Evolution of trends in the live kidney transplant donor-recipient relationship.

OBJECTIVE: This study examined the changing demographics and age profile between living donors and their recipients. A 46-year review of living donor renal transplants in a single transplant center was performed. PATIENTS: The study included 923 consecutive living donor renal transplants from January 1966 until December 2011. RESULTS: These 923 living donor kidneys transplants represent 41% of all transplants performed during this 46-year review. The majority involved sibling donation (39.5%) followed by parent to child (32.5%). Dividing the 46-year timeframe into quartiles, the mean age of donors has remained stable at 39.3 ± 10.9 years. In contrast, the mean age of recipients has trended upwards, from 28 ± 10.7 years in the first quartile (1966-1978) to 37 ± 17.5 years in the latest quartile (2001-2011). This represents an increase every year of approximately 4 months (P < .001). Over the same period, the difference between a given donor's age and their recipient's has decreased every year by approximately 4 months (P < .001). In a linear regression model of donor-recipient categories and their age difference over time, we found that both the child-to-parent and grandchild-to-grandparent groups had the largest effect on the donor-recipient age difference when compared to the classic parent-to-child relationship. CONCLUSION: This review of center-specific data shows that the difference in the age of the donor to their recipient has been narrowing over time. We have determined that this is primarily due to changes in donor-recipient demographics with an increasing number of younger donors to older recipients. Although the medical risks to donors living with a single kidney have yet to be shown different than that of the general population, the increasing volume of donors who are younger and those with no relation to the recipient should prompt closer follow-up within the transplantation medical community.

Does ultrasonic energy for surgical dissection reduce the incidence of renal transplant lymphocele?

OBJECTIVE: To determine the difference in post-renal transplant lymphocele rate based on the surgical dissection technique for control of lymphatics by examining the historical case group under the direction of a single, university-based surgeon in a retrospective, cohort study. PATIENTS: Five hundred thirty-two consecutive renal transplant patients from January 1994 to December 2009. FINDINGS: Of the 532 cases studied, 259 (48.7%) had suture ligation and 273 (51.3%) employed ultrasonic dissection (UD) for control of lymphatics during renal transplantation. There was no difference found in the rate of lymphocele formation, requiring either percutaneous or surgical drainage, when surgical ties (8.9%) were compared to UD (9.2%; P=.999). Logistic regression analysis showed that the odds ratio for developing a lymphocele was independent of surgical dissection technique. Within the logistic analysis, the prediction for lymphocele was increased 3.29 times for pediatric patients (P=.002) and increased 2.97 times for those who received a living donor graft (P=.001), and there was a trend for those with a history of more than one renal transplant of 2.01 times (P=.079). SUMMARY: Surgical dissection technique was not a factor in the development of post-renal transplant lymphocele. Younger age, living donor transplant, and repeat transplant status were found to be predictive variables for symptomatic lymphoceles requiring drainage, which may be considered when patients present for posttransplant evaluations for laboratory alterations.

Laparoscopic treatment of post renal transplant lymphoceles.

BACKGROUND: Traditionally, a post transplant lymphocele (PTL) is drained by widely opening the wall connecting the lymphocele cavity to the intraperitoneal space via laparotomy. We hypothesize that laparoscopic techniques can be effectively used for the treatment of PTL. METHODS: Patients requiring intervention for PTL between 1993 and 2002 were identified via a retrospective review. Results of drainage via laparotomy and laparoscopy were compared. RESULTS: During the study period 685 renal transplants (391 cadaveric, 294 living) were performed. The incidence of lymphocele was 5% [34/685 (36 cases)]. The indications for surgical drainage were local symptoms (69%), graft dysfunction (14%), or both (17%). The mean time to surgical therapy was 4.9 months. Laparoscopic drainage was performed in 25 patients (74%) and open drainage in 9 patients (26%). Open procedures were performed in cases for: previous abdominal surgery (5), undesirable lymphocele characteristics or location (2), or with concomitant open procedures (3). There were no conversions or operative complications in either group. There was no difference in operative time for the laparoscopic group vs the open group (108 +/- 6 vs 123 +/- 18 min, p = 0.8). Hospital stay was significantly shorter for the laparoscopic group (1.7 +/- 0.8 vs 3.8 +/- 1.0, p = 0.0007), with 88% of laparoscopic patients being either overnight admissions or same day surgery. Two patients (5%) developed symptomatic recurrences requiring reoperation [1 laparoscopic (4%), 1 open (10%)]. CONCLUSIONS: Laparoscopic fenestration of a peritransplant lymphocele is a safe and effective treatment. The large majority of patients treated with laparoscopic fenestration were discharged within one day of surgery. Unless contraindications exist, laparoscopy should be considered first-line therapy for the surgical treatment of posttransplant lymphocele.

