A prospective audit project into the adequacy of pain assessment in the medical and surgical wards in a North London District General Hospital.

BACKGROUND: Accurate assessment of pain is associated with improved pain management, which can lead to better patient outcomes. It has been recommended that all patients have their pain assessed and the scores documented as the 'fifth vital sign'. METHOD: All inpatients in the medical and surgical wards in our hospital were asked directly to score their pain according to the hospital-wide scoring system. Their observation charts and drug charts were then reviewed in order to determine the accuracy of documented pain assessments and the subsequent analgesic management. RESULTS: Of the 208 patients reviewed, 20 (15%) patients on medical wards and 26 (38%) patients on surgical wards were in moderate to severe pain. Documentation of pain scores was not universal, with 29 (14%) patients having no score documented with their last set of observations. Of those with a score recorded, it was not found to correlate with the scores reported on direct questioning in 41% of medical patients and 71% of surgical patients. Provision of analgesia was also found to differ between medical and surgical wards. DISCUSSION: The care of pain in the wards falls below the standards set by the Royal College of Anaesthetists. It is necessary to undertake a programme of education to increase awareness of the problem and to improve assessment and management to enhance the patient experience.

Dopaminergic involvement in effort-based but not impulsive reward processing in smokers.

BACKGROUND: A reduction in reward responsivity and an increase in temporal discounting of rewards are both evident in smokers during acute abstinence compared to satiation. However, it is not yet known whether these processes can be modulated pharmacologically in smokers, other than with nicotine or tobacco. METHODS: A double-blind placebo controlled crossover design assessed the effects of 0.5 mg pramipexole, a dopamine D2/D3 agonist, in smokers following 2 h of abstinence. Reward responsivity was measured using an effort-based card sorting task. Temporal discounting of monetary reward was assessed using Area Under the Curve (AUC) analysis, and affective and subjective effects were indexed. RESULTS: On placebo, smokers showed an equivalent speed of card sorting when a financial incentive was provided compared to when it was not. Conversely, more cards were sorted under rewarded compared to non-rewarded trials after pramipexole, indicating an improvement in reward responsivity. Temporal discounting of monetary reward was not affected by pramipexole. Drug treatment also decreased positive affect and increased drowsiness. CONCLUSIONS: A single dose of pramipexole can enhance effort-based reward responsivity, but does not alter temporal discounting in smokers. These findings highlight pharmacological correlates of reward processing deficits in nicotine dependence and offer potential targets for their treatment.

Performance on a probabilistic inference task in healthy subjects receiving ketamine compared with patients with schizophrenia.

Evidence suggests that some aspects of schizophrenia can be induced in healthy volunteers through acute administration of the non-competitive NMDA-receptor antagonist, ketamine. In probabilistic inference tasks, patients with schizophrenia have been shown to 'jump to conclusions' (JTC) when asked to make a decision. We aimed to test whether healthy participants receiving ketamine would adopt a JTC response pattern resembling that of patients. The paradigmatic task used to investigate JTC has been the 'urn' task, where participants are shown a sequence of beads drawn from one of two 'urns', each containing coloured beads in different proportions. Participants make a decision when they think they know the urn from which beads are being drawn. We compared performance on the urn task between controls receiving acute ketamine or placebo with that of patients with schizophrenia and another group of controls matched to the patient group. Patients were shown to exhibit a JTC response pattern relative to their matched controls, whereas JTC was not evident in controls receiving ketamine relative to placebo. Ketamine does not appear to promote JTC in healthy controls, suggesting that ketamine does not affect probabilistic inferences.

Changes in cue reactivity and attentional bias following experimental cue exposure and response prevention: a laboratory study of the effects of D-cycloserine in heavy drinkers.

RATIONALE: The effects of D-cycloserine (DCS) in animal models of anxiety disorders and addiction indicate a role for N-methyl D-aspartate (NMDA) receptors in extinction learning. Exposure/response prevention treatments for anxiety disorders in humans are enhanced by DCS, suggesting a promising co-therapy regime, mediated by NMDA receptors. Exposure/response prevention may also be effective in problematic drinkers, and DCS might enhance habituation to cues in these individuals. Since heavy drinkers show ostensible conditioned responses to alcohol cues, habituation following exposure/response prevention should be evident in these drinkers, with DCS enhancing this effect. OBJECTIVES: The objective of this study is to investigate the effect of DCS on exposure/response prevention in heavy drinkers. METHODS: In a randomised, double-blind, placebo-controlled study, heavy social drinkers recruited from the community received either DCS (125 mg; n = 19) or placebo (n = 17) 1 h prior to each of two sessions of exposure/response prevention. Cue reactivity and attentional bias were assessed during these two sessions and at a third follow-up session. Between-session drinking behaviour was recorded. RESULTS: Robust cue reactivity and attentional bias to alcohol cues was evident, as expected of heavy drinkers. Within- and between-session habituation of cue reactivity, as well as a reduction in attentional bias to alcohol cues over time was found. However, there was no evidence of greater habituation in the DCS group. Subtle stimulant effects (increased subjective contentedness and euphoria) which were unrelated to exposure/response prevention were found following DCS. CONCLUSIONS: DCS does not appear to enhance habituation of alcohol cue reactivity in heavy non-dependent drinkers. Its utility in enhancing treatments based on exposure/response prevention in dependent drinkers or drug users remains open.