Smoking cessation advice: Swiss physicians lack training

OBJECTIVES: To assess the use and appropriateness of medical advice for smoking cessation provided by registrars in a General Medicine Outpatient Department to an unselected patient population in Switzerland. METHODS: A prospective observational study in which 314 consecutive outpatients were contacted by phone within 24h after their consultation. Questions and information concerning smoking asked and/or provided by the registrar to patients were collected. RESULTS: Eleven registrars (mean age 34 years (range 29-40), 54% females, mean of 5 years (range 3.5-6 years) postgraduate medical training) worked in the Basel University Hospital Medical Outpatient Department during the study period from 01.01.2006 to 31.03.2006. In total 314 participants (mean 48 years, age range 16-71 years, 50% females) completed the study. Registrars queried 81% of the patients about smoking, but inquired about smoking duration only in 44% of the patients. Twenty-eight percent of the patients received information about the risks related to smoking, whereas cessation was discussed only with 10% and offered to 9% of the patients. CONCLUSION: Though most junior physicians in the survey asked about smoking, they failed to appropriately address tobacco-related health issues and offer cessation advice in the majority of cases. Extended regular training for physicians on smoking-related issues will be necessary in order to improve counselling of smokers and meet the global tobacco challenge.

Reliability of operational data from pig herds and performance ratings by veterinarians and pig farmers collected during telephone interviews for the evaluation of a PCV2 piglet vaccination

BackgroundThe aim of the present study was to evaluate the feasibility of using a telephone survey in gaining an understanding of the possible herd and management factors influencing the performance (i.e. safety and efficacy) of a vaccine against porcine circovirus type 2 (PCV2) in a large number of herds and to estimate customers¿ satisfaction.ResultsDatasets from 227 pig herds that currently applied or have applied a PCV2 vaccine were analysed. Since 1-, 2- and 3-site production systems were surveyed, the herds were allocated in one of two subsets, where only applicable variables out of 180 were analysed. Group 1 was comprised of herds with sows, suckling pigs and nursery pigs, whereas herds in Group 2 in all cases kept fattening pigs. Overall 14 variables evaluating the subjective satisfaction with one particular PCV2 vaccine were comingled to an abstract dependent variable for further models, which was characterized by a binary outcome from a cluster analysis: good/excellent satisfaction (green cluster) and moderate satisfaction (red cluster). The other 166 variables comprised information about diagnostics, vaccination, housing, management, were considered as independent variables. In Group 1, herds using the vaccine due to recognised PCV2 related health problems (wasting, mortality or porcine dermatitis and nephropathy syndrome) had a 2.4-fold increased chance (1/OR) of belonging to the green cluster. In the final model for Group 1, the diagnosis of diseases other than PCV2, the reason for vaccine administration being other than PCV2-associated diseases and using a single injection of iron had significant influence on allocating into the green cluster (P¿<¿0.05). In Group 2, only unchanged time or delay of time of vaccination influenced the satisfaction (P¿<¿0.05).ConclusionThe methodology and statistical approach used in this study were feasible to scientifically assess ¿satisfaction¿, and to determine factors influencing farmers¿ and vets¿ opinion about the safety and efficacy of a new vaccine.

Workflow Interruptions and Failed Action Regulation in Surgery Personnel

Background Workflow interruptions during surgery may cause a threat to patient's safety. Workflow interruptions were tested to predict failure in action regulation that in turn predicts near-accidents in surgery and related health care. Methods One-hundred-and-thirty-three theater nurses and physicians from eight Swiss hospitals participated in a cross-sectional questionnaire survey. The study participation rate was 43%. Results Structural equation modeling confirmed an indirect path from workflow interruptions through cognitive failure in action regulation on near-accidents (p < 0.05). The indirect path was stronger for workflow interruptions by malfunctions and task organizational blockages compared with workflow interruptions that were caused by persons. The indirect path remained meaningful when individual differences in conscientiousness and compliance with safety regulations were controlled. Conclusion Task interruptions caused by malfunction and organizational constraints are likely to trigger errors in surgery. Work redesign is recommended to reduce workflow interruptions by malfunction and regulatory constraints.

Time trends in avoidable cancer mortality in Switzerland and neighbouring European countries 1996-2010.

