Assessment of the estuarine shoreline microplastics and mesoplastics of the River Itchen, Southampton (UK) for contaminants and for their interaction with invertebrate fauna.

The presence of shoreline microplastics (1-5 mm) and mesoplastics (5-25 mm) in estuarine ecosystems is ubiquitous, but there remains little data on their composition, contamination status and ecological impacts. Chessel Bay Nature Reserve, situated in the internationally protected Itchen Estuary in Southampton, UK, has serious issues with shoreline plastic accumulation. In evaluating potentially adverse ecological impacts, the influence of quantities of shoreline microplastic (mp) and mesoplastic (MeP) material and adsorbed contaminants (PAHs and trace metals) on the biometrics and population dynamics of the burrowing supralittoral amphipod, Orchestia gammarellus, was assessed in this study. mp/MeP concentrations were variable in surface (0-42%: 0-422,640 mg/kg dry sediment) and subsurface horizons (0.001-10%: 11-97,797 mg/kg dry sediment). Secondary microplastics accounted for 77% of the total microplastic load (dominated by fragments and foams), but also comprised 23% nurdles/pellets (primary microplastics). Sorption mechanisms between contaminants and natural sediments were proposed to be the main contributor to the retention of PAHs and trace metal contaminants and less so, by mp/MeP. O. gammarellus populations showed a positive correlation with microplastic concentrations (Spearman correlation, R = 0.665, p = 0.036). Some reported toxicological thresholds were exceeded in sediments, but no impacts related to chemical contaminant concentrations were demonstrated. This study highlights a protected site with the severe plastic contamination, and the difficulty in demonstrating in situ ecotoxicological impacts.

Microplastics in European sea salts - An example of exposure through consumer choice and of interstudy methodological discrepancies.

Microplastics are contaminants of emerging concern, not least due to their global presence in marine surface waters. Unsurprisingly, microplastics have been reported in salts harvested from numerous locations. We extracted microplastics from 13 European sea salts through 30% H2O2 digestion and filtration over 5-µm filters. Filters were visually inspected at magnifications to x100. A subsample of potential microplastics was subjected to Raman spectroscopy. Particle mass was estimated, and human dose exposure calculated. After blank corrections, median concentrations were 466 ± 152 microplastics kg-1 ranging from 74 to 1155 items kg-1. Traditionally harvested salts contained fewer microplastics than most industrially harvested ones (t-test, p < 0.01). Approximately 14 µg of microplastics (< 12 particles) may be absorbed by the human body annually, of which a quarter may derive from a consumer choosing sea salt. We reviewed existing studies, showing that targeting different particle sizes and incomplete filtrations hinder interstudy comparison, indicating the importance of method harmonisation for future studies. Excess salt consumption is detrimental to human health; the hazardousness of ingesting microplastics on the other hand has yet to be shown. A portion of microplastics may enter sea salts through production processes rather than source materials.

Toxicity of tributyltin to the European flat oyster Ostrea edulis: Metabolomic responses indicate impacts to energy metabolism, biochemical composition and reproductive maturation.

Tri-Butyl Tin (TBT) remains as a legacy pollutant in the benthic environments. Although the toxic impacts and endocrine disruption caused by TBT to gastropod molluscs have been established, the changes in energy reserves allocated to maintenance, growth, reproduction and survival of European oysters Ostrea edulis, a target species of concerted benthic habitat restoration projects, have not been explored. This study was designed to evaluate the effect of TBT chloride (TBTCl) on potential ions and relevant metabolomic pathways and its association with changes in physiological, biochemical and reproductive parameters in O. edulis exposed to environmental relevant concentrations of TBTCl. Oysters were exposed to TBTCl 20 ng/L (n = 30), 200 ng/L (n = 30) and 2000 ng/L (n = 30) for nine weeks. At the end of the exposure, gametogenic stage, sex, energy reserve content and metabolomic profiling analysis were conducted to elucidate the metabolic alterations that occur in individuals exposed to those compounds. Metabolite analysis showed significant changes in the digestive gland biochemistry in oysters exposed to TBTCl, decreasing tissue ATP concentrations through a combination of the disruption of the TCA cycle and other important molecular pathways involved in homeostasis, mitochondrial metabolism and antioxidant response. TBTCl exposure increased mortality and caused changes in the gametogenesis with cycle arrest in stages G0 and G1. Sex determination was affected by TBTCl exposure, increasing the proportion of oysters identified as males in O. edulis treated at 20ng/l TBTCl, and with an increased proportion of inactive stages in oysters treated with 2000 ng/l TBTCl. The presence and persistence of environmental pollutants, such as TBT, could represent an additional threat to the declining O. edulis populations and related taxa around the world, by increasing mortality, changing reproductive maturation, and disrupting metabolism. Our findings identify the need to consider additional factors (e.g. legacy pollution) when identifying coastal locations for shellfish restoration.

