The effect of a combined influenza/pneumococcal immunization reminder letter.

BACKGROUND: The effect of a combined influenza and pneumococcal immunization reminder letter on increasing influenza and pneumococcal immunization rates, and the timeliness of receiving immunizations after receipt of a reminder letter, have not been examined. This study addresses these issues using a sample of new Medicare beneficiaries residing in Hawaii. METHODS: Newly enrolled Medicare beneficiaries in Hawaii from 25 September 1995 through 31 August 1996 were randomly assigned to one of three groups: Group 1, no letter (n=2144); Group 2, influenza immunization reminder letter only (n=2213); or Group 3, pneumococcal and influenza immunization reminder letter (n=2171). Health Care Financing Administration claims data were compared among groups. RESULTS: In Group 3, the influenza immunization rate increased 3.8 percentage points (n=87; p=0.017) compared with Group 1. The Group 3 pneumococcal immunization rate increased 3.5 percentage points (n=78; p<0.001) compared to Group 1 and 4.0 percentage points (n=86; p<0.001) compared to Group 2. Sixty-six beneficiaries in Group 3 received simultaneous pneumococcal and influenza immunizations, a significant difference compared to Group 1 or Group 2. Increases in immunizations were observed immediately following the reminder letters and the effect persisted for 5 to 7 weeks. CONCLUSIONS: The combination letter increased both influenza and pneumococcal immunization rates and the simultaneous administration of immunizations without detrimental effect to influenza immunization rates. A combined reminder letter is inexpensive and recommended as part of a multicomponent campaign for adult immunization.

Gastric foreign bodies: no longer a cross to bear.

Flexible video gastroscopy can be combined with laparoscopic techniques to aid extraction of difficult gastric foreign bodies. A case is presented describing this technique.

Transcystic biliary decompression after direct laparoscopic exploration of the common bile duct.

BACKGROUND: A purpose-designed transcystic common bile duct (CBD) decompression cannula is described for use as an alternative to T-tube insertion following laparoscopic direct CBD exploration. This permits safe primary closure of the choledochotomy. METHODS: Following direct supraduodenal laparoscopic clearance of large common bile duct stones, the biliary decompression cannula is inserted percutaneously inside its peel-away sheet over a guide-wire into the CBD via the cystic duct. When in place, the cannula is secured to the cystic duct by two catgut extracorporeal Roeder knots and the choledochotomy is then closed. The terminal multiperforated S-shaped segment of the Cuschieri biliary decompression cannula prevents postoperative dislodgement. RESULTS: Transcystic decompression of the extrahepatic biliary tract using the Cuschieri cannula has been used in 12 patients who underwent laparoscopic supraduodenal CBD exploration for large or occluding stones. There was no instance of postoperative dislodgement of the cannula and all patients had effective drainage of the common bile duct (average 300 ml bile per 24 h). The procedure was uncomplicated in all but one patient who developed self-limiting leakage from the CBD suture line in the early postoperative period. The median hospital stay after surgery was 4 days, with a range of 3 to 10 days. The cystic duct decompression cannula was capped and sealed under an occlusive dressing at the time of discharge. Removal of the cannula was carried out without any complications as a day case 11-16 days after surgery. CONCLUSIONS: Transcystic biliary decompression is safe and effective. The experience with is use indicates that compared to T-tube drainage, transcystic decompression may accelerate recovery and reduce the hospital stay in patients following laparoscopic direct exploration of the CBD. Its insertion is less technically demanding than placing a T-tube through the choledochotomy. Transcystic decompression with complete primary closure of the CBD realizes the full benefits of the single-stage management of common bile duct calculi and permits confirmation of complete stone clearance after surgery.

Laparoscopy: the ultimate diagnostic tool for a bleeding Meckel's diverticulum.

Laparoscopy is useful in the diagnosis and treatment of a complicated Meckel's diverticulum. A case is presented describing the technique.

Thoracoscopic management of thoracic duct injury.

Thoracotomy has long been the conventional surgical approach in dealing with chylothorax due to thoracic duct injury which has been refractory to conservative treatment. The development of thoracoscopic access provides an alternative means of dealing with thoracic duct injuries thereby reducing the morbidity from thoracotomy and prolonged chylous leak. It will encourage earlier intervention in thoracic duct injury.

Comparison of direct vision and electronic two- and three-dimensional display systems on surgical task efficiency in endoscopic surgery.

Task efficiency and knot strength was evaluated under standardized conditions using direct vision and electronic imaging with two-dimensional (2-D) and three-dimensional (3-D) systems. Three operators with different endoscopic surgical experience tied a surgeon's knot with standard endoscopic instruments using the three different visual systems in random order. Each operator tied 20 knots with each visual system. Median task efficiency (defined as the time to complete the knot) was 35.0 (interquartile range (i.q.r.) 30.3-43.8) s for direct vision and 53.0 (i.q.r. 45.3-62.8) s and 53.5 (i.q.r. 45.0-64.8) s for 2-D and 3-D imaging respectively (P < 0.05). With respect to direct vision, this represented an overall degradation of task efficiency with the use of electronic imaging of 52 per cent, with no detectable difference between 2-D and 3-D imaging. The knot strength, representing the degree of tightening, was weaker with electronic imaging but the difference was not significant due largely to variation between the three operators.

