Occurrence of micropollutants in surface waters: Monitoring of Portuguese Lima and Douro River estuaries and interconnecting northwest coast.

This study monitored the occurrence of 34 MPs in 2 Portuguese estuaries and adjacent coastal area using solid-phase extraction and liquid chromatography-tandem mass spectrometry, covering: (i) an extensive monitoring study area; (ii) a multi-class group of organic MPs, including some outlined in European Union guidelines for water protection; (iii) a year-long monitoring campaign including different seasons; (iv) samples collected at both flood and ebb tide; and (v) samples taken from the water surface and bottom at each sampling point. Results showed that a specific group of compounds prevailed in the monitored areas, with concentrations depending on season, tide, and location. In general, the MPs found more frequently were isoproturon and perfluorooctanesulfonic acid, along with pharmaceuticals trimethoprim, acetaminophen, tramadol, diclofenac, and ketoprofen, which were mostly detected at higher concentrations. Although most MPs have been detected at very low levels, their persistent and widespread presence highlights the need for mitigation measures and effective water treatment solutions able to address them.

Removal of metals and emergent contaminants from liquid digestates in constructed wetlands for agricultural reuse.

Given the increasing pressure on water bodies, it is imperative to explore sustainable methodologies for wastewater treatment and reuse. The simultaneous presence of multiples contaminants in complex wastewater, such as the liquid effluents from biogas plants, can compromise biological treatment effectiveness for reclaiming water. Vertical subsurface flow constructed wetlands were established as low-cost decentralized wastewater treatment technologies to treat the liquid fraction of digestate from municipal organic waste with metals, antibiotics, and antibiotic resistance genes, to allow its reuse in irrigation. Twelve lab-scale planted constructed wetlands were assembled with gravel, light expanded clay aggregate and sand, testing four different treating conditions (liquid digestate spiked with oxytetracycline, sulfadiazine, or ofloxacin, at 100 µg/ L, or without dosing) during 3 months. Physicochemical parameters (pH, chemical oxygen demand (COD), nutrients, metals, and antibiotics), the microbial communities dynamics (through 16S high-throughput sequencing) and antibiotic resistance genes removal (qPCR) were monitored in influents and effluents. Systems removed 85.8%-96.9% of organic matter (as COD), over 98.1% of ammonium and phosphate ions, and 69.3%-99.4% of nitrate and nitrite ions, with no significant differences between the presence or absence of antibiotics. Removal of Fe, Mn, Zn, Cu, Pb and Cr exceeded 82% in all treatment cycles. The treatment also removed oxytetracycline, sulfadiazine and ofloxacin over 99%, and decreased intl1, tetA, tetW, sul1 and qnrS gene copies. Nonetheless, after 3 months of ofloxacin dosing, qnrS gene started being detected. Removal processes relied on high HRT (14 days) and various mechanisms including sorption, biodegradation, and precipitation. Microbial community diversity in liquid digestate changed significantly after treatment in constructed wetlands with a decrease in the initial Firmicutes dominance, but with no clear effect of antibiotics on the microbial community structure. Removals above 85% and 94% were observed for Streptococcus and Clostridium, respectively. Results suggest that vertical subsurface flow constructed wetlands were a suitable technology for treating the liquid digestate to reuse it in irrigation agricultural systems, contributing to the circular bioeconomy concept. However, a more profound understanding of effective wastewater treatment strategies is needed to avoid antibiotic resistance genes dissemination.

Potential of nature-based solutions to reduce antibiotics, antimicrobial resistance, and pathogens in aquatic ecosystems. a critical review.

This comprehensive scientific review evaluates the effectiveness of nature-based solutions (NBS) in reducing antibiotics (ABs), combating antimicrobial resistance (AMR), and controlling pathogens in various aquatic environments at different river catchment levels. It covers conventional and innovative treatment wetland configurations for wastewater treatment to reduce pollutant discharge into the aquatic ecosystems as well as exploring how river restoration and saltmarshes can enhance pollutant removal. Through the analysis of experimental studies and case examples, the review shows NBS's potential for providing sustainable and cost-effective solutions to improve the health of aquatic ecosystems. It also evaluates the use of diagnostic indicators to predict NBS effectiveness in removing specific pollutants such as ABs and AMR. The review concludes that NBS are feasible for addressing the new challenges stemming from human activities such as the presence of ABs, AMR and pathogens, contributing to a better understanding of NBS, highlighting success stories, addressing knowledge gaps, and providing recommendations for future research and implementation.

