Impact of appointment reminders on vaccination coverage at an urban clinic.

OBJECTIVE: To test if appointment reminders blinded to immunization status improve kept-appointment and vaccination coverage rates. Design. Controlled trial. SETTING: Pediatric clinic serving a low-income community in New York City. INTERVENTION: Children ages 4 through 18 months (n = 1273) scheduled sequentially for clinic appointments were systematically assigned to 1 of 4 study groups: control (n = 346); postcard (n = 314); telephone call (n = 307); and postcard and telephone call (n = 306). OUTCOME MEASURES: Kept-appointment and vaccination coverage rates. RESULTS: Children assigned to the postcard and telephone group were 1.75 times more likely to keep their appointments than controls (95% confidence interval [CI] = 1.2, 2.5). Children who actually received the postcard and telephone reminders were 2.3 times more likely to keep an appointment than controls (95% CI = 1.4, 3.7). Children who kept appointments were 2.3 times more likely to be up-to-date with their immunizations (95% CI = 1.7, 3.2). The reminders selectively increased vaccination coverage for the subgroup of children who were not up-to-date before the appointment (chi(2) = 11.2). The cost of the reminders was $.67 for the postcard and $1.58 for the postcard and telephone. Assuming 5000 visits per year and $100 reimbursement per visit, the return on each dollar invested was $10 for the postcard and $7.28 for the postcard and telephone reminder. CONCLUSIONS: Appointment reminders blind to immunization status are a practical and cost-effective strategy to increase kept-appointment rates for all children, and, through this mechanism, reach and vaccinate children who are not up-to-date.appointment reminder, vaccination coverage.

Use of a hospital practice management system to provide initial data for a pediatric immunization registry.

An ongoing challenge in the creation of clinical information systems is the capture of structured clinical information from health care providers while avoiding duplicate data recording. Because immunizations are reimbursable medical procedures, practice management systems that already capture such procedures may be used as a source of clinical data for information systems. We instituted a method for capturing such data on one campus of a multi-institution pediatric immunization registry. We measured the effectiveness of this capture by comparing it to manual audits of selected paper charts over 26 months. Of the immunizations documented by chart audit, 39.69% were captured by the practice management system. Of those not captured, we estimate that a substantial portion were immunizations administered elsewhere and as a result not submitted as a claim through the practice management system. In turn, this was affected by a rate of patient disengagement from primary care of 49%. We discuss the issues associated with using claims data to capture clinical information in the setting of an immunization registry and review possible explanations for this data capture rate.

Additive effects of late preconditioning produced by monophosphoryl lipid A and the early preconditioning mediated by adenosine receptors and KATP channel.

BACKGROUND: The cardioprotective effect of preconditioning can be exerted within 1 to 2 hours after initial ischemia, termed classical or early preconditioning, or can reappear 24 hours later as second window or late preconditioning. The objective of this study was to study the interaction between late and early preconditioning and to determine the potential underlying mechanism. METHODS AND RESULTS: Adenosine receptor agonists and a KATP channel opener were used to achieve early preconditioning, and Monophosphoryl lipid A (MLA) was used to induce late preconditioning. Cultured chick ventricular myocytes were used as a myocyte model of simulated ischemia and preconditioning. Prior treatment of the myocyte with MLA caused a dose-dependent decrease in the ischemia-induced myocyte injury 24 hours later, consistent with a late preconditioning effect. L-NMMA, glibenclamide, or 5-hydroxydecanoic acid administered during the ischemia blocked the MLA effect. Twenty four hours after MLA treatment, a 5-minute exposure to ischemia, adenosine, adenosine A1 agonist CCPA, or A3 agonist resulted in less myocyte injury during the subsequent prolonged ischemia, as compared with cells pretreated with the vehicle and subsequently exposed to the same early preconditioning stimuli. In addition to its ability to enhance the early preconditioning effect by A1 and A3 agonists, MLA pretreatment also increased the phorbol ester- and pinacidil-mediated early preconditioning effect. CONCLUSIONS: This study defined a novel interaction in which the cardioprotective effect of early preconditioning is additive to that of late preconditioning and raised the possibility that both agents can be used as combined therapy in the treatment of ischemic heart disease.