QUESTION UNDER STUDY What are the trends in avoidable cancer mortality in Switzerland and neighbouring countries? METHODS Mortality data and population estimates 1996-2010 were obtained from the Swiss Federal Statistical Office for Switzerland and the World Health Organization Mortality Database (http://www.who.int/healthinfo/mortality_data/en/) for Austria, Germany, France and Italy. Age standardised mortality rates (ASMRs, European standard) per 100 000 person-years were calculated for the population <75 years old by sex for the following groups of cancer deaths: (1) avoidable through primary prevention; (2) avoidable through early detection and treatment; (3) avoidable through improved treatment and medical care; and (4) remaining cancer deaths. To assess time trends in ASMRs, estimated annual percentage changes (EAPCs) with 95% confidence intervals (95% CIs) were calculated. RESULTS In Switzerland and neighbouring countries cancer mortality in persons <75 years old continuously decreased 1996-2010. Avoidable cancer mortality decreased in all groups of avoidable cancer deaths in both sexes, with one exception. ASMRs for causes avoidable through primary prevention increased in females in all countries (in Switzerland from 16.2 to 20.3 per 100 000 person years, EAPC 2.0 [95% CI 1.4 to 2.6]). Compared with its neighbouring countries, Switzerland showed the lowest rates for all groups of avoidable cancer mortality in males 2008-2010. CONCLUSION Overall avoidable cancer mortality decreased, indicating achievements in cancer care and related health policies. However, increasing trends in avoidable cancer mortality through primary prevention for females suggest there is a need in Switzerland and its European neighbouring countries to improve primary prevention.

Factors Controlling Species Richness in Alpine Plant Communities: An Assessment of the Importance of Stress and Disturbance

This study explores whether the high variability of vascular plant diversity among alpine plant communities can be explained by stress and/or disturbance intensities. Species numbers of 14 alpine plant communities were sampled in the Swiss Alps. To quantify the intensity of 13 stress and 6 disturbance factors potentially controlling plant life in these communities, a survey was conducted by asking numerous specialists in alpine vegetation to assess the importance of the different factors for each community. The estimated values were combined in stress- and disturbance-indices which were compared with diversity according to the Intermediate Stress Hypothesis, the Intermediate Disturbance Hypothesis, and the Dynamic Equilibrium Model, respectively. Each of these theories explained a part of the variability in the species richness, but only the Dynamic Equilibrium Model provided a complete and consistent explanation. The last model suggests that community species richness within the alpine life zone is generally controlled by stress intensity. Disturbance and competition seem to play a secondary role by fine-tuning diversity in specific communities. As diversity is primarily limited by stress, a moderation of temperature-related stress factors, as a result of global warming, may cause a shift of the equilibrium between stress, disturbance, and competition in alpine ecosystems.

Contraceptive use in women by body mass index categories

The prevalence of obesity has increased sharply in the United States since the mid 1970's. Obese women who become pregnant are at increased risk of pregnancy complications for both mother and fetus. This study assessed whether women in higher body mass index (BMI) categories engage in the preventive behaviors of contraception more frequently than normal weight women. It also evaluated the type of contraception used by both obese and normal weight women. The study used cross-sectional data from 7 states participating in the Family Planning Module of the 2006 Behavioral Risk Factor Surveillance System (BRFSS). The Behavioral Risk Factor Surveillance System survey is an annual random digit dialed telephone survey of the non-institutionalized civilian population aged 18 years and older. The Family Planning Module was administered by Arizona, Kentucky, Minnesota, Missouri, Montana, Oregon, and Wisconsin. Of the 4,757 women who participated in the Family Planning Module, 2,244 (53.2%) were normal weight, 1,202 (25.6%) were overweight, and 1,072 (21.2%) were obese. The majority of these women 4,115 (86.2%) reported using some type of contraception to prevent pregnancy. Six hundred forty two women (13.8%) stated they did not use any type of contraception to prevent pregnancy. Within body mass index categories, 14% of normal weight women, 13% of overweight women, and 13.4% of obese women did not use any type of contraception. Neither the bivariate analysis nor the logistic regressions found body mass index categories to be statistically associated with contraceptive use. The relationship between body mass index categories and contraceptive method was found to be statistically significant. The predictive probability graph found that women at all levels of BMI have a lower probability of using barrier contraception methods as compared to procedural and hormonal methods. Hormonal contraception methods have the highest probability of use for women with a BMI of 15 to 25. In contrast, the probability of using procedural contraception methods is relatively flat and less than hormonal methods for BMI between 15 and 25. However, the probability of using procedural contraception increases dramatically with a BMI greater than 25. At a BMI greater than 42, women have a greater than 50% probability of using procedural contraception. Although a relationship between body mass index and contraception use was not found, contraception method was found to be associated with body mass index. The reasons why normal weight women prefer hormonal contraception while overweight/obese women are more likely to use procedural methods needs to be explored. By understanding the relationship between obesity and contraception, we can hopefully decrease unintended pregnancies and overall improve pregnancy related health outcomes. To determine if relationships between contraception use/type and body mass index exist, further research needs to be conducted on a national level. ^

