Defining disease severity in atopic dermatitis and psoriasis for the application to biomarker research: an interdisciplinary perspective.

More severe atopic dermatitis and psoriasis are associated with a higher cumulative impact on quality of life, multimorbidity and healthcare costs. Proactive, early intervention in those most at risk of severe disease may reduce this cumulative burden and modify the disease trajectory to limit progression. The lack of reliable biomarkers for this at-risk group represents a barrier to such a paradigm shift in practice. To expedite discovery and validation, the BIOMarkers in Atopic Dermatitis and Psoriasis (BIOMAP) consortium (a large-scale European, interdisciplinary research initiative) has curated clinical and molecular data across diverse study designs and sources including cross-sectional and cohort studies (small-scale studies through to large multicentre registries), clinical trials, electronic health records and large-scale population-based biobanks. We map all dataset disease severity instruments and measures to three key domains (symptoms, inflammatory activity and disease course), and describe important codependencies and relationships across variables and domains. We prioritize definitions for more severe disease with reference to international consensus, reference standards and/or expert opinion. Key factors to consider when analysing datasets across these diverse study types include explicit early consideration of biomarker purpose and clinical context, candidate biomarkers associated with disease severity at a particular point in time and over time and how they are related, taking the stage of biomarker development into account when selecting disease severity measures for analyses, and validating biomarker associations with disease severity outcomes using both physician- and patient-reported measures and across domains. The outputs from this exercise will ensure coherence and focus across the BIOMAP consortium so that mechanistic insights and biomarkers are clinically relevant, patient-centric and more generalizable to current and future research efforts.

Atopic dermatitis (AD), and psoriasis are long-term skin conditions that can significantly affect people's lives, especially when symptoms are severe. Approximately 10% of adults and 20% of children are affected by AD, while psoriasis affects around 5% of people in the UK. Both conditions are associated with debilitating physical symptoms (such as itch) and have been linked to depression and anxiety. Biomarkers are naturally occurring chemicals in the human body and have potential to enhance the longer-term management of AD and psoriasis. Currently, there are no routinely used biomarkers that can identify people who experience or will go on to develop severe AD and psoriasis. For this reason, research is under way to understand which biomarkers are linked to severity. In this study, a multidisciplinary team of skin researchers from across Europe, along with patient groups, discussed the complexities of studying severity-related biomarkers. We identified a number of severity measurement approaches and there were recommendations for future biomarker research, including (i) considering multiple measures as no single measure can encompass all aspects of severity, (ii) exploring severity measures recorded by both healthcare professionals and patients, as each may capture different aspects, and (iii) accounting for influencing factors, such as different treatment approaches, that may impact AD and psoriasis severity, which make it challenging to compare findings across studies. Overall, we anticipate that the insights gained from these discussions will increase the likelihood of biomarkers being effectively applied in real-world settings, to ultimately improve outcomes for people with AD and psoriasis.

Ethics at the Centre of Global and Local Challenges: Thoughts on the Future of Business Ethics.

