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Techniques and instrumentation for minimally invasive surgical procedures originated in gynecologic surgery, but the benefits of surgery with small incisions or no incisions at all have prompted the expansion of these techniques into numerous specialties. Technologies such as robotic assistance, single-incision laparoscopic surgery, natural orifice transluminal endoscopic surgery, and video-assisted thoracoscopic surgery have led to the continued expansion of minimally invasive surgery into new specialties. With this expansion, perioperative nurses and other members of the surgical team are required to continue to learn about new technology and instrumentation, as well as the techniques and challenges involved in using new technology, to help ensure the safety of their patients. This article explores the development of minimally invasive procedures and offers suggestions for increasing patient safety.

Routine determination of the nodal status in colon cancer is strongly dependent on the individual quality and technique of histopathological assessment and surgical lymph node dissection. We evaluated whether sentinel lymph node biopsy (SLNB) could contribute to an improvement in staging. At least one SLN (median n=2) was detected (detection rate 84%) in each of 38 of 45 patients with primary colon cancer. Ten of these 38 were found to have lymph node metastases by HE staining (26%), six of them in the SLN. Nine of the 28 patients that were initially nodal-negative by HE revealed one micrometastasis and eight cases of isolated tumor cells by immunohistochemical (IHC) staining (32% upstaging response). Including the IHC-positive cases, 19 of the 38 patients were nodal-positive (50%), 15 of them with tumor-infiltrated SLN (overall sensitivity of SLNB 79%). Using the dye method, SLNB is clinically practicable and leads in the majority of the patients to the detection of SLN. The selective, intensified histopathological assessment of SLN identifies small tumor cell deposits in a relevant percentage of patients with little and clinically practicable effort.

Chronic peritoneal dialysis (PD) can be complicated by encapsulating peritoneal sclerosis (EPS), a rare but the most severe complication associated with long-term PD. Morbidity and mortality are still high (range from 25% to 55%) especially in the first year after diagnosis. The international Society for Peritoneal Dialysis (ISPD) defined EPS by clinical signs of abdominal pain, bowel obstruction or weight loss in late stages of the disease. Clinical symptoms, radiologic findings and histologic criteria are the three diagnostic pillars.

Surgical therapy is becoming increasingly complex. Besides new surgical techniques, sophisticated diagnostic methods and innovative interventional procedures must be integrated into the therapeutic concept to increase the efficacy of surgery. Accurate application of these techniques requires close cooperation between surgeons, other medical specialists, and technicians. Consequently, there is a significant need for structures promoting efficient communication, organization, and interaction in surgical departments. New techniques developed from telecommunication and information technology enable the transferal of complex medical data at any time to any place and are therefore the basis for telemedical applications. Telemedicine and other new techniques such as virtual operation planning, simulation, and intraoperative navigation promise to increase the efficacy of surgical therapy in the future. This paper provides an overview of the applications of telesurgery and currently available techniques.

We evaluated the feasibility of the sentinel lymph node technique to refine staging and potentially individualize therapy for anal cancer. Seventeen patients with cancer of the anal canal underwent peritumoral injection of 99mTc-colloid, followed 17 hours later by lymphoscintigraphy. A selective lymph node biopsy (SLNB) was attempted in 12 of 13 cases with scintigraphically detected SLNs. Lymph node metastases were present in 5 of 12 cases (42%); in 2 of these 5 cases, micrometastases were detected only by immunohistochemical staining. Hence, SLNB refines the diagnostic workup for anal cancer and provides an accurate basis for individualized therapy.

The use of minimally invasive procedures for the management of gastrointestinal cancer is increasing. The aim of this study was to investigate the role of high-frequency miniprobe endoscopic ultrasound (EUS) for therapeutic decisions making in patients with gastric or colonic tumors.A total of 137 patients underwent EUS with a 12.5-MHz miniprobe for preoperative staging of tumors of the stomach ( n = 49) or colon ( n = 88). After resection, the surgical path was reviewed to analyze the role of preoperative staging with miniprobes.Miniprobe EUS enabled accurate assessment of the infiltration depth of gastric and colonic tumors. The overall accuracy rates were 88% and 87%, respectively. The lymph node status was predicted correctly in 82% of the patients (sensitivity, 61%, specificity, 94%). Based on the results of miniprobe EUS, patients with gastric cancer were accurately selected to undergo endoscopic mucosal resection, laparoscopic resection, or open surgery in 100%, 91%, and 86% of the cases, respectively. In patients with colonic tumors, the treatment decision analysis showed that the stratification was correct in 90% of the patients.Miniprobe EUS is a reliable method for validating treatment decisions for patients undergoing minimally invasive procedures for gastric and colonic tumors. This method is particularly valuable in the management of colon cancer, because endoscopic and laparoscopic resections can be offered to selected patients as an alternative to open surgery.

