To assess the impact of centralization of prostate cancer surgery and radiotherapy services on the choice of prostate cancer treatment.This national population‐based study used linked cancer registry data and administrative hospital‐level data for all 16 621 patients who were diagnosed between 1 January 2017 and 31 December 2018 with intermediate‐risk prostate cancer and who underwent radical prostatectomy (RP) or radical radiation therapy (RT) in the English National Health Service (NHS). Travel times by car to treating centres were estimated using a geographic information system. We used logistic regression to assess the impact of the relative proximity of alternative treatment options on the type of treatment received, with adjustment for patient characteristics.P < 0.001). Conversely, patients were more likely to receive RT if their nearest centre offered RT and the extra travel time to a hospital providing RP was >15 min ; P < 0.001). There was a negligible impact on the type of treatment received if centres providing alternative treatment options were ≤15‐min travel time from each other.Of the 78 NHS hospitals that provide RT or RP for prostate cancer, 41% provide both, 36% provide RT and 23% provide RP. Compared to patients who had both treatment options available at their nearest centre where overall 57% of patients received RT and 43% RP, patients were less likely to receive RT if their nearest centre offered RP only and the extra travel time to a hospital providing RT was >15 min ; The relative proximity of prostate cancer treatment options to a patient's residence is an independent predictor for the type of radical treatment received. Centralization policies for prostate cancer should not focus on one treatment modality but should consider all treatments to avoid a negative impact on treatment choice. HESHospital Episode StatisticsIMDIndex of Multiple DeprivationIQRinterquartile rangeLSOAlower super output areaRCSRoyal College of SurgeonsRPradical prostatectomyRTradiation therapyRTDSNational Radiotherapy Data Set1Cancer surgical services, particularly for prostate, pancreatic and oesophageal cancer, continue to be centralized to fewer high‐volume centres . Whilst Prostate cancer is almost unique as a tumour type because patients diagnosed with intermediate‐risk disease are potentially eligible for up to three curative treatments: radical prostatectomy (RP), external beam radiation therapy (RT) or brachytherapy . Given tThe type of treatment received by patients diagnosed with prostate cancer may be influenced by hospital or health system factors rather than by patient‐level factors such as differences in disease severity, age or comorbidity . FactorsWhen considering access to prostate cancer treatment, a potential barrier that has received little attention is that RT and RP, the mainstays of prostate cancer treatment, are often not co‐located at the patient's nearest treatment centre . PatientIn this national population‐based study in the English NHS, we first assessed the availability of RT and RP in the nearest prostate cancer treatment centre for patients with intermediate‐risk prostate cancer. Second, we investigated the impact of the relative proximity of these alternative treatment options on the type of prostate cancer treatment received by considering the extra travel burden when either RT or RP was not available in the nearest centre.22.1All 91 207 patients who were newly diagnosed with prostate cancer between 1 January 2017 and 31 December 2018, according to the English Cancer Registry using the International Classification of Diseases‐10 diagnosis code C61 were eligible for inclusion. Prostate cancer risk was based on TNM stage , GleasonThe English Cancer Registry data were linked at the patient level with Hospital Episode Statistics (HES), an administrative database of all hospital episodes in the English NHS  and the . A total population of 16 621 patients were eligible for analysis.Of the 30 942 patients identified with intermediate‐risk disease, 1633 were excluded because they received brachytherapy and 12 544 were excluded because they did not have a recorded treatment, representing patients on active surveillance or watchful waiting 2.2Patients were categorized into the ethnic groups Asian, Black, Mixed, White, or Other, as defined in the 2001 Census in England and Wales . The Roy2.3In the analysis we used travel time to capture the distance between a patient's residence and each prostate cancer treatment centre in the English NHS. The population‐weighted centroids of the LSOAs of the patients' residence and the full postal codes for the hospitals providing RT or RP were used to calculate travel times according to the fastest route by car (using Ordnance Survey MasterMap Highways Network). For each patient, the difference in travel time between their nearest surgical and radiotherapy centre was calculated.In the analysis we considered three groups: Group 1: patients who had both RT and RP available at their nearest prostate cancer treatment centre; Group 2: patients who only had RT available at their nearest treatment centre; and Group 3: patients who only had RP available at their nearest treatment centre. The travel time difference for Group 1 was 0 min and for Groups 2 and 3 represented the extra travel time from the patient's nearest prostate cancer treatment centre to the centre offering the alternative treatment modality.n = 5160), 28.4% had an RP centre an additional 15 min further away and 12.8% had an RP provider an additional 30 min away, with a maximum travel time difference of 90 min. Of the patients in Group 3, who only had RP available at their nearest centre (n = 3644), 16.2% had an RT centre an additional 15 min away and 2.3% had an RT centre an additional 30 min away, with a maximum travel time difference of 40 min.Travel time categories for the analysis were based on the distribution of the difference in travel times between a patient's residence and their nearest RP and RT centre. It was also important to select categories that were relevant to inform clinical practice and policy. Of the patients in Group 2, who only had RT available at their nearest centre ;Only RT available at the nearest centre and the extra travel time to a hospital providing RP is more than 15 min;Only RT available at the nearest centre and the extra travel time to a hospital providing RP is less than 15 min;Only RP available at the nearest centre and extra travel time to a hospital providing RT is less than 15 min;Only RP available at the nearest centre and the extra travel time to a hospital providing RT is more than 15 min.Patients were therefore allocated to one of five categories depending on what services were available at their nearest prostate cancer treatment centre and the extra travel time to centres offering the alternative treatment option. The categories are defined below:2.4Data were complete for age, comorbidity, and socioeconomic status. In our final population, 6.7% of patients had missing ethnicity data. Missing values for ethnicity were not imputed as there could be a systematic rather than a random mechanism underlying missingness . PatientP values smaller than 0.05 were considered statistically significant. An odds ratio (OR) larger than 1 indicated that the odds of receiving RT was larger and an OR smaller than 1 indicated that the odds of receiving RT was smaller than when RT and RP were both offered in the nearest hospital.Multivariable logistic regression was used to estimate the association between the actual treatment (RP or RT) and the relative proximity of the two treatment options to a patient's residence according to the five travel time categories outlined above. The baseline comparison group was patients who had both treatment options (RP and RT) available at their nearest centre. The regression model was used to test whether the differences in the odds of receiving RT as the travel time difference increased or decreased was statistically significant. We adjusted for the following patient characteristics in the regression model: age, comorbidity, socioeconomic status and ethnicity. These variables were included as categorical variables. A sensitivity analysis was also undertaken restricting the study population to patients aged 75 years and under, given that very few operations are undertaken in the age category of over 75 years.stata version 14 was used to undertake the statistical analyses .As an additional analysis, we used interaction terms to assess to what extent the observed associations between the relative proximity of the two treatment options and the treatment they actually received varied according to four patient characteristics: age (patients older than 70 vs patients aged 70 or younger); comorbidity (patients with one or more comorbidity as defined by the Charlson comorbidity index vs patients with no comorbidity); socioeconomic status (patients from more deprived backgrounds (IMD 3–5) vs patients from less deprived backgrounds (IMD 1–2); ethnicity (patients from ethnic minority groups vs White patients). Wald tests were performed to test the statistical significance of the interaction terms. Ethics approval for use of secondary anonymized patient‐level datasets for these analyses was received from the NHS Research Ethics Committee on 1 June 2020, reference: 20/WA/0161.3Of the 16 621 patients with intermediate‐risk prostate cancer, 7221 (43.4%) received RP and 9400 (56.6%) received RT  provided both, 28 (36%) provided RT alone and 18 (23%) provided RP alone. Nationally, across all patients, the median (IQR) travel time by car to their nearest RP centre was 21.0 (13–33) min and to their nearest RT centre it was 20.7 (12–31) min.n = 7817), the nearest RT and RP service was in the same hospital. For 31.0% of the patients (n = 5160), an RT centre was closer than an RP centre and, conversely, for 22.0% (n = 3644), an RP centre was closer than an RT centre . Conversely, patients were more likely to receive RT (63% of patients received RT and 37% received RP) if their nearest centre offered only RT and the extra travel time to a hospital providing RP was more than 15 min .Compared to having both RT and RP available at the nearest centre. We found that patients were less likely to receive RT (52% of patients received RT and 48% received RP) if the nearest centre offered RP only and the extra travel time to a hospital providing RT was more than 15 min . Similarly, there was no significant impact if the patients nearest hospital offered RP and the extra travel time to a hospital providing RT was less than 15 min .Where the extra travel time between the nearest RT and RP centre was less than 15 min, the differences in the proportions of men receiving RT or RP were small and largely insignificant compared to centres where both services were co‐located. If the nearest centre offered RT and the extra travel time to a hospital providing RP was less than 15 min, there was in fact a marginally lower chance of receiving RT . In addition, we found that men from minority ethnic backgrounds were less likely to receive radical RT . A sensitivity analysis restricting the population to men aged 75 years and under did not show any significant changes in the observed associations between travel time difference and the likelihood of receiving radical RT , which  < 0.001 .Whilst these findings are important, our study moves beyond a more traditional assessment of access, which tends to focus on utilization rates of a single treatment modality rather than the inter‐dependency between treatment options and their relative proximity. Our findings are particularly pertinent for prostate cancer, where centralization of RP services in the English NHS has been occurring at pace (the number of RP centres has decreased from 65 to 51 in the last 10 years), with little or no change in the number of RT centres given the patient volumes and the necessity for these centres to deliver treatment across all tumour types .Currently, only 40% of all NHS hospitals providing prostate cancer treatment in England are “comprehensive cancer centres” whereby RP and RT services for prostate cancer are available at the same site. Whilst the creation of a comprehensive centre presents an ideal solution, the reality is that not all services can be co‐located. However, our findings should inform future centralization initiatives because they show that there are potentially thresholds in the travel time trade‐off effects for cancer patients who