Background-Severe chest pain is common in mesothelioma. Percutaneous cervical cordotomy, which interrupts the spinothalamic tract at the C1/C2 level causing contralateral loss of pain sensation, is particularly appropriate in mesothelioma as the tumour is unilateral and systemic analgesia may be ineVective and is limited by harmful side eVects. Method-A retrospective review was performed to determine the eVectiveness and complication rate of this procedure. Results-Fifty two patients were using opioids prior to cordotomy. The median daily dose of morphine before and after cordotomy was 100 mg (range 0-1000 mg) and 20 mg (range 0-520 mg), respectively (p<0.001). Forty three patients (83%) had a reduction in pain such that their dose of opioid could be at least halved. Twenty patients (38%) were able to stop completely. Recurrence of pain requiring an increase in opioid medication was recorded in 18 patients at a median time of nine weeks (range 0.7-26 weeks). Four patients developed mild weakness, two had troublesome dysaesthesia. The median time from cordotomy to death was 13 weeks (range 0.3-52 weeks). Six early deaths within two weeks of cordotomy occurred early in the series and reflect postoperative chest infection and poor selection as the patients were in the terminal stages of mesothelioma. Conclusions-Percutaneous cervical cordotomy is successful in treating pain from mesothelioma. There was a low complication rate in this series. Referral to a unit experienced in cordotomy is recommended as soon as pain from chest wall invasion is suspected.

Percutaneous cervical cordotomy (PCC) is a recognized procedure for control of pain due to thoracic malignancies. Caution with PCC in those with precarious lung function has previously been advised. Thirty-five patients were studied in a prospective study of respiratory function before and after PCC for control of pain from pleural mesothelioma or other thoracic malignancy using standard, easily applied tests. Mean duration of survival was 83 days (range 3-360 days). FEV1.0 and FVC did not alter significantly after the procedure. There was no relationship between any of the respiratory function variables measured and survival. Transient nocturnal hypoxemia occurred during the night immediately following PCC in 6 patients. Unilateral PCC does not worsen respiratory function in patients with pleural mesothelioma or other thoracic malignancies. Poor respiratory function before PCC does not predict survival or complications. It should not be a barrier to use of PCC.

Efficacy and safety profile of long-term nitrofurantoin in urinary infections: 18 years' experience.

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A 47-year-old woman sustained a gunshot wound to the left thigh. The entry wound was on the anteromedial aspect and the exit wound was on the posterolateral aspect of the thigh. She presented a month later with burning, predominantly superficial pain and cold hyperalgesia aVecting part of the left leg and foot in a stocking distribution. She had full pulses bilaterally, numbness to both pin prick and light touch on the sole and lateral aspect of the left foot, wasting of the calf muscles, weakness of dorsiflexion, and cold leg.Temperature profiles were requested (figures 1 and 2). Magnetic resonance imaging (MRI) scan of the left thigh showed evidence of the previous gunshot wound with the sciatic nerve identified in continuity but deviated at the site of the bullet track and surrounded by scar tissue. The patient had some relief of her symptoms following a left lumbar sympathetic block using a local anaesthetic, but continued to take oral analgesics. Questions