Das Konzept der Sentinel-Lymphknoten-Entnahme basiert auf der Annahme, dass es immer einen oder einige wenige Lymphknoten gibt,die aus einem Tumor freigesetzte Tumorzellen primar aufnehmen. Die Wahrscheinlichkeit, Makro- oder Mikrometastasen bzw. isolierte Tumorzellen aufzufinden, ist damit in diesem Lymphknoten am grosten. Diese Annahme setzt einen gerichteten, nicht zufallig verteilten Abstrom von Tumorzellen aus dem Tumorgewebe voraus.

Bis heute steht keine zuverlassige Methode fur die pra- bzw. intraoperative Vorhersage des Lymphknotenstatus bei Patienten mit gastrointestinalen Tumoren zur Verfugung. Nach der erfolgreichen Etablierung der Sentinel-Lymphknoten-Biopsie (SLNB) bei Melanom- und Brustkrebserkrankungen werden weiterfuhrende Untersuchungen auf diesem Gebiet nun auf gastrointestinale Tumorerkrankungen ausgedehnt. In Ubereinstimmung mit aktuellen Ergebnissen stellen Darm- und Magenkarzinome vielversprechende Entitaten fur das SLN-Konzept dar. Erste Ergebnisse zeigen, dass die Methode zuverlassig den Lymphknotenstatus erfasst und damit in Zukunft vermehrt Einfluss auf adjuvante Therapiekonzepte bzw. auch auf das chirurgische Resektionsausmas nehmen wird. Zwei Methoden stehen fur die SLNB zurzeit zur Verfugung: die Farbstoffmethode und die Radiokolloidmethode. Welche Methode fur die jeweilige Tumorentitat am sinnvollsten ist und welche Ergebnisse derzeit hiermit erzielt werden, soll nachfolgend erortert werden.

BACKGROUND Synovial sarcoma is a rare tumor frequently occurring in adolescents and young adults. The preferred location, at the distal parts of the extremities, and the high incidence of distant metastases represent major challenges for treatment. The purpose of this study is to analyze the indications for surgery in the context of a multimodal therapy. PATIENTS AND METHODS Between October 1992 and December 2000, 41 patients were treated surgically for synovial sarcoma of the extremities. Their mean age was 35 years (range: 11-75 years). Extracompartmental tumor growth was present in more than 90% of the patients. Fourteen patients (34%) presented with a tumor size of less than 5 cm (T1) while 27 patients (66%) showed lesions greater than 5 cm (T2). At the time of presentation, seven patients had distant metastases; three located in the lung and four in lymph nodes. RESULTS Due to a locally unresectable tumor or synchronous distant metastases, 28 patients (68%) underwent preoperative systemic chemotherapy (n=9) or isolated limb perfusion (n=18) or both (n=1). In 29 patients, limb-conserving surgery was possible. Of the 12 patients (29%) who required amputation, 85% had a distal tumor. Sixteen patients received additional postoperative radio- and/or chemotherapy. After a median follow-up of 30 months, only two patients (7%) had developed a local recurrence, while seven patients (20%) suffered from new, distant metastases. The 5-year overall survival rate was 82%. CONCLUSION With a combined modality treatment, it is possible to achieve excellent local control rates and long-term survival in patients with synovial sarcoma of the extremities. Neoadjuvant treatment can enable limb-sparing surgery in most patients, even if the tumors are located in anatomically difficult areas.

Background: The aim of this study was to investigate whether endosonography on demand with miniprobes and conventional endoscopic ultrasound improves the accuracy of endosonographic staging of upper gastrointestinal tract cancer. Methods: Altogether, 173 patients underwent endoscopic ultrasonography for preoperative staging of esophageal (n = 63) or gastric cancer (n = 110). Depending on the endoscopic appearance (i.e., size and growth pattern), tumors were examined with a linear-array echoendoscope (7.5 MHz) or with high-resolution miniprobes (12.5 MHz). The results of preoperative staging were correlated with histopathology of the resection specimen. Results: The overall accuracy of miniprobe ultrasonography and endoscopic ultrasound in assessing the infiltration depth of upper gastrointestinal cancer was 87% and 81%, respectively. Miniprobe ultrasonography was superior to conventional endoscopic ultrasound in the staging of early cancers, particularly T1 tumors (accuracy, 81% vs 56%). The combined accuracy of both techniques for all tumor stages was 82%. Correct diagnosis of lymph node involvement was obtained with miniprobe ultrasonography or endoscopic ultrasound in 76% and 71% of the cases, respectively. The combined accuracy in assessing the lymph node status was 73% (sensitivity, 68%; specificity, 81%). Conclusions: Endosonography on demand using either miniprobes or conventional endoscopic ultrasound may result in more effective and less invasive staging of esophageal and gastric cancer. Selective use of high-resolution miniprobes and conventional endoscopic ultrasound offers accurate staging of all tumor stages.