are eligible for more than one curative treatment modality.Furthermore, our finding that older and less fit patients were less likely to have RP if the centre providing prostate surgery was more than an extra 15‐min travel time away demonstrates that we need to ensure that centralization does not disproportionately affect access to specific demographic groups. One approach to avoid this is to undertake an empirical assessment of the potential impact of policy initiatives aiming to centralize or reconfigure services to ensure that the inherent extra travel burden does not disproportionately affect vulnerable groups, for whom barriers to access to cancer treatment are well documented . MethodsWhilst our study does highlight that the configuration of specialist prostate cancer treatment services impacts on the treatment that men with prostate cancer receive, overcoming access barriers by changing the structure or design of the service is a complex and expensive approach. Therefore, short‐term options to overcome these barriers may include the greater use of joint uro‐oncology clinics , patientOf note, we found that patients from ethnic minority backgrounds were more likely to receive RP than RT. This is in part likely to relate to the younger age of these men compared to White men and explains why the association was attenuated in the fully adjusted regression model when including other patient characteristics. However, further qualitative work is needed to understand potential factors underpinning differences in treatment preference in patients from different ethnic minority backgrounds.The strengths of this population‐based study in the English NHS include the large number of patients included, which underlines the representativeness of our results for a state‐funded health service, and the high level of accuracy and completeness of most of the routinely collected data items.Our analytical approach used average drive times, which is the standard measure of travel distance for this kind of analyses and is considered superior to using straight‐line distances. However, we acknowledge that drive times are variable depending on the time of day, which may affect patients' decision making. We also undertook a sensitivity analysis (not presented) using public transport times. Although travel times by public transport are typically longer than drive times, the observed associations were not different. In this analysis we used a threshold travel time difference between treatment options of 15 min. This was based on the distribution of travel time differences nationally and directly relates to the configuration of prostate cancer treatment services in England. These thresholds would potentially need to be adapted for analyses in different country settings depending on the configuration of services.We did not include brachytherapy treatments given the small proportion of patients receiving this treatment relative to RP and RT in the English NHS. In addition, previous work has highlighted that the highly centralized nature of brachytherapy services in the NHS has resulted in access deficits , 23.In terms of limitations, there will be factors not available in our dataset which may have an impact the type of treatment that was received, including the use of public or hospital transport and perceptions of hospital quality , 32. HowIn conclusion, we demonstrated that the configuration of prostate cancer services and the relative proximity of centres providing RT and RP to the patients' place of residence was associated with the type of treatment that men with intermediate‐risk prostate cancer received. Patients were more likely to choose a treatment modality that was delivered closest to them. The results varied according to the patient's age, comorbidity, socioeconomic deprivation, and ethnic background, which demonstrates that centralization initiatives may affect equity in access to cancer services.Policy initiatives focusing on centralizing prostate cancer services need to consider the potential impact of extra travel time on the type of cancer treatments that patients receive. Our results demonstrate that centralization policies for prostate cancer should not focus on one modality but should consider the full range of treatment modalities available to avoid a negative impact on treatment choice.Alison Tree reports research funding from Elekta, Varian and Accuray and Honoraria/travel assistance: Elekta, Accuray, Janssen. All other authors have no disclosures of interest.Table S1 Results of the univariate and multivariate analysis for patients aged 75 and under, assessing the impact of patient characteristics and the relative proximity of radiotherapy and surgical services to a patient’s residence on the choice of treatment modality.Table S2 Table of the odds ratios for the interactions between age; comorbidity; ethnicity; and socioeconomic status on the association between the relative proximity of radiotherapy and surgical services to a patients residence on the choice of treatment modality.Click here for additional data file.


The study's aims were to (1) assess family members' perceptions of the quality of the counselling they received while visiting a loved one in an adult ICU and (2) identify factors that influence family members' perceptions of counselling quality.A cross‐sectional survey of visiting family members of adult ICU patients.n = 55) at eight ICUs across five Finnish university hospitals completed a cross‐sectional survey.Family members . Interaction was associated with understanding . Family members felt that intensive care professionals did not adequately ensure that they understood counselling‐related issues and that they lacked opportunities to give feedback, in 29% of cases, staff asked the family members whether they understood the counselling and 43% of family members had opportunities to offer feedback. However, the family members felt that the counselling they received during ICU visits was beneficial.Family members assessed the quality of counselling in adult ICUs to be good. Factors associated with the quality of counselling were knowledge, family‐centred counselling, and interaction. Family members' ability to live normally was associated with understanding of the loved one's situation ( Its results are reported in accordance with the strengthening of the reporting of observational studies in epidemiology (STROBE) statement   of an ICU patient. Respondents were family members visiting adult intensive care units at eight University Hospitals in Finland. The first author maintained active contact with the research coordinators to increase the response rate. A total of 100 questionnaires were distributed to the university hospitals and the response rate was 55%.4.3The quality of family members' counselling in intensive care was analysed in terms of its content, implementation, and benefits. For this purpose, 13 sum variables were developed based on the CQIF. The internal consistency of these sum variables was assessed by computing their Cronbach's alpha values, which ranged from 0.67 to 0.92 . Descriptive statistics (frequencies and percentages) were computed and missing values were replaced. Principal component analysis (PCA) with varimax rotation was used to analyse the relationships between the variables  to determine whether trends in one variable could be explained by trends in another. The threshold for statistical significance was set at p < 0.05  to 5 (excellent). The mean age of the respondents was 53 years  but were less satisfied with the knowledge received about the duration of the loved one's stay in the hospital after leaving the ICU (79%) and the care they would need after leaving the hospital (69%).During bedside visits, family members were satisfied with the knowledge they received about pain management for loved ones (100%), examinations (98%), equipment (98%) and medical aids used in their loved one's care and follow‐up (98%). They were also satisfied with their opportunities to visit the loved one's bedside (96%) and the duration of the loved one's intensive care (91%). Family members were less satisfied with the knowledge they received about risk factors for recovery (80%), preventing infection (83%), accepting the loved one's changed appearance (86%), and knowledge about post‐ICU care (81%).ρ = 0.747, R2 = 0.56, p < 0.001) during the bedside visit. Both types of knowledge were significantly associated with the interaction during counselling  received family‐centred counselling. Table ρ = 0.613, R2 = 0.38, p < 0.001) and knowledge of medical aids and follow‐up care . Interaction during counselling was significantly associated with family‐centred counselling  and family‐centred counselling  were significantly associated with understanding the loved one's situation. Family members' ability to live a normal life was associated with understanding of the loved one's situation  and of intensive care in general (93%). In addition, most respondents felt that the counselling encouraged family members to meet their loved one in the unfamiliar ICU environment (86%), improved their understanding of intensive care (93%), and promoted a positive attitude towards ICPs (87%).Counselling had stronger positive benefits on attitudes towards intensive care among respondents whose loved one had been admitted to the ICU from home (via the emergency room) than among those whose loved one was admitted electively or from another ward or hospital Table .5.1.4Family members stated that their need for counselling was strongest when their loved one was first moved to the ICU for treatment (91%). They also agreed that they needed a summary of what had happened to their loved one before being moved to the ward. Half of the respondents (54%) felt that they received up‐to‐date counselling material.6Family members considered the quality of counselling in the studied ICUs to be good. Factors related to the quality of counselling were knowledge, family‐centred counselling, and interaction. The family members felt that the counselling they received during ICU visits was beneficial. Respondents were also satisfied with the content and benefits of the counselling they received while visiting their loved one in an adult ICU. They were most dissatisfied with the implementation of counselling and the availability of up‐to‐date counselling material. The counselling of family members in an adult ICU is an integrated process that can be divided into pre‐visit counselling (e.g. in the family room) and bedside counselling. It is important to assess satisfaction with counselling in both phases because family members of adult ICU patients play both receptive and participatory roles , which was seen as the key measure of counselling quality. This is consistent with previous reports indicating that counselling on the patient's situation helps family members deal with the experience of having a loved one in intensive care  to strengthen dialogue‐based counselling is needed to identify effective counselling methods for use in adult ICUs. Most of the family members participating in our study were over 40 years old (78%) and had not anticipated their loved one's admission to the ICU (53%). Information on this issue could be provided to ICPs to help them when interacting with family members. There is a need to clarify the counselling needs of family members of different ages, particularly given that younger respondents reported lower satisfaction with counselling than older respondents in this study.6.1The study has two notable limitations. First, the respondents were not randomly selected. Second, the number of respondents was somewhat low, which may limit the generalizability of the study results. Completed questionnaires were received from 55 family members with relatives being treated at ICUs in five university hospitals. The response rate was acceptable given that average survey response rates are typically between 20% and 40%.  and authorized by all five Finnish university hospitals. Participation in the study was voluntary and anonymous, and data were collected in compliance with the concept of privacy by design and default established in the general data protection regulation (GDPR) of the European Union. The researchers cannot identify which intensive care professionals did or did not respond to the survey. The collected electronic data do not include personal data and were saved on a computer secured with a password. Only the researchers had access to this computer.