Residents' risk perception due to operations of a copper smelter located near residential communities in El Paso, Texas

A face to face survey addressing environmental risk perception was conducted in January through March 2010. The 35 question survey was administered to a random sample of 73 households in El Paso, Texas. The instrument, administered in two adjacent residential communities neighboring an inactive copper smelter solicited responses about manmade and naturally occurring health risks and sources of health information that might utilized by respondents. The objective of the study was to determine if intervention which occurred in one of the communities increased residents' perception of risk to themselves and their families. The study was undertaken subsequent to increased attention from news media and public debate surrounding the request to reopen the smelter's operations. Results of the study indicated that the perception of environmental related health concerns were not significantly correlated with residence in a community receiving outreach and intervention. Both communities identified sun exposure as their greatest perceived environmental risk followed by cigarette smoking. Though industrial by products and chemical pollution were high ranking concerns, respondents indicated they felt that the decision not to reopen the smelter reduced risk in these areas. Residents expressed confidence in information received from the local health district though most indicated they received very little information from that source indicating an opportunity for public health education in this community as a strategy to address future health concerns.^

A comparison of healthcare access, healthcare utilization and asthma self-management for Hispanic children in border and non-border regions of Texas

The purpose of this culminating experience was to investigate the relationships between healthcare utilization, insurance coverage, and socioeconomic characteristics of children with asthma along the Texas-Mexico Border. A secondary data analysis was conducted on cross-sectional data from the Texas Child Asthma Call-back Survey, a follow-up survey to the random digit dialed Behavior Risk Factor Surveillance Study (BRFSS) conducted between 2006-2009 ( n = 556 adults living in households with a child with asthma).^ The proportion of Hispanic children with asthma in Border areas of Texas was more than twice that of non-Border areas (84.8% vs. 28.8%). Parents in Border areas were less likely to have their own health insurance (OR = 0.251, 95% C.I. = 0.117-0.540) and less likely to complete the survey in English than Spanish (OR = 0.251 95% C.I. = 0.117-0.540) than parents in non-Border areas. No significant socio-economic or health care utilization differences were noted between Hispanic children living in Border areas compared to Hispanic children living in non-Border areas. Children with asthma along the Texas-Mexico Border, regardless of ethnicity and language, have insurance coverage rates, reported cost barriers to care, symptom management, and medication usage patterns similar to those in non-Border areas. When compared to English-speakers, Spanish-speaking parents in Texas as a whole are far less likely to be taught what to do during an asthma attack (50.2% vs. 78.6%).^ Language preference, rather than ethnicity or geographical residence, played a larger role on childhood asthma-related health disparities for children in Texas. Spanish-speaking parents in are less likely to receive adequate asthma self-management education. Investigating the effects of Hispanic acculturation rates and incongruent parent-child health insurance coverage may provide better insight into the health disparities of children along the Texas-Mexico Border.^

Practice and attitude differences in physician cigarette use: A study of prevalence, physicians' role, and smoking policy awareness in Dubai, UAE

