The median number of symptoms found using systematic assessment was tenfold higher (p<0.001) than those volunteered. Specific detailed symptom inquiry is essential for optimal palliation in advanced disease.

N-methyl-D-aspartate (NMDA) receptor antagonists relieve neuropathic pain in animal models, but side effects of dissociative anesthetic channel blockers, such as ketamine, have discouraged clinical application. Based on the hypothesis that low-affinity NMDA channel blockers might have a better therapeutic ratio, we carried out two randomized, double-blind, crossover trials comparing six weeks of oral dextromethorphan to placebo in two groups, made up of 14 patients with painful distal symmetrical diabetic neuropathy and 18 with postherpetic neuralgia. Thirteen patients with each diagnosis completed the comparison. Dosage was titrated in each patient to the highest level reached without disrupting normal activities; mean doses were 381 mg/day in diabetics and 439 mg/day in postherpetic neuralgia patients. In diabetic neuropathy, dextromethorphan decreased pain by a mean of 24% (95% CI: 6% to 42%, p = 0.01), relative to placebo. In postherpetic neuralgia, dextromethorphan did not reduce pain (95% CI: 10% decrease in pain to 14% increase in pain, p = 0.72). Five of 31 patients who took dextromethorphan dropped out due to sedation or ataxia during dose escalation, but the remaining patients all reached a reasonably well-tolerated maintenance dose. We conclude that dextromethorphan or other low-affinity NMDA channel blockers may have promise in the treatment of painful diabetic neuropathy.

We evaluated extensor mechanism function in 10 patients after they had arthroscopically assisted ACL reconstruction using the central third of the patellar tendon. The patients were randomly selected 12 to 24 months after reconstruction. All had rehabilitation where range of motion was initiated within the 1st postoperative week. All patients stated that they were satisfied and considered their knee to be stable. The KT-1000 maximum measurements (30 to 40 pounds) averaged an increase of 1.7 mm when compared with the opposite knee. Subjective complaints, such as anterior knee pain, grating, and weakness, were common and only 3 of 10 patients returned to all of their preinjury sports. Persistent radiographic abnormalities were common. Physical examination and functional testing also revealed persistent dysfunction of the extensor mechanism in patients with radiographic abnormalities. Isokinetic testing at 60 deg/sec showed an average quadriceps deficit of 18% compared to the normal extremity. Axial computed tomography scans revealed significant decrease in quadriceps cross-sectional area. Magnetic resonance imaging and computed tomography confirmed persistent defects at the harvest site; there was significant anterior knee scar formation in these patients. Despite achieving ligamentous stability, patients still experienced permanent weakness, functional deficits, patellar chondrosis, and pain after ACL reconstruction using the central one-third of the patellar tendon.

The anorexia-cachexia syndrome is a common problem in advanced cancer. Although many possible etiologies have been investigated, the cause has not been determined. Appropriate clinical evaluation is necessary to identify those patients who may respond to available, symptomatic treatments.

Hydromorphone is a more potent opioid analgesic than morphine and is used for moderate to severe pain. It can be administered by injection, by infusion, by mouth, and rectally. Oral bioavailability is low. The kidney excretes hydromorphone and its metabolites. Some metabolites may have greater analgesic activity than hydromorphone itself but are unlikely to contribute to the pharmacological activity of hydromorphone. With the exception of pruritus, sedation and nausea and vomiting, which may occur less after hydromorphone than after morphine, the side-effects of these drugs are similar. On a milligram basis hydromorphone is five times as potent as morphine when given by the oral route, and 8.5 times as potent as morphine when given intravenously.