EMBO Molecular Medicine, Yin et al report new proteomic data on maternal blood samples and a novel bioinformatic and artificial intelligence approach for the early diagnosis and screening of CHD.Congenital heart disease (CHD) comprises several cardiovascular abnormalities existing from birth. Cardiac defects range from minor asymptomatic lesions to potentially life‐threatening situations. Early fetal echocardiography, the gold standard for the in‐utero diagnosis of CHD, is inaccurate at identifying defects in pulmonary veins and atrioventricular valves or lesions that occur later or progress during pregnancy. In this issue of  P. Madeddu discusses the potential of maternal blood proteomics for early diagnosis and screening of congenital heart disease as reported by JY. Zhao and colleagues, in this issue of EMBO Mol Med. Improved therapeutic results have been obtained thanks to the wider access to centers equipped to the care for vulnerable infants, the development of innovative pediatric anesthesiologic and surgical techniques for correction of complex CHDs, and effective postoperative follow‐up Rao, . Neverthet al, Genetic and molecular biomarkers have been proposed to aid the early identification of CHD  and spliceosomal RNAs impacting on SOX4 and Notch developmental pathways in the myocardium of children with Tetralogy of Fallot compared with normally developing children  and induced pluripotent stem cells (iPSCs), or direct reprogramming of differentiated cells  into cardiomyocytes. A fundamental study from Dr. Srivastava's laboratory and Gladstone colleagues mapped out the entire network of interactions between the GATA4 and TBX5 proteins using human iPSC‐derived precursor heart cells. A 273‐protein network generated from DNA sequencing data from over 3,000 children with CHD, and their parents was investigated using a computational tool that ranks the candidates according to their likelihood of contributing to CHD  of 0.938  or were healthy (70 control subjects) using the modified gas chromatograph‐mass spectrometry method. The top biomarkers associated with CHD were 4‐hydroxybenzeneacetic acid, 5‐trimethylsilyloxy‐n‐valeric acid, propanedioic acid, hydracrylic acid, and uric acid, which was interpreted with the fact the short‐chain fatty acids and aromatic amino acid metabolism may be relevant with CHD (Xie et al (There are several elements of originality in the study from Yin et al . Apart fWhether the early protein modules diverge during fetal maturation remains to be ascertained through a longer follow‐up of the hierarchical clustering analysis. Adoption of a labeled machine‐learning strategy, tested already in this study but necessarily requiring validation in a much large cohort, could lead to a high accuracy classification of different CHD groups. Unsupervised learning models could be also advantageous for handling very large volumes of data in real time.As with all innovative studies, this one carries limitations, questions, and controversies. The authors anticipate that CHD detection in underdeveloped regions is problematic because of low accessibility to specialistic hospitals. The introduction of a maternal blood test within a Point‐of‐Care Technology plan may aid the screening of CHD in poor regions. Improvement in patient outcomes would still depend on whether the local healthcare system has the infrastructure to translate the data into better clinical outcomes (Mitra & Sharma, Prenatal diagnosis of complex CHD helps families to decide whether to continue with pregnancy and allows swift referral of CHD babies to specialistic centers for delivery and corrective surgery planning. Early diagnosis should increase the survival rate and decrease the rate of complications. A recent review article highlighted the controversial evidence for prenatal diagnosis ability in reducing neonatal mortality and morbidity. Moreover, a rigorous comparison of the cost/benefit of performing or not a prenatal diagnosis using indirect methods such a maternal blood proteomics is still missing Bonnet, . While tThe authors declare that they have no conflict of interest.


Worldwide, companies are increasingly making claims about their current climate efforts and their future mitigation commitments. These claims tend to be underpinned by carbon credits issued in voluntary carbon markets to offset emissions. Corporate climate claims are largely unregulated which means that they are often (perceived to be) misleading and deceptive. As such, corporate climate claims risk undermining, rather than contributing to, global climate mitigation. This paper takes as its point of departure the proposition that a better understanding of corporate climate claims is needed to govern such claims in a manner that adequately addresses potential greenwashing risks. To that end, the paper reviews the nascent literature on corporate climate claims relying on the use of voluntary carbon credits. Drawing on the reviewed literature, three key dimensions of corporate climate claims as related to carbon credits are discussed: 1) the intended use of carbon credits: offsetting versus non‐offsetting claims; 2) the framing and meaning of headline terms: net‐zero versus carbon neutral claims; and 3) the status of the claim: future aspirational commitments versus stated achievements. The paper thereby offers a preliminary categorization of corporate climate claims and discusses risks associated with and governance implications for each of these categories. The nascent literature on the use of voluntary carbon credits in corporate climate claims is reviewed to offer a categorization of such claims based on three key dimensions: the intended use of carbon credits, the framing and meaning of headline terms, and the status of the claim. For each category, the paper discusses associated risks and governance implications. Many companies that are currently marketing “carbon‐neutral” products and services also claim to have already fully “neutralized” the greenhouse gas (GHG) impacts of such products. Most of today's corporate climate claims—not only carbon neutral and net zero, but also carbon negative, carbon free, climate neutral and climate positive—rely to a greater or lesser extent on the use of carbon credits generated from voluntary carbon markets to offset corporate emissions. This large and ever‐increasing number of claims inevitably raises the question: are such corporate climate claims accurately reflecting the efforts undertaken by companies to mitigate climate change?By 1 February 2023, 8296 companies had signed up to the United Nations‐backed “Race to Zero” campaign, while the Science Based Targets initiative (SBTi) lists 4483 companies as taking climate action and 2217 companies with approved science‐based targets.1, 2 The lack of transparency around climate‐related claims casts a shadow over companies’ climate strategies and their engagement in voluntary carbon markets, posing reputational, litigation, and regulatory risks. More worryingly, misleading and non‐authentic corporate claims can put the achievement of the temperature goals of the Paris Agreement on climate change at risk by negatively affecting capital deployment and deterring government action by making decision‐makers believe that more ambitious policies and regulation may not be needed.Few companies release details on whether offsetting is used to complement or substitute investments into abatement of GHG emissions generated by a company's operations or within its value chain.7, 8 However, to fully maximize this potential, it is important that claims based on engagement in carbon markets accurately reflect the nature of that engagement.While the risks associated with corporate claims should be addressed through more robust governance, they need not necessarily discourage investments in carbon markets. On the contrary, carbon markets with high‐quality protocols, methodologies, and monitoring frameworks provide a valuable opportunity through which companies can contribute to climate change mitigation and secure the environmental integrity of emission reductions achieved. Investments in carbon markets can also have positive spill‐over (or leakage) effects by facilitating knowledge generation, technology transfer, and access to finance into regions that do not normally benefit from private investments.9 Howe—and methodologies for generating carbon credits are subjected to increasing academic and civil society scrutiny—voluntary carbon markets themselves and, more specifically, the claims that companies can make when they engage with such markets, continue to be insufficiently understood. Illustrating the limited public understanding of claims, a study under German consumers found that only 3% were aware of the details behind the popular “climate neutral” claim. This lack of both academic and public understanding of corporate climate claims hampers governance efforts to increase the transparency around such claims, leaving room for greenwashing and its associated risks for both companies and the global climate system.Despite this imperative, there is, as of yet, no consensus on what it means for a corporate claim to accurately reflect its contribution to global climate mitigation, nor is it well understood how claims can be governed to ensure that they are commensurate with global climate mitigation efforts. Indeed, while the potential of market‐based solutions to contribute to global climate change mitigation is increasingly discussed in the academic literature12—and as well as international initiatives that work on developing principles for environmentally and socially robust carbon markets, such as the Integrity Council for Voluntary Carbon Market's Core Carbon Principles. We further refer readers to refs.  analysis grew almost on a weekly basis.”Kreibich and Hermwille4 find—Guix, Ollé, and Font propose a classification of claims according to the type of message being communicated, distinguishing between product, process, image and fact claims  are explicit about their intention to not use carbon credits to offset emissions, while 216 (45%) companies explicitly intend to use offsetting. Yet, despite the prominence of carbon credits in corporate climate strategies, companies remain rather opaque about this in their claims, as illustrated by the remaining 230 (48%) of the large companies analyzed by Kreibich and Hermwille that are ambiguous about their use of offsets. In this context, Hale et al. find that only 87 (21%) of the 417 large companies with climate targets in their sample have set some pre‐conditions on how to use them.Our review illustrates the relevance of carbon credits generated on voluntary markets in corporate climate claims. Of the 482 large companies with climate pledges analyzed by Kreibich and Hermwille,4 only In considering corporate carbon footprints a market externality, Bertini et al. further demonstrate how carbon offsetting is an economically attractive climate governance option to firms as well as governments. In this context, a distinction can be observed in whether carbon credits are used to “net out” and compensate emissions—that is, every increase in GHG emissions somewhere must be compensated through an emission reduction measured against a baseline elsewhere—or to neutralize residual emissions—that is, GHG removals are used to achieve a balance in emissions and removals of GHGs. While it was deemed sufficient to net out emissions at a transaction level in the early eras of global climate policy when voluntary carbon markets were emerging, limiting global warming to a specific temperature goal—be it 1.5 or 2C—will require emissions to net to zero at a global atmospheric rather than transactional level. Translating such a global net‐zero target into sufficiency criteria for carbon offsetting at the transaction and claims level—and determining an appropriate role of emission reductions and emission removals therein—is a subjective exercise on which consensus is yet to be achieved, as discussed in the following subsection of our results.The prominence of carbon credits in claims can be attributed to the global nature of climate change—providing scope for compensation across geographies—as well as the inability of organizations to balance