To commemorate 40 years since the founding of the Journal of Business Ethics, the editors in chief of the journal have invited the editors to provide commentaries on the future of business ethics. This essay comprises a selection of commentaries aimed at creating dialogue around the theme Ethics at the centre of global and local challenges. For much of the history of the Journal of Business Ethics, ethics was seen within the academy as a peripheral aspect of business. However, in recent years, the stakes have risen dramatically, with global and local worlds destabilized by financial crisis, climate change, internet technologies and artificial intelligence, and global health crises. The authors of these commentaries address these grand challenges by placing business ethics at their centre. What if all grand challenges were framed as grand ethical challenges? Tanusree Jain, Arno Kourula and Suhaib Riaz posit that an ethical lens allows for a humble response, in which those with greater capacity take greater responsibility but remain inclusive and cognizant of different voices and experiences. Focussing on business ethics in connection to the grand(est) challenge of environmental emergencies, Steffen Böhm introduces the deceptively simple yet radical position that business is nature, and nature is business. His quick but profound side-step from arguments against human-nature dualism to an ontological undoing of the business-nature dichotomy should have all business ethics scholars rethinking their "business and society" assumptions. Also, singularly concerned with the climate emergency, Boudewijn de Bruin posits a scenario where, 40 years from now, our field will be evaluated by its ability to have helped humanity emerge from this emergency. He contends that Milieudefensie (Friends of the Earth) v. Royal Dutch Shell illustrates how human rights take centre stage in climate change litigation, and how business ethics enters the courtroom. From a consumer ethics perspective, Deirdre Shaw, Michal Carrington and Louise Hassan argue that ecologically sustainable and socially just marketplace systems demand cultural change, a reconsideration of future interpretations of "consumer society", a challenge to the dominant "growth logic" and stimulation of alternative ways to address our consumption needs. Still concerned with global issues, but turning attention to social inequalities, Nelarine Cornelius links the capability approach (CA) to global and corporate governance, arguing that CA will continue to lie at the foundation of human development policy, and, increasingly, CSR and corporate governance. Continuing debate on the grand challenges associated with justice and equality, Laurence Romani identifies a significant shift in the centrality of business ethics in debates on managing (cultural) differences, positing that dialogue between diversity management and international management can ground future debate in business ethics. Finally, the essay concludes with a commentary by Charlotte Karam and Michelle Greenwood on the possibilities of feminist-inspired theories, methods, and positionality for many spheres of business ethics, not least stakeholder theory, to broaden and deepen its capacity for nuance, responsiveness, and transformation. In the words of our commentators, grand challenges must be addressed urgently, and the Journal of Business Ethics should be at the forefront of tackling them.

A global perspective on the functional responses of stream communities to flow intermittence.

The current erosion of biodiversity is a major concern that threatens the ecological integrity of ecosystems and the ecosystem services they provide. Due to global change, an increasing proportion of river networks are drying and changes from perennial to non-perennial flow regimes represent dramatic ecological shifts with potentially irreversible alterations of community and ecosystem dynamics. However, there is minimal understanding of how biological communities respond functionally to drying. Here, we highlight the taxonomic and functional responses of aquatic macroinvertebrate communities to flow intermittence across river networks from three continents, to test predictions from underlying trait-based conceptual theory. We found a significant breakpoint in the relationship between taxonomic and functional richness, indicating higher functional redundancy at sites with flow intermittence higher than 28%. Multiple strands of evidence, including patterns of alpha and beta diversity and functional group membership, indicated that functional redundancy did not compensate for biodiversity loss associated with increasing intermittence, contrary to received wisdom. A specific set of functional trait modalities, including small body size, short life span and high fecundity, were selected with increasing flow intermittence. These results demonstrate the functional responses of river communities to drying and suggest that on-going biodiversity reduction due to global change in drying river networks is threatening their functional integrity. These results indicate that such patterns might be common in these ecosystems, even where drying is considered a predictable disturbance. This highlights the need for the conservation of natural drying regimes of intermittent rivers to secure their ecological integrity.

High diversity and local endemism in Aotearoa New Zealand's groundwater crustacean fauna.

