Predicting the need for topical anesthetic in the pediatric emergency department.

OBJECTIVE: To investigate the potential for pediatric emergency department (ED) triage nurses to apply a topical anesthetic (ie, eutectic mixture of local anesthetic) for intravenous catheter (IV) insertion. METHODS: Prospective cross-sectional survey over a 2-month period, with post hoc application of internally developed prediction rules. Eligible patients were children presenting to the ED triage area of an urban children's hospital. RESULTS: A total of 2596 (86.7% of eligible children) had a triage nursing prediction performed. Nurse prediction of IV insertion had a sensitivity of 72% (95% CI: 66,78), a specificity of 90% (88,91), and a positive predictive value (PPV) of 49% (44,54). Objective factors such as high-risk medical history (chronic neurologic, hematologic, cardiac, endocrine, or gastrointestinal illness) and high-risk chief complaint (gastrointestinal illness, skin infection, and previous seizure) were incorporated into a predictive score used to predict IV insertion independently with a sensitivity of 33% (27,39) and a PPV of 43% (44,54). Addition of the objective predictors to nursing prediction increased the sensitivity to 76% (70,81) with a PPV of 43% (38,47). Of the patients, 95% received an IV insertion

Cocaine abstinence symptomatology and treatment attrition.

Premature termination from outpatient cocaine treatment predicts a number of poor outcomes, including higher rates of relapse and unemployment. This study attempted to predict dropouts from outpatient cocaine treatment, as well as those unable to achieve initial abstinence from cocaine, using two baseline variables that had previously been shown to predict treatment dropout: a measure of the severity of cocaine abstinence symptomatology using the Cocaine Selective Severity Assessment (CSSA) and the initial urine toxicology. Results of logistic regression analyses indicated that those with more intense abstinence symptoms, as measured by the CSSA, were five times more likely to terminate treatment prematurely. When combined with the CSSA, the initial urine did not significantly predict dropouts. The CSSA and the baseline urine were equal in their ability to predict those who would fail in their initial attempts to achieve abstinence. Implications for treatment are discussed.

Random versus nonrandom assignment in the evaluation of treatment for cocaine abusers.

Cocaine-abusing patients randomly assigned to day-hospital or inpatient rehabilitation were compared with patients who self-selected these treatment settings to examine differences in substance use and psychosocial outcomes under experimental and nonexperimental designs. There was little evidence of setting or assignment effects or Setting x Assignment interactions over the 12-month follow-up period. However, Assignment x Time interactions were obtained with 2 measures of cocaine use and measures of family-social and psychiatric problem severity. These interactions indicated greater problem severity at intake among the randomized patients coupled with greater improvements by the 3-month follow-up relative to the nonrandomized patients. Findings suggest that randomized studies of treatment for cocaine abuse may produce somewhat larger estimates of improvement than what is observed in more typical treatment situations.

A typology of antisociality in methadone patients.

Multistage cluster analyses with replications were used to sort score profiles of 252 methadone maintained men on 4 continuous measures of antisociality--childhood conduct disorder and adult antisocial personality disorder symptoms, the revised Psychopathy Checklist, and the Socialization scale of the California Psychological Inventory. The analysis yielded 6 replicable and temporally stable cluster groups varying in degree and pattern of antisociality. The groups were statistically compared on sets of external criterion variables--Addiction Severity Index measures of past and recent substance abuse and functioning and lifetime criminal history. Axis I and II symptomatology, anxiety and depression, object relations and reality testing, hostility, guilt, and machiavellianism. The expression of antisociality in the 6 groups and differences found among them on the external variables supported the validity of a more complex conceptualization of antisociality than is provided by antisocial personality disorder.

Prediction of 7 months methadone maintenance treatment response by four measures of antisociality.