their own operational emissions and removals, while consumers and other stakeholders increasingly demand that they do so.83 In 4.1.3 emphasize the intrinsically scientific nature of net zero as a concept, defined in relation to the global atmosphere: “if the objective is to keep the rise in global average temperatures within certain limits, physics implies that there is a finite budget of carbon dioxide that is allowed into the atmosphere, alongside other greenhouse gases. Beyond this budget, any further release must be balanced by removal into sinks.” Such a balance is to be achieved and maintained on multi‐decadal timescales.Several articles in our review offer insights into what it means for a company to claim that their products, services or operations are, or will by a future date be, net zero or carbon neutral. In their paper, Fankhauser et al.6 emph observe that before net zero can be considered a useful “frame of reference” for structuring climate action, it must be translated into decarbonization pathways through “ethical judgements, social concerns, political interests, fairness dimensions, economic considerations and technology transitions.” In this context, net‐zero claims typically signal a state of equilibrium between the residual emissions and the emission removals of the operations of an entire company. When used in this way, net zero implies that carbon credits—in this case, strictly representing emission “removals”, as emission “reductions” are ineligible—are exclusively used to neutralize those residual emissions that cannot feasibly be abated due to a lack of available technologies.Authors also note the difficulty in operationalizing net zero as a claim. Fankhauser et al.6 obse builds on “the established theory of carbon neutrality” to analyze the concept of carbon neutral airports. In this context, carbon neutrality claims typically refer to a certain amount of product, service, or operational GHG emissions that has been offset or compensated through carbon credits issued on voluntary carbon markets. In contrast to net‐zero claims, the use of carbon credits for carbon neutrality claims is typically done without a clear link to a global climate mitigation target, broader company climate strategy or within supply‐chain abatement efforts— although the degree to which this is the case varies .Another frequently used term in formulating corporate climate claims is carbon neutrality, on which several authors in our review elaborate. For example, Baxter85 bui empirical account of insurance firm Allianz—which claims to have achieved carbon neutrality in 2012 and has committed to becoming net zero by 2050—further elucidates this distinction in how carbon neutral and net zero are often used by companies. While Allianz claims to have achieved carbon neutrality solely through carbon offsetting, their commitment to net zero is more stringent in that, in addition to offsetting, it involves claiming to adopt a decarbonization pathway aligned with 1.5C, achieving green electricity by 2023 and phasing out coal in their investment portfolio by 2040.Dawson, Dargusch, and Hill's24 emp and McArthur). For example, Hale et al. note that the terminology used in formulating corporate climate claims is still “in its infancy”, emphasizing how “terms are sometimes used interchangeably despite implying different climate outcomes.” As such, the authors themselves use net zero to represent “a heterogeneous array of targets.”However, we find that this distinction between net‐zero and carbon‐neutrality claims is not always observed in the literature  in climate ambition in a certain country, corporate actors may indeed claim emission reductions and removals that would have happened at a later stage through public policies. Then climate benefits are claimed twice, once toward a corporate climate target and once toward a government goal under the Paris Agreement. In such cases a corporate claim that suggests that an investment in carbon credits has lowered global emissions cannot be guaranteed, leading to an overestimation of the extent of climate action that has taken place.A number of authors is concerned that the use of carbon credits issued on voluntary carbon markets by companies to achieve their climate targets may undermine national efforts to reach the global temperature goals of the Paris Agreement.4, 64.3Given the proliferation in corporate climate claims and their associated risks, our review points to two major governance implications for the efficacy of carbon markets as a climate mitigation pathway. Consumers that are unaware of or ignore the harmful effects of their purchasing decisions through the allure of offsetting would benefit from claims that are transparent about the role of offsetting in corporate strategies. For instance, claims may carry clarifying disclaimers for consumers at the point of purchase, stipulating that offsetting is an imperfect solution to global climate mitigation and that their consumption is still associated with carbon being emitted to the atmosphere. In addition, offering consumers real‐time feedback on their consumption levels has been found to mitigate the risk of rebounding associated with voluntary carbon offsetting.First, the reviewed literature points to a need for claims to be formulated more clearly and transparently such as to better signal the volume and nature of climate action taking place and avoid the myriad of risks associated with incommensurate corporate climate claims.92 Con Rewarding only those claims that companies can credibly prove to have achieved today disincentivizes future climate mitigation efforts, while focusing only on long‐term commitments discourages front‐loaded emission reductions. Transparent reporting which shows incremental yet steady improvements is important to bridge the short‐ and long‐ term, while allowing companies the time required to develop their strategies, obtain agreements and implement steps. In addition, companies are encouraged to adopt both long‐term targets outlining their general commitments, as well as interim short‐ and medium term goals, which are to be complementary and internally consistent.Second, given the breadth of consistent climate action required to reach atmospheric net zero and keep global temperatures to 1.5 or well below 2C above pre‐industrial levels, there is a need to encourage climate efforts in the short‐, medium‐, and long‐term.4, 64.4 Examples of concepts that are commonly used in relation to corporate climate claims but could benefit from further academic analysis include the very notion of offsetting itself and how this relates to the intended use of carbon credits—as well as the way such distinctions are reflected in common terminology such as net zero, carbon neutral, climate neutral, among others. Furthermore, scientific research can play an important role in assessing how companies are progressing toward their climate targets, as well as understanding and explaining the lack of transparency currently observed around the use of carbon credits in claims. Finally, scientific research can shed further light on how alternative climate governance arrangements may interact with carbon offsetting to influence the quality of corporate climate claims and their associated risks, including, for example, the influence of carbon pricing, the progressive increase in ambition and accounting for nationally determined contributions (NDC) under the Paris Agreement on the use of carbon markets and corporate climate claims.Our review points to two research gaps around the use of carbon credits in corporate climate claims. First, there is a need to further improve the scientific understanding around many of the concepts used when formulating corporate climate claims, including through a better understanding of the socio‐political contexts in which they are manifest and a better translation into criteria that indicate when such concepts are used robustly.3, 6 For example, questions remain about the (in)abilities of consumers and stakeholders to distinguish between robust and misleading claims when these involve carbon credits, the factors on which this (in)ability is contingent, and how this (in)ability ultimately affects their decision‐making processes. The modelling of cognitive decision‐making processes can help shed light on these questions. Finally, further research could point to strategies and interventions that help manage the risks that manifest when consumers are liable to misinterpret the use of carbon credits in corporate climate claims.Second, given that stakeholders must interpret claims and adjust their decisions accordingly, there is a need to improve our scientific understanding of the behavioral implications of the use of carbon credits in corporate climate claims.93 For5 Over the next decade, finance for carbon credits generation has therefore the potential to play an important role in funding sustainable development and climate mitigation projects in the Global South. However, our review highlighted several conceptual weaknesses and risks associated with the use of carbon credits to compensate for emissions generated at a spatial and temporal distance.Investments in mitigation projects driven by the desire to generate carbon credits have real‐world advantages for the countries and communities that benefit from well‐designed carbon projects and programs that would otherwise not be implemented.97 Ove1)The intended use of carbon credits: offsetting versus non‐offsetting claims2)The framing and meaning of headline terms: net‐zero versus carbon‐neutrality claims3)The status of the claim: aspirational commitments versus stated achievementsFor such carbon finance to effectively contribute to global climate change mitigation, improved transparency, and more robust governance of corporate climate claims is needed. In the following, we distil three key dimensions that apply to climate‐related claims where the use of carbon credits constitutes an essential feature of the claim. We show how more clarity around each dimension contributes to the transparency around corporate climate claims, providing insights for future governance arrangements. The three key dimensions discussed here are:5.1 Instead, companies are encouraged to make use of a non‐offset (or non‐compensatory) claims to articulate and announce their contribution to global mitigation efforts. Proposed non‐compensatory claims include: “mitigation contribution”, “impact claim” table, contribution to “global carbon neutrality”, or “global net‐zero” through beyond value change mitigation. Carbon credits used for non‐offsetting purposes could be linked to a quantified mitigation claim, whereby companies support climate action outside of their value chains by cancelling carbon credits from standard's registries. In this case, the purchased and cancelled carbon credits are not to be counted toward the companies’ corporate net zero targets, nor should this transaction be communicated as such.TableTo tackle the risk of double claiming associated with offsetting, an increasing number of leading organizations and market experts encourage companies to engage in voluntary carbon market transactions without using the acquired carbon credits to offset emissions that occurred within their value chains.101 In Non‐offsetting claims circumvent the risks of double claiming and potential disincentives for corporate or government mitigation action. Such claims allow corporates to communicate “beyond value chain mitigation” (BVCM) that goes beyond the near‐ or long‐term targets of companies. While the non‐offsetting use of carbon credits has gained a lot of support from civil‐society and governments, it is not clear yet how much acceptance the proposed claim will find with corporate actors.Generally, non‐compensatory claims avoid many of the pitfalls and risks that come with offsetting and are preferable over compensatory claims.106 No This aligns the terminology of mitigation outcomes generated under the Article 6 twith emerging proposals for the voluntary markets, which also suggest claiming ‘mitigation contributions’ (for instance).This links the acquisition of carbon credits to a quantified mitigation claim that further contributes to the goals of the Paris