We used DNA barcoding to assess the diversity and distribution of New Zealand's groundwater amphipods and isopods (Crustacea) and to determine whether biodiversity and endemism within tectonically active New Zealand are similar to those of more tectonically stable continents. Sixty-five wells were sampled in seven aquifers across four regions within the North and South islands of New Zealand, and resident invertebrates were morphologically identified and then assessed using sequencing of the mitochondrial DNA cytochrome c oxidase subunit one (COI) gene. Invertebrates were found in 54 wells. Of the 228 individual amphipods and isopods found in 36 of the wells, 154 individuals were successfully sequenced for COI (68% success rate) from 25 wells, with at least one well in each aquifer containing sequenced individuals. Of the 45 putative species identified using Barcode Index Numbers (BINs), 30 BINs (78% of all taxa and 83% of amphipods) were previously unrecorded. Substantial morphologically cryptic, species-level diversity was revealed, particularly within the amphipod Family Paraleptamphopidae. Similarly, one isopod taxon morphologically identified as Cruregens fontanus was assigned to five well-separated BINs based on COI sequences. Endemism appeared high, with all taxa regionally endemic; 87% of species were restricted to one aquifer and more than 50% restricted to one well. Non-saturated species accumulation curves indicated that, while additional sampling may increase the range of some currently identified taxa, additional range-restricted taxa are also likely to be discovered. Patterns of diversity and short-range endemism were similar to those found elsewhere, including locations which are more tectonically stable. The predominance of local endemism within New Zealand's groundwater fauna suggests that land-use activities and groundwater extraction require careful evaluation to minimize threats to groundwater biodiversity.

Pre-Implementation Assessment of the Acceptability of Using Circulating microRNAs for Follow-Up of Malignant Germ-Cell Tumors.

BACKGROUND: MicroRNAs from the miR-371~373 and miR-302/367 clusters, particularly miR-371a-3p, are promising biomarkers for blood-based diagnosis and disease monitoring of malignant germ cell tumors (GCTs) and are nearing clinical implementation. These biomarkers have superior sensitivity and specificity compared with current markers alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). We explored patient acceptability of using circulating microRNAs to replace multiple serial computed tomography (CT) scans in malignant GCT follow-up. PATIENTS AND METHODS: Two workshops involved interactive presentations and focus groups. Discussions were digitally recorded and transcribed verbatim. Qualitative thematic analysis of transcripts identified the key themes. RESULTS: Prior to the workshops, potential participants expressed concern about the adoption of new blood tests due to personal experiences of the limitations of existing (AFP/HCG) markers. Twelve males (22-57 years of age; currently, 26-59 years of age) with a malignant GCT diagnosis participated; all were in follow-up. Three had experienced recurrence. Participants had cumulative exposure of between 1 and 15 CT scans. Data saturation was reached at the second workshop; five themes emerged underpinning preference for microRNA testing versus CT scans: (1) increased sensitivity and safety, (2) reduced financial costs, (3) reduced time for testing and results, (4) practicalities, and (5) reduced anxiety. However, some participants perceived an increased diagnostic capacity of CT scans versus blood testing. CONCLUSION: This first user consultation of circulating microRNA testing for future malignant GCT follow-up suggests high acceptability with potential patient and healthcare system benefits.

Management of Late Relapses After Chemotherapy in Testicular Cancer: Optimal Outcomes with Dose-intense Salvage Chemotherapy and Surgery.

BACKGROUND: Late relapse (LR) in testicular cancer is defined as disease recurrence more than 2yr after primary treatment. Optimal management for this rare group is unknown. OBJECTIVE: To identify prognostic factors relevant to outcomes in a large LR series following primary treatment with platinum-based chemotherapy. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective analysis of all patients treated for advanced testicular cancer within the Anglian Germ Cell Cancer Network between 1995 and 2016. We identified 53 cases of LR following initial treatment for metastatic disease with platinum-based chemotherapy, and collected data on patient and tumour characteristics, treatments, and outcomes. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Progression-free survival (PFS) and overall survival (OS) were calculated for all patients. Survival curves were plotted according to the Kaplan-Meier method and univariate analysis of descriptive variables was performed using the log-rank method. RESULTS AND LIMITATIONS: Across the cohort, PFS at 36 mo was 41% and OS was 61%. Multiple factors were correlated with PFS. Use of dose-intense or high-dose chemotherapy was associated with better PFS compared to conventional-dose chemotherapy (PFS 48 vs 9.8 mo; p=0.0036). Resection of residual disease post-relapse chemotherapy was associated with better PFS (hazard ratio 3.46; p=0.0076). There was a nonsignificant trend towards worse PFS in very late (>7 yr) relapses. The study is limited by its retrospective nature and selection bias cannot be excluded. CONCLUSIONS: This study provides new insight into prognostic factors in LR. It confirms that surgery is critical to optimal outcomes, and suggests that dose-intense or high-dose chemotherapy in multisite nonresectable disease should be considered wherever feasible. PATIENT SUMMARY: We studied patients with testicular cancer that recurred at least 2yr after initial treatment with chemotherapy. We found that patients who are able to have surgery to remove cancer and who have more intensive chemotherapy may be more likely to live longer.

