Pain on injection of prilocaine plain vs. lidocaine with epinephrine. A prospective double-blind study.

BACKGROUND: Prilocaine has been described as causing less pain on injection than lidocaine with epinephrine, possibly because of the higher pH of the prilocaine anesthetic solution. METHODS: Three hundred ten consecutively seen patients in a general practice received a total of 334 maxillary buccal infiltration or inferior alveolar block injections, administered under clinical conditions by one of two dentists. Immediately afterward, patients rated the pain from each injection on a six-point scale. Twenty of these patients (in 21 separate appointments) received, and were asked to rate the pain associated with, a second injection of a contralateral tooth. The authors analyzed the pain response by operator, location of injection, patient's age, patient's sex and anesthetic. RESULTS: The difference in perceived pain between lidocaine and prilocaine was not statistically significant. Regardless of the anesthetic used, the perceived pain was usually no more than mild. Of 334 injections, 292 (87 percent) were rated as causing either no pain or mild pain. CONCLUSIONS: Under clinical conditions, there is no statistically significant difference between injection pain associated with prilocaine plain vs. that associated with lidocaine with 1:100,000 epinephrine. CLINICAL IMPLICATIONS: Since there is no significant difference in associated pain on injection between prilocaine plain and lidocaine with 1:100,000 epinephrine, dentists may prefer lidocaine with epinephrine. Since there is less anesthetic in each cartridge of lidocaine, it may require the use of less anesthetic per patient, and the vasoconstrictor can prolong its duration.

Does interview date affect match list position in the emergency medicine national residency matching program match?

OBJECTIVE: Some residency applicants believe that the date on which they interview with a residency program influences how the program ranks them in the National Residency Matching Program (NRMP). Therefore, the authors studied whether interview date affects match list position in the emergency medicine (EM) residency match. METHODS: Forty-four Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs participated in this multicenter study. The interview date and match list position were collected for each interviewee for the 1997-98 season. Programs were also asked about factors that might potentially bias interview date assignment. Statistical analyses were performed both with and without these programs included. Interview dates and match list positions were standardized into percentile date and percentile rank for each program and were compared using linear regression analysis. Scatterplots graphed interview date vs match list position. Two-sample t-tests compared interview dates for ranked and nonranked interviewees. RESULTS: Data were collected for 3,800 individual interviews; 14% of these resulted in unranked applicants. Twenty-three programs, representing 1,997 interviews, reported potential bias in their interview date assignment. Regression analysis revealed an R(2) of 0.018268 (correlation coefficient = 0. 1352, 95% CI = 0.0992 to 0.1617) for all programs, R(2) of 0.010626 (correlation coefficient = 0.1031, 95% CI = 0.0571 to 0.1485) for programs without reported potential bias, and R(2) of 0.02444 (correlation coefficient = 0.1563, 95% CI = 0.10887 to 0.20309) for programs with reported bias. Scatterplots revealed no linear correlation. Two-sample t-tests for all programs, and programs with and without reported bias showed no significant difference in average interview date for ranked and unranked interviewees (both with p > 0.2). CONCLUSION: In this study, interview date for EM residency positions in the 1997-98 season did not affect match list position among ranked applicants. Moreover, interview date had nno effect on the decision to leave candidates unranked.

Validation of volume measurements in esophageal pseudotumors using 3D endoluminal ultrasound.

The purpose of this study was to validate the accuracy and reliability of volume measurements using three-dimensional (3D) endoluminal ultrasound (ELUS) in canine pseudotumor esophageal specimens in vitro. Pseudotumors were created by injecting various volumes of US gel (0.1-1.0 ml) into canine esophageal specimens. A stepping-motor was used to pull either a 9, 12.5 or 20 MHz transducer through the lumen of the specimen at 1.5 mm/s. Images were downloaded to a LIFE computer system for 3D reconstruction. Volume measurements were made by two investigators and compared to spiral CT images. Averaging across all measurements, the average magnitude of error was 8.7% in individual US determinations and 11. 9% in CT measures. Volumes estimated from images spaced 0.5 and 1.0 mm apart, from images in the original and reconstructed planes, and from different scan frequencies, produced percentage errors that were not statistically significantly different from each other on ELUS. 3D ELUS can be used accurately and reproducibly to measure tumor volumes with a low mean percent in vitro.