Assessing the effectiveness of microplastic extraction methods on fishmeal with different properties.

Microplastic presence in fishmeal is an emerging research area because of its potential to enter food chains, and the importance of fishmeal within global food security. However, fishmeal is a complex medium dependant on fish composition. This study measured properties (organics, carbonates, protein and density) of five fishmeal types (trimmings, sardine and anchovy, krill, tuna and salmon), sourced from locations worldwide (Norway, South America, Antarctica, Spain and Scotland). Microplastic recovery rates were compared for existing methodologies using sodium chloride overflows and potassium hydroxide digestions and then compared to newly developed methods. These methods included dispersants and calcium chloride density separations which were developed and designed to be environmentally conscious and affordable, which we argue should become an international standard approach for researchers. A calcium chloride overflow with dispersant and potassium hydroxide digestion provided the highest recovery rate in sardine and anchovy fishmeal (66.3%). Positive correlations with recovery rate were found with protein content, and negative correlations with organic content. Low recovery rates found here suggest microplastics in fishmeal reported in the literature are underestimated. With complex media such as fishmeal, attention must be paid to variation between types and composition when choosing methods and interpreting results.

Evidence of underestimation in microplastic research: A meta-analysis of recovery rate studies.

Research on microplastics in the environment is of high interest to many scientists and industries globally. Key to the success of this research is the accuracy, efficiency, reliability, robustness and repeatability of the method(s) used to isolate the microplastics from environmental media. However, with microplastics now being found in new complex media, many multifaceted methods have been developed to research the quantities of these pollutants. To validate new methods, recovery studies can be undertaken by spiking the test medium with known quantities of plastics. The method is typically run as normal, and the recovered plastics counted to give a recovery rate. A current issue in this field is that methods are rarely or poorly validated in this way. Here, we conducted a meta-analysis on 71 recovery rate studies. We found sediment was the most studied medium and saline solutions were the most used reagents. Polyethylene and polystyrene were the most used spiking polymers, which is relevant to the most common polymers in the environment. We found that recovery rates were highest from plant material, whole organisms and excrement (>88%), and lowest from fishmeal, water and soil (58-71%). Moreover, all reagents but water were able to recover more than 80% of the spiked plastics. We believe we are the first (to our knowledge) to provide an overarching indication for the underestimation of microplastics in the environment of approximately 14% across the studies we reviewed, varying with the methods used. Furthermore, we recommend that the quality, use and reporting of recovery rate studies should be improved to aid the standardisation and replication of microplastic research.

Multi-parametric magnetic resonance imaging assessment of whole tumour heterogeneity for chemoradiotherapy response prediction in rectal cancer.

