Telephone reminders improve adolescent clinic attendance: a randomized controlled trial.

OBJECTIVES: To measure the effect of telephone reminders on adolescent clinic attendance. METHODS: Clinic bookings of adolescents were randomly assigned to either a telephone reminder one day prior to their appointment, or a routine booking (no reminder). The setting was four general adolescent health clinics within a tertiary public adolescent health care service at the Centre for Adolescent Health. The main outcome measures were clinic non-attendance, reason for non-attendance, and satisfaction with the booking system. RESULTS: One hundred and seventy one adolescent appointments were studied. Of these, 51.5% were female, and 25% of bookings were for new, rather than review appointments. One hundred and one adolescents were randomly allocated to the reminder group, of whom 87% were contacted. The use of reminders (intention to treat analysis) significantly reduced the non-attendance rate from 20% to 8% (odds ratio 0.35; P = 0.03). Non-attendance was three times more likely for a new appointment than for review appointments. 'Forgetting' was the most common explanation given by patients (35%) who did not attend. Seventy-nine per cent of parents reported telephone reminders were helpful at prompting attendance. CONCLUSION: Telephone reminders greatly improved attendance at these adolescent clinics. The background non-attendance rate and the proportion of high-risk patients for non-attendance (new appointments in this setting) will determine whether reminders are more efficiently targeted at specific bookings than used routinely.

Intracranial bleed during bridge to transplant may not preclude a successful result.

We report the case of a 29-year-old man who suffered sub-arachnoid bleeding while stabilized on a biventricular assist device as a bridge to cardiac transplantation. We adjusted his anti-coagulation therapy to control the bleeding and to concurrently minimize thrombosis while on support. He underwent 2 craniotomy operations to evacuate sub-arachnoid hematomas, and he underwent a subsequent operation to debride and close the dura. Eighteen days later, he underwent successful orthotopic heart transplant and was discharged to home 3 weeks post-transplant.

Bridge to recovery for postcardiotomy failure: is there still a role for centrifugal pumps?

BACKGROUND: Early implantation of centrifugal devices in patients with postcardiotomy cardiogenic shock may provide a bridge to recovery and allow subsequent long-term survival. METHODS: Since January 1989, 62 patients were supported with centrifugal pumps because of failure to wean from cardiopulmonary bypass. Indications were postcardiotomy cardiogenic shock (PCCS) (n = 60), bridge to cardiac retransplantation (n = 1), and right ventricular failure (n = 1). Patients' ages ranged from 23 to 78 years; 40 were men (65%), and 22 were women (35%). Twenty-two patients (35%) had a left ventricular assist device; 9 patients (15%) had a right ventricular assist device; and 31 patients (50%) had a biventricular assist device. Length of support ranged from 1 day to 19 days. RESULTS: Forty-two patients (68%) were weaned successfully; 27 patients survived to discharge (44%). Complications included bleeding (n = 41, 66%), renal failure (n = 28, 45%), and respiratory failure (n = 26, 42%). Currently, 23 patients survived 10 or more years (n = 1), 6 to 10 years (n = 7), 1 to 5 years (n = 10), and less than 1 year (n = 5). CONCLUSIONS: Centrifugal pumps are available, easy to use, and relatively inexpensive. Our experience justifies their continued use as a bridge to recovery for patients with postcardiotomy cardiogenic shock, despite the availability and increasing use of more expensive devices.

Staged repair of acute type I aortic dissection and coarctation in pregnancy.

A 29-year-old gravid female presented at 22 weeks gestation with an acute Type I aortic dissection and coarctation of the aorta. She underwent emergent repair of her aortic dissection using cardiopulmonary bypass and hypothermia. At 25 weeks gestation, she underwent repair of her coarctation of the aorta. The patient had a cesarean delivery of a viable, normal male infant at 39 weeks gestation.

Use of the "chimney patch" technique for Norwood stage I procedures.

The Norwood stage I procedure is often used for the initial treatment of infants with hypoplastic left heart syndrome. This procedure creates a systemic arterial to pulmonary artery shunt to establish pulmonary blood flow. We describe a method to facilitate placement of this shunt by attaching a polytetrafluoroethylene shunt to a pulmonary artery homograft patch before performing the median sternotomy. This technique facilitates the performance of the proximal shunt anastomosis and expedites the procedure.

Homograft replacement of mitral valve in children.

BACKGROUND: Recent reports have demonstrated successful early outcomes using mitral valve homografts in adults. We report our early results after homograft mitral valve replacement in 4 children with previous atrioventricular septal defects, previous placement of a prosthetic valve, and rheumatic valvular disease. METHODS: Between May 1996 and June 1997, 4 children (ages 5, 11, 13, and 15 years) underwent mitral valve replacement with cryopreserved mitral valve homografts at our institution. Preoperative echocardiography confirmed moderately severe to severe mitral regurgitation, stenosis, or both in all 4 patients. RESULTS: Successful homograft valve replacement was achieved in all 4 patients. Based on symptoms, physical examinations, and echocardiographic follow-up, all four homograft mitral valves are functioning well with normal hemodynamics. None of these patients are receiving warfarin. Follow-up has been limited to 10 months. CONCLUSIONS: In children requiring mitral valve replacement, the use of mitral valve homografts offers advantages over prosthetic valves, such as the avoidance of complications associated with thrombosis and anticoagulation. Homograft mitral valve replacement is technically feasible in children with congenital and rheumatic heart disease and previous prosthetic valves.