Agreement without risking the double claiming of emission reductions.In December 2022, non‐offsetting claims also received formal recognition in the context of the negotiations of Article 6.4 of the Paris Agreement during the 27th session of the conference of the parties to the United Nations Framework Convention on Climate Change (COP‐17). Article 6.4 units that are not authorized for use against another country's NDC or other international mitigation purposes are now classified as “mitigation contribution A6.4ERs”.105 Th Corresponding adjustments refer to a double‐entry bookkeeping procedure agreed in Paragraph 36 of decision 1/CP.21 and elaborated in the context of the rulebook for Article 6 agreed at COP‐26 in Glasgow to prevent double claiming. It compels the transferring country to adjust upward its NDC‐covered emissions whenever the country authorizes and transfers an Article 6 mitigation outcome for compliance purposes. These mandatory accounting adjustments represent a positive confirmation of the government of the country where a carbon project is hosted that the country will not claim the emission reductions or removals from such project against its NDC. The adjustments made by the acquiring and transferring entity therefore “correspond”, and there is no double claiming of the emissions.Double claiming can also be avoided through “corresponding adjustments.”106 CoNotably, the Glasgow Decision on Article 6.2 of the Paris Agreement provides guidance on the operationalization “corresponding adjustments” but does not specify whether, when and how countries should engage in Article 6, and if or how the voluntary carbon markets may be linked. Specifically, while Article 6 mandates corresponding adjustments for mitigation outcomes used to meet another NDC or to comply with other international emission reduction obligations, it does not prescribe corresponding adjustments to the voluntary carbon market. companies are strongly encouraged to declare whether such credits are backed by a host country adjustment or not, along with its implications associated with  double claiming effects. This may be achieved through a clear link to the relevant electronic registry portraying the existence (or absence) of a host country authorization, followed by the actual corresponding adjustment communicated by the host country in its biennial transparency reports under the Paris Agreement. This process would ensure full transparency and readily available information to investors and regulators in relation to potential double claiming of the impacts produced by the carbon credits underpinning a particular offsetting claim.As an increasing number of voluntary carbon market stakeholders demand corresponding adjustments when carbon credits are used to offset corporate emissions,109 co5.2Table the Carbon Neutral Protocol by the Climate Impact Partners, and the Climate Neutral Certified Standard. In turn, net zero gained particular momentum with Intergovernmental Panel on Climate Change's (IPCC) 2018 Special Report on the impacts of global warming of 1.5 °C and the need to achieve net zero carbon dioxide emissions globally by 2050, followed by Science Based Targets initiative's (SBTi) updated set of target validation criteria for corporates willing to align their strategies with the latest science.Corporate climate claims contain a gamut of terminologies such as net zero, carbon neutral, carbon zero, climate positive, or carbon negative. While these concepts continue to evolve, a general  distinction can be observed between net zero and carbon neutral to frame the use of carbon credits in corporate climate claims Table3. Thes To credibly claim to be committed to net‐zero, companies must have adopted a Paris‐aligned and science‐based target to reduce their value chain emissions at a specific rate and by a specific date and must be progressing steadily toward that goal. Furthermore, companies must clearly communicate when their net‐zero claim is aspirational in nature  and when they are on a pathway to net‐zero (but are not net‐zero yet), in addition to reporting annually on their trajectory and progress.Net‐zero claims typically express a commitment by a company that their entire operations will reach an equilibrium of net zero emissions by some future date, whereby carbon credits are used only to neutralize  residual emissions that cannot feasibly be abated due to a lack of available technologies.4, 6 While carbon neutrality as an overarching concept refers to the global balance of emissions and removals, corporates tend to use a weaker definition of carbon neutrality that links the emissions of a company or specific products and services to emission reductions certified by voluntary carbon market programs. Given their reliance on carbon credits—and in light of their failure to incentivize a move away from business as usual and toward global net zero emissions—companies that use carbon neutral claims should inform stakeholders of i) how they define carbon neutrality and how they seek to achieve such neutrality and ii) how the carbon neutrality claim fits into the company's Paris‐aligned decarbonization pathway.In turn, carbon neutrality claims typically communicate that a product, service or company has a “neutral” impact on the global carbon emission levels, a feat often achieved through a substantial reliance on the use of carbon credits for offsetting purposes.88 Whi5.3TableFinally, a distinction can be made between claims that signal a commitment to future climate action (a “commitment claim”) and those that state that a particular climate impact has already been achieved (an “achievement claim”) Table4. and may lead to greenwashing. Thus, to be credible, commitment claims must be, at the very least, backed by accountability mechanisms.Commitment claims are forward looking and ex‐ante. They are aspirational in nature and represent voluntarily set goals that a company wishes to achieve at some point in the future. Commitment claims often communicate a corporate headline target to be reached by a certain year in the medium‐ to long‐ term. However, commitments pose the risk that they will not be met despite a company's genuine efforts—a situation we may refer to as “greenwishing”—or that they are a disguise for a company taking little to no action. Commitment claims therefore carry the risk of being “cheap talk” or “symbolic management”,102 anIn contrast to commitment claims, achievement claims inform ex‐post about the successes of past behavior. Achievement claims state a particular quality already achieved and entice the market to take informed decisions accordingly. In general, these claims convey a concrete statement of fact, as opposed to a promise or aspiration to reach a goal by a future date. The most common carbon credit achievement claim is that of “carbon neutrality” made at point of sale of products, or in relation to specific brands or businesses. Due to their materiality to consumers, the risk of rebounding is particularly large for achievement claims, pointing to the importance of disclaimers.84Due to the volume of global climate mitigation required to keep temperatures to 1.5 or 2C above pre‐industrial levels, achievement and commitment climate claims must come in tandem and be formulated in a manner that reinforces each other. For the majority of companies and sectors, a complete balance between emissions and removals can only be realistically achieved at some point toward mid‐century. Until that net‐zero moment, a robust climate achievement claim  must always be accompanied by an equally robust commitment claim . At the same time, a long‐term commitment  can only be deemed credible and acceptable if underpinned by annual value chain GHG reductions that are in line with the announced net zero trajectory.Notably, both commitment and achievement claims may be responsibly used by corporates that also wish to address their historical GHG emissions . A corporate could, for instance, communicate to its stakeholders the intention to “take responsibility” for all its historical emissions by 2040, making publicly available a detailed methodology and time‐series GHG inventory for these past emissions, along with a detailed forward‐looking roadmap of how these would be addressed in the short‐, mid‐, and long‐term 2050. Such a commitment claim would then need to be backed by regular  actions and achievements that fully demonstrate the company is on track to meet this long‐term commitment through a mix of offsetting and non‐offsetting initiatives .5.4FigureOur review and ensuing discussion underscore that the commensurateness between a corporate climate claim and its climate impact depends on the quality of the policies and actions underlying said claim, as well as the framing and status of the claim itself Figure3. Buil How to operationalize this in practice will depend both on shared understandings of the total mitigation action necessary to reach global temperature goals, as well as on the type of corporate climate claim. Our categorization and discussion of claims allow us to observe a general distinction between achievement claims—which are typically  carbon neutrality claims that rely substantially on offsetting—and commitment claims—which are typically  net‐zero claims that rely only to a limited extent on offsetting  distinction between those claims that signal a long‐term commitment to contributing to climate mitigation—which are typically net‐zero claims that tend to be defined over the long‐term, in line with global decarbonization pathways and without allowing offsets to substitute value‐chain emissions—and those claims that have already been achieved—which are often carbon neutrality claims, that tend to rely substantially on carbon offsetting in place of direct corporate emission reductions. As this distinction has legal and governance implications, our categorization offers a useful basis for informing the existing and emerging governance of corporate climate claims.We are aware that our analysis offers only initial insights and preliminary steps toward a full taxonomy of standardized and transparent corporate climate‐related claims. Not taking account of the quality of carbon credits is a first limitation of our review. While most quality criteria are relevant for all corporate climate claims, additional criteria for specific sub‐categories of claims are beginning to be formulated, such as the use of carbon credits representing emission removals (rather than reduced or avoided emissions) for net‐zero claims. In addition to the research gaps that emerged from our review and are presented in Section It is also important to note that our proposed demarcation between achievement‐ and commitment claims is not absolute, nor is it fixed in time. In other words, our proposal is that most  achievement claims are currently carbon neutrality claims that rely on offsetting, whereas most commitment claims are currently net zero claims relying less on offsetting. Nevertheless, we recognize that many companies also have aspirational carbon neutrality goals, which are not yet achieved at the time they are announced, while net zero targets that are currently aspirational do allow for continuous accountability which may result in achievement over time. As the governance of claims continues to develop and corporate climate commitments are increasingly achieved, the balance between achievement‐ and commitment claims—as well as their associated features, risks, and governance gaps—is therefore likely to shift. The proposed distinction between achievement‐ and commitment claims can thus be interpreted as characteristic of the landscape of corporate climate claims at this specific moment in time when corporate climate claims are proliferating, and robust governance is only beginning to emerge. As such, we hope that this preliminary categorization of corporate climate claims and the general distinction between achievement‐ and commitment claims, as currently observed, serves as a valuable reference point for analyzing the corporate climate claims landscape as it continues to develop and becomes increasingly governed.The authors declare no conflict of interest.Supporting InformationClick here for additional data file.


