Pediatric vaccination appointment scheduling: experience from an Italian clinic

Issue/problem

Since 2012 pediatric vaccination coverages in Italy have been decreasing. Negative trends have been recorded especially for hexavalent and MMR vaccines. In mid-2017 the Italian government passed an act making ten vaccines compulsory. Most recent data show the act is working, however other aspects of the process should be improved.

Description of the problem

Parents are invited to bring their children to the clinic through letters or telephone calls. Vaccination appointments are scheduled during weekdays, either in the morning, the afternoon, or both. Each session is carried out by a physician and a nurse, with a new patient scheduled every ten minutes. Appointments and vaccinations are registered on the vaccine-specific electronic health record (SISPC).

Results

In March 2019, the vaccination clinic worked 21 days for a total of 29 sessions. 823 appointments were available, 797 of them (96.8%) had a patient scheduled before the session started. 547 (68.6%) attended the vaccination appointment, 98.4% of them were vaccinated (538, 67.5% of the total patients scheduled). Among those who did not attend the scheduled appointment, only 108 (43.2%) agreed to reschedule. Eventually, only 58.3% of these patients attended the rescheduled appointment. No statistically significant differences among those who attended and those who did not attend the appointment were found among the variables retrieved from SISPC: day, time, vaccination planned (type, and if mandatory or not), sex, age.

Lessons

A third of available vaccination appointments in our clinic were lost. Despite the ease through which patients can reschedule an appointment, many choose not to and left their appointments unattended. Although missing a vaccination appointment can be appropriate - e.g. when the child is sick - and great effort should be put to achieve the goal of improving coverages, policymakers should also consider provisions to discourage such behaviors for a better use of resources.

Key messages

A third of available vaccination appointments in our clinic were lost in a month. Keeping in mind the goal of improving coverages, policymakers should aim for the best possible use of resources.

Investigating sperm cryopreservation in a model tunicate, Ciona intestinalis sp. A

In cryopreservation procedures, the capacity to protect the cells from freezing and thawing processes is sensitive to the choice of the cryoprotective agent (CPA) and to its optimal concentration. The advancement of research on Tunicate model species has raised interest in liquid nitrogen cryopreservation for the storage and distribution of genetic resources. Ciona intestinalis (Linnè, 1767) consists of a complex of cryptic taxa that are central to several areas of investigation, from comparative genomics to invasive biology. Here we investigated how five CPAs, three chilling rates and two freezing rates influence semen cryopreservation in C. intestinalis sp. A. By using larval morphology and motility as endpoints, we estimated that long term semen storage requires 10% dimethyl sulfoxide as a protective agent, -1°C/min chilling rate (18°C to 5°C) and -13°C/min freezing rate (5°C to -80°C), followed by immersion in liquid nitrogen.

GnRH Agonist Treatment before Total Laparoscopic Hysterectomy for Large Uteri

STUDY OBJECTIVE

To evaluate whether uterine shrinkage induced by gonadotropin-releasing hormone (GnRH) agonists in women with a large uterus (>14 wks) may facilitate total laparoscopic hysterectomy.

DESIGN

Randomized, prospective study (Canadian Task Force classification I).

SETTING

University-affiliated hospital.

PATIENTS

Sixty-two women with symptomatic uterine myomas (size 16-20 wks).

INTERVENTIONS

Total laparoscopic hysterectomy for benign pathology.

MEASUREMENTS AND MAIN RESULTS

Before surgery, women were assigned, at a ratio of 1:1 by random selection, to receive injections of triptorelin depot 11.25 mg 3 months before surgery (group A) or no treatment (group B). Uterine volume, mean operating time, uterine weight, drop in hemoglobin, intraoperative complications, conversions to laparotomy, and hospital stay were recorded. Triptorelin decreased uterine volume, calculated by ultrasonography, by 26.5% in group A, whereas the volume remained unchanged in group B. Statistical differences were found between groups concerning uterine weight, operating time, and drop in hemoglobin level. Three patients in group B were converted to laparotomy because of uterine size.

CONCLUSION

In women with a large uterus, a 3-month preoperative course of GnRH may facilitate laparoscopic hysterectomy, decreasing uterine size, operating time, and blood loss.

Primary ovarian leiomyosarcoma as a new component in the nevoid basal cell carcinoma syndrome: a case report

The case of primary leiomyosarcoma of the ovary in a 20-year-old Italian woman with nevoid basal cell carcinoma syndrome (NBCC) is described. This report first shows the association of ovarian leiomyosarcoma with NBCC, expanding the complex nature of this syndrome.

Laparoscopic myomectomy for fibroids penetrating the uterine cavity: is it a safe procedure?

