Longitudinal assessment of hepatitis C fibrosis progression by collagen and smooth muscle actin morphometry in comparison to serum markers.

BACKGROUND: Assessment of fibrosis progression in chronic liver disease relies upon non-invasive tools and changes in semi-quantitative histopathology scores that may not be reliable. AIM: To assess the diagnostic performance of the FibroSURE (FS) index and collagen/alpha smooth muscle actin (α-SMA) morphometry in relation to longitudinal changes in fibrosis on paired biopsies. METHODS: The study cohort included 201 chronic hepatitis C (CHC) nonresponders enrolled in a prior phase II anti-fibrotic study. Serum FS and paired biopsies, with both collagen and α-SMA morphometry, were evaluated at baseline and week 52. RESULTS: Study patients were mostly male (67%) and Caucasian (77%), with Ishak stages 2 (n = 79), 3 (n = 88) and 4 (n = 30), excluded (n = 4 stage 1 or 5). Mean biopsy length was 22.9 mm. For baseline Ishak 2/3 vs. 4, there were no significant differences in AUROCs for collagen (0.71), SMA (0.66) or FS (0.70). At week 52, 62% of patients had no change in Ishak stage, but collagen/α-SMA increased by 34-51% (P < 0.0001), and FS decreased by 5% (P = 0.008). Among the 33% of patients with +/-1 Ishak stage change, FS changes were not significant, but α-SMA increased 29-72%, and collagen increased by 12-38% (P = 0.01 for +1 only). CONCLUSIONS: Longitudinal changes in collagen and α-SMA morphometry are apparent prior to change in histological stage or FibroSURE in CHC nonresponders with intermediate fibrosis. This likely reflects quantitative morphological differences that are not detected by routine histological staging or serum markers such as FibroSURE.

Hemodynamic patterns of anterior communicating artery aneurysms: a possible association with rupture.

BACKGROUND AND PURPOSE: The anterior communicating artery (AcomA) is a predilect location of aneurysms which typically carry higher rupture risks than other locations in the anterior circulation. The purpose of this study was to characterize the different flow types present in AcomA aneurysms and to investigate possible associations with rupture. MATERIALS AND METHODS: Patient-specific computational models of 26 AcomA aneurysms were constructed from 3D rotational angiography images. Bilateral images were acquired in 15 patients who had both A1 segments of the anterior cerebral arteries, and models of the whole anterior circulation were created by fusing the reconstructed left and right arterial trees. Computational fluid dynamics simulations were performed under pulsatile flow conditions measured on a healthy subject. Visualizations of flow velocity, instantaneous streamlines, and wall shear stress (WSS) were performed. These were analyzed for flow patterns, size of the impaction zone, and peak WSS and then correlations were made with prior history of rupture. RESULTS: Aneurysms with small impaction zones were more likely to have ruptured than those with large impaction zones (83% versus 63%). Maximum intra-aneurysmal WSS (MWSS) for the unruptured aneurysms ranged from 10 to 230 dyne/cm(2) (mean, 114 dyne/cm(2)) compared with ruptured aneurysms, which ranged from 35 to 1500 dyne/cm(2) (mean, 271 dyne/cm(2)). This difference in MWSS was statistically significant at 90% confidence levels (P = .10). CONCLUSIONS: Aneurysms with small impaction zones, higher flow rates entering the aneurysm, and elevated MWSS are associated with a clinical history of previous rupture.

Complement levels before and after dives with a high risk of DCS.

BACKGROUND: Previously, complement activation has been associated with decompression sickness (DCS). However data, both in humans and in animals, are controversial. HYPOTHESIS: Complement activation and depletion occurs after exposure to the hyperbaric environment and is associated with increasing risk of DCS. METHODS: We obtained serological samples from 102 dives (120-300 feet of seawater) with a constant partial pressure of O2 set at 1.3 ATA in thirty-five U.S. Navy diver volunteers. Blood was obtained within one hour of diving and within one hour of surfacing. Plasma was extracted and analyzed for complement depletion. The risk of DCS was estimated using a validated model of DCS risk. RESULTS: Pre-post dive concentrations of C3a were significantly related to estimated risk of DCS (Figure 1), but the variation in predicted DCS explained by C3a was small (correlation co-efficient (r2 = 0.19, p < 0.0001). CONCLUSIONS: There was a reduction in total Ca3 levels in divers after exposure to dives with a high estimated risk of DCS. This decomplementation appeared to increase as the estimated risk of DCS increased.