Distal radial metaphyseal forces in an extrinsic grip model: implications for postfracture rehabilitation.

The purpose of this study was to establish the relationship between force at the distal radius and power grip force of the hand, a common functional and rehabilitation maneuver. This information will provide limits of allowable grip forces during postfixation rehabilitation and guide design requirements for fixation systems. By designing a model of power grip using the extrinsic hand musculotendinous units, we were able to compare grip force with force at the distal radius. Our results show that to obtain 10 N of grip force, approximately 26.3 N of force is transmitted through the distal radius, 52.4 N is transmitted through the radius and ulna combined, and 30.0 N needs to be applied to the flexor tendons. Fifty-one percent of the total forearm force was transmitted through the distal radius in this model. If all forearm forces were transmitted through the radius, 52 N of force would be transmitted through the distal radius to obtain 10 N of grip force. The clinical application of this model suggests that since failure forces of tested distal radius fixation systems range from 55 to 825 N, rehabilitation grip force should not exceed 10 to 159 N, depending on the type of fixation.

The anterior intermeniscal ligament of the knee. An anatomic study.

The purpose of this study was to identify the presence of the anterior intermeniscal ligament of the knee and to study its attachment patterns and relationships to other anatomic structures within the knee. Fifty unpaired cadaveric knees were dissected. An identifiably distinct anterior intermeniscal ligament was found in 47 specimens (94%). The average length was 33 mm and the average midsubstance width was 3.3 mm. The average perpendicular distance from the anterior intermeniscal ligament to the anterior margin of the tibial insertion of the anterior cruciate ligament was 7.8 mm (range, 2.0 to 13.5). The anterior intermeniscal ligament was the primary attachment for the anterior horn of the medial meniscus in 12 knees (24%); 7 knees (14%) had no tibial insertion and 5 knees (10%) had only a fine fascial tibial connection. Successful arthroscopic evaluation, surgical repair, and meniscal allograft reconstruction can be enhanced by a precise knowledge of the anterior intermeniscal ligament anatomy, especially when identifying the various insertion patterns of the anterior horn of the medial meniscus. A correct understanding of these patterns is helpful for avoiding patient injury during surgical procedures (particularly arthroscopic ACL reconstructions) performed in close proximity to the anterior intermeniscal ligament of the knee.

Gadolinium-enhanced breathhold three-dimensional time-of-flight renal MR angiography in the evaluation of potential renal donors.

PURPOSE: To evaluate the utility of gadolinium-enhanced three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) of the renal arteries in the evaluation of potential renal donors. MATERIALS AND METHODS: Fifty consecutive patients underwent gadolinium-enhanced 3D-TOF MRA of the renal arteries as part of their evaluation as possible renal donors. All imaging was performed on a 1.5-T system with use of a torso phased-array coil. Conventional T1-weighted axial spin-echo and T2-weighted axial fast spin-echo imaging was performed to evaluate the renal parenchyma. Coronal dynamic MRA was performed during bolus injection of 40 mL of gadolinium with use of a 3D-TOF sequence requiring a breathhold of approximately 30 seconds. Maximum-intensity-projection reconstructions were obtained of the renal arterial and venous anatomy. All studies were prospectively evaluated by a single radiologist experienced with body MRA. Intraoperative findings were used as the reference standard in 35 patients. To evaluate interobserver variability, each examination was evaluated for image quality, renal artery number, and anatomy by two radiologists experienced with MRA and blinded to the other's interpretations and surgical results. RESULTS: Ninety-eight percent of all MRAs were graded as diagnostic quality (Kappa value = 0.38; P < .05). Multiple renal arteries were identified in 29 (29%) of 100 kidneys. Four of 50 patients studied (8%) had renal parenchymal abnormalities identified with MR imaging. Sensitivity and specificity for accessory renal artery detection was 71% and 95%, respectively. Overall, accuracy for MRA in determining renal artery number was 90%. CONCLUSION: Gadolinium-enhanced breathhold 3D-TOF renal MRA is sufficient to assess the renal arteries in potential donors.