OBJECTIVE

The purpose of the study was to evaluate the post-operative course and follow up of women who had undergone laparoscopic removal of intramural fibroids penetrating the uterine cavity.

DESIGN

Retrospective study.

SETTING

Center for Reconstructive Pelvic Endosurgery, Italy.

POPULATION

Thirty-four women with fibroids penetrating the uterine cavity.

METHODS

Laparoscopic myomectomy.

MAIN OUTCOME MEASURES

Feasibility and safety of surgical technique, length of operation, blood loss, intra- or post-operative complications, length of hospital stay, resolution of symptoms and future obstetric outcome.

RESULTS

The mean operative time was 79 (SD 30) minutes; the mean reduction in haemoglobin was 1.1 +/- 0.9 g/dL. No intra- or post-operative complications were observed. The average post-operative stay in hospital was 54 (SD 22) hours. Nineteen (73%) out of 26 patients who had experienced symptoms prior to surgery reported resolution of these symptoms post-operatively. All patients resumed work within a mean time of 20 (SD 8) days. Among 23 of the 32 patients attempting pregnancy during the follow up period, nine (39%) conceived within one year. Seven pregnancies went to term without complications.

CONCLUSIONS

The clinical results of this study suggest that laparoscopic myomectomy for intramural fibroids penetrating the uterine cavity is a safe procedure, providing well known advantages of minimal access surgery.

Low-dose flutamide (125 mg/day) as maintenance therapy in the treatment of hirsutism

OBJECTIVE

To evaluate the safety and efficacy of a low dose of flutamide (125 mg/day) in maintaining the clinical results already obtained using a higher dose (250 mg/day), in women suffering from hirsutism.

METHOD

Forty-three women suffering from hirsutism of varying origin received 250 mg/day of flutamide as an initial treatment for 12 months and, subsequently, 125 mg/day of flutamide for an additional 12 months as a maintenance treatment. Hirsutism was evaluated by the Ferriman-Gallwey score, and hair diameter and hair growth rate were determined by a special image analysis processor. Biochemical, clinical and hormonal parameters were evaluated in basal conditions and every 2-6 months.

RESULTS

The significant decrease in the hirsutism score, hair diameter and hair growth rate during the initial treatment period was confirmed at the end of the maintenance treatment period. Androgen levels decreased up to the end of the initial treatment period and partially decreased during the maintenance treatment. During the initial treatment period, 4 subjects showed an increase of aspartate aminotransferase and alanine aminotransferase and dropped out. During the maintenance treatment period, no side effects or complications were observed.

CONCLUSION

Satisfactory management of hirsutism with flutamide seems to be represented by an initial treatment period using 250 mg/day to achieve satisfactory results, followed by a long maintenance treatment period using 125 mg/day.

Fertility and tumor recurrence rate after conservative laparoscopic management of young women with early-stage borderline ovarian tumors

OBJECTIVE

To evaluate the efficacy of laparoscopic conservative surgery in young women with borderline ovarian tumors who want to preserve their childbearing potential, and to assess whether pregnancy influences the recurrence rate during the follow-up evaluation period.

DESIGN

Retrospective study.

SETTING

Center for Reconstructive Pelvic Endosurgery, Reproductive Medicine Unit, S. Orsola Hospital, University of Bologna, Italy.

PATIENT(S)

Nineteen women (mean age 27.4 +/- 4.7) with borderline ovarian tumors who underwent laparoscopy between January 1995 and January 1998. All of the women wanted to preserve their fertility.

INTERVENTION(S)

A standardized conservative laparoscopic approach and a strict follow-up schedule.

MAIN OUTCOME MEASURE(S)

A complete preoperative examination.

RESULT(S)

Follow-up evaluations (mean 42 +/- 19 months) were made available to all patients. Among 19 patients, 10 attempted pregnancy and 6 conceived spontaneously. All six pregnancies went to term and the disease did not affect the gestation or the follow-up period after the pregnancy (24.5 +/- 15.7 months).

CONCLUSION(S)

Conservative laparoscopic management of borderline ovarian tumors is a potentially safe alternative in young women who want to retain their childbearing potential. Fertility and pregnancy outcome remain excellent in these women. Our preliminary data seem to indicate that the recurrence rate after pregnancy is not influenced by this approach.

Conservative treatment of recurrent ovarian fibromas in a young patient affected by Gorlin syndrome

The case of recurrent bilateral ovarian fibromas occurring in a 22 year old Italian girl affected by Gorlin syndrome is reported. Ovarian fibromas occur in 75% of female patients with Gorlin syndrome and their recurrence has rarely been reported in the literature. Management is guided by the benign nature of the lesion and consists of surgical removal of the fibroma. Preservation of the normal ovarian tissue is recommended even though there is risk of recurrence of the fibroma.