Creation and first 20 years of the society for the stimulus properties of drugs (SSPD).

Clinical observations and novels in the 19th century recognized that memory of some events can be retrieved only under the influence of the same drug condition that was present during the event. This dissociative effect of drugs probably reflects the same drug effects that were later called the discriminative stimulus effects of drugs. The Society for Stimulus Properties of Drugs (SSPD) was founded in 1978 as a forum for communications and periodic meetings on this drug effect. During its early years many of its members were psychologists, but subsequent to that time the most frequent research application has been for the pharmacological purpose of identifying new drugs that have the same discriminative stimulus attributes as a prototype training drug. The majority of members have been in the United States, but several major international meetings have been in Europe. The methods used by the society's members involve both neuropharmacological and psychological processes, allowing them to make unique contributions to the study of both mind and brain.

Emergency medicine: the Italian experience.

The Italian health care system is largely socialized, with priorities and policies established both nationally and regionally. Currently emergency medicine in Italy is practiced mainly by traditional specialists, such as internists and surgeons, and the scope of emergency medicine practice is not as broad as that seen in the United States. However, dedicated training programs in emergency medicine have recently been developed, and it appears that in the future, specially trained emergency physicians will be increasingly available. Emergency medicine is currently viewed as a sub-specialty of internal medicine, and it is unclear whether emergency medicine will be recognized as an independent specialty.

Pain reduction in lidocaine administration through buffering and warming.

This study compared the pain from intradermal infiltration of (1) plain lidocaine, (2) warmed lidocaine, (3) buffered lidocaine, and (4) warmed, buffered lidocaine. A randomized, double-blind, Latin Square design of 20 volunteers was used. Each volunteer was injected with a series of four test solutions on four separate occasions, for 16 total injections each. Each volunteer served as his or her own control. The mean pain scores for the four solutions were: 44.2 for plain lidocaine, 42.2 for warmed lidocaine, 36.7 for buffered lidocaine, and 29.2 for warmed, buffered lidocaine. Buffered lidocaine was statistically less painful than both plain lidocaine and warmed lidocaine. Warmed, buffered lidocaine was significantly less painful than all other solutions, including buffered lidocaine (P < .005). However, warmed lidocaine did not yield pain scores significantly different from plain lidocaine. In this experimental model, warmed lidocaine was not superior to plain lidocaine, but warmed, buffered lidocaine caused significantly less pain than plain lidocaine, buffered lidocaine, or warmed lidocaine. Thus, there may be benefit from heating the buffered lidocaine now in common clinical use.

Isradipine prevents global and regional cocaine-induced changes in brain blood flow: a preliminary study.

The L-type calcium channel antagonist, isradipine, reduces brain ischemia in animal models of ischemic stroke. These effects of isradipine appear more pronounced in dopamine (DA) rich brain regions. These same DA-rich brain regions have also been shown to be the areas most affected by cocaine-induced ischemic changes. Using a novel quantified approach to single photon emission computerized tomography, we demonstrated that isradipine pre-treatment prevented cocaine-induced ischemic changes, especially in these DA-rich brain regions. This is the first demonstration that any medication, including isradipine, can prevent the ischemic effects of cocaine on brain blood flow. Isradipine may, therefore, be a useful therapeutic agent for the prevention of brain ischemia in cocaine addicts.

Demonstration of dose-dependent global and regional cocaine-induced reductions in brain blood flow using a novel approach to quantitative single photon emission computerized tomography.

Ischemic stroke is a common cause of morbidity and mortality in cocaine addicts. Because the previous semiquantitative single photon emission computerized tomography (SPECT) method for measuring brain blood flow does not quantify blood flow, the magnitude and specificity of cocaine's effects during drug taking has not been well established. Here, using a novel quantitative approach to SPECT, we established that intravenous cocaine administration to nine recently abstinent cocaine-dependent subjects was associated with significant decreases in global and regional brain blood flow to dopamine-rich areas such as the prefrontal, frontal temporal, and subcortical gray matter. Establishing the utility of this relatively new quantitative SPECT technique provides an important tool for the management of vascular disorders of the brain. Additionally, identifying the site-specific effects of cocaine provides targets for the development of putative therapeutic medications to attenuate or minimize ischemic stroke in cocaine addicts.

