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Due to its novelty and scale, the EMBER project is a key study within the prescribed burning evidence base. However, it has several significant but overlooked methodological flaws. In this paper, we outline and discuss these flaws. In doing so, we aim to highlight the current paucity of evidence relating to prescribed burning impacts on ecosystem services within the British uplands. We show that the results of the EMBER project are currently unreliable because: it used a correlative space‐for‐time approach; treatments were located within geographically separate and environmentally distinct sites; environmental differences between sites and treatments were not accounted for during statistical analysis; and, peat surface temperature results are suggestive of measurement error. Policy Implications. Given the importance of the EMBER project, our findings suggest that (a) government agencies and policymakers need to re‐examine the strengths and limitations of the prescribed burning evidence base; and, (b) future work needs to control for site‐specific differences so that prescribed burning impacts on ecosystem services can be reliably identified.

This article deals with four linked but distinct aspects of care for women with breast cancer, with an emphasis on the pivotal role of the general practitioner: 1. Modern medicine is fast recognising the need for psychosocial support of patients; in fact, for an integrated approach to caring for the whole person at all stages of illness. 2. Oncological treatment of metastatic disease needs to be individualised and based on realistic expectations of outcome balanced against side effects. 3. An open dialogue about the role and appropriateness of so-called 'alternative' or 'complementary' therapies is needed. 4. Despite significant improvements in palliative care quality and access in Australia in the last decade, many practitioners still require support and advice in this demanding area of care (particularly about difficult symptom control).

Eighteen inpatients receiving morphine for cancer pain in a palliative care unit were recruited to a study employing a range of neuropsychological tests to assess cognitive function. The tests employed were National Adult Reading Test, Williams Delayed Recall Test, Immediate Memory for Digits, Trailing Making Test, and the Digit Symbol Substitution Test. These data were correlated with biochemical tests of renal and hepatic function, morphine dose, route of administration, plasma morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) concentrations. Despite having no clinical evidence of impairment of cognitive function, the level of current intellectual functioning (Symbol Digit Substitution Test) was on average two standard deviations below normal. Immediate memory appeared to be well preserved, but Delayed Recall and Trailing Making Test scores were significantly above normal. There was no significant correlation between morphine dose, or plasma morphine and M3G and M6G concentrations, and the neuropsychological test results, although a weak correlation was found between plasma morphine concentration and digits forward (r = -0.47, p < 0.05) and Digit Symbol Substitution scores (r = -0.46, p < 0.05). Seven patients had some degree of nausea or vomiting, ascribed as an opioid adverse effect, and had higher serum creatinine concentrations, worse neuropsychological performance, and significantly higher plasma M3G concentrations (p < 0.05). These data provide some evidence to suggest that cognitive functioning in patients with advanced cancer receiving morphine may be significantly impaired despite apparent clinical normality. From these data it is not possible to determine what relative causal contribution the disease and the drug made to these observations, although renal function, plasma morphine, and M3G concentrations may be important. Future research should address a broad range of neuropsychological testing to assist in the modification of prac

* The Victorian Supreme Court has decided that artificial nutrition and hydration provided through a percutaneous gastrostomy tube to a woman in a persistent vegetative state may be withdrawn. * The judge ruled, in line with a substantial body of international medical, ethical and legal opinion, that any form of artificial nutrition and hydration is a medical procedure, not part of palliative care, and that it is a procedure to sustain life, not to manage the dying process. * Thus, the law does not impose a rigid obligation to administer artificial nutrition or hydration to people who are dying, without due regard to their clinical condition. The definition of key terms such as "medical treatment", "palliative care", and " reasonable provision of food and water" in this case will serve as guidance for end-of-life decisions in other states and territories. * The case also reiterates the right of patients, and, when incompetent, their validly appointed agents or guardians, to refuse medical treatment. * Where an incompetent patient has not executed a binding advance directive and no agent or guardian has been appointed, physicians, in consultation with the family, may decide to withdraw medical treatment, including artificial nutrition or hydration, on the basis that continuation of treatment is inappropriate and not in the patient's best interests. However, Victoria and other jurisdictions would benefit from clarification of this area of the law.

Contains fulltext : 57294.pdf (publisher's version ) (Closed access), Breakthrough pain (BKP) is a transitory flare of pain that occurs on a background of relatively well controlled baseline pain. Previous surveys have found that BKP is highly prevalent among patients with cancer pain and predicts more severe pain, pain-related distress and functional impairment, and relatively poor quality of life. An international group of investigators assembled by a task force of the International Association for the Study of Pain (IASP) evaluated the prevalence and characteristics of BKP as part of a prospective, cross-sectional survey of cancer pain. Fifty-eight clinicians in 24 countries evaluated a total of 1095 patients with cancer pain using patient-rated items from the Brief Pain Inventory (BPI) and observer-rated measures. The observer-rated information included demographic and tumor-related data, the occurrence of BKP, and responses on checklists of pain syndromes and pathophysiologies. The clinicians reported BKP in 64.8% of patients. Physicians from English-speaking countries were significantly more likely to report BKP than other physicians. BKP was associated with higher pain scores and functional interference on the BPI. Multivariate analysis showed an independent association of BKP with the presence of more than one pain, a vertebral pain syndrome, pain due to plexopathy, and English-speaking country. These data confirm the high prevalence of BKP, its association with more severe pain and functional impairment, and its relationship to specific cancer pain syndromes. Further studies are needed to characterize subtypes of BKP. The uneven distribution of BKP reporting across pain specialists from different countries suggests that more standardized methods for diagnosing BKP are needed.

Objective: To assess the effect of opioid substitution (substituting one member of the opioid class for another) on the incidence and severity of adverse effects in palliative-care patients who experience unacceptable, refractory adverse effects when taking an opioid drug. Design(s): Prospective audit of clinical records. Setting(s): Palliative Care Program, Monash Medical Centre, Melbourne, Victoria (comprising an acute 10-bed palliative care unit and a palliative care consultative service). Patient(s): All palliative care inpatients and patients referred to the consultative service who underwent opioid substitution between February 1996 and June 1997. Outcome measures: Adverse effects and pain control profiles before and after opioid substitution. Result(s): 55 opioid substitutions were undertaken in 49 patients. 49 substitutions were for adverse effects. The substitution produced partial or complete relief from confusion in 18 of 25 cases, from nausea and vomiting in 13 of 19, and from drowsiness in 8 of 15. Substitution also abolished myoclonus associated with renal failure in one patient. Conclusion(s): We found that the incidence and severity of adverse effects differed between opioids in the same patient. A trial of opioid substitution (usually in consultation with a specialist pain or palliative care unit and with auditing of outcomes) should be considered for patients with intolerable, refractory adverse effects of opioids.