Can an invasive species compensate for the loss of a declining native species? Functional similarity of native and introduced oysters.

The widespread introduction of the Pacific oyster, Magallana gigas, has raised concerns regarding its potential impact on the functioning of invaded ecosystems. Concurrently, populations of the European oyster, Ostrea edulis, are in decline. We quantified the functional role of the native oyster, O. edulis, in terms of nutrient cycling and associated infaunal biodiversity and compared it directly to that of the invading oyster, M. gigas. The presence and density of both species were manipulated in the field and we tested for differences in concentration of ammonium, phosphate, total oxidised nitrogen and silicate in pore-water; total organic nitrogen and carbon in sediment; microbial activity; chlorophyll concentration; and the assemblage structure and richness of associated benthic taxa. No differences in nutrient cycling rates or associated benthic assemblages were identified between both oyster species. Nutrient concentrations were mostly affected by differences in oyster density and their significance varied among sampling events. Our findings suggest that M. gigas could compensate for the loss of ecosystem functions performed by O. edulis in areas where native oysters have been extirpated.

Protection alone may not promote natural recovery of biogenic habitats of high biodiversity damaged by mobile fishing gears.

The horse mussel Modiolus modiolus (L.) is a large marine bivalve that aggregates to create complex habitats of high biodiversity. As a keystone species, M. modiolus is of great importance for the functioning of marine benthic ecosystems, forming biogenic habitats used to designate Marine Protected Areas (MPAs). The present study investigates the condition of M. modiolus beds historically subjected to intense scallop fishing using mobile fishing gears. The study, conducted seven years after the introduction of legislation banning all forms of fishing, aimed to establish whether natural habitat recovery occurs after protection measures are put in place. Lower biodiversity and up to 80% decline in densities of M. modiolus were recorded across the current distributional range of the species in Strangford Lough, Northern Ireland. The decline in biodiversity in most areas surveyed was consistent with that observed in biogenic reefs impacted by mobile fishing gears elsewhere. Epifauna, including sponges, hydroids and tunicates, experienced the most substantial decline in biodiversity, with up to 64% fewer taxa recorded in 2010 compared with 2003. Higher variability in community composition and a shift towards faunal assemblages dominated by opportunistic infaunal species typical of softer substrata were also detected. Based on these observations we suggest that, for biogenic habitats, the designation of MPAs and the introduction of fishing bans alone may not be sufficient to reverse or halt the negative effects caused by past anthropogenic impacts. Direct intervention, including habitat restoration based on translocation of native keystone species, should be considered as part of management strategies for MPAs which host similar biogenic reef habitats where condition and natural recovery have been compromised.

Identifying, highlighting and reducing polypharmacy in a UK hospice inpatient unit using improvement Science methods.

Polypharmacy, the concurrent use of multiple medications by one individual is a growing global issue driven by an ageing population and increasing prevalence of multi-morbidity[1]. Polypharmacy can be problematic: interactions between medications, reduced adherence to medication, burden of medication to patients, administration time, increased risk of errors and increased cost. Quality improvement methods were applied to identify and highlight polypharmacy patients with the aim of reducing their average number of regular tablets/capsules per day by 25%. The project was delivered within a UK based 27 bedded hospice inpatient unit. A series of PDSA cycles studied interventions focusing on the identification of patients with polypharmacy, the highlighting of these patients to prescribers for review and the views of patients about their medication. For the purposes of the study, polypharmacy was defined as greater than ten regular medicines and/or greater than twenty regular tablets/capsules each day. The interventions tested included patients on regular paracetamol and strong opioids being offered a trial without regular paracetamol, a constipation guide promoting the use of combination laxatives, education of prescribers around dose strengths, checklist of recommendations was placed in case notes and a sticker was used on the medicine chart to highlight patients in need of polypharmacy review. The introduction of a trial without paracetamol and a laxative guide led to reductions in polypharmacy. The sticker and checklist were successful interventions for highlighting patients with polypharmacy. Quality improvement methods were used to plan, try, test and implement simple interventions for patients on the hospice inpatient unit. This has led to a 25% reduction in the average regular tablet/capsules burden , a 16% reduction in the average number of regular medications and a 30% reduction in the average volume of liquid medication per patient without an increase in the use of 'as required' medication or length of stay.

Benthic assemblages associated with native and non-native oysters are similar.

Invasive species can impact native species and alter assemblage structure, which affects associated ecosystem functioning. The pervasive Pacific oyster, Crassostrea gigas, has been shown to affect the diversity and composition of many host ecosystems. We tested for effects of the presence of the invasive C. gigas on native assemblages by comparing them directly to assemblages associated with the declining native European oyster, Ostrea edulis. The presence of both oyster species was manipulated in intertidal and subtidal habitats and reefs were constructed at horizontal and vertical orientation to the substratum. After 12months, species diversity and benthic assemblage structure between assemblages with C. gigas and O. edulis were similar, but differed between habitats and orientation, suggesting that both oyster species were functionally similar in terms of biodiversity facilitation. These findings support evidence, that non-native species could play an important role in maintaining biodiversity in systems with declining populations of native species.

