Staffing Models: Making Increased Acuity Safe in the Pediatric ICU.

Traditional staffing models rely on the productivity metric of hours per patient day, lacking the ability to adequately capture the nursing workload. Acuity-based staffing considers the patient population's acuity for appropriate nursing workload. Using process improvement methodology, a pediatric ICU transitioned to an acuity-based staffing model resulting in an 11.3% ( P < 0.05) reduction in the acuity per nursing assignment and a decrease in reportable safety events by 61.3% ( P < 0.05).

Primary infection with dengue or Zika virus does not affect the severity of heterologous secondary infection in macaques.

Zika virus (ZIKV) and dengue virus (DENV) are genetically and antigenically related flaviviruses that now co-circulate in much of the tropical and subtropical world. The rapid emergence of ZIKV in the Americas in 2015 and 2016, and its recent associations with Guillain-Barré syndrome, birth defects, and fetal loss have led to the hypothesis that DENV infection induces cross-reactive antibodies that influence the severity of secondary ZIKV infections. It has also been proposed that pre-existing ZIKV immunity could affect DENV pathogenesis. We examined outcomes of secondary ZIKV infections in three rhesus and fifteen cynomolgus macaques, as well as secondary DENV-2 infections in three additional rhesus macaques up to a year post-primary ZIKV infection. Although cross-binding antibodies were detected prior to secondary infection for all animals and cross-neutralizing antibodies were detected for some animals, previous DENV or ZIKV infection had no apparent effect on the clinical course of heterotypic secondary infections in these animals. All animals had asymptomatic infections and, when compared to controls, did not have significantly perturbed hematological parameters. Rhesus macaques infected with DENV-2 approximately one year after primary ZIKV infection had higher vRNA loads in plasma when compared with serum vRNA loads from ZIKV-naive animals infected with DENV-2, but a differential effect of sample type could not be ruled out. In cynomolgus macaques, the serotype of primary DENV infection did not affect the outcome of secondary ZIKV infection.

Modified vaccinia virus Ankara encoding influenza virus hemagglutinin induces heterosubtypic immunity in macaques.

UNLABELLED: Current influenza virus vaccines primarily aim to induce neutralizing antibodies (NAbs). Modified vaccinia virus Ankara (MVA) is a safe and well-characterized vector for inducing both antibody and cellular immunity. We evaluated the immunogenicity and protective efficacy of MVA encoding influenza virus hemagglutinin (HA) and/or nucleoprotein (NP) in cynomolgus macaques. Animals were given 2 doses of MVA-based vaccines 4 weeks apart and were challenged with a 2009 pandemic H1N1 isolate (H1N1pdm) 8 weeks after the last vaccination. MVA-based vaccines encoding HA induced potent serum antibody responses against homologous H1 or H5 HAs but did not stimulate strong T cell responses prior to challenge. However, animals that received MVA encoding influenza virus HA and/or NP had high frequencies of virus-specific CD4(+) and CD8(+) T cell responses within the first 7 days of H1N1pdm infection, while animals vaccinated with MVA encoding irrelevant antigens did not. We detected little or no H1N1pdm replication in animals that received vaccines encoding H1 (homologous) HA, while a vaccine encoding NP from an H5N1 isolate afforded no protection. Surprisingly, H1N1pdm viral shedding was reduced in animals vaccinated with MVA encoding HA and NP from an H5N1 isolate. This reduced shedding was associated with cross-reactive antibodies capable of mediating antibody-dependent cellular cytotoxicity (ADCC) effector functions. Our results suggest that ADCC plays a role in cross-protective immunity against influenza. Vaccines optimized to stimulate cross-reactive antibodies with ADCC function may provide an important measure of protection against emerging influenza viruses when NAbs are ineffective. IMPORTANCE: Current influenza vaccines are designed to elicit neutralizing antibodies (NAbs). Vaccine-induced NAbs typically are effective but highly specific for particular virus strains. Consequently, current vaccines are poorly suited for preventing the spread of newly emerging pandemic viruses. Therefore, we evaluated a vaccine strategy designed to induce both antibody and T cell responses, which may provide more broadly cross-protective immunity against influenza. Here, we show in a translational primate model that vaccination with a modified vaccinia virus Ankara encoding hemagglutinin from a heterosubtypic H5N1 virus was associated with reduced shedding of a pandemic H1N1 virus challenge, while vaccination with MVA encoding nucleoprotein, an internal viral protein, was not. Unexpectedly, this reduced shedding was associated with nonneutralizing antibodies that bound H1 hemagglutinin and activated natural killer cells. Therefore, antibody-dependent cellular cytotoxicity (ADCC) may play a role in cross-protective immunity to influenza virus. Vaccines that stimulate ADCC antibodies may enhance protection against pandemic influenza virus.