Zootermopsis angusticollis, on two different wood types and conducted behavioral assays to test whether nestmate discrimination can be constrained by common environmental conditions. We found that non‐nestmates elicited higher rates of identity checking and defense behavior compared to nestmates, but there was no effect of wood type on the strength of behavioral responses to non‐nestmates. We also found that one key cooperative behavior  was performed equally toward both nestmates and non‐nestmates. These findings offer no support for the hypothesis that common wood type constrains the nestmate recognition system of single piece nesting termites. We suggest that where groups encounter each other frequently in a common environment, selection will favor discrimination based on genetic and/or higher resolution environmentally mediated cues.Recognition of group members is an important adaptation in social organisms because it allows help to be directed toward kin or individuals that are likely to reciprocate, and harm to be directed toward members of competing groups. Evidence in a wide range of animals shows that responses to outgroups vary with context, suggesting that cues to group membership also depend on the social or environmental context. In termites, intergroup encounters are frequent and their outcomes highly variable, ranging from destruction of a colony to colony fusion. As well as genetic factors, nestmate recognition in social insects commonly relies on cues that are mediated by environmental factors such as food source. However, single‐piece nesting termite colonies share nesting material and food source with rival colonies (their wood substrate serves as both). In principle, the shared environment of single‐piece nesting termite colonies could constrain their ability to identify non‐nestmates, contributing to some of the variation seen in encounters, but this has not been investigated. In this study, we raised incipient colonies of a single‐piece nesting termite,  Group member recognition is crucial in social evolution and cues to group identity are often derived from the environment. In single‐piece nesting termite species competing colonies live in and feed on the same log, which could potentially constrain nestmate recognition. We tested this by experimentally introducing non‐nestmate intruders raised on either the same or a different wood substrate and found non‐nestmates were not treated differently based on wood type. Nestmate discrimination mechanisms can operate even in a common environment and appear linked to environmental cues on a much finer scale than previously recognized. Different species of wood are also likely to differ in these factors, containing different microbial communities, decomposing at different rates, and responding differently to environmental factors. Although two colonies of single‐piece nesting termites found in different species of wood would not meet each other and interact in nature, if termites do acquire recognition cues from their environment, these are likely to be most divergent amongst colonies on different species of wood. The limited environment that these termites experience  provides an experimental opportunity to test the effect of environmentally mediated cues on nestmate recognition where these cues are likely to differ to the greatest extent.Zootermopsis angusticollis (Hagen), rearing colonies on two different types of wood substrate. We then conducted assays of the behavioral responses of pseudergates to an introduced non‐nestmate (or nestmate control).We tested whether single‐piece nesting termites responded differently to non‐nestmates who were raised on the same wood type as them, compared to those raised on a different wood type. This would allow us to determine whether nestmate recognition was constrained for individuals reared on the same type of wood during encounters with individuals from different colonies. We manipulated the environment of incipient colonies of the single‐piece nesting termite, Zootermopsis termites show a more aggressive response to heterospecifics than to non‐nestmate conspecifics  termites discriminate non‐nestmates from nestmates, but not between non‐nestmates reared on different wood types because the environment does not play a primary role in nestmate recognition; (b) termites discriminate non‐nestmates but are less able to discriminate those raised on the same wood type as them because they use environmentally mediated cues and discrimination ability is  related to cue difference; (c) termites discriminate non‐nestmates but are less able to discriminate those raised on a different wood type to them because although they might use environmentally mediated cues, there has been no selection on interactions involving termites with extreme cue divergence because termites on different wood types would not meet in nature; and (d) termites do not discriminate non‐nestmates from nestmates Figure . Zooterm22.1Z. angusticollis colonies from Redwood Regional Park . Whole, natural colonies were collected under permit from East Bay Regional Parks and the California Department of Fish and Wildlife, and imported under license from the UK Animal and Plant Health Agency to the Centre for Ecology and Conservation, University of Exeter, UK.Stock colonies used to find all incipient colonies used in the experiment were established by collecting whole natural Betula; Cole et al., Each stock colony was housed in a 35‐L plastic box containing a mixture of their native wood and birch  at least 1 month prior to trials, typically during transfer to the larger Petri dish, and supplied with sycamore ad libitum thereafter. Neither birch nor sycamore are natural nesting woods for Z. angusticollis, but both are hardwoods, on which termites can raise a colony . The birch wood used was collected from the local area in Penryn and all came from a single tree; the sycamore also came from a single sourcing of wood chips, but it cannot be guaranteed that all sycamore came from the same tree. Using single wood sources controlled for additional differences in the wood, for example, different growth rates in different regions.After they were established, we continued to provide silver birch ad libitum throughout development to 25 of the incipient colonies; 14 incipient colonies were transferred onto sycamore  in distilled water, and was maintained by spraying colonies with distilled water approximately twice weekly.2.2Experiments were carried out over two trial days in February and March 2020 at the Centre for Ecology and Conservation, University of Exeter, UK. Trials were conducted in batches of three replicates at a time. For each replicate, three termite pseudergates from an incipient colony were placed into an uncovered 50‐mm round Petri dish containing a cut‐to‐size circle of dry filter paper. Groups were left to settle for 2 min under red light (provided by two bulbs positioned around 1.5 m above the Petri dishes) in an otherwise dark room. A fourth pseudergate, a newcomer, was then introduced and allowed to interact for a 3‐min ‘trial period’. While 3 min is a short period of time, it was sufficient to allow the four individuals opportunity to interact and observe the immediate response to the newcomer. The newcomer was one of: a non‐nestmate raised on the same type of wood ; a non‐nestmate raised on a different type of wood ; or a nestmate control  post hoc from the videos and divided the newcomer's length by the mean length of individuals in the interacting group (excluding the newcomer). Thus, a size ratio >1 means the newcomer was larger than the mean of the group, and vice versa if the size ration was <1.The relatedness of the newcomer to the group of termites was unknown because we did not know the relatedness of the stock colonies to each other, and we did not know which stock colonies all incipient colonies were established from. Of the 28 non‐nestmate pairings for which we knew the parental  stock colonies, four shared a parental stock colony and 24 did not; for nine pairings, we did not know the parental stock colonies; and 17 pairings were controls. There were therefore insufficient data to establish whether genetic relatedness had an effect on behavioral response to newcomers in this experiment.Videos were coded using Behavioral Observation Research Interactive Software  occurred sufficiently for statistical analysis. Allogrooming and recoiling were observed in 23, and antennation was observed in 53 of the 54 replicates. Trophallaxis involving the newcomer occurred in four replicates ; biting of the introduced individual was recorded in one replicate ; butting was never recorded. Trophallaxis, biting, and butting were, therefore, excluded from statistical analyses.βi∼N0,2.5). We fitted separate models for each behavior. We assumed a zero‐inflated beta distribution for the data in the allogrooming and antennation models, following guidelines in Douma and Weedon  to fit generalized linear mixed effects models (GLMMs) to (untransformed) data under a Bayesian framework, using scale‐adjusted, weakly informative priors  also always contained the main effect of wood type because all controls (nestmates) were necessarily reared on the same wood type. We interpret inclusion Bayes factors as evidence for an effect of each fixed effect in line with convention set out in Jeffreys  such thaN = 43 trials). To determine whether inbreeding status helped to explain our observed data, we calculated the Bayes factor in favor of the model including inbreeding status over the model without including inbreeding status . We found weak evidence of an effect of inbreeding status on allogrooming, but we found no evidence that inbreeding status had an effect on antennation or recoiling. Because this analysis required removing 11 replicates, and because there was no evidence of an effect of inbreeding, we report models that do not include inbreeding status in the main text, and report our inbreeding analysis here in Appendix Since a large proportion of our incipient colonies were established from inbred pairs of alates from the same stock colony, we conducted an additional post hoc analysis to identify whether a group's inbreeding status played a role in their behavioral response. For the three behaviors analyzed , we added an additional fixed term to each model: inbreeding status, a two‐level factor describing whether the incipient colony was established using (inbred) alates from the same stock colony or (outbred) alates from different stock colonies. There were seven incipient colonies  for which the origin of one or both of the alates was unknown; trials involving these colonies were therefore excluded from this additional analysis  as the group to which they were introduced. This result suggests that broad‐scale diet might not be a dominant driver of nestmate recognition in single‐piece nesting termites, a group in which colony–colony competition can occur frequently and between colonies reared in a common environment. Termites in our experiment did respond differently to non‐nestmates compared to nestmate controls—they were not more aggressive, but termites recoiled from and antennated toward non‐nestmates more than nestmates. Interestingly, we found evidence that nestmates and non‐nestmates received equal allogrooming—a behavior associated with cooperation. We suggest that frequent colony fusion in this group might select for recognition of out‐group members without the aggression typically associated with intergroup encounters.The lack of discrimination between the two different out‐groups (same‐wood and different‐wood) in this experiment might be explained by mechanistic constraints on diet‐mediated cue variation in single‐piece nesting termites. While there is a direct link between diet and gut microbiome or diet and cuticular hydrocarbons in some insect taxa  along with a lack of aggression toward non‐nestmates was unexpected but not unprecedented , this experimental design likely caused some level of disruption to the termites, and this might have affected the range and frequency of behaviors that we observed. The impact of experimental design is evidenced in previous nestmate recognition experiments: trials in which termites are introduced in the novel environment of an open Petri dish (as in our experiment) tend to report lower rates of aggression than similar studies in which colonies are allowed to meet in more naturalistic enclosed settings  can vary. Our results support the idea that when groups frequently interact in a common environment, high‐resolution recognition cues, such as genetic cues, highly heterogeneous environmental factors, or their interaction, might be selected as more reliable indicators of group membership. Genetic or high‐resolution cues could be particularly important in species for which appropriate behavior toward out‐group members is context‐dependent and can change over time, for example, because of group fusion, as in single‐piece nesting termites, or because of fissioning events such as eviction or dispersal in some other social animals. Further experimental work will be important for understanding the potential mechanisms that organisms use to classify conspecifics in different contexts, particularly when there are important fitness consequences to incorrect decisions.Rebecca F. B. Padget: Conceptualization ; data curation (lead); formal analysis (lead); investigation (lead); methodology ; writing – original draft (lead); writing – review and editing . Michael A. Cant: Conceptualization ; funding acquisition ; methodology ; project administration (supporting); supervision ; writing – review and editing . Faye J. Thompson: Conceptualization ; funding acquisition ; methodology ; project administration (lead); supervision ; writing – original draft (supporting); writing – review and editing .7This work was supported by a Natural Environment Research Council grant number: NE/S000046/1, awarded to F.J.T. and M.A.C.Appendix S1Click here for additional data file.