Living with Advanced Hormone-Sensitive Prostate Cancer and Treatment with Abiraterone and Androgen Deprivation Therapy: The Patient, Nursing and Physician Perspective.

This article is co-authored by a patient with metastatic hormone-sensitive prostate cancer who is receiving abiraterone and androgen deprivation therapy treatment in Manchester, UK. The patient relates his personal experiences struggling with the diagnosis, his experience with treatment and the physical, emotional and psychosexual impact on his life. After his diagnosis, the patient has become an outspoken advocate and fundraiser for prostate cancer awareness and wants to ensure that novel treatments with proven efficacy and tolerability, such as abiraterone, are available for all men in his condition. The specialist nursing and physician perspectives, provided by healthcare professionals based in London who are not directly involved in this patient's care, were written in response to the challenges and concerns highlighted by this patient. The role of the specialist nurse as a key healthcare professional in the cancer patient journey, particularly in managing the complex physical and emotional side effects of treatment, is highlighted in this perspective piece. The physician reviews the current difficulties of establishing an effective screening programme in prostate cancer, the common side effects of hormone treatment and the significant progress and challenges in novel drug development and prescription in metastatic hormone-sensitive prostate cancer. While written primarily from the perspective of a patient and healthcare professionals in England, many messages in this commentary would resonate with patients and professionals involved in the care of prostate cancer worldwide.

Improved predictability of peak periphyton in rivers using site-specific accrual periods and long-term water quality datasets.

Prevention of excessive periphyton standing crop (quantified as chlorophyll a) is among primary objectives for river management. Defensible instream nutrient criteria to achieve periphyton chlorophyll a targets at the site scale require robust predictive models. Such models have proved elusive because peak chlorophyll a depends on multiple factors in addition to nutrients. A key predictor may be accrual period, which depends on river flow variability and the flow magnitudes (effective flows, EF) at which periphyton biomass removal is initiated. In this study we used a seven-year dataset from 44 gravel-bed river sites in the Manawatu-Whanganui region, New Zealand, to explore the relative importance of accrual period, nutrients, and other variables in explaining peak chlorophyll a, using a regression approach. We also assessed the effect of combining data from multiple years. Previous empirical studies have used a universal flow metric (3 × median flow) to define accrual period (Da3). We calculated site-specific EF, which varied from 2 × to 15 × median flow. Accrual period based on EF (DaEF) outperformed Da3 in models. However, in the study region, more variance in chlorophyll a was explained by conductivity (EC) and dissolved inorganic nitrogen (DIN) than by DaEF. The best models derived from multi-year datasets included EC, DIN and DaEF as predictors and accounted for up to 82% of the variance in peak chlorophyll a. Models from annual data were weaker and more variable in strength and predictors. The models indicated that EC and DaEF should be considered when setting DIN criteria for periphyton outcomes in the study region. The principles we used in developing the models may have broad relevance to the management of periphyton in other regions.

Dose-dense chemotherapy for untreated poor-prognosis and relapsed germ-cell tumours: an 18-year experience with GAMEC chemotherapy.