BACKGROUND AND PURPOSE: Prediction of chemoradiotherapy response (CRT) in locally advanced rectal cancer would enable stratification of management. The purpose was to prospectively evaluate multi-parametric magnetic resonance imaging (MRI) assessment of tumour heterogeneity combining diffusion weighted imaging (DWI) and dynamic contrast enhanced (DCE) MRI for the prediction of CRT response in locally advanced rectal cancer. MATERIALS AND METHODS: Patients with Stage II or III rectal adenocarcinoma undergoing neoadjuvant CRT and surgery underwent MRI (DWI and DCE) before, during (week 3), and after CRT (1 week before surgery). Patients with histopathology tumour regression grade (TRG) 0-1 were classified as responders, and TRG 2-3 were classified as non-responders. A whole tumour voxel-wise technique was used to produce apparent diffusion coefficient (ADC) and Ktrans (Tofts model) histograms derived from DWI and DCE-MRI, respectively. Logistic regression was used to predict response status for ADC and Ktrans quantiles. RESULTS: Thirty-three patients were included in this analysis; 16 responders, and 17 non-responders. On heterogeneity analysis, odds of being a responder were significantly higher after CRT (before surgery) for higher ADC 75th (p = 0.049) and ADC 90th (p = 0.034) percentile values. The Ktrans quantiles were lower in non-responders than responders before and during CRT, and higher after CRT although no significant association with response status was observed (p ≥ 0.10). CONCLUSIONS: DWI-MRI after CRT (before surgery) incorporating a histogram analysis of whole tumour heterogeneity was predictive of CRT response in patients with locally advanced rectal cancer. DCE-MRI did not add value in response prediction. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12616001690448.

Developing a systematic method for extraction of microplastics in soils.

Microplastics are an environmental issue of global concern. Although they have been found in a range of environments worldwide, their contamination in the terrestrial environment is poorly understood. The lack of standardised methods for their detection and quantification is a major obstacle for determining the risk they pose to soil environments. Here we present a systematic comparison of microplastic extraction methods from soils, taking into account the characteristics of the soil medium to determine the best methods for quantification. The efficiency of organic matter removal using hydrogen peroxide, potassium hydroxide and Fenton's reagent was measured. Soils with a range of particle size distribution and organic matter content were spiked with a variety of microplastic types. Density separation methods using sodium chloride, zinc chloride and canola oil were tested. Recovery efficiencies were calculated and the impact of the reagents on the microplastics was quantified using Attenuated Total Reflectance (ATR) Fourier Transform-Infrared (FTIR) spectroscopy. The optimal organic removal method was found to be hydrogen peroxide. The recovery efficiency of microplastics was variable across polymer types. Overall, canola oil was shown to be the optimal method for density separation, however, efficiency was dependent on the amount of organic matter in the soil. This outcome highlights the importance of including matrix-specific calibration in future studies considering a wide range of microplastic types, to avoid underestimation of microplastic contamination. We show here that methods for extracting microplastics from soils can be simple, cost-effective and widely applicable, which will enable the advancement of microplastic research in terrestrial environments.

Uncertainty about the risks associated with microplastics among lay and topic-experienced respondents.

Microplastics are contaminants of emerging concern but there is currently a lack of evidence on actual risks relating to them, despite claims in media and scientific articles. Research on people's perceptions on microplastics is in its infancy. Here we present part of a larger survey about people's perceptions of issues with microplastics. Our analysis of 1681 responses across the globe to an online questionnaire demonstrates a certain level of uncertainty, not only in lay people but also respondents who study/work on the topic of plastics and microplastics as a pollutant. This uncertainty ranges from level of concern about microplastics as an environmental issue to existing evidence for effects. Further, there is some discrepancy between risk perception and state of the research. Some of this may be driven by scientific work with some serious limitations in reporting and methods. This highlights the need for fact-checking of circulating information about microplastics, but also for addressing the discordance between ecotoxicological risk and how risk is framed within the scientific community.

Microplastics in fish and fishmeal: an emerging environmental challenge?

Microplastics are contaminants of emerging concern; they are ingested by marine biota. About a quarter of global marine fish landings is used to produce fishmeal for animal and aquaculture feed. To provide a knowledge foundation for this matrix we reviewed the existing literature for studies of microplastics in fishmeal-relevant species. 55% of studies were deemed unsuitable due to focus on large microplastics (> 1 mm), lack of, or limited contamination control and polymer testing techniques. Overall, fishmeal-relevant species exhibit 0.72 microplastics/individual, with studies generally only assessing digestive organs. We validated a density separation method for effectiveness of microplastic extraction from this medium and assessed two commercial products for microplastics. Recovery rates of a range of dosed microplastics from whitefish fishmeal samples were 71.3 ± 1.2%. Commercial samples contained 123.9 ± 16.5 microplastics per kg of fishmeal-mainly polyethylene-including 52.0 ± 14.0 microfibres-mainly rayon. Concentrations in processed fishmeal seem higher than in captured fish, suggesting potential augmentation during the production process. Based on conservative estimates, over 300 million microplastic particles (mostly < 1 mm) could be released annually to the oceans through marine aquaculture alone. Fishmeal is both a source of microplastics to the environment, and directly exposes organisms for human consumption to these particles.

