Patient satisfaction with an advanced nurse practitioner (ANP) integrated community chest pain clinic

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Martha McMenamin Scholarship, small grant awarded

Background

Patient presentations with chest pain to the Emergency Department (ED) account for 9% of ED attendances. In the primary care setting chest pain is a common presenting complaint with an over diagnosis/suspicion of stable angina, however General Practitioners (GPs) lack access to a cardiac specialist in a timely fashion. As a result 31% of all ED chest pain patients are referred by GPs. The innovative integrated community chest pain clinic (ICCPC) commenced in September 2020. This Advanced Nurse Practitioner (ANP) led clinic aims to provide an alternative avenue to which GPs can directly refer patients with non-acute chest pain, thereby shifting the focus of care from the acute hospital environment

Purpose

Integrated community based care and ANP led care are new phenomena to the Irish patient. This paper explores patient satisfaction with the ANP led integrated community chest pain clinic

Method

This quantitative descriptive study invited participation from ICCPC patients over a six-month period (N=177). The questionnaire was adapted from Cross et al, (2010). Return of the anonymous questionnaire was by freepost/Qualtrics. Ratings were based on a five-point scale from ‘Poor’ to ‘Excellent’. Satisfaction and experience of ANP led community care was evaluated and satisfaction with appointment scheduling, waiting times, service provision and follow-up care was measured. Quantitative data were analysed using descriptive statistics. A combination of ‘good’ very good’ and ‘excellent’ are taken to mean a positive rating. Ethical approval was granted by the hospital ethics committee.

Results

A response rate of 43.5% (n=77) was achieved, including female (55.2%) white Irish (85.1%) and age range 50–69 yrs (53%). Confidence in the level of assessment by the ANP received a 100% (n=77) positive rating. All responders felt safe in the clinic 100% (n=74). Appointment waiting times received positive ratings: GP to ICCPC waiting times 98% (74/75); referral from ICCPC to hospital for stress test 92% (35/38); and 94.3% (50/53) positive rating regarding waiting times for phone-reported test results. Suggestions for improvements included the need for clearer signage/easier access to the ICCPC and a preference for follow-up check-ups by the ICCPC. If discharged for hospital follow up some wished for clearer follow-on care plans from the hospital.

Conclusion and Implications

This study suggests that the ANP led integrated community chest pain clinic plays a crucial role in meeting the needs of integrated patient centred care. The ANP led clinic was well received by patients and is a blueprint for other community initiatives. Many positive comments were included, with one participant stating "this service should be in every community, I think this would encourage people to go to the GP about mild chest pain without the fear of being sent to ED".

Emergency Department chest pain patient experience time (PET): the impact of ANP cardiology autonomy from triage to diagnosis

Funding Acknowledgements

Type of funding sources: None.

Background

Chest pain accounts for 8% of local Emergency Department (ED) presentations. Patient experience time (PET) is the entire time each patient spends in ED and the national ED PET goal is 6 - 9 hours. The Cardiology Advanced Nurse Practitioner (ANP) consult service reduced PET for patients with chest pain from 17 hours, however the average PET for patients presenting with chest pain remains high at 10 hours in 2019.

Aim

To assess the impact on of ANP Cardiology autonomy on the PET of chest pain patients who present to a busy ED.

Method

Building on 6 years of ANP chest pain consultations in the ED, cardiology ANPs expanded their caseload to fully manage chest pain patients directly from the waiting room as named clinicians, instead of an ED doctor.  The ANP managed the patient completely from triage to diagnosis, resulting in discharge or admission. Enablers included ANP referral for ionising radiation and medicinal prescribing, with buy in from ED Consultants and Cardiology clinical lead. All patients managed directly by the ANP from 2017-2019 were included in the data analysis. The ED symphony system was used as a clinical and audit tool. ANP chest pain PET was compared to ED Doctor chest pain PET. This service evaluation was approved by the hospital audit committee. 

Results

197 patients who presented with chest pain were autonomously managed by one ANP as a named clinician over 3 years. Sixty-four percent were managed completely autonomously.  Eighty per cent were discharged from ED. ANP decision time from initial assessment to admit or discharge was 2.6 hours. The ANP average chest pain PET time was 7.5 hours compared to average ED doctor chest pain PET of 9.5 hours.

