Clinical governance and chronic pain: towards a practical solution.

There have been many studies into the effectiveness of single interventions in pain, however, little is known of performance or outcome of pain clinics where treatment often consists of multiple, complex interventions. Many pain clinicians currently experience considerable difficulty in fulfilling the requirements of clinical governance and completing a personal portfolio. There is a clear and urgent need for a viable method of monitoring performance. This study describes a well-developed computer-based system - Pain Audit Collection System (PACS). PACS has been designed by pain clinicians through consensus and its success in uptake suggests that it is a viable method for outcome evaluation. An analysis is provided of outcome data in typical pain clinics. Further work is needed to investigate the utility of this data.

Elements of episodic-like memory in animals.

A number of psychologists have suggested that episodic memory is a uniquely human phenomenon and, until recently, there was little evidence that animals could recall a unique past experience and respond appropriately. Experiments on food-caching memory in scrub jays question this assumption. On the basis of a single caching episode, scrub jays can remember when and where they cached a variety of foods that differ in the rate at which they degrade, in a way that is inexplicable by relative familiarity. They can update their memory of the contents of a cache depending on whether or not they have emptied the cache site, and can also remember where another bird has hidden caches, suggesting that they encode rich representations of the caching event. They make temporal generalizations about when perishable items should degrade and also remember the relative time since caching when the same food is cached in distinct sites at different times. These results show that jays form integrated memories for the location, content and time of caching. This memory capability fulfils Tulving's behavioural criteria for episodic memory and is thus termed 'episodic-like'. We suggest that several features of episodic memory may not be unique to humans.

Testing episodic memory in animals: a new approach.

Episodic memory involves the encoding and storage of memories concerned with unique personal experiences and their subsequent recall, and it has long been the subject of intensive investigation in humans. According to Tulving's classical definition, episodic memory "receives and stores information about temporally dated episodes or events and temporal-spatial relations among these events." Thus, episodic memory provides information about the 'what' and 'when' of events ('temporally dated experiences') and about 'where' they happened ('temporal-spatial relations'). The storage and subsequent recall of this episodic information was thought to be beyond the memory capabilities of nonhuman animals. Although there are many laboratory procedures for investigating memory for discrete past episodes, until recently there were no previous studies that fully satisfied the criteria of Tulving's definition: they can all be explained in much simpler terms than episodic memory. However, current studies of memory for cache sites in food-storing jays provide an ethologically valid model for testing episodic-like memory in animals, thereby bridging the gap between human and animal studies memory. There is now a pressing need to adapt these experimental tests of episodic memory for other animals. Given the potential power of transgenic and knock-out procedures for investigating the genetic and molecular bases of learning and memory in laboratory rodents, not to mention the wealth of knowledge about the neuroanatomy and neurophysiology of the rodent hippocampus (a brain area heavily implicated in episodic memory), an obvious next step is to develop a rodent model of episodic-like memory based on the food-storing bird paradigm. The development of a rodent model system could make an important contribution to our understanding of the neural, molecular, and behavioral mechanisms of mammalian episodic memory.

A district general hospital pain management programme. First year experiences and outcomes.

A pain management programme was set up in a large District General Hospital to improve the management of the many patients with chronic non-malignant pain who do not respond to interventional medicine. Outcome measures studied were depression, anxiety, disability, pain locus of control, illness behaviour and patient satisfaction with the programme. The first five of these measures showed statistically significant improvements whilst patient satisfaction with the programme was high at both assessments. In addition, there were marked decreases in the consumption of analgesics and sedative drugs. We conclude that a multidisciplinary pain management programme is a cost effective and constructive way of treating patients whose pain does not respond to interventional management.

Day care surgery for Dupuytren's contracture.

Contrary to standard practice in the United Kingdom, primary surgery for Dupuytren's contracture can be performed safely on a day care basis provided that strict criteria are followed. Although demanding on Consultant surgical time, this policy offers a considerable saving in hospital resources.

Postoperative extradural analgesia following thoracic surgery: a feasibility study.

The feasibility of providing postoperative analgesia using thoracic extradural blockade following thoracotomy has been assessed. Extradural block was produced by intermittent injections of 0.5% bupivacaine with adrenaline 1:200,000 or a continuous infusion of 0.25% or 0.125% bupivacaine. The only toxic symptom was drowsiness which was most frequent after a continuous infusion of 0.25% bupivacaine and with arterial plasma bupivacaine concentrations above 1.5 mug/ml. Arterial hypotension was a troublesome complication with all techniques although stability of arterial pressure was more easily achieved with a continuous infusion technique. However, this produced a high incidence of urinary retention. Practical aspects and effectiveness of providing extradural analgesia in patients following thoracotomy are discussed.