Thoracic esophageal perforation: one surgeon's experience.

Recognition of the importance of early diagnosis and aggressive, definitive surgical intervention has brought about a dramatic decline in mortality related to distal esophageal perforation. In the following retrospective analysis, we have examined all cases of thoracic esophageal perforations diagnosed, consulted, and/or treated by one author (PDK) at the Inova Fairfax Hospital from June 1, 1988 through March 17, 2005. These cases consisted of 48 patients (34 male) with a mean age of 59.4 years (range, 20-92). Among 25 patients with early diagnosis (< or = 24 h), hospital survival was 92%, increasing to 96% when early diagnosis was combined with surgical treatment. Among the 23 patients with late diagnosis (> 24 h), hospital survival was 82.6%, increasing to 92.3% when treated with surgery. We recommend aggressive, definitive surgery for thoracic esophageal perforations, regardless of time of diagnosis. In the absence of phlegmon or implacable obstruction, primary repair offers excellent results with the shortest length of stay. Resection and reconstruction are the best choices in circumstances where significant phlegmon or distal obstruction render primary repair hazardous or inapplicable. Diversion, preferably with proximal and distal esophageal exclusion, may be necessary for patients too ill to undergo more formidable surgery. Conservative, medical therapy may be appropriate in patients with 'microperforations' with no continuing leak. Finally, comfort measures alone may be appropriate where circumstances merit no effort at resuscitation.

Psychometric properties of the Illness Attitudes Scale in psychiatric patients.

This study assessed the factorial structure of the 29-item Illness Attitudes Scale in a population of 82 psychiatric patients hospitalized for gastrointestinal complaints. Factor analysis yielded three factors of the Illness Attitudes Scale in these patients, which have been interpreted Health Anxiety, Illness Behavior, and Health Habits. The internal consistency of these factors, estimated by Cronbach alpha, were .86, .80, and .58, respectively. The Health Anxiety and Illness Behavior scores were significantly intercorrelated .43, but scores on Health Habits were not significantly correlated with either Health Anxiety (r = .19) or Illness Behavior (r = .14). These findings are consistent with previous reports that two factors of the Illness Attitudes Scale possess reliable psychometric properties. Cross-validation with other patient populations is required to confirm the validity of the Illness Attitudes Scale factor structure testing at least 5 participants per item of the scale.

Comparison of 26-item and 20-item versions of the Toronto Alexithymia Scale for psychiatric outpatients.

This study compared the 20-item revised Toronto Alexithymia Scale with the 26-item version for 257 psychiatric outpatients. Scores on the 20-item version significantly correlated with those on the 26-item inventory even when controlled for depressed mood. Furthermore, the 20-item scale showed greater internal consistency. Factor analysis for both versions indicated three subfactors but the factors in the TAS-20 accounted for greater common variance (92%) than for the factors in the TAS-26 (78%). The total variance accounted for by these factors on the TAS-20 (45%) was also greater than for the TAS-26 (38%).

Medical exclusion of sick children from child care centers: a plea for reconciliation.

BACKGROUND: Policies for excluding ill children from child care can affect parental absenteeism from the workplace and the utilization of pediatric health care resources. METHODS: We surveyed a representative sample of 310 child care centers throughout Virginia to assess policies for excluding children with fever, common upper respiratory tract illnesses, or head lice. RESULTS: Of the 183 center directors (59%) who returned completed surveys, 119 (69%) considered a temperature of 100.0 degrees F to 100.4 degrees F to represent fever, but methods for measuring temperature varied widely. Most centers excluded children with low-grade fever, even in the absence of changes in their behavior. Other low-threshold policies could exclude afebrile children with white nasal or eye discharge and children with hair nits, even after treated with a pediculicidal shampoo. CONCLUSIONS: Exclusion policies among child care centers in Virginia vary widely and often are inconsistent with current standards of medical practice. More uniform implementation of exclusion policies established by national consensus panels of experts is needed to reduce unnecessary exclusion of children from child care centers.

Relationship between alexithymia, dissociation and personality in psychiatric outpatients.