Effects of topical oral antiseptic rinses on bacterial counts of saliva in healthy human subjects.

Wound infections remain a significant source of morbidity in patients undergoing major head and neck operations that invade the aerodigestive tract. Infection rates have been significantly reduced by the administration of perioperative intravenous antibiotics; however, the incidence of infection remains unacceptably high. This study was undertaken to help identify an oral antiseptic that could significantly reduce the bacterial colony count of human saliva. A randomized, prospective clinical trial was conducted to analyze and compare the effects of Listerine antiseptic and Peridex oral rinse on the aerobic and anaerobic bacterial counts in healthy human subjects. Thirty healthy adult volunteers between the ages of 18 and 61 participated in the study. The patients were randomized to receive normal saline solution, Listerine antiseptic, or Peridex oral rinse. Aerobic and anaerobic bacterial colony counts of saliva were measured before treatment and at 1 and 4 hours after treatment. Both Listerine antiseptic and Peridex oral rinse significantly reduced bacterial counts at 1 hour after treatment in our volunteers. At 4 hours after treatment, Peridex oral rinse showed a further reduction in the bacterial colony count whereas Listerine antiseptic showed no difference compared with normal saline solution. At 4 hours after treatment, Peridex oral rinse reduced the total bacterial colony count by 85%.

A novel cardioprotective function of adenosine A1 and A3 receptors during prolonged simulated ischemia.

The possible cardioprotective roles of adenosine A1 and A3 receptors were investigated in a cardiac myocyte model of injury. The adenosine A3 receptor is a novel cardiac receptor capable of mediating potentially important cardioprotective functions. Prolonged hypoxia with glucose deprivation was used to simulate ischemia and to induce injury in cardiac ventricular myocytes cultured from chick embryos 14 days in ovo. When present during the prolonged hypoxia, the adenosine A3 agonists N6-(3-iodobenzyl)adenosine-5'-N-methyluronamide (IB-MECA) and 2-chloro-N6-(3-iodobenzyl)adenosine-5'-N-methyluronamide (CI-IB-MECA) caused a dose-dependent reduction in the extent of hypoxia-induced injury as manifested by a decrease in the amount of creatine kinase released and the percentage of myocytes killed. The adenosine A1 agonists 2-chloro-N6-cyclopentyladenosine (CCPA), N6-cyclohexyladenosine, and adenosine amine congener were also able to cause a decrease in the extent of myocyte injury. The A1 receptor-selective antagonist 8-cyclopentyl-1,3-dipropylxanthine blocked the cardioprotective effect of the A1 but not of the A3 agonists. Conversely, the selective A3 antagonists MRS-1191 and MRS-1097 blocked the protection induced by CI-IB-MECA but had minimal effect on that caused by CCPA. Thus the cardioprotective effects of A1 and A3 agonists were mediated by their respective receptors. This study defines a novel cardioprotective function of the cardiac A3 receptor and provides conclusive evidence that activation of both A1 and A3 receptors during hypoxia can attenuate myocyte injury.

Characterization of a replication-competent retrovirus resulting from recombination of packaging and vector sequences.

A replication-competent retrovirus (RCR) was detected by S+/L- assays in three lots of retroviral vector G1Na that were harvested on consecutive days from a single culture of PA317/G1Na producer cells. Using a number of retrovirus-specific primer pairs, it was shown that this RCR was a novel recombinant created by exchanges between G1Na and helper sequence pPAM3 and was not an existing RCR introduced by cross-contamination. Sequencing of clones of DNA amplified in six independent PCR reactions confirmed that the 3' portion of this RCR was composed of retroviral envelope sequences unique to pPAM3 joined to a 3' long terminal repeat (LTR) unique to G1Na. Comparison of pPAM3 and G1Na sequences at the site corresponding to this junction revealed a short segment of patchy nucleotide identity (8 out of 10 bp), suggesting that these helper and vector sequences were joined by homologous recombination. Generation of RCR by exchanges between helper and vector sequences underscores the necessity of testing by efficient methods all retroviral vectors for the presence of RCR before their use. Production of 171 lots (855 liters) of various retroviral vectors that were free of RCR, including 42 lots of G1Na, however, indicates that the combination of exchanges required to generate an RCR are infrequent in this system.