This study aims to evaluate the effectiveness of two different distraction techniques (Audio Video Distraction/Video Game Distraction) in the management of anxious pediatric patients during dental treatment.One hundred and five children were randomly divided into three groups; Group A: active distraction using video games on a tablet device and wireless joystick (VG). Group B: passive distraction using video on tablet, and wireless headphones (AV). Group C (Control group): basic behavior guidance technique Tell Show Do was used (C). The children were selected from the department of pediatric dentistry at the Faculty of Dentistry, Damascus University, who required pulpotomy in primary mandibular molars. All children were assessed by: Simplified Wong‐Baker FACES for pain scale (self‐report), and “HOUPT” Behavior Rating Scale for Overall Behavior (non‐self‐report), at the end of treatment.p = .000), The active distraction (VG) group was superior to the control group (C) in overall behavior as appeared in HOUPT scale (p = .041), but it was no statistically significant differences between (VG) group and (AV) group in overall behavior (p = .605). With the use of Bluetooth technology and wireless devices, the workspace was comfortable for the dentist and did not interfere with the movement of his hands.One hundred and five children completed the study (57 boys and 48 girls) aged between 6 and 10 years (mean age of 7.4 years). The active distraction (VG) group was superior to the passive distraction (AV) group and the control group (C) on the pain scale with statistically significant differences as appeared in Simplified Wong‐Baker Scale  and was better than negative distraction by video cartoons on the tablet device. After ethical consent was obtained, informed consent was obtained from parents or guardians to participate in this study.This clinical trial was conducted in the Department of Pediatric Dentistry at Damascus University in protocol record (IRB No. UDDS‐1987‐15082019/SRC‐1450) and approved by 2.2α = .05, and power = .95). The effect size was calculated according to previous studies  active distraction with using video games on a tablet device, wireless joystick, and wireless headphones.Group B: (AV) passive distraction with using video on tablet and wireless headphones.Group C: (C) Control group with basic behavior guidance techniques (tell show do) and without using any type of distraction aids.The child was interviewed, examined, and his degree of cooperation was evaluated according to the Frankl Behavior Rating Scale definitely positive or positive. After the child sat on the dental chair, he was chosen the electronic game for the (VG) group and the cartoon film for the (AV) group.For group A (VG): The children were taught how to play through a wireless controller (joystick) and put on wireless headphones, then played for 5 min before starting the treatment and continued to play during the entire procedure.For group B (AV): The child watched his favorite movie for 5 min before starting the treatment with headphones and continued watching during the entire procedure.For group C (C): The traditional methods of managing behavior were followed without any intervention. The technique (Tell ‐ Show ‐ Do) was followed.2.6The Simplified Wong‐Baker FACES pain rating scale was used in this study due to the reliability that was proved by Haji‐Bakr‐and AL‐monakel .3p = (.041) and a significant difference was noticed between three groups on the pain scale p = (.000) as shown in  completed the study. In all groups, pain and behavioral scale scores  were recorded. One‐way ANOVA statistical test was done, and a significant difference was noticed between three groups on the overall behavior scale p = .020) and between Group A (VG) and Group C (C) (p = .000) toward Group A, so the use of video games reduces the pain described by children. While there are no statistically significant differences between Group B (AV) and Group C (C) (p = .665), as shown in  and Group B (AV) p = .00 and betp = .035). On the other hand, there were no statistically significant differences compared to the overall behavior scale between the Group A(VG) and Group B (AV) (p = .605), as well as between Group B (AV) and Group C (C) (p = .605), as shown in  and Group C (C) p = .05. On theThis indicates that the use of video games with joystick and portable tablet added a significant improvement in the behavior of children and reduce the self‐reported pain during the primary mandibular molar pulpotomy.All connections were via Bluetooth and we did not use any wired devices so that the workspace remained empty and didn't interfere with the movement of the doctor's hands.There were no statistically significant differences between males and females in three groups according to the scales used in the research HOUPT Scale and W‐B Scales, as shown in Table .4Dental fear and anxiety have an impact on the quality of dental treatment  in reducing perceived pain during pulpotomy in children.There are many scales for classifying behavior in children, the most famous of which is the Frankel Scale, which divides behavior into four categories  Dean, . In thisThis study dealt with a new technique that a child plays video games through a wireless joystick linked via Bluetooth with a portable tablet on the dental chair and placing Bluetooth headphones during pulpotomy, starting from IAN injection (Inferior Alveolar Nerve Block) and ending with the final restoration, because of the use of Bluetooth Dental treatment usually includes painful procedures, repetitive injections, use of sharp tools at high speed, and frequent visits. These aspects affect the child's ability to tolerate treatment, which poses a challenge to the dentist and, therefore, it is difficult to achieve successful dental treatment if the child's behavior is not controlled technology and wireless devices, the workspace was comfortable for the dentist and did not interfere with the movement of his hands, The tablet was placed in a high position on the dental chair, so the child raised his head high, which facilitated treatment.As our study results show, the use of the joystick and video games added a significant improvement in the behavior of children and the self‐reported pain during the dental treatment procedure, so that all children in active distraction group were treated with acceptable and satisfaction general behavior according to the scales used in the research. Thus, our method of distraction outperformed the passive distraction using video films. this is due to the physical activity of the child and they were blocked out from the surrounding environment, and our results agreed with many research that have been studied the effectiveness of active distraction through video games on a tablet device while performing different dental procedures, and their results showed that active distraction is superior to passive distraction (Attar & Baghdadi, In addition, active distraction using the joystick, which was fixed to the dental chair, was superior in pain control during pulpotomy compared to using AV distraction and control group, but it was similar in child behavioral management during pulpotomy compared to using AV distraction.Active distraction using video games is superior to passive distraction using video games for pain described by children, although other studies used an effective technique in improving self‐reported pain, PlayStation video games did not affect overall behavior (Guinot et al., Some studies have found that playing video games has improved a child's adaptation to the dentist, compared to watching cartoons while injecting local anesthesia. In addition, playing a video game and watching cartoons film during dental treatment reduced heart rate, compared to traditional distraction techniques (Kumprasert et al., On the other hand, some studies used effective distraction in reducing the vomiting reflex while taking the upper and lower alginate impression, and they used the Intellectual Colored Game, which distracted the child's attention during the stressful alginate impression (Kulkarni et al., In contrast to our study, some studies found that distraction did not provide additional advantages in reducing fear and pain when compared to traditional methods such as directing behavior and positive reinforcement, but it is a way to attract the child's attention and activate the child's nervous and emotional centers, which leads to relaxation (Al‐Khotani et al., This study found that playing a video game during dental treatment could better method a child's cooperation with the dentist, compared with watching cartoons and other conventional distractions (Cozzi et al., 5Within the limits of this study, it can be concluded that the use of video games via joystick on tablets and headphones gave the best result in relieving dental anxiety and pain during pulpotomy in children.Although the use of cartoon films through the tablet and headphones did not reduce the described pain in children, it was acceptable in managing children's behavior when performing the dental treatment and may lead to desirable behaviors in future visits.A limitation of this study was the inability to blind the external investigator from the use of joystick and headphones, and the unacceptability of some children to use joystick and headphones.Ekram AlSibai conceived the idea and provided the treatment. Ekram AlSibai contributed to the writing. Hasan Alzoubi to the documenting. Nada Bshara conceived the idea and supervised the treatment. Laith Al Sabek contributed to study design.The authors declare no conflict of interest.