OBJECTIVE: To report a single-centre experience of the regimen GAMEC (granulocyte colony-stimulating factor, actinomycin-D, methotrexate with folinic acid rescue, etoposide and cisplatin) over 18 years in both untreated disease and relapse settings. METHODS: This retrospective cohort study was based on 162 patients who received GAMEC dose-dense chemotherapy incorporating actinomycin and high dose methotrexate. Survival outcomes were compared. Risk categorization based on (1) the International Prognostic Factor Study Group (IPFSG) criteria and (2) two factors, lactate dehydrogenase (LDH) levels greater than the upper limit of normal and age ≥35 years, were also compared in terms of survival outcomes using Cox proportional hazard regression modelling. RESULTS: Seventy-five patients with poor-prognosis disease, according to International Germ Cell Cancer Collaborative Group classification, received GAMEC as initial therapy. With a median follow-up of 63 months, the median progression-free survival (PFS) was >14 months. The 2-year PFS rate was 61.5% (95% confidence interval [CI] 49.1-71.6), and the 3-year overall survival (OS) rate was 71.9%. Seventy-six patients received GAMEC as second-line therapy (following failure of bleomycin, etoposide and cisplatin or etoposide cisplatin). The median PFS was 7.5 months (95% CI 5.2-not evaluable), the 2-year PFS rate was 43.5% (95% CI 32.1-54.4) and the 3-year OS rate was 53.7% (95% CI 41.6-64.3). In the third-line setting (n = 11), the 2-year PFS was 18.2% (95% CI 2.8-44.2). Overall, the treatment-related death rate declined from 10.5% in the first 15 years to 2.6% in the last 5 years. CONCLUSION: GAMEC was an effective regimen in untreated poor-prognosis disease and on relapse following conventional cisplatin and etoposide-based chemotherapy. Risk categorization based on LDH/age is more sensitive than that based on the updated IPFSG criteria. It is possible to identify patients who are particularly likely to benefit from this treatment, which has the important advantages of short duration and absence of bleomycin, particularly in patients with central nervous system and mediastinal disease. Low-dose induction treatment is associated with safer delivery of treatment without compromising survival.

Current-use pesticides in New Zealand streams: Comparing results from grab samples and three types of passive samplers.

New Zealand uses more than a ton of pesticides each year; many of these are mobile, relatively persistent, and can make their way into waterways. While considerable effort goes into monitoring nutrients in agricultural streams and programs exist to monitor pesticides in groundwater, very little is known about pesticide detection frequencies, concentrations, or their potential impacts in New Zealand streams. We used the 'Polar Organic Chemical Integrative Sampler' (POCIS) approach and grab water sampling to survey pesticide concentrations in 36 agricultural streams in Waikato, Canterbury, Otago and Southland during a period of stable stream flows in Austral summer 2017/18. We employed a new approach for calculating site-specific POCIS sampling rates. We also tested two novel passive samplers designed to reduce the effects of hydrodynamic conditions on sampling rates: the 'Organic-Diffusive Gradients in Thin Films' (o-DGT) aquatic passive sampler and microporous polyethylene tubes (MPTs) filled with Strata-X sorbent. Multiple pesticides were found at most sites; two or more were detected at 78% of sites, three or more at 69% of sites, and four or more at 39% of sites. Chlorpyrifos concentrations were the highest, with a maximum concentration of 180 ng/L. Concentrations of the other pesticides were generally below 20 ng/L. Mean concentrations of individual pesticides were not correlated with in-stream nutrient concentrations. The majority of pesticides were detected most frequently in POCIS, presumably due to its higher sampling rate and the relatively low concentrations of these pesticides. In contrast, chlorpyrifos was most frequently detected in grab samples. Chlorpyrifos concentrations at two sites were above the 21-day chronic 'No Observable Effect Concentration' (NOEC) values for fish and another two sites had concentrations greater than 50% of the NOEC. Otherwise, concentrations were well-below NOEC values, but close to the New Zealand Environmental Exposure Limits in several cases.

An observational evaluation of a new foam adhesive dressing.

