Learning from the QUEST multicentre feasibility randomization trials in breast reconstruction after mastectomy

BACKGROUND: Breast reconstruction aims to improve health-related quality of life after mastectomy. However, evidence guiding patients and surgeons in shared decision-making concerning the optimal type or timing of surgery is lacking.

METHODS: QUEST comprised two parallel feasibility phase III randomized multicentre trials to assess the impact of the type and timing of latissimus dorsi breast reconstruction on health-related quality of life when postmastectomy radiotherapy is unlikely (QUEST A) or highly probable (QUEST B). The primary endpoint for the feasibility phase was the proportion of women who accepted randomization, and it would be considered feasible if patient acceptability rates exceeded 25 per cent of women approached. A companion QUEST Perspectives Study (QPS) of patients (both accepting and declining trial participation) and healthcare professionals assessed trial acceptability.

RESULTS: The QUEST trials opened in 15 UK centres. After 18 months of recruitment, 17 patients were randomized to QUEST A and eight to QUEST B, with overall acceptance rates of 19 per cent (17 of 88) and 22 per cent (8 of 36) respectively. The QPS recruited 56 patients and 51 healthcare professionals. Patient preference was the predominant reason for declining trial entry, given by 47 (53 per cent) of the 88 patients approached for QUEST A and 22 (61 per cent) of the 36 approached for QUEST B. Both trials closed to recruitment in December 2012, acknowledging the challenges of achieving satisfactory patient accrual.

CONCLUSION: Despite extensive efforts to overcome recruitment barriers, it was not feasible to reach timely recruitment targets within a feasibility study. Patient preferences for breast reconstruction types and timings were common, rendering patients unwilling to enter the trial.

The Hidden benefits of “poster presentation assessment”: Skill acquirement and learning; evaluated from the nursing students perspective

Introduction
This paper reports to an exercise in evaluating poster group work and poster presentation and the extra learning and skill acquisition that this can provide to nursing students, through a creative and stimulating assessment method. Much had been written about the benefits of using posters as an assessment method, yet there appears to be a lack of research that captures the student experience.
Aim
This evaluative study sought to evaluate the student experience by using a triangulation approach to evaluation:
Methodology
All students from the February 2015 nursing intake, were eligible to take part (80 students) of which 71 participated (n=71). The poster group presentations took place at the end of their first phase of year one teaching and the evaluation took place at the end of their first year as undergraduate. Evaluation involved;
1. Quantitative data by questionnaires
2. Qualitative data from focus group discussions
Results
A number of key themes emerged from analysis of the data which captured the “added value” of learning from the process of poster assessment including:
 Professionalism: developing time keeping skills, presenting skills.
 Academic skills: developing literature search, critic and reporting
 Team building and collaboration
Overall 88% agreed that the process furnished them with additional skills and benefits above the actual production of the poster, with 97% agreeing that these additional skills are important skills for a nurse.
Conclusion
These results would suggest that the process of poster development and presentation furnish student nurses with many additional skills that they may not acquire through other types of assessment and are therefore beneficial. The structure of the assessment encourages a self-directed approach so students take control of the goals and purposes of learning. The sequential organization of the assessment guides students in the transition from dependent to self-directed learners.

Determining the response of African biota to climate change: using the past to model the future

Prediction of biotic responses to future climate change in tropical Africa tends to be based on two modelling approaches: bioclimatic species envelope models and dynamic vegetation models. Another complementary but underused approach is to examine biotic responses to similar climatic changes in the past as evidenced in fossil and historical records. This paper reviews these records and highlights the information that they provide in terms of understanding the local- and regional-scale responses of African vegetation to future climate change. A key point that emerges is that a move to warmer and wetter conditions in the past resulted in a large increase in biomass and a range distribution of woody plants up to 400–500 km north of its present location, the so-called greening of the Sahara. By contrast, a transition to warmer and drier conditions resulted in a reduction in woody vegetation in many regions and an increase in grass/savanna-dominated landscapes. The rapid rate of climate warming coming into the current interglacial resulted in a dramatic increase in community turnover, but there is little evidence for widespread extinctions. However, huge variation in biotic response in both space and time is apparent with, in some cases, totally different responses to the same climatic driver. This highlights the importance of local features such as soils, topography and also internal biotic factors in determining responses and resilience of the African biota to climate change, information that is difficult to obtain from modelling but is abundant in palaeoecological records.