BACKGROUND: The relationship between alexithymia and dissociation is not known. Both mechanisms ward off overwhelming affective states; hence, this report examines the relationship between dissociation, alexithymia, depressed mood and the five-factor model of personality in a sample of psychiatric outpatients. METHODS: One hundred and sixteen outpatients were evaluated using the Toronto Alexithymia Scale (TAS), the Dissociative Experiences Scale (DES), NEO Five-Factor Inventory and visual analog scales assessing depression and anxiety. Data was analyzed using multivariate analysis of variance, logistic regression and linear regression techniques. RESULTS: Depressed mood accounted for the group differences between the global TAS and DES scores. Using DES both dimensionally and categorically with regression models, there was minimal contribution of DES or its subfactors to predict TAS. CONCLUSIONS: These data reaffirm previous findings that dissociation fundamentally differs from alexithymia. Dissociation involves a change of one's sense, of self, whereas alexithymia reflects a cognitive state of externally oriented thinking with an inability to identify and report discrete emotions.

Same-day transfer of patients to the cardiac telemetry unit after surgery: the Rapid after Bypass Back into Telemetry (RABBIT) program.

Early data from this project suggest that the RABBIT program fulfilled the process improvement goals of decreasing costs of cardiac surgery and maintaining high quality. Decreased cost was achieved by decreasing time to extubation and decreasing length of stay in the ICU and the total length of stay in the hospital. The cost savings were achieved without compromising the quality of care, which was assessed by measuring rates of readmission to the ICU and to the hospital and by surveying patients about their level of satisfaction. The success of the RABBIT program can be attributed to several factors. First, members of the cardiac surgery quality improvement team worked well together to solve problems and overcome obstacles, particularly after the pilot program. Second, naming the program helped to motivate staff, physicians, and patients. Outcome data was shared with the staff quarterly, and successes were celebrated. Finally, the use of a facilitator early in the process to establish the process with the surgeons and the staff was invaluable. Opportunities for continued improvement include resolving operational difficulties related to availability of beds and staffing, continuing work with physicians in changing practice patterns, increasing efficiency in scheduling operating rooms, and adjusting the preoperative education provided to patients and their families about the length of stay to expect. Quarterly outcome analysis continues, with reports to the cardiac surgery quality improvement team. The team continues to explore creative solutions to the aforementioned issues, as the goal of having 25% of patients who undergo cardiac surgery be transferred to the CTU on the day of surgery has remained elusive.

A comparison of manual and mechanical ventilation during pediatric transport.

OBJECTIVE: To compare the amount of variability in ventilation during intrahospital transport of intubated pediatric patients ventilated either manually or with a transport ventilator. DESIGN: Prospective, randomized study. SETTING: Tertiary, multidisciplinary, pediatric intensive care unit. PATIENTS: Forty-nine pediatric postoperative heart patients who required transport while still intubated. INTERVENTIONS: Patients were randomized to receive either manual ventilation during transport or ventilation by a portable mechanical ventilator. Baseline ventilatory and hemodynamic parameters were recorded before and during transport. Before and after arterial blood gases were also obtained. All other aspects of care were identical. MEASUREMENTS AND MAIN RESULTS: There was a statistically significant greater amount of variation in ventilation during transport with manual technique as opposed to the mechanical ventilator. A Student's t-test on pre- to post-blood gas differences showed a significantly lower PetCO2 (p = .02) in the manually ventilated patients when compared with the mechanically ventilated patients. Values for PCO2 were higher, but only marginally significant (p = .08). Repeated measures analysis of variance using these same pre- and post blood gas values confirmed the significant decrease in PetCO2 (p = .05). Minute to minute variation in PetCO2 during transport was greater and the mean values significantly lower in the manually ventilated group (p < .05). Hemodynamic data were remarkably stable when examined both before and after transport and on a minute to minute basis during transport. CONCLUSIONS: Manual ventilation during intrahospital transport results in greater fluctuation of ventilatory parameters from an established baseline than does use of a transport ventilator. No clinically significant changes in status occurred during the brief period of transport studied.

Humoral immunity to commensal oral bacteria in human infants: salivary secretory immunoglobulin A antibodies reactive with Streptococcus mitis biovar 1, Streptococcus oralis, Streptococcus mutans, and Enterococcus faecalis during the first two years of life.

