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Differences between 5-Minute and 15-Minute Measurement Time Intervals of the CGM Sensor Glucose Device Using GH-Method: Math-Physical Medicine (No. 281)

Introduction

This paper describes the research results by comparing the glucose data from a Continuous Glucose Monitor (CGM) sensor device collecting glucose at 5-minute (5-min) and 15-minute (15-min) intervals during a period of 125 days, from 2/19/2020 to 6/23/2020, using the GH-Method: math-physical medicine approach. The purposes of this study are to compare the measurement differences and to uncover any possible useful information due to the different time intervals of the glucose collection.

Methods

Since 1/1/2012, the author measured his glucose values using the finger-piercing method: once for FPG and three times for PPG each day. On 5/5/2018, he applied a CGM sensor device (brand name: Libre) on his upper arm and checked his glucose measurements every 15 minutes, a total of ~80 times each day. After the first bite of his meal, he measured his Postprandial Plasma Glucose (PPG) level every 15 minutes for a total of 3-hours or 180 minutes. He maintained the same measurement pattern during all of his waking hours. However, during his sleeping hours (00:00-07:00), he measured his Fasting Plasma Glucose (FPG) in one-hour intervals.

With his academic background in mathematics, physics, computer science, and engineering including his working experience in the semiconductor high-tech industry, he was intrigued with the existence of “high frequency glucose component” which is defined as those lower glucose values (i.e. lower amplitude) but occurring frequently (i.e.. higher frequency). In addition, he was interested in identifying those energies associated with higher frequency glucose components such as the various diabetes complications that would contribute to the damage of human organs and to what degree of impact. For example, there are 13 data-points for the 15-minute PPG waveforms, while there are 37 data-points for the 5-minute PPG waveforms. These 24 additional data points would provide more information about the higher frequency PPG components.

Starting from 2/19/2020, he utilized a hardware device based on Bluetooth technology and embedded with customized application software to automatically transmit all of his CGM collected glucose data from the Libre sensor directly into his customized research program known as the eclaireMD system, but in a shorter time period for each data transfer. On the same day, he made a decision to transmit his glucose data at 5-minute time intervals continuously throughout the day; therefore, he is able to collect ~240 glucose data within 24 hours.

He chose the past 4-months from 2/19/2020 to 6/19/2020, as his investigation period for analyzing the glucose situation. The comparison study included the average glucose, high glucose, low glucose, waveforms (i.e. curves), correlation coefficients (similarity of curve patterns), and ADA-defined TAR/TIR/TBR analyses. This is his secondresearch report on the 5-minute glucose data. His first paper focused on the most rudimentary comparisons [1].

References 2 through 4 explained some example research using his developed GH-Method: math-physical medicine approach [2,3].

Results

The top diagram of Figure 1 shows that, for 125 days from 2/19/2020 – 6/23/2020, he has an average of 259 glucose measurements per day using 5-minute intervals and an average of 85 measurements per day using 15-minute intervals. Due to the signal stability of using Bluetooth technology, for the 5-min, it actually has 259 data instead of the 240 data per day.

IMROJ-5-3-516-g001

Figure 1. Daily glucose, 30-days & 90-days moving average glucose of both 15-minutes and 5-minutes.

The middle diagram of Figure 1 illustrates the 30-days moving average of the same dataset as the “daily” glucose curve. Therefore, after ignoring the curves during the first 30 days, we focus on the remaining three months and can detect the trend of glucose movement easier than “daily” glucose data chart. There are two facts that can be observed from this middle diagram. First, the gap between 5-min and 15-min is wider in the second month, while the gap becomes smaller during the third and fourth month. This means that the 5-min results are converging with the 15-min results.Secondly, both curves of 5-min and 15-min are much higher than the finger glucose (blue line). This indicates that the Libre sensor provides a higher glucose reading than the finger glucose. From the listed data below, the CGM sensor daily average glucoses are about 8% to 10% higher than the finger glucose.

5-min sensor: 118 mg/dL (108%)

15-min sensor: 120 mg/dL (110%)

Finger glucose: 109 mg/dL (100%).

The bottom diagram of Figure 1 is the 90-days moving average glucose. Unfortunately, his present dataset only covers 4 months due to late start of collecting his 5-min data; however, the data trend of the last month, from 5/19-6/23/2020, can still provide a meaningful trend indication. As time goes by, additional data will continue to be collected, his 5-min glucose’s 90-days moving trend will be seen more clearly.

Figure 2 shows the synthesized views of his daily glucose, PPG, and FPG.Here, “synthesized” is defined as the average data of 125 days.For example, the PPG curve is calculated based on his 125×3=375 meals. Listed below is a summary of his primary glucose data (mg/dL) in the format of “average glucose/extreme glucose”. Extreme means either maximum or minimum, where the maximum for both daily glucose and PPG due to his concerns of hyperglycemic situation, and the minimum for FPG due to his concerns of insulin shock. The percentage number in prentice is the correlation coefficients between the curves of 15-min and 5-min.

Daily (24 hours):15-min vs. 5-min

117/143vs. 119/144(99%)

PPG (3 hours):15-min vs. 5-min

126/135vs. 125/134(98%)

FPG (7 hours):15-min vs. 5-min

102/95 vs. 105/99 (89%).

Those primary glucose values between 15-min and 5-min are close to each other in the glucose categories. It is evident that the author’s diabetes conditions are under well control for these 4 months. However, by looking at Figure 2 and three correlation coefficients %, we can see that daily glucose and PPG have higher similarity of curve patterns (high correlation coefficients of 98% and 99%) between 15-min and 5-min, but FPG curves have a higher degree of mismatch in patterns (lower correlation coefficient of 89%). This signifies that his FPG values during sleeping hours have a bigger difference between 15-min and 5-min.

IMROJ-5-3-516-g002

Figure 2. Synthesized daily glucose, PPG, and FPG of both 15-minutes and 5-minutes.

Figure 3 are the results using candlestick model [4,5]. The top diagram is the 15-min candlestick chart and the bottom diagram is the 5-min candlestick chart. Candlestick chart, also known as the K-Line chart, includes five primary values of glucoses during a particular time period; “day” is used in this study. These five primary glucose data are:

Start: beginning of the day.

Close: end of the day.

Minimum: lowest glucose.

Maximum: highest glucose.

Average: average for the day.

Listed below are five primary glucose values of both 15-min and 5-min.

15-min: 108/116/86/170/120.

5-min: 111/116/84/173/118.

IMROJ-5-3-516-g003

Figure 3. Candlestick charts of both 15-minutes and 5-minutes.

By ignoring the first two glucoses, start and close, let us focus on the last three glucoses: minimum, maximum, and average. The 5-min method has a lower minimum and a higher maximum than the 15-min method. This is due to the 5-min method capturing more glucose data; therefore, it is easier to catch the lowest and highest glucoses during the day. The difference of 2mg/dL between 15-min’s average 120 mg/dL and 5-min’s average 118 mg/dL is only a negligible 1.7%.

Again, it is also obvious from these candlestick charts that the author’s diabetes conditions are under well control for these 4 months.

Conclusion

In summary, the glucose differences between 5-min and 15-min based on simple arithmetic and statistical calculations are not significant enough to draw any conclusion or make any suggestion on which are the “suitable” or better measurement time intervals. However, the author will continue his research to pursue this investigation of energy associated with higher-frequency glucose components in order to determine the glucose energy’s impact or damage on human organs (i.e. diabetes complications).

The author has read many medical papers about diabetes. The majority of them are related to the medication effects on glucose symptoms control, not so much on investigating and understanding “glucose” itself. This situation is similar to taming and training a horse without a good understanding of the temperament and behaviors of the animal. Medication is like giving the horse a tranquilizer to calm it down. Without a deep understanding of glucose behaviors, how can we truly control the root cause of diabetes disease by only managing the symptoms of hyperglycemia?

References

  1. Hsu, Gerald C. eclaireMD Foundation, USA (2020) Analyzing CGM sensor glucoses at 5-minute intervals using GH-Method: math-physical medicine (No. 278).
  2. Hsu, Gerald C. eclaireMD Foundation, USA(2020) Predicting Finger PPG by using Sensor PPG waveform and data via regression analysis with three different methods using GH-Method: math-physical medicine (No. 249).
  3. Hsu, Gerald C. eclaireMD Foundation, USA (2019) Applying segmentation pattern analysis to investigate postprandial plasma glucose characteristics and behaviors of the carbs/sugar intake amounts in different eating places using GH Method: math-physical medicine (No. 150).
  4. Hsu, Gerald C. eclaireMD Foundation, USA (2019) A case study of the impact on glucose, particularly postprandial plasma glucose based on the 14-day sensor device reliability using GH-Method: math-physical medicine (No. 124).
  5. Hsu, Gerald C. eclaireMD Foundation, USA. Comparison study of PPG characteristics from candlestick model using GH-Method: Math-Physical Medicine (No. 261).

Unusual Sella Mass: Pituitary Abscess (PA)

Abstract

Pituitary abscess (PA) caused by an infectious process is a rare cause of Sellar mass. The clinical features and radiological appearance of PA as an intra- or supra-sellar mass are similar to many other pituitary lesions, and so they are often misdiagnosed as pituitary tumor.

70% of cases occur in a previously healthy pituitary gland. These are classified as primary pituitary abscesses, persumbly secondary to either hematogenous spread or as an extension from an adjacent infective focus such as meningitis, sphenoid sinusitis, Cavernous sinus thrombophlebitis or contaminated cerebrospinal fluid (CSF) fistula.

The rest are secondary abscesses, and arise from pre-existing lesions, such as an adenoma, apoplexy in a tumor, a craniopharyngioma, or a complicated Rathke’s cleft cyst and lymphoma. The risk factors are for PA are immunosuppression, previous irradiation or surgical procedures to the pituitary gland [1].

In almost 50% of cases, the pathogenic microorganism causing the infection is not isolated. A history of recent meningitis sinusitis or head surgery can be the source [2].

Correct diagnosis before surgery is difficult and is usually confirmed intra- or post-operatively. The early surgical intervention allows appropriate antibiotic therapy and hormone replacement resulting in reduced mortality and morbidity. A long term follow-up is recommended because of the high risk of recurrence and of postoperative hormone deficiencies.

Keywords

Pituitary abscess, Papilledema, Panhypopituitarism, Rathke’s cleft cyst, Propionibacterium acnes

Introduction

A pituitary abscess (PA) represents 0.2%-0.6% of all pituitary lesions and can be life threatening. It can have a prolonged disease course. The first case was reported by Heslop in 1848, and so far, <300 cases have been reported worldwide [3]. It is an infectious process that presents as a mass in the Sella. Clinical features and the radiological appearance of the PA as an intra or suprasellar mass are similar to many other pituitary lesions, so it is often misdiagnosed as a cystic pituitary tumor, craniopharyngioma, and Rathke’s cyst. It can be life-threatening if not appropriately diagnosed or treated, and the outcome is difficult to predict. Fortunately, the majority of the cases have a chronic course. The disease has a higher prevalence in females between the age of 12 to 76 years. The average period it takes to diagnose from the onset of symptoms is around 8 years.

PA can occur as a primary disease or can be secondary to infections caused by either hematogenous spread or as an extension from an adjacent infected tissue such as meningitis, sphenoid sinusitis, Cavernous sinus thrombophlebitis or contaminated cerebrospinal fluid fistula 70% of cases occur in a previously healthy pituitary gland. These are classified as primary pituitary abscesses, and the rest are secondary abscesses that arise from pre-existing lesions, such as an adenoma, apoplexy in a tumor, a craniopharyngioma or a complicated Rathke’s cleft cyst and lymphoma [4].

In almost 50% of cases, the pathogenic microorganism causing the infection cannot be isolated. A history of recent meningitis sinusitis or head surgery can be the source [2].

Correct diagnosis before surgery is difficult and is usually confirmed intra- or post-operatively. The early surgical intervention allows appropriate antibiotic therapy and hormone replacement resulting in reduced mortality and morbidity. A long term follow-up is recommended because of the high risk of recurrence and postoperative hormone deficiencies.

We present 2 cases of pituitary abscess in young women. One presented with bilateral papilledema and the other with panhypopituitarism. Both had a sellar mass on an MRI scan, and the diagnosis was made intra-operatively. Microbiological culture in both cases was positive for Propionibacterium acnes (P.acnes). P.acnes is a gram-positive organism, a part of the normal skin microbe. This organism is most commonly isolated from wounds following craniotomies after Staphylococcus aureus and streptococcus epidermidis. Low-grade infections can manifest between 3-36 months.

Case 1

A 14-year old South Asian girl presented with a one-month history of worsening frontal headaches that occurred daily, associated with vomiting, nausea, lethargy, photophobia, and sleep disturbance. Aside from well-controlled asthma, she has been previously healthy. There was no recent travel history or infectious contacts. On examination, she appeared alert and active. She had bilateral papilledema, suggesting raised intracranial pressure (ICP). She was apyrexial and systemically well. Her cerebral magnetic resonance imaging (MRI) scan revealed a soft tissue mass in the pituitary fossa extending up towards the optic chiasm, with mild edema in the optic nerve and tracts. The scan also showed an enlarged pituitary gland and thickened stalk. The findings suggest an inflammatory process like hypophysitis, particularly Langerhans cell histiocytosis (LCH) because of her age. There were no other features of LCH. She had a normal liver US and skeletal survey. She had no symptoms of Diabetes insipidus. Her pituitary hormones were normal, including the stimulated cortisol. Her Prolactin was elevated. Her serum sodium and osmolality were normal. Her ESR was slightly raised, but autoantibodies, serum tumor markers, ACE, and the Quantiferon tuberculosis test were negative. Her IgG4 subclass was normal (Table 1). The formal ophthalmology review did not show evidence of bilateral papilledema. Her symptoms improved with oral analgesics, and steroid treatment was not initiated.

Table 1: Results at initial presentation.

                    Short Synacthen test

Time T=0 T-30 T=60
Cortisol (nmol/L) 186 452 594

                   Baseline tests

Test Result Normal range
IGF-1(nmol/L) 47.9 18.3 to 63.5
TSH (mU/L) 1.62 0.51-4.3
T4 (pmol/L) 13.3 10.8-19
LH (IU/L) 4.3 Follicular phase 2-13

Mid cycle 14-6

Luteal phase 1-11

FSH (IU/L) 1.8 Follicular phase 4-13

Mid cycle 5-22

Luteal phase 2-8

Postmenopause>25

ACTH (ng/L) <3 0-50
Prolactin (mU/L) 806 102-496
Serum Na mmol/L 144 133-146
Serum Osmolality mOsmo/Kg 293 282-300
Random Urine Osmolality mOsmo/Kg 475 100-1400
LDH (u/L) 188 120 to 300
HCG (IU/L) <1 0-1
alpha Fetoprotein (kU/L) 1 0-10
C-Reactive protein (mg/L) 1.5 0-5
ESR (mm/h) 28 1-12
Complement C3 (g/l) 1.1 0.75-1.65
Complement C4 (g/l) 0.29 0.14-0.54
Antinuclear antibodies Negative
Angiotensin convert enzyme (U/L) 42 16-85
IgG4 (g/L) 0.04 0-1.3

 

A repeat MRI scan 3 months later discussed in a multidisciplinary meeting was reported to suggest Rathke’s cleft cyst abscess/ Pituitary abscess (Figures 1 and 2). She underwent a trans-sphenoidal endoscopic pituitary biopsy for diagnosis. The appearances suggested a Rathke’s left cyst and a pituitary abscess. Immunostaining for ACTH, FSH, LH, growth hormone, TSH and Prolactin, chromogranin, synaptophysin, and collagen IV was consistent with anterior pituitary tissue. Microbiological culture on prolonged incubation was positive for Propionibacterium with no acid-fast bacilli growth. TB culture was also negative. She received a 6-week course of antibiotics, including 2 weeks of intravenous ceftriaxone and oral metronidazole followed by 4 weeks of oral co-amoxiclav. Her headaches and vomiting deteriorated after biopsy with a peak CRP of 218 mg/L, which resolved following medical treatment. Imaging with MRI and baseline pituitary function blood tests has since been repeated following the 6 weeks to assess the management’s effectiveness, which showed normal results. The patient reported the resolution of headaches and able to resume full-time schooling.

fig 1 414

Figure 1: MRI at presentation.

fig 2 414

Figure 2: MRI 3 months after transphenoidal surgery.

Case 2

29 years old Caucasian fine arts student presented to the emergency department with fever, headaches, profuse sweating, tiredness, and blurring of vision. Her symptoms, particularly headaches, had worsened over the last 12 months. She had noticed polydipsia and polyuria. She also had amenorrhoea for twelve months. She was treated at her local hospital twice in the preceding 3 years with symptoms of headaches, fever, weight loss, and vomiting. She had a lumbar puncture 3 times to rule out a possibility of central nervous system infection. On both occasions, she was discharged home after empirical treatment with antibiotics for suspected meningitis. There was no other past medical history. There was no recent travel history or infectious contacts. She was not on any regular medications.

The initial pituitary MRI and contrast-enhanced MRI scan revealed the absence of the posterior pituitary bright spot and a thickened pituitary stalk with a deviation of infundibulum to the right. There was a homogenous hyperintense area within the pituitary gland with no discernable pituitary tissue. This area was hypointense on T2 (Figures 3-5). The differential diagnosis was apoplexy, hypophysitis or a proteinaceous cystic lesion replacing or compressing the pituitary gland. The optic nerves and the chiasm appeared normal. Her investigations confirmed her to have hypopituitarism with Diabetes insipidus (Table 2). Her lumbar puncture showed no CSF abnormality. Her tumor markers and Quantiferon for tuberculosis were negative. The case was discussed in multidisciplinary meeting (MDT) and with empirical diagnosis of hypophysitis, she was started on prednisolone with the replacement of deficient hormones, including Desmopressin. She showed no improvement in her clinical symptoms. A 3 month interval scan showed an increase in the size of the pituitary gland with further thickening of the stalk and optic chiasm displaced superiorly. After the second discussion in MDT, she had a pituitary biopsy. During surgery, soft yellow-white pus-like material was drained after dural incision. The microscopy showed necrotic material with a little amount of compressed anterior pituitary gland, chronic inflammation, and no evidence of adenoma or granuloma or giant cells was found. No acid-fast bacilli or organisms were seen on gram staining, and the culture for TB was negative. There was scanty growth of Propionibacterium acneformis. Her interval scan 3 months later showed complete resolution of the non-enhancing T1 hypertense pituitary tissue with a further decrease in the size of the pituitary gland. She remains on full hormones replacement. She had an insulin tolerance test that confirmed her growth hormone deficiency, and she is now on growth hormone replacement. She remains on hydrocortisone, Thyroxine, female hormone replacement, and Desmopressin.

fig 3 414

Figure 3: MRI at presentation.

fig 4 414

Figure 4: MRI 3 months later.

fig 5 414

Figure 5: MRI post-surgery.

Table 2: Results at initial presentation.

                   Short Synacthen test

Time T=0 T-30
Cortisol (nmol/L) 148 169

                   Baseline tests

Test Result Normal range
IGF-1(nmol/L) 12.7 11.9-40.7
TSH (mU/L) 1.35 0.27-4.20
T4 (pmol/L) 5.3 10.8-25.5
LH (IU/L) 3.1 Follicular phase 2-13

Mid cycle 14-96

Luteal phase 1-11

FSH (IU/L) 5.1 Follicular phase 4-13

Mid cycle 5-22

Luteal phase 2-8

Postmenopause>25

Oestradiol (pmol/L) <92 92-1462
Prolactin (mU/L) 577 102-496
Serum Na mmol/L 142 133-146
Serum Osmolality mOsmo/Kg 301 275-295
Random Urine Osmolality mOsmo/Kg 154 100-1400
CSF-b HCG (IU/L) <2 <2
CSF-alpha fetoprotein (µg/L) <1 <1
C-reactive protein (mg/L) 1.4 0-5
ESR (mm/h) 3 1-12
Antinuclear antibodies Negative
IgG4 (g/L) <0.01 0-1.3

Discussion

A pituitary abscess is an infectious process characterized by the accumulation of purulent material in the sella turcica. It is rare, and can be a life-threatening condition unless promptly diagnosed and treated. We report 2 cases of secondary pituitary abscess in young women. The first case was due to abscess in the Rahtke’s cleft cyst (RCC), and the second was Pituitary gland abscess with a history of otitis media and repeated lumbar punctures for presumed meningitis.

The clinical presentation of PA is nonspecific, such as headaches, pituitary hypofunction, and visual disturbances, whereas the infection can be discreet and inconstant [5,6]. Symptoms can be acute, subacute, or chronic, explaining the late diagnosis; in some cases. Visual disturbance, including hemianopia, can be present in 50% of cases. Headache without a particular pattern is a regular feature (70-90%) and can be debilitating. Anterior pituitary hypofunction due to destruction and necrosis of the gland is the commonest presentation resulting in fatigue and amenorrhoea (54-85%). In one series, 28 out of the 33 patients had anterior pituitary hypofunction. Pituitary hormone deficiencies persist in the majority of patients following treatment Up to 70% of patients with PA can have central Diabetes insipidus. In contrast, fever with signs of meningeal irritation is reported in 25% of cases [5].

MRI is the imaging of choice for the pituitary lesions. PA can present as a suprasellar mass (65%) or as an intrasellar mass (35%). A typical PA appears as a single cystic or partially cystic mass that is hypointense on T1-weighted image and hyperintense in T2-weighted image. It can show a rim of enhancement after contrast gadolinium. The posterior pituitary bright spot is mostly absent in majority of the cases (Wang et al.). The lesion’s signal depends on protein, water, lipid content, and whether there is hemorrhage. Imaging can also show the invasion of an adjacent anatomical structure, peripheral meningeal enhancement, thickening of the pituitary stalk, and paranasal sinus enhancement [6].