The use of tobacco products ruins the health of millions of people around the world. On average, tobacco users die nearly seven years earlier than non-tobacco users. n1 Cigarette smoking is a particular concern in the developing countries of the Middle East and Gulf Cooperation Council (GCC) region where smoking prevalence is expected to increase. This is due to the tobacco industry's vigorous commercial and marketing activities. n3 Smoking prevalence among physicians is considered to be an effective indicator of a society's readiness to identify the smoking epidemic and its related health diseases. n4 There is a lack of detailed data on the smoking prevalence among healthcare professionals, particularly physicians, in the United Arab Emirates (UAE). This cross sectional study is the first to address smoking practices among physicians working at the Department of Health and Medical Services (DOHMS); in Dubai, UAE. ^ This study describes the cigarette smoking prevalence among DOHMS Physicians, physician attitudes towards tobacco use and tobacco bans; physician attitudes towards smoking cessation techniques (among smokers and non-smokers); and physician awareness of official anti-smoking policies. Data for the study was collected through the use of an adapted WHO standardized questionnaire, the Global Health Professionals Survey. The questionnaire was administered by the researcher to physicians (n=288) at their work place. Date was analyzed using the SPSS analytic software program. ^ Twelve percent of DOHMS physicians smoked cigarettes. Regardless of smoking status, the majority supported a tobacco ban in hospitals and public places, and a ban on tobacco advertising. There is a significant relationship between physician smoking status and discussing risks of tobacco use (p < 0.05). Non-smoking physicians reported spending more time with patients discussing hazards of smoking (p < 0.01). Non-smokers reported providing more counseling than their smoking colleagues. The majority of DOHMS physicians (63%) reported a lack of knowledge about 5As/ 5Rs. The majority of physicians also reported they are aware of hospital smoking policies that restrict smoking. Regardless of physician smoking status, DOHMS physicians are not very actively involved in smoking cessation activities. This cross sectional study is the first to address smoking programs, policies, and practices among physicians in Dubai, UAE. Findings support the need for increased physical smoking cessation training as well as the development of smoking cessation programs for tobacco control, and programs with a focus on physician participation in reducing tobacco and cigarette use among the general population.^

Recommendations for dementia caregiver stress interventions based on Intervention Mapping guidelines

Stress can affect a person's psychological and physical health and cause a variety of conditions including depression, immune system changes, and hypertension (Alzheimer's Association, 2010; Aschbacher et al., 2009; Fredman et al., 2010; Long et al., 2004; Mills et al., 2009; von Känel et al., 2008). The severity and consequences of these conditions can vary based on the duration, amount, and sources of stress experienced by the individual (Black & Hyer, 2010; Coen et al., 1997; Conde-Sala et al., 2010; Pinquart & Sörensen, 2007). Caregivers of people with dementia have an elevated risk for stress and its related health problems because they experience more negative interactions with, and provide more emotional support for, their care recipients than other caregivers. ^ This paper uses a systematic program planning process of Intervention Mapping to organize evidence from literature, qualitative research and theory to develop recommendations for a theory- and evidence-based intervention to improve outcomes for caregivers of people with dementia. A needs assessment was conducted to identify specific dementia caregiver stress influences and a logic model of dementia caregiver stress was developed using the PRECEDE Model. Necessary behavior and environmental outcomes are identified for dementia caregiver stress reduction and performance objectives for each were combined with selected determinants to produce change objectives. Planning matrices were then designed to inform effective theory-based methods and practical applications for recommended intervention delivery. Recommendations for program components, their scope and sequence, the completed program materials, and the program protocols are delineated along with ways to insure that the program is adopted and implemented after it is shown to be effective.^

Minors’ Access to Contraceptive Services

Over the past 30 years, states have expanded minors’ authority to consent to health care, including care related to sexual activity. This trend reflects U.S. Supreme Court rulings extending the constitutional right to privacy to a minor’s decision to obtain contraceptives and concluding that rights do not “come into being magically only when one attains the state-defined age of majority.” It also reflects the recognition that while parental involvement is desirable, many minors will remain sexually active but not seek services if they have to tell their parents. As a result, confidentiality is vital to ensuring minors’ access to contraceptive services. Even when a state has no relevant policy or case law, physicians may commonly provide medical care to a mature minor without parental consent, particularly if the state allows a minor to consent to related health services.

Stable isotope ratios of foraminifera from sediment cores off northeastern Brazil

The western South Atlantic boundary currents represent a sensitive system within the global thermohaline circulation (THC). We investigated the impact of deglacial THC changes on the western tropical Atlantic studied in six high resolution sediment cores from the upper continental slope of Brazil. The stratigraphy of the cores is mainly based on 14C AMS dating of monospecific foraminiferal samples. Changes in the upper layer tropical ocean during the deglaciation are inferred from stable oxygen isotope measurements on planktic and benthic foraminifera. Variations in the delta18O residuals are assumed to be mainly temperature related. During the Oldest and Younger Dryas cooling periods, two major deglacial THC disturbances are reported from North Atlantic sediment cores. Concomitant to the repeated THC slowdown, we observe an upper layer warming in the tropical ocean. A reduced northward heat export from the tropical areas during these periods (weak North Brazil Current) is additionally reflected by low meridional gradients in the stable oxygen records. This generally agrees with results from coupled ocean atmosphere models.

