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The Editor and team would like to take this opportunity to extend the warmest Season’s Greetings to all of our readers and to wish every success in the coming year.

For those working in palliative medicine in the U.K. we can look forward to working with clinical governance, re-validation and appraisals not to mention the NHS Plan and the development of the Cancer Networks Within all of these C.M.E. is a key element for the professional development of the individual and integral with the evolution of the new structures. The learning curve is steep at the moment and much time is being spent on management matters and away from clinical practice. However, the policy of this journal remains to focus on issues of clinical relevance and we apologise that this issue is slightly overdue.

In this issue Dr. Quigley outlines some of the newer agents used in the management of neuropathic pain. The understanding of the mechanisms of neuropathic pain has led to some considerable advances through the 1990’s and it is now very unusual for patients with severe pain not to have at least one neuropathic agent added to their standard analgesic medication. It is interesting to reflect that we now rarely see patients taking very large doses of morphine, whereas ten or more years ago prescriptions for morphine at doses in excess of 1000mg were not uncommon. This is undoubtedly due to the better use of co-analgesics and neuropathic agents. The development of novel channel blockers is an exciting prospect for the next few years.

Tenesmus is a particular type of pain that is often extremely difficult to manage. Drs Rich and Ellershaw give an account of contemporary practice. The problem is that this symptom is often associated with pelvic tumours which are either refractory to treatment or have recurred despite therapy. These provide one of the greatest challenges for the palliative care physician – not only is the pain extremely difficult to manage but also there are a lot of accompanying problems with bowel and bladder management and swelling of the lower limbs. In the upper G.I. tract, the team from Scarborough reports the successful placement of an expanding metal stent in the stomach. The use of stenting for obstruction to the oesophagus is well established and the advent of the modern expanding metal stent has opened opportunities to relieve obstruction elsewhere in the gut. Unfortunately, such stents are expensive and their placement requires considerable expertise. Treatment failures are not uncommon. Nonetheless, obstruction to the gut is extremely unpleasant and good palliation (by whatever means) is often difficult to achieve particularly if the level of obstruction is high.

Venous thrombo-embolism is common in patients with advanced malignant disease and is often a major contributory cause of death. However, the use of prophylactic anticoagulation amongst hospice inpatients is unusual. Dr Johnson’s work in this area is well known and her article rightly draws attention to the anxieties associated with the use of anticoagulants in patients with advanced disease. There are on-going trials of the use of low molecular weight heparin in oncology. Further exploration in the palliative care setting is needed– a good opportunity for collaborative research.