The concept of using heat to stop bleeding goes back hundreds of years. Researchers have constructed a variety of devices that used electricity as a means to heat tissue and control bleeding. Electrosurgery became widely used in the late 1920s because of the urgent need to safely control bleeding in operative procedures. This article will cover basics of electricity and electrosurgery, clinical applications, technologies, and nursing care during electrosurgery.

Up to now, no reliable methods for the pre- or intraoperative prediction of the nodal status are available in gastrointestinal cancer patients. Therefore, after the successful application of the sentinel lymph node concept in melanoma and breast cancer, ongoing research on this field is extended to gastrointestinal tumor entities. According to recent experiences, the most promising tumor entities are colon, gastric and anal cancer. First results with these patients indicate that the method could be a reliable predictor of the nodal status and, thus, may have important future implications for adjuvant therapy and the extent of surgery. The dye method for colon cancer and the combined method (dye and radiocolloid) for gastric cancer seem to be appropriate approaches, even when the general experience is still low. In rectal cancer, however, current experience failed yet to yield satisfying results. Up to now, anal cancer has not been a focus of publication, even when the concept seems to be very attractive for the evaluation of the inguinal lymph node status.

The value of endorectal ultrasound (EUS) in the diagnosis of recurrent rectal cancer is limited by the inability to differentiate between malignant and benign lesions. We have prospectively investigated the role of EUS with transrectal ultrasound-guided biopsy in the postoperative follow-up of rectal cancer.Since 1995, patients who had undergone a sphincter-saving operation for rectal cancer (n = 312) were followed-up by a standard program including rectal palpation, carcinoembryonic antigen monitoring, computed tomography, and EUS. Transrectal EUS-guided biopsy of perirectal lesions was performed in 68 patients with perirectal lesions by using a rigid endoprobe with a 10 MHZ multiplane transducer and special targeting device.Overall local recurrence was observed in 36 patients. Intraluminal recurrence was diagnosed by proctoscopy in 12 patients. Transrectal EUS-guided biopsy showed pelvic recurrence in 22 of 68 patients with perirectal lesions. Biopsy specimens with benign histology were obtained from 41 patients, and the procedure failed in 5 cases (accuracy, 92%). There was a strong agreement between transrectal biopsy results and the final diagnosis (kappa = 0.84), the sensitivity and specificity being 91% and 93%, respectively. In contrast, clinical examination (kappa = 0.27), computed tomography (kappa = 0.47), or EUS (kappa = 0.42) showed only a moderate level of agreement with the histopathologic diagnosis, mainly because of the limited specificity of all 3 methods (65% vs 46% vs 57%). EUS-guided biopsy was significantly more accurate than computed tomography and EUS (P.01). The biopsy results had a considerable impact on the management in 18 of 68 patients (26%).Transrectal EUS-guided biopsy is a safe and efficient method for tissue sampling of perirectal lesions. This minimally invasive and inexpensive technique improves the accuracy of endorectal ultrasound in the diagnosis of recurrent rectal cancer.

Loss of chromosomes 1, 2, 6, 10, 13, 17, and 21 is a characteristic finding in chromophobe renal-cell carcinoma (ChRCC). Previously, cytogenetic and molecular genetic techniques were used in demonstrating the chromosomal monosomies in ChRCCs. We performed interphase fluorescent in situ hybridization (FISH) using centromeric probes for chromosomes 1, 2, 6, and 10 on touch imprint smears from six histologically proven ChRCCs. All six ChRCC tumors showed one FISH signal corresponding to one copy number for each of these chromosomes. The percent cells with one FISH signal ranged from 48-88% (chromosome 1), 36-89% (chromosome 2), 26-98% (chromosome 6), and 64-99% (chromosome 10). In addition, 3 of the 6 cases were further studied with centromeric probes for chromosomes 13, 17, and 21. All three revealed monosomy of these three chromosomes. We conclude that interphase FISH performed on touch imprint smears is a relatively simple, rapid, and reliable method for detecting chromosome abnormalities which are specific for ChRCCs.

Although common worldwide, hepatocellular carcinoma is relatively rare in the United States. However, for unknown reasons, the incidence is rising. Multiple causes exist, but chronic viral hepatitis in the setting of cirrhosis is probably the most common. Despite limitations, AFP measurement and multiple-phase abdominal CT are the most sensitive tests for diagnosis. Surgical resection and liver transplantation are at present the only treatment options that offer potential for long-term survival or cure in limited-stage hepatocellular carcinoma. Otherwise, the prognosis is poor, and 1-year survival is rare. Future efforts should focus on improving detection of early-stage disease and improving preventive measures to reduce viral hepatitis infection, transmission, and progression.