Following the work of Winter demonstrating the benefits of moist wound healing, there has been a constant stream of wound care products launched into the market to support this concept. This article will describe the findings of an observational evaluation to observe, document and analyse the clinical effectiveness of a new foam adhesive dressing, UrgoTul® Absorb Border (Urgo Medical). The main objective of the evaluation was to define the parameters to allow data capture that would demonstrate the clinical effectiveness of the dressing. Parameters studied and analysed included atraumatic pain-free dressing changes; ease of dressing application; comfort and conformability; exudate management; ability of the dressing to stay in place; and peri-wound skin management. A total of 25 patients with wounds suitable to be dressed using the evaluation product were recruited following a full documented wound assessment by the tissue viability nurse. Participants were selected across the organisation from acute hospital wards and outpatient departments, care homes, wound care clinics and the participants' own homes. Digital photography was used to demonstrate improvement or deterioration of the wound bed and surrounding skin, and images were assessed by non-participating clinicians to confirm documented observations made within the evaluation. The dressing was found to be clinically effective in both chronic and acute wound types, and had an excellent level of participant acceptance.

A field study of household attack rates and the effectiveness of macrolide antibiotics in reducing household transmission of pertussis.

Bordetella pertussis (whooping cough) is an endemic, highly contagious bacterial respiratory infection, which is notifiable to Australian state and territory health departments. Between 2008 and 2011 there was a substantial outbreak in New South Wales with an initial increase in cases occurring in North Coast New South Wales from late 2007. During September and October 2011 the North Coast Public Health Unit conducted a household study of secondary attack rates to assess the effectiveness of pertussis vaccination as well as the timely use of antibiotics in preventing household transmission. At the time the study was commenced, notified cases included a large proportion of individuals with a documented history of vaccination against pertussis. We found lower attack rates amongst vaccinated compared with non-vaccinated subjects in all age groups, with the exception of the 5-11 years age group, who were also primarily responsible for the introduction of pertussis into the household. There was an increased risk of pertussis transmission from the household first primary case to contacts when antibiotic treatment was commenced later than 7 days after the onset of symptoms compared with within 7 days. This protective effect of timely antibiotic treatment in relation to transmission highlights the need to control for antibiotic treatment in field studies of pertussis. The benefits of timely diagnosis and use of antibiotics in preventing household transmission underscore the importance of early presentation and diagnosis of pertussis cases, particularly in households with susceptible occupants.

A phase Ib study investigating the combination of everolimus and dovitinib in vascular endothelial growth factor refractory clear cell renal cancer.

BACKGROUND: Everolimus (mammalian target of rapmaycin (mTOR) inhibitor) and dovitinib (vascular endothelial growth factor (VEGF) and fibroblast growth factor 2 (FGF-2) inhibitor) demonstrate activity in metastatic clear cell renal cancer. The combination of these agents has a broad spectrum of relevant activity. The combination is explored in this phase Ib study. METHODS: Patients with metastatic clear cell renal cancer who have failed VEGF targeted therapy were eligible. Up to four cohorts of three to six patients (3+3 design) were treated with escalating doses of everolimus and dovitinib. Dose-limiting toxicities (DLTs) were assessed to determine the maximum tolerated dose (MTD). An expansion cohort (n=15) was investigated to obtain additional efficacy information. Sequential fluorodeoxyglucose positron emission tomography (FDG-PET) was used as a surrogate marker of response. RESULTS: Overall 18 patients were recruited into the study. Fifteen patients received the MTD, which was everolimus 5mg orally (PO) once daily (OD) and dovitinib 200mg PO day 1-5/7. The MTD was associated with toxicity, which included fatigue, mucositis and diarrhoea in 73%, 53% and 53% (Common Toxicity Criteria (CTC) grade 1-4) of patients, respectively. Frequent biochemical abnormalities occurred (such as hypertriglyceridaemia in 67%). Higher doses of the combination were not tolerable due to grade 3 fatigue in 2/3 patients and grade 3 nausea in 1/3 patients within 1 month of therapy. The response rate at the MDT was 1/15 (7%) while the progression free survival for the MTD was 7 months (95% confidence interval (CI) 2.2-11 months). Pharmacokinetic data at the MTD showed stable kinetics with time. CONCLUSION: Dovitinib and everolimus had modest activity, but did not meet all of the planned efficacy end-points. Fatigue was the dose limiting toxicity.