Methods for detection of West Nile virus antibodies in mosquito blood meals.

We describe and compare 2 qualitative serologic techniques for detecting West Nile virus (WNV)-specific antibodies in mosquito blood meals. The techniques are the biotin microsphere immunoassay (b-MIA) and the inhibition platform of the VectorTest™ WNV antigen assay (VecTest-inhibition). To demonstrate the ability of these tests to detect WNV-neutralizing antibodies, we experimentally exposed feeding mosquitoes to blood containing 5 concentrations of 6B6C-1, a flavivirus-neutralizing monoclonal antibody. Antibody concentrations were quantified using the 90% plaque-reduction neutralization test (PRNT90). After 24 h of blood-meal digestion at 22.5°C, the threshold PRNT90 titer of detection was ≤18 for b-MIA and ≤50 for VecTest-inhibition. Both tests reliably detected antibodies in 3 of 3 blood meals that had been digested for up to 30 h, or were about 25% digested. The b-MIA was also applied to mosquitoes that had engorged on avian blood in Arizona following a WNV epidemic in 2010. There was no significant difference in the WNV antibody prevalence determined by b-MIA (52% of 71 avian blood meals) compared to the WNV-neutralizing antibody prevalence in birds determined by direct sampling (49% of 234 birds). VecTest-inhibition requires fewer resources and may be used in the field without a laboratory, but consumes the entire blood meal and relies on subjective interpretation of results. The b-MIA requires a laboratory and sophisticated equipment and reagents. Results for b-MIA are analyzed objectively and can be applied to mosquito blood meals with greater confidence than the VecTest-inhibition method and thus can contribute substantially to research and surveillance programs that would benefit from the detection of specific WNV antibodies in mosquito blood meals.

Impact of prior flavivirus vaccination on immunogenicity and efficacy of an inactivated Zika vaccine in Indian rhesus macaques.

Flaviviruses are antigenically related. We evaluated the immunogenicity and efficacy of Takeda's purified inactivated Zika vaccine (PIZV) candidate in macaques previously vaccinated with several commercially available heterologous flavivirus vaccines. Heterologous flavivirus vaccination did not elicit Zika virus (ZIKV) neutralizing antibodies and did not impact neutralizing antibody titers after one dose of PIZV. After a second PIZV dose previous vaccination with flavivirus vaccines had variable impact on ZIKV neutralizing antibody titers. However, all macaques were protected against viremia after Zika virus challenge 8-12 months post-PIZV vaccination. Therefore, vaccine-induced immunity against heterologous flavivirus vaccines does not impact PIZV efficacy in macaques.

An enzootic vector-borne virus is amplified at epizootic levels by an invasive avian host.

Determining the effect of an invasive species on enzootic pathogen dynamics is critical for understanding both human epidemics and wildlife epizootics. Theoretical models suggest that when a naive species enters an established host-parasite system, the new host may either reduce ('dilute') or increase ('spillback') pathogen transmission to native hosts. There are few empirical data to evaluate these possibilities, especially for animal pathogens. Buggy Creek virus (BCRV) is an arthropod-borne alphavirus that is enzootically transmitted by the swallow bug (Oeciacus vicarius) to colonially nesting cliff swallows (Petrochelidon pyrrhonota). In western Nebraska, introduced house sparrows (Passer domesticus) invaded cliff swallow colonies approximately 40 years ago and were exposed to BCRV. We evaluated how the addition of house sparrows to this host-parasite system affected the prevalence and amplification of a bird-associated BCRV lineage. The infection prevalence in house sparrows was eight times that of cliff swallows. Nestling house sparrows in mixed-species colonies were significantly less likely to be infected than sparrows in single-species colonies. Infected house sparrows circulated BCRV at higher viraemia titres than cliff swallows. BCRV detected in bug vectors at a site was positively associated with virus prevalence in house sparrows but not with virus prevalence in cliff swallows. The addition of a highly susceptible invasive host species has led to perennial BCRV epizootics at cliff swallow colony sites. The native cliff swallow host confers a dilution advantage to invasive sparrow hosts in mixed colonies, while at the same sites house sparrows may increase the likelihood that swallows become infected.