Effects of acute intravenous cocaine on cardiovascular function, human learning, and performance in cocaine addicts.

Continuous non-invasive cardiovascular monitoring in eight healthy cocaine addicts receiving intravenous cocaine (0.325 mg/kg or 0.650 mg/kg) or placebo in double-blind, randomized, cross-over fashion demonstrated significant dose-dependent increases in pulse and mean arterial pressure following cocaine. Pulse and mean arterial pressure peaked 5 min post-cocaine injection and maximal response was sustained for a further 15 min and 35 min afterwards, respectively. Cocaine administration had no significant effect on peripheral oxygen saturation, and no clinically significant abnormalities of rhythm or conduction were seen on the electrocardiogram. These doses and method of single-dose intravenous cocaine administration, and our procedures for cardiovascular monitoring, appear relatively safe for laboratory studies of healthy cocaine addicts with no pre-existing cardiovascular disease. In addition, cocaine-taking (0.325 mg/kg i.v. and 0.650 mg/kg i.v.) was associated with enhanced attention (i.e. increased numbers of correct responses on the Rapid Visual Information Processing Task), but the trend towards reduced reaction time did not achieve statistical significance. Cocaine-taking resulted in a small but statistically insignificant improvement in learning on the Digit Symbol Substitution Task. These results suggest that cocaine-taking in rested subjects is associated with some cognitive enhancement.

The relative salience of morphine and contextual cues as conditioned stimuli.

Two experiments were conducted to delineate further the properties of conditioning when morphine is used as a conditioned stimulus (CS) in the conditioned suppression of drinking paradigm. Experiment 1 used a test for overshadowing designed to compare the relative salience of contextual cues (metal box) and morphine induced cues (6 mg/kg, IP) as CSs when each was paired with a foot shock unconditioned stimulus (US) in water deprived rats. Six groups (six rats each) were exposed to conditioning procedures during which the conditioning context was present 19 h (groups 1 and 2), 90 min (groups 3 and 4), or 5 min (groups 5 and 6) before shock onset, and morphine (in groups 1, 3, and 5) or saline (in groups 2, 4, and 6) was injected 10 min before shock. Subsequently, the magnitude of suppression of drinking in response to morphine, to the metal box, and to morphine plus the metal box was measured. Only group 1 (19 h group) suppressed drinking in response to morphine, while groups 3-6 suppressed drinking whenever tested in the metal box. The results indicate that morphine cues acted as a CS that elicited suppression of drinking in group 1, and that contextual cues present up to 90 min before morphine cues overshadowed morphine. Experiment 2 showed that expression of the conditioned response to morphine was blocked by naloxone.

Model curriculum for physician training in emergency ultrasonography.

A model curriculum for the implementation and training of physicians in emergency medicine ultrasonography is described. Widespread use of limited bedside ultrasonography by emergency physicians will improve diagnostic accuracy and efficiency, increase the quality of care, and prove to be a cost-effective technique for the practice of emergency medicine.

Evaluation of the injured hand.

Hand disorders are common emergency department problems. They may be associated with long-term disability and significant financial impact for the patient and society. In many areas of clinical medicine, highly technical diagnostic and therapeutic modalities have taken center stage. In contrast, an accurate history and carefully performed physical examination of the hand retains a central and pivotal role in hand evaluation and treatment.

A prospective study to identify high-yield criteria associated with acute intracranial computed tomography findings in head-injured patients.

We conducted a multicenter, prospective study of head-injured patients to identify high-yield clinical criteria for acute intracranial injuries. Emergency patients with a history of blunt head trauma occurring within 2 weeks and who underwent nonenhanced cranial computed tomography (CT) were entered onto the study during a 12-month period. Of the 264 patients, 32 (12%) had abnormal CT findings. Nine high-yield variables were associated with abnormal CT findings: alcohol use before injury, antegrade amnesia, prolonged loss of consciousness, anisocoria and/or fixed and dilated pupils, abnormal Babinski reflex, focal motor paralysis, cranial nerve deficit, Glasgow coma scale score of less than 15, and clinical signs of basilar skull fracture. Patients 2 years old or younger or older than 60 years of age showed a significantly greater prevalence of abnormal CT findings than patients of other ages.