Diffusion-weighted magnetic resonance imaging (DWI) is widely used to differentiate cerebral abscess from other necrotic masses. Brain abscesses typically show high intensity on DWI with decreased apparent diffusion coefficient (ADC) value in their central region. The high intensity on DWI is useful but not specific to PA because pituitary apoplexy can also exhibit high intensity on DWI [7]. The accuracy of DWI in PA remains controversial. In the Wang et al. case series, PA was misdiagnosed in one-third of the case [6]. The radiological differential diagnosis includes, Rathke’s cleft cyst, cystic pituitary adenoma, arachnoid, and dermoid cysts, metastases, glioblastoma multiforme, chronic hematoma, and multiple sclerosis [8]. Rathke’s cleft cyst mainly can mimic a pituitary abscess [9]. RCC is the second most common incidentaloma after adenomas and accounts for 20% of incidental pituitary lesions at autopsy. The incidence of RCCs in children was reported to be much lower than in adults. However, the prevalence is now believed to be much higher, especially among those with the endocrine-related disorder [10]. Gunes et al. reported the radiological appearance of RCC on MRI in 13.5% of the children who underwent MRI for the investigation of endocrine-related disorders. Patients with RCC are usually asymptomatic, but symptomatic RCC is more common in females in both adult and pediatric populations [11]. RCC can cause significant morbidity such as headache, visual disturbances, chemical meningitis, endocrine dysfunction (hypothyroidism, menstrual abnormalities, diabetes insipidus, adrenal dysfunction, and very rarely apoplexy). Short stature, growth deceleration, delayed puberty are also reported in children and adolescents.

The diagnosis of PA in most cases can only be confirmed after surgical exploration, due to overlapping of clinical signs, symptoms, imaging, and laboratory findings with other sellar lesions. Signs of inflammation are present in less than a third of the patients. The PA should be included in the differential diagnosis of patients with headaches or signs of pituitary dysfunction and patients with pituitary mass who develop signs of meningeal inflammation.

The main treatment for PA in patients with mass effect is Transsphenoidal excision (TSS) with decompression of sella and antibiotic therapy. This can result in the resolution of visual abnormalities. Treatment is effective for typical symptoms such as fever, headache, and visual changes. Patients with shorter duration of symptoms and those with primary abscess have better improvement in their pituitary dysfunction. Majority of the patients remain with pituitary dysfunction even after the treatment.

Antibiotic therapy should to started promptly even in the patients who are waiting for microbiology and histological confirmation for about 4–6 weeks [1,12]. Empirical treatment with ceftriaxone is indicated until the results are available. Hormone replacement is commenced depending on the hormone deficits including stress dose glucocorticoid therapy. Hypocortisolemia should be recognized among patients presenting with sellar masses, as early diagnosis and treatment improve survival and endocrinological outcome. Patients who suffer from the pituitary abscess may eventually have a good quality of life if they are diagnosed and treated early. A craniotomy is reserved for larger lesions with the suprasellar extension or where transsphenoidal surgery is ineffective [13]. In a series published with 66 patients, 81.8% of patients recovered completely, 12.1% of patients had at least one operation for recurrence, and only one patient had died [14].

There are widespread pathogenic microorganisms in abscesses. These include Gram-positive bacteria, Gram-negative bacteria, anaerobes, and fungi [8,11]. Streptococcus and Staphylococcus are the most predominant Grampositive bacteria, whereas Escherichia coli, Mycobacterium, and Neisseria have also been reported [3,10,11]. Aspergillus fumigatus is mostly isolated in cases of secondary PA. Immunosuppressed patients mostly have Candida and Histoplasma. Cultures are positive only in 50% of cases; therefore, broad-spectrum antibiotics are given as empirical treatment. The pathogen identification is important for the therapeutic management [15].

Both patients had culture-positive for Propionibacterium acnes (P. acnes). This organism is seated deeply in the pilosebaceous glands, mainly in the scalp and face. It is a slow-growing, pleomorphic, non-spore-forming gram-positive anaerobic bacillus that is a universal component of the normal skin microbiota. It is usually considered a contaminant of blood cultures but occasionally can cause serious infections, including postoperative central nervous system (CNS) infections. P. acnes are the most commonly isolated organism after Staphylococcus aureus and Staphylococcus epidermidis following craniotomies. In the presence of heavy infiltrates, the Gram stain is not reliable. Gram stain is only positive in about 10.5% of clinically significant infections with moderate growth. P. acnes behave in a less aggressive manner than other postsurgical organisms and only accounts for a small fraction of CNS infections [16]. P. acnes abscesses typically follow craniotomy, shunts, access to reservoirs, trauma, and foreign bodies. Granulomatous responses have been documented in the CNS following P. acnes infections.

P. acnes grow slowly in the laboratory. This can cause in a delay in diagnosis, missed diagnosis, or delay in treatment if specimens are not cultured for an extended period. Cultures may not grow for as long as 14 days, so samples should be held beyond the usual 5 to 7 days. Gram stain may not be a reliable technique for the rapid diagnosis of P. acnes infections. When there is evidence of an abundant inflammatory response in the Gram-stained smear, a more careful evaluation of cultures must be performed. Polymerase chain reaction for the 16S rRNA or mass spectrometry can be a useful tool for rapid identification and typing of P. acnes following recovery in culture. Propionibacterium is susceptible to antibiotics used for the treatment of anaerobic infections, including penicillin, erythromycin, lincomycin, and clindamycin, but not metronidazole, which is notably ineffective against P. acnes [17].

Patients with PA should be followed up with serial MRI of the pituitary, hormonal profile and visual fields at 3, 6, and 12 months after surgery. The recurrence rate is variable and depends on the nature of the abscess (primary or secondary. The majority of relapses are associated with either an immunological defect or previous pituitary surgery [12,18].

Conclusion

We presented 2 cases of unusual sellar mass from an abscess in an adolescent and a young adult due to P. acnes, both responded well to treatment.

The pituitary abscess should be included as the differential diagnosis of patients with a sellar or a suprasellar mass, headaches, pituitary dysfunction, and meningeal inflammation.

The diagnosis is difficult before surgery because of overlapping clinical signs, radiological and laboratory findings with other sellar lesions.

Broad-spectrum antibiotics should be started empirically even before the culture results are available.

Culture is positive only in 50% of cases, and in case of unusual bacteria like P. acnes, an extended culture is required for the confirmation of the diagnosis.

Pituitary dysfunction should be recognized and appropriately treated particularly glucocorticoid replacement.

Transsphenoidal surgery is the treatment of choice and this is followed by pronged 4-6 weeks of broad-spectrum antibiotic therapy.

Early and efficient surgical and medical management results in lower mortality and higher recovery of pituitary hormone function.

Patients should be followed up with MRI imaging, assessment of the hormone replacement if required, and visual field assessment because of a chance of recurrence.

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    12. Vates GE, Berger MS, Wilson CB, et al. (2001) Diagnosis and management of pituitary abscess: a review of twenty-four cases. J Neurosurg 95: 233-241. [crossref]
    13. Karagiannis AKA, Dimitropoulou F, Papatheodorou A, Lyra S, Seretis A, Vryonidou A, et al. (2016) Pituitary abscess: a case report and review of the literature. Endocrinol Diabetes Metab Case Rep [crossref]
    14. Ling X, Zhu T, Luo Z, Zhang Y, Chen Y, Zhao P, Si Y (2017) A review of pituitary abscess: our experience with surgical resection and nursing care. Transl Cancer Res 6(4): 852-859.
    15. Achermann Y, Goldstein EJC, Coenye T, Shirtliff ME, et al. (2014) Propionibacterium acnes: from Commensal to Opportunistic Biofilm-Associated Implant Pathogen. Clin Microbiol Rev 27: 419-440. [crossref]
    16. Chung S, Kim JS, Seo SW, Ra EK S, Joo SI, Kim SY, Park SS, Kim EC, et al. (2011) A Case of Brain Abscess Caused by Propionibacterium acnes 13 Months after Neurosurgery and Confirmed by 16S rRNA Gene Sequencing. Korean J Lab Med 31(2): 122-126. [crossref]
    17. Yacoub AT, Khwaja S, Daniel L, et al. (2015) Propionibacterium acnes Causing Central Nervous System Infections: A Case Report and Review of Literature. Infectious Diseases in Clinical Practice 23: 60-65. [crossref]
    18. Batool SM, Mubarak F, Enam SA, et al. (2019) Diffusion-weighted magnetic resonance imaging may be useful in differentiating fungal abscess from malignant intracranial lesion: Case report. Surg Neurol Int 10: 13. [crossref]

A Safety Signal’s Significance with the COVID-19 Coronavirus

Introduction

The global pandemic involving COVID-19 (coronavirus) has produced unprecedented challenges for the medical, healthcare providers and our world community. The World Health Organization (WHO 2020) initially declared COVID-19 a pandemic, pointing to the over numerous cases of the coronavirus illness in over a hundred countries and territories around the world and the sustained risk of further global spread [1,2]. The term pandemic is most often applied to new influenza strains, and the Centers for Disease Control and Prevention (CDC) use it to refer to strains of virus that are able to infect people easily and spread from person to person in an efficient and sustained manner. Such a declaration refers to the spread of a disease, rather than the severity of the illness it causes. A pandemic declaration can result in increased levels of stress, anxiety, panic and levels of functional depression for some individuals [3]. Recognized is the realization that these unusual circumstances create significant uncertainty and unease in the professional and personal lives of health care professionals and their patients.

Definition of a Safety Signal

“Safety signals” are learned cues that predict the nonoccurrence of an aversive event. As such, safety signals are potent inhibitors of fear and stress responses. Investigations of safety signal learning have increased over the last few years due in part to the finding that traumatized persons are unable to use safety cues to inhibit fear, making it a clinically relevant phenotype.

The coronavirus has traumatized some which has been recognized as a state of heightened fear or anxiety in environments globally. This symptom has been conceptualized as a generalization of the fear conditioned during the traumatic experience that becomes resistant to extinction. As opposed to danger learning where a cue is paired with aversive stimulation, safety learning involves associating distinct environmental stimuli also known as safety signals that can be used an applied when aversive events occur as in a global pandemic.

During periods of high stress such as during this Covid-19 pandemic, fear often permeates the lives of many because if the unknown nature of this illness. This occurs because of the absence of a learned safety signal. Such safety signals can inhibit fear responses to cues in the environment. As such, safety signals are only learned when the subject expects danger but it does not necessarily occur. More fundamental to the clinical importance of a safety signal is the distinction between safe and dangerous circumstances. Thus, identifying the mechanisms of safety learning represents a significant goal for basic neuroscience that should inform future prevention and treatment of trauma and other anxiety disorders.

With COVID-19 global pandemic, the World Health Organization (2020) continues to ask countries to “take urgent and aggressive action.” World leaders continue holding international teleconferences with health officials to address the most effective way to protect the public and develop public health policy for the coronavirus that has caused multiple illnesses and deaths worldwide.

Transitioning the Pandemic

The urgency has created stressful life experiences for all ages that pose the potential for illness resulting for some in disabling fear, a hallmark of anxiety and stress-related disorders [4]. Researchers at Yale University and Weill Cornell Medicine report on a novel way that could help combat such anxiety experienced at times like these. When life events as the spread of the Corvid 19 triggers excessive fear and the absence of a safety signal. In humans, a symbol or a sound that is never associated with adverse events can relieve anxiety through an entirely different brain network than that activated by fear and worry. Each individual must find their own “safety signal” whether that is a mantra, song, a person, or even an item like a stuffed animal that represents the presence of safety and security.

The Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and other reputable agencies have advocated on how to address the coronavirus by washing hands frequently, avoid sharing personal items, and maintaining social distance from others beyond immediate family.

While it’s still unclear exactly how much of the current coronavirus outbreak has been fueled by asymptomatic, mildly symptomatic, or pre-symptomatic individuals, the risk of contagion exists. A yet to be published article in the CDC journal “Emerging Infectious Disease” (CDC 2020) reports that the time between cases in a chain of transmission is less than a week, with more than 10% of patients being infected by someone who has the virus but does not yet have symptoms according to Dr. Luren Meyers, a professor of integrative biology at UT Austin, who was part of a team of scientists from the United States, France, China and Hong Kong examining this viral threat.

Earlier this year, researchers in China published a research letter in the Journal of the American Medical Association, outlining a case of an asymptomatic woman in Wuhan, China who reportedly spread the virus to five family members while traveling to Anyang, China-all of whom developed COVID-19 pneumonia. The sequence of events suggests that the coronavirus may have been transmitted by the asymptomatic carrier,” [5].

Prevention Interventions

Coordinated regional efforts are underway under the direction of the Centers for Disease Control and Prevention (CDC) that provides guidelines aimed at prevention intervention. Each individual should make the effort to create one’s own “safety signal” by following the recommendations of the CDC (2020). Know how it spreads and that there is currently no vaccine to prevent coronavirus disease (COVID-19). Critical for prevention is avoided exposing the virus. The virus is thought to spread mainly from person-to-person. Between people who are in close contact with one another. Through respiratory droplets produced when an infected person coughs or sneezes. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.

Disinfecting by washing hands often with soap and water for at least twenty seconds especially after you have been in a public place or after blowing your nose, coughing, or sneezing. If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry. Avoid touching the eyes, nose, and mouth with unwashed hands Put distance between yourself and other people if COVID-19 is spreading in your community. This is especially important for people who are at higher risk of getting immune compromised illness.

Health care calls for “sheltering in place” are effort to provide primary prevention it’s important to stay home to slow the spread of COVID-19, and if you must go out, practice personal quarantine. While we stay home, don’t let fear and anxiety about the COVID-19 pandemic become overwhelming. Managing mental health issues can be aided by taking breaks from watching, reading, or listening to news stories and social media. It remains important to take the time to connect with others. Networking with friends and loved ones over the phone or via video chat about the thoughts and feelings experienced during this pandemic is very important to maintain mental health daring three times. Employ the use mindful meditation, eating healthy meals, exercising regularly, and getting plenty of sleep.

Take steps to protect yourself and others. Stay sheltered in place especially when you’re sick. Shelter in place means to seek safety within the building one already occupies, rather than to evacuate the area or seek a community emergency shelter. The American Red Cross says the warning is issued when “chemical, biological, or radiological contaminants which would include exposure to the coronavirus.

Efforts must be made to cover one’s mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow. Throw used tissues in the trash. Immediately wash your hands with soap and water for at least 20 seconds. If soap and water are not readily available, clean your hands with a hand sanitizer that contains at least 60% alcohol.

It is important to wear a facemask for your own health as well as the health of others. Everyone should wear a facemask when they are around other people (e.g., sharing a room or vehicle) and before entering a healthcare provider’s office. If someone is not able to wear a facemask due to breathing difficulties, then these individuals should cover all coughs and sneezes, and people who are caring for theme should wear a facemask when they enter ones room. Wear a facemask when caring for someone who is showing any signs or symptoms of respiratory infection and fever.

When considering the anxiety and apprehension individuals may experience with the vulnerabilities of the present pandemic and future epidemics of this proportion, patient medical education can provide a buffer against the Prevention interventions that include cleaning and disinfecting objects and surfaces that are touched regularly. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks. If surfaces are dirty, clean them: Use detergent or soap and water prior to disinfection. With first signs of symptoms, take advantage of Virtual Care in an effort to minimize unnecessary visits to an emergency room or health care provider’s office, which can also decrease the spread of illness and/or infection of many conditions, including COVID-19. Finally, each individual is encouraged to establish one’s own “safety signal” by adhering to the multiple precautions that include the guidelines developed and promoted by the World Health organization and the Centers for Disease Control and Prevention (CDC 2020).

References

  1. Centers for Disease Control (2020) Coronavirus Disease 2019 (COVID-19).
  2. World Health Organization (2020) Coronavirus disease 2019 (COVID-19): Situation Report-38.
  3. Miller TW (2015) Problem Epidemics in Recent Times. Health & Wellness. Lexington Kentucky: Rock point Publisher Incorporated.
  4. Miller TW (2010) Handbook of Stressful Transitions across the Life Span. New York: Springer Publishers Incorporated.
  5. Huang C, Wang Y, Li X, et al. (2020) Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 395: 497-506.

Self-Recovery of Pancreatic Beta Cell’s Insulin Secretion Based on 10+ Years Annualized Data of Food, Exercise, Weight, and Glucose Using GHMethod: Math-Physical Medicine (No. 339)

Abstract

The author was inspired from reading two recently published medical papers regarding pancreatic beta cells insulin secretion or diabetes reversal via weight reduction. The weight reduction is directly related to the patient’s lifestyle improvement through diet and exercise. He has published six medical papers on beta cells based on different stages in observations of his continuous glucose improvements; therefore, in this article, he will investigate food ingredients, meal portions, weight, and glucose improvement based on his 10+ years of collected big data.

Here is the summary of his findings:

  1. His successful weight reduction, from 220 lbs. in 2010 to 171 lbs. in 2020, comes from his food portion reduction and exercise increase.
  2. His lower carbs/sugar intake amount, from 40 grams in 2010 to 12 grams in 2020, is resulted from his learned food nutrition knowledge and meal portion reduction, from 150% in 2010 to 67% in 2020.
  3. His weight reduction contributes to his FPG reduction, from 220 mg/dL in 2010 to 104 mg/dL in 2020. His carbs/sugar control and increased walking steps, from 2,000 steps in 2010 to ~16,000 steps in 202, have contributed to his PPG reduction, from 300 mg/dL in 2010 to 109 mg/dL in 2020. When both FPG and PPG are reduced, his daily glucose is decreased as well, from 280 mg/dL in 2010 to 108 mg/dL in 2020.
  4. His damaged beta cell’s insulin production and functionality, most likely, have been repaired about 16% for the past 6 years or 27% in the past 10 years at a self-repair rate of 2.7% per year.

The conclusion from this paper is a 2.7% annual beta cells self-repair rate which is similar to his previously published papers regarding his range of pancreatic beta cells self-recovery of insulin secretion with an annual rate between 2.3% to 3.2%.

To date, the author has written seven papers discussing his pancreatic beta cell’s self-recovery of insulin secretion. In his first six papers [1-7], he used several different “cutting angles” or “analysis approaches” to delve deeper into this complex biomedical subject and achieved consistent results within the range of 2.3% to 3.2% of annual self-recovery rate.

He used a quantitative approach with precision to discover and reconfirm his pancreatic beta cell’s health state by linking it backwards step-by-step with his collected data of glucose, weight, diet, and exercise. He has produced another dataset for a self-repair rate of 2.7% which is located right in the middle between 2.3% and 3.2% from his previous findings.

In his opinion, type 2 diabetes (T2D) is no longer a non-reversible or non-curable disease. Diabetes is not only “controllable” but it is also “self-repairable”, even though at a rather slow rate. He would like to share his research findings and his persistent efforts from the past decade with his medical research colleagues and to provide encouragement to motivate other T2D patients like himself to reverse their diabetes conditions.

Introduction

The author was inspired from reading two recently published medical papers regarding pancreatic beta cells insulin secretion or diabetes reversal via weight reduction. The weight reduction is directly related to the patient’s lifestyle improvement through diet and exercise. He has published six medical papers on beta cells based on different stages in observations of his continuous glucose improvements; therefore, in this article, he will investigate food ingredients, meal portions, weight, and glucose improvement based on his 10+ years of collected big data.

Methods

Background

To learn more about his developed GH-Method: math-physical medicine (MPM) research methodology, readers can review his article, Biomedical research methodology based on GH-Method: math-physical medicine (No. 54 and No. 310), in Reference [1] to understand his MPM analysis method.

Diabetes History

In 1995, the author was diagnosed with severe type 2 diabetes (T2D). His daily average glucose reached 280 mg/dL with a peak glucose at 398 mg/dL and his HbA1C was at 10% in 2010. Since 2005, he has suffered many kinds of diabetes complications, including five cardiac episodes (without having a stroke), foot ulcer, renal complications, bladder infection, diabetic retinopathy, and hypothyroidism.

As of 9/30/2020, his daily average glucose is approximately 106 mg/dL and HbA1C at 6.1%. It should be mentioned that he started to reduce the dosage of his three different diabetes medications (maximum dosages) in early 2013 and finally stop taking them on 12/8/2015. In other words, his glucose record since 2016 to the present is totally “medication-free”.

Beginning on 1/1/2012, he started to collect his weight value in the early morning and his glucose values four times a day: FPG x1 in the early morning and PPG x3 at two hours after the first bite of each meal. Since 1/1/2014, he also started to collect his carbs/sugar amount in grams and post-meal walking steps. Prior to these two dates, especially during the period of 2010 to 2012, the manually collected biomarkers and lifestyle details were scattered and unorganized. Therefore, those annualized data from 2010 to 2012 or 2014 were guesstimated values with his best effort. It should be further mentioned that on 1/1/2013, he began to reduce his dosages of three diabetes educations step by step. By 1/1/2015, he was only taking 500 mg of Metformin for controlling his diabetes conditions. Finally, he completely ceased taking Metformin on 12/8/2015; therefore, since 1/1/2016, his body has been completely free of any diabetes medications.

Other Research Results

Recently, a Danish medical research team has published an article on JAMA which emphasizes a strengthen lifestyle program can reverse” T2D. This program includes a weekly exercise (5-6 times and 30-60 minutes each time), daily walking more than 10,000 steps using smart phone to keep a record, personalized diet and nutritional guidance by healthcare professionals, etc. The observed results from this Danish report are patientsoverall HbA1C reduction of 0.31%, and their diabetes medication dosage reduction from 73% to 26%.

DiRECT research report from UK also indicated that an aggressive weight reduction program can induce improvement on diabetes conditions. This UK program includes low-calories diet for 3-5 months with 825-853 K-calories per day, plus daily walking of 15,000 steps per day. The observed results from this UK report are patientsoverall HbA1C reduction of 0.9%, weight reduction of 10 kg (or 22 lbs.), and reduced diabetes medication dosage as well.

The Author’s Approach

Inspired by the results from the two European studies and based on his own collected big data over the past 10+ years, from 2010 to 2020, he decided to conduct a similar research on his own. He has separated his 10+ years data into two periods. The first period of 5 years, from 2010 to 2014, with partially collected and partially guesstimated data under different degrees of medication influence, and the second period of 6 years, from 2015 to 2020, with a complete set of collected raw data stored in software and severs without any medication influence.