Chin augmentation. An important adjunctive procedure to rhinoplasty.

Augmentation mentoplasty is a cosmetic procedure designed specifically to supplement deficient fullness of the mental area. Patients seeking care from rhinoplastic surgeons for nasal corrective procedures may not be aware of a deficiency, which is the most common abnormality in this area. Complete evaluation of the full facial profile, which should be performed in all potential rhinoplasty patients, identifies such abnormalities. The general concepts of preoperative evaluation, corrective options available, including make of implant materials, and complications are discussed. Patients with mild to moderate microgenia can be simply corrected by augmentation mentoplasty to balance the facial profile. The most common method of adding fullness in the chin area is use of an implantable material. This article discusses the advantages and disadvantages of the available materials.

The effects of topical oral clindamycin antibiotic rinses on the bacterial content of saliva on healthy human subjects.

The use of systemic antibiotics for major head and neck surgical procedures involving the upper aerodigestive tract is now accepted as an important part of perioperative patient care. Despite knowledge of the high counts of bacteria present in saliva, no preoperative regimen for preparing the mouth has been standardized. Surgical wounds come in contact with saliva during the course of many head and neck procedures. While wound infection rates have been decreased with the use of prophylactic systemic antibiotics, serious morbidity still exists from postoperative wound infections. Reducing the bacterial counts in saliva preoperatively may further decrease wound infection rates. A prospective randomized pilot study of twenty healthy human subjects compared the effects of an oral rinse with clindamycin vs. a placebo rinse of normal saline. There was a statistically significant reduction in both aerobic and anaerobic colony counts in the clindamycin group at 4 hours after treatment. For the group that rinsed with placebo, there was an actual increase in counts 4 hours after treatment. It is concluded that oral rinses with clindamycin can reduce the bacterial content of saliva for a sufficient length of time to be effective as a preoperative prophylactic measure for head and neck surgery involving the upper aerodigestive tract. Future studies are planned to evaluate other potentially effective agents. A logical continuation is a clinical study of preoperative and postoperative rinses.

Dermal healing after local skin flaps and chemical peel.

Like cells respond to injury through repair mechanisms unique for each cell type (eg, regeneration of the epidermis, granulation over exposed fat). How simultaneous chemical peel affects a local skin flap and why minimal differences in chemical peels can result in significant differences in outcome is not fully understood. In this study guinea pig skin was exposed to skin flap elevation, chemical peel, or a combination of the two. Biopsy specimens were taken at 3 to 35 days after injury and the histologic sections were studied. Results demonstrate that (1) lifting a flap causes changes in the subcutaneous tissue and reticular dermis that makes it more vulnerable to secondary injury and (2) the reticular dermis responds to injury as two physiologically distinct layers, although it appears histologically homogeneous. The upper reticular dermis heals by reorganization, while the deeper reticular dermis heals by scar formation. The differing response to injury of these cell layers may in part explain the low safety margin in aggressive chemical peels.

Viability of skin flaps subjected to simultaneous chemical peel with occlusive taping.

This study was undertaken to determine whether the application of a standardized chemical peel with an occlusive tape dressing to an acutely raised skin flap (as in combining rhytidectomy with chemical peel) affects skin flap viability. Thirty-six 4-cm x 4-cm dorsal skin flaps were raised on guinea pigs and sutured back into place. Eighteen of these flaps were simultaneously treated with a single application of Baker's solution and a 24-hour occlusive tape dressing. A mean of 3.1 cm2 of the nonpeeled flaps necrosed, compared with 6.3 cm2 of the peeled flaps, a statistically significant increase in tissue loss in flaps that were simultaneously chemically peeled. We conclude that application of Baker's solution with an occlusive tape dressing to an acutely raised skin flap impairs skin flap viability and may result in skin flap necrosis.