Microbial response to a port fuel spill: Community dynamics and potential for bioremediation.

Following a fuel leakage inside a Portuguese maritime port, we conducted parallel 30-day experiments using contaminated seawater and fuel, sampled five days after the incident. This study aimed to (i)survey the native microbial community response to the spilled fuel and (ii)evaluate the efficacy of bioremediation, both biostimulation and bioaugmentation with a lyophilized bacterial consortium (Rhodococcus erythropolis, Pseudomonas sp.), in accelerating hydrocarbon degradation. Metabarcoding analysis revealed a shift in microbial communities, with increased abundance of hydrocarbon-degraders (e.g. Alcanivorax, Thalassospira). Ninety-five hydrocarbonoclastic bacteria were isolated, including key groups from the enriched communities. The lyophilized bacteria added in bioaugmentation, enhanced the abundance of hydrocarbon-degraders over time and were recovered throughout time. Bioremediation treatments favoured biodegradation, achieving over 60 % removal of total petroleum hydrocarbons after 15 days, contrasting with natural attenuation where almost no TPH was removed. This work highlights the potential of bioremediation technologies to accelerate hydrocarbon-degrading activity, for oil spills inside ports.

Occurrence of microplastics and metals in European seabass produced in different aquaculture systems: Implications for human exposure, risk, and food safety.

Microplastics (MPs) are emerging contaminants of increasing concern as they may cause adverse effects and carry other contaminants, which may potentially compromise human health. Despite occurring in aquatic ecosystems worldwide, the knowledge about MP presence in different aquaculture systems and their potential impact on seafood products is still limited. This study aimed to determine the levels of MPs in water, feed, and European seabass (Dicentrarchus labrax) from three relevant aquaculture systems and estimate human exposure to MPs and metals through seabass consumption. The recirculating aquaculture system (RAS) had the highest MP occurrence in water and feed. MP levels in seabass followed the aquaculture system's levels in water and feed, with RAS-farmed fish presenting the highest MP load, both in the fish gastrointestinal tract (GIT) and muscle, followed by pond-, and cage-farmed fish. MPs' characteristics across aquaculture systems and fish samples remained consistent, with the predominant recovered particles falling within the MP size range. The particles were visually characterized and chemically identified by micro-Fourier Transform Infrared Spectroscopy (µFTIR). Most of these particles were fibres composed of man-made cellulose and PET. MP levels in GIT were significantly higher than in muscle for pond- and RAS-farmed fish, MPs' bioconcentration factors >1 indicated bioconcentration in farmed seabass. Metal concentrations in fish muscle were below permissible limits, posing low intake risks for consumers according to the available health-based guidance values and estimated dietary scenarios.

Uncovering microplastics contamination in canned seafood.

There is limited research on the occurrence of microplastics (MPs) in canned seafood. All types of canned seafood investigated in the present study were contaminated. After sample digestion in 30 % hydrogen peroxide, a total of 40 MPs were recovered. Fibers were the most common type, blue was the dominant colour, and Fourier Transform Infrared Spectroscopy (FTIR) identified polyester as the most common polymer. Considering all samples, an average of 3.5 ± 5.2 MPs/can was obtained, with octopus in tomato sauce and tuna in olive oil presenting the highest contamination (5.2 ± 7.5 MPs/can and 5.2 ± 5.1 MPs/can, respectively). Also, significant differences between the number of MPs in the seafood tissues and immersion liquids were verified. The present study demonstrates MPs occurrence in canned seafood, a potential contamination pathway for humans. More research on the different stages of the canning processing is vital for understanding MPs contamination in cans.

Metformin and lamotrigine sorption on a digestate amended soil in presence of trace metal contamination.