His trend of thoughts include a sequence from cause to consequence as listed below from top to bottom:

  • Food and meal’s portion %
  • K-calories per day
  • Weight (lbs.)
  • FPG (mg/dL)
  • Carbs/sugar intake (grams)
  • Walking
  • PPG (mg/dL)
  • Daily glucose (mg/dL)

He has further conducted nine calculations of correlation coefficient based on the above parameters to examine the degree of connections between any 2 elements of these total 8 parameters. It should be mentioned that the correlation coefficients can only be done between two data sets, or two curves.

More importantly, in addition to examining the raw data, he also placing an emphasis on the annual change rate percentage, its trend, and their comparisons of these 8 parameters.

Results

Figure 1 shows his background data table which includes his calculated annual averages of the 8 parameters plus proteins, fat, and daily K-calories, based on his daily data collected during 2010 to 2020.

fig 1

Figure 1: Background data table.

Figure 2 depicts the annual change rate percentage of his food (meal portion %, K-calories, and carbs/sugar) and his weight. In this figure, meal portion and weight have similar change rates which means the less he eats, the lighter his weight. Also, carbs/sugar amount and K-calories have similar change rates which means the less his K-calories, the less his carbs/sugar intake amount.

fig 2

Figure 2: Annual change rates of Weight and Food (meal portion, K-calories, and carbs/sugar).

Figure 3 illustrates the similar trend of annual data of his weight and three food components (meal portion, K-calories, and carbs/sugar amount).

fig 3

Figure 3: Annual change rates of Weight and Food (meal portion, K-calories, and carbs/sugar).

Exercise is a missing component from this figure which is also essential on weight reduction. The more he eats, the higher intake amounts of his K-calories and his carbs/sugar as well. During the past decade on his effort for weight reduction, he has focused on reducing both of his meal portion percentage and carb/sugar intake amount. As a result, he was able to reduce his weight from 220 lbs (100 kg) and his average glucose from 280 mg/dL in 2010 to 171 lbs. (78 kg) and 106 mg/dL in 2020 (without any medication).

Figure 4 reflects the annual change rate percentage of his daily glucose, weight and carbs/sugar amount. In this figure, the change rates of his glucose and weight are remarkably similar, almost a mirror image, which indicates the lower his weight, the lower his glucose. This finding matches the two European studies and the common knowledge possessed by healthcare professionals. The reason for the obviously mismatched change rates between carbs/sugar and glucose or weight is due to the missing component of exercise which is equally important on glucose reduction.

fig 4

Figure 4: Annual change rates of Weight, Glucose, and Carbs/sugar.

Figure 5 focuses exclusively on the relationships among data of glucose, carbs/sugar, and exercise. The positive correlation coefficient between glucose and carbs/sugar is expressed by these two similar moving trends. On the other hand, the negative correlation coefficient between glucose and exercise (walking) is expressed by these two opposite moving trends.

fig 5

Figure 5: Annual data of Weight, Glucose, and Carbs/sugar.

Figures 6-8 collectively collective together to show the 9 sets of calculated correlation coefficients among those 8 listed elements in above section of Methods. A better illustration of these three figures can be found in a table, where all of the calculated correlations are above 90%, which means they are highly connected to each other (Figure 9). Even the correlation of -89% between glucose and walking exercise is also extremely high in a negative manner.

fig 6

Figure 6: Correlation coefficients among Weight, K-calories, meal portion.

fig 7

Figure 7: Correlation coefficients among Weight, Glucose, Carbs/sugar.

fig 8

Figure 8: Correlation coefficients among PPG, Carb/sugar, Walking, FPG, Weight.

fig 9

Figure 9: A combined data table of 9 correlation coefficients among 8 elements.

Figure 10 reveals the detailed annual change rates of 8 elements for a 10+ year period from 2010 to 2020. It should be pointed out that his average change rates within 6 years from 2015 through 2020 are 2.7% per year for both FPG and PPG, and 3.4% for daily glucose. This conclusion is similar to his six previously published papers regarding his pancreatic beta cell’s self-recovery rate of insulin secretion. Most likely, his beta cells insulin production and functionality have been repaired about 16% during the past 6 years or 27% during the past 10 years at a self-repair rate of 2.7% per year.

fig 10

Figure 10: A combined data table of annual change rates of 7 elements, especially glucose change rates of 2.7%.

Here is the summary of his findings:

  1. His successful weight reduction, from 220 lbs. in 2010 to 171 lbs. in 2020, comes from his food portion reduction and exercise increase.
  2. His lower carbs/sugar intake amount, from 40 grams in 2010 to 12 grams in 2020, is resulted from his learned food nutrition knowledge and meal portion reduction, from 150% in 2010 to 67% in 2020.
  3. His weight reduction contributes to his FPG reduction, from 220 mg/dL in 2010 to 104 mg/dL in 2020. His carbs/sugar control and increased walking steps, from 2,000 steps in 2010 to ~16,000 steps in 202, have contributed to his PPG reduction, from 300 mg/dL in 2010 to 109 mg/dL in 2020. When both FPG and PPG are reduced, his daily glucose is decreased as well, from 280 mg/dL in 2010 to 108 mg/dL in 2020.
  4. His damaged beta cell’s insulin production and functionality, most likely, have been repaired about 16% for the past 6 years or 27% in the past 10 years at a self-repair rate of 2.7% per year.

Summary

To date, the author has written seven papers discussing his pancreatic beta cell’s self-recovery of insulin secretion. In his first six papers [2-7], he used several different “cutting angles” or “analysis approaches” to delve deeper into this complex biomedical subject and achieved consistent results within the range of 2.3% to 3.2% of annual self-recovery rate.

He used a quantitative approach with precision to discover and reconfirm his pancreatic beta cell’s health state by linking it backwards step-by-step with his collected data of glucose, weight, diet, and exercise. He has produced another dataset for a self-repair rate of 2.7% which is located right in the middle between 2.3% and 3.2% from his previous findings.

In his opinion, type 2 diabetes (T2D) is no longer a non-reversible or non-curable disease. Diabetes is not only “controllable” but it is also “self-repairable”, even though at a rather slow rate. He would like to share his research findings and his persistent efforts from the past decade with his medical research colleagues and to provide encouragement to motivate other T2D patients like himself to reverse their diabetes conditions.

References

  1. Hsu, Gerald C. eclaireMD Foundation, USA. “GH-Method: Methodology of math-physical medicine, No. 54 and No. 310.”
  2. Hsu, Gerald C. eclaireMD Foundation, USA. “Changes in relative health state of pancreas beta cells over eleven years using GH-Method: math-physical medicine (No. 112).”
  3. Hsu, Gerald C. eclaireMD Foundation, USA. “Probable partial recovery of pancreatic beta cells insulin regeneration using annualized fasting plasma glucose via GH-Method: math-physical medicine (No. 133).”
  4. Hsu, Gerald C. eclaireMD Foundation, USA. “Probable partial self-recovery of pancreatic beta cells using calculations of annualized fasting plasma glucose using GH-Method: math-physical medicine (No. 138).”
  5. Hsu, Gerald C. eclaireMD Foundation, USA. “Guesstimate probable partial self-recovery of pancreatic beta cells using calculations of annualized glucose data using GH-Method: math-physical medicine (No. 139).”
  6. Hsu, Gerald C. eclaireMD Foundation, USA. “Relationship between metabolism and risk of cardiovascular disease and stroke, risk of chronic kidney disease, and probability of pancreatic beta cells self-recovery using GH-Method: Math-Physical Medicine (No. 259).”
  7. Hsu, Gerald C. eclaireMD Foundation, USA. “Self-recovery of pancreatic beta cell’s insulin secretion based on annualized fasting plasma glucose, baseline postprandial plasma glucose, and baseline daily glucose data using GH-Method: math-physical medicine (No. 297).”

Disease, Duration and Death

Abstract

Life has always been threaten by diseases, calamities, catastrophes leading to death caused by various known or unknown, animate or inanimate objects in human’s relatively medium life span. Ever since the documentation of the human history, it is well known that man loved their body and prefer to live in accordance with their wishes. When rationale judgment became prominent after the experiences and observations of life and death events, they started searching remedies such as medicine. This is how medicine evolved since our early civilization. With the development of reason, logic, observation, experimentation and practical application, we learned tremendous ways of saving body, brain and behavior. However, as time passes human environment changes unpredictably leading to change in human behavior and attitude towards objects/materials and living beings. It is not only a matter of physical, biological or cosmic change but also behavior of everything that brought unprecedented events such as unexpected war, epidemic, catastrophes etc. leading to death [1,2]. Measurement of several physical parameters of human and universal bodies has become routine but various functions/characters in relation to time has yet to measure fully. This is the point we fall short to save humans promptly resulting high number of unexpected loss of life such as in COVID-19 pandemic. Among 1554960 covid-19 infected population in more than 209 countries, territories and two conveyances 5.9% died, and among the deaths more than 80% occurring in just 10 countries (USA, Spain, Italy, Germany, France, China, Iran, UK, Belgium, Netherlands) of the world in the last three months duration [2].

Disease is an abnormal architecture/anatomy, function, condition of the body and mind in a specific duration. Many times and circumstances death occurs due to unprecedented cause, behavior or ignorance. Therefore, it is essential to know the unknown environment and diverse nature and behavior of human beings to diagnose epidemicity of the disease. Despite vast scientific discoveries and new achievement, there is a big hole in the measurement of core human behavior and intelligence. Human body, intelligence and behavior plays a great role in the defense mechanism as well as association in the causation, development, cessation of disease in specific duration in specific place/s. So far we are devoid of the precise knowledge on the creation of covid-19 however many scientists have been trying to explore the mystery of the occurrences, nature and impact on the human population of the globe [3].

The duration or natural course of illness or diseases is important in the management of cases, carrier as well as prevention of complications and death [4]. Alert researchers identify the key factors of the disease when there is sudden rise of cases of similar features in a short period. Ignorance about the nature of pathogen and ignorance of the general population about the disease leads to higher number of deaths in a very short duration. Lack of alertness in changing behavior and environment of the disease in the population further complicates its management and increases the number of deaths. The challenge of the new disease, ignorance on the part of environment and human behavior help to expand disease dimensions in terms of time, place and person.

Opportunities such as chance, experience, observation and experimentation lead to discovery and development of medicine and care system that can make our life easier, comfortable and lengthier. This is the beauty of medical discipline, research and practice in human population. A dynamic patience where a body and brain searches a remedy continuously in response to disease is probably the best stimulus to initiate new knowledge, skills, practice to cure patient and prevent death. Lack of precise knowledge of duration and the nature of the disease is biggest obstacles in managing covid-19 at present and many more diseases that are possible in the future. Following the spread of disease and management of the patient (source) meticulously in global environment, recording the evidences and continuous sharing among the fellow researchers and responsible individuals are the most important aspects of pandemic control.

Alertness, continuous searches, dynamic patience can help humans to increase its capacity to deal with covid-19 pandemic. Change in seasonality in different geographical regions may affect duration of the diseases and distribution of death in humans. This demands thinking globally and acting globally.

Keywords

Covid-19, Death, Disease, Duration, Pandemic

References

  1. Riedel S (2004) Biological warfare and bioterrorism: a historical review. BUMCProceedings17: 400-406. [crossref]
  2. Covid-19 Coronavirus Pandemic, Worldometer. Accessed on April 09, 2020, 16:30 GMT.
  3. Zhou P, Yang X, Wang X, Hu B, Zhang L, et al. (2020) A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature579: 270-273. [crossref]
  4. Rothan HA,ByrareddySN (2020) The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. Journal of Autoimmunity109: 102433. [crossref]

Telemedicine: Enabling Patients with Arrhythmias in Self-Care Behaviors

Abstract

The study, Telemedicine: Enabling Patients with Arrhythmias in Self-Care Behaviors study is designed for early recognition and treatment of an arrhythmia and optimizing patients’ medication, activity, and arrhythmia self-efficacy. Telemedicine is a method which allows health care professionals to evaluate, diagnose, and treat patients within their homes and remote locations [1]. Connecting with patients via video and telephone visits allows the caregiver access and assists the patient in improving self-care behaviors and self-efficacy in managing arrhythmias [1,2]. This pilot telemedicine study provides earlier diagnosis of abnormal arrhythmias and increased patient involvement and self-efficacy of one’s health care solutions [2]. The Telemedicine: Enabling patients in Self-Care Behaviors study started in February 2020, prior to the onset of the Covid 19 pandemic. The study has been placed on hold since March 17, 2020. In a response to the Covid-19 pandemic (separate from this study) multiple medical and nursing practices have adopted telemedicine to maintain ongoing care appointments [3]. The study displays the complementing use of three survey tools (Medication Understanding and Self-Efficacy Tool, Functioning Self Efficacy Scale, and Arrhythmia Specific questionnaire in Tachycardia an Arrhythmia) with monitoring devices (loop recorders, Kardia-TM, pacemakers and cardioverter defibrillators-ICDs) coupled with telephone and video visits to pinpoint arrhythmia changes and exact patient reactions and discussion to reinforce self-efficacy behaviors.

Keywords

Telemedicine, arrhythmia, self-efficacy, behavior.

Introduction

The purpose of the study, Telemedicine: Enabling Patients with Arrhythmias in Self-Care Behaviors (T:EPASB) is to provide an alternative to in person visits, decreased the time of diagnosis and treatment of an arrhythmia via the internet, and enable patients to improve self-efficacy of arrhythmia care behaviors. Self-efficacy can be defined as the individual’s belief in oneself to handle a set of circumstances or changes in physical or mental well-being [2].

The first outcome of the study is to determine if subjects in a telemedicine program for the care of cardiac arrhythmias have  any difference in [1] time of arrhythmia recognition [2], time of arrhythmia diagnosis by a healthcare provider, and [3] time of treatment initiation compared with patients enrolled in standard care for cardiac arrhythmias. The second outcome of the study examines subjects’ self-efficacy of medication use, functional self-efficacy, and arrhythmia self-efficacy. A data collection tool was utilized with a simplistic check off system used to mark when one recognized changes in symptoms such as increased palpitations, fatigue, activity intolerance, shortness of breath, and any other change in symptoms associated with an arrhythmia. The tool allowed for quick responses to these symptoms with self-initiated blood pressure check, heart rate check, increased fluids, or taking an additional beta blocker, sitting down and resting, and calling the electrophysiology (EP) office for advice (Appendix A).

Background Information

University based tertiary care clinics, which  treat  irregular heart rhythms, are known as arrhythmia clinics and formally called electrophysiology departments [4]. These departments have been in existence prior to the early 1960’s and their technology has continued to evolve over time. The need to meet with patients and discuss  their abnormal and irregular heart rhythms has entailed prescribing medications to slow the heart rate, prescribing medications to eliminate abnormal heart rhythms, and implanting devices to further control the heart rhythms, known as pacemakers (PPM) and implantable cardioverter-defibrillators (ICDs) [4]. The continued improvement in technology and expansion of such departments has led to a need for increased numbers of patient appointments, dual appointments for arrhythmia management and pacemaker or ICD management, and coordinated appointments with other cardiology sub-specialties [5]. This increased frequency and duration of appointments places stress upon patients with longer drives, wait times, financial stressors of parking, food, and gas costs in reaching such appointments [6]. With such stressors, a need for computer assisted video visits has evolved [6]. The monitoring  of  arrhythmias  involves  home  monitoring via external disposable monitors which are affixed on  the chest wall, small implanted monitors (loop recorders), and utilizing the monitoring features of permanent pacemakers (PPMs) or implantable cardioverter defibrillators (ICDs).

Review of literature

The T:EPASB is based upon studies showing improved clinical outcomes with the use of telemedicine. The TRUST trial compares the use of a telephone video conference to conventional in person visits with individuals with ICDs. The TRUST trial determined the efficacy and safety for monitoring ICDs and the reduction of in person visits [7,8]. This study displayed an adverse event rates of 10.4 for each group [7,10] and no difference in the telemedicine versus the in person visit group.

The Poniente trial determined there was no difference in arrhythmia detection and functional capacity in monitoring elderly patients with pacemakers via home monitoring compared with in person monitoring [9]. The CHOICE AF was a pilot study to test the feasibility of brief telephone-based program to target improving cardiovascular risk factors and health related quality of life in patients with atrial fibrillation [11], showing great potential for a telephone- based program.

A study by Ryan et. al. (2018) [13] verified the efficacy of theory based Integrated Theory of Health Behavior Change (ITHBC) intervention utilizing a cellular phone application to increase women’s initiation and long-term maintenance of osteoporosis self-management behaviors. This study takes a chronic disease state, osteoporosis, and combines ITHBC prompted behaviors with a cellular phone application to assist women in behavior change. Suter et. al. (2011) [14] used self-efficacy as a key component in managing one’s health noting patient empowerment in the management of chronic disease conditions such as diabetes mellitus and heart failure. The study identified the essence of telemedicine in its ability to empower patients with skills in managing one’s chronic health condition.

Theoretical Framework

Integrated Theory of Health Behavior Change (ITHBC) was used in guiding this study as it notes the importance in assisting individuals in becoming increasingly involved in their own health care [2]. This theory links a relationship between the way one views one’s own health care and an overall sense of wellness. Dr. Ryan’s study of those with chronic health care diagnosis’ and improving specific health care behaviors highlighted the need to 1) have a change in how one reacts followed by 2) one’s resultant behavior with an improved sense of wellness (when assisted with behavior changes). Essential components for behavior change include a desire to change, self- reflection, positive social-influence and support required in creating the change [2].

Methods and Materials

The study is a prospective randomized controlled study, in which informed consent was obtained. Randomization included subjects picking from sealed envelopes which were numbered, labelled with a folded card within each envelop stating either standard versus telemedicine visits. The University of Michigan Hospital IRB number: IRB00001995.

Inclusion/Exclusion Criteria:

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Methods

The study was introduced to the subjects during an initial meeting with an explanation of the study and an explanation of the consent. After the informed consent was obtained, the subjects were randomized into telemedicine or standard in person six- month visits.

With the initial visit, surveys were completed with telemedicine and standard visit groups. Telemedicine subjects received monthly visits for three consecutive months and standard received a six month return visits (Appendix B-study schematic). Interventions provided to the telemedicine group included discussion and reinforcement of medication, functional activity and arrhythmia self-efficacy, guided discussion, and social support.

The surveys utilized were the Medication Understanding and Self-Efficacy Tool, Functioning Self Efficacy Scale, and Arrhythmia Specific questionnaire in Tachycardia an Arrhythmia (MUSE, FSES, ASTA) surveys. All three surveys were provided on the first day of the study to each study group subject and on the last day of the study for each study group subject. Key questions were compared with a calculation of the mean for these questions, comparing the standard group with the telemedicine group. (Appendix C, D, E– MUSE, FSES, and ASTA surveys).

There were chart reviews and analysis of monitored data from devices  revealing  onset  of  arrhythmias,  times  of  diagnosis’  and treatments in the telemedicine group compared with the standard group. The T:EPASB utilizes the null hypothesis to demonstrate no difference in time of recognition of an arrhythmia, time to diagnosis and treatment of the arrhythmia, between the telemedicine group as compared with the standard group. The null hypothesis is be used in the Medication Understanding and Use Self- Efficacy (MUSE), ASTA (Arrhythmia Specific questionnaire in Tachycardia and Arrhythmia) and FSES (Shortened Functional Self Efficacy Scale) surveys. A paired T test with the difference in the means of answers to survey questions was utilized in calculating a P value for select survey questions (Appendix C).

Measures

Arrhythmias can be multifactorial and can cause no perceived symptoms versus serious symptoms such as palpitations, fast and pounding heart beats, sweating, chest pain and or pressure, anxiety, fear, and depression [15]. One single survey may not capture the data experienced by the subject and not every survey relates to the self- efficacy of these perceived events. The MUSE survey gives information on medication compliance, cost barriers, number of medications, physicians and pharmacies and hospitalizations. The FSES gives a scale of the subject’s self- efficacy to cope with the arrhythmia and day to day functioning. The ASTA survey is the most specific survey to arrhythmias and the symptoms associated with arrhythmias; but does not reflect the medications or functional capabilities.

The MUSE survey was tested for validity and reliability in measuring   patients’ self-   efficacy   in   understanding   and   using prescription medications [12]. FSES displayed good internal consistency and satisfactory criterion and convergent validity in assessing the degree of confidence self-functioning while facing decline in health and function [16]. ASTA, displayed content validity for all items, and internal consistency [17].

Data Collection Sheet and Demographics:

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Pilot Study Results

From late February 2020 to March 2020, 9 patients were enrolled in the Telemedicine study and randomized to either standard visits or telemedicine visits. Three patients declined the study, one patient noted he would join the study, but only if he received a Kardia monitoring device (he was not enrolled in the study as this could not be guaranteed and he noted his intention of simply gaining the Kardia device) and was not enrolled due to ethical concerns.

All subjects signed the informed consent and received copies of the protocol and consent, including the clause that they may drop out of the study. Each subject was given instruction on filling out surveys and were given the opportunity to answer questions by the nurse practitioner (NP) in clinic and the research assistant. The surveys were reviewed and scored by the research assistant and double scored with the author of the study. The surveys pinpointed the overall arrhythmia burden, degree to which subjects felt the arrhythmia, and physical and mental coping levels in relation to the arrhythmia. The surveys gave the caregiver (Nurse Practitioners and Physician Assistants within the EP clinic) specific areas to discuss, reinforce, and empower the subject in arrhythmia behavior change. The time of recognition, diagnosis and treatment of arrhythmias was deferred due to the Covid 19 pandemic and this monitoring data is attained only for daily arrhythmia management.

Appendix D gives the overview of all survey results for T:EPASB. The overview gives the researcher a quick glimpse of any problem areas such with decreased self-efficacy of medication use, or functional capacity or arrhythmia knowledge and understanding.

Results of the MUSE survey show near complete compliance in medication use with only one missed dose of medications from one subject. MUSE tallied results also show no financial constraints to medication obtainment in all nine subjects. There was a 0.8679:1 ratio with number of number of physicians treating to number of medical diagnosis; with a mean of 2.89 physicians prescribing medications to a mean of 3.33 medical diagnosis for the 9 subjects evaluated (Appendix B). When combining the surveys, key data becomes clear. The subjects scoring the lowest functional status self-efficacy, subject 5a and subject 9a with scores of 43 and 44 respectively, scored 37 and 54 respectively on the ASTA arrhythmia burden survey. One can note poor functional self-efficacy, but not necessarily related to arrhythmia burden in subject 5a, while poor functional self-efficacy may be related to a higher arrhythmia burden in subject 9a. Another complementing data point will be specific arrhythmia logs within monitoring- devices; once this deferred data is allowed within the study. Another interesting finding is the subject 8a who has a high arrhythmia burden noted with ASTA of 46, but a very good FSES score of 64.