Validation of a method to quantify microfibres present in aquatic surface microlayers.

Many of the methods for microplastics quantification in the environment are criticised creating problems with data validity. Quantification of microplastics in the surface microlayer of aquatic environments using glass plate dipping holds promise as a simple field method, but its efficiency has yet to be validated. We tested a standard glass plate dipping method to assess recovery of four common polymer microfibres and two common natural fibres, under three different salinities (freshwater, brackish water, saltwater). Overall recovery rates were low (26.8 ± 1.54%) but higher recoveries were observed under saltwater treatments (36.5 ± 3.01%) than brackish water (24.5 ± 1.92%) or freshwater (19.3 ± 1.92%). The fibre types showed different recovery rates, with acrylic yielding significantly higher recovery rates (37.0 ± 2.71%) than other fibres across treatments. No clear relationship between the density of the fibres and the recovery efficiency was seen. We suggest that, where this method is used for monitoring microplastics, the results will typically underestimate the total amount present, but that recovery is sufficiently consistent to allow comparison of differences between sampling locations. When comparing data across river-estuarine or similar transects salinity should be monitored to account for salinity-induced differences in sampling recovery.

Identification of tidal trapping of microplastics in a temperate salt marsh system using sea surface microlayer sampling.

Microplastics are contaminants of increasing global environmental concern. Estuaries are a major transport pathway for land-derived plastics to the open ocean but are relatively understudied compared to coastal and open marine environments. The role of the "estuarine filter", by which the supply of sediments and contaminants to the sea is moderated by processes including vegetative trapping and particle flocculation, remains poorly defined for microplastics land to sea transfer. Here, we focus on the sea surface microlayer (SML) as a vector for microplastics, and use SML sampling to assess microplastic trapping in a temperate marsh system in Southampton Water, UK. The SML is known to concentrate microplastics relative to the underlying water and is the first part of rising tidal waters to traverse intertidal and upper tidal surfaces. Sampling a salt marsh creek at high temporal resolution allowed assessment of microplastics in-wash and outflow from the salt marsh, and its relationship with tidal state and bulk suspended sediment concentrations (SSC), over spring and neap tides. A statistically significant decrease in microplastics abundance from the flood tide to the ebb tide was found, and a weak positive relationship with SSC observed.

Disengagement from mental health treatment and re-offending in those with psychosis: a multi-state model of linked data.

BACKGROUND AND AIMS: Individuals with psychosis are over-represented in the criminal justice system and, as a group, are at elevated risk of re-offending. Recent studies have observed an association between increased contacts with mental health services and reduced re-offending, as well as reduced risk of re-offending in those who are ordered to mental health treatment rather than punitive sanctions. In furthering this work, this study examines the effect of disengagement from mental health treatment on probability of re-offence in offenders with psychosis over time. METHODS: Data linkage was conducted with judicial, health and mortality datasets from New South Wales, Australia (2001-2015). The study population included 4960 offenders with psychosis who received non-custodial sentences and engaged with community-based mental health treatment. Risk factors for leaving treatment and/or reconviction were examined using multivariate cox regression. Further, a multi-state model was used to observe the probabilities associated with individuals moving between three states: conviction, disengagement from mental health treatment and subsequent re-conviction. RESULTS: A threefold increase was observed in the risk of re-offending for those who disengaged from treatment compared to those who did not (aHR = 2.76, 95% CI 1.65-4.62, p < 0.001). The median time until re-offence was 195 days, with the majority (67%) being convicted within one year of leaving treatment. A higher risk of leaving treatment was found for those born outside of Australia, with substance-related psychosis, and a history of violent offence. CONCLUSIONS: The findings argue for an emphasis on continued engagement with mental health services following release for offenders with psychosis and identify subgroups within this population for whom concentrated efforts regarding treatment retention should be targeted.

