Modified-release morphine or placebo for chronic breathlessness: the MABEL trial protocol.

Chronic breathlessness, a persistent and disabling symptom despite optimal treatment of underlying causes, is a frightening symptom with serious and widespread impact on patients and their carers. Clinical guidelines support the use of morphine for the relief of chronic breathlessness in common long-term conditions, but questions remain around clinical effectiveness, safety and longer term (>7 days) administration. This trial will evaluate the effectiveness of low-dose oral modified-release morphine in chronic breathlessness. This is a multicentre, parallel group, double-blind, randomised, placebo-controlled trial. Participants (n=158) will be opioid-naïve with chronic breathlessness due to heart or lung disease, cancer or post-coronavirus disease 2019. Participants will be randomised 1:1 to 5 mg oral modified-release morphine/placebo twice daily and docusate/placebo 100 mg twice daily for 56 days. Non-responders at Day 7 will dose escalate to 10 mg morphine/placebo twice daily at Day 15. The primary end-point (Day 28) measure will be worst breathlessness severity (previous 24 h). Secondary outcome measures include worst cough, distress, pain, functional status, physical activity, quality of life, and early identification and management of morphine-related side-effects. At Day 56, participants may opt to take open-label, oral modified-release morphine as part of usual care and complete quarterly breathlessness and toxicity questionnaires. The study is powered to be able to reject the null hypothesis and an embedded normalisation process theory-informed qualitative substudy will explore the adoption of morphine as a first-line pharmacological treatment for chronic breathlessness in clinical practice if effective.

Understanding the effects of adverse childhood experiences on older people.

There is increasing recognition that adverse childhood experiences are linked to suboptimal mental and physical health in later life. Despite this, there has been little research into the effects of adverse childhood experiences on older people. This article gives an overview of the long-term mental and physical effects of adverse childhood experiences and discusses how childhood trauma may manifest in older people. The author also discusses how nurses and unpaid family carers may themselves have been exposed to adverse childhood experiences and how this may affect their caring role. It is crucial that nurses adopt a trauma-informed approach to the care of older people to take account of possible adverse childhood experiences and prevent re-traumatisation.

The impact of animals on patient wellbeing.

Animals can be highly significant to people but overlooked in nursing assessments and care plans. Nurses need to appreciate this issue and support these relationships. This article summarises how animals can affect healthcare and wellbeing, and outlines what nurses can do to ensure this aspect of holistic care is not overlooked.

General practice registrars as teachers: a questionnaire-based evaluation.

OBJECTIVES: To determine how many General Practice (GP) Registrars in the London Deanery taught medical students during their final year of training. For those who did teach, to evaluate their experiences and for those who did not, to identify perceived barriers to teaching. DESIGN: Cross sectional survey of GP Registrars in the London Deanery completing their training in August 2010. SETTING: Online survey of GP Registrars sent after completion of training via the London Deanery GP Vocational Training Scheme (VTS) programme administrators. PARTICIPANTS: GP Registrars in the London Deanery completing their training in August 2010. MAIN OUTCOME MEASURE: The proportion of London Deanery GP registrars completing training in August 2010 who taught medical students during their registrar year. RESULTS: Over half of respondents were involved in some form of medical student teaching during their registrar year. Most of those who taught felt it enhanced their training, and the majority of those who did not teach would have liked to. Commonly cited barriers to teaching were: students not attached to the practice; not being given the opportunity to teach; and not having time to teach. CONCLUSIONS: This evaluation demonstrated that GP registrars are either already involved with undergraduate teaching or want to get involved and the majority who teach feel that it enhances their training. A UK-wide study investigating the experiences and views of both GP registrars and GP trainers is warranted and qualitative work using focus groups or semistructured interviews would be valuable to develop the questionnaire for wider dissemination.

The evidence for and against 'PhysioDirect' telephone assessment and advice services.

Patients have experienced inadequate access to physiotherapy since the inception of the National Health Service (NHS). Over the last 50 years, many initiatives have been introduced to address this problem, the most recent being a new patient management pathway known as 'PhysioDirect'. Within these services, physiotherapists offer initial assessment and advice by telephone, sometimes supported by computerised algorithms, and patients are sent written self-management and exercise advice by post. For some patients, face-to-face physiotherapy care will be offered where this is considered to be more appropriate. Although several such services have been developed across the UK, there is no robust evidence about clinical and cost-effectiveness, nor the acceptability of PhysioDirect to patients, physiotherapists or primary care organisations. This debate article summarises models of PhysioDirect, the links to other healthcare developments and relevant evidence to date about this type of service. By providing a summary of the arguments for, and key concerns about, PhysioDirect, this article stresses the need for more definitive evidence from high-quality randomised controlled trials before widespread roll-out across the NHS.

Hydrology and water quality of the headwaters of the River Severn: Stream acidity recovery and interactions with plantation forestry under an improving pollution climate.

This paper presents new information on the hydrology and water quality of the eroding peatland headwaters of the River Severn in mid-Wales and links it to the impact of plantation conifer forestry further down the catchment. The Upper Hafren is dominated by low-growing peatland vegetation, with an average annual precipitation of around 2650 mm with around 250 mm evaporation. With low catchment permeability, stream response to rainfall is "flashy" with the rising limb to peak stormflow typically under an hour. The water quality is characteristically "dilute"; stormflow is acidic and enriched in aluminium and iron from the acid organic soil inputs. Baseflow is circum-neutral and calcium and bicarbonate bearing due to the inputs of groundwater enriched from weathering of the underlying rocks. Annual cycling is observed for the nutrients reflecting uptake and decomposition processes linked to the vegetation and for arsenic implying seasonal water-logging within the peat soils and underlying glacial drift. Over the decadal scale, sulphate and nitrate concentrations have declined while Gran alkalinity, dissolved organic carbon and iron have increased, indicating a reduction in stream acidification. Within the forested areas the water quality is slightly more concentrated and acidic, transgressing the boundary for acid neutralisation capacity as a threshold for biological damage. Annual sulphate and aluminium concentrations are double those observed in the Upper Hafren, reflecting the influence of forestry and the greater ability of trees to scavenge pollutant inputs from gaseous and mist/cloud-water sources compared to short vegetation. Acidification is decreasing more rapidly in the forest compared to the eroding peatland possibly due to the progressive harvesting of the mature forest reducing the scavenging of acidifying inputs. For the Lower Hafren, long-term average annual precipitation is slightly lower, with lower average altitude, at around 2520mm and evaporation is around double that of the Upper Hafren.