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Current guidelines and regulations require trusts to take full responsibility for deaths within their premises. Higher than expected deaths indicate poor standards of care or negligence. NHS Trusts need to put systems in place to ensure that they learn and extrapolate risk factors through in-depth review of care provided to patients prior to their deaths, curb and ultimately diminish relative mortality through improved practices, and improve care and safety for the whole organisation. Mortality reviews can provide insight into the standard of care that dying patients receive; this matters as NHS Hospitals are the main providers of terminal care, nationally.

To the editor We thank Professor Mercadante for his interest in our work and welcome the opportunity to comment. The indication for cordotomy in the cohort reported was for cancer pain which had not been successfully treated with opioid and adjuvant analgesia. The indication was further supported by referral from experienced practitioners in palliative care and/or oncology and ratified by experienced specialists in pain medicine working in tertiary referral centres, as part of multidisciplinary teams including specialist palliative care. All but two of our patients were on strong opioid medication in significant dosage at the time of cordotomy. We accept that all patients may not have exhausted every analgesic entity (eg, trial of multiple …

The analgesic effectiveness and adverse effect incidence of a daily dose of 10 or 20 mg of oral methadone were evaluated in 18 patients with a diverse range of chronic neuropathic pain syndromes, who had all responded poorly to traditional analgesic regimens. Analgesia was seen after each dose of methadone. As compared with placebo, the 20 mg daily dose (given as 10 mg bd) resulted in statistically significant (P=0.013–0.020) improvements in patient Visual Analogue Scale ratings of maximum pain intensity, average pain intensity and pain relief, recorded at the same time daily. The analgesic effects extended over 48 hours, as shown by statistically significant (P=0.013–0.020) improvements in all three outcomes on the rest days instituted between each daily dose. Analgesic effects (lowered maximum pain intensity and increased pain relief, on the day of dosing only) were also seen when the lower daily dose of 10 mg methadone (given as 5 mg bd) was used, but these failed to reach statistical significance (P=0.064 and 0.065, respectively). Interpatient analysis showed that the analgesic effects were not restricted to any particular type of neuropathic pain. Patient compliance was high throughout the trial. One patient withdrew during the 10 mg and six during the 20 mg methadone treatment periods. This is the first double-blind randomized controlled trial to demonstrate that methadone has an analgesic effect in neuropathic pain.

A diverse range of opioids and enantiomers were examined for their ability to displace binding at the [(3)H] MK-801-labelled site of the N-methyl-D-aspartate (NMDA) receptor in rat forebrain, displacement which is equitable with non-competitive NMDA receptor antagonist activity. Surprisingly, d-morphine, but not natural l-morphine, has low micromolar affinity for the site, suggesting clinical potential for racemic dl-morphine in the treatment of neuropathic pain with reduced development of tolerance. The opioid mu-receptor agonists: levorphanol, d- and dl-methadone, displayed similar properties. With the exception of the case of d-morphine, the structural requirements for affinity correspond closely with those previously found for the inhibitory effects of opioids on monoamine uptake.

Introduction: Persistent infection with sexually transmitted, high-risk human papillomavirus (HPV) types is the cause of all cervical cancers and some anogenital and oropharyngeal cancers. HPV is an extremely common asymptomatic infection but little known and poorly understood by the public. Patients with HPV-related cancers have new and challenging information needs due to the complex natural history of HPV and the stigma of sexual transmission. They may ask questions that are outside the remit of the traditional cancer consultation, and there is a lack of guidance on how to counsel them. This study aims to fulfil that need by developing and testing cancer site-specific scripted consultations.Methods and analysis: A synthesis of findings generated from previous work, a systematic review of information-based interventions for patients with HPV-related cancers, and interviews with cancer clinicians will provide the evidence base underpinning provisional messages. These will be explored in three phases of face-to-face interviews with 75-90 purposively selected patients recruited in cancer clinics to: (1) select and prioritise the most salient messages, (2) phrase the messages appropriately in plain English and, (3) test their acceptability and usefulness. Phases 1 and 2 will draw on card-sorting methods used in website design. In phase three, we will create cancer site-specific versions of the script and test them using cognitive interviewing techniques.Ethics and dissemination: The study has received ethical approval. Findings will be published in a peer-reviewed journal. The final product will be cancer-specific scripted consultations, most likely in the form of a two-sided information sheet with the most important messages to be conveyed in a consultation on one side, and frequently asked questions for later reading on the reverse. However, they will also be appropriate and readily adaptable to web-based uses.