The antidiabetic drug metformin and antiepileptic drug lamotrigine are contaminants of emerging concern that have been detected in biowaste-derived amendments and in the environment, and their fate must be carefully studied. This work aimed to evaluate their sorption behaviour on soil upon digestate application. Experiments were conducted on soil and digestate-amended soil as a function of time to study kinetic processes, and at equilibrium also regarding the influence of trace metals (Pb, Ni, Cr, Co, Cu, Zn) at ratio pharmaceutical/metal 1/1, 1/10, and 1/100. Pharmaceutical desorption experiments were also conducted to assess their potential mobility to groundwater. Results revealed that digestate amendment increased metformin and lamotrigine adsorbed amounts by 210% and 240%, respectively, increasing organic matter content. Metformin adsorption kinetics were best described by Langmuir model and those of lamotrigine by Elovich and intraparticle diffusion models. Trace metals did not significantly affect the adsorption of metformin in amended soil while significantly decreased that of lamotrigine by 12-39%, with exception for Cu2+ that increased both pharmaceuticals adsorbed amounts by 5 - 8%. This study highlighted the influence of digestate amendment on pharmaceutical adsorption and fate in soil, which must be considered in the circular economy scenario of waste-to-resource.

Methodology optimization to quantify microplastic presence in planktonic copepods, chaetognaths and fish larvae.

Two of the groups most impacted by microplastics (MPs) are zooplankton and fish larvae, either through MPs ingestion or absorption. Although there has been an increase of studies focusing on MPs ingestion by these organisms, there is still no standardized methodology for the quantification of MPs present in plankton. For example, some reagents normally used to digest plankton and recover MPs appear adversely to affect some plastic characteristics. This can potentially lead to underestimating the amount and types of MPs present in the organisms analyzed. Hence, this work aimed to optimize a methodology to quantify MPs present in plankton, namely zooplankton and fish larvae, and ensuring MPs integrity. Hence, the planktonic organism tissues were digested using 30% (v/v) H2O2 solution at different temperatures and incubation periods while preserving the integrity and polymer characteristics of 13 types of MPs. MPs' characteristics were register before and after the tests, by visual inspection and Fourier Transform Infrared Spectroscopy (FTIR) analysis, to evaluate the integrity and features of MPs. With this methodology, MPs recovery was above 85% for all types of plastic tested. The proposed methodology is a rapid protocol, with a maximum of 7 h of incubation, that ensures simultaneously the full digestion of the organism tissues and the complete preservation of all the plastic characteristics, namely color, size and polymer type.•A methodology was optimized to quantify microplastics present in zooplankton (copepods, chaetognaths and fish larvae).•Thirteen types of microplastics (fibers and fragments of different polymers) were used to test the efficiency of the methodology ensuring the maintenance of the integrity of plastics.•With this methodology, microplastic recovery was above 85% for all the types of microplastic tested and no changes in their characteristics were observed.

Spatial distribution and temporal trends of butyltin compounds (TBT, DBT & MBT) in short sediment cores of the SW Portuguese Shelf (western Iberian Margin, NE Atlantic).

Spatial patterns and temporal trends of the butyltin compounds tributyltin (TBT), dibutyltin (DBT), and monobutyltin (MBT) were investigated in a set of sediment samples collected along the SW Portuguese continental shelf. This region did not reach the Good Environmental Status (GES) in accordance with the Marine Strategy Framework Directive (MSFD) during a first evaluation carried out in 2012. Overall, MBT and DBT were the predominant organotin species detected, but high concentrations of TBT were found in and around disposal sites for dredge sludge derived from the dredging in navigation channels, harbours, and shipyard facilities of the Tagus and Sado estuaries. Although Portuguese regulations for monitoring sediment quality in relation to dredging activities consider only PAH, PCB and HCB, they also dictate that other organic contaminants such as butyltin compounds (BTs) should be monitored if suspicion of high values exists, but no action limits are defined for these (MAOTDR, 2007). Without action limits, the monitoring recommendation given in the regulations is not put into practice. Considering their toxicity, BT derivates should be integrated in the legislation, because they represent an environmental threat in the relocation of dredged material, especially when derived from harbour and shipyards areas. Based on this study, we recommend giving more attention to the amounts and impacts of BTs in sediments at dredged material disposal sites (DMDS) and their surroundings. Or even better, in order to be more efficient, monitoring should be done at the source of the dredged materials and not at the sink. In case it is not done, the monitoring of concentrations of TBT (and other BTs) in sediments and organisms, including imposex studies, at all Portuguese sites for disposal of dredged material receiving slightly to strongly contaminated dredged material must be developed.

Cadmium effects on net N2O production by the deep-sea isolate Shewanella loihica PV-4.