Zero-order correlational and simultaneous regression analyses were performed to ascertain the comparative validity of four measures of antisociality for predicting the initial 7 months treatment response of 193 male methadone maintenance (MM) patients. Predictor variables were the number of childhood conduct disorder (CD) behaviors, number of adult antisocial personality disorder (A-APD) behaviors, the revised Psychopathy Checklist (PCL-R) score and the revised California Psychological Inventory-Socialization (CPI-So) scale score. The outcome measures were completion/noncompletion of 7 months of treatment, percent positive during-treatment of cocaine, opiate and benzodiazepine urine toxicologies, and change from baseline to 7 months follow-up in seven Addiction severity index (ASI) composite scores (CSs). All four measures of antisociality were significantly correlated with treatment noncompletion, although only the PCL-R score was significant in the predictor model. The PCL-R predicted more positive cocaine urines. At the individual level, both PCL-R and CPI-So were associated with more positive benzodiazepine urines, but neither contributed a significant amount of variance when both were entered in the model. None of the predictors were significantly associated with self reported improvement in the CSs. The PCL-R and CPI-So were more successful in predicting outcomes than the two behavior-based measures.

Saline with benzyl alcohol as intradermal anesthesia for intravenous line placement in children.

BACKGROUND: It has been suggested that saline with benzyl alcohol preservative has anesthetic properties when injected intradermally. We compared the pain associated with intravenous line (i.v.) placement in patients who received intradermal lidocaine, intradermal saline + benzyl alcohol preservative, or no anesthesia. METHODS: We performed a prospective randomized clinical trial in a convenience sample of children over 6.8 years old seen in the emergency department of a large, urban children's hospital. Children received either intradermal saline with 0.9% benzyl alcohol preservative, intradermal lidocaine, or no anesthesia prior to i.v. placement. The patient recorded the pain of the entire procedure on a visual analog scale. In the two groups that received an intradermal injection, the patient also recorded the pain of the first and second injection on a similar scale. RESULTS: Ninety-nine children were studied, 33 in each group. Pain scores were not normally distributed. The median pain scores in millimeters for the entire procedure were 41.0 (interquartile range, 11 to 62) in the nonanesthetic group, 9.0 (interquartile range 3 to 37) in the saline with benzyl alcohol group, and 10.0 (interquartile range, 4 to 32) in the lidocaine group (P = 0.006 for saline vs nonanesthetic, P = 0.04 for lidocaine vs nonanesthetic, P = 0.57 for saline vs lidocaine). There was no difference between groups with regard to baseline anxiety, demographic characteristics, size of i.v. inserted, number of i.v. attempts, or pain upon intradermal injection. CONCLUSION: Saline with benzyl alcohol and 1% lidocaine are equally effective as intradermal anesthetics for i.v. line placement in children, and are both more effective than no anesthesia.

A cocaine-positive baseline urine predicts outpatient treatment attrition and failure to attain initial abstinence.

The primary study objective was to ascertain whether a prior finding that the baseline cocaine urine toxicology predicted treatment dropout for cocaine dependent outpatients could be extended to three additional cocaine dependent outpatient treatment samples and whether the urine toxicology also predicted attainment of initial abstinence for the four samples. A secondary objective was to ascertain the extent to which other baseline variables accounted for additional outcome variance over and above that afforded by urine toxicology. To evaluate the first objective, the relationships between the baseline cocaine urine and each of two measures of within treatment response--the completion of treatment or the attainment of initial abstinence--were determined for each of the treatment samples. The second objective was evaluated by a stepwise, hierarchical logistic regression analysis, with the urine toxicology entered in the first step, baseline Addiction Severity Index (ASI) variables in the second step, and achievement of initial abstinence as the outcome. In all four samples, patients with a urine indicative of recent cocaine use were less than half as likely to complete treatment or achieve initial abstinence. Individual ASI baseline variables did not contribute statistically significant variance over and above that predicted by the cocaine urine toxicology. The findings confirm the utility of the initial cocaine urine as a predictor of unfavorable outpatient treatment response.