Secretory immunoglobulin A (SIgA) antibodies reactive with the pioneer oral streptococci Streptococcus mitis biovar 1 and Streptococcus oralis, the late oral colonizer Streptococcus mutans, and the pioneer enteric bacterium Enterococcus faecalis in saliva samples from 10 human infants from birth to age 2 years were analyzed. Low levels of salivary SIgA1 and SIgA2 antibodies reactive with whole cells of all four species were detected within the first month after birth, even though S. mutans and E. faecalis were not recovered from the mouths of the infants during the study period. Although there was a fivefold increase in the concentration of SIgA between birth and age 2 years, there were no differences between the concentrations of SIgA1 and SIgA2 antibodies reactive with the four species over this time period. When the concentrations of SIgA1 and SIgA2 antibodies reactive with all four species were normalized to the concentrations of SIgA1 and SIgA2 in saliva, SIgA1 and SIgA2 antibodies reactive with these bacteria showed a significant decrease from birth to 2 years of age. Adsorption of each infant's saliva with cells of one species produced a dramatic reduction of antibodies recognizing the other three species. Sequential adsorption of saliva samples removed all SIgA antibody to the bacteria, indicating that the SIgA antibodies were directed to antigens shared by all four species. The induction by the host of a limited immune response to common antigens that are likely not involved in adherence may be among the mechanisms that commensal streptococci employ to persist in the oral cavity.

Beach week: a high school graduation rite of passage for sun, sand, suds, and sex.

BACKGROUND: Every year, thousands of suburban high school graduates from mid Atlantic states flock to nearby coastal beaches for a long-anticipated rite of passage known as "beach week." Sand, sun, and sea, and also smoking, binge drinking, drugs, and sex, are reported to be dominant themes. OBJECTIVE: To document risk-taking behaviors by girls during beach week. METHOD: Fifty-nine female suburban high school graduates who attended beach week in 1996 volunteered to fill out a confidential printed survey. Twenty-five girls (42%) completed the survey during a typical beach week party. Their activities were verified on site by a peer, recommended by her grade advisor for her integrity and popularity. Breath alcohol values were obtained at entry and departure from the party. The remaining 34 girls completed the supervised survey 2 to 3 months later. RESULTS: Daily cigarette smoking (54%), daily drunkenness (75%), and sex (46%) were the norm among respondents of our survey. Few reported first-time sex (n = 4) or drug use (n = 2). Abstinence from drugs (67%) and sex (55%) was not unusual but only 12% abstained from getting drunk. Sixteen girls (64%) reported that they drank 8 or more beers/wine during a typical beach week party. By departure from the party, 15 girls had breath alcohol values of 0.017 mmol/L or greater (reference range, <21.7 mmol/L), and 8 additional girls had breath alcohol values of 0.01 mmol/L to 0.015 mmol/L. Fifteen percent of the 59 reported injuries or illness were related to alcohol or drugs. CONCLUSION: Most respondents enjoyed beach week but a large percentage engaged in serious risk-taking behaviors.

Humoral immunity to commensal oral bacteria in human infants: salivary antibodies reactive with Actinomyces naeslundii genospecies 1 and 2 during colonization.

The secretory immune response in saliva to colonization by Actinomyces naeslundii genospecies 1 and 2 was studied in 10 human infants from birth to 2 years of age. Actinomyces species were not recovered from the mouths of the infants until approximately 4 months after the eruption of teeth. However, low levels of secretory immunoglobulin A1 (SIgA1) and SIgA2 antibodies reactive with whole cells of A. naeslundii genospecies 1 and 2 were detected within the first month after birth. Although there was a fivefold increase in the concentration of SIgA between birth and age 2 years, there were no differences between the concentrations of SIgA1 and SIgA2 antibodies reactive with A. naeslundii genospecies 1 and 2 over this period. When the concentrations of SIgA1 and SIgA2 antibodies reactive with whole cells of A. naeslundii genospecies 1 and 2 were normalized to the concentrations of SIgA1 and SIgA2 in saliva, the A. naeslundii genospecies 1- and 2-reactive SIgA1 and SIgA2 antibodies showed a significant decrease from birth to 2 years of age. The fine specificities of A. naeslundii genospecies 1- and 2-reactive SIgA1 and SIgA2 antibodies were examined by Western blotting of envelope proteins. Similarities in the molecular masses of proteins recognized by SIgA1 and SIgA2 antibodies, both within and between subjects over time, were examined by cluster analysis and showed considerable variability. Taken overall, our data suggest that among the mechanisms Actinomyces species employ to persist in the oral cavity are the induction of a limited immune response and clonal replacement with strains differing in their antigen profiles.