Conclusions

As social distancing now impacts more than ever on usual ED pressures, caseload expansion by the Cardiology ANPs evidences further PET reductions for patients who present with chest pain in line with targets. As only one ANP is on the floor and not every shift, many hours of the PET occurred in the ED prior to the ANP ‘clicking’ on as a named clinician. Professional courage to completely manage this potentially high risk cohort autonomously has been welcomed patients and ED staff. PET of the chest pain patient has the potential to reduce further with more ANPs proficient in chest pain assessment within the emergency department setting.

How a pandemic changed advanced nurse practitioner (ANP) chest pain assessment from face-to-face to virtual: The impact on clinical workload, diagnosis & patient safety

Funding Acknowledgements

Type of funding sources: None.

Chest pain presentations to the Emergency Dept. (ED) account for 8% of ED cases annually. In response to the pandemic the usual care pathway of nurse-led assessment in ED and discharge to a chest pain clinic (Ingram  2017) ceased, as face-to-face clinics and diagnostics were curtailed, and staff redeployed. A virtual chest pain clinic was created by one ANP. Telehealth is defined as ‘the entire spectrum of activities used to deliver care remotely, without direct physical contact with the patient’ (Wosik  2020)

Purpose

This analysis aims to compare the outcomes of the Covid-19 virtual chest pain clinic in 2020 to the same face-to- face clinic period in 2019 with a focus on i. Clinic workload, ii. Patient Outcomes iii. Patient Safety,

Methods

The ANP performed a telephone consultation and referred for limited diagnostic testing or discharged to primary care. The patient management system (iPIMS) was used as a clinical and audit tool. This service evaluation was registered as quality improvement project.

Results

From 1/4/20 to 21/7/2020, 130 e-referrals were received compared to 154 face-to-face consults in the same period of 2019. The overall number of clinic episodes was 17% greater during the pandemic period (Fig.1), carried out by 1/3 of the 2019 staff quota. Access to exercise stress testing (EST) was reduced by 88%.  CHD was diagnosed in 26%. Virtual assessment in this high risk group in the absence of timely diagnostics is a risk however 30 day mortality was 0%.

Discussion

  The pandemic of covid-19 required a rapid redesign of the chest pain service in the midst of staff redeployment. Whilst the total number of referrals is less that the same timeframe in 2019 the ‘virtual’ nature of the service created additional episodes of care with the need for the return clinic in person or by telephone.

Conclusion

In response to the pandemic the change to a virtual clinic was enabled by ANP experience and permitted continued safe discharge of chest pain patients from the ED. The virtual service does add to the ANP clinical workload with potential risk. As it requires more office time, it prevents the ANP presence in the ED.  It is hoped in time to return to the original model of care as this will be more efficient for the service and the patient.

TP2-4 The impact of social deprivation upon global traumatic brain injury outcome

Objectives

The aim of this study was to assess the impact of social deprivation upon global TBI outcome.

Design

The study was a prospective observational study.

Subjects

1332 consecutive adult TBI patients were recruited into the study. 131 study participants were lost within the study.

Methods

All patients were assessed by the acute TBI team at the point of their injuries. Both injury and demographic data was collated at this point including: age, gender, medical comorbidities and GCS. The measure of social deprivation used, was the Indices of Multiple Deprivation (IMD) Score. The outcome measure, conducted at 12 months post-injury, was the GOSE. Univariate analyses were conducted prior to the final Multinomial Regression, between the GOSE score and injury factors.

Results

With regard to the representation of IMD deciles, the study population and the general population are two independent groups, but the standard deviation is sufficiently similar for them to be considered pooled (equal variance)(t-test p=0.139). Within the univariate analyses statistically significant relationships were noted between IMD and GOSE (p≤0.00). There was no relationship noted between IMD and GCS at the time of injury (p=0.409), or medical co-morbidity (p=0.682). The multinominal regression revealed a significant relationship between between worsening GOSE and IMD, Age, Medical Comorbidity and GCS (p≤0.00).