Home vaccination for children behind in their immunisation schedule: a randomised controlled trial.

OBJECTIVE: To ascertain the effectiveness of a home vaccination service for children behind in their vaccination schedule. DESIGN: Randomised controlled trial of nurse-administered vaccination at home. Children were allocated at random to the intervention or the control group before any contact with the parents was made. SETTING: 10 council areas in north-west metropolitan Melbourne defined by 56 postcode zones. Six-week intervention period from November 1996. PARTICIPANTS: 405 children--all those in the study area (n = 2610) 90 days late (age 9 months) for their third diphtheria-tetanus-pertussis/poliomyelitis/Haemophilus influenzae type B (DTP/OPV/Hib) vaccination, or 120 days late (age 16 months) for their measles-mumps-rubella (MMR) vaccination, according to the Australia Childhood Immunisation Register. MAIN OUTCOME MEASURES: Number of children completing DTP/OPV/Hib or MMR during the intervention period, and number up to date before intervention. RESULTS: Verification of vaccination status with the parents revealed that 123 (60%) of the children in the intervention group and 113 (56%) of those in the control group were up to date with their vaccinations, leaving a study population of 81 (intervention group) and 88 (control group). Vaccination was achieved in 46 (57%) intervention children and 24 (27%) control children (risk ratio [RR], 2.08; 95% CI, 1.4-3.1; P < 0.001). For DTP/OPV/Hib, 18/32 (56%) intervention children and 12/36 (33%) control children were vaccinated, (P = 0.06). For MMR, 28/49 (57%) and 12/52 (23%) children were vaccinated, respectively (P < 0.001). Home vaccinations were completed with 26 families (including five siblings). The average cost per child vaccinated as a result of the home program was $92.52. CONCLUSION: Home vaccination for children behind in their immunisation schedule is an effective, acceptable and relatively cheap method of completing recommended vaccinations. We recommend that a home vaccination program be widely implemented and made available, particularly for disadvantaged families.

A method for estimating baseline health care costs.

STUDY OBJECTIVES: Studies estimating the cost of specific illnesses do not generally take into account the fact that health care costs would have been incurred in the absence of the disease of interest. The goal of this study was to develop a method of estimating age specific baseline health care costs. These costs were calculated for Australian men, and their magnitude was compared with the costs of caring for men with HIV infection. DESIGN: Information about health service usage was obtained from the 1989-90 national health survey and linked with data on the costs of services to obtain average monthly costs for individual and total health services. SETTING: The Australian community. PARTICIPANTS: Average total health service costs per man per month were $103 (Australian). Hospital admissions comprised approximately 40% of these costs and casualty/outpatient visits, consultations with a doctor, and prescribed medication comprised 10%, 13%, and 12%, respectively. Costs increased with age, from around $60 per month for men aged 20-39 years to $213 per month for men aged 60 and over. CONCLUSION: Baseline costs comprised around 18% of health care costs for men with asymptomatic HIV infection, but less than 1% of costs for men with AIDS. These estimates provide an essential baseline for determining the costs attributable to specific diseases.

Expression of retroviral transduced human CD18 in murine cells: an in vitro model of gene therapy for leukocyte adhesion deficiency.

Leukocyte adhesion deficiency (LAD) is an autosomal recessive disease caused by a defective CD18 gene. The cell-surface glycoprotein encoded by this gene CD18 is normally expressed in cells of the hematopoietic system. An in vitro murine model of CD18 gene replacement therapy was developed to investigate the feasibility of an in vivo murine hematopoietic stem cell gene therapy model. Human CD18-transducing retroviruses were used to transfer a functional human CD18 gene into a variety of cells including (i) murine lymphoblasts (which express murine CD11a and murine CD18), (ii) murine fibroblasts (which have no endogenous murine CD11a/CD18 expression), and (iii) murine fibroblasts, which have been stably transfected with a human CD11a gene. In murine lymphoblasts, human CD18 was expressed on the cell surface as a heterodimer with murine CD11a. Cell-surface expression of human CD18 had no apparent effect on the level of endogenous murine CD11a/CD18 expression. Immunoprecipitation of cell-surface labeled proteins in murine lymphoblasts with a human CD18 specific antibody co-precipitated murine CD11a. Human CD18 can be detected by immunochemistry in the cytoplasm of fibroblasts infected with CD18 encoding retrovirus, but coexpression with CD11a is required for cell-surface expression of either subunit in fibroblasts. These studies suggest that human CD18 will form a heterodimer with murine CD11a and that human CD18 is not expressed on the cell surface of cells not expressing CD11. This provides the basis for the development of a murine hematopoietic stem cell gene replacement therapy model for the treatment of LAD.