Discussion

The T:EPASB pilot study has shown the importance of offering an alternative to conventional in person visits, offering counseling in  managing  one’s  self-efficacy  for  arrhythmia  care,  and  providing reinforcement and social support in managing one’s arrhythmia care. The study illustrates the importance of gathering complementing data on arrhythmia management including medication use and understanding, functional self-efficacy, and arrhythmia self-efficacy. The triad of these surveys provides an excellent overview of one’s arrhythmia self-efficacy. With such data, the medical and nursing provider may offer patient specific counseling. There is an advantage of having a specifically timed event, match a corresponding subject’s complaint. The use of implanted and portable monitoring data gives an excellent overview of the subject’s associated heart rhythm abnormality. The MUSE survey used alone gives a false sense that there may not be any need for any reinforcement of self-efficacy of medication or arrhythmia understanding. When this survey is coupled with the FSES and ASTA, trends begin to develop and specific areas of intervention, such as improved daily activity levels, decreased arrhythmia burdens via medications or activity, utilization of beta or calcium channel blockers, increased fluids, and or activity training to improve arrhythmias may be discussed. The surveys when used  together  display  specific  areas  to  improve  subject’s  knowledge, one’s confidence and self-efficacy in arrhythmia management. Those with higher arrhythmia burdens in which the subject feels palpitations, fatigue, and side effects have a greater need for intervention which strengthen self-efficacy and social support for medication use, functional activities and arrhythmia management [16,17]. This pilot T:EPASB study continues to show great potential and will likely mimic the TRUST, CHOICE-AF and Poinete trials in identifying, diagnosing, and treating arrhythmias with no difference in timing of these events with telemedicine compared with in person follow up visits with prompt device monitoring. The study has already helped to pinpoint areas of difficulties with arrhythmias, medications, and functional capacity. Via interventions such as affirming knowledge, counselling medication usage, and validating activity and exercise efforts and knowledge, the caregiver  may  help  improve  the  subjects’  overall  functional  capacity in coping with one’s arrhythmia. The study’s evaluated questions have not reached significant p values, as the study has been Anecdotally, the overall response to telemedicine has been very positive with comments like, “this is so much better”, “I can concentrate on what you are teaching me, without the long drive” and “this information seems to stick much better, when I learn it at home” and “can we make more telemedicine appointments”. The T:EPASB study can in no way be fully assessed at this early point, but its potential to assist in improving patients’ self-efficacy via increased patient interaction, reinforcement of arrhythmia details, and social support will surely lead to further studies using telemedicine and a triad of survey tools.

Authorship:

Kathleen Fasing, DNP-c, MS,

ACNP Madonna University,

Livonia MI

University of Michigan, Staff ACNP, Ann Arbor, Michigan

kfasing@med.umich.edu

DNP Project Chair: Patricia Clark, DNP, RN, ACNP-BC,

ACNS- BC, CCRN, Madonna University,

pclark@madonna.edu

DNP Project Member: Rachel Mahas, PhD, MS, MPH,

Madonna University, rmahas@madonna.edu

DNP Project Member: Vicki Ashker, DNP, MSA, RN,

CCRN, Madonna University, vashker@madonna.edu

Milwaukee- Self Management Science for your great research on self- efficacy and your ITHBC theory and allowing its use.

Sara Carmel- Ben Gurion University of Negev- Public Health Faculty Member- for your behavior research and functional self- efficacy tool and allowing its use.

Ulla Walfridsson RN, PhD-Division of Nursing Science; Dept of Medicine & Health Sciences, Linkping, Sweeden- for sharing your incredible arrhythmia assessment tool and allowing its use.

Sangeeta Lathkar-Pradhan- Research Assistant for ongoing support and patience.

Rachel Wessel- Research Assistant for exacting perseverance.

Hakan Oral, MD- University of Michigan EP Director- thanks for believing in me.

Dr. Patricia Clark- DNP committee lead and advisor and patience extraordinaire.

My husband- Gregory Fasing BSN, RCIS- for his forever support.

Acknowledgements

Thank you so much for all who assisted in this project including and in equal acknowledgement.

Polly Ryan PhD, RN, CNS-BC – University of Wisconsin

References

  1. Kay, Misha, Santos, Takane (2010) Telemedicine opportunities and development in member states, Global observatory for eHealth series, virtualhospital.org.uk. (1,2). [crossref]
  2. Ryan, P. (2009) Integrated theory of health behavior change: Background and intervention development, Clinical Nurse Specialist, 23 (3): 161-172. (3, 5,18,19). [crossref]
  3. Lovett-Rockwell, K. & Gilroy, A. (2020) Incorporating telemedicine as part of COVID-19 Outbreak response systems, The American Journal of Managed Care, 26 (4): 147-148. Doi.org/10.37765/ajmc.,(4). [crossref]
  4. Fozzard (2011) History of basic science in cardiac electrophysiology, Cardiac electrophysiologycinics, 3, 1, 1-10. Doi:10.1016/j.ccep.2010.10.010,(6,7). [crossref]
  5. Phend, C. (2020) Telehealth shaping up for Covid-19- Cardiology illustrates what specialties can do to be ready, Medpage today.,(8).
  6. Maffei, R., Hudson, Y. & Skim Dunn, M. (2008) Telemedicine for urban uninsured: A pilot Framework for specialty care planning sustainability, J E health, 14(9), 925- 931 [crossref]
  7. Dalouk,  K.,  Gandhi,  N.,  Jessel,  P.,  MacMurdy,  K.  et.  al.  (2017)  Outcomes   of telemedicine  videoconferencing  clinic  versus   in-person   clinic   follow-up for implantable cardioverterdefibrillator recipients, Circulation arrhythmia electrophysiology, 10, (11,13).
  8. Varma, N., Epstein, A., Irimpen, A., Schweikert, R., & Love, C. (2010) Efficacy and safety of automatic remote monitoring for implantable cardioverter-defibrillator follow-up: The Lumos-T safely reduces routine office device follow-up, TRUST trial, Circulation, 122: 325332.,(12). [crossref]
  9. Lopez-Villegas, A., Catalan-Matamoros, D., Robles-Musso, E., & Peiro, S. (2015) Effectiveness of pacemaker tele-monitoring on quality of life, functional capacity, event detection and workload: The PONIENTE trial, Geriatrics and gerontology international, 16 (11).,(14). [crossref]
  10. Varma, N. & Ricci, R. (2013) Telemedicine and cardiac implants: what is the benefit? European heart journal, 34 (25), 1885-1895.(15).
  11. Lowres, N., Redfern, J., & Freedman, S. (2014) Choice of health options in prevention of cardiovascular events for people with  atrial  fibrillation  (CHOICE  AF):  A  pilot study, European journal of cardiovascular nursing, doiorg.proxy.lib.umich. edu/10.1177/14745114549687. (16). [crossref]
  12. Cameron, K., Ross, E., Clayman, M., Bergeron, A., et. al. (2010) Measuring patients’ self-efficacy in understanding and using prescription medication, PatientEducation Couns, 80 (3); 372376. Doi: 10.1016/j.pec.2010.06.029.,(17,21). [crossref]
  13. Ryan, P., Papanek, P., Csuka, M., Brown, M., et. al. (2018) Background and method of the striving to be strong study, a RCT test the efficacy of a mhealth self-management intervention, Contemporary Clinical Trials, 71, 80-87.,(16). [crossref]
  14. Suter, B., Suter, W. N., & Johnston, D. (2011) Theory-based telehealth and patient empowerment, Population Health Management, 14 (2).,(19). [crossref]
  15. Withers, K., Wood, K., Carolan-Rees, G, Patrick, H., et.al. (2015) Living on a knife edge- the daily struggle of coping with symptomatic cardiac arrhythmias, Health quality life outcomes, 13:86.,(20). [crossref]
  16. Tovel, H. & Carmel, S. (2015) Functional Self-Efficacy Scale- FSES: Development, evaluation, and contribution to well-being, Research on aging, 1-22. Doi: 10.1177/0164027515596583. (16,22,24). [crossref]
  17. Walfridsson, U., Arestedt, K., & Stromberg, A. (2012) Development and validation of a new arrhythmia-specific questionnaire in tachycardia and arrhythmia (ASTA) with focus on symptom burden, Health quality life outcomes, 10-44, doi: 10.1186/1477- 7525-10-44.,(23,25). [crossref]

Appendix A. Data Collection Tool- Aid for patient at home.

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2 points each for every activity noted along the vertical axis; showing an activity taken due to the symptom noted on the horizontal axis. Subject to keep weekly log of number of symptoms and number of points for response activities.

Appendix B: Study Schematic

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Appendix C: Three Surveys

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Walfridsson, U., Arestedt, K., & Stromberg, A. (2012) Development and validation of a new arrhythmia-specific questionnaire in tachycardia and arrhythmia (ASTA) with focus on symptom burden, Health quality life outcomes, 10-44, doi: 10.1186/1477- 7525-10-44.,(23,25).

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Appendix D: Scores of completed surveys:

Survey Scores: Key- Muse– Shows any difficulty in taking; or understanding medications. FSES

highest the better functional status; highest possible =65. ASTA– the highest the worse arrhythmia burden, symptoms, and mental and physical QOL.

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Appendix D. – Answers to the above scores

Muse Survey Answers

Question 1– How many prescriptions medications do you take regularly?

Mean= 5.33 medications; Median 4 Medications; Mode 5 medications with a low answer of 2 and high answer of 19 medications.

Question 2– During the past have you forgotten to take any medication? “Only 1 yes.

Question 3– In the past did you not fill or stop taking the prescription due to cost? All answered no.

Question 4– In a typical month how many pharmacies do you use; including mail order? Six subjects answered 1/ 3 subjects answered 2.

Question 5– Have you been admitted to the hospital in the past six months? –Three subjects -yes.

Question 6– How many physicians prescribed medications for you in the past year? – mean answer 2.89.

Question 7– How many medical conditions which you are receiving treatment? – mean answer 3.33

FSES Shortened Survey * Higher scores showing better functional status

This survey gained very differing results for patient. Two subjects scored the total possible of 65 points indicating the best functional status and answered 5 (maximal score) for all 13 questions. One subject answered 3 for each of the 13 questions with a score of 39 and indicating day to day function was exactly in the middle of the survey. Other subjects gave a variable scoring with specific areas and gave a scattered response, depending upon the question. Two of the subjects gave responses in the 2 range, or lower level of functional capabilities. Scores listed in 1a-9a order: 65/ 57/ 53/ 65/ 43/ 39/ 63/ 64/ 44.

ASTA Survey The survey is scored into three categories- presence of arrhythmia, symptoms associated with the arrhythmia and Health related Quality of life (QOL)- both mental and physical. Higher the score- the higher the arrhythmia burden, more symptoms and more impact on the health related QOL. Scores listed in 1a- 9a order: 39/39/38/21/37/50/21/46/54.

Appendix E.

Average Scores Pre and Post (n=9)

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When two pandemics meet

Abstract

The COVID-19 pandemic has emerged in the middle of another pandemic which is far from under control: the cardiometabolic syndrome pandemic. Recently published data suggests patients with obesity are at a higher risk of being hospitalized and placed on a mechanical ventilator for COVID-19 than patients with a normal body weight. We discuss the pathophysiology behind this relationship and the implications in the global fight against COVID-19.

Keywords

COVID-19; coronavirus; obesity; cardiometabolic syndrome.

No one single mechanism is responsible for disease progression into severity in COVID-19 cases as in almost all diseases -chronic or not, transmissible or not-. We as scientists are trained to observe, identify differences and similarities between cases and arrive at possible explanations called hypothesis that can help the scientific community to develop effective strategies to combat the illness.

To this day several factors have been identified and when put together they tell a storyline that sums up the pathophysiology of severity in COVID-19 shown in Figure 1.

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Figure 1. Schematic representation of shared pathophysiology in COVID-19 cases with underlying metabolic illness. [1]. DIC: Disseminated Intravascular Coagulation.

But how does this scenario come to be? The answer comes from a previous pandemic that has been around for many years: the Cardiometabolic Syndrome (CMS) pandemic. CMS is defined by a combination of metabolic disorders that include diabetes mellitus, systemic arterial hypertension, central obesity, and dyslipidemia. All these conditions lead to elevated heart disease risk, which in turn is the leading cause of death in first world countries and doesn´t fall far behind in the rest of the world as well. This global epidemic to some doesn´t seem so scary being that it cannot be transmitted through droplets or by touching “infected” surfaces. Thisidea, however, isn´t completely true. The first risk factor for this group of diseases is being overweight or obesity, and this is in a sense “transmitted”. Eating habits are a cultural phenomenon, and from one generation to the next, families and communities pass on grocery lists, recipes and pantry contents. As of 2019 the global mean prevalence of obesity was measured at 19.5%. This number has almost tripled since 1975 and is currently the number one risk factor associated with premature death. Obesity as a risk factor for disease usually means it leads to chronic diseases such as the ones previously mentioned, but nowadays we are observing a different consequence of being overweight. An elevated body mass index has become a high-risk factor for severity in COVID-19 cases. [2]

Table 1 shows the evidence on the previous statement. A study by Zheng et al of 214 patients in Wuhan, China with laboratory confirmed COVID-19 showed that the presence of a Body Mass Index (BMI) >25 kg/m2 was associated with a near-6 fold increased risk of severe illness, even after adjusting for age and other comorbidities. [3] Of 4,103 COVID-19 cases in New York City the chronic condition which conferred the strongest association with critical illness was obesity, with 39.8% of hospitalized patients having obesity. [4]

Table 1. Epidemiological studies on COVID-19 outcomes and obesity related risk-factors

Author, Region and Date

Subjects

Findings

Z. Wu [7]
Mainland China
Updated Feb 11, 2020

72,314 suspicious cases of COVID-19
44,672 lab-confirmed cases

2.3% Case-Fatality Rate
Mild cases 81%
Severe cases 14%
Critical cases 5%

S. Garg [8]
USA (COVID-NET)
March 1-30, 2020

1,482 hospitalized patients

89% of patients had one or more underlying conditions:
Hypertension 49.7%
Obesity 48.3%
Chronic lung disease 34.6%
Diabetes Mellitus 28.3%
Cardiovascular disease 27.88%

Among patients 18-49 years-old obesity was the most prevalent underlying condition (59%).

P. Goyal [9]
New York City, US
Mar 3-27, 2020

First 393 cases of COVID-19 adults hospitalized in New York

Patients who required invasive mechanical ventilation were more likely to be male, have obesity and elevated liver-function and inflammatory markers.

S. Richardson [10]
New York, USA
Mar 1 – Apr 4, 2020

5,700 hospitalized patients

Most common comorbidities among hospitalized patients:
Hypertension 56.6%
Obesity 41.7% – (Morbid obesity 19%)
Diabetes Mellitus 33.8%

G. Grasselli [11]
Milan, Italy
Feb 20 – Mar 18, 2020

73 patients in intensive care unit

Over 80% of patients in ICU were overweight or had obesity.
Normal weight – 19%
Overweight – 51.9%
Obesity 1 – 15.4%
Obesity 2 – 11.5%
Obesity 3 – 1.9%

Zheng [3]
Wenzhou, China
Jan 1 – Feb 29, 2020

214 patients with lab confirmed COVID-19
Ages 18-75

A BMI equal to or greater than 25 kg/m2 was associated with a 6-fold increased risk of severe illness.
This risk remained significant even after adjusting for age and other comorbidities.

Petrilli [4]
New York
Mar 1 – Apr 7, 2020

4,103 cases of COVID-19
1,999 hospitalized

The chronic condition with the strongest association to critical illness was obesity.
39.8% of hospitalized patients had obesity.

Qingxian [12]
Mainland China
Jan 11 – Feb 16, 2020

383 patients admitted to a hospital in Shenzen

After adjusting for age, sex, disease history and treatment the overweight group was 2.42 times more likely to develop severe pneumonia.

A. Simonnet [5]
Lille, France
Feb 27 – Apr 5, 2020

124 patients admitted to ICU for COVID-19.
Compared to control group from 2019

Obesity was significantly more frequent among cases of COVID-19 (47.6%) compared to control group (25.2%).
The median BMI of patients requiring intubation was 31.1 kg/m2 compared to 27 kg/m2 in the patients who did not require intubation.
In individuals with a BMI ³35 kg/m2 the odds ratio for intubation was 7.36 compared to individuals with a normal BMI.

Among 124 patients admitted for COVID-19 to a hospital in Lille, France 47.6% had obesity. Patients with a BMI of greater than 35 kg/m2 were 7.36 times more likely to require a ventilator than patients with a BMI of less than 25 kg/m2. [5] In Milan more than 80% of 73 patients treated in an ICU were overweight or had obesity, when the rates of overweigh and obesity in Italy are only 35.4% of the population. [6]

Two main explanations play a role in this complicated infectious disease in association with weight problems. The first one is the chronic inflammatory state it conveys. Recent studies have found that adipose tissue secretes extracellular vesicles that function as vectors which can modify cellular function in the recipient through the information they carry. Data suggests that this mechanism is used by fat to induce monocyte differentiation into active macrophages and high secretion of IL-1 and TNF-α among other cytokines. [13] The second one is the fact that patients with obesity have been found to have higher concentrations of pro-thrombotic factors as compared to normal-weight controls. Some of these altered parameters include higher D-dimer, fibrinogen and factor VII; as well as lower fibrinolysis because of higher plasminogen activator inhibitor-1. [14]

Besides increased inflammatory cytokines, obesity englobes several pathophysiological factors which affect the risk and outcomes of patients with COVID-19. In the respiratory tract obesity may cause pulmonary restriction, decreased pulmonary volumes and ventilation-perfusion mismatching. Patients with obesity are more likely to present diabetes mellitus and atherosclerosis which may be complicated by COVID-19. Additionally, there is limited data on the right dosing of antimicrobials in obesity and bioavailability of drugs used to treat patients with this disease may be affected by altered protein binding, metabolism and volume of distribution. [15]

On the other hand, new information is developing every day concerning COVID-19 cases and more data is suggesting that bad prognosis is linked to thromboembolic events caused by inflammation, hypoxia and coagulation abnormalities. One study by Klok et alstudied 184 Intensive Care Unit (ICU) patients with confirmed COVID-19, and found that 31% showed thrombotic complications, of which 81% was due to pulmonary embolism. [16] When we put two and two together, the relationship becomes apparent. Obesity is a clear catalyzer for severe COVID-19 cases. In a country like Mexico, where the prevalence for overweight and obesity in over 20-year-olds is 75.2%, this relationship is very threatening. [17]

It seems that the best way to prevent bad outcomes from this novel disease (as well as from infectious diseases in general) is to be in good health prior to contracting it in the first place. As for those patients who already suffer from CMS or one of its components, preventive treatment is our main recommendation. These patients should be at optimal glycemic, systemic arterial pressure and cholesterol level goals. A study by Carter et al also suggests that vitamin D deficiencies (also more common in patients with obesity) have been linked to worse cytokine storms. To this end, physical activity as well as sun exposure is effective ways to boost vitamin D levels. [18]

This sound reasonable, right? Well, reasonable doesn´t always mean achievable in all populations. Vulnerable communities around the world are struggling every day just to have access to general medical attention. These communities are also at an increased risk of exposure to COVID-19. Working from home is a privilege that is unavailable for many people from a lower socio-economic status. Social distancing is considerably more difficult for people living in overcrowded neighborhoods. Emerging epidemiological studies in the U.S. suggest a disproportionate burden of illness and higher death rates among minority groups. [9]

Currently there is no gold standard treatment for COVID-19, however, all this data suggests that global efforts need to be directed towards prevention and education. Pre-existing conditions need to be under control and lifestyle habits should be aimed towards getting enough exercise and a proper nutrition. [19,20]

References

  1. Xiong M, Liang X, Wei YD (2020) Changes in Blood Coagulation in Patients with Severe Coronavirus Disease 2019 (COVID‐19): A Meta‐Analysis. Br J Haematol.[crossref]
  2. Blüher M (2019)Obesity: global epidemiology and pathogenesis. Nat Rev Endocrinol15:288-298.
  3. Zhou F, Yu T, Du R, Fan G, Liu Y et al. (2020) Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet.395: 1054-1062. [crossref]
  4. Petrilli CM, Jones SA, Yang J, Rajagopalan H, O’Donnell LF, Chernyak Y, Horwitz LI (2020) Factors associated with hospitalization and critical illness among 4,103 patients with COVID-19 disease in New York City. medRxiv.
  5. Simonnet A, Chetboun M, Poissy J, Raverdy V, Noulette J et al. (2020) Intensive Care COVID‐19 and Obesity study group. High prevalence of obesity in severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) requiring invasive mechanical ventilation. Obesity.[crossref]
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Differences between 5-Minute and 15-Minute Measurement Time Intervals of the CGM Sensor Glucose Device Using GH-Method: Math-Physical Medicine (No. 281)

Introduction

This paper describes the research results by comparing the glucose data from a Continuous Glucose Monitor (CGM) sensor device collecting glucose at 5-minute (5-min) and 15-minute (15-min) intervals during a period of 125 days, from 2/19/2020 to 6/23/2020, using the GH-Method: math-physical medicine approach. The purposes of this study are to compare the measurement differences and to uncover any possible useful information due to the different time intervals of the glucose collection.

Methods

Since 1/1/2012, the author measured his glucose values using the finger-piercing method: once for FPG and three times for PPG each day. On 5/5/2018, he applied a CGM sensor device (brand name: Libre) on his upper arm and checked his glucose measurements every 15 minutes, a total of ~80 times each day. After the first bite of his meal, he measured his Postprandial Plasma Glucose (PPG) level every 15 minutes for a total of 3-hours or 180 minutes. He maintained the same measurement pattern during all of his waking hours. However, during his sleeping hours (00:00-07:00), he measured his Fasting Plasma Glucose (FPG) in one-hour intervals.

