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The unprecedented expansion of lithium mining in closed‐basin brines is sparking concerns that mine‐related brine abstraction will stress freshwater resources and harm sensitive wetland ecosystems. These fears stoke preexisting conflicts between indigenous communities, governments, and mining interests. However, until now there has not been a comprehensive evaluation of how groundwater flux to wetlands in these systems responds to brine and freshwater abstraction to support these concerns. This study characterizes the hydrogeologic relationship between both brine and freshwater abstraction and groundwater discharge to wetlands in closed‐basin brine systems utilizing groundwater‐flow models representing three closed‐basin brine system endmembers. The models show that regardless of hydrogeologic conditions, fresh groundwater abstraction has a 200%–2,300% larger impact than halite brine abstraction on groundwater‐dependent wetlands over a 200‐year period. The primary control mechanisms for groundwater discharge response to abstraction are proximity to the abstraction point and density‐driven storage flux, which magnifies the impacts of freshwater abstraction and buffers the impacts of brine abstraction. Observations of changes in wetland vegetation near existing lithium brine mines show a 90% reduction in vegetated wetland area in response to freshwater abstraction but no observable change in response to brine abstraction, in agreement with the results of the modeling study. These findings demonstrate that minimizing freshwater use is more effective at protecting groundwater‐dependent wetlands than limiting brine drawdowns in closed‐basin brine systems.

Background Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is established in the management of pseudomyxoma peritonei (PMP), selected cases of peritoneal mesothelioma, and resectable colorectal or ovarian peritoneal metastases in Western countries. However, the efficacy and feasibility of these techniques are not well established in the Asian population, and little has been reported on long‐term survival outcomes for surgically resected PMP patients. Materials and Methods Retrospective analysis of a prospective database of short‐ and longer‐term outcomes of consecutive patients who underwent CRS and HIPEC for PMP in a newly established peritoneal malignancy unit in Japan between 2010 and 2016. Results A total of 105 patients underwent CRS and HIPEC and 57 maximal tumor debulking (MTD) for pseudomyxoma peritonei. In the CRS group, the primary tumor was appendiceal in 94 patients (90%) followed by ovarian and colorectal. Major postoperative complications occurred in 22/105 patients (21%) with one in‐hospital mortality (0.9%). The 5‐year overall and disease‐free survival rates for the CRS group were 74.2% and 50.1%, respectively. Multivariate analysis revealed unfavorable histology to be the significant predictor of reduced overall and disease‐free survival. Completeness of cytoreduction, CA19‐9, and CA125 were also associated with disease‐free survival. Conclusions This is the first report on long‐term outcomes and survival analysis of CRS and HIPEC for PMP in the Asian population. CRS and HIPEC can be conducted with reasonable safety and favorable survival in a new center. Complete tumor removal and histological type are the strongest prognostic factors for both overall and disease‐free survival. CRS and HIPEC can be conducted safely with favorable survival in a new center. Complete tumor removal and histological type are the strongest prognostic factors for both overall and disease‐free survival in PMP.

Background Pre-operative chemoradiotherapy (CRT) for MRI-defined, locally advanced rectal cancer is primarily intended to reduce local recurrence rates by downstaging tumours, enabling an improved likelihood of curative resection. However, in a subset of patients complete tumour regression occurs implying that no viable tumour is present within the surgical specimen. This raises the possibility that surgery may have been avoided. It is also recognised that response to CRT is a key determinant of prognosis. Recent radiological advances enable this response to be assessed pre-operatively using the MRI tumour regression grade (mrTRG). Potentially, this allows modification of the baseline MRI-derived treatment strategy. Hence, in a ‘good’ mrTRG responder, with little or no evidence of tumour, surgery may be deferred. Conversely, a ‘poor response’ identifies an adverse prognostic group which may benefit from additional pre-operative therapy. Methods/design TRIGGER is a multicentre, open, interventional, randomised control feasibility study with an embedded phase III design. Patients with MRI-defined, locally advanced rectal adenocarcinoma deemed to require CRT will be eligible for recruitment. During CRT, patients will be randomised (1:2) between conventional management, according to baseline MRI, versus mrTRG-directed management. The primary endpoint of the feasibility phase is to assess the rate of patient recruitment and randomisation. Secondary endpoints include the rate of unit recruitment, acute drug toxicity, reproducibility of mrTRG reporting, surgical morbidity, pathological circumferential resection margin involvement, pathology regression grade, residual tumour cell density and surgical/specimen quality rates. The phase III trial will focus on long-term safety, regrowth rates, oncological survival analysis, quality of life and health economics analysis. Discussion The TRIGGER trial aims to determine whether patients with locally advanced rectal cancer can be recruited and subsequently randomised into a control trial that offers MRI-directed patient management according to radiological response to CRT (mrTRG). The feasibility study will inform a phase III trial design investigating stratified treatment of good and poor responders according to 3-year disease-free survival, colostomy-free survival as well as an increase in cases managed without a major resection. Trial registration ClinicalTrials.gov, ID: NCT02704520 . Registered on 5 February 2016.

