprehensive analysis of all variant types. We combined established bioinformatics tools for phenotypic and genomic analysis with our novel algorithms (SVRare, ALTSPLICE and GREEN-DB) to detect and annotate structural, splice site and non-coding variants. RESULTS: Our diagnostic yield was 43/122 cases (35%), although 47/122 cases (39%) were considered solved when considering novel candidate genes with supporting functional data into account. Structural, splice site and deep intronic variants contributed to 20/47 (43%) of our solved cases. Five genes that are novel, or were novel at the time of discovery, were identified, whilst a further three genes are putative novel disease genes with evidence of causality. We identified variants of uncertain significance in a further fourteen candidate genes. The phenotypic spectrum associated with RMND1 was expanded to include polymicrogyria. Two patients with secondary findings in FBN1 and KCNQ1 were confirmed to have previously unidentified Marfan and long QT syndromes, respectively, and were referred for further clinical interventions. Clinical diagnoses were changed in six patients and treatment adjustments made for eight individuals, which for five patients was considered life-saving. CONCLUSIONS: Genome sequencing is increasingly being considered as a first-line genetic test in routine clinical settings and can make a substantial contribution to rapidly identifying a causal aetiology for many patients, shortening their diagnostic odyssey. We have demonstrated that structural, splice site and intronic variants make a significant contribution to diagnostic yield and that comprehensive analysis of the entire genome is essential to maximise the value of clinical genome sequencing

Characteristics of 698 patients with dissociative seizures: A UK multicenter study

Objective We aimed to characterize the demographics of adults with dissociative (nonepileptic) seizures, placing emphasis on distribution of age at onset, male:female ratio, levels of deprivation, and dissociative seizure semiology. Methods We collected demographic and clinical data from 698 adults with dissociative seizures recruited to the screening phase of the CODES (Cognitive Behavioural Therapy vs Standardised Medical Care for Adults With Dissociative Non‐Epileptic Seizures) trial from 27 neurology/specialist epilepsy clinics in the UK. We described the cohort in terms of age, age at onset of dissociative seizures, duration of seizure disorder, level of socioeconomic deprivation, and other social and clinical demographic characteristics and their associations. Results In what is, to date, the largest study of adults with dissociative seizures, the overall modal age at dissociative seizure onset was 19 years; median age at onset was 28 years. Although 74% of the sample was female, importantly the male:female ratio varied with age at onset, with 77% of female but only 59% of male participants developing dissociative seizures by the age of 40 years. The frequency of self‐reported previous epilepsy was 27%; nearly half of these epilepsy diagnoses were retrospectively considered erroneous by clinicians. Patients with predominantly hyperkinetic dissociative seizures had a shorter disorder duration prior to diagnosis in this study than patients with hypokinetic seizures (P < .001); dissociative seizure type was not associated with gender. Predominantly hyperkinetic seizures were most commonly seen in patients with symptom onset in their late teens. Thirty percent of the sample reported taking antiepileptic drugs; this was more common in men. More than 50% of the sample lived in areas characterized by the highest levels of deprivation, and more than two‐thirds were unemployed. Significance Females with dissociative seizures were more common at all ages, whereas the proportion of males increased with age at onset. This disorder was associated with socioeconomic deprivation. Those with hypokinetic dissociative seizures may be at risk for delayed diagnosis and treatment

Characteristics of 698 patients with dissociative seizures: A UK multicenter study

Objective We aimed to characterize the demographics of adults with dissociative (nonepileptic) seizures, placing emphasis on distribution of age at onset, male:female ratio, levels of deprivation, and dissociative seizure semiology. Methods We collected demographic and clinical data from 698 adults with dissociative seizures recruited to the screening phase of the CODES (Cognitive Behavioural Therapy vs Standardised Medical Care for Adults With Dissociative Non‐Epileptic Seizures) trial from 27 neurology/specialist epilepsy clinics in the UK. We described the cohort in terms of age, age at onset of dissociative seizures, duration of seizure disorder, level of socioeconomic deprivation, and other social and clinical demographic characteristics and their associations. Results In what is, to date, the largest study of adults with dissociative seizures, the overall modal age at dissociative seizure onset was 19 years; median age at onset was 28 years. Although 74% of the sample was female, importantly the male:female ratio varied with age at onset, with 77% of female but only 59% of male participants developing dissociative seizures by the age of 40 years. The frequency of self‐reported previous epilepsy was 27%; nearly half of these epilepsy diagnoses were retrospectively considered erroneous by clinicians. Patients with predominantly hyperkinetic dissociative seizures had a shorter disorder duration prior to diagnosis in this study than patients with hypokinetic seizures (P < .001); dissociative seizure type was not associated with gender. Predominantly hyperkinetic seizures were most commonly seen in patients with symptom onset in their late teens. Thirty percent of the sample reported taking antiepileptic drugs; this was more common in men. More than 50% of the sample lived in areas characterized by the highest levels of deprivation, and more than two‐thirds were unemployed. Significance Females with dissociative seizures were more common at all ages, whereas the proportion of males increased with age at onset. This disorder was associated with socioeconomic deprivation. Those with hypokinetic dissociative seizures may be at risk for delayed diagnosis and treatment