Effects of the interaction between temperature and steroid hormones on gametogenesis and sex ratio in the European flat oyster (Ostrea edulis).

Throughout Europe, populations of Ostrea edulis have been in decline since the 1970s. Temperature has an important influence on physiological, biochemical and reproductive attributes of oysters. It is also the most easily modulated environmental factor in hatcheries, so it is useful to understand the implications of temperature variation in driving gametogenesis and sex development in a protandrous sequential hermaphrodites such as O. edulis. To understand the effect of temperature on gametogenesis and sex ratio, as well as the potential mechanism of sex determination through the role of steroid hormone homologues, oysters were exposed to three temperatures (10, 14, and 18 °C) for four months. Gametogenic stage and sex ratio were assessed histologically for each treatment. In parallel, concentrations of estradiol (E2)- and testosterone (T)- were determined in developing gonads. Our data show that by some biometric parameters, gametogenesis and sex ratio were significantly influenced by temperature during the experiment. There was a weak but significant correlation between E2 and T concentration during the treatments. However, and importantly, a direct relation between gonadal maturation, sex determination and hormones concentration was not found. These results suggest that gametogenesis and sex determination are predominantly affected by temperature in this species, and that steroids may not be actively involved as endogenous modulators in sex determination. Rising sea water temperatures and warmer condition through the year could cause an accelerated gametogenesis and skewed sex ratios in natural populations of O. edulis.

Evaluation of existing methods to extract microplastics from bivalve tissue: Adapted KOH digestion protocol improves filtration at single-digit pore size.

Methods standardisation in microplastics research is needed. Apart from reagent-dependent effects on microplastics, varying target particle sizes can hinder result comparison between studies. Human health concerns warrant recovery of small microplastics. We compared existing techniques using hydrogen peroxide, Proteinase-K, Trypsin and potassium hydroxide to digest bivalve tissue. Filterability, digestion efficacy, recoverability of microplastics and subsequent polymer identification using Raman spectroscopy and a matching software were assessed. Only KOH allowed filtration at ≤25 µm. When adding a neutralisation step prior to filtration, KOH digestates were filterable using 1.2-µm filters. Digestion efficacies were >95.0% for oysters, but lower for clams. KOH destroyed rayon at 60 °C but not at 40 °C. Acrylic fibre identification was affected due to changes in Raman spectra peaks. Despite those effects, we recommend KOH as the most viable extraction method for exposure risk studies, due to microplastics recovery from bivalve tissues of single-digit micrometre size.

When do patient reported quality of life indicators become prognostic in breast cancer?

BACKGROUND: Various patient reported quality-of-life indicators are independently prognostic for survival in metastatic breast cancer and other cancers. The same measures recorded at first diagnosis of early breast cancer carry no corresponding prognostic information. The present study aims to assess at what time in the disease evolution the prognostic association appears. METHODS: Among 8024 patients enrolled in one of seven randomized controlled trials in early-stage breast cancer 3247 had a breast cancer relapse after a median follow-up of 12.1 years. Of these 677 had completed QL indicator assessments within defined windows 1, 2 or 3 months prior to relapse. We performed Cox regression analyses using these assessments and using identical instruments after relapse. All analyses were stratified by trial and adjusted for baseline clinicopathologic factors. RESULTS: QL indicators in the months before relapse were not significantly prognostic for subsequent survival with the possibly chance exception of mood at the second month before relapse. After relapse, physical well-being was statistically significantly associated with survival (P < 0.001). This prognostic significance increased in later post-relapse assessments. Similar findings were observed using patient-reported indicators for nausea and vomiting, appetite, coping effort, and health perception. CONCLUSIONS: Before cancer relapse, QL indicators were not generally prognostic for subsequent survival. After relapse, QL indicators substantially predicted OS, with a stronger association later in the course of relapsed disease. Simple patient perception of disease burden seems unlikely to explain this sudden change: rather the patient's awareness of disease relapse must contribute.