With his academic background in mathematics, physics, computer science, and engineering including his working experience in the semiconductor high-tech industry, he was intrigued with the existence of “high frequency glucose component” which is defined as those lower glucose values (i.e. lower amplitude) but occurring frequently (i.e.. higher frequency). In addition, he was interested in identifying those energies associated with higher frequency glucose components such as the various diabetes complications that would contribute to the damage of human organs and to what degree of impact. For example, there are 13 data-points for the 15-minute PPG waveforms, while there are 37 data-points for the 5-minute PPG waveforms. These 24 additional data points would provide more information about the higher frequency PPG components.

Starting from 2/19/2020, he utilized a hardware device based on Bluetooth technology and embedded with customized application software to automatically transmit all of his CGM collected glucose data from the Libre sensor directly into his customized research program known as the eclaireMD system, but in a shorter time period for each data transfer. On the same day, he made a decision to transmit his glucose data at 5-minute time intervals continuously throughout the day; therefore, he is able to collect ~240 glucose data within 24 hours.

He chose the past 4-months from 2/19/2020 to 6/19/2020, as his investigation period for analyzing the glucose situation. The comparison study included the average glucose, high glucose, low glucose, waveforms (i.e. curves), correlation coefficients (similarity of curve patterns), and ADA-defined TAR/TIR/TBR analyses. This is his secondresearch report on the 5-minute glucose data. His first paper focused on the most rudimentary comparisons [1].

References 2 through 4 explained some example research using his developed GH-Method: math-physical medicine approach [2,3].

Results

The top diagram of Figure 1 shows that, for 125 days from 2/19/2020 – 6/23/2020, he has an average of 259 glucose measurements per day using 5-minute intervals and an average of 85 measurements per day using 15-minute intervals. Due to the signal stability of using Bluetooth technology, for the 5-min, it actually has 259 data instead of the 240 data per day.

IMROJ-5-3-516-g001

Figure 1. Daily glucose, 30-days & 90-days moving average glucose of both 15-minutes and 5-minutes.

The middle diagram of Figure 1 illustrates the 30-days moving average of the same dataset as the “daily” glucose curve. Therefore, after ignoring the curves during the first 30 days, we focus on the remaining three months and can detect the trend of glucose movement easier than “daily” glucose data chart. There are two facts that can be observed from this middle diagram. First, the gap between 5-min and 15-min is wider in the second month, while the gap becomes smaller during the third and fourth month. This means that the 5-min results are converging with the 15-min results.Secondly, both curves of 5-min and 15-min are much higher than the finger glucose (blue line). This indicates that the Libre sensor provides a higher glucose reading than the finger glucose. From the listed data below, the CGM sensor daily average glucoses are about 8% to 10% higher than the finger glucose.

5-min sensor: 118 mg/dL (108%)

15-min sensor: 120 mg/dL (110%)

Finger glucose: 109 mg/dL (100%).

The bottom diagram of Figure 1 is the 90-days moving average glucose. Unfortunately, his present dataset only covers 4 months due to late start of collecting his 5-min data; however, the data trend of the last month, from 5/19-6/23/2020, can still provide a meaningful trend indication. As time goes by, additional data will continue to be collected, his 5-min glucose’s 90-days moving trend will be seen more clearly.

Figure 2 shows the synthesized views of his daily glucose, PPG, and FPG.Here, “synthesized” is defined as the average data of 125 days.For example, the PPG curve is calculated based on his 125×3=375 meals. Listed below is a summary of his primary glucose data (mg/dL) in the format of “average glucose/extreme glucose”. Extreme means either maximum or minimum, where the maximum for both daily glucose and PPG due to his concerns of hyperglycemic situation, and the minimum for FPG due to his concerns of insulin shock. The percentage number in prentice is the correlation coefficients between the curves of 15-min and 5-min.

Daily (24 hours):15-min vs. 5-min

117/143vs. 119/144(99%)

PPG (3 hours):15-min vs. 5-min

126/135vs. 125/134(98%)

FPG (7 hours):15-min vs. 5-min

102/95 vs. 105/99 (89%).

Those primary glucose values between 15-min and 5-min are close to each other in the glucose categories. It is evident that the author’s diabetes conditions are under well control for these 4 months. However, by looking at Figure 2 and three correlation coefficients %, we can see that daily glucose and PPG have higher similarity of curve patterns (high correlation coefficients of 98% and 99%) between 15-min and 5-min, but FPG curves have a higher degree of mismatch in patterns (lower correlation coefficient of 89%). This signifies that his FPG values during sleeping hours have a bigger difference between 15-min and 5-min.

IMROJ-5-3-516-g002

Figure 2. Synthesized daily glucose, PPG, and FPG of both 15-minutes and 5-minutes.

Figure 3 are the results using candlestick model [4,5]. The top diagram is the 15-min candlestick chart and the bottom diagram is the 5-min candlestick chart. Candlestick chart, also known as the K-Line chart, includes five primary values of glucoses during a particular time period; “day” is used in this study. These five primary glucose data are:

Start: beginning of the day.

Close: end of the day.

Minimum: lowest glucose.

Maximum: highest glucose.

Average: average for the day.

Listed below are five primary glucose values of both 15-min and 5-min.

15-min: 108/116/86/170/120.

5-min: 111/116/84/173/118.

IMROJ-5-3-516-g003

Figure 3. Candlestick charts of both 15-minutes and 5-minutes.

By ignoring the first two glucoses, start and close, let us focus on the last three glucoses: minimum, maximum, and average. The 5-min method has a lower minimum and a higher maximum than the 15-min method. This is due to the 5-min method capturing more glucose data; therefore, it is easier to catch the lowest and highest glucoses during the day. The difference of 2mg/dL between 15-min’s average 120 mg/dL and 5-min’s average 118 mg/dL is only a negligible 1.7%.

Again, it is also obvious from these candlestick charts that the author’s diabetes conditions are under well control for these 4 months.

Conclusion

In summary, the glucose differences between 5-min and 15-min based on simple arithmetic and statistical calculations are not significant enough to draw any conclusion or make any suggestion on which are the “suitable” or better measurement time intervals. However, the author will continue his research to pursue this investigation of energy associated with higher-frequency glucose components in order to determine the glucose energy’s impact or damage on human organs (i.e. diabetes complications).

The author has read many medical papers about diabetes. The majority of them are related to the medication effects on glucose symptoms control, not so much on investigating and understanding “glucose” itself. This situation is similar to taming and training a horse without a good understanding of the temperament and behaviors of the animal. Medication is like giving the horse a tranquilizer to calm it down. Without a deep understanding of glucose behaviors, how can we truly control the root cause of diabetes disease by only managing the symptoms of hyperglycemia?

References

  1. Hsu, Gerald C. eclaireMD Foundation, USA (2020) Analyzing CGM sensor glucoses at 5-minute intervals using GH-Method: math-physical medicine (No. 278).
  2. Hsu, Gerald C. eclaireMD Foundation, USA(2020) Predicting Finger PPG by using Sensor PPG waveform and data via regression analysis with three different methods using GH-Method: math-physical medicine (No. 249).
  3. Hsu, Gerald C. eclaireMD Foundation, USA (2019) Applying segmentation pattern analysis to investigate postprandial plasma glucose characteristics and behaviors of the carbs/sugar intake amounts in different eating places using GH Method: math-physical medicine (No. 150).
  4. Hsu, Gerald C. eclaireMD Foundation, USA (2019) A case study of the impact on glucose, particularly postprandial plasma glucose based on the 14-day sensor device reliability using GH-Method: math-physical medicine (No. 124).
  5. Hsu, Gerald C. eclaireMD Foundation, USA. Comparison study of PPG characteristics from candlestick model using GH-Method: Math-Physical Medicine (No. 261).

Albedo Changes Drive 4.9 to 9.4°C Global Warming by 2400

Abstract

This study ties increasing climate feedbacks to projected warming consistent with temperatures when Earth last had this much CO2 in the air. The relationship between CO2 and temperature in a Vostok ice core is used to extrapolate temperature effects of today’s CO2 levels. The results suggest long-run equilibrium global surface temperatures (GSTs) 5.1°C warmer than immediately “pre-industrial” (1880). The relationship derived holds well for warmer conditions 4 and 14 million years ago (Mya). Adding CH4 data from Vostok yields 8.5°C warming due to today’s CO2 and CH4 levels. Long-run climate sensitivity to doubled CO2, given Earth’s current ice state, is estimated to be 8.2°C: 1.8° directly from CO2 and 6.4° from albedo effects. Based on the Vostok equation using CO2 only, holding ∆GST to 2°C requires 318 ppm CO2. This means Earth’s remaining carbon budget for +2°C is estimated to be negative 313 billion tonnes. Meeting this target will require very large-scale CO2 removal. Lagged warming of 4.0°C (or 7.4°C when CH4 is included), starting from today’s 1.1°C ∆GST, comes mostly from albedo changes. Their effects are estimated here for ice, snow, sulfates, and cloud cover. This study estimates magnitudes for sulfates and for future snow changes. Magnitudes for ice, cloud cover, and past snow changes are drawn from the literature. Albedo changes, plus their water vapor multiplier, caused an estimated 39% of observed GST warming over 1975-2016. Estimated warming effects on GST by water vapor; ocean heat; and net natural carbon emissions (from permafrost, etc.), all drawn from the literature, are included in projections alongside ice, snow, sulfates, and clouds. Six scenarios embody these effects. Projected ∆GSTs on land by 2400 range from 2.4 to 9.4°C. Phasing out fossil fuels by 2050 yields 7.1°C. Ending fossil fuel use immediately yields 4.9°C, similar to the 5.1°C inferred from paleoclimate studies for current CO2 levels. Phase-out by 2050 coupled with removing 71% of CO2 emitted to date yields 2.4°C. At the other extreme, postponing peak fossil fuel use to 2035 yields +9.4°C GST, with more warming after 2400.

Introduction

The December 2015 Paris climate pact set a target of limiting global surface temperature (GST) warming to 2°C above “pre-industrial” (1750 or 1880) levels. However, study of past climates indicates that this will not be feasible, unless greenhouse gas (GHG) levels, led by carbon dioxide (CO2) and methane (CH4), are reduced dramatically. Already, global air temperature at the land surface (GLST) has warmed 1.6°C since the 1880 start of NASA’s record [1]. (Temperatures in this study are 5-year moving averages from NASA, Goddard Institute for Space Studies, in °C. Baseline is 1880 unless otherwise noted.) The GST has warmed by 2.5°C per century since 2000. Meanwhile, global sea surface temperature (=(GST – 0.29 * GLST)/0.71) has warmed by 0.9°C since 1880 [2].

The paleoclimate record can inform expectations of future warming from current GHG levels. This study examines conditions during ice ages and during the most recent (warmer) epochs when GHG levels were roughly this high, some lower and some higher. It strives to connect future warming derived from paleoclimate records with physical processes, mostly from albedo changes, that produce the indicated GST and GLST values.

The Temperature Record section examines Earth’s temperature record, over eons. Paleoclimate data from a Vostok ice core covering 430,000 years (430 ky) is examined. The relations among changes in GST relative to 1880, hereafter “∆°C”, and CO2 and CH4 levels in this era colder than now are estimated. These relations are quite consistent with the ∆°C to CO2 relation in eras warmer than now, 4 and 14 Mya. Overall climate sensitivity is estimated based on them. Earth’s remaining carbon budget to keep warming below 2°C is calculated next, based on the equations relating ∆°C to CO2 and CH4 levels in the Vostok ice core. That budget is far less than zero. It requires returning to CO2 levels of 60 years ago.

The Feedback Pathways section discusses the major factors that lead from our present GST to the “equilibrium” GST implied by the paleoclimate data, including a case with no further human carbon emissions. This path is governed by lag effects deriving mainly from albedo changes and their feedbacks. Following an overview, eight major factors are examined and modeled to estimate warming quantities and time scales due to each. These are (1) loss of sulfates (SO4) from ending coal use; (2) snow cover loss; (3) loss of northern and southern sea ice; (4) loss of land ice in Antarctica, Greenland and elsewhere; (5) cloud cover changes; (6) water vapor increases due to warming; (7) net emissions from permafrost and other natural carbon reservoirs; and (8) warming of the deep ocean.

Particular attention is paid to the role that anthropogenic and other sulfates have played in modulating the GST increase in the thermometer record. Loss of SO4 and northern sea ice in the daylight season will likely be complete not long after 2050. Losses of snow cover, southern sea ice, land ice grounded below sea level, and permafrost carbon, plus warming the deep oceans, should happen later and/or more slowly. Loss of other polar land ice should happen still more slowly. But changes in cloud cover and atmospheric water vapor can provide immediate feedbacks to warming from any source.

In the Results section, these eight factors, plus anthropogenic CO2 emissions, are modeled in six emission scenarios. The spreadsheet model has decadal resolution with no spatial resolution. It projects CO2 levels, GSTs, and sea level rise (SLR) out to 2400. In all scenarios, GLST passes 2°C before 2040. It has already passed 1.5°. The Discussion section lays out the implications of Earth’s GST paths to 2400, implicit both in the paleoclimate data and in the development of specific feedbacks identified for quantity and time-path estimation. These, combined with a carbon emissions budget to hold GST to 2°C, highlights how crucial CO2 removal (CDR) is. CDR is required to go beyond what emissions reduction alone can achieve. Fifteen CDR methods are enumerated. A short overview of solar radiation management follows. It may be required to supplement ending fossil fuel use and large-scale CDR.

The Temperature Record

In a first approach, temperature records from the past are examined for clues to the future. Like causes (notably CO2 levels) should produce like effects, even when comparing eras hundreds of thousands or millions of years apart. As shown in Figure 1, Earth’s surface can grow far warmer than now, even 13°C warmer, as occurred some 50 Mya. Over the last 2 million years, with more ice, temperature swings are wider, since albedo changes – from more ice to less ice and back – are larger. For GSTs 8°C or warmer than now, ice is rare. Temperature spikes around 55 and 41 Mya show that the current one is not quite unique.

fig 1

Figure 1: Temperatures and Ice Levels over 65 Million Years [3].

Some 93% of global warming goes to heat Earth’s oceans [4]. They show a strong warming trend. Ocean heat absorption has accelerated, from near zero in 1960: 4 zettaJoules (ZJ) per year from 1967 to 1990, 7 from 1991 to 2005, and 10 from 2010 to 2016 [5]. 10 ZJ corresponds to 100 years of US energy use. The oceans now gain 2/3 as much heat per year as cumulative human energy use or enough to supply US energy use for 100 years [6] or the world’s for 17 years. By 2011, Earth was absorbing 0.25% more energy than it emits, a 300 (±75) million MW heat gain [7]. Hansen deduced in 2011 that Earth’s surface must warm enough to emit another 0.6 Wm-2 heat to balance absorption; the required warming is 0.2°C. The imbalance has probably increased since 2011 and is likely to increase further with more GHG emissions. Over the last 100 years (since 1919), GSTs have risen 1.27°C, including 1.45°C for the land surface (GLST) alone [1]. The GST warming rate from 2000 to 2020 was 0.24°C per decade, but 0.35 over the most recent decade [1,2]. At this rate, warming will exceed 2°C in 2058 for GST and in 2043 for GLST only.

Paleoclimate Analysis

Atmospheric CO2 levels have risen 47% since 1750, including 40% since 1880 when NASA’s temperature records begin [8]. CH4 levels have risen 114% since 1880. CO2 levels of 415 parts per million (ppm) in 2020 are the highest since 14.1 to 14.5 Mya, when they ranged from 430 to 465 ppm [9]. The deep ocean then (over 400 ky) ranged around 5.6°C±1.0°C warmer [10] and seas were 25-40 meters higher [9]. CO2 levels were almost as high (357 to 405 ppm) 4.0 to 4.2 Mya [11,12]. SSTs then were around 4°C±0.9°C warmer and seas were 20-35 meters higher [11,12].

The higher sea levels in these two earlier eras tell us that ice then was gone from almost all of the Greenland (GIS) and West Antarctic (WAIS) ice sheets. They hold an estimated 10 meters (7 and 3.2 modeled) of SLR between them [13,14]. Other glaciers (chiefly in Arctic islands, the Himalayas, Canada, Alaska, and Siberia) hold perhaps 25 cm of SLR [15]. Ocean thermal expansion (OTE), currently about (~) 1 mm/year [5], is another factor in SLR. This corresponds to the world ocean (to the bottom) currently warming by ~0.002°Kyr-1. The higher sea levels 4 and 14 Mya indicate 10-30 meters of SLR that could only have come from the East Antarctic ice sheet (EAIS). This is 17-50% of the current EAIS volume. Two-thirds of the WAIS is grounded below sea level, as is 1/3 in the EAIS [16]. Those very areas (which are larger in the EAIS than the WAIS) include the part of East Antarctica most likely to be subject to ice loss over the next few centuries [17]. Sediments from millions of years ago show that the EAIS then had retreated hundreds of kilometers inland [18].

CO2 levels now are somewhat higher than they were 4 Mya, based on the current 415 ppm. This raises the possibility that current CO2 levels will warm Earth’s surface 4.5 to 5.0°C, best estimate 4.9°, over 1880 levels. (This is 3.4 to 3.9°C warmer than the current 1.1°C.) Consider Vostok ice core data that covers 430 ky [19]. Removing the time variable and scatter-plotting ∆°C against CO2 levels as blue dots (the same can be done for CH4), gives Figure 2. Its observations span the last 430 ky, at 10 ky resolution starting 10 kya.

fig 2

Figure 2: Temperature to Greenhouse Gas Relationship in the Past.

Superimposed on Figure 2 are trend lines from two linear regression equations, using logarithms, for temperatures at Vostok (left-hand scale): one for CO2 (in ppm) alone and one for both CO2 and CH4 (ppb). The purple trend line in Figure 2, from Equation (1) for Vostok, uses only CO2. 95% confidence intervals in this study are shown in parentheses with ±.

(1) ∆°C = -107.1 (±17.7) + 19.1054 (±3.26) ln(CO2).

The t-ratios are -11.21 and 11.83 for the intercept and CO2 concentration, while R2 is 0.773 and adjusted R2 is 0.768. The F statistic is 139.9. All are highly significant. This corresponds to a climate sensitivity of 13.2°C at Vostok [19.1054 * ln (2)] for doubled CO2, within the range of 180 to 465 ppm CO2. As shown below, most of this is due to albedo changes and other amplifying feedbacks. Therefore, climate sensitivity will decline as ice and snow become scarce and Earth’s albedo stabilizes. The green trend line in Figure 2, from Equation (2) for Vostok, adds a CH4 variable.

(2) ∆°C = -110.7 (±14.8) +11.23 (±4.55) ln(CO2) + 7.504 (±3.48) ln(CH4).

The t-ratios are -15.05, 4.98, and 4.36 for the intercept, CO2, and CH4. R2 is 0.846 and adjusted R2 is 0.839. The F statistic of 110.2 is highly significant. To translate temperature changes at the Vostok surface (left-hand axis) over 430 ky to changes in GST (right-hand axis), the ratio of polar change to global over the past 2 million years is used, from Snyder [20]. Snyder examined temperature data from many sedimentary sites around the world over 2 My. Her results yield a ratio for polar to global warming: 0.618. This relates the left- and right-hand scales in Figure 2. The GST equations, global instead of Vostok local, corresponding to Equations (1) and (2) for Vostok, but using the right-hand scale for global temperature, are:

(3) ∆°C = -66.19 + 11.807 ln(CO2) and

(4) ∆°C = -68.42 + 6.94 ln(CO2) + 4.637 ln(CH4).

Both equations yield good fits for 14.1 to 14.5 Mya and 4.0 to 4.2 Mya. Equation 3 yields a GST climate sensitivity estimate of 8.2° (±1.4) for doubled CO2. Table 1 below shows the corresponding GSTs for various CO2 and CH4 levels. CO2 levels range from 180 ppm, the lowest recorded during the past four ice ages, to twice the immediately “pre-industrial” level of 280 ppm. Columns D, I and N add 0.13°C to their preceding columns, the difference the 1880 GST and the 1951-80 mean GST used for the ice cores. Rows are included for CO2 levels corresponding to 1.5 and 2°C warmer than 1880, using the two equations, and for the 2020 CO2 level of 415 ppm. The CH4 levels (in ppb) in column F are taken from observations or extrapolated. The CH4 levels in column K are approximations of the CH4 levels about 1880, before human activity raised CH4 levels much – from some mixture of fossil fuel extraction and leaks, landfills, flooded rice paddies, and large herds of cattle.

Other GHGs (e.g., N2O and some not present in the Vostok ice cores, such as CFCs) are omitted in this discussion and in modeling future changes. Implicitly, this simplifying assumption is that the weighted rate of change of other GHGs averages the same as CO2.

Implications

Applying Equation (3) using only CO2, now at 415 ppm, yields a future GST 4.99°C warmer than the 1951-80 baseline. This translates to 5.12°C warmer than 1880, or 3.99°C warmer than 2018-2020 (2). This is consistent not only with the Vostok ice core records, but also with warmer Pliocene and Miocene records using ocean sediments from 4 and 14 Mya. However, when today’s CH4 levels, ~ 1870 ppb, are used in Equation (4), indicated equilibrium GST is 8.5°C warmer than 1880. Earth’s GST is currently far from equilibrium.

Consider the levels of CO2 and CH4 required to meet Paris goals. To hold GST warming to 2°C requires reducing atmospheric CO2 levels to 318 ppm, using Equation (3), as shown in Table 1. This requires CO2 removal (CDR), at first cut, of (415-318)/(415-280) = 72% of human CO2 emissions to date, plus any future ones. Equation (3) also indicates that holding warming to 1.5°C requires reducing CO2 levels to 305 ppm, equivalent to 81% CDR. Using Equation (4) with pre-industrial CH4 levels of 700 ppb, consistent with 1750, yields 2°C GST warming for CO2 at 314 ppm and 1.5°C for 292 ppm CO2. Human carbon emissions from fossil fuels from 1900 through 2020 were about 1600 gigatonnes (GT) of CO2, or about 435 GT of carbon [21]. Thus, using Equation (3) yields an estimated remaining carbon budget, to hold GST warming to 2°C, of negative 313 (±54) GT of carbon, or ~72% of fossil fuel CO2 emissions to date. This is only the minimum CDR required. First, removal of other GHGs may be required. Second, any further human emissions make the remaining carbon budget even more negative and require even more CDR. Natural carbon emissions, led by permafrost ones, will increase. Albedo feedbacks will continue, warming Earth farther. Both will require still more CDR. So, the true remaining carbon budget may actually be in the negative 400-500 GT range, and most certainly not hundreds of GT greater than zero.