Demand for lithium for batteries is growing rapidly with the global push to decarbonize energy systems. The Salar de Atacama, Chile holds ∼42% of the planet's reserves in the form of brine hosted in massive evaporite aquifers. The mining of these brines and associated freshwater use has raised concerns over the environmental responsibility of lithium extraction, yet large uncertainties remain regarding fundamental aspects of governing hydrological processes in these environments. This incomplete understanding has led to the perpetuation of misconceptions about what constitutes sustainable or renewable water use and therefore what justifies responsible allocation. We present an integrated hydrological assessment using tritium and stable oxygen, and hydrogen isotopes paired with remotely sensed and terrestrial hydroclimate data to define unique sources of water distinguished by residence time, physical characteristics, and connectivity to modern climate. Our results describe the impacts of prolonged drought on surface and groundwaters and demonstrate that nearly all inflow to the basin is composed of water recharged >65 years ago. Still, modern precipitation is critical to sustaining important wetlands around the salar. Recent large rain events have increased surface water and vegetation extents and terrestrial water storage while mining‐related water withdrawals have continued. As we show, poor conceptualizations of these complex hydrological systems have perpetuated the misallocation of water and the misattribution of impacts. These fundamental issues apply to arid regions globally. Our new framework for hydrological assessment in these basins moves beyond calculating gross inputs‐outputs at a steady state to include all compartmentalized stores that constitute “modern” budgets. Plain Language Summary Lithium is a critical resource for the green energy transition as the primary component in lithium‐ion batteries. Most of the planet's resources occur in water‐scarce environments, like Salar de Atacama, Chile where almost half the world's supply exists. Large amounts of very salty groundwater and some freshwater is extracted to recover the lithium. Yet, persistent gaps remain in our understanding of how water moves in these environments and therefore the impacts its extraction may have on surrounding ecosystems. We employ a combination of satellite and ground‐based hydroclimatological data to assess the system. Our results show that prolonged drought and a subsequent wetter period are the primary drivers of surface hydrology changes and that most of the water here is very old, highlighting the shortcomings of current water allocations. This work presents a data‐driven framework that allows water sustainability and lithium extraction to be adequately assessed in these arid regions. Key Points Freshwater inflows and the modern water budget at Salar de Atacama are dominated by relic groundwater A drought coincident with increases in groundwater extraction complicates the attribution of specific anthropogenic environmental impacts Freshwater use and allocated water rights at Salar de Atacama appear to not meet sustainable metrics

Cancer in pregnancy is uncommon, with an incidence of about one to two cases in every 1000 pregnancies. There are no randomised trials on any aspect of the management of cancer in pregnancy. Stage for stage cancer outcomes are similar in women who are pregnant compared with those who are not. Misdiagnosis and delayed diagnosis are common where the index of suspicion by the mother and health carers is low. Surgical interventions pose some risk to the fetus, especially laparotomy for abdominal tumours and procedures undertaken during the first trimester. Chemotherapy is teratogenic in the early stages, but seems to be safe in later pregnancy, and radiotherapy can be used for localised tumours remote from the uterus, such as head and neck or limb neoplasms. Suspicious symptoms should be appropriately investigated during pregnancy, and recent advances in non-ionising-radiation staging techniques, such as MRI and ultrasound, are especially helpful. Surgical interventions can be safely undertaken with minimum risk, although there is almost always some element of maternal–fetal conflict.

ObjectiveBowel dysfunction is common following a restorative rectal cancer resection, but symptom severity and the degree of quality of life impairment is highly variable. An internationally validated patient-reported outcome measure, Low Anterior Resection Syndrome (LARS) score, now enables these symptoms to be measured. The study purpose was: (1) to develop a model that predicts postoperative bowel function; (2) externally validate the model and (3) incorporate these findings into a nomogram and online tool in order to individualise patient counselling and aid preoperative consent.DesignPatients more than 1 year after curative restorative anterior resection (UK, median 54 months; Denmark (DK), 56 months since surgery) were invited to complete The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 version3 (EORTC QLQ-C30 v3), LARS and Wexner incontinence scores. Demographics, tumour characteristics, preoperative/postoperative treatment and surgical procedures were recorded. Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, risk factors for bowel dysfunction were independently assessed by advanced linear regression shrinkage techniques for each dataset (UK:DK).ResultsPatients in the development (UK, n=463) and validation (DK, n=938) datasets reported mean (SD) LARS scores of 26 (11) and 24 (11), respectively. Key predictive factors for LARS were: age (at surgery); tumour height, total versus partial mesorectal excision, stoma and preoperative radiotherapy, with satisfactory model calibration and a Mallow's Cp of 7.5 and 5.5, respectively.ConclusionsThe Pre-Operative LARS score (POLARS) is the first nomogram and online tool to predict bowel dysfunction severity prior to anterior resection. Colorectal surgeons, gastroenterologist and nurse specialists may use POLARS to help patients understand their risk of bowel dysfunction and to preoperatively highlight patients who may require additional postoperative support.

High-elevation wetlands in South America are not well described despite their high sensitivity to human impact and unique biodiversity. We describe the hydroclimatological and limnological characteristics of 21 wetlands on the High Andean Plateau of Argentina, synthesizing information gathered over ten years (2010–2020). We collected physical-chemical, phytoplankton, and zooplankton data and counted flamingos in each wetland. We also conducted an extensive analysis of climatic patterns and hydrological responses since 1985. These wetlands are shallow, with a wide range of salinity (from fresh to brine), mostly alkaline, and are dominated by carbonate and gypsum deposits and sodium-chloride waters. They tend to have high nutrient concentrations. Plankton shows a low species richness and moderate to high dominance of taxa. Flamingos are highly dependent on the presence of Bacillariophyta, which appears to be positively linked to silica and soluble reactive phosphorus availability. Climatic conditions show a strong region-wide increase in average air temperature since the mid-1980s and a decrease in precipitation between 1985–1999 and 2000–2020. These high-elevation wetlands are fundamentally sensitive systems; therefore, having baseline information becomes imperative to understanding the impact of climatic changes and other human perturbations. This work attempts to advance the body of scientific knowledge of these unique wetland systems.