Background There is no validated way of measuring diagnostic delay in cancer, especially covering patient and primary care delays. An instrument is needed in order to determine the effect of potential interventions to reduce delay and improve cancer morbidity and mortality. Methods Development of a postal questionnaire tool to measure patient and primary care time responses to key symptoms and signs. The pilot questionnaire was sent to 184 patients with suspected cancer. Results The response rate was only 85/184 (46.2%). Anxiety was cited as one reason for this low response. Patients returning questionnaires were more likely to be women and more likely to be younger. 84/85 (98.8%) provided consent to access medical records, and questions regarding health profile, smoking and socio-economic profile were answered adequately. Outcome data on their cancer diagnosis was linked satisfactorily and the question about GP-initiated investigations was answered well. Estimated dates for symptom duration were preferred for patient delays, but exact dates were preferred for primary care delays; however there was a significant amount of missing data. Conclusion A more personal approach to the collection of data about the duration of symptoms in this group of people is needed other than a postal questionnaire. However elements of this piloted questionnaire are likely to figure strongly in future development and evaluation of this tool.

Methadone is a potent opioid analgesic with other non-opioid properties. It has an analgesic and side effect profile similar to morphine. It is difficult to use because of a long and variable half-life. Conversion to methadone from other opioids is complex so it is best used in specialist settings.

Some opioids may have advantages over morphine in specific circumstances because of their pharmacokinetic and pharmacodynamic profiles. The fentanyl analogues may have greatest utility for episodic pain. Theoretical advantages such as NMDA receptor antagonism and inhibition of the re-uptake of biogenic monoamines have not been confirmed as producing better efficacy or tolerability in clinical studies.

Introduction There are around 1800 new cases of mesothelioma annually in the UK.The incidence of mesothelioma is still rising and is expected to peak between 2010 and 2015.Symptom control is central to the management of patients with mesothelioma. The National Mesothelioma Framework (2007) has suggested that patients should have access to services that offer cordotomy to provide relief from pain. There is however, great inequity in the provision of services offering cordotomy; the level of evidence to support the provision of invasive neuro-destructive procedures such as cordotomy is poor. For this small group of patients the procedures may yield significant analgesic benefit, however there is an as yet unquantified associated morbidity. This is a pilot study that focuses on cordotomy. Aims and Methods To establish consensus on the role of cordotomy in mesothelioma related pain and to set up a National Registry. We undertook a systematic review of the literature, and used a novel web based consensus methodology approach to clarify the role of cordotomy in the management of mesothelioma-related pain. We examined whether there was sufficient evidence to support continued provision and commissioning of cordotomy, and provide a benchmark for the availability and use of this procedure in the treatment of pain associated with mesothelioma in the U.K. The study culminated in a Consensus Conference at the Royal Society of Medicine on the 10th October 2011. Following this, we will establish a national registry study for cordotomy in mesothelioma-related pain management with Dendrite Clinical Systems. Results The results of the systematic review and web based consensus work will be presented. 101 participants completed the web based questionnaire; there were two rounds of Delphi before consensus was reached. Availability of cordotomy in the U.K. will be discussed. Conclusion The approach of systematic review, Web Based Delphi, Nominal Group and Consensus Conference was successful. In view of this we plan to apply the methodology to other interventional approaches in palliative and supportive care. A surprise finding was the quantity of qualitative data that came through the web based consensus tool.