Conclusions

There is a statically significant relationship between increasing social deprivation and worsening global TBI outcomes.

A New Standard DNA Damage (SDD) Data Format

Our understanding of radiation-induced cellular damage has greatly improved over the past few decades. Despite this progress, there are still many obstacles to fully understand how radiation interacts with biologically relevant cellular components, such as DNA, to cause observable end points such as cell killing. Damage in DNA is identified as a major route of cell killing. One hurdle when modeling biological effects is the difficulty in directly comparing results generated by members of different research groups. Multiple Monte Carlo codes have been developed to simulate damage induction at the DNA scale, while at the same time various groups have developed models that describe DNA repair processes with varying levels of detail. These repair models are intrinsically linked to the damage model employed in their development, making it difficult to disentangle systematic effects in either part of the modeling chain. These modeling chains typically consist of track-structure Monte Carlo simulations of the physical interactions creating direct damages to DNA, followed by simulations of the production and initial reactions of chemical species causing so-called "indirect" damages. After the induction of DNA damage, DNA repair models combine the simulated damage patterns with biological models to determine the biological consequences of the damage. To date, the effect of the environment, such as molecular oxygen (normoxic vs. hypoxic), has been poorly considered. We propose a new standard DNA damage (SDD) data format to unify the interface between the simulation of damage induction in DNA and the biological modeling of DNA repair processes, and introduce the effect of the environment (molecular oxygen or other compounds) as a flexible parameter. Such a standard greatly facilitates inter-model comparisons, providing an ideal environment to tease out model assumptions and identify persistent, underlying mechanisms. Through inter-model comparisons, this unified standard has the potential to greatly advance our understanding of the underlying mechanisms of radiation-induced DNA damage and the resulting observable biological effects when radiation parameters and/or environmental conditions change.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

Mortality reporting in interventional radiology: experience of a pilot audit with the Scottish Audit of Surgical Mortality

AIM

To describe the initial pilot phase of the 2009 Scottish Audit of Surgical Mortality (SASM), which includes outcomes and difficulties that arose during any interventional radiology (IR) procedure performed on patients in this audit over an 18 month period.

MATERIALS AND METHODS

Approximately 40 consultant interventional radiologists from all units in Scotland elected to participate in the audit. Each response was then peer reviewed after anonymisation of the patient and institution. If a relevant ACON (area for consideration or area of concern) was generated, this was checked by one of the other reviewers before communication with the original reporting radiologist and colleagues. There was then a right of reply by the reporting unit before formal documentation was sent out.

RESULTS

Initial results were analysed after 18 months period, during which time 95 forms relating to deaths of surgical inpatients were sent to interventional radiologists identified as having been involved in an IR procedure at some time during the patient's admission. Seventy-one forms had been returned by July 2010, of which 46 had gone through the entire SASM process. From these, 10 ACONs were attributed. Anonymised case vignettes and reports from these were used as educational tools.

CONCLUSION

Involvement with SASM is a useful process. Significant safety issues and learning points were identified in the pilot. The majority of ACONs identified by the audit were in patients who had undergone percutaneous biliary interventions.

Quantum control of the spin-orbit interaction using the Autler-Townes effect

We have demonstrated quantum control of the spin-orbit interaction based on the Autler-Townes (ac-Stark) effect in a molecular system using a cw optical field. We show that the enhancement of the spin-orbit interaction between a pair of weakly interacting singlet-triplet rovibrational levels, G (1)Π(g)(v=12,J=21,f)-1 (3)Σ(g)(-)(v=1,N=21,f), separated by 750 MHz in the lithium dimer, depends on the Rabi frequency (laser power) of the control laser. The increase in the spin-orbit interaction due to the control field is observed as a change in the spin character of the individual components of the perturbed pair.

‘Kissing stent’ insertion is not safe or durable

Background

The morbidity, and clinical and haemodynamic outcome of kissing stent insertion was assessed.

Methods

A prospectively gathered database of endovascular procedures performed between 1 January 1993 and 31 December 1998 was analysed.