Mosquito (Diptera: Culicidae) bloodmeal sources during a period of West Nile virus transmission in Puerto Rico.

Host bloodmeals of indigenous Caribbean mosquitoes have not been studied previously. We identified vertebrate DNA in 90 blood-engorged mosquitoes belonging to four genera (Aedes, Culex, Deinocerites, and Uranotaenia) and 12 species that were collected in Puerto Rico within a geographic and temporal focus of West Nile virus transmission in 2007. It was found that 62 (68.8%) bloodmeals were from reptiles, 18 (20.0%) from birds, and 10 (11.1%) from mammals. Only one bloodmeal of 18 derived from Culex (Culex) species was passerine, suggesting a preference for nonpasserine birds and other vertebrates (i.e., reptiles) among the candidate WNV vectors. We interpret the results with respect to vectorial capacity for West Nile virus, an emerging arbovirus throughout the Caribbean Basin.

Seroconversion for West Nile and St. Louis encephalitis viruses among sentinel horses in Colombia.

We prospectively sampled flavivirus-naïve horses in northern Colombia to detect West Nile virus (WNV) and St. Louis encephalitis virus (SLEV) seroconversion events, which would indicate the current circulation of these viruses. Overall, 331 (34.1%) of the 971 horses screened were positive for past infection with flaviviruses upon initial sampling in July 2006. During the 12-month study from July 2006-June 2007, 33 WNV seroconversions and 14 SLEV seroconversions were detected, most of which occurred in the department of Bolivar. The seroconversion rates of horses in Bolivar for the period of March-June 2007 reached 12.4% for WNV and 6.7% for SLEV. These results comprise the first serologic evidence of SLEV circulation in Colombia. None of the horses sampled developed symptoms of encephalitis within three years of initial sampling. Using seroconversions in sentinel horses, we demonstrated an active circulation of WNV and SLEV in northern Colombia, particularly in the department of Bolivar. The absence of WNV-attributed equine or human disease in Colombia and elsewhere in the Caribbean Basin remains a topic of debate and speculation.

Single dose of chimeric dengue-2/Zika vaccine candidate protects mice and non-human primates against Zika virus.

The development of a safe and effective Zika virus (ZIKV) vaccine has become a global health priority since the widespread epidemic in 2015-2016. Based on previous experience in using the well-characterized and clinically proven dengue virus serotype-2 (DENV-2) PDK-53 vaccine backbone for live-attenuated chimeric flavivirus vaccine development, we developed chimeric DENV-2/ZIKV vaccine candidates optimized for growth and genetic stability in Vero cells. These vaccine candidates retain all previously characterized attenuation phenotypes of the PDK-53 vaccine virus, including attenuation of neurovirulence for 1-day-old CD-1 mice, absence of virulence in interferon receptor-deficient mice, and lack of transmissibility in the main mosquito vectors. A single DENV-2/ZIKV dose provides protection against ZIKV challenge in mice and rhesus macaques. Overall, these data indicate that the ZIKV live-attenuated vaccine candidates are safe, immunogenic and effective at preventing ZIKV infection in multiple animal models, warranting continued development.

Natural infection of vertebrate hosts by different lineages of Buggy Creek virus (family Togaviridae, genus Alphavirus).

Buggy Creek virus (BCRV; family Togaviridae, genus Alphavirus) is an arbovirus transmitted by the ectoparasitic swallow bug (Hemiptera: Cimicidae: Oeciacus vicarius) to cliff swallows (Petrochelidon pyrrhonota) and house sparrows (Passer domesticus). BCRV occurs in two lineages (A and B) that are sympatric in bird nesting colonies in the central Great Plains, USA. Previous work on lineages isolated exclusively from swallow bugs suggested that lineage A relies on amplification by avian hosts, in contrast to lineage B, which is maintained mostly among bugs. We report the first data on the BCRV lineages isolated from vertebrate hosts under natural conditions. Lineage A was overrepresented among isolates from nestling house sparrows, relative to the proportions of the two lineages found in unfed bug vectors at the same site at the start of the summer transmission season. Haplotype diversity of each lineage was higher in bugs than in sparrows, indicating reduced genetic diversity of virus amplified in the vertebrate host. BCRV appears to have diverged into two lineages based on different modes of transmission.