Table 1: Projected Equilibrium Warming across Earth’s Surface from Vostok Ice Core Analysis (1951-80 Baseline).

table 1

The difference between current GSTs and equilibrium GSTs of 5.1 and 8.5°C stem from lag effects. The lag effects come mostly from albedo changes and their feedbacks. Most albedo changes and feedbacks happen over days to decades to centuries. Ones due to land ice and vegetation changes can continue over longer timescales. However, cloud cover and water vapor changes happen over minutes to hours. The specifics (except vegetation, not examined or modelled) are detailed in the Feedback Pathways section below.

However, the bottom two lines of Table 1 probably overestimate the temperature effects of 500 and 560 ppm of CO2, as discussed further below. This is because albedo feedbacks from ice and snow, which in large measure underlie the derivations from the ice core, decline with higher temperatures outside the CO2 range (180-465 ppm) used to derive and validate Equations (1) through (4).

Feedback Pathways to Warming Indicated by Paleoclimate Analysis

To hold warming to 2°C or even 1.5°, large-scale CDR is required, in addition to rapid reductions of CO2 and CH4 emissions to almost zero. As we consider the speed of our required response, this study examines: (1) the physical factors that account for this much warming and (2) the possible speed of the warming. As the following sections show, continued emissions speed up amplifying feedback processes, making “equilibrium” GSTs still higher. So, rapid emission reductions are the necessary foundation. But even an immediate end to human carbon emissions will be far from enough to hold warming to 2°C.

The first approach to projecting our climate future, in the Temperature Record section above, drew lessons from the past. The second approach, in the Feedback Pathways section here and below, examines the physical factors that account for the warming. Albedo effects, where Earth reflects less sunlight, will grow more important over the coming decades, in part because human emissions will decline. The albedo effects include sulfate loss from ending coal burning, plus reduced extent of snow, sea ice, land-based ice, and cloud cover. Another key factor is added water vapor, a powerful GHG, as the air heats up from albedo changes. Another factor is lagged surface warming, since the deeper ocean heats up more slowly than the surface. It will slowly release heat to the atmosphere, as El Niños do.

A second group of physical factors, more prominent late this century and beyond, are natural carbon emissions due to more warming. Unlike albedo changes, they alter CO2 levels in the atmosphere. The most prominent is from permafrost. Other major sources are increased microbial respiration in soils currently not frozen; carbon evolved from warmer seas; release of seabed CH4 hydrates; and any net decreased biomass in forests, oceans, and elsewhere.

This study estimates rough magnitudes and speeds of 13 factors: 9 albedo changes (including two for sea ice and four for land ice); changes in atmospheric water vapor and other ocean-warming effects; human carbon emissions; and natural emissions – from permafrost, plus a multiplier for the other natural carbon emissions. Characteristic time scales for these changes to play out range from decades for sulfates, northern and southern sea ice, human carbon emissions, and non-polar land ice; to centuries for snow, permafrost, ocean heat content, and land ice grounded below sea level; to millennia for other land ice. Cloud cover and water vapor respond in hours to days, but never disappear. The model also includes normal rock weathering, which removes about 1 GT of CO2 per year [22], or about 3% of human emissions.

Anthropogenic sulfur loss and northern sea ice loss will be complete by 2100 and likely more than half so by 2050, depending on future coal use. Snow cover and cloud cover feedbacks, which respond quickly to temperature change, will continue. Emissions from permafrost are modeled as ramping up in an S-curve through 2300, with small amounts thereafter. Those from seabed CH4 hydrates and other natural sources are assumed to ramp up proportionately with permafrost: jointly, by half as much. Ice loss from the GIS and WAIS grounded below sea level is expected to span many decades in the hottest scenarios, to a few centuries in the coolest ones. Partial ice loss from the EAIS, led by the 1/3 that is grounded below sea level, will happen a bit more slowly. Other polar ice loss should happen still more slowly. Warming the deep oceans, to reestablish equilibrium at the top of the atmosphere, should continue for at least a millennium, the time for a circuit of the world thermohaline ocean circulation.

This analysis and model do not include changes in (a) black carbon; (b) mean vegetation color, as albedo effects of grass replacing forests at lower latitudes may outweigh forests replacing tundra and ice at higher latitudes; (c) oceanic and atmospheric circulation; (d) anthropogenic land use; (e) Earth’s orbit and tilt; or (f) solar output.

Sulfate Effects

SO4 in the air intercepts incoming sunlight before it arrives at Earth’s surface, both directly and indirectly via formation of cloud condensation nuclei. It then re-radiates some of that energy upward, for a net cooling effect at Earth’s surface. Mostly, sulfur impurities in coal are oxidized to SO2 in burning. SO2 is converted to SO4 by chemical reactions in the troposphere. Residence times are measured in days. Including cooling from atmospheric SO4 concentrations explains a great deal of the variation between the steady rise in CO2 concentrations and the variability of GLST rise since 1880. Human SO2 emissions rose from 8 Megatonnes (MT) in 1880 to 36 MT in 1920, 49 in 1940, and 91 in 1960. They peaked at 134 MT in 1973 and 1979, before falling to 103-110 during 2009-16 [23]. Corresponding estimated atmospheric SO4 concentrations rose from 41 parts per billion (ppb) in 1880 (and a modestly lower amount before then), to 90 in 1920, 85 in 1940, and 119 in 1960, before reaching peaks of 172-178 during 1973-80 [24] and falling to 130-136 over 2009-16. Some atmospheric SO4 is from natural sources, notably dimethyl sulfides from some ocean plankton, some 30 ppb. Volcanoes are also an important source of atmospheric sulfates, but only episodically (mean 8 ppb) and chiefly in the stratosphere (from large eruptions), with a typical residence time there of many months.

Figure 3 shows the results of a linear regression analysis, in blue, of ∆°C from the thermometer record and concentrations of CO2, CH4, and SO4. SO4 concentrations between the dates referenced above are interpolated from human emissions, added to SO4 levels when human emissions were very small (1880). All variables shown are 5-year moving averages and SO4 is lagged by 1 year. CO2, CH4, and SO4 are measured in ppm, ppb and ppb, respectively. The near absence of an upward trend in GST from 1940 to 1975 happened at a time when human SO2 emissions rose 170% from 1940 to 1973 [23]. This large SO4 cooling effect offset the increased GHG warming effect, as shown in Figure 3. The analysis shown in Equation (5) excludes the years influenced by the substantial volcanic eruptions shown. It also excludes the 2 years before and 2-4 years after the years of volcanic eruptions that reached the stratosphere, since 5-year moving temperature averages are used. In particular, it excludes data from the years surrounding eruptions labeled in Figure 3, plus smaller but substantial eruptions in 1886, 1901-02, 1913, 1932-33, 1957, 1979-80, 1991 and 2011. This leaves 70 observations in all.

fig 3

Figure 3: Land Surface Temperatures, Influenced by Sulfate Cooling.

Equation (5)’s predicted GLSTs are shown in blue, next to actual GLSTs in red.

(5) ∆°C = -20.48 (±1.57) + 09 (±0.65) ln(CO2) + 1.25 (±0.33) ln(CH4) – 0.00393 (±0.00091) SO4

R2 is 0.9835 and adjusted R2 0.9828. The F-statistic is 1,312, highly significant. T-ratios for CO2, CH4, and SO4 respectively are 7.10, 7.68, and -8.68. This indicates that CO2, CH4, and SO4 are all important determinants of GLSTs. The coefficient for SO4 indicates that reducing SO4 by 1 ppb will increase GLST by 0.00393°C. Deleting the remaining human 95 ppb of SO4 added since 1880, as coal for power is phased out, would raise GLST by 0.37°C.

Snow

Some 99% of Earth’s snow cover, outside of Greenland and Antarctica, is in the northern hemisphere (NH). This study estimates the current albedo effect of snow cover in three steps: area, albedo effect to date, and future rate of snow shrinkage with rising temperatures. NH snow cover averages some 25 million km2 annually [25,26]. 82% of month-km2 coverage is during November through April. 25 million km2 is 2.5 times the 10 million km2 mean annual NH sea ice cover [27]. Estimated NH snow cover declined about 9%, about 2.2 million km2, from 1967 to 2018 [26]. Chen et al. [28] estimated that NH snow cover decreased by 890,000 km2 per decade for May to August over 1982 to 2013, but increased by 650,000 km2 per decade for November to February. Annual mean snow cover fell 9% over this period, as snow cover began earlier but also ended earlier: 1.91 days per decade [28]. These changes resulted in weakened snow radiative forcing of 0.12 (±0.003) W m-2 [28]. Chen estimated the NH snow timing feedback as 0.21 (±0.005) W m-2 K-1 in melting season, from 1982 to 2013 [28].

Future Snow Shrinkage

However, as GST warms further, annual mean snow cover will decline substantially with GST 5°C warmer and almost vanish with 10°. This study considers analog cities for snow cover in warmer places and analyzes data for them. It follows with three latitude and precipitation adjustments. The effects of changes in the timing of when snow is on the ground (Chen) are much smaller than from how many days snow is on the ground (see analog cities analysis, below). So, Chen’s analysis is of modest use for longer time horizons.

NH snow-covered area is not as concentrated near the pole as sea ice. Thus, sun angle leads to a larger effect by snow on Earth’s reflectivity. The mean latitude of northern snow cover, weighted over the year, is about 57°N [29], while the corresponding mean latitude of NH sea ice is 77 to 78°N. The sine of the mean sun angle (33°) on snow, 0.5454, is 2.52 times that for NH sea ice (12.5° and 0.2164). The area coverage (2.5) times the sun angle effect (2.52) suggests a cooling effect of NH snow cover (outside Greenland) about 6.3 times that for NH sea ice. [At high sun angles, water under ice is darker (~95% absorbed or 5% reflected when the sun is overhead, 0°) than rock, grass, shrubs, and trees under snow. This suggests a greater albedo contrast for losing sea ice than for losing snow. However, at the low sun angles that characterize snow latitudes, water reflects more sunlight (40% at 77° and 20% at 57°), leaving much less albedo contrast – with white snow or ice – than rocks and vegetation. So, no darkness adjustment is modeled in this study]. Using Hudson’s 2011 estimate [30] for Arctic sea ice (see below) of 0.6 W m-2 in future radiative forcing, compared to 0.1 to date for the NH sea ice’s current cooling effect, indicates that the current cooling effect of northern snow cover is about 6.3 times 0.6 W m-2 = 3.8 W m-2. This is 31 times the effect of snow cover timing changes, from Chen’s analysis.

To model evolution of future snow cover as the NH warms, analog locations are used for changes in snow cover’s cooling effect as Earth’s surface warms. This cross-sectional approach uses longitudinal transects: days of snow cover at different latitudes along roughly the same longitude. For the NH, in general (especially as adjusted for altitude and distance from the ocean), temperatures increase as one proceeds southward, while annual days of snow cover decrease. Three transects in the northern US and southern Canada are especially useful, because the increases in annual precipitation with warmer January temperatures somewhat approximate the 7% more water vapor in the air per 1°C of warming (see “In the Air” section for water vapor). The transects shown in Table 2 are (1) Winnipeg, Fargo, Sioux Falls, Omaha, Kansas City; (2) Toronto, Buffalo, Pittsburgh, Charleston WV, Knoxville; and (3) Lansing, Detroit, Cincinnati, Nashville. Pooled data from these 3 transects, shown at the bottom of Table 2, indicate 61% as many days as now with snow cover ≥ 1 inch [31] with 3°C local warming, 42% with 5°C, and 24% with 7°C. However, these degrees of local warming correspond to less GST warming, since Earth’s land surface has warmed faster than the sea surface and observed warming is generally greater as one proceeds from the equator toward the poles; [1,2,32] the gradient is 1.5 times the global mean for 44-64°N and 2.0 times for 64-90°N [32]. These latitude adjustments for local to global warming pair 61% as many snow cover days with 2°C GLST warming, 42% with 3°C, and 24% with 4°C. This translates to approximately a 19% decrease in days of snow cover per 1°C warming.

Table 2: Snow Cover Days for Transects with ~7% More Precipitation per °C. Annual Mean # of Days with ≥ 1 inch of Snow on Ground.

table 2

This study makes three adjustments to the 19%. First, the three transects feature precipitation increasing only 4.43% (1.58°C) per 1°C warming. This is 63% of the 7% increase in global precipitation per 1°C warming. So, warming may bring more snowfall than the analogs indicate directly. Therefore the 19% decrease in days of snow cover per 1°C warming of GLST is multiplied by 63%, for a preliminary 12% decrease in global snow cover for each 1°C GLST warming. Second, transects (4) Edmonton to Albuquerque and (5) Quebec to Wilmington NC, not shown, lack clear precipitation increases with warming. But they yield similar 62%, 42%, and 26% as many days of snow cover for 2, 3, and 4°C increases in GST. Since the global mean latitude of NH snow cover is about 57°, the southern Canada figure should be more globally representative than the 19% figure derived from the more southern US analysis. Use of Canadian cities only (Edmonton, Calgary, Winnipeg, Sault Ste. Marie, Toronto, and Quebec, with mean latitude 48.6°N) yields 73%, 58%, and 41% of current snow cover with roughly 2, 3, and 4°C warming. This translates to a 15% decrease in days of snow cover in southern Canada per 1°C warming of GLST. 63% of this, for the precipitation adjustment, yields 9.5% fewer days of snow cover per 1°C warming of GLST. Third, the southern Canada (48.6°N) figure of 9.5% warrants a further adjustment to represent an average Canadian and snow latitude (57°N). Multiplying by sin(48.6°)/sin(57°) yields 8.5%. The story is likely similar in Siberia, Russia, north China, and Scandinavia. So, final modeled snow cover decreases by 8.5% (not 19, 12 or 9.5%) of current amounts for each 1°C rise in GLST. In this way, modeled snow cover vanishes completely at 11.8°C warmer than 1880, similar to the Paleocene-Eocene Thermal Maximum (PETM) GSTs 55 Mya [3].

Ice

Six ice albedo changes are calculated separately: for NH and Antarctic (SH) sea ice, and for land ice in the GIS, WAIS, EAIS, and elsewhere (e.g., Himalayas). Ice loss in the latter four leads to SLR. This study considers each in turn.

Sea Ice

Arctic sea ice area has shown a shrinking trend since satellite coverage began in 1979. Annual minimum ice area fell 53% over the most recent 37 years [33]. However, annual minimum ice volume shrank faster, as the ice also thinned. Estimated annual minimum ice volume fell 73% over the same 37 years, including 51% in the most recent 10 years [34]. Trends in Arctic sea ice volume [34] are shown in Figure 4, with their corresponding R2, for four months. One set of trend lines (small dots) is based on data since 1980, while a second, steeper set (large dots) uses data since 2000. (Only four months are shown, since July ice volume is like November’s and June ice volume is like January’s). The graph suggests sea ice will vanish from the Arctic from June through December by 2050. Moreover, NH sea ice may vanish totally by 2085 in April, the minimum ice volume month. That is, current volume trends yield an ice-free Arctic Ocean about 2085.

fig 4

Figure 4: Arctic Sea Ice Volume by Month and Year, Past and Future.

Hudson estimated that loss of Arctic sea ice would increase radiative forcing in the Arctic by an amount equivalent to 0.7 W m-2, spread over the entire planet, of which 0.1 W m-2 had already occurred [30]. That leaves 0.6 W m-2 of radiative forcing still to come, as of 2011. This translates to 0.31°C warming yet to come (as of 2011) from NH sea ice loss. Trends in Antarctic sea ice are unclear. After three record high winter sea ice years in 2013-15, record low Antarctic sea ice was recorded in 2017-19 and 2020 is below average [27]. If GSTs rise enough, eventually Antarctic land ice and sea ice areas should shrink. Roughly 2/3 of Antarctic sea ice is associated with West Antarctica [35]. Therefore, 2/3 of modeled SH sea ice loss corresponds to WAIS ice volume loss and 1/3 to EAIS. However, to estimate sea ice area, change in estimated ice volume is raised to the 1.5 power (using the ratio of 3 dimensions of volume to 2 of area). This recognizes that sea ice area will diminish more quickly than the adjacent land ice volume of the far thicker WAIS (including the Antarctic Peninsula) and the EAIS.

Land Ice

Paleoclimate studies have estimated that global sea levels were 20 to 35 meters higher than today from 4.0 to 4.2 Mya [13,14]. This indicates that a large fraction of Earth’s polar ice had vanished then. Earth’s GST then was estimated to be 3.3 to 5.0°C above the 1951-80 mean, for CO2 levels of 357-405 ppm. Another study estimated that global sea levels were 25-40 meters higher than today’s from 14.1 to 14.5 Mya [11]. This suggests 5 meters more of SLR from vanished polar ice. The deep ocean then was estimated to be 5.6±1.0°C warmer than in 1951-80, in response to still higher CO2 levels of 430-465 ppm CO2 [11,12]. Analysis of sediment cores by Cook [20] shows that East Antarctic ice retreated hundreds of kilometers inland in that time period. Together, these data indicate large polar ice volume losses and SLR in response to temperatures expected before 2400. This tells us about total amounts, but not about rates of ice loss.

This study estimates the albedo effect of Antarctic ice loss as follows. The area covered by Antarctic land ice is 1.4 times the annual mean area covered by NH sea ice: 1.15 for the EAIS and 0.25 for the WAIS. The mean latitudes are not very different. Thus, the effect of total Antarctic land ice area loss on Earth’s albedo should be about 1.4 times that 0.7 Wm-2 calculated by Hudson for NH sea ice, or about 1.0 Wm-2. The model partitions this into 0.82 Wm-2 for the EAIS and 0.18 Wm-2 for the WAIS. Modeled ice mass loss proceeds more quickly (in % and GT) for the WAIS than for the EAIS. Shepherd et al. [36] calculated that Antarctica’s net ice volume loss rate almost doubled, from the period centered on 1996 to that on 2007. That came from the WAIS, with a compound ice mass loss of 12% per year from 1996 to 2007, as ice volume was estimated to grow slightly in the EAIS [36,37] over this period. From 1997 to 2012, Antarctic land ice loss tripled [36]. Since then, Antarctic land ice loss has continued to increase by a compound rate of 12% per year [37]. This study models Antarctic land ice losses over time using S-curves. The curve for the WAIS starts rising at 12% per year, consistent with the rate observed over the past 15 years, starting from 0.4 mm per year in 2010, and peaks in the 2100s. Except in CDR scenarios, remaining WAIS ice is negligible by 2400. Modeled EAIS ice loss increases from a base of 0.002 mm per year in 2010. It is under 0.1% in all scenarios until after 2100, peaks from 2145 to 2365 depending on scenario, and remains under 10% by 2400 in the three slowest-warming scenarios.

The GIS area is 17.4% of the annual average NH sea ice coverage [27,38], but Greenland experiences (on average) a higher sun angle than the Arctic Ocean. This suggests that total GIS ice loss could have an albedo effect of 0.174 * cos (72°)/cos (77.5°) = 0.248 times that of total NH sea ice loss. This is the initial albedo ratio in the model. The modeled GIS ice mass loss rate decreases from 12% per year too, based on Shepherd’s GIS findings for 1996 to 2017 [37]. Robinson’s [39] analysis indicated that the GIS cannot be sustained at temperatures warmer than 1.6°C above baseline. That threshold has already been exceeded locally for Greenland. So it is reasonable to expect near total ice loss in the GIS if temperatures stay high enough for long enough. Modeled GIS ice loss peaks in the 2100s. It exceeds 80% by 2400 in scenarios lacking CDR and is near total by then if fossil fuel use continues past 2050.

The albedo effects of land ice loss, as for Antarctic sea ice, are modeled as proportional to the 1.5 power of ice loss volume. This assumes that the relative area suffering ice loss will be more around the thin edges than where the ice is thickest, far from the edges. That is, modeled ice-coved area declines faster than ice volume for the GIS, WAIS, and EAIS. Ice loss from other glaciers, chiefly in Arctic islands, Canada, Alaska, Russia, and the Himalayas, is also modeled by S-curves. Modeled “other glaciers” ice volume loss in the 6 scenarios ranges from almost half to almost total, depending on the scenario. Corresponding SLR rise by 2400 ranges from 12 to 25 cm, 89% or more of it by 2100.

In the Air: Clouds and Water Vapor

As calculated by Equation (5), using 70 years without significant volcanic eruptions, GLST will rise about 0.37°C as human sulfur emissions are phased out. Clouds cover roughly half of Earth’s surface and reflect about 20% [40] of incoming solar radiation (341 W m–2 mean for Earth’s surface). This yields mean reflection of about 68 W m–2, or 20 times the combined warming effect of GHGs [41]. Thus, small changes in cloud cover can have large effects. Detecting cloud cover trends is difficult, so the error bar around estimates for forcing from cloud cover changes is large: 0.6±0.8 Wm–2K–1 [42]. This includes zero as a possibility. Nevertheless, the estimated cloud feedback is “likely positive”. Zelinka [42] estimates the total cloud effect at 0.46 (±0.26) W m–2K –1. This comprises 0.33 for less cloud cover area, 0.20 from more high-altitude ones and fewer low-altitude ones, -0.09 for increased opacity (thicker or darker clouds with warming), and 0.02 for other factors. His overall cloud feedback estimate is used for modeling the 6 scenarios shown in the Results section. This cloud effect applies both to albedo changes from less ice and snow and to relative changes in GHG (CO2) concentrations. It is already implicit in estimates for SO4 effects. 1°C warmer air contains 7% more water vapor, on average [43]. That increases radiative forcing by 1.5 W m–2 [43]. This feedback is 89% as much as from CO2 emitted from 1750 to 2011 [41]. Water vapor acts as a warming multiplier, whether from human GHG emissions, natural emissions, or albedo changes. The model treats water vapor and cloud feedbacks as multipliers. This is also done in Table 3 below.