A comparison of efficacy of sargramostim (yeast-derived RhuGM-CSF) and filgrastim (bacteria-derived RhuG-CSF) in the therapeutic setting of chemotherapy-induced myelosuppression.

A randomized, double-blind, multicenter study in 181 afebrile cancer patients with ANC levels < 500/microL receiving myelosuppressive chemotherapy was undertaken to compare sargramostim (yeast-derived recombinant human granulocyte-macrophage colony-stimulating factor, RhuGM-CSF) and filgrastim (bacteria-derived recombinant human granulocyte colony-stimulating factor, RhuG-CSF) in the treatment of chemotherapy-induced myelosuppression. Patients received daily subcutaneous (SC) injections of either agent until ANC levels reached at least 1500/microL. There was no statistical difference between treatment groups in the mean number of days to reach an ANC of 500/microL, but the mean number of days to reach ANC levels of 1000/microL and 1500/microL was approximately one day less in patients receiving filgrastim. Fewer patients in the sargramostim arm were hospitalized, and they had a shorter mean length of hospitalization, mean duration of fever, and mean duration of i.v. antibiotic therapy compared with patients who received filgrastim. Both growth factors were well tolerated. No patient was readmitted to the hospital after growth factor was discontinued. Sargramostim and filgrastim have comparable efficacy and tolerability in the treatment of standard-dose chemotherapy-induced myelosuppression in community practice.

Computerized PN ordering optimizes timely nutrition therapy in a neonatal intensive care unit.

OBJECTIVE: To determine whether automation could accelerate the parenteral nutrition (PN) ordering and delivery process with concurrent improvements in the quality of nutrition therapy. DESIGN: The time required to order, process, and deliver PN orders and specific nutrient composition of the PN solution were collected prospectively for 2 weeks on all neonatal intensive care unit (NICU) patients receiving PN during both the manual phase (before automation) and computer phase of the study. SUBJECTS/SETTING: A total of 81 newborn infants in the NICU receiving PN for more than 5 days completed the study. STATISTICAL ANALYSES: Student's unpaired t test was used to evaluate differences between computer and manual methods for all outcome variables of interest. RESULTS: The time required to write and deliver PN orders was significantly lower using computer rather than manual methods (1.4 +/- 0.2 vs 4.5 +/- 0.5 minutes; P = .0001). Significant improvements in the nutrient composition of the PN solution resulted from use of computer ordering for energy (93.4 +/- 1.48 vs 79.2 +/- 1.8 kcal/kg per day; P = .0001), protein (2.92 +/- 0.02 vs 2.7 +/- 0.03 g protein per kilogram per day; P = .0001), calcium (2.3 +/- 0.1 vs 1.8 +/- 0.1 mEq/kg per day; P = .0005), and phosphate (1.3 +/- 0.06 vs 0.9 +/- 0.06 mM/kg per day; P = .0001). In addition, alkaline phosphatase levels improved (272 +/- 11 vs 404 +/- 25 U/L; P = .0001) and caloric and protein goals were achieved sooner (5.9 +/- 0.4 vs 8.7 +/- 0.8 days; P = .0045) when computer ordering rather than the manual method of ordering PN was used. IMPLICATIONS: Our findings indicate that automating the process of writing and delivering PN orders saved time because it eliminated repetitive tasks and tedious calculations previously required of neonatologists, dietitians, and pharmacists. Patient care in our population of neonates was enhanced by improving the nutrient content of the PN solution.

Marijuana to prevent nausea and vomiting in cancer patients: a survey of clinical oncologists.