Challenges for tree officers to enhance the provision of regulating ecosystem services from urban forests.

Urbanisation and a changing climate are leading to more frequent and severe flood, heat and air pollution episodes in Britain's cities. Interest in nature-based solutions to these urban problems is growing, with urban forests potentially able to provide a range of regulating ecosystem services such as stormwater attenuation, heat amelioration and air purification. The extent to which these benefits are realized is largely dependent on urban forest management objectives, the availability of funding, and the understanding of ecosystem service concepts within local governments, the primary delivery agents of urban forests. This study aims to establish the extent to which British local authorities actively manage their urban forests for regulating ecosystem services, and identify which resources local authorities most need in order to enhance provision of ecosystem services by Britain's urban forests. Interviews were carried out with staff responsible for tree management decisions in fifteen major local authorities from across Britain, selected on the basis of their urban nature and high population density. Local authorities have a reactive approach to urban forest management, driven by human health and safety concerns and complaints about tree disservices. There is relatively little focus on ensuring provision of regulating ecosystem services, despite awareness by tree officers of the key role that urban forests can play in alleviating chronic air pollution, flood risk and urban heat anomalies. However, this is expected to become a greater focus in future provided that existing constraints - lack of understanding of ecosystem services amongst key stakeholders, limited political support, funding constraints - can be overcome. Our findings suggest that the adoption of a proactive urban forest strategy, underpinned by quantified and valued urban forest-based ecosystem services provision data, and innovative private sector funding mechanisms, can facilitate a change to a proactive, ecosystem services approach to urban forest management.

Patients' preferred and perceived roles in making decisions about adjuvant chemotherapy for non-small-cell lung cancer.

BACKGROUND: People with cancer have varying preferences for involvement in decision-making between active, collaborative and passive roles. We sought the preferred and perceived involvement in decision-making among patients considering adjuvant chemotherapy (ACT) after resection of early non-small cell lung cancer (NSCLC). METHODS: Patients considering ACT for NSCLC were asked to complete a self-administered questionnaire at baseline and 6 months. Preferred and perceived decision-making roles were assessed by the Control Preferences Scale (CPS). We examined differences between preferred and perceived roles, differences in preferred roles over time, determinants of preferences, and differences in treatment preferences between patients preferring active and less active roles. RESULTS: 98 patients completed the baseline questionnaire; 75 completed the 6 month questionnaire. Most patients were male (55%) with a median age of 64 years (range, 43-79 years). Preferred role in decision-making at baseline (n=98) was active in 27%, collaborative in 47%, and passive in 27%. Perceived decision-making roles matched the preferred role in 79% of patients. Individuals' role preferences often varied between baseline and 6 months, but there was no consistent direction to the change (25% changed preference to more active involvement, 22% to less active). Preferring a more active role was associated with university education (OR 2.9, p=0.02), deciding not to have ACT (OR 5.0, p<0.01), and worse health-related quality of life (HRQL) during ACT: physical well-being (OR 4.4, p=0.05), overall well-being (OR 5.5, p=0.02), sleep (OR 8.4, p<0.01) and shortness of breath (OR 7.6, p=0.01). Patients who preferred an active decision-making role judged larger survival benefits necessary to make ACT worthwhile than those preferring a passive role. CONCLUSION: Most patients with resected NSCLC preferred and perceived a collaborative role in decision-making about ACT. Clinicians should elicit and consider patients' preferences for involvement in decision-making when discussing ACT for NSCLC.

Impact of Improved Glycemic Control on Cardiac Function in Type 2 Diabetes Mellitus.