Splenectomy in high-risk patients with splenomegaly.

BACKGROUND: Splenectomy in patients with massive splenomegaly and hematologic malignancy results in higher morbidity and mortality with primarily palliative benefit. METHODS: From a 14-year experience with 172 splenectomies, the perioperative course of 39 high-risk patients with splenomegaly was reviewed for comorbidities, indications, complications, and mortality. RESULTS: Twenty-three males and 16 females with a mean age of 54.2 years and a mean 12.8-day postoperative length of stay were reviewed. Sixteen patients (41%) had 23 major complications related to age (P = 0.047) and operative time (P = 0.01). Intraoperative transfusion was related to splenic size (P = 0.04), and estimated blood loss (P = 0.02) was inversely related to use of splenic artery preligation. Three perioperative deaths were secondary to sepsis and multi-organ system failure. CONCLUSION: Splenomegaly and comorbidities of the primary disease result in higher morbidity and mortality. Splenic artery preligation is valuable to limit intraoperative blood loss and facilitate splenectomy.

Long-term cytokine alterations following allogeneic blood transfusion.

BACKGROUND: Allogeneic blood transfusion is associated with an increased risk of infection and higher cancer recurrence rates. Previous research has shown that blood transfusion results in multiple immune effects, including cytokine alterations. The purpose of this study was to measure the long term kinetics of splenocyte cytokine production in transfused mice. METHODS: Balb/c mice received either syngeneic transfusion (Syn-BT) or allogeneic transfusion (Allo-BT) from C3H-HeN mice. Splenocyte production of IL-2, IL-6, IL-10, and IFN-gamma was quantitated by ELISA on post-transfusion days 5, 10, 21, and 30. RESULTS: Both Allo-BT and Syn-BT produced significant alterations in cytokine production, but Allo-BT produced the most dramatic and enduring effects as summarized: IL-2: Production of IL-2 was suppressed at day 5, (p < 0.0001), but then rose, peaking at day 21, 30% greater than control values (p < 0.05). IL-6: Allo-BT mice showed suppression of IL-6 throughout the study period (p < 0.005 vs controls, each time point). IL-10: A 5-fold increase in IL-10 production was seen at day 5 after Allo-BT (p < 0.0001 vs control). Production of IL-10 was suppressed at days 10 and 21 (p < 0.001), but returned to control levels by day 30, gamma-IFN: At day 5 post Allo-BT, gamma-IFN was 4 x greater than controls (p < 0.0001). Gamma-IFN production was suppressed at day 10, but then rose at days 21 and 30 to nearly 3 x control levels (p < 0.0001). CONCLUSION: Allo-BT produced multiple cytokine alterations that were of prolonged duration. These results provide a theoretic explanation for the multiple, long-term immunomodulating effects seen in patients who have received transfusions.

Distinct effects of allogeneic blood transfusion on splenocyte cytokine production after hemorrhagic shock.

UNLABELLED: Allogeneic blood transfusion is known to be immunosuppressive in the settings of cancer and transplantation, but the contribution of blood transfusion to immunomodulation after hemorrhage is unknown. Our purpose was to determine the influence of allogeneic blood transfusion upon cytokine profiles following hemorrhagic shock, using a model which approximates the clinical setting. METHODS: Male C3H/HeN mice were hemorrhaged via femoral arterial catheters to a mean arterial pressure (MAP) of 35 +/- 5 mm Hg, which was maintained for 1 h. Mice were resuscitated with autologous blood (auto BT) or allogeneic blood (allo BT) from Balb/c mice (both equivalent to volume of shed blood), and crystalloid (2X the volume of shed blood)-infused at 0.05 ml/min. Animals were sacrificed at 1, 2, and 5 days postshock, and splenocytes were cultured for 24 h with anti-CD3 antibody. Supernatants were assayed for IL-2, IL-6, IL-10, and gamma-IFN by ELISA. RESULTS: Regardless of transfusion status, hemorrhagic shock resulted in increased IL-6 and gamma-IFN by Day 2 postshock. Distinct cytokine alterations after allogeneic transfusion were as follows. IL-2: transient elevation of splenocyte IL-2 production in the shock + allo BT group (P < 0.005 vs. shock + auto BT) at Postshock Day 2. IL-6: suppression in IL-6 production in the shock + allo BT group by Postshock Day 5 (P < 0.05 vs. shock + auto BT). IL-10: persistently elevated IL-10 production following shock + allo BT (Day 1, P < 0.001 vs. shock + auto BT; Day 5; P < 0.05 vs. shock + auto BT). gamma-IFN: elevation in gamma-IFN production by Day 5 in the shock + allo BT group (P < 0.0005 vs. shock + auto BT). CONCLUSIONS: Allogeneic blood transfusion results in distinct alterations in splenocyte production of IL-2, IL-6, IL-10, and gamma-IFN after hemorrhagic shock. This model reflects the clinical usage of blood products and demonstrates some of the immune alterations after transfusion.