Evaluating palliative care ward staffing using bed occupancy, patient dependency, staff activity, service quality and cost data.

BACKGROUND: Palliative care staffing has remained unchallenged for decades while service provision has changed markedly, bringing new workforce demands. There is little evidence to inform hospice workforce structures, which strive to deliver the highest-quality holistic care. AIM: The study had three main aims, to: (i) adapt the acuity-quality workforce planning method used extensively in the UK National Health Service (NHS) for use in hospices; (ii) compare hospice and NHS palliative care staffing establishments and their implications; and (iii) create ward staffing benchmarks and formulae for hospice managers. DESIGN: A method adapted from a widely used nursing workforce planning and development (WP&D) study was used to collect data in hospice and palliative care wards. SETTING: Twenty-three palliative care and hospice wards, geographically representing England, were studied. RESULTS: A dataset, which profiles and benchmarks hospice and NHS palliative care ward occupancy, patient dependency, staff activity, ward establishments, quality and costs in 23 palliative care and hospice wards has been created. The database reveals large differences between hospice and palliative care wards. For example, hospice wards are better staffed and more expensive to run but staff deliver higher-quality care (measured using an established service quality audit) despite facing heavier workloads. Consequently, staffing multipliers are created to help managers estimate workload-based ward staffing. CONCLUSIONS: This dataset provides evidence-based recommendations to inform palliative care nursing workforce modelling, including deciding future nursing workforce size and mix based on rising workloads. The new dataset is suitable for use in UK hospice wards and may be appropriate for future international use.

Incidence and causes for syringe driver site reactions in palliative care: A prospective hospice-based study.

BACKGROUND: Syringe drivers are routinely used in palliative care for the subcutaneous infusion of drugs for pain and symptom control. Local site reactions occurring at the site of infusion can lead to patient discomfort and the potential for sub-optimal symptom control. AIM: The aim of this study was to investigate whether there was a correlation between drugs administered subcutaneously via a syringe driver and the incidence of syringe driver site reactions, further linking this to time to syringe driver site reaction. DESIGN: Prospective quantitative data collection of syringe driver use for 170 hospice inpatients. SETTING/PARTICIPANTS: Specialist palliative care inpatient facility in the UK. Syringe driver recording forms were retrieved from case notes of consecutive patients who received medication via a syringe driver. RESULTS: An association between the presence of cyclizine and levomepromazine and the incidence of syringe driver site reactions was identified. A marked difference in incidence of syringe driver site reaction was observed between the two study centres (26.5% vs. 7.7%). Although baseline patient characteristics were comparable, a difference in practice between the centres was identified, i.e. use of parenteral cannulae. An association between the time a syringe driver was in situ and the occurrence of a syringe driver site reaction was also demonstrated. CONCLUSIONS: Recommendations can be made for the frequency of syringe driver site changes based on which drugs are in use. Incidental findings from the study have been used to change practice at the hospice study site, with regard to choice of parenteral cannulae.

Can the spread of non-native oysters (Crassostrea gigas) at the early stages of population expansion be managed?

The Pacific oyster (Crassostrea gigas) was introduced into Strangford Lough, Northern Ireland in the 1970s. It was assumed that local environmental conditions would not facilitate successful reproduction. However, in the 1990s there were reports of C. gigas outside licensed aquaculture sites and this investigation set out to ascertain the current distribution, years of likely recruitment and population structure of the species. C. gigas were found distributed widely throughout the northern basin during surveys; the frequency distribution suggesting C. gigas is not recruiting every year. Establishment of feral populations of C. gigas elsewhere have linked to habitat change. A pilot cull was initiated to assess the success rate of early intervention. This paper demonstrates the potential benefits of responding rapidly to initial reports of non-native species in a way that may curtail establishment and expansion. The method advocated in simple and can be recommended to the appropriate regulatory authorities.

Exploring differences in referrals to a hospice at home service in two socio-economically distinct areas of Manchester, UK.