Mineral quantification of a Jordan Cretaceous outcrop (Section GM3, Ghawr Al Mazar, Ghor al Mazrar)

Cyclic fluctuations in global sea level during epochs of warm greenhouse climate have remained enigmatic, because absence or subordinate presence of polar ice during these periods precludes an explanation by glacio-eustatic forcing. An alternative concept suggests that the water-bearing potential of groundwater aquifers is equal to that of ice caps and that changes in the dynamic balance of aquifer charge versus discharge, as a function of the temperature-related intensity of the hydrological cycle, may have driven eustasy during warm climates. However, this idea has long been neglected for two reasons: 1) the large storage potential of subsurface aquifers was confused with the much smaller capacity of rivers and lakes and 2) empirical data were missing that document past variations in the hydrological cycle in relation to eustasy. In the present study we present the first empirical evidence for changes in precipitation, continental weathering intensity and evaporation that correlate with astronomically (long obliquity) forced sea-level cycles during the warmest period of the Cretaceous (Cenomanian-Turonian). We compare sequence-stratigraphic data with changes in the terrigenous mineral assemblage in a low-latitude marine sedimentary sequence from the equatorial humid belt at the South-Tethyan margin (Levant carbonate platform, Jordan), thereby avoiding uncertainties from land-ocean correlations. Our data indicate covariance between cycles in weathering and sea level: predominantly chemical weathering under wet climate conditions is reflected by dominance of weathering products (clays) in deposits that represent sea-level fall (aquifer charge > discharge). Conversely, preservation of weathering-sensitive minerals (feldspars, epidote and pyroxenes) in transgressive sediments reflects decreased continental weathering due to dryer climate (aquifer discharge > charge). Based on our results we suggest that aquifer-eustasy represents a viable alternative to glacio-eustasy as a driver of cyclic 3rd-order sea-level fluctuations during the middle Cretaceous greenhouse climate, and it may have been a pervasive process throughout Earth history.

Stable isotope ratios in shells of marine organisms

Oxygen and carbon isotope analyses have been carried out on calcareous skeletons of important recent groups of organisms. Annual temperature ranges and distinct developmental stages can be reconstructed from single shells with the aid of the micro-sampling technique made possible by modern mass-spectrometers. This is in contrast to the results of earlier studies which used bulk sampIes. The skeletons analysed are from Bermuda, the Philippines, the Persian Gulf and the continental margin off Peru. In these environments, seasonal salinity ranges and thus annual variations in the isotopic composition of the water are small. In addition, environmental parameters are weIl documented in these areas. The recognition of seasonal isotopic variations is dependant on the type of calcification. Shells built up by carbonate deposition at the margin, such as molluscs, are suitable for isotopic studies. Analysis is more difficult where chambers are added at the margin of the shell but where older chambers are simultaneously covered by a thin veneer of carbonate e. g. in rotaliid foraminifera. Organisms such as calcareous algae or echinoderms that thicken existing calcareous parts as weIl as growing in length and breadth are the most difficult to analyse. All organisms analysed show temperature related oxygen-isotope fractionation. The most recent groups fractionate oxygen isotopes in accordance with established d18O temperature relationships (Tab. 18, Fig. 42). These groups are deep-sea foraminifera, planktonic foraminifera, serpulids, brachiopods, bryozoa, almost all molluscs, sea urchins, and fish (otoliths). A second group of organisms including the calcareous algae Padina, Acetabularia, and Penicillus, as weIl as barnacles, cause enrichment of the heavy isotope 18O. Finally, the calcareous algae Amphiroa, Cymopolia and Halimeda, the larger foraminifera, corals, starfish, and holothurians cause enrichment of the lighter isotope 16O. Organisms causing non-equilibrium fractionation also record seasonal temperature variations within their skeletons which are reflected in stable-oxygen-isotope patterns. With the exception of the green algae Halimeda and Penicillus, all organisms analysed show lower d13C values than calculated equilibrium values (Tab. 18, Fig. 42). Especially enriched with the lighter isotope 12C are animals such as hermatypic corals and larger foraminifera which exist in symbiosis with other organisms, but also ahermatypic corals, starfish, and holothurians. With increasing age of the organisms, seven different d13C trends were observed within the skeletons. 1) No d13C variations are observed in deep-sea foraminifera presumably due to relatively stable environmental conditions. 2) Lower d13C values occur in miliolid larger foraminifera and are possibly related to increased growth with increasing age of the foraminifera. 3) Higher values are found in planktonic foraminifera and rotaliid larger foraminifera and can be explained by a slowing down of growth with increasing age. 4) A sudden change to lower d13C values at a distinct shell size occurs in molluscs and is possibly caused by the first reproductive event. 5) A low-high-Iow cycle in calcareous algae is possibly caused by variations in the stage of calcification or growth. 6) A positive correlation between d18O and d13C values is found in some hermatypic corals, all ahermatypic corals, in the septa of Nautilus and in the otoliths of fish. In hermatypic corals from tropical areas, this correlation is the result of the inverse relationship between temperature and light caused by summer cloud cover; in other groups it is inferred to be due to metabolic processes. 7) A negative correlation between d18O and d13C values found in hermatypic corals from the subtropics is explained by the sympathetic relationship between temperature and light in these latitudes. These trends show that the carbon isotope fractionation is controlled by the biology of the respective carbonate producing organisms. Thus, the carbon isotope distribution can provide information on the symbiont-host relationship, on metabolic processes and calcification and growth stages during ontogenesis of calcareous marine organisms.