Stereotactic core needle biopsy and the workup of mammographic breast lesions.

OBJECTIVE: To evaluate the influence of stereotactic core needle biopsy (SCNB) as an alternative to wire localization biopsy (WLB) on the evaluation and workup of nonpalpable mammographic lesions. DESIGN: A 4-year retrospective clinical review. SETTING: University hospital and clinics. PATIENTS: All patients evaluated for nonpalpable mammographic lesions after screening, diagnostic mammography, or both during the 4-year period of the study were included. OUTCOME PARAMETERS: Changes in the number and types of mammograms and diagnostic biopsies and the histologic findings using each technique (SCNB vs WLB), including total number of cancers diagnosed. RESULTS: The number of screening mammograms and WLBs performed remained constant compared with a marked increase in the number of diagnostic mammograms and SCNBs. The rates of positive findings for each biopsy technique were consistent while the total number of cancers diagnosed increased dramatically. The percentage of biopsy specimens with positive results (ductal carcinoma in situ and invasive cancers) for SCNB was 13.3% compared with 26.2% for WLB specimens. There has also been an increase in the number of cancers found, from 22 in the first year to 54 in the fourth year. In the first year, 45% of these cancers were diagnosed by SCNB; in the fourth year, 83% of the cancers were diagnosed by SCNB. CONCLUSION: Stereotactic core needle biopsy has replaced WLB as the standard for the diagnostic biopsy of suspicious, nonpalpable mammographic lesions. Since adopting this technique, more patients have been examined and their conditions diagnosed as breast cancer in an efficient, cost-effective manner.

Organ donors and nondonors. An American dilemma.

The principal motive for organ donation in the United States remains altruism. Surveys suggest that if the life-threatening and critical shortage of cadaveric donor organs were appropriately understood by the public, an altruistic response would lead to increased donation. However, despite intense educational efforts appealing to altruism, cadaveric organ donation has not increased substantially while the number of patients in need of a life-saving organ has grown markedly. To understand why organ donation has not increased, a telephone survey and focus group sessions of volunteers who were either for or against donation (donors and nondonors, respectively) were reviewed. The focus group nondonors demonstrated a remarkable lack of trust in the fairness of organ allocation and in the success of transplantation; indeed, this mistrust extended to the entire medical profession. The donors in the focus groups, on the other hand, believed that the system worked equitably, although their knowledge about organ donation and transplantation was equivalent to that of nondonors. For organ donation to increase, efforts must be directed toward those who are not convinced that donation is for the common welfare. One way to increase organ donation is for physicians to educate their patients better regarding the equity and success of transplantation.

Influence of allogeneic blood transfusion on natural killer cell activity in burn-injured mice.

Allogeneic blood transfusion (Allo/BT) and burn injury modify the cellular immune response in patients under a variety of circumstances. We designed this study to investigate the influence of Allo/BT, burn injury, and the combination of the two on in vivo natural killer (NK) cell activity in a murine model. This study demonstrated significant enhancement of in vivo NK cell activity in noninjured BALB/c mice receiving Allo/BT from C3H mice when compared to both the control and syngeneic blood transfusion group at posttransfusion day 5. When burn-injured mice were compared to sham-stressed mice, the burn-injured mice showed significant suppression of in vivo NK cell activity. Furthermore, in this strain combination model, Allo/BT modulated the suppressive effect of burn injury on in vivo NK cell activity at posttransfusion day 5 and postburn day 7.

Magnetic resonance imaging characteristics of a lead pencil foreign body in the hand.

Foreign body detection and removal from the hand can present a challenging problem for the hand surgeon. Imaging studies often are of little help and may even be misleading regarding the size and location of the object. This article reports imaging techniques used in the detection of foreign bodies and presents a case in which magnetic resonance imaging was used to localize a lead-pencil foreign body in the hand prior to surgical removal. We also present the results of magnetic resonance imaging analysis of several lead pencils, showing a similar signal that indicates that iron and magnesium were responsible for the artifact seen on the magnetic resonance image.