Persistence of Buggy Creek virus (Togaviridae, Alphavirus) for two years in unfed swallow bugs (Hemiptera: Cimicidae: Oeciacus vicarius).

Alphaviruses (Togaviridae) have rarely been found to persist for long in the adult insects that serve as their vectors. The ectoparasitic swallow bug (Hemiptera: Cimicidae: Oeciacus vicarius Horvath), the vector for Buggy Creek virus (BCRV; Togaviridae, Alphavirus), lives year-round in the mud nests of its host, the cliff swallow (Petrochelidon pyrrhonota Vieillot). We measured the prevalence of BCRV in swallow bugs at sites with cliff swallows present and at the same sites after cliff swallows had been absent for 2 yr. We collected bugs directly from cliff swallow nests in the field and screened bug pools with BCRV-specific real-time-polymerase chain reaction (RT-PCR) and plaque assay. At two colony sites last occupied by birds 2 yr earlier, we found 12.5 and 55.6% of bug pools positive for BCRV RNA by RT-PCR. Infection rates (per 1,000 bugs) for these sites were 1.32 and 7.39. RNA prevalence in the unfed bugs was not significantly different from that in fed bugs 2 yr earlier at the same sites. The RNA-positive samples from unfed bugs failed to yield cytopathic BCRV by Vero-cell plaque assay. However, viral RNA concentrations did not differ between unfed bugs and bugs at active sites, and over 84% of positive bug pools were cytopathic to Vero cells 4-5 wk later, after cliff swallows moved into one of the colony sites. These data demonstrate the persistence of potentially infectious BCRV in unfed swallow bugs for at least 2 yr in nature.

Complete Protection in Macaques Conferred by Purified Inactivated Zika Vaccine: Defining a Correlate of Protection.

A critical global health need exists for a Zika vaccine capable of mitigating the effects of future Zika epidemics. In this study we evaluated the antibody responses and efficacy of an aluminum hydroxide adjuvanted purified inactivated Zika vaccine (PIZV) against challenge with Zika virus (ZIKV) strain PRVABC59. Indian rhesus macaques received two doses of PIZV at varying concentrations ranging from 0.016 µg - 10 µg and were subsequently challenged with ZIKV six weeks or one year following the second immunization. PIZV induced a dose-dependent immune response that was boosted by a second immunization. Complete protection against ZIKV infection was achieved with the higher PIZV doses of 0.4 µg, 2 µg, and 10 µg at 6 weeks and  with 10 ug PIZV at  1 year following vaccination. Partial protection was achieved with the lower PIZV doses of 0.016 µg and 0.08 µg. Based on these data, a neutralizing antibody response above 3.02 log10 EC50 was determined as a correlate of protection in macaques. PIZV elicited a dose-dependent neutralizing antibody response which is protective for at least 1 year following vaccination.

Persistent West Nile virus infection in the house sparrow (Passer domesticus).

Long-term persistence of West Nile virus (WNV) infection within vertebrate reservoir hosts is a potential mechanism for overwintering of this (and other) arbovirus(es) at temperate latitudes. The house sparrow (Passer domesticus), an established amplifying host for WNV and other arboviruses, was used as a model to confirm chronicity of WNV infection in passerine birds and to evaluate the feasibility of two overwintering mechanisms: blood-borne infection of arthropod vectors (recrudescence) and oral infection of vertebrate reservoir hosts (ingestion of infected tissues through predation). WNV-inoculated sparrows were monitored for persistent infection for up to 2 years. Infectious virus persisted in tissues through 43 days, but not in sera beyond 6 days. Viral RNA persisted in tissues through 65 days. Chronicity of WNV infection in some tissues, but not blood, supports the predation mechanism of WNV overwintering, but not recrudescence. RNA persistence impacts interpretation and etiologic determination of avian mortality.

Isolation of Buggy Creek virus (Togaviridae: Alphavirus) from field-collected eggs of Oeciacus vicarius (Hemiptera: Cimicidae).

