Strategy for increasing detection rates of drug and alcohol abuse in paediatric emergency departments.

AIM: To determine whether implementation of criteria for performing a toxicology screen and increasing staff awareness improve detection of substance abuse among adolescents presenting to the emergency department. METHODS: Patients 12 to 18 years of age presenting to one of three emergency departments in Israel were included in a prospective cohort study. In the 'study' hospital, a set of criteria for urine toxicology screen and measurements of ethanol serum level were implemented. No specific interventions were implemented in the two other hospitals. The main outcome measure was the rate of substance abuse detection. RESULTS: The number of adolescents seen in the participating centres was 3200 at the study hospital, and 3493 and 2792 at the two other hospitals. High blood ethanol concentrations were found in 49 patients at the study hospital compared with 30 and 19 patients at the two other hospitals (p < 0.001). Illicit drugs were detected in 13, 4 and 1 patients, respectively (p = 0.002). CONCLUSIONS: Introducing structured guidelines for ordering toxicological screening increases the detection of alcohol and drug of abuse among adolescents presenting to paediatric emergency departments.

EMLA cream prior to digital nerve block for ingrown nail surgery does not reduce pain at injection of anesthetic solution.

BACKGROUND: Needle penetration and local anesthetic infiltration are painful steps of digital ring block. The objective of this study was to evaluate the efficacy of EMLA cream application prior to digital ring block for surgery for ingrown big toenail. METHODS: We conducted a prospective, double-blinded, placebo-controlled, randomized clinical trial with 81 patients (range: 12-75 years, mean +/- SD: 30.3 +/- 17.5 years), who underwent big toenail surgery. Prior to the digital block, EMLA cream (Group E) or a placebo cream (Group P) was applied. A visual analog scale (VAS) and a verbal rating score (VRS) from 1 to 10, 10 being most severe pain, were used for assessment of pain during the skin needle penetration and during the infiltration of the anesthetic product. RESULTS: Data of the VAS and of the VRS during the two steps, respectively, show no significant difference in pain rating between the two groups. In Group E, the gender of the patients had a significant effect on pain perception. Male patients reported less pain than female patients, both during the needle skin penetration and during the infiltration step (P < 0.005). In Group P, reported pain did not differ by gender in either step of the procedure. CONCLUSIONS: We found no clinical benefit in using EMLA during digital nerve block. Although the digital nerves are not deeply located in the small subcutaneous space of the digit, topical anesthesia may not reach them. Moreover, swelling due to injection of the anesthetic product in this small space may also amplify the sensation of pain.

Alkalinizing local anesthetic does not decrease pain during injection for dorsal penile nerve block.

STUDY OBJECTIVE: To evaluate whether alkalizing local anesthetic with sodium bicarbonate reduces pain related to infiltration of local anesthetic during dorsal penile nerve block for circumcision. DESIGN: Prospective, randomized, double-blind, controlled study. SETTING: E. Wolfson Medical Center, Holon, Israel. PATIENTS: 144 patients aged 15 to 54 years (mean +/- SD = 22.7 +/- 8.8 years), randomized before the block into four groups of 36 patients each. INTERVENTIONS: Group A (control) received a standard solution of 1 mg/kg lidocaine 2% mixed with 0.5 mg/kg bupivacaine 0.5% without epinephrine (pH = 6.3). Patients in Group B, Group C, and Group D received this mixture added with 8.4% sodium bicarbonate for a mean final pH of 6.90, 7.16, and 7.43, respectively. Penile block was performed using a 23-gauge needle by an anesthetist who was blinded to the pH of the solution. MEASUREMENTS AND MAIN RESULTS: Patients were questioned regarding pain suffered during injection of the anesthetic solutions by another physicians who also was blinded to the drug used. Pain was rated by a previously reported subjective pain scale. Mean pain scales were 2.0 +/- 0.17, 2.3 +/- 0.15, 2.2 +/- 0.16, and 1.94 +/- 0.15 for Groups A to D, respectively. The differences between these results were not statistically significant. CONCLUSION: Alkalinizing the acidic local anesthetic solution by sodium bicarbonate does not decrease pain related to infiltration during penile nerve block for circumcision.

Detecting psychological distress among patients attending secondary health care clinics. Self-report and physician rating.

A study was conducted to determine the prevalence of psychological distress, as reported by patients and their physicians, in orthopedic, neurology, dermatology, and ophthalmology clinics; to study their accuracy in detecting psychological distress; and to determine if there is any connection among psychological distress, accuracy of detecting distress, and use of mental health and primary health care physicians' prognosis for the somatic complaints. Five hundred and fifty-six patients, ages 18-21, responded to the Psychiatric Epidemiology Research Interview Demoralization Scale (PERI-D), a measure of psychological distress, and to questions about their mental health and use of mental health and primary health services. Physicians, who were blind to patients' responses, were asked to what extent they thought the cause of patients' complaints was physical and to what extent they thought it was psychological in nature, and to prognosticate. Based on the PERI-D, about 25% of patients were distressed, this was less for females than males and varied between clinics. Based on self-reporting, about 14% of patients (males and females) were distressed. Based on physician reporting, about 17% (males less) were distressed. Physicians identified 35% of the PERI-D-distressed cases and 79% of nondistressed cases. About 66% of patients identified their distress and 83% their lack of distress. Increased use of primary health care and mental health care was related to distress. The prognosis was negatively related to distress. Based on this study, there is a need for more attention to psychological distress among secondary health care patients. Patients' ability to identify their distress suggests the importance of involving the patient in the diagnostic process. Correct detection of distress alone does not appear to decrease the use of primary medical and mental health services.

Early and long-term effects of electroconvulsive therapy and depression on memory and other cognitive functions.

Twenty-seven medication-free, depressed patients (Research Diagnostic Criteria, endogenous subtype) were administered a comprehensive battery testing memory and other cognitive functions before and after a series of bilateral, brief-pulse electroconvulsive therapy (ECT) administered according to a dosage-titration procedure (8.9 +/- 1.981 treatments). A subset of patients (N = 14) were reexamined at 1 month and 6 months after the conclusion of the treatment. Anterograde (verbal and visuospatial tasks), as well as retrograde (famous and personal events), memory function was significantly impaired at the end of the ECT series. By 1 month follow-up, performance had improved to pre-ECT (depression) levels on both anterograde and retrograde tasks and exceeded these by 6 months. The memory deficits induced by ECT were not a consequence of generalized cognitive impairment. Furthermore, depression and ECT were shown to independently affect memory, and recovery from depression was not a consequence of the amnestic action of the treatment. The results generally confirm previous reports regarding the nature of ECT-induced memory impairment, in a different language and culture. They suggest that long-term effects of the treatment on memory are even less prominent than previously observed.