Holocene climate change, vegetation history and human impact in the Central Mediterranean: evidence from the Maltese Islands

Holocene climates and human impact in the Mediterranean basin have received much attention, but the Maltese Islands in the Central Mediterranean, although a pivotal area, have been little researched. Here, sedimentary and palynological data are presented for three cores from the Holocene coastal and shallowmarine
deposits of the Maltese Islands. These show deforestation from Pinus-Cupressaceae woodland in the early Neolithic, and then a long, but relatively stable history of agriculturally degraded environments to the present day. The major climate events which have affected the Italian and Balkan peninsulas to the
north, and Tunisia to the south, are not reflected in the pollen diagrams from the Maltese Islands because of the strong anthropogenic imprint on the Maltese vegetation from early in the Neolithic. Previous suggestions of environmentally-driven agricultural collapse at the end of the Neolithic appear, however,
to be substantiated and may be linked to regional aridification around 4300 cal. BP. Depopulation in early Medieval times is not supported by the current palynological evidence.

Stomatal proxy record of CO2 concentrations from the last termination suggests an important role for CO2 at climate change transitions

A new stomatal proxy-based record of CO₂ concentrations ([CO₂]), based on Betula nana (dwarf birch) leaves from the Hässeldala Port sedimentary sequence in south-eastern Sweden, is presented. The record is of high chronological resolution and spans most of Greenland Interstadial 1 (GI-1a to 1c, Allerød pollen zone), Greenland Stadial 1 (GS-1, Younger Dryas pollen zone) and the very beginning of the Holocene (Preboreal pollen zone). The record clearly demonstrates that i) [CO₂] were significantly higher than usually reported for the Last Termination and ii) the overall pattern of CO₂ evolution through the studied time period is fairly dynamic, with significant abrupt fluctuations in [CO₂] when the climate moved from interstadial to stadial state and vice versa. A new loss-on-ignition chemical record (used here as a proxy for temperature) lends independent support to the Hässeldala Port [CO₂] record. The large-amplitude fluctuations around the climate change transitions may indicate unstable climates and that " tipping-point" situations were involved in Last Termination climate evolution. The scenario presented here is in contrast to [CO₂] records reconstructed from air bubbles trapped in ice, which indicate lower concentrations and a gradual, linear increase of [CO₂] through time. The prevalent explanation for the main climate forcer during the Last Termination being ocean circulation patterns needs to re-examined, and a larger role for atmospheric [CO₂] considered.

A Late Pleistocene record of climate and environmental change from the northern and southern Kelabit Highlands of Sarawak, Malaysian Borneo

A late Pleistocene vegetation record is presented, using multi-proxy analysis from three palaeochannels in the northern (Bario) and southern (Pa'Dalih) Kelabit Highlands of Sarawak, Malaysian Borneo. Before 50 000 cal a BP and until approximate to 47 700 cal a BP [marine isotope stage 3 (MIS3)], two of the sites were probably being influenced by energetic fluvial deposition, possibly associated with strong seasonality. Fluvial activity declines between 47 700 and 30 000 cal a BP (MIS3), and may be associated with a reduction in seasonality with overall stability in precipitation. The pollen record between 47 700 and 30 000 cal a BP generally shows much higher representation of upper-montane taxa compared with the Holocene, indicating often significantly reduced temperatures. After 35 000-30 000 cal a BP and until the mid-Holocene, hiatuses appear in two of the records, which could be linked to fluvial down-cutting during the late/mid Holocene. Despite the jump in ages, a pronounced representation of Ericaceae and upper-montane taxa, represented both at Bario and at Pa'Dalih, corresponds to a further lowering of temperatures during the Last Glacial Maximum (MIS2). Thick charcoal bands in the PDH 210 record also suggest periods of extreme aridity between 30 200 and 12 700 cal a BP. This is followed by energetic fluvial deposition of sands and gravels, and may reflect a significant increase in seasonality.

Mire ontogeny, environmental and climate change inferred from fossil beetle successions from Hatfield Moors, eastern England

Results of a fossil Coleoptera (beetle) fauna from a fen edge sequence from Hatfield Moors, Humberhead Levels, are presented. Mire ontogeny inferred from this location and others are discussed, particularly in the light of previous palynological and plant macrofossil investigations. Peat initiation across most of the site centres around 3000 cal BC, characterised by a Calluna-Eriophorum heath with areas of Pinus-Betula woodland. The onset of peat accumulation on the southern margins of the site was delayed until 1520-1390 cal BC and appears to overlap closely with a recurrence surface at a pollen site (HAT 2) studied by Brian Smith (1985, 2002) dated to 1610-1440 cal BC, suggesting that increased surface wetness may have caused mire expansion at this time. The faunas illustrate the transition from eutrophic and mesotrophic fen to ombrotrophic raised mire, although the significance of both Pinus- and Calluna-indicating species through the sequence suggests that heath habitats may have continued to be important. Elsewhere, this earlier phase of rich fen is lacking and mesotrophic mire developed immediately above nutrient poor sands, with ombrotrophic conditions indicated soon after. Correspondence analysis of the faunas provides valuable insights into the importance of sandy heath habitats on Hatfield Moors. The continuing influence of the underlying coversands suggests these may have been instrumental in mire ontogeny. The research highlights the usefulness of using Coleoptera to assess mire ontogeny, fluctuations in site hydrology and vegetation cover, particularly when used in conjunction with other peatland proxies. The significance of a suite of extinct beetle species is discussed with reference to forest history and climate change.