Thrombotic thrombocytopenic purpura: indications for and results of splenectomy.

BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening disorder of unknown pathophysiology. The role of splenectomy in the multimodality therapy of TTP is controversial. MATERIALS AND METHODS: All charts of patients with TTP at the University of Utah between 1984 and 1994 were reviewed to evaluate various treatment regimens, and specifically, the impact of splenectomy on morbidity and survival. RESULTS: Of the 15 patients identified, 14 underwent initial treatment with plasmapheresis and steroids. Nine patients were treated with medical therapy only, 6 of whom completely recovered, while 3 patients died. Six patients failed plasmapheresis and underwent splenectomy. There were no operative complications or postoperative deaths. All surgical patients had no active disease at last follow-up. CONCLUSION: Plasmapheresis and steroid administration remain the first-line therapy for TTP. This series documents that splenectomy offers excellent results with minimal morbidity and mortality in patients who do not respond to or who relapse after plasmapheresis.

Selective use of image-guided large-core needle biopsy of the breast: accuracy and cost-effectiveness.

OBJECTIVE: We examined the accuracy and cost-effectiveness of large-core needle breast biopsy in a selected group of patients with mammographically detected lesions. MATERIALS AND METHODS: We selectively used large-core needle biopsy to sample breast lesions that were intermediate (neither clearly benign nor clearly malignant) and wire localization biopsy to sample breast lesions that were strongly suggestive of cancer. We compared 2 years' experience using this protocol with the preceding 2 years at the University of Utah Health Sciences Center during which we did only a few large-core needle biopsies on a nonselective basis. RESULTS: Our biopsy rate increased from one biopsy per 36 mammographic screening examinations to one per 26 (p = .001) when the protocol was used. The cost of biopsy per cancer detected decreased from $11,555 to $8356. The specificity of large-core needle biopsy was 98%; the sensitivity based on limited follow-up was 100%. CONCLUSION: Large-core needle biopsy is an accurate and cost-effective method for sampling breast lesions when used in a selective fashion.

The effects of oral pentoxifylline on the cytokine release syndrome during inductive OKT3.

The cytokine release syndrome (CRS) accompanying OKT3 therapy is a major cause of posttransplant morbidity. The pathogenesis of this syndrome has been attributed to the synthesis of tumor necrosis factor, interleukin 2 (IL-2), interleukin 6 (IL-6), and gamma-interferon in response on T lymphocyte stimulation by OKT3. The hemorrheologic agent pentoxifylline (PTX) inhibits the synthesis of TNF alpha in vitro in response to a variety of stimuli, including OKT3. We performed a randomized, double-blinded trial of PTX during OKT3 induction in recipients of cadaveric renal allografts. Patients received either PTX 800 mg or placebo 2 hr before the initial dose of OKT3 and every 8 hr thereafter during the first 3 posttransplant days. Serum TNF alpha and IL-6 concentrations were measured pre-OKT3 and at 2 and 6 hr post-OKT3 on the first 3 posttransplant days. Despite the achievement of apparently adequate plasma levels of PTX and its active metabolites, no difference was observed in the incidence or severity of clinical manifestations of CRS. Serious manifestations of CRS--including acute pulmonary edema, encephalopathy, and aseptic meningitis--were not seen in either group. Serum TNF alpha and IL-6 concentrations were similar in PTX and control patients throughout the course of the study. Plasma levels of PTX and its active metabolites did not correlate with serum TNF alpha levels, serum IL-6 levels, or the incidence and severity of clinical manifestations of CRS.

Torque required to loosen single-tooth implant abutment screws before and after simulated function.

The amount of torque required to loosen screws from three different antirotational screw-retained abutment/implant combinations was compared (with and without adhesive sealant applied) after 6 kg of force was applied during simulated intraoral movements. Movements were generated over two simulated time periods, representing 1 and 6 months. There was no significant decrease (alpha < .05) in the torque required to loosen the screws after either time period when using Calcitek Omnilock or Stryker Minimatic. The Core-Vent Bio-Vent specimens, however, exhibited a significant decrease (alpha < .05) in the amount of torque required to loosen the screws at the 1-month test period only. The addition of adhesive sealant significantly increased (alpha < .05) the amount of torque necessary to loosen the screws only in the Core-Vent specimens.