This study aimed to describe patient self‐reported distress over time and how this was associated with wellbeing, and supportive care needs over a 6‐month period from commencing chemoradiotherapy for high grade glioma (HGG).In this prospective cohort study, participants completed surveys at three time points: before chemoradiotherapy, at 3 and 6 months. These included Distress Thermometer, Functional Assessment of Cancer/Brain Cancer Treatment‐general (Fact‐G/FACT‐BR), Supportive Care Needs Scale (SF‐34) and Brain Tumour Specific subscale. Patient survival time was also collected. Group‐based trajectory modelling was performed. Multinominal logistic regression assessed variables associated with different distress trajectory groups.One hundred and sixteen participants completed assessments at baseline, 89 participants at 3 and 64 at 6 months. Four distress trajectory groups were identified; consistent low distress (18%), low to high distress (38%), high‐to low distress (24%) and consistent high distress (19%). Younger participants tended to report decreased distress over time, whereas older participants reported consistently high distress. High distress trajectory participants had less education, lower physical wellbeing, more unmet needs, but higher functional wellbeing compared to the low to high distress trajectory. The number of unmet needs paralleled the patterns of distress over time. The highest unmet needs in people with HGG and high distress were disease specific changes in mental ability and physical side effects.This study demonstrates people with HGG experience ongoing distress and highlights a need for continuous distress and unmet needs screening and referrals. Hypotheses: (1) Participants experience increasing distress from commencement of chemoradiotherapy until 6 months later as their disease progresses; and, (2) High distress is associated with higher unmet needs at baseline, 3 and 6 months later.22.1We conducted a prospective cohort study. Detailed information on participant recruitment, study tools, and baseline outcomes have been reported previously.2.2The questionnaire comprised four sections. Section Survival time was defined as time from date of diagnosis to date of death with patients censored at date last known alive (if lost to follow up) or study censor date (31 December 2017) for those patients known to be alive. Proximity to death was defined as the time in months between date of death and date of each survey. This was censored at 50 months for the 5% who survived past 50 months or were alive at study censor date.Self‐reported carer distress measured using the DT at each of the three time points was included as a covariate in this analysis. All other carer data is reported elsewhere.2.3t‐tests and chi‐square tests respectively.Equality of means and proportions were assessed using The DT is traditionally analysed by defining a cut‐point representing distress. The original cut‐off point used was 5 , however, more recent studies propose 4 as cut‐off points for identifying people with HGG with clinically meaningful distress, although this can vary by diagnosis. We used a cut point of 4 and above to identify ‘moderate’ distress, and a cut point of 7 and above to represent ‘severe’ distress.Distress has been reported to be higher close to time of diagnosis,Group‐based trajectory modelling was used to assign probabilities of individual patients following different trajectories of distress over time.3One hundred and sixteen participants completed the baseline survey. The sociodemographic and clinical characteristics of the cohort and baseline measures of distress and QOL have been reported elsewhere.Eighty‐nine participants completed the survey at 3 and 64 at 6 months. Baseline characteristics, distress levels, wellbeing and supportive care needs of the 64 participants at 6 months were compared with the 52 participants who died or withdrew from the study after completing the baseline questionnaire to assess differences between groups Figure . Partici3.1Individual patterns of participant distress levels were highly variable over time  Figure . Some reOf participants who reported no distress at baseline, around 45% remaining in the study reported moderate or severe distress at later time points. Whereas of those reporting severe distress at baseline, almost one third those who remained in the study reported no distress at later time periods.Group‐based trajectory analyses was performed to identify other factors associated with groups of participants who tended to follow similar patterns of distress over time, while accounting for patterns of attrition.3.2Of all participants in distress trajectory groups who started with high distress, younger participants tended to report decreased distress over time, whereas those reporting consistently high distress were older on average Table . BaselinThe high distress trajectory group of participants reported a much greater number of unmet needs at time of chemoradiotherapy and evidence their carers were more distressed at baseline Table . This grA multinomial logistic regression model was constructed to determine which of these baseline characteristics remained associated with distress trajectory group membership after adjusting for other variables Table . Relativ3.3The baseline number of unmet needs was higher in the distress trajectory groups that started high from the time of first survey Table . A summaWith focus on the 16 questions of the brain cancer‐specific module of unmet needs, we observed distinct patterns of unmet needs by distress trajectory group. We assessed both any unmet need (low/moderate/high) Figure  and mode4This study aimed to describe individuals' self‐reported distress and how this related to wellbeing and supportive care needs over a 6 month period from starting combined chemoradiotherapy for HGG. While we initially hypothesised participants would experience increasing distress over time, our findings demonstrated a variety of distress trajectories. Group‐based trajectory modelling revealed some people experienced persistent distress throughout the study, while others maintained low levels of distress and others moved from high to low or vice‐versa. Individuals may have different coping skills and their response to their diagnosis depends on support received and how others are coping with their disease.,Importantly, high distress at the time of starting chemoradiotherapy reflected a higher number of unmet needs, demonstrating the strong relationship between distress and unmet needs as seen in other populations during active treatmentWe found higher patient distress was associated with higher carer baseline distress and a greater number of unmet needs when chemoradiotherapy commenced. Our results identified practical, physical, and emotional unmet needs in these populations that are clearly driving distress. Most of this unmet need centred on the unwanted physical and mental changes specific to brain cancer. While needs decreased or fluctuated they remained higher in the high distress group compared to others. Legal assistance (from the brain tumour specific needs tool) was a high need which fluctuated over time for participants in the high distress group. The high distress group also identified, on the brain tumour specific needs tool, that they had increasing needs for financial assistance/advice, information on new research and treatment options, practical support at home, accessing rehabilitation services and neuropsychological support.The brain tumour specific unmet needs identified and associated with higher distress highlight the urgent need for routine screening for unmet needs, increased referral to support services, and improved interventions to address these needs for the wellbeing of patients and carers. Renovanz et al.Of all patients in the different distress trajectory groups who started with high distress, younger participants tended to report decreased distress over time, whereas those reporting consistently high distress were older on average. Previous research has highlighted the need to identify at risk adolescent and young adult cancer patients and refer them for psychosocial support.Participants in the high distress and the low to high distress trajectory groups had shorter survival times and reported more baseline dependency than the other groups reflecting both deteriorating health states and recognition of limited remaining life. Higher distress for participants with shorter survival times is unsurprising with this group facing their own mortality and likely to be experiencing progressive neurological deficits, although we did not specifically assess for this. Recent work by Loughan et al.n = 50) finding that at 6 months participants had lower levels of depression and stress and higher existential well‐being and QOL. Our team has also been trialling a nurse‐led intervention (Care‐IS) with carers of HGG patients to improve carer preparedness and reduce carer distress.Interventions focusing on supporting people with HGG and carers to identify their fears and plan for the future such as Tele‐MAST ’) may be beneficial in reducing patient depression and improving patient and carer mental health and QOL.4.1Our data demonstrate the urgent need for policy changes to implement regular screening for distress and unmet needs in HGG populations. To enable needs of patients and carers to be effectively addressed, clinical pathways to guide referrals, increased workforce particularly neuropsychology, and targeted interventions are critical. We have successfully implemented a stepped‐care model for management of distress, anxiety, and depression in general cancer populations incorporating psycho‐education, online cognitive behaviour therapy, and referral for in person care.Systematically screening and providing support flexibly may help overcome disparities in access to support services in vulnerable HGG populations. Technological solutions may facilitate screening and access to interventions and resources. Of particular importance, is the need to assess the effectiveness of telehealth/internet delivered services to increase access in people with limited mobility, time, financial resources, and a high burden of health system interactions.It is clear advanced care and end‐of‐life planning should be discussed with patients and families early. Our data depicts high levels of distress and existential concerns as end‐of‐life approaches. What is unknown is how often and how effectively these conversations occur. Advanced and end‐of‐life care planning should not be a one‐time conversation, but continued throughout the care trajectory to assess and assist with changing needs and perceptions.4.2We conducted this exploratory study over a 6‐month period, but acknowledge distress and unmet needs are likely to be affected by key clinical events, such as disease recurrence, which we did not assess. The study time points were selected to balance the information obtained with participant burden. Participants had the choice to either complete the questionnaires in the clinic or at home and carers were able to assist with the completion of the surveys. While this is a limitation of the study, involvement of carers increased completion rates and assisted with patient comprehension. Completion rates declined over time, as anticipated in a group juggling competing demands and declining health. However, participant withdrawal was accounted for during trajectory analysis and participant characteristics did not differ between those who continued or withdrew due to disease progression. Additional data collection after 6 months would have provided further insight into participant distress and needs; however, we were cognisant of the difficulties of maintaining adherence and chose to stop at 6 months to reduce participant burden and account for the high attrition due to deterioration in patient health and the associated increase in caregiver burden.5This study has demonstrated people continue to experience distress following a diagnosis of HGG and are likely to benefit from screening for distress and unmet needs. People need support dealing with unmet needs specific to brain cancer including: changes in mental ability, physical side effects, feeling like a different person, appearance changes and others treating them differently. Interventions should include support for both patients and carers and must focus on addressing these unmet needs to reduce distress.Georgia Halkett, Elizabeth Lobb and Anna Nowak contributed to the study conception and design. Katrina Spilsbury provided statistical advice and analysed the data. Critical feedback on data analysis and interpretation was provided by all authors. The first draft of the manuscript was written by Georgia Halkett and all authors commented on multiple versions of the manuscript. All authors read and approved the final manuscript.The authors have no relevant financial or non‐financial interests to disclose.This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Human Research Ethics Committees of Sir Charles Gairdner Hospital (2006‐146), Curtin University (03/2007), and Cancer Institute NSW (2008/08/092).Witten informed consent was obtained from all individual participants included in the study.Supporting Information S1Click here for additional data file.