Timing and climate forcing of volcanic eruptions for the past 2,500 years

Volcanic eruptions contribute to climate variability, but quantifying these contributions has been limited by inconsistencies in the timing of atmospheric volcanic aerosol loading determined from ice cores and subsequent cooling from climate proxies such as tree rings. Here we resolve these inconsistencies and show that large eruptions in the tropics and high latitudes were primary drivers of interannual-to-decadal temperature variability in the Northern Hemisphere during the past 2,500 years. Our results are based on new records of atmospheric aerosol loading developed from high-resolution, multi-parameter measurements from an array of Greenland and Antarctic ice cores as well as distinctive age markers to constrain chronologies. Overall, cooling was proportional to the magnitude of volcanic forcing and persisted for up to ten years after some of the largest eruptive episodes. Our revised timescale more firmly implicates volcanic eruptions as catalysts in the major sixth-century pandemics, famines, and socioeconomic disruptions in Eurasia and Mesoamerica while allowing multi-millennium quantification of climate response to volcanic forcing.

How can a knowledge of the past help to conserve the future? Biodiversity conservation and the relevance of long-term ecological studies

This paper evaluates how long-term records could and should be utilized in conservation policy and practice. Traditionally, there has been an extremely limited use of long-term ecological records (greater than 50 years) in biodiversity conservation. There are a number of reasons why such records tend to be discounted, including a perception of poor scale of resolution in both time and space, and the lack of accessibility of long temporal records to non-specialists. Probably more important, however, is the perception that even if suitable temporal records are available, their roles are purely descriptive, simply demonstrating what has occurred before in Earth’s history, and are of little use in the actual practice of conservation. This paper asks why this is the case and whether there is a place for the temporal record in conservation management. Key conservation initiatives related to extinctions, identification of regions of greatest diversity/threat, climate change and biological invasions are addressed. Examples of how a temporal record can add information that is of direct practicable applicability to these issues are highlighted. These include (i) the identification of species at the end of their evolutionary lifespan and therefore most at risk from extinction, (ii) the setting of realistic goals and targets for conservation ‘hotspots’, and (iii) the identification of various management tools for the maintenance/restoration of a desired biological state. For climate change conservation strategies, the use of long-term ecological records in testing the predictive power of species envelope models is highlighted, along with the potential of fossil records to examine the impact of sea-level rise. It is also argued that a long-term perspective is essential for the management of biological invasions, not least in determining when an invasive is not an invasive. The paper concludes that often inclusion of a long-term ecological perspective can provide a more scientifically defensible basis for conservation decisions than the one based only on contemporary records. The pivotal issue of this paper is not whether long-term records are of interest to conservation biologists, but how they can actually be utilized in conservation practice and policy.

4 ◦C and beyond: what did this mean for biodiversity in the past?

How do the predicted climatic changes (IPCC, 2007) for the next century compare in magnitude and rate to those that Earth has previously encountered? Are there comparable intervals of rapid rates of temperature change, sea-level rise and levels of atmospheric CO2 that can be used as analogues to assess possible biotic responses to future change? Or are we stepping into the great unknown? This perspective article focuses on intervals in time in the fossil record when atmospheric CO2 concentrations increased up to 1200 ppmv, temperatures in mid- to high-latitudes increased by greater than 4 ?C within 60 years, and sea levels rose by up to 3 m higher than present. For these intervals in time, case studies of past biotic responses are presented to demonstrate the scale and impact of the magnitude and rate of such climate changes on biodiversity. We argue that although the underlying mechanisms responsible for these past changes in climate were very different (i.e. natural processes rather than anthropogenic), the rates and magnitude of climate change are similar to those predicted for the future and therefore potentially relevant to understanding future biotic response. What emerges from these past records is evidence for rapid community turnover, migrations, development of novel ecosystems and thresholds from one stable ecosystem state to another, but there is very little evidence for broad-scale extinctions due to a warming world. Based on this evidence from the fossil record, we make four recommendations for future climate-change integrated conservation strategies.