Table 3: Observed GST Warming from Albedo Changes, 1975-2016.

table 3

Albedo Feedback Warming, 1975-2016, Informs Climate Sensitivities

Amplifying feedbacks, from albedo changes and natural carbon emissions, are more prominent in future warming than direct GHG effects. Albedo feedbacks to date, summarized in Table 3, produced an estimated 39% of GST warming from 1975 to 2016. This came chiefly from SO4 reductions, plus some from snow cover changes and Arctic sea ice loss, with their multipliers from added water vapor and cloud cover changes. On the top line of Table 3 below, the SO4 decrease, from 177.3 ppb in 1975 to 130.1 in 2016, is multiplied by 0.00393°C/ppb SO4 from Equation (5). On the second line, in the second column, Arctic sea ice loss is from Hudson [30], updated from 0.10 to 0.11 W m–2 to cover NH sea ice loss from 2010 to 2016. The snow cover timing change effect of 0.12 W m–2 over 1982-2013 is from Chen [28]. But the snow cover data is adjusted to 1975-2016, for another 0.08 W m-2 in snow timing forcing, using Chen’s formula for W m-2 per °C warming [28] and extra 0.36°C warming over 1975-82 plus 2013-16. The amount of the land ice area loss effect is based on SLR to date from the GIS, WAIS, and non-polar glaciers. It corresponds to about 10,000 km2, less than 0.1% of the land ice area.

For the third column of Table 3, cloud feedback is taken from Zelinka [42] as 0.46 W m–2K–1. Water-vapor feedback is taken from Wadhams [43], as 1.5 W m–2K–1. The combined cloud and water-vapor feedback of 1.96 W m–2K–1 modeled here amounts to 68.8% of the 2.85 total forcing from GHGs as of 2011 [41]. Multiplying column 2 by 68.8% yields the numbers in column 3. Conversion to ∆°C in column 4 divides the 0.774°C warming from 1880 to 2011 [2] by the total forcing of 2.85 W m-2 from 1880 to 2011 [41]. This yields a conversion factor of 0.2716°C W-1m2, applied to the sum of columns 2 and 3, to calculate column 4. Error bars are shown in column 5. In summary, estimated GST warming over 1975-2016 from albedo changes, both direct (from sulfate, ice, and snow changes) and indirect (from cloud and water-vapor changes due to direct ones), totals 0.330°C. Total GST warming then was 0.839°C [2]. (This is more than the 0.774°C (2) warming from 1880 to 2011, because the increase from 2011 to 2016 was greater than the increase from 1880 to 1975.) So, the ∆GST estimated for albedo changes over 1975-2016, direct and indirect, comes to 0.330/0.839 = 39.3% of the observed warming.

1975-2016 Warming Not from Albedo Effects

The remaining 0.509°C warming over 1975-2016 corresponds to an atmospheric CO2 increase from 331 to 404 ppm [44], or 22%. This 0.509°C warming is attributed in the model to CO2, consistent with Equations (3) and (1), using the simplification that the sum total effect of other GHGs changes as the same rate as for CO2. It includes feedbacks from H2O vapor and cloud cover changes, estimated, per above, as 0.686/(1+1.686) of 0.509°C, which is 0.207°C or 24.7% of the total 0.839°C warming over 1975-2016. This leaves 0.302°C warming for the estimated direct effect of CO2 and other factors, including other GHGs and factors not modeled, such as black carbon and vegetation changes, over this period.

Partitioning Climate Sensitivity

With the 22% increase in CO2 over 1975-2016, we can estimate the change due to a doubling of CO2 by noting that 1.22 [= 404/331] raised to the power 3.5 yields 2.0. This suggests that a doubling of CO2 levels – apart from surface albedo changes and their feedbacks – leads to about 3.5 times 0.509°C = 1.78°C of warming due to CO2 (and other GHGs and other factors, with their H2O and cloud feedbacks), starting from a range of 331-404 ppm CO2. In the model, for projected temperature changes for a particular year, 0.509°C is multiplied by the natural logarithm of (the CO2 concentration/331 ppm in 1975) and divided by the natural logarithm of (404 ppm/331 ppm), that is divided by 0.1993. This yields estimated warming due to CO2 (plus, implicitly, other non-H2O GHGs) in any particular year, again apart from surface albedo changes and their feedbacks, including the factors noted that are not modelled in this study.

Using Equation (3), warming associated with doubled CO2 over the past 14.5 million years is 11.807 x ln(2.00), or 8.184°C per CO2 doubling. The difference between 8.18°C and 1.78°C, from CO2 and non-H2O GHGs, is 6.40°C. This 6.40°C climate sensitivity includes the effect of albedo changes and the consequent H2O vapor concentration. Loss of tropospheric SO4 and Arctic sea ice are the first of these to occur, with immediate water vapor and cloud feedbacks. Loss of snow and Antarctic sea ice follow over centuries to decades. Loss of much land ice, especially where grounded above sea level, happens more slowly.

Stated another way, there are two climate sensitivities: one for the direct effect of GHGs and one for amplifying feedbacks, led by albedo changes. The first is estimated as 1.8°C. The second is estimated as 6.4°C in epochs, like ours, when snow and ice are abundant. In periods with little or no ice and snow, this latter sensitivity shrinks to near zero, except for clouds. As a result, climate is much more stable to perturbations (notably cyclic changes in Earth’s tilt and orbit) when there is little snow or ice. However, climate is subject to wide temperature swings when there is lots of snow and ice (notably the past 2 million years, as seen in Figure 1).

In the Oceans

Ocean Heat Gain: In 2011, Hansen [7] estimated that Earth is absorbing 0.65 Wm-2 more than it emits. As noted above, ocean heat gain averaged 4 ZJ per year over 1967 to 1990, 7 over 1991-2005, and 10 over 2006-16. Ocean heat gain accelerated while GSTs increased. Therefore, ocean heat gain and Earth’s energy imbalance seem likely to continue rising as GSTs increase. This study models the situation that way. Oceans would need to warm up enough to regain thermal equilibrium with the air above. While oceans are gaining heat (now ~ 2 times cumulative human energy use every 3 years), they are out of equilibrium. The ocean thermohaline circuit takes about 1,000 years. So, if human GHG emissions ended today, this study assumes that it could take Earth’s oceans 1,000 years to thermally re-equilibrate heat with the atmosphere. The model spreads the bulk of that over 400 years, in an exponential decay shape. The rate peaks during 2130 to 2170, depending on the scenario. The modeled effect is about 5% of total GST warming. Ocean thermal expansion (OTE), currently about 0.8 mm/year [5], is another factor in SLR. Changes to its future values are modeled as proportional to future temperature change.

Land Ice Mass Loss, Its Albedo Effect, and Sea Level Rise: Modeled SLR derives mostly from modeled ice sheet losses. Their S-curves were introduced above. The amount and rate parameters are informed by past SLR. Sea levels have varied by almost 200 meters over the past 65 My. They were almost 125 meters lower than now during recent Ice Ages [3]. SLR reached some 70 meters higher in ice-free warm periods more than 10 Mya, especially more than 35 Mya [3]. From Figure 1, Earth was largely ice-free when deep ocean temperature (DOT) was 7°C or more, for SLR of about 73 meters from current levels, when DOT is < 2°C. This yields a SLR estimate of 15 meters/°C of DOT in warm eras. Over the most recent 110-120 ky, 110 meters of SLR is associated with 4 to 6°C GST warming (Figure 2), or 19-28 meters/°C GST in a cold era. The 15:28 warm/cold era ratio for SLR rate shows that the amount of remaining ice is a key SLR variable. However, this study projects only 1.5 to 4 meters rate of SLR by 2400 per °C of GST warming, but still rising. The WAIS and GIS together hold 10-12 meters of SLR [15,16]. So, 25-40 meter SLR during 14.1-14.5 Mya suggests that the EAIS lost about 1/3 to 1/2 of its current ice volume (20 to 30 meters of SLR, out of almost 60 today in the EAIS [45]) when CO2 levels were last at 430-465 ppm and DOTs were 5.6±1.0°C [11,12]. This is consistent with this study’s two scenarios with human CO2 emissions after 2050 and even 2100: 13 and 21 meters of SLR from the EAIS by 2400, with Δ GLSTs of 8.2 and 9.4°C. DeConto [19] suggested that sections of the EAIS grounded below sea level would lose all ice if we continue emissions at the current rate, for 13.6 or even 15 meters of SLR by 2500. This model’s two scenarios with intermediate GLST rise yield SLR closest to his projections. SLR is even higher in the two warmest scenarios. Modeled SLR rates are informed by the most recent 19,000 years of data ([46,47], chart by Robert A. Rohde). They include a SLR rate of 3 meters/century during Meltwater Pulse 1A for 8 centuries around 14 ky ago. They also include 1.5 meters/century over the 70 centuries from 15 kya to 8 kya. The DOT rose 3.3°C over 10,000 years, for an average rate of 0.033°C per century. However, the current SST warming rate is 2.0°C per century [1,2], about 60 times as great. Although only 33-40% as much ice (73 meters SLR/(73+125)) is left to melt, this suggests that rates of SLR will be substantially higher, at current rates of warming, than the 1.5 to 3 meters per century coming out of the most recent ice age. In four scenarios without CDR, mean rates of modeled SLR from 2100 to 2400 range from 4 to 11 meters per century.

Summary of Factors in Warming to 2400

Table 4 summarizes the expected future warming effects from feedbacks (to 2400), based on the analyses above.

Table 4: Projected GST Warming from Feedbacks, to 2400.

table 4

The 3.5°C warming indicated, added to 1.1°C warming since 1880, or 4.6°C, is 0.5°C less than the 5.1°C warming based on Equation (4) from the paleoclimate analysis. This gap suggests four overlapping possibilities. First, underestimations (perhaps sea ice and clouds) may exceed overestimations (perhaps snow) for the processes shown in Table 4. Underestimation of cloud feedbacks, and their consequent warming, is quite possible. Using Zelinka’s 0.46 Wm–2K–1 in this study, instead of the IPCC central estimate of 0.6, is one possibility. Moreover, recent research suggests that cloud feedbacks may be appreciably stronger than 0.6 Wm–2K–1 [48]. Second, change in the eight factors not modelled (black carbon, vegetation and land use, ocean and air circulation, Earth’s orbit and tilt, and solar output) may provide feedbacks that, on balance, are more warming than cooling. Third, temperatures used here for 4 and 14 Mya may be overestimated or should not be used unadjusted. Notably, the joining of North and South America about 3 Mya rearranged ocean circulation and may have resulted in cooling that led to ice periodically covering much of North America [49]. Globally, Figure 1 above suggests this cooling effect may be 1.0-1.6°C. In contrast, solar output increases as our sun ages, by 7% per billion years [50], so that solar forcing is now 1.4 W m–2 more than 14 Mya and 0.4 more than 4 Mya. A brighter sun now indicates that, for the same GHG levels and albedo levels, GST would be 0.7°C warmer than it would have been 14 Mya and 0.2°C warmer than 4 Mya. Fourth, nothing (net) may be amiss. Underestimated warming (perhaps permafrost, clouds, sea ice, black carbon) may balance overestimated warming (perhaps snow, land ice, vegetation). The gap would then be due to a lower albedo climate sensitivity than 6.4°C, as discussed above using data for 1975-2016, because all sea ice and much snow vanish by 2400.

Natural Carbon Emissions

Permafrost: One estimate of the amount of carbon stored in permafrost is 1,894 GT of carbon [51]. This is about 4 x carbon that humans have emitted by burning fossil fuels. It is also 2 x as much as in Earth’s atmosphere. More permafrost may lie under Antarctic ice and the GIS. DeConto [52] proposed that the PETM’s large carbon and temperature (5-6°C) excursions 55 Mya are explained by “orbitally triggered decomposition of soil organic carbon in circum-Arctic and Antarctic terrestrial permafrost. This massive carbon reservoir had the potential to repeatedly release thousands of [GT] of carbon to the atmosphere-ocean system”. Permafrost area in the Northern Hemisphere shrank 7% from 1900 to 2000 [53]. It may shrink 75-88% more by 2100 [54]. Carbon emissions from permafrost are expected to accelerate, as the ground in which they are embedded warms up. In general, near-surface air temperatures have been warming twice as fast in the Arctic as across the globe as a whole [32]. More research is needed to estimate rates of permafrost warming at depth and consequent carbon emissions. Already in 2010, Arctic permafrost emitted about as carbon as all US vehicles [55]. Part of the carbon emerges as CH4, where surface water prevents carbon under it being oxidized. That CH4 changes to CO2 in the air over several years. This study accounts for the effects of CO2 derived from permafrost. MacDougall et al. estimated that thawing permafrost can add up to ~100 ppm of CO2 to the air by 2100 and up to 300 more by 2300, depending on the four RCP emissions scenarios [56]. This is 200 GT of carbon by 2100 plus 600 GT more by 2300. The direct driver of such emissions is local temperatures near the air-soil interface, not human carbon emissions. Since warming is driven not just by emissions, but also by albedo changes and their multipliers, permafrost carbon losses from thawing may proceed faster than MacDougall estimated. Moreover, MacDougall estimated only 1,000 GT of carbon in permafrost [56], less than more recent estimates. On the other hand, a larger fraction of carbon may stay in permafrost soil in than MacDougall assumed, leaving deep soil rich in carbon, similar to that left by “recent” glaciers in Iowa.

Other Natural Carbon Emissions

Seabed CH4 hydrates may hold a similar amount of carbon to permafrost or somewhat less, but the total amount is very difficult to measure. By 2011, subsea CH4 hydrates were releasing 20-30% as much carbon as permafrost was [57]. This all suggests that eventual carbon emissions from permafrost and CH4 hydrates may be half to four times what MacDougall estimated. Also, the earlier portion of those emissions may happen faster than MacDougall estimated. In all, this study’s modeled permafrost carbon emissions range from 35 to 70 ppm CO2 by 2100 and from 54 to 441 ppm CO2 by 2400, depending on the scenario. As stated earlier, this model simply assumes that other natural carbon reservoirs will add half as much carbon to the air as permafrost does, on the same time path. These sources include outgassing from soils now unfrozen year-round, the warming upper ocean, seabed CH4 hydrates, and any net decrease in worldwide biomass.

Results

The Six Scenarios

  1. “2035 Peak”. Fossil-fuel emissions are reduced 94% by 2100, from a peak about 2035, and phased out entirely by 2160. Phase-out accelerates to 2070, when CO2 emissions are 25% of 2017 levels, then decelerates. Permafrost carbon emissions overtake human ones about 2080. Natural CO2 removal (CDR) mostly further acidifies the oceans. But it includes 1 GT per year of CO2 by rock weathering.
  2. “2015 Peak”. Fossil-fuel emissions are reduced 95% by 2100, from a peak about 2015, and phased out entirely by 2140. Phase-out accelerates to 2060, when CO2 emissions are 40% of 2017 levels, then decelerates. Compared to a 2035 peak, natural carbon emissions are 25% lower and natural CDR is similar.
  3. “x Fossil Fuels by 2050”, or “x FF 2050”. Peak is about 2015, but emissions are cut in half by 2040 and end by 2050. Natural CDR is the same as for the 2015 Peak, but is lower to 2050, since human CO2 emissions are less. This path has a higher GST from 2025 to 2084, while warming sooner from less SO4 outweighs less warming from GHGs.
  4. “Cold Turkey”. Emissions end at once after 2015. Natural CDR is only by rock weathering, since no new human CO2 emissions push carbon into the ocean. After 2060, cooling from ending CO2 emissions earlier outweighs warming from ending SO2
  5. “x FF 2050, CDR”. Emissions are the same as for “x FF 2050”, as is natural CDR. But human CDR ramps up in an S-curve, from less than 1% of emissions in 2015 to 25% of 2015 emissions over the 2055 to 2085 period. Then they ramp down in a reverse S-curve, to current levels in 2155 and 0 by 2200.
  6. “x FF 2050, 2xCDR” is like “x FF 2050, CDR”, but CDR ramps up to 52% of 2015 emissions over 2070 to 2100. From 2090, it ramps down to current levels in 2155 and 0 by 2190. CDR = 71% of CO2 emissions to 2017 or 229% of soil carbon lost since farming began [58], almost enough to cut CO2 in the air to 313 ppm, for 2°C warming.

Projections to 2400

The results for the six scenarios shown in Figure 5 spread ocean warming over 1,000 years, more than half of it by 2400. They use the factors discussed above for sea level, water vapor, and albedo effects of reduced SO4, snow, ice, and clouds. Permafrost emissions are based on MacDougall’s work, adjusted upward for a larger amount of permafrost, but also downward and to a greater degree, assuming much of the permafrost carbon stays as carbon-rich soil as in Iowa. As first stated in the introduction to Feedback Pathways, the model sets other natural carbon emissions to half of permafrost emissions. At 2100, net human CO2 emissions range from -15 GT/year to +2 GT/year, depending on the scenario. By 2100, CO2 concentrations range from 350 to 570 ppm, GLST warming from 2.9 to 4.5°C, and SLR from 1.6 to 2.5 meters. CO2 levels after 2100 are determined mostly by natural carbon emissions, driven ultimately by GST changes, shown in the lower left panel of Figure 5. They come from permafrost, CH4 hydrates, unfrozen soils, warming upper ocean, and biomass loss.

fig 5

Figure 5: Scenarios for CO2 Emissions and Levels, Temperatures and Sea Level.

Comparing temperatures to CO2 levels allows estimates of long-run climate sensitivity to doubled CO2. Sensitivity is estimated as ln(2)/ln(ppm/280) * ∆T. By scenario, this yields > 4.61° (probably ~5.13° many decades after 2400) for 2035 Peak, > 4.68° (probably ~5.15°) for 2015 Peak, > 5.22° (probably 5.26°) for “x FF by 2050”, and 8.07° for Cold Turkey. Sensitivities of 5.13, 5.15 and 5.26° are much less than the 8.18° derived from the Vostok ice core. This embodies the statement above, in the Partitioning Climate Sensitivity section, that in periods with little or no ice and snow [here, ∆T of 7°C or more – the 2035 and 2015 Peaks and x FF by 2050 scenarios], this albedo-related sensitivity shrinks to 3.3-3.4°. Meanwhile, the Cold Turkey scenario (with a good bit more snow and a little more ice) matches well the relationship from the ice core (and validated to 465 ppm CO2, in the range for Cold Turkey: 4 and 14 Mya). Another perspective is the climate sensitivity starting from a base not of 280 ppm CO2, but from a higher level: 415 ppm, the current level and the 2400 level in the Cold Turkey case. Doubling CO2 from 415 to 830 ppm, according to the calculations underlying Figure 5, yields a temperature in 2400 between the x FF by 2050 and the 2015 Peak cases, about 7.6°C and rising, to perhaps 8.0°C after 1-2 centuries. This yields a climate sensitivity of 8.0 – 4.9 = 3.1°C in the 415-830 ppm range. The GHG portion of that remains near 1.8° (see Partitioning Climate Sensitivity above). But the albedo feedbacks portion shrinks further, from 6.4°, past 3.3° to 1.3°, as thin ice and most snow are gone, as noted above, plus all SO4 from fossil fuels, leaving mostly thick ice and feedbacks from clouds and water vapor.

Table 5 summarizes estimated temperatures effects of 16 factors in the 6 scenarios to 2400. Peaking emissions now instead of in 2035 can keep eventual warming 1.1°C lower. Phasing out fossil fuels by 2050 gains another 1.2°C relatively cooler. Ending fossil fuel use immediately gains another 2.2°C. Also removing 2/3 of CO2 emissions to date gains another 2.4°C relatively cooler. Eventual warming in the higher emissions scenarios is a good bit lower than what would be inferred by using the 8.2°C climate sensitivity based on an epoch rich in ice and snow. This is because the albedo portion of that climate sensitivity (currently 6.4°) is greatly reduced as ice and snow disappear. More human carbon emissions (the first three scenarios especially) warm GSTs further, especially from less snow and cloud cover, more water vapor, and more natural carbon emissions. These in turn accelerate ice loss. All further amplify warming.

Table 5: Factors in Projected Global Surface Warming, 2010-2400 (°C).

table 5

Carbon release from permafrost and other reservoirs is lower in scenarios where GSTs do not rise as much. GSTs grow to the end of the study period, 2400, except for the CDR cases. Over 99% of warming after 2100 is due to amplifying feedbacks from human emissions during 1750-2100. These feedbacks amount to 1.5 to 5°C after 2100, in the scenarios without CDR. Projected mean warming rates with continued human emissions are similar to current rates of 2.5°C per century over 2000-2020 [2]. Over the 21st century, they range from 62 to 127% of the rate over the most recent 20 years. The mean across the 6 scenarios is 100%, higher in the 3 warmest scenarios. Warming slows in later centuries. The key to peak warming rates is disappearing northern sea ice and human SO4, mostly by 2050. Peak warming rates per decade in all 6 scenarios occur this century. They are fastest not for the 2035 Peak scenario (0.38°C), but for Cold Turkey (.80°C when our SO2 emissions stop suddenly) and xFF2050 (0.48°C, as SO2 emissions phase out by 2050). Due to SO4 changes, peak warming in the x FF 2050 scenario, from 2030 to 2060, is 80% faster than over the past 20 years, while for the 2035 Peak, it is only 40% faster. Projected SLR from ocean thermal expansion (OTE) by 2400 ranges from 3.9 meters in the 2035 Peak scenario to 1.5 meters in the xFF’50 2xCDR case. The maximum rate of projected SLR by 2400 is 15 meters from 2300 to 2400, in the 2035 Peak scenario. That is 5 times the peak 8-century rate 14 kya. However, the mean SLR rate over 2010-2400 is less than the historical 3 meters per century (from 14 kya) in the CDR scenarios and barely faster for Cold Turkey. The rate of SLR peaks from 2130 to 2360 for the 4 scenarios without CDR. In the two CDR scenarios, projected SLR comes mostly from the GIS, OTE, and the WAIS. But the EAIS is the biggest contributor in the three fastest warming scenarios.