Deep-sea mining may lead to the release of high concentrations of metals into the surrounding seabed, which can disturb important ecosystem functions provided by microbial communities. Among these, the production of N2O and its reduction to N2 is of great relevance since N2O is an important greenhouse gas. Metal impacts on net N2O production by deep-sea bacteria are, however, currently unexplored. Here, we evaluated the effects of cadmium (Cd) on net N2O production by a deep-sea isolate, Shewanella loihica PV-4. We performed a series of Cd exposure incubations in oxic conditions and determined N2O fluxes during induced anoxic conditions, as well as the relative expression of the nitrite reductase gene (nirK), preceding N2O production, and N2O reductase gene (nosZ), responsible for N2O reduction. Net N2O production by S. loihica PV-4 exposed to Cd was strongly inhibited when compared to the control treatment (no metal). Both nirK and nosZ gene expression were inhibited in reactors with Cd, but nirK inhibition was stronger, supporting the lower net N2O production observed with Cd. The Cd inhibition of net N2O production observed in this study poses the question whether other deep-sea bacteria would undergo the same effects. Future studies should address this question as well as its applicability to complex communities and other physicochemical conditions, which remain to be evaluated.

Tailoring of Mesoporous Silica-Based Materials for Enhanced Water Pollutants Removal.

The adsorptive performance of mesoporous silica-based materials towards inorganic (metal ions) and organic (dyes) water pollutants was investigated. Mesoporous silica materials with different particle size, surface area and pore volume were prepared and tailored with different functional groups. These materials were then characterised by solid-state techniques, namely vibrational spectroscopy, elemental analysis, scanning electron microscopy and nitrogen adsorption-desorption isotherms, allowing the successful preparation and structural modifications of the materials to be confirmed. The influence of the physicochemical properties of the adsorbents towards the removal of metal ions (Ni2+, Cu2+ and Fe3+) and organic dyes (methylene blue and methyl green) from aqueous solutions was also investigated. The results reveal that the exceptionally high surface area and suitable ζ-potential of the nanosized mesoporous silica nanoparticles (MSNPs) seem to favour the adsorptive capacity of the material for both types of water pollutants. Kinetic studies were performed for the adsorption of organic dyes by MSNPs and large-pore mesoporous silica (LPMS), suggesting that the process follows a pseudo-second-order model. The recyclability along consecutive adsorption cycles and the stability of the adsorbents after use were also investigated, showing that the material can be reused. Current results show the potentialities of novel silica-based material as a suitable adsorbent to remove pollutants from aquatic matrices with an applicability to reduce water pollution.

Buried and surface oil degradation - Evaluating bioremediation to increase PAHs removal through linear mathematical models.

A bioremediation approach with tide simulation for buried and surface oil degradation was tested for removal of two, three and four rings polycyclic aromatic hydrocarbons (PAHs). Linear models depicted degradation constants of individual PAH as simple additive function of their initial concentrations (C0) in contaminated sand, hydrophobicity, sampling layer and treatment conditions. For all PAHs and treatment conditions, the degradation of oil in buried layers was faster than at the surface. Naturally-occurring microorganisms proved to be efficient for bioremediation of PAHs and were stimulated by fertilizer addition (biostimulation, BS). Bioaugmentation (BA) by addition of a slurry of a native oil-degraders pre-stimulated consortium did not show faster PAH degradation than BS. Degradation was more rapid for PAH present at low C0 and with intermediate hydrophobicity. Bioremediation of beach sand either with surface or buried crude oil is a cost-effective strategy to clean-up different hydrocarbon families, including persistent ones, such as PAHs.

Microplastic contamination in large migratory fishes collected in the open Atlantic Ocean.

Fishes are one of the most important components of the oceans and are exposed to several anthropogenic pressures, namely microplastic (MP), contaminants that are now ubiquitous worldwide. Taking advantage of the 2020 Circumnavigation Expedition carried by the NRP Sagres tall ship of the Portuguese Navy, fish samples from the southern Atlantic ocean were collected to evaluate possible MP contamination. In a total of 14 weeks of campaign, seven large migratory fishes of commercial interest were collected across the middle Atlantic Ocean and along the South American Atlantic coast. All individuals were contaminated with MPs, with an average of 18 ± 11 MPs/fish. In all fish sampled, both the gastrointestinal tract and gills presented MPs, indicating different contamination pathways including via their preys and from surrounding water, respectively. A total of 124 MPs were observed, where 72 % were fibers and 28 % particles, mostly of blue color (85 %), and with rayon and nylon as the most abundant polymers. This study is an important contribution to increase the scientific knowledge of MP contamination in mesopelagic fishes used for human consumption and collected in the open waters, reinforcing the need for further research regarding MP contamination in top predatory species from high trophic levels.