BACKGROUND: Patients with type 2 diabetes mellitus are at risk of heart failure. Specific therapeutic interventions for diabetic heart disease are still elusive. We aimed to examine the impact of improved glycemic control on left ventricular (LV) function in these patients. METHODS AND RESULTS: A total of 105 subjects with type 2 diabetes mellitus (aged 54±10 years) and poor glycemic control received optimization of treatment for blood glucose, blood pressure, and cholesterol to recommended targets for 12 months. LV systolic and diastolic function, measured by LV global longitudinal strain (GLS) and septal e' velocities, were compared before and after optimization. At baseline, patients had impaired LV systolic (GLS -14.9±3.2%) and diastolic function (e' 6.2±1.7 cm/s). After 12 months, glycated hemoglobin (HbA1c) decreased from 10.3±2.4% to 8.3±2.0%, which was associated with significant relative improvement in GLS of 21% and septal e' of 24%. There was a progressively greater improvement in GLS as patients achieved a lower final HbA1c. Patients achieving an HbA1c of <7.0% had the largest improvement. The 15 patients whose HbA1c worsened experienced a decline in GLS. Patients who improved their HbA1c by ≥1.0% had a significantly higher relative improvement in e' than those who did not (32% versus 8%; P=0.003). Baseline GLS, decrease in body mass index, and treatment with metformin were additional independent predictors of GLS improvement. CONCLUSIONS: Improvements in glycemic control over a 12-month period led to improvements in LV systolic and diastolic function. This may have long-term prognostic implications.

Patients' and doctors' preferences for adjuvant chemotherapy in resected non-small-cell lung cancer: What makes it worthwhile?

BACKGROUND: Adjuvant chemotherapy (ACT) in non-small-cell lung cancer (NSCLC) improves overall survival, but the benefits must be weighed against its harms. We sought to determine the survival benefits that patients and their doctors judged sufficient to make ACT in NSCLC worthwhile. METHODS: 122 patients completed a self-administered questionnaire at baseline and 6 months (before & after ACT, if they had it); 82 doctors completed the questionnaire once only. The time trade-off method was used to determine the minimum survival benefits judged sufficient in four hypothetical scenarios. Baseline survival times were 3 years & 5 years and baseline survival rates (at 5 years) were 50% & 65%. RESULTS: At baseline, the median benefits judged sufficient by patients were an extra 9 months (Interquartile range (IQR) 1-12 months) beyond 3 years & 5 years and an extra 5% (IQR 0.1-10%) beyond 50% & 65%. At 6 months (n=91), patients' preferences had the same median benefit (9 months & 5%) but varied more (IQRs 0-18 months & 0-15%) than at baseline. Factors associated with judging smaller benefits sufficient were deciding to have ACT (P=0.01, 0.02) and better well-being (P=0.01, 0.006) during ACT. Doctors' preferences, compared with patients' preferences, had similar median benefits (9 months & 5%) but varied less (IQR 6-12 months versus 1-12 months, P<0.001; 5%-10% versus 0.1-10%, P<0.001). CONCLUSION: Most patients and doctors judged moderate survival benefits sufficient to make ACT in NSCLC worthwhile, but the preferences of doctors varied less than those of patients. Doctors should endeavour to elicit patients' preferences during discussions about ACT in NSCLC.

Front gardens to car parks: changes in garden permeability and effects on flood regulation.

This study addresses the consequences of widespread conversion of permeable front gardens to hard standing car parking surfaces, and the potential consequences in high-risk urban flooding hotspots, in the city of Southampton. The last two decades has seen a trend for domestic front gardens in urban areas to be converted for parking, driven by the lack of space and increased car ownership. Despite media and political attention, the effects of this change are unknown, but increased and more intense rainfall, potentially linked to climate change, could generate negative consequences as runoff from impermeable surfaces increases. Information is limited on garden permeability change, despite the consequences for ecosystem services, especially flood regulation. We focused on eight flooding hotspots identified by the local council as part of a wider urban flooding policy response. Aerial photographs from 1991, 2004 and 2011 were used to estimate changes in surface cover and to analyse permeability change within a digital surface model in a GIS environment. The 1, 30 and 100 year required attenuation storage volumes were estimated, which are the temporary storage required to reduce the peak flow rate given surface permeability. Within our study areas, impermeable cover in domestic front gardens increased by 22.47% over the 20-year study period (1991-2011) and required attenuation storage volumes increased by 26.23% on average. These increases suggest that a consequence of the conversion of gardens to parking areas will be a potential increase in flooding frequency and severity - a situation which is likely to occur in urban locations worldwide.