Perspectives

The results show that the GST is far from equilibrium; barely more than 20% of 5.12°C warming to equilibrium. However, the feedback processes that warm Earth’s climate to equilibrium will be mostly complete by 2400. Some snow melting will continue. So will melting more East Antarctic and (in some scenarios) Greenland ice, natural carbon emissions, cloud cover and water vapor feedbacks, plus warming the deep ocean. But all of these are tapering off by 2400 in all scenarios. Two benchmarks are useful to consider: 2°C and 5°C above 1880 levels. The 2015 Paris climate pact’s target is for GST warming not to exceed 2°C. However, projected GST warming exceeds 2°C by 2047 in all six scenarios. Focus on GLSTs recognizes that people live on land. Projected GLST warming exceeds 2°C by 2033 in all six scenarios. 5° is the greatest warming specifically considered in Britain’s Stern Review in 2006 [59]. For just 4°, Stern suggested a 15-35% drop in crop yields in Africa, while parts of Australia cease agriculture altogether [59]. Rind et al. projected that the major U.S. crop yields would fall 30% with 4.2°C warming and 50% with 4.5°C warming [60]. According to Stern, 5° warming would disrupt marine ecosystems, while more than 5° would lead to major disruption and large-scale population movements that could be catastrophic [59]. Projected GLST warming passes 5°C in 2117, 2131, and 2153 for the three warmest scenarios. But it never does in the other three. With 5° GLST warming, Kansas, until recently the “breadbasket of the world”, would become as hot in summer as Las Vegas is now. Most of the U.S. warms faster than Earth’s land surface in general [32]. Parts of the U.S. Southeast, including most of Georgia, become that hot, but much more humid. Effects would be similar elsewhere.

Discussion

Climate models need to account for all these factors and their interactions. They should also reproduce conditions for previous eras when Earth had this much CO2 in the air, using current levels of CO2 and other GHGs. This study may underestimate warming due to permafrost and other natural emissions. It may also overestimate how fast seas will rise in a much warmer world. Ice grounded below sea level (by area, ~2/3 of the WAIS, 2/5 of the EAIS, and 1/6 of the GIS) can melt quickly (decades to centuries). But other ice can take many centuries or millennia to melt. Continued research is needed, including separate treatment of ice grounded below sea level or not. This study’s simplifying assumptions, that lump other GHGs with CO2 and other natural carbon emissions proportionately with permafrost, could be improved with modeling for the individual factors lumped here. More research is needed to better quantify the 12 factors modeled (Table 5) and the four modeled only as a multiplier (line 10 in Table 5). For example, producing a better estimate for snow cover, similar to Hudson’s for Arctic sea ice, would be useful. So would other projections, besides MacDougall’s, of permafrost emissions to 2400. More work on other natural emissions and the albedo effects of clouds with warming would be useful.

This analysis demonstrates that reducing CO2 emissions rapidly to zero will be woefully insufficient to keep GST less than 2°C above 1750 or 1880 levels. Policies and decisions which assume that merely ending emissions will be enough will be too little, too late: catastrophic. Lag effects, mostly from albedo changes, will dominate future warming for centuries. Absent CDR, civilization degrades, as food supplies fall steeply and human population shrinks dramatically. More emissions, absent CDR, will lead to the collapse of civilization and shrink population still more, even to a small remnant.

Earth’s remaining carbon budget to hold warming to 2°C requires removing more than 70% of our CO2 emissions to date, any future emissions, and all our CH4 emissions. Removing tens of GT of CO2 per year will be required to return GST warming to 2°C or less. CDR must be scaled up rapidly, while CO2 emissions are rapidly reduced to almost zero, to achieve negative net emissions before 2050. CDR should continue strong thereafter.

The leading economists in the USA and the world say that the most efficient policy to cut CO2 emissions is to enact a worldwide price on them [61]. It should start at a modest fraction of damages, but rise briskly for years thereafter, to the rising marginal damage rate. Carbon fee and dividend would gain political support and protect low-income people. Restoring GST to 0° to 0.5°C above 1880 levels calls for creativity and dedication to CDR. Restoring the healthy climate on which civilization was built is a worthwhile goal. We, our parents and our grandparents enjoyed it. A CO2 removal price should be enacted, equal to the CO2 emission price. CDR might be paid for at first by a carbon tax, then later by a climate defense budget, as CO2 emissions wind down.

Over 1-4 decades of research and scaling up, CDR technology prices may drop far. Sale of products using waste CO2, such as concrete, may make the transition easier. CDR techniques are at various stages of development and prices. Climate Advisers provides one 2018 summary for eight CDR approaches, including for each: potential GT CO2 removed per year, mean US$/ton CO2, readiness, and co-benefits [62]. The commonest biological CDR method now is organic farming, in particular no-till and cover cropping. Others include several methods of fertilizing or farming the ocean; planting trees; biochar; fast-rotation grazing; and bioenergy with CO2 capture. Non-biological ones include direct air capture with CO2 storage underground in carbonate-poor rocks such as basalts. Another increases surface area of such rocks, by grinding them to gravel, or dust to spread from airplanes. They react with weak carbonic acid in rain. Another adds small carbonate-poor gravel to agricultural soil.

CH4 removal should be a priority, to quickly drive CH4 levels down to 1880 levels. With a half-life of roughly 7 years in Earth’s atmosphere, CH4 levels might be cut back that much in 30 years. It could happen by ending leaks from fossil fuel extraction and distribution, untapped landfills, cattle not fed Asparagopsis taxiformis, and flooding rice paddies. Solar radiation management (SRM) might play an important supporting role. Due to loss of Arctic sea ice and human SO4, even removing all human GHGs (scenario not shown) will likely not bring GLST back below 2°C by 2400. SRM could offset these two soonest major albedo changes in coming decades. The best known SRM techniques are (1) putting SO4 or calcites in the stratosphere and (2) refreezing the Arctic Ocean. Marine cloud brightening could play a role. SRM cannot substitute for ending our CO2 emissions or for vast CDR, both of them soon. We may need all three approaches working together.

In summary, the paleoclimate record shows that today’s CO2 level entails GST roughly 5.1°C warmer than 1880. Most of the increase from today’s GST will be due to amplification by albedo changes and other factors. Warming gets much worse with continued emissions. Amplifying feedbacks will add more GHGs to the air, even if we end our GHG emissions now. Further GHGs will warm Earth’s surface, oceans and air even more, in some cases much more. The impacts will be many, from steeply reduced crop yields (and widespread crop failures) and many places too hot to survive sometimes, to widespread civil wars, billions of refugees, and many meters of SLR. Decarbonization of civilization by 2050 is required, but far from enough. Massive CO2 removal is required as soon as possible, perhaps supplemented by decades of SRM, all enabled by a rising price on CO2.

List of Acronyms

List of Acro

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Factors Influencing the Adoption of Cocoa Agroforestry Systems in Mitigating Climate Change in Ghana: The Case of Sefwi Wiawso in Western Region

Introduction

Climate change is having great impact on agricultural productivity worldwide. Agriculture is strongly influenced by weather and climate [1,2]. Climate change and variability adversely affect environmental resources such as soil and water upon which agricultural production depends, which poses a serious threat to sustainable agricultural production [2]. In Ghana climate variability and change is expected to have an adversely effect on the agriculture sector. According to the NIC, (2009) by 2030 temperature are projected to rise by 0.5 °C. This situation would result in fewer rainy days and more extreme weather conditions like prolonged droughts. The impacts of a changing climate will have direct and indirect effects on global and domestic food systems [3,4]. Rioux [5] reported that climate change has affected yields in food crop production in many Africa countries. If the issues of climate change and variability are not addressed incomes and food security of rural households in Ghana would be undermined because there would be increased incidence of diseases and pest as well as prolonged variable rainfall patterns.

Cocoa production employs over 15 million people worldwide with over 10.5 million workers in West Africa [6]. Cocoa, in addition to cereals and other root and tuber  crops  contribute  largely  to  food security in Ghana. In Ghana cocoa production is an essential component of  rural  livelihoods  and  its  cultivation  is  considered a ‘way of life’ in many production communities [7]. The cocoa sub sector cocoa employs about 800,000 farm families spread across the cocoa growing regions of Ghana and generating about $2 billion in foreign exchange annually [8,9]. The expansion of cocoa production is replacing substantial areas of primary forest. It’s of no surprise that the total area under cocoa cultivation increased by 50,000 hectares between 2012 and 2013 and there is no indication that the rate is slowing down. According to Anim Kwapong et al. [10] the government of Ghana recognizes that climate change is already negatively affecting Ghana’s cocoa sector in myriad ways and that, it is likely to continue hampering Ghana’s environmental and socio-economic prospects in the coming decades. Cocoa agroforestry system has been identified as is an important strategy that can ameliorate climate change [11].

This system can play a dual role of mitigation and adaptation, which makes it one of the best responses to climate change. It is noted that agroforestry has multi-functional purposes which makes it one of  the most promising strategies for climate change adaptation [11,12]. The use of trees and shrubs in agricultural systems help to tackle the triple challenge of securing food security, mitigation and reducing the vulnerability and increasing the adaptability of agricultural systems to climate change [13,14]. With this view, serious attention must be given to cocoa agroforestry which is capable of reducing temperatures and enhancing the growing of cocoa thus sustaining livelihood of many households in this climate changing pattern. According to previous studies [11,13,15] agroforestry as an adaptation strategy could sustain agricultural production and enhance farmers’ ability to improve livelihoods and will minimize the impacts of climate change which include drought, variable rainfall and extreme temperatures. Agroforestry as a forest-based system plays a significant role in conserving existing carbons, thereby limiting carbon emissions and also absorbing carbons that are released into the atmosphere [16]. Nair [17] also indicated that agroforestry has received international attention as an effective strategy for carbon sequestration and greenhouse mitigation. Cocoa agroforestry can increase farmers’ resilience and position them strategically to adapt to the impacts of a changing climate. This system of cocoa production can be very useful because it generates quite substantial benefits on arable lands in diverse ways; trees in agricultural fields improve soil fertility through control of erosion, improve nitrogen content of the soil and increase organic matter of the soil [18,19]. Agroforestry can also transform degraded lands into productive agricultural lands and improves productive capacities of soils [18]. Although agroforestry is not new in Ghana, it is quite optimistic that effective adoption to climate change will contribute towards the achievement of sustainable development and to a large extent, the attainment of the Sustainable Development Goals (SDGs). Despite the immeasurable benefits of cocoa agroforestry system, adoption is not widespread and for that matter success stories are found in isolated cocoa farming areas among few adapters of cocoa agroforestry system initiatives. Aidoo and Fromm [20] report that although cocoa farmers are aware about sustainability issues, they hardly adopt sustainable production practices. It is quite not always the case that policies are implemented as they were intended and so the need to assess farmers’ perspectives on cocoa agroforestry adoption and implementation especially when climate change has become a serious constraint to cocoa production in Ghana. Traditional coping mechanisms to the impact of climate change in the Western Region of Ghana include mixed cropping, non-farm activities and traditional agroforestry practices by some individual cocoa farmers. However, non-shade cocoa production systems, bush burning, slash and burn farming methods expose the cocoa communities to further impacts of climate change. This calls for swift attention from all, especially cocoa farmers in the study communities to tackle the problem. Despite the economic, environmental and sustainable cocoa production potential via agroforestry systems, farmers have not adopted cocoa agroforestry practices entirely especially in Sefwi Wiawso District. Understanding cocoa farmers decision making processes in ensuring sustainable food supply and cocoa yield in cocoa agroforestry system is critical. Research frontiers in cocoa agroforestry systems need to be identified and better understand barriers to adoption and the development of strategies to support cocoa agroforestry that enhance food security in climate changing conditions. The objectives of this study are therefore to empirically assess the factors that affect farmers’ decision to adopt cocoa agroforestry systems and determine cocoa farmers’ perception on cocoa agroforestry as an adaptation strategy to climate change.

Methodology

The study was conducted at Sefwi Wiawso in the Western and region of Ghana. The district lies within latitudes 6º 00“and 6º 30 North and Longitudes 2º 15‟ and 2º 45 West. The District covers an area of about 2,634 square kilometers. The detailed hydrometeorological characteristics of the study area are provided in Table 1.

Table 1: Hydrometeorological characteristics of the study area.

Characteristics

Levels

Mean temperature

Maximum: 33°C Minimum: 26°C

Climate

Tropical rainforest

Average humidity

Dry season: 50-75%
Rainy season: 85-90%

Average rainfall

1500-1800 mm

Topography

Undulating

Soil condition

Loamy

Average elevation

206 m

A stratified random sampling technique was employed in the selection of the 300 cocoa farmers interviewed for the study. In the first stage, Western Region was purposively selected due to the fact that apart from being one of the highest cocoa producing regions    in Ghana, it is one of the regions which has experienced significant impact as a result of climate change. In the second stage, Sefwi Wiawso was randomly selected. In the third stage, five communities were randomly selected. In the final stage 60 cocoa farmers were randomly selected from each village. Primary data were employed in the study. The primary data consisted of qualitative data and household survey interviews. Specifically, the primary data were collected through focus group discussions (FGD), stakeholder interviews, and field observations. The household survey interviews employed both open- ended and close ended survey instruments.

To examine the factors that influence a household’s decision to participate in agroforestry a logistic regression model was employed.

The model was specified as:

ESCC-2-1-202-e001

Where: i = 1, 2, 3………., k are the observations, α= constant. β = the regression parameter to be estimated. βX= linear combination of independent variables.  Zi= the log odds of choice for the  ithobservation. Pi= the probability of observing
a specific outcome of the dependent variable (adoption). Xn = nth explanatory observation. u = the error term.

Results and Discussion

The gender composition of the cocoa farmers among revealed that 81.5 percent of the respondent are males with 19.5 percent been females. This indicates that cocoa production is a male dominated occupation in the study area. In Ghana cocoa production is considered a male job but this is not the situation at the study sites because both women and men play a critical role in the production cycle. Within the last 30 years, cocoa farmers observed some impacts of climate change in the study communities, information gather from the cocoa farmers showed that there has been varying pattern in rainfall and sunshine. With regards to drought, overwhelming 98 percent of cocoa farmers reported the occurrence of drought in the study area and linked it to climate change. The pattern of rainfall distribution has changed as reported from the study. The study reported high level of windstorm, high incidence of flooding and frequent occurrences of pests and disease on their cocoa farms in recent time. These are attributed to climate change. Frequent felling of trees, non-shade cocoa production systems, wood harvesting for charcoal and firewood and bush burning among others were mention as some course of changing climate in the farming communities. About two thirds of the farmers reported unplanned trees harvesting as a major cause for variable rainfall thus climate change. This suggest that majority of farmers are aware of some of the causes of climate change in the study area. About 58 percent of cocoa farmers are using doing the non-shade cocoa production system. This result confirms a report [21], indicating that high proportion of Ghana’s cocoa is grown in full sun at the expense of primary or secondary forest conversion. A study [22] reported that shaded tree densities, and average number of tree species per hectare vary according to cultural tradition and ethnic group, age of farms, proximity to markets, and intensity of farming, this situation is similar to that of the study area after personal interaction with the cocoa farmers. This current trend of no shade is not only common in Ghana but other cocoa growing countries like Cote d’Ivoire, Malaysia, Indonesia and Ecuador. A study [23] in Ecuador reported that half of the new cocoa plantations are now full-sun and are from high-yielding variety. A study [24] also revealed that in Sulawesi cocoa farmers are switching from long-fallow shifting cultivation of food crops to intensive full-sun cocoa. This current trend of cocoa production put the food security of these cocoa farmers in doubt with the impact of climate change.

Cocoa farmers acknowledge the benefits of adopting cocoa agroforestry system in cocoa production. Farmers indicated that cocoa agroforestry has the potential of maintaining soil moisture, improving soil fertility as well as suppressing weeds within the cocoa farm. A study by Bentley [23] on cocoa farmers in Ecuador also indicated similar characteristics. Cocoa farmers acknowledged that no shade cocoa system is agriculturally unsustainable and is becoming common in the study area. The study reported that cocoa agroforestry mimics the natural sub canopy cover of traditional cocoa tree in the forest thus good practice to mitigate climate change. The shade trees selected by the cocoa farmers need to provide products and additional income when sold. Terminalia superb, Milicia excels, Terminalia ivorensis, Cedrella odorata,Ceiba pentandra and Ceiba pentandraas are the most dominant shade tree on cocoa farms  and are retained because of their economic importance. Eighty-five percent have little knowledge about the tree rights in the community although there are existing policies and legislations in Ghana. The average knowledge of useful species in this cocoa farming communities are fading out. For example, some of the younger farmers interviewed retain shade trees on an interest in the knowledge of their parents and grandparents.

Cocoa farmers have various levels of perception on certain characteristics of cocoa agroforestry. About 54 percent of cocoa farmers strongly perceive that cocoa agroforestry improves yield of cocoa. These trees ensure a microclimate condition which enhance the yield of the cocoa and thus mitigate climate change. Other perception held by cocoa farmers for cocoa agroforestry are enhancing soil moisture, improve farm humidity and environment, protecting young cocoa trees from pest and diseases and direct sun rays (Table 2).

Table 2: Perception of cocoa farmers on cocoa agroforest in mitigating climate change.

Cocoa agroforestry ensure sustainable yield

Strongly agree

162 (54)

Agree

66 (22)

Undecided

54 (18)

Disagree

18 (6)

Cocoa agroforestry improves soil fertility

Strongly agree

195 (65)

Agree

75 (25)

Undecided
Disagree

30 (10)

Cocoa agroforestry improve farm humidity

Strongly agree

204 (68)

Agree

60 (20)

Undecided

18 (6)

Disagree

8 (24)

Cocoa agroforestry enhance rainfall

Strongly agree

225 (75)

Agree

45 (15)

Undecided

21 (7.0)

Disagree

9 (3.0)

Cocoa agroforestry serves as a wind break on farms

Strongly agree

240 (80)

Agree

45 (15)

Undecided
Disagree

15 (5)

Factors Affecting Adoption of Climate-Smart Agriculture Innovations in Isolation and in Combination

Farmers’ adaption decisions were found to be influenced by several varying factors. The factors include farming experience, agricultural land size, belonging to farmer association, access to extension services, awareness of climate change, and experience in farming.

Results from the regression are reported here to tell the factors determining of adoption of individual farmer. The base category used in the analysis was non-adoption. Table 3 report coefficients and marginal effects from MNL regression respectively. Marginal effects (Table 3) are reported and discussed here. In this instance,  the marginal effects measure the expected change in probability of   a certain choice (of a cocoa agroforestry system) being made with respect to a unit change in an explanatory variable, all in comparison to the no adoption category.

Table 3: Factors influencing farmers adaption decision.

Variable Name

Estimate

SE

Wald

p (Sig.)

Odds ratio

Agriculture land size

0.239

.139

2.944

.086*

.787

Experience in farming

0.823

.388

4.499

.034**

2.278

Member of farmer Assciation

1.037

.453

5.240

.022**

2.821

Gender

0.474

.502

.892

.345

1.607

Awareness of climate change

0.063

.054

1.378

.0240**

1.065

Age of respondent

-011

.016

.447

.504

0.989

Access to extension service

2.976

0.756

15.510

.000***

0.51

Constant

2.901

1.092

7.060

.008***

18.19

Model chi-square 53.87 p<0.000

-2 log likelihood 171.058a

Nagelkerke (R Square) .730

***Significant at 1%, **Significant at 5%, *Significant at 10%.

Results are compared to the base category of no-adoption. The results indicated that adoption of cocoa agroforestry is negatively associated with age of farmer and positively associated with agriculture land size, experience in farming, member of farmer association, gender, awareness of climate change and access to extension service. Results imply that probability of adopting cocoa agroforestry decreases with ageing of cocoa farmer possibly due to risk aversion of innovative practices like cocoa agroforestry by older cocoa farmers. The positive association of cocoa agroforestry adoption with agriculture land size imply that larger plot sizes could be more flexible to experiment with cocoa agroforestry. Also, the positive association of extension could be due to availability of information for cocoa farmers with access to it. The factors of cocoa agroforestry adoption is in agreement with studies [25,26]. Extension services are very critical for availing necessary information on cocoa agroforestry. Overall, results show the importance of cocoa agroforestry system at the farmer level in building resilience to climate variability and change as well as other productivity related challenges in cocoa farming in Ghana. Adoption of cocoa agroforestry system reduces the impacts of climate change on cocoa productivity and hence farmer incomes. The enhanced impact of adopting cocoa agroforestry systems possibly arise as a result of the micro climatic conditions that is favorable for cocoa production. Findings of the study conform to other related literature that indicates that, adoption  of new agricultural technologies needs to positively impact on productivity, income and other welfare related variables of the adaptors.

Conclusion and Recommendation

Cocoa researchers and development partners are becoming more concern with welfare of cocoa farm in Ghana by promoting cocoa agroforestry systems which is essential in a bid to improve climate resilience. Cocoa agroforestry has the potential to improve soil fertility, regulate soil temperature, control soil moisture among other benefits. The study outcomes have shown that climatic changes have occurred over the years and these have had effect on the annual cocoa yield. The study revealed that some cocoa farmers are presently ignorant about their tree ownership on their farms. It therefore recommended that agricultural extension officers should educate these farmers on tree rights. Cocoa farmers in the study areas have noticed changes   in climate conditions through their own experiences and careful observations over the year of farmers. Also, respondents reported that cocoa agroforestry systems can offer numerous environmental, social and financial benefits, and can lead to an alternative way to mitigate climate change and variability. Land size, member of farmer association, experience in farming, awareness of climate change and access to extension service are the main factors that influence cocoa farmers’ decision to adopt cocoa agroforestry system. There is the need for effective provision of extension services through farmer field school programs. Programs of this nature have the potential to change farmers’ attitudes towards adopting a technology. Access to information and credit needs to be enhanced so as to get the needed logistics for managing cocoa agroforestry systems. This would facilitate farmers’ access to information about technical issues of the systems and how it can be managed in mitigating climate change. Finally, government should support cocoa famers through subsidies and long-term loans. There is also the need for more concerted and strong collaborative effort among Ghana COCOBOD, the Ministry of Food and Agriculture and Forestry Commission so as to reach greater a policy impacts on cocoa agroforestry system.

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