Removing chemical and biological pollutants from swine wastewater through constructed wetlands aiming reclaimed water reuse.

Reusing reclaimed wastewater is needed to fight water scarcity, reduce freshwater consumption and conserve water resources, but one must ensure that hazardous substances are fully removed/eliminate before that reuse. The potential of lab-scale constructed wetlands (CWs) for the removal of chemical and biological contaminants from livestock wastewater, while maintaining nutrient levels for fertilization, was assessed, evaluating changes in microbial communities, with particular focus on potential pathogens. CW microcosms with two different substrates (lava rock or light expanded clay aggregate), both planted with Phragmites australis, were tested. After 15 days of treatment, removal rates were higher than 80% for Cd, Cr, Cu, Fe, Pb and Zn, in general with no significant differences between the two different substrates. Organic matter and nutrients were also removed but their levels still allowed the used of the treated wastewater as a fertilizer Removal of bacterial contamination was estimated through enumeration of cultivable bacteria. High removal rates of fecal indicator bacteria were observed, reaching >95% for enterococci and >98% for enterobacteria after 15 days of treatment, decreasing hazardous biological contaminants initially present in the wastewater. In addition, the microbial communities in the initial and treated wastewater, and in the plant roots bed substrate, were characterized by using 16SrRNA gene amplicon sequencing. Microbial communities in the CW systems showed a clear shift comparatively with the initial wastewater showing system adaptation and removal potentialities. This also revealed an important removal of the most represented potential pathogenic genus, Clostridium, which relative abundance decreased from 33% to 1% through the treatment. Overall, CWs showed potential to be efficient in removing chemical and biological contaminants, while maintaining moderated levels of nutrients, allowing the reuse of reclaimed water in agriculture, namely as fertilizer. Current results will contribute for the optimization and use of CWs for a sustainable treatment of liquid wastes, promoting the circular economy.

Optimization of an Analytical Protocol for the Extraction of Microplastics from Seafood Samples with Different Levels of Fat.

Marine organisms are affected by the ubiquitous occurrence of microplastics (MPs) in the environment. Several protocols have been described to extract and quantify MPs in seafood, although their complex matrices, with high level of fat, can compromise the efficiency of MPs extraction. To solve this issue, the present study aimed to develop a detailed methodology suitable to process seafood samples with different levels of fat, namely fish and molluscs, from fresh and canned sources, including the immersive liquids from the cans. Sample digestion was tested using different solutions (10% KOH, 30% H2O2), temperatures (40 °C, 65 °C) and incubation times (24, 48, 72 h). For fat removal, three detergents (two laboratory surfactants and a commercial dish detergent) and 96% ethanol were tested, as well as the manual separation of fat. The methodology optimized in this study combined a digestion with 30% H2O2 at 65 °C, during 24 to 48 h, with a manual separation of the fat remaining after the digestion. All steps from the present methodology were tested in six types of polymers (PE-LD, PET, PE, AC, PS, and lycra), to investigate if these procedures altered the integrity of MPs. Results showed that the optimized methodology will allow for the efficient processing of complex seafood samples with different fat levels, without compromising MPs integrity (recoveries rate higher than 89% for all the polymers tested).

Correction: Tomasino et al. Diversity and Hydrocarbon-Degrading Potential of Deep-Sea Microbial Community from the Mid-Atlantic Ridge, South of the Azores (North Atlantic Ocean). Microorganisms 2021, 9, 2389.

The authors wish to make the following corrections to this paper [...].

Antibiotics removal from aquaculture effluents by ozonation: chemical and toxicity descriptors.