Alphaviruses (Togaviridae) rarely have been found to be vertically transmitted from female arthropods to their progeny. We report two isolations of Buggy Creek virus (BCRV), an ecologically unusual alphavirus related to western equine encephalomyelitis virus, from field-collected eggs of cimicid swallow bugs (Oeciacus vicarius Horvath), the principal vector for BCRV. Ten percent of egg pools were positive for BCRV, and we estimated minimum infection rates to be 1.03 infected eggs per 1,000 tested. The results show potential vertical transmission of BCRV, represent one of the few isolations of any alphavirus from eggs or larvae of insects in the field, and are the first report of any virus in the eggs of cimicid bedbugs. The specialized ecological niche of BCRV in swallow bugs and at cliff swallow (Petrochelidon pyrrhonota Vieillot) nesting sites may promote vertical transmission of this virus.

West Nile virus detection in nonvascular feathers from avian carcasses.

West Nile virus (WNV) is a public health threat and has caused the death of thousands of North American birds. As such, surveillance for WNV has been ongoing, utilizing numerous biological specimens and testing methods. Nonvascular (i.e., fully grown) feathers would provide a simple method of collection from either dead or live birds of all ages and molt cycles, with presumably less biosafety risk compared with other specimen types, including feather pulp. The current study evaluates WNV detection in nonvascular feathers removed from naturally infected avian carcasses of several species groups. Feathers of corvid passeriforms had the highest sensitivity of detection (64%), followed by noncorvid passeriforms (43%), columbiforms (33%), and falconiforms (31%). Storing feathers for 1 year at -20 degrees C or at ambient room temperature resulted in detection rates of infectious WNV of 16% and zero, respectively, but had no effect on detection rates of WNV RNA in a subset of matched feather pairs (47% for both storage temperatures). The efficacy of WNV detection in nonvascular feathers is greatly enhanced by testing multiple feathers. The advantages of using nonvascular feathers over other tissues may outweigh the relatively low detectability of WNV RNA in certain situations such as remote areas lacking resources for acquiring other types of samples or maintaining the cold chain.

Mosquitoes used to draw blood for arbovirus viremia determinations in small vertebrates.

Serial samples from the same individuals may be required for certain virological studies, however, some small animals cannot easily be blood-sampled. Therefore, we evaluated the use of Culex quinquefasciatus Say and Aedes albopictus Skuse mosquitoes as "biological syringes" to draw blood for virus titer determinations in small vertebrates. Groups of chicks (Gallus gallus), hamsters (Mesocricetus auratus), and house sparrows (Passer domesticus) were experimentally infected with West Nile virus (WNV) or Highlands J virus (HJV). In general, good correlation was seen between mosquito- and syringe-derived blood samples at titers ≥5.0 log10 pfu/mL serum as compared with titers <5.0 log10 pfu/mL serum for chicks, hamsters, and sparrows. Ninety-two percent (24/26) of sparrows with virus titers >105 pfu/mL serum had mosquito- and syringe-derived titers within one log of each other. Sparrow viremia profiles generated from single mosquito blood meals and syringe were not significantly different (p>0.05). This technique is valuable for assessing the roles of small vertebrates in the ecologies of arboviruses, and could be used in applications beyond virology and infectious diseases, when <10 µL of whole blood is required.

A rapid immunization strategy with a live-attenuated tetravalent dengue vaccine elicits protective neutralizing antibody responses in non-human primates.

Dengue viruses (DENVs) cause approximately 390 million cases of DENV infections annually and over 3 billion people worldwide are at risk of infection. No dengue vaccine is currently available nor is there an antiviral therapy for DENV infections. We have developed a tetravalent live-attenuated DENV vaccine tetravalent dengue vaccine (TDV) that consists of a molecularly characterized attenuated DENV-2 strain (TDV-2) and three chimeric viruses containing the pre-membrane and envelope genes of DENV-1, -3, and -4 expressed in the context of the TDV-2 genome. To impact dengue vaccine delivery in endemic areas and immunize travelers, a simple and rapid immunization strategy (RIS) is preferred. We investigated RIS consisting of two full vaccine doses being administered subcutaneously or intradermally on the initial vaccination visit (day 0) at two different anatomical locations with a needle-free disposable syringe jet injection delivery devices (PharmaJet) in non-human primates. This vaccination strategy resulted in efficient priming and induction of neutralizing antibody responses to all four DENV serotypes comparable to those elicited by the traditional prime and boost (2 months later) vaccination schedule. In addition, the vaccine induced CD4(+) and CD8(+) T cells producing IFN-γ, IL-2, and TNF-α, and targeting the DENV-2 NS1, NS3, and NS5 proteins. Moreover, vaccine-specific T cells were cross-reactive with the non-structural NS3 and NS5 proteins of DENV-4. When animals were challenged with DENV-2 they were protected with no detectable viremia, and exhibited sterilizing immunity (no increase of neutralizing titers post-challenge). RIS could decrease vaccination visits and provide quick immune response to all four DENV serotypes. This strategy could increase vaccination compliance and would be especially advantageous for travelers into endemic areas.