Hepatic cryotherapy for liver tumors. Development and clinical evaluation of a high-efficiency insulated multineedle probe system for open and laparoscopic use.

A high-efficiency hepatic cryosurgical unit has been developed and evaluated. It is capable of simultaneously driving three implantable insulated cryoneedle probes. The system has been used to treat 18 patients with secondary and 4 patients with primary liver cancer: open (n = 12), total laparoscopic (n = 6), laparoscopic assisted (n = 4). In three patient laparoscopic cryotherapy was repeated inside 6 months. Intraoperative bleeding was encountered in three patients undergoing high-volume hepatic freezing but the bleeding was easily controlled. A fall in the core body temperature was encountered in 10 out of 22 patients and averaged 0.4 degree C. There was one postoperative death from liver failure in an 80-year-old patient in whom a large hepatoma was frozen. The most consistent postoperative biochemical change was hyperbilirubinaemia (n = 3). A right-sided pleural effusion developed in two patients after freezing of lesions on the superior surface of the right lobe. A survival benefit was encountered in three patients, one with central cholangiocarcinoma and the other two with large solitary secondary deposits (melanoma, colon cancer). Seven patients with multiple metastases and two patients with large hepatomas developed recurrence at the frozen site or elsewhere in the liver inside 12 months of follow-up and no clinical benefit could be demonstrated by cryotherapy in this group. In nine patients, the follow-up has been too short (< 18 months) to permit any conclusion on outcome. The current limitations of hepatic cryotherapy are largely due to incomplete tumor destruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic subtotal cholecystectomy.

Laparoscopic subtotal cholecystectomy has been carried out on 5 patients during a 28-month period. The indications were severe inflammation/fibrosis in 3 patients, cirrhosis with mild portal hypertension in 1 patient and the Mirizzi syndrome in the last patient. There were no deaths and only minor in hospital morbidity. Subtotal cholecystectomy carried out laparoscopically is a safe procedure and can be used in selected patients in order to avoid conversion to an open operation.

Bilateral endoscopic splanchnicectomy through a posterior thoracoscopic approach.

The technique of bilateral total splanchnicectomy performed through a posterior thoracoscopic approach is described. The advantages of this route include excellent visual exposure of the neural anatomy of the sympathetic and avoidance of single lung anaesthesia. The procedure was performed for the relief of intractable pain in patients with advanced pancreatic cancer (n = 3) and patients suffering from chronic pancreatitis (n = 5). Persistent relief of pain until death was obtained in the patients with pancreatic cancer (2, 4, 6 months). In patients with chronic pancreatitis, the benefit to date has varied with the severity of the disease. In two patients with severe advanced disease and previous percutaneous blocks, the relief of pain lasted only 3 and 5 weeks and both patients required resection for renewed intractable pain. In three patients with minimal change disease, relief of pain has been good in the short term (maximum follow-up of 8 months). Bilateral thoracoscopic total splanchnicectomy merits further evaluation in patients with pancreatic pain. No complications including hypotension have been encountered.

A new treatment for acquired reactive perforating collagenosis.

Acquired reactive perforating collagenosis is reported in an insulin dependent diabetic patient with renal impairment, managed successfully with surgical debridement and split skin grafting. The literature on treatment of reactive perforating collagenosis is reviewed.

A new radio-opaque injection technique for tissue preservation.

This study has investigated the action of two commonly available preservatives, chlorbutol and chlorocresol, on fresh cadaver tissue. If the arterial system of the subject is perfused first with either preservative then the progression of tissue necrosis can be delayed for up to 1 month. The preservative can be combined with the lead oxide-gelatin mixture described by Rees and Taylor without compromising the results of radiographic studies. Both chlorocresol and chlorbutol have the advantage over formalin of retaining the normal colour and texture of the tissues. A regimen is suggested which has all of the advantages of the mixture originally described by Salmon, but is much simpler and cheaper to produce. It has proved successful when used in whole cadavers but the visceral contents must be removed at an early stage.

Dental consideration for the child with cleft palate.

The dentist's role in the care of the child with cleft palate involves his delivery of the examination, restorative and preventive procedures, and prosthetic, orthodontic, and orthopedic therapy. The practitioner is urged to enthusiastically and intelligently render treatment to these children to the full extent of his capabilities. It also must be remembered that because of the nature of the defect, children with clefts frequently are under demanding therapy from many specialists over their years of growth and development. We must not neglect our obligation to these individuals, but priorities must be taken into consideration for the overall best interest of the patient.