Results

Bilateral kissing stents were deployed in 12 patients (median age 62 (range 43–67) years; five men and seven women). Indications were bilateral intermittent claudication (IC) in nine patients, unilateral IC with contralateral rest pain in two and bilateral rest pain/tissue loss in one. Major morbidity occurred in three patients and comprised bilateral distal iliac dissection (treated medically), distal embolization (thrombolysis and suction aspiration) and false aneurysm (surgical repair). All patients reported an immediate improvement in symptoms. However, at a median (range) follow-up of 27 (3–70) months, symptoms have deteriorated in 13 legs, the ankle: brachial pressure index has fallen by more than 0·15 (with respect to values immediately after the procedure) in 15 legs, six stents have occluded (bilaterally in two patients, unilaterally in two) and four stents have stenosed significantly (greater than 50 per cent). Four patients have undergone aortobifemoral grafting and one further patient has undergone bilateral amputation following failed revascularization necessitated by stent thrombosis.

Conclusion

In contrast to the single previously published series of 20 patients which found the technique to be ‘effective’ with ‘few serious adverse events’, present data suggest that kissing stents are associated with significant morbidity and a poor outcome.

Clinical governance: learning and changing practice

CONTEXT

This paper describes a very simple, non-threatening method for improving communication and sharing learning points.

OBJECTIVE

To test whether sharing anonymised reporting of problems and helpful hints is acceptable and useful to staff.

DESIGN

A pink slip (pinkie) was designed and made available in every clinic venue. All staff were asked to write about any episodes where practice was less than optimum or to share good clinical experiences. The forms could be completed anonymously if preferred. A senior nurse collated the reports monthly and fed them back to all staff as a report. In May 2000 all staff were surveyed for their opinion of the scheme.

RESULT

Over 22 months, 139 'pinkies' were returned. Fifty-six of the 100 'less than optimum' events were classified as 'system failures'. The response to the staff survey was very positive, with 62% of staff replying. Fifty-four of the 55 staff found the scheme helpful. A third of those who responded had contributed and all but two individuals felt able to contribute if the situation arose again.

CONCLUSION

This simple system of self completed pink slips has allowed examples of less than optimum practice and helpful suggestions to be shared across a large service that has a predominantly part time work force providing services from over 15 venues. The system is seen as non-threatening and was acceptable to over 95% of the staff who responded to the survey. Fifty percent of doctors and nurses had made a submission. Changes in practice have resulted since its introduction.

Epidermal diseases in bottlenose dolphins: impacts of natural and anthropogenic factors

Experimental studies have highlighted the potential influence of contaminants on marine mammal immune function and anthropogenic contaminants are commonly believed to influence the development of diseases observed in the wild. However, estimates of the impact of contaminants on wild populations are constrained by uncertainty over natural variation in disease patterns under different environmental conditions. We used photographic techniques to compare levels of epidermal disease in ten coastal populations of bottlenose dolphins (Tursiops truncatus) exposed to a wide range of natural and anthropogenic conditions. Epidermal lesions were common in all populations (affecting > 60% of individuals), but both the prevalence and severity of 15 lesion categories varied between populations. No relationships were found between epidermal disease and contaminant levels across the four populations for which toxicological data were available. In contrast, there were highly significant linear relationships with oceanographic variables. In particular, populations from areas of low water temperature and low salinity exhibited higher lesion prevalence and severity. Such conditions may impact on epidermal integrity or produce more general physiological stress, potentially making animals more vulnerable to natural infections or anthropogenic factors. These results show that variations in natural environmental factors must be accounted for when investigating the importance of anthropogenic impacts on disease in wild marine mammals.

Assessment of postruminal amino acid digestibility of roasted and extruded whole soybeans with the precision-fed rooster assay