Experimental infection of Eurasian collared-dove (Streptopelia decaocto) with West Nile virus.

The Eurasian collared-dove (Streptopelia decaocto) has recently experienced a population explosion in North America. It is frequently infected with West Nile virus (WNV). To test the hypothesis that the Eurasian collared-dove is competent to transmit WNV, we experimentally infected two cohorts of doves with two different strains of WNV, CO08, and NY99, respectively. Both virus strains induced a low-level viremia, capable of infecting a small fraction of vector mosquitoes. We suggest that the Eurasian collared-dove plays a relatively insignificant role as an amplifying host for WNV, but it may be important where it is locally abundant.

Avian hosts of West Nile virus in Arizona.

West Nile virus (WNV) causes sporadic outbreaks of human encephalitis in Phoenix, Arizona. To identify amplifying hosts of WNV in the Phoenix area, we blood-sampled resident birds and measured antibody prevalence following an outbreak in the East Valley of metropolitan Phoenix during summer, 2010. House sparrow (Passer domesticus), house finch (Haemorhous mexicanus), great-tailed grackle (Quiscalus mexicanus), and mourning dove (Zenaida macroura) accounted for most WNV infections among locally resident birds. These species roost communally after early summer breeding. In September 2010, Culex vector-avian host contact was 3-fold greater at communal bird roosts compared with control sites, as determined by densities of resting mosquitoes with previous vertebrate contact (i.e., blood-engorged or gravid mosquitoes). Because of the low competence of mourning doves, these were considered weak amplifiers but potentially effective free-ranging sentinels. Highly competent sparrows, finches, and grackles were predicted to be key amplifying hosts for WNV in suburban Phoenix.

EMLA application exceeding two hours improves pediatric emergency department venipuncture success.

The purpose of this study was to determine whether placing Eutectic Mixture of Local Anesthetics (EMLA) at emergency department (ED) triage improves venipuncture success. Emergency department triage nurses prospectively identified patients aged 0-18 years assessed to have 50% or greater chance of needing venipuncture while in the emergency department. Identified patients received EMLA or no intervention according to randomized 24-h blocks. Data were collected on need for venipuncture, venipuncture success (defined as obtaining access in one attempt), and duration and success of EMLA application (defined as EMLA occluded between 1 and 5 h). Parents' satisfaction and perception of pain were assessed with a 5-item scale. Consent was obtained from 267 out of 287 patients, in whom 111 of 154 venipunctures were successful (72%). EMLA (n = 100) and no-intervention (n = 167) groups did not differ by age or dehydration-related illnesses. Nurses flagged patients more often on days when EMLA was not applied (χ(2) = 37.8, df2, p < 0.0001), but with lower specificity of needing venipuncture (48.5% no-intervention venipuncture rate vs. 73% venipuncture rate with EMLA (χ(2) = 14.4, df2, p = 0.0001). Of the 73 EMLA patients undergoing venipuncture, 2 removed EMLA at unknown times; 2 had application duration longer than 5 h, and nurses chose non-EMLA venipuncture sites for 8. Punctures through EMLA sites with appropriate duration were successful in 51/61 (84%) versus 58/89 (65%) in untreated skin (p = 0.01, odds ratio (OR) = 2.8; 95% confidence interval (CI) [1.3, 6.2]). Success in intention-to-treat groups did not differ (OR = 1.8, 95% CI [0.87, 3.7]). Improved venipuncture success was seen linearly with increased application duration (p = 0.018). Parents perceived less pain with punctures through EMLA sites (p = 0.006). Venipuncture through an EMLA site reduced pain and improved success. Rates improved with increasing application duration. Barriers to triage EMLA placement should be evaluated. Application longer than 2 h should be studied further as a means to improve success. EMLA was supplied as a part of the Investigator-sponsored study program of AstraZeneca.