Effective patient outcomes using a gelling fibre dressing.

Exudate has an important function within the process of wound healing; however, maintaining the wound bed at the optimum moisture level is a key factor in the wound's progression (Moore, 2005). A patient's experience of living with a wound is often tarnished when leakage caused by the fluid discharged is unmanageable, which can subsequently have a negative effect on daily living and quality of life (Edwards, 2003). Such wounds can cause substantial pain, suffering, loss of self-esteem, family distress, and a considerable financial cost to the NHS (Dowsett, 2011). It is estimated that 2-3% of the local healthcare budget will be spent on chronic wound management (Posnett et al, 2009). This article will present three case studies demonstrating the effective use of a gelling fibre dressing (Durafiber, Smith & Nephew) used on different wound aetiologies, including the clinical benefits and patient outcomes.

Clinical evaluation of Allevyn Gentle Border Lite™ within one health trust.

This article outlines the financial cost of wound care and the importance of appropriate dressings to achieve both clinical and economic outcomes. A clinical evaluation of Allevyn Gentle Border Lite™ including 50 patients within one health trust was undertaken to assess ease of application, wear time, ease of removal, durability and patient comfort. An observation is made that wound care is complex and health professionals require a knowledge and understanding of the wound healing process, pain, dressing products, asepsis, microbiology, pharmacology, psychosocial factors, and ethics, and should possess good communication skills. A conclusion is made that the 50 patient evaluation demonstrates the flexibility of the Allevyn Gentle Border Lite, which allows for a secure fit, provides active fluid management in its control of exudates, may be applied to patients with fragile skin, thereby avoiding the need for secondary retention, and may be used on difficult-to-dress areas.

Balancing quality and cost effectiveness.

It is not uncommon to open a nursing journal and be faced with dominating articles that focus on discussions around quality and cost-effective care. During this time of austerity, tissue viability services are not immune from the increasing pressure to improve patient care while reducing costs.

The assessment and management of skin tears in care homes.

This article discusses a project conducted in Worcestershire nursing homes to review current practices in the management of skin tears and the subsequent development and implementation of guidelines resulting in a standardised client care package. An initial audit in five care homes was followed by an in-depth audit in 52 homes over a 12-week period. This led to the development of resources and the 'STAR box' to assist with implementation of timely and appropriate care delivery.

Flooding impacts on responses of a riparian consumer to cross-ecosystem subsidies.

Landscape-driven processes impact the magnitude and direction of cross-ecosystem resource subsidies, but they may also control consumers' numerical and functional responses by altering habitat availability. We investigated effects of the interaction between habitat availability and subsidy level on populations of a riparian fishing spider, Dolomedes aquaticus, using a flood disturbance gradient in the Waimakariri River catchment, New Zealand. D. aquaticus predominantly eat aquatic prey as they hunt from the water surface. However, D. aquaticus biomass peaked at rivers with intermediate flood disturbance, rather than at less flood-prone rivers where the biomass of aquatic insect prey was markedly higher. Flooding positively influenced spider habitat quality, and an experimental manipulation at stable rivers indicated that unembedded cobbles, preferred D. aquaticus habitat, were a limiting factor, preventing response to the increased prey resource at stable sites. Potential terrestrial prey abundance was low, did not vary across the disturbance gradient, and is likely to have been a much smaller component of the fishing spiders' diet than aquatic insect prey. Thus landscape-driven factors not only controlled the magnitude of resource subsidies, but also influenced the ability of consumers to respond to them by altering the physical nature of the ecosystem boundary.