The objectives of these studies were to predict the effects of roasting and extrusion temperatures of whole soybeans (SB) on intestinal protein digestibility in cattle. Intestinal digestibility was assessed with a two-stage in vitro or in situ ruminal incubation/precision-fed cecectomized rooster bioassay. In Exp. 1, whole SB (raw SB or SB roasted to 141, 149, or 157 degrees C exit temperature from a commercial roaster and steeped for 30 min) were incubated in strained ruminal fluid and McDougall's buffer (50:50) at 39 degrees C for 16 h. In Exp. 2, SB (ground raw SB or SB extruded at 116, 138, or 160 degrees C) were placed in polyester bags (20 x 30 cm) and suspended in the ventral rumen of steers for 16 h. Lyophilized residue of the in vitro or in situ incubations and samples of raw SB and most extensively heated SB (roasted SB at 157 degrees C or extruded SB at 160 degrees C) for each respective experiment were crop-intubated to cecectomized roosters. Total excreta were collected for 48 h after intubation and lyophilized, and amino acid (AA) concentrations were determined. In Exp. 1, total AA digestibility was 61.6 and 84.5% for unincubated whole raw SB and 157 degrees C roasted SB, respectively, and 66.2, 88.9, 91.3, and 91.6% for in vitro residues of whole raw SB and SB roasted at 141, 149, and 157 degrees C, respectively. Trypsin inhibitor (TI) activity was 20.09, 1.69, 1.54, and 1.84 mg/g fat-free DM for unincubated whole raw SB and 141, 149, and 157 degrees C roasted SB, respectively, and 30.84, 1.01, .90, and .26 mg/g fat-free DM for in vitro residues of whole raw SB, 141, 149, and 157 degrees C roasted SB, respectively. In Exp. 2, total AA digestibility was 68.5 and 87.7% for unincubated ground raw SB and 160 degrees C extruded SB, respectively, and 81.9, 91.3, 89.7, and 89.4% for in situ residues of ground raw SB and 116, 138, and 160 degrees C extruded SB, respectively. Trypsin inhibitor activity was 17.61, 4.89, 4.08, and 1.56 mg/g fat-free DM for unincubated ground raw SB, 116, 138, and 160 degrees C extruded SB, respectively, and 3.62, .59, .55, and .21 mg/g fat-free DM for incubated ground raw SB, 116, 138, and 160 degrees C extruded SB, respectively. Heat treatment by roasting and extrusion improved AA digestibilities of SB, but there were no differences detected among the roasting or extrusion temperatures. Ruminal fermentation did not eliminate the negative effects of TI activity on intestinal digestibility of AA in whole SB but did reduce TI activity in ground SB.

Efficacy and kinetics of opioid action on acutely dissociated neurons

Opioids have been shown to cause a potent inhibition of neurons in the locus ceruleus (LC) in vivo in brain slices and isolated neurons; however, the kinetics of opioid action have not been described. In this study, we used acutely isolated LC neurons to examine opioid and alpha2-adrenoceptor action on potassium and calcium currents. [Met]Enkephalin (ME), [D-Ser2,Leu5,Thr6]-enkephalin, etorphine, and [D-Ala2,N-Me-Phe4,Gly-ol5]enkephalin increased potassium conductance, whereas morphine and naloxone were antagonists. The time constant of potassium channel activation was approximately 0.7 sec and was the same for each agonist. The amplitude of the current and the time constant of decay were dependent on the agonist, suggesting that agonist efficacy and affinity, respectively, determined these parameters. The amplitude of potassium current induced by the alpha2-adrenoceptor agonist UK14304 was not significantly different from that induced by ME, but the time constant of current activation was half that of ME, and the decline was more rapid. When potassium conductances were blocked with the combination of internal cesium and external barium, opioid and alpha2 agonists had no effect at potentials more negative than -50 mV and decreased barium currents at potentials between -40 and +20 mV. Both morphine and clonidine caused a small inhibition of barium current. In dorsal root ganglion cells, morphine alone had small and inconsistent effects on the calcium current, but it always competitively antagonized the inhibition caused by [D-Ala2,N-Me-Phe4,Gly-ol5]enkephalin. The results in isolated LC neurons suggest 1) the amplitude and time course of the opioid-induced potassium current depend on agonist efficacy and affinity and 2) the coupling of both mu-opioid and alpha2-adrenoceptors to calcium channels seems to be more efficient than that to potassium channels.

Ultrasound evaluation of the paediatric prostate

OBJECTIVE

To document the shape, echogenicity and volume range of the normal paediatric prostate on transabdominal ultrasound, and to determine the feasibility of imaging the seminal vesicles and prostatic urethra with transabdominal ultrasound.