(Table 1) Age determination of stalagmites of the Marcello Arévalo Cave in Chile

Stalagmites are important palaeo-climatic archives since their chemical and isotopic signatures have the potential to record high-resolution changes in temperature and precipitation over thousands of years. We present three U/Th-dated records of stalagmites (MA1-MA3) in the superhumid southern Andes, Chile (53°S). They grew simultaneously during the last five thousand years (ka BP) in a cave that developed in schist and granodiorite. Major and trace elements as well as the C and O isotope compositions of the stalagmites were analysed at high spatial and temporal resolution as proxies for palaeo-temperature and palaeo-precipitation. Calibrations are based on data from five years of monitoring the climate and hydrology inside and outside the cave and on data from 100 years of regional weather station records. Water-insoluble elements such as Y and HREE in the stalagmites indicate the amount of incorporated siliciclastic detritus. Monitoring shows that the quantity of detritus is controlled by the drip water rate once a threshold level has been exceeded. In general, drip rate variations of the stalagmites depend on the amount of rainfall. However, different drip-water pathways above each drip location gave rise to individual drip rate levels. Only one of the three stalagmites (MA1) had sufficiently high drip rates to record detrital proxies over its complete length. Carbonate-compatible element contents (e.g. U, Sr, Mg), which were measured up to sub-annual resolution, document changes in meteoric precipitation and related drip-water dilution. In addition, these soluble elements are controlled by leaching during weathering of the host rock and soils depending on the pH of acidic pore waters in the peaty soils of the cave's catchment area. In general, higher rainfall resulted in a lower concentration of these elements and vice versa. The Mg/Ca record of stalagmite MA1 was calibrated against meteoric precipitation records for the last 100 years from two regional weather stations. Carbonate-compatible soluble elements show similar patterns in the three stalagmites with generally high values when drip rates and detrital tracers were low and vice versa. d13C and d18O values are highly correlated in each stalagmite suggesting a predominantly drip rate dependent kinetic control by evaporation and/or outgassing. Only C and O isotopes from stalagmite MA1 that received the highest drip rates show a good correlation between detrital proxy elements and carbonate-compatible elements. A temperature-related change in rainwater isotope values modified the MA1 record during the Little Ice Age (~0.7-0.1 ka BP) that was ~1.5 °C colder than today. The isotopic composition of the stalagmites MA2 and MA3 that formed at lower drip rates shows a poor correlation with stalagmite MA1 and all other chemical proxies of MA1. 'Hendy tests' indicate that the degassing-controlled isotope fractionation of MA2 and MA3 had already started at the cave roof, especially when drip rates were low. Changing pathways and residence times of the seepage water caused a non-climatically controlled isotope fractionation, which may be generally important in ventilated caves during phases of low drip rates. Our proxies indicate that the Neoglacial cold phases from ~3.5 to 2.5 and from ~0.7 to 0.1 ka BP were characterised by 30% lower precipitation compared with the Medieval Warm Period from 1.2 to 0.8 ka BP, which was extremely humid in this region.