Antibiotics are often applied in aquaculture to prevent fish diseases. These substances can cause disturbances on receiving waters, when not properly eliminated from the aquaculture effluents. In this work, ozone (O3) was investigated as a possible oxidizing agent to remove fishery antibiotics from aquaculture effluents: florfenicol (FF), oxytetracycline (OTC), sulfadimethoxine (SDM), sulfamethoxazole (SMX), and trimethoprim (TMP). Batch experiments were performed using ultrapure water and aquaculture effluents spiked with a mixture of target antibiotics at relatively high concentrations (10 mg L-1 each). OTC, SMX and TMP were fully removed (< 30 min) regardless of the tested conditions, mainly by O3 direct attack. In contrast, FF was partially removed in 30 min (∼ 10 and 60%, in aquaculture effluents and ultrapure water, respectively), but only in the presence of hydroxyl radicals (HO•), the FF concentrations reaching levels below the detection limits in ultrapure water after 60 min. In the case of SDM, its degradation was highly influenced by the selected water matrix, but with removals always higher than 68%. In continuous-flow experiments applying more environmentally relevant antibiotic concentrations (100 ng L-1 each) and low O3 doses (1.5 mg L-1), ozonation highly removed (> 98%) all tested antibiotics from aquaculture effluents with a hydraulic retention time (HRT) of 10 min, except FF (68%). Although by-products were detected in treated samples, zebrafish (Danio rerio) embryotoxicity tests did not show a toxicity increase by applying this ozonation treatment. Ozonation is thus a possible solution to remove antibiotics from aquaculture effluents. Still, full-scale studies in aquaculture farms are needed, and generation of HO• may be favoured to readily oxidize the FF antibiotic.

Revisiting pesticide pollution: The case of fluorinated pesticides.

Fluorinated pesticides acquired a significant market share in the agrochemical sector due to the surge of new fluoroorganic ingredients approved in the last two decades. This growing trend has not been accompanied by a comprehensive scientific and regulatory framework entailing all their potential negative impacts for the environment, especially when considering the hazardous properties that may result from the incorporation of fluorine into organic molecules. This review aims to address the safe/hazardous dichotomy associated with fluorinated pesticides by providing an updated outlook on their relevancy in the agrochemical sector and how it leads to their role as environmental pollutants. Specifically, the environmental fate and distribution of these pesticides in the ecosystems is discussed, while also analysing their potential to act as toxic substances for non-target organisms.

Atlas of the microbial degradation of fluorinated pesticides.

Fluorine-based agrochemicals have been benchmarked as the golden standard in pesticide development, prompting their widespread use in agriculture. As a result, fluorinated pesticides can now be found in the environment, entailing serious ecological implications due to their harmfulness and persistence. Microbial degradation might be an option to mitigate these impacts, though environmental microorganisms are not expected to easily cope with these fluoroaromatics due to their recalcitrance. Here, we provide an outlook on the microbial metabolism of fluorinated pesticides by analyzing the degradation pathways and biochemical processes involved, while also highlighting the central role of enzymatic defluorination in their productive metabolism. Finally, the potential contribution of these microbial processes for the dissipation of fluorinated pesticides from the environment is also discussed.

Advanced oxidation technologies and constructed wetlands in aquaculture farms: What do we know so far about micropollutant removal?

Aquaculture is the fastest growing animal food-producing sector. Water is the central resource for aquaculture, and it is essential that its quality be preserved. Micropollutants (MPs) can reach aquaculture through anthropogenic addition or inlet water, and may cause harmful effects such as endocrine disruption and antibiotic resistance, adversely affecting the fish species being farmed. Furthermore, the discharge of aquaculture effluents into the environment may contribute to the deterioration of water courses. In this sense, the implementation of environmentally responsible measures in aquaculture farms is imperative for the protection of ecosystems and human health. The European Commission (EC) has recently launched a guiding document promoting ecological aquaculture practices; however, options for water treatment are still lacking. Conventional processes are not designed to deal with MPs; this review article consolidates relevant information on the application of advanced oxidation technologies (AOTs) and constructed wetlands (CWs) as potential strategies in this regard. Although 161 studies on the application of AOTs or CWs in aquaculture have already been published, only 34 focused on MPs (28 on AOTs and 6 on CWs), whereas the others reported the removal of contaminants such as bacteria, organic matter, solids and inorganic ions. No study coupling both treatments has been reported to date for the removal of MPs from aquaculture waters. AOTs and CWs are prospective alternatives for the treatment of aquacultural aqueous matrices. However, the type of aquaculture activity and the specifications of these available technologies should be considered while selecting the most suitable treatment option.