PATIENTS AND METHODS

Transabdominal ultrasound of the prostate was performed in 36 boys, aged 7 months-13.5 years (mean 7.7 years), with normal prostates.

RESULTS

Generally the prostate was hypoechoic, ellipsoidal in shape with a volume range of 0.4-5.2 ml (mean 1.2). The seminal vesicles were demonstrated in 56% of boys but only occasionally could the urethra be visualized. No colour flow was demonstrated within the prostate.

CONCLUSION

The paediatric prostate can be easily visualized by transabdominal ultrasound. This technique may be of value in the investigation of incontinence, posterior urethral valves and seminal vesicle pathology, and in the monitoring of prostatic volume in hypogonadal boys.

Colour Doppler sonography of the normal paediatric testis

Colour Doppler imaging (CDI) potentially provides the facility to differentiate torsion of the testis from inflammatory pathology. Normal control data are required for the purposes of interpretation of abnormal findings. Fifty boys with normal testes were examined by CDI using the Acuson 128XP System. Testicular blood flow was demonstrated in both testes in 58% of boys whilst 34% had no detectable flow. Eight per cent had demonstrable flow demonstrated on one side only. These results indicate that caution should be exercised in diagnosing testicular torsion on colour flow findings alone.

Colour Doppler sonography of femoral vein stenosis: a report of three cases

Colour Doppler sonography (CDS) is becoming an increasingly popular method of examining the deep venous system of the lower limb, particularly in the investigation of possible deep venous thrombosis (DVT). We describe a further application of CDS observed in three intravenous (i.v.) drug abusers who presented with symptoms mimicking a DVT. All three cases had femoral vein stenosis occurring at their injection site. This was demonstrated by CDS and at the same time DVT excluded.

Colour Doppler imaging of the acute paediatric scrotum

The differentiation of the causes of acute scrotal pathology by clinical means alone is prone to inaccuracy, resulting in inappropriate surgical exploration. Colour Doppler imaging (CDI) provides the facility to assess blood flow. Torsion of the testis impedes blood flow, whereas it is enhanced or normal in inflammatory pathology. We have investigated 40 cases of acute scrotal disease by means of CDI in which the radiologist performing the test was unaware of the preliminary clinical diagnosis. The clinical diagnostic accuracy was 60%, whereas the diagnostic accuracy of CDI was 82%. CDI provides an effective means of enhancing diagnostic accuracy.

Testicular torsion: missed diagnosis on colour Doppler sonography

Colour Doppler sonography is of value in diagnosing scrotal pathology. We report a case of testicular torsion misdiagnosed as a paratesticular tumour by colour Doppler sonography and highlight some of the pitfalls involved in this technique.

Computed tomographic findings in two patients with vascular hamartomas

The clinical, computed tomographic (CT) and histological findings of two patients with vascular hamartomas are presented. The appearances on CT of the two lesions were markedly different. Although both lesions were histopathologically benign, one showed a more disorganized architecture on histology and clinically behaved in a more aggressive manner. The CT findings in this case reflected the histological picture and could have been interpreted as a malignant process if viewed in isolation. Review of the literature and the cases presented suggest that the CT appearances of vascular hamartomas can be diverse, and to avoid a misdiagnosis the radiological features should be considered in conjunction with the clinical and histopathological findings.

Double-blind comparison of topical lignocaine-prilocaine cream (EMLA) and lignocaine infiltration for arterial cannulation in adults

In a double-blind, double-dummy study, the efficacy of topical 5% EMLA cream was compared with that of lignocaine infiltration in alleviating the pain of arterial cannulation. Forty unpremedicated adults were allocated randomly to four groups to receive EMLA cream alone, EMLA and 0.9% saline infiltration, EMLA and 1% lignocaine infiltration or placebo cream and 1% lignocaine infiltration. Following arterial cannulation, pain was assessed by the patient using a visual analogue score and by an independent observer using a four-category verbal rating score. Significantly lower pain scores were observed in all patients receiving EMLA compared with those receiving placebo cream and lignocaine infiltration by both patient (P less than 0.01) and observer (P less than 0.001) assessments. There were no significant differences between the three EMLA groups.