Centrally acting drugs act as conditioned stimuli in a conditioned suppression of drinking task.

An experiment was conducted to test whether centrally acting drugs could act as conditioned stimuli (CS) in a classical conditioning paradigm in which electric shock acted as the unconditioned stimulus (US) and suppression of drinking was used as an indicator of a conditioned response (CR). Thirsty rats were allowed to drink water during daily classical conditioning sessions which took place in their home cages. The CS was either a drug injected before the session or a "cocktail" of sensory stimuli (light + tone + vibration) turned on at the beginning of the session. Part way through some sessions the animals received electric foot shock as the US. Two different drugs and the sensory cocktail were used as CSs in a discriminated classical conditioning paradigm in which one drug or stimulus (the CS+) predicted the subsequent occurrence of shock, and the other two conditions acted as CS- stimuli and predicted absence of shock. After an average of 5.7 pairings of the CS+ with shock, conditioned suppression of drinking was observed; the CR occurred only during tests preceded by the CS+ drug or stimulus. At one time or another during the experiment, pentobarbital, phencyclidine, morphine, and pentylenetetrazol were employed as the CS+. Each acquired the ability to elicit a CR, although pentobarbital was noticeably less effective than the other three drugs. All conditioning trials took place in hanging metal cages, but the CR generalized into plastic cages with sawdust floors. Each rat received three successive phases of conditioning with a different CS+ condition employed in each phase; each phase of conditioning was followed by extinction of the CR.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphine as a conditioned stimulus in a conditioned emotional response paradigm.

A Pavlovian conditioning experiment was conducted to determine whether morphine (6 mg/kg, IP) could act as a conditioned stimulus (CS) when paired with an electric shock unconditioned stimulus (US), and later produce a conditioned suppression of drinking (CR) in water deprived rats. Seven groups were tested for conditioning after exposure to one of the following conditioning procedures: (1) morphine paired with shock; (2) morphine alone with no shock; (3) shock but no morphine; (4) no shock and no morphine; (5) morphine paired with vocalizations of shocked rats; (6) saline paired with shock; (7) saline alone with no shock. Groups 1 and 2 tested whether morphine could act as a CS. Groups 3 and 4 tested for sensitization. Group 5 tested whether exposure to the vocalizations of other rats could act as a US when paired with a morphine CS. Groups 6 and 7 tested whether cues associated with the injection procedure could act as a CS. Only subjects in group 1 showed conditioned suppression of drinking, when compared to control groups. Overall, the results indicate that morphine could act as a conditioned stimulus and that several of the more obvious possible sources of artifact did not significantly contribute to the CR that is produced.

Pericardial complications of cardiac surgery: emphasis on the diagnostic role of echocardiography.

Pericardial effusions are common following cardiac surgery; uncommonly they are large in size and may cause tamponade, either in the early or late postoperative period. Such effusions causing tamponade may be circumcardiac, but are frequently loculated, in which case one or more cardiac chambers is selectively compressed. Fortunately, echocardiography is capable of imaging not only the presence, location, and size of the pericardial effusion, but also indicating the presence of tamponade. Constrictive pericarditis resulting from cardiac surgery is being recognized with increasing frequency and has been associated with various echocardiographic abnormalities. This review also discusses certain other pericardial complications of cardiac surgery including supraventricular arrhythmias, chylopericardium, and posttransplant problems.

The cost of quality in health care.

The potential fiscal impact of improved quality on health care providers and organizations is substantial. In this era of dwindling health care resources, proposals that may limit cost increases while improving quality represent true win-win situations. There is a need for a substantial amount of health care research in this fertile area of quality improvement.

The management of patient complaints and dissatisfaction.

Patient satisfaction is an integral component of the measurement of health care quality. Proper attention to patient complaints is one part of a patient satisfaction management strategy aimed at revealing and alleviating the causes of patient dissatisfaction.