An appointment-keeping improvement package for outpatient pediatrics: systematic replication and component analysis.

Child health-care appointments that are not kept are an important pediatric problem. Previous research has shown that reducing effort (with a parking pass) and reminding patients (with mailed and telephone reminders) significantly improved appointment keeping for first-time and patient-scheduled appointments. This study, using a posttest-only group design, evaluated the effects of various combinations of that intervention applied to clinic-scheduled follow-up appointments. All combinations of the intervention significantly increased cancellations, but none increased appointments kept or decreased appointments not kept significantly. Log linear analyses showed that the lag time between scheduling and the appointment significantly influenced appointment keeping. The results suggest that if clinics want to increase cancellations, a mailed reminder and effort reduction are sufficient. To increase appointment keeping, other interventions, such as reduced lag time, may be necessary.

Case report 723. Popliteal artery aneurysm.

An unusually large, noncalcified popliteal artery aneurysm causing cortical erosion was erroneously diagnosed as a soft-tissue sarcoma. The case stresses the importance of excluding a vascular cause of a mass whenever biopsy is considered. We review the clinical and radiological features of popliteal artery aneurysm and describe the appearance of the aneurysm on MR.

Hemodialysis-related amyloidomas of bone.

Lytic bone lesions secondary to amyloid deposition are a recently described complication of long-term hemodialysis. The authors refer to these tumorlike deposits as amyloidomas in a review of the subject and four proved cases. This entity typically appears as multiple well-defined, juxta-articular lytic lesions without matrix calcification. The duration of hemodialysis is probably the greatest risk factor for development of these intraosseous amyloidomas. Ultrastructurally, this new type of amyloid originates from beta 2-microglobulin, a low-molecular-weight serum protein that is not filtered by standard dialysis membranes.

Sonographically guided paracentesis for palliation of symptomatic malignant ascites.

The technique, results, and complications of 109 consecutive sonographically guided therapeutic paracenteses performed on 43 patients with malignant ascites are summarized. A 5.5-French Sacks One-Step Catheter was used in all cases but five in which tissue resistance prohibited passage of the catheter through the abdominal wall. The procedure was performed on an inpatient basis 70 times and in an outpatient setting 39 times. Colonic, ovarian, and breast carcinomas accounted for over 50% of the tumors resulting in malignant fluid collections. Three complications (hypotension, 2.6%) were directly related to the procedure; two of them were fatal (1.6%). The amount of ascitic fluid drained within the first 24 hr averaged 3.5 l at rates of 100-150 ml/sec. Ninety-five procedures (87%, in 39 patients) resulted in improvement of symptoms after drainage as manifested by decreased pain from abdominal distention, alleviation of nausea, improved appetite, or decreased dyspnea. The duration of symptomatic relief ranged from 4 days to 45 days (mean, 10.4 days). Sonographically guided paracentesis is an effective procedure that can be performed for short-term relief of symptoms caused by malignant ascites.

Decreasing dangerous infant behaviors through parent instruction.

One adult and three adolescent mothers with 1-year-old infants were taught to reduce their infants' potential for injury in the home. After being taught to increase their positive interactions with their infants, the mothers were taught to child-proof the home, to use playpen time-out for potentially dangerous behaviors, and to give positive attention for safe behaviors. A multiple baseline design across subjects was used to evaluate functional control. Potentially dangerous behaviors, observed during 10 min of free play, decreased from variable and, at times, high rates during baseline to stable near-zero rates after treatment. These target behaviors remained low at a 7-month follow-up assessment.

Primary encopresis: evaluation and treatment.

Cathartic and behavioral treatment procedures for eliminating diurnal and nocturnal primary encopresis were investigated using a multiple-baseline design across four children. The dependent and independent variables measured were appropriate bowel movements, soiling accidents, independent toiletings, and cathartic use. Over 177 reliability observations (home visits) were conducted. For two of the children, treatment with cathartics and child-time remedied their soiling accidents and increased their independent toiletings in 8 to 11 weeks. While the cathartics and child-time increased the rate of appropriate bowel movements, they did not eliminate the soiling accidents with the other two children. Independent toiletings for these two children were achieved after 32 to 39 weeks of treatment when punishment procedures (positive practice, time-out, and hourly toilet sits) were incorporated and the suppositories were faded systematically.