A prospective study was carried out of 125 hospital inpatients with malignant disease, referred to the King's College Hospital advisory palliative care team. A palliative care assessment (PACA) tool was developed in order to assess the outcome of interventions made within two weeks of referral with regard to: symptom control, change in the patients' and their relatives' insight regarding diagnosis and prognosis, and facilitation of patient placement. Reliability was assessed by cross-observer analysis, and validity by comparison with data obtained using the McCorckle symptom distress scale in a separate group of hospice inpatients. At initial assessment, the commonest symptom was pain, as reported by 74% of patients. One-third of the patients were unsure of their diagnosis and placement had not been decided in 61%. In total, the team undertook 245 pharmacological interventions for symptom control, 165 interventions regarding insight and 114 interventions concerning placement. Analysis of the data showed statistically significant improvements in pain (p < 0.001), nausea (p < 0.009), insomnia (p < 0.004), anorexia (p < 0.001) and constipation (p < 0.02). Discussion regarding diagnosis significantly changed the insight of patients (p < 0.001) and relatives (p < 0.02). Appropriate placement was assisted by interventions undertaken by the team. This study shows that a hospital palliative care team is effective at improving symptom control, facilitates understanding of the diagnosis and prognosis, and contributes to the appropriate placement of patients.

The respiratory responses to intravenous morphine sulphate (0.12 mg/kg), morphine-6-glucuronide (M6G: 0.03 mg/kg) and placebo were assessed in 6 healthy volunteers, using a single blind randomised crossover design. Five of these subjects underwent an additional study of M6G at 0.06 mg/kg. Respiratory rate, minute volume and end-tidal CO2 were continuously measured using a low resistance non-rebreathing circuit, a mass spectrometer and a dry gas meter. The ventilatory responses to CO2 exposures (5.5% for 4 min) were assessed 40 and 20 min before, and 20, 40 and 80 min after drug administration. Following placebo and M6G (at both doses) no change in end-tidal CO2 occurred whilst the subjects were breathing air, whereas following morphine a significant rise was seen (P less than 0.05). Morphine reduced the ventilatory response to 5.5% CO2 at all times tested (P less than 0.05) and M6G (at both doses) reduced the response to CO2 at 20 and 40 min after administration, but to a lesser degree than did morphine (P less than 0.05).

Ketanserin, a selective S2 serotonergic antagonist, was assessed against placebo in a double-blind cross-over study of 16 patients with chronic peripheral burning pain. Nine of these had signs of reflex sympathetic dystrophy (RSD). All patients underwent 4 intravenous regional treatments, 2 with ketanserin (10 mg for upper limb pain, 20 mg for lower limb pain) and 2 with placebo. In those patients with RSD ketanserin and not placebo provided significant (P less than 0.05) sustained pain relief as assessed by linear analogue scales. In patients who did not fulfil the criteria for RSD no significant relief was seen with placebo or ketanserin. Following tourniquet release, drowsiness, shakiness and faintness were reported at a higher (P less than 0.05) frequency after ketanserin than after placebo. All side effects were mild and transient, and no changes occurred in heart rate or blood pressure following ketanserin that were significantly different from those seen following placebo. A role for serotonin in the pathogenesis of RSD is proposed.

The analgesic efficacy and CSF pharmacokinetics of intrathecal morphine sulphate and morphine-6-glucuronide (M6G) were compared in a single-blind crossover study. Lumbar intrathecal catheters were sited in three patients with chronic cancer pain, and morphine sulphate 500 micrograms or M6G 500 micrograms given via the catheter on separate days. CSF was sampled for 24 h following drug administration and analysed for morphine and M6G by high pressure liquid chromatography. The mean (SD) requirement for patient controlled analgesia with pethidine was 393.3 (227.4) mg/24 h during the morphine limb of the trial and 226.7 (113.6) mg/24 h during the M6G limb. M6G was not detected in CSF following administration of morphine. Fitting of CSF concentrations to triexponential curves revealed mean (SD) alpha, beta and gamma half-lives of 13.2 (7.4), 54.9 (31.5) and 222.5 (100) min for morphine and 11.2 (2.4), 67.3 (49.9) and 619.3 (629.7) min for M6G.