Marijuana, if rescheduled by the Drug Enforcement Agency, would be the only Food and Drug Administration (FDA)-approved drug to be administered by smoking. American physicians need timely, factual information about probable usage patterns and potential adverse effects of medical marijuana, and a factual complete review of the literature on the subject. We mailed a survey to 1,500 American clinical oncologists. Of particular interest was whether and how often in the past 24 months these physicians recommended smoked marijuana, synthetic tetrahydrocannabinol, or 5-HT3 (serotonin) antagonists (ondansetron [Zofran], granisetron [Kytril]) for their patients. We also inquired whether and how often the oncologists would prescribe marijuana in the form of cigarettes, were it to be FDA-approved. Completed surveys were received from 1,122 (75%) of the oncologists. The percentages of oncologists who prescribed or recommended selected antiemetics more than five times between 1992 and 1994 were 98% for 5-HT, antagonists, 6% for dronabinol (Marinol), and 1% for smoked marijuana. We also found that 332 (30%) of the oncologist-respondents to this nationwide survey supported rescheduling of marijuana for medical purposes; however, two thirds (67%) of the 332 respondents who were in favor of rescheduling estimated that they would write less than one prescription per month for marijuana cigarettes. A comprehensive literature review failed to provide persuasive evidence to recommend marijuana as a needed antiemetic medicine.

Antimicrobial prescribing for acute purulent rhinitis in children: a survey of pediatricians and family practitioners.

BACKGROUND: The tenet that children with acute purulent rhinitis need not be treated with antibiotics unless drainage persists for 7 to 10 days is taught to medical students and residents in primary care specialties but may not be adhered to in actual clinical practice. Because of the global increase in bacterial resistance stemming largely from the overuse of antibiotics, we sought to determine how acute purulent rhinitis is managed in the primary care setting. METHODS: We surveyed all 450 pediatricians (PD) and family practitioners (FP) in northern Virginia who were in active practice in 1994. The survey instrument was a questionnaire containing two clinical vignettes followed by a series of multiple choice or fill-in-the-blanks questions. Initial nonresponders received up to three additional mailings of the same questionnaire. RESULTS: There were 346 (77%) evaluable responses. Seventy-one percent of FP and 53% of PD (P = 0.001) immediately prescribed antibiotics for infants with scant, green nasal mucopurulent secretions of 1 day duration; fewer treated an older child immediately (50% FP vs. 24% PD, P < 0.00001). Only 15% of FP vs. 23% of PD (P = 0.07) waited for 7 to 10 days of persistent purulent nasal drainage in infants before prescribing antibiotics. Ninety-four percent of FP and 95% of PD (P = 0.8) indicated that they would prescribe antibiotics immediately for infants with acute purulent rhinitis who attended day care. For otitis-prone children who were not in day care, 86% of FP and 78% of PD (P = 0.02) would also treat without delay. The reasons given for prompt antibiotic therapy were (1) the belief that many untreated patients would develop persistent purulent nasal drainage, (2) concern that acute otitis media would develop, (3) pressure from mothers to prescribe an antibiotic and/or (4) the desire to allow employed parents to return to work earlier. Amoxicillin was the initial choice for 89% of FP vs. 76% of PD (P = 0.003). Most FP (89%) and PD (97%) were concerned about the increase in bacterial resistance rates arising from unnecessary antibiotic prescribing (P = 0.01). CONCLUSIONS: Most infants and children with acute purulent rhinitis of short duration were treated with antibiotics despite professed concerns over the spread of bacterial resistance; the practice was more prevalent among FP.

Avirulence of Candida albicans FAS2 mutants in a mouse model of systemic candidiasis.

Disruption of both alleles of the Candida albicans FAS2 gene abolishes the ability of the organism to establish infection in a murine model of systemic candidiasis. Within 72 h all mice inoculated with 10(6) CFU of the parental C. albicans strain had died. In contrast, all animals inoculated with the mutant strain CFD2 survived for the course of the experiment (21 days). Animals infected with either mutant strain CFD1 or CFD3, in which only one FAS2 allele was disrupted, also succumbed to infection, but mortality was not observed until 4 days postinfection and survivors remained for up to 20 days postinfection. The results demonstrate that FAS2 is required for successful C. albicans infection.

EMLA cream as a topical anesthetic before office phlebotomy in children.

We studied the effectiveness of EMLA cream (2.5% lidocaine, 2.5% prilocaine) in reducing distress, anxiety, and pain associated with phlebotomy in pediatric outpatients. This was a randomized, double-blind, placebo-controlled study using EMLA cream or placebo 1 hour before phlebotomy. Distress, anticipatory anxiety, pain, and adverse reactions were measured. Measurements of distress and ease of procedure, as well as changes in heart rate, showed significant improvement with EMLA cream as compared with placebo. Pain was decreased with use of EMLA cream. Anticipatory anxiety levels were equal within both groups. Ratings of cream efficacy by parent/observer scales were in favor of EMLA cream.