A prospective randomized trial comparing low dose flutamide, finasteride, ketoconazole, and cyproterone acetate-estrogen regimens in the treatment of hirsutism

Sixty-six hirsute women were randomized and treated with 1) flutamide (n = 15), 250 mg/day; 2) finasteride (n = 15), 5 mg/day; 3) ketoconazole (n = 16), 300 mg/day; and 4) ethinyl estradiol (EE)-cyproterone acetate (CPA; n = 20), 0.01 mg EE/day for the first week, 0.02 mg EE/day for the second week, and 0.01 mg EE/day for the third week, followed by a pause of 7 days, then 12.5 mg CPA/day added during the first 10 days of every month for 12 months. Hirsutism was evaluated by the Ferriman-Gallwey score, and hair diameter and hair growth rate were determined by a special image analysis processor in basal conditions and after 90, 180, 270, and 360 days of treatment. All treatments produced a significant decrease in the hirsutism score, hair diameter, and daily hair growth rate: flutamide, -55 +/- 13%, -21 +/- 14%, and -37 +/- 18%; finasteride, -44 +/- 13%, -16 +/- 12%, and -27 +/- 14%; ketoconazole, -53 +/- 18%, -14 +/- 12%, and -30 +/- 21%; and EE-CPA, -60 +/- 18%, -20 +/- 11%, and -28 +/- 21%. Some differences existed among treatments with regard to effectiveness; EE-CPA and flutamide seem to be the most efficacious in improving hirsutism. For the hirsutism score, a greater decrease was seen with EE-CPA (-60 +/- 18%) than with finasteride (-44 +/- 13%; P < 0.01) and a greater decrease was seen with flutamide (-58 +/- 18%) than with finasteride (-44 +/- 13%; P < 0.05). Flutamide is the fastest in decreasing hair diameter; EE-CPA is the fastest in slowing down hair growth, even though at the end of the treatment there was a significant difference between flutamide and finasteride only (-41 +/- 18% vs. -27 +/- 14%; P < 0.05). Flutamide, ketoconazole, and EE-CPA induced a significant decrease in total and free testosterone, 5alpha-dihydrotestosterone, dehydroepiandrosterone, dehydroepiandrosterone sulfate, and androstenedione plasma levels. During the EE-CPA treatment, gonadotropins were suppressed, and the sex hormone-binding globulin level increased. Finasteride induced a decrease in dehydroepiandrosterone sulfate and 5alpha-dihydrotestosterone and an increase in testosterone levels. Very few side-effects were observed during treatment with low doses of flutamide, EE-CPA, and particularly finasteride. Flutamide induced a decrease whereas EE-CPA induced an increase in triglycerides and cholesterol, showing higher values within the normal range. Ketoconazole induced several side-effects and complications, and several people dropped out of the study. Despite different modalities of action and significantly different effects on androgen levels, low doses of flutamide, finasteride, and EE-CPA constitute very satisfactory alternative therapeutic regimens in the treatment of hirsutism.

Contraceptive and therapeutic effectiveness of two low-dose ethinylestradiol and cyproterone acetate regimens in the treatment of hirsute patients

OBJECTIVE

To compare the effectiveness of two very low-dose ethinylestradiol and cyproterone acetate regimens in the treatment of hirsutism.

PATIENTS

Eighteen hirsute women were randomized into two different regimens of cyproterone acetate and ethinylestradiol in a reverse sequential pattern: group 1 (0.28 mg ethinylestradiol monthly), group 2 (0.32 mg ethinylestradiol monthly). Both groups received 12.5 mg/day cyproterone acetate for the first 10 days of treatment each month.

MAIN OUTCOME MEASURES

Hirsutism scores were measured according to the Ferriman and Gallwey scoring system and side-effects and complications were recorded during the 6 months of therapy. Ovulation was monitored by radioimmunoassay of estradiol, follicle stimulating hormone (FSH), luteinizing hormone (LH) and progesterone levels. The pituitary response was studied using a gonadotropin releasing hormone test.

RESULTS

Hirsutism scores decreased significantly in both groups at the end of the 6 months (-30%). All patients were anovulatory, as documented by the reduction of the LH, FSH, estradiol and progesterone levels. Pretreatment basal LH and FSH levels were higher than LH and FSH levels during the treatment. Side-effects were observed only occasionally with some differences between the two therapeutic regiments.

CONCLUSION

Both treatments greatly improve hirsutism, reduce clinical problems and side-effects, guarantee both anovulation and contraceptive effectiveness and afford an optimal control of the menstrual cycle.