Sexual self-defense versus the liaison dangereuse: a strategy for AIDS prevention in the '90s.

The present public health strategy to encourage the adoption of "safe sex" practices to contain the AIDS epidemic in America is incomplete. Current policy is responsive to and appropriate for control of homosexual, but not heterosexual transmission. Powerful societal forces restrict a woman's perception of risk. Consequently, the adoption of safe sex (condom use/insistence on use) by women at risk has not matched safe sex practice by homosexual men. Predictably, pattern two (heterosexual, maternal-fetal) HIV transmission is now rapidly increasing in the United States, particularly among minority women. In anticipation of an intensified pattern two subepidemic, AIDS containment policy should be reoriented to develop the role of women in AIDS prevention. An initiative, termed "sexual self-defense" (SSD), combines the technology of double-barrier (female irrespective of male) protection with a "universal precautions" approach to long-term sexual risk management. The initiative addresses both per-contact infectiousness and new partner acquisition, the principal determinants of HIV spread. As a female-targeted strategy, SSD is a timely supplement to existing programs, consistent with the direction of contemporary women's movements in the United States. A "street smart" approach, SSD bridges ethnic and socioeconomic individual differences. As a unifying philosophy of risk management in health promotion, SSD may avert the threatened fragmentation of AIDS control from existing programs of sexually transmitted disease control and teenage pregnancy prevention.

PIP: Current efforts to control the spread of AIDS in the US are lacking for a variety of reasons. Pattern 1 male homosexual transmission has seen a significant drop because of education and prevention campaigns within the gay community. Pattern 2 heterosexual/maternal-fetal transmission has seen a significant increase because of a lack of effective programs to directly address this particular subepidemic. The AIDS deaths for women 15-44 have increased 75% over 3 years. Neonatal infection rates of 1.0-2.4% are common in metropolitan hospitals. The best method of serving this need is the sexual self-defense(SSD) concept. This program incorporates changing heterosexual women's attitudes an perceptions about risk, and changing their behavior so that they universally use double barrier protection for all sexual activity. Double barrier protection includes condoms and spermicides like nonoxynol-9. The biggest obstacle has been a failure by women to see their risk factor properly. Another problem has been the Bush administration's failure to properly frame the problem. The Presidential Commission on The Human Immunodeficiency Virus lists hemophiliacs over bisexuals an IV drug users as risk groups. Studies has shown that 50% of HIV-infected women attending family planning clinics do not associate their sexual behavior with high risk. Thus voluntary testing for HIV could be missing 50% of the infected women because they do not consider themselves at risk and thus do not get tested. Another problem stems from the fact that condom use is very low in primary relationships. Men may use condoms when they see prostitutes, but will not use them with their girlfriend. This behavior exemplifies the misperception of risk. Just as the defensive driving program got people to drive safely, SSD must get people to have sex safely. It is the responsibility of the government to educate the people about SSD, just as the surgeon general educated people about the risks of smoking in 1964.

Improving the use of early follow-up care after emergency department visits. A randomized trial.

OBJECTIVE: To test the hypothesis that the appropriateness of parents' use of early follow-up care after emergency department (ED) visits can be improved by postvisit support from a nurse practitioner. DESIGN: Randomized controlled trial, single blinded. SETTING: Urban university hospital ED linked to hospital's primary care center. PARTICIPANTS: Parents of 190 children younger than 8 years who sought care in the ED for acute illnesses and who were treated as outpatients with primary care center follow-up at the discretion of ED clinicians. INTERVENTION: Parents in the experimental group were called by a nurse practitioner who offered both individualized guidance regarding follow-up and access to a nurse practitioner for further help as needed. The control group received "usual" follow-up advice during ED visits. MEASUREMENTS/MAIN RESULTS: In the week after the ED visits, parents in the experimental group, compared with parents in the control group, were more compliant with instructions regarding follow-up (79% vs 61%), less apt to miss appointments (15% vs 31%), and less apt to "shop" elsewhere for care (2% vs 9%). Appropriateness of follow-up was assessed in "blinded" fashion using preestablished guidelines. Inappropriate use of follow-up care was significantly reduced among experimental group subjects (10% vs 20%). CONCLUSION: The nurse practitioner's intervention improved parents' use of follow-up care in our sample. Overall care for episodic ED users might be improved by similar interventions.