In order to provide equitable access to hospice at home palliative care services, it is important to identify the socio-economic factors associated with poorer access. In this population-based study we aimed to test the inverse care law by exploring how socio-economic status and other key demographic indicators were associated with referral rates in two distinct areas (Salford and Trafford) served by the same service. Secondary data from the UK National Census 2001, North West Cancer Intelligence Service (2004) and hospice at home service referral data (2004-06) was collated for both areas. Descriptive analysis profiled electoral ward characteristics whilst simple correlations and regression modelling estimated associations with referral rates. Referral rates were lower and cancer mortality higher in the most deprived areas (Salford). Referral rates were significantly associated with deprivation, particularly multiple deprivation, but not significantly associated with cancer mortality (service model and resources available were held constant). At the population level, the socio-economic characteristics of those referred to hospice at home rather than service provision strongly predicted referral rates. This has implications for the allocation and targeting of resources and contributes important findings to future work exploring equitable access at organizational and professional levels.

Experiences of 24-hour advice line services: a framework for good practice and meeting NICE guidelines.

This article presents a framework for the practical implementation of a 24-hour specialist palliative care advice line, illustrated by two case examples from the authors' experience. In the UK, National Institute for Health and Clinical Excellence guidance requires provision of 24-hour access to specialist palliative care advice for healthcare professionals and carers regardless of a patient's location. Effective implementation of a telephone advice line for specialist advice is one approach to addressing the current variability in palliative care service provision, both in the UK and elsewhere. The authors were unable to identify a model with documentation for ensuring adequate clinical governance of an advice line in the literature and so present their own. The accompanying case examples demonstrate the difference between 'evolution of services by demand' and taking a systemic approach to service design. Key recommendations for practice are outlined for an effective advice line service which incorporates training and education into the clinical governance structures of the host organization.

Complementary therapists' training and cancer care: a multi-site study.

PURPOSE: To explore professional experience and training of complementary therapists working within cancer care. METHOD: A Questionnaire survey of complementary therapists practising in three cancer care settings in North West England. RESULTS: Respondents (n=51; n=47 female; mean age 50 years, range 23-78 years) had varied career backgrounds; 24 were healthcare professionals who also practised as complementary therapists (nurse n=19; physiotherapist n=3; doctor n=2) whilst 27 were complementary therapists with no prior healthcare background. Twenty-eight respondents reported working as therapists within a supportive and palliative care setting for over 6 years. Forty-seven respondents had undertaken healthcare-related continuing professional development in complementary therapies, although only just over half of the sample (n=27) had received cancer-specific training. Cancer-related complementary therapy training related to the adaptation of therapies and comprised predominantly short courses. There was a lack of standardisation in the training received, nor was it clear how many courses were accredited. CONCLUSION: Findings highlight the need for standardisation of training for complementary therapy provision in cancer care and statutory review of continuing professional development within this emerging field.

Development of a holistic admission assessment: an integrated care pathway for the hospice setting.

This article describes the development of a holistic admission assessment for all inpatients admitted to a 66-bedded hospice, structured in the form of an integrated care pathway (ICP). The need for an improved assessment process was identified by clinical staff, who recognized that the existing assessment was not truly holistic and was dependent on the skills of the assessors. The assessment also lacked appropriate goals and actions. The recently published National Institute for Clinical Excellence (NICE) guidance on Improving Supportive and Palliative Care for Adults with Cancer, has also highlighted key areas for the improvement of patient assessment in specialist palliative care (NICE, 2004). Implementation of the ICP has resulted in a systematic and timely holistic assessment process for patients. The ICP addresses effectively the NICE recommendations for the assessment of specialist palliative care patients.

Current issues in the delivery of complementary therapies in cancer care--policy, perceptions and expectations: an overview.

This review discusses the current policies, perceptions and expectations around the use of complementary therapies (CTs) in cancer care. Whilst the last two decades have seen a marked increase in the demand for and provision of CTs amongst cancer patients, this has not been matched with an increase in the understanding of their effectiveness or their benefits to cancer patients. The issues discussed highlight the need to understand more fully the benefits of integrated services. Important questions raised here relate to what patients perceive as being the primary benefits/expected outcomes of CTs and how, if at all, they see their relationship with CT practitioners as different from that with "orthodox" clinicians. The challenge is clearly to find a common ground between "orthodox" professionals, CT practitioners and patients.

Professionals' perceptions of maintaining personhood in hospice care.

This qualitative study examines the attempts made by hospice staff to support and maintain the personhood of hospice patients. The study was conducted over a six-month period at two hospice facilities in northwest England. Thirty staff members were interviewed about their interpretation of the hospice philosophy and how this influences their work with regard to patient personhood. Staff employed methods of normalizing the often-distressing symptoms that accompany serious illness, with the aim of maintaining personhood and dignity. Related to the support of personhood, is the concept of the "special" patient. Staff members discussed feelings of attachment towards particular patients that had developed out of the care-giving relationship. There was no suggestion that staff perceived special patients as receiving preferential treatment at the expense of other patients. However, experiences with "special" patients positively impacted staff members by reinforcing occupational choice and the inherent rewards of the profession.