Major chromosome abnormalities are present in 0.65% of all neonates. Fluorescent in situ hybridization [FISH]is useful in diagnosing microdeletion syndromes that would otherwise be difficult to diagnose using standard cytogenetics. In this study, we used FISH analysis in the laboratory diagnosis of 4 patients with Prader-Willi Syndrome [del[15][q11.2q12], 4 patients with Di George syndrome [del[22][q11.2q11.23] and 4 patients with Williams syndrome [del[7][q11.23q11.23]. High-resolution chromosome analysis in all these patients was either normal or inconclusive but all the syndromes were confirmed using FISH. We recommend cytogenetic analysis should always be supplemented with FISH to diagnose all cases suspected of a microdeletion syndrome

In unserer Studie sollten mogliche Kurzzeiteffekte der sommerlichen Ozonexposition auf lungenmechanische Mesgrosen von Kindern erfast werden. Fur Kinder ohne Pollenallergie ergaben sich dabei statistisch signifikante, negative Assoziationen der Ozonexposition und der Mesgrosen “Forcierte Vitalkapazitat” und “Einsekundenkapazitat”. Aktuelle Ozonexpositionen sind bei Kindern mit einer Einschrankung der Lungenvolumina assoziiert. Das gesundheitliche Risiko der chronischen Ozonexposition mus noch geklart werden.

Die Haufigkeit von Asthma und asthmatypischen Beschwerden bei Schulkindern wurde in sechs deutschen und drei osterreichischen Gebieten landlichen Charakters untersucht. Das standardisierte Fragebogen-Panel basierte auf bereits veroffentlichten, validierten Instrumenten fur das Kindesalter. Daten von 1.624 Probanden im Alter zwischen 6 und 9 Jahren wurden analysiert. Die mittlere Lebenszeitpravalenz von Asthma (ISAAC-Item Nr. 6) betrug 4.5 % (Spannbreite 2.4-6.6 %), die von arztlich diagnostiziertem Heuschnupfen 5.7 % (1.6-15.8 %). Die 12-Monatspravalenzen fur ‘pfeifende Atemgerausche’ (ISAAC-Item Nr. 2) betrug 9.0 % (6.0-12.9 %), fur ‘pfeifende Atemgerausche nach Anstrengung’ (ISAAC-Item Nr. 7) 5.2 % (2.4-8.4 %);fur Atemnot 5.1 % (3.2-9.3 %). ‘Pfeifende Atemgerausche’ in den letzten 12 Monaten wurden bei 58.3 % der Asthmatiker (n=72) und nur 6.6 % der Nichtasthmatiker (n=1539) beobachtet. Eine Adjustierung der Gebietspravalenzen fur Alter, Geschlecht, Passivrauchexposition und elterliche Atopie fuhrte nur vereinzelt zu Differenzen gegenuber den rohen Haufigkeiten. Anhand der logistischen Regressionen wiesen die Gebiete Ried-A, Freudenstadt und Donautal einen Trend zu erhohten relativen Risiken (Odds-Ratios) von Asthma und asthmatypischen Symptomen gegenuber der Referenz Odenwald auf. Eine alternative Darstellungsform mit Bezug der Gebietspravalenzen auf das gewichtete Pravalenz-Mittel akzentuierte dagegen Abweichungen fur Gebiete mit niedriger Morbiditat (Odenwald, Villingen, Voralpen). Schlussfolgerung: Gebietsunterschiede hinsichtlich der Asthma- und Beschwerde-Morbiditat wurden nachgewiesen und blieben auch nach Adjustierung fur potentielle Storvariablen konstant. Allerdings kann die Wahl der Darstellungsform (Relatives Risiko versus Abweichung vom gewichteten Pravalenz-Mittel) eine unterschiedliche suggestive Wirkung hervorrufen.

Breast cancer is the most common cancer in women and is the second (after lung cancer) leading cause of cancer deaths in women. Knowledge of breast cancer and its epidemlology, natural course, and response to treatment continue to evolve, making the survival rates for patients with breast cancer more optimistic. Women with breast cancer must decide, in partnership with expert physicians and nurses, what their options are for screening, diagnosis, and treatment. This article provides an overview of options available to women diagnosed with breast cancer.

SURGICAL SMOKE is a part of the environment during operative and invasive procedures. As lasers and electrosurgery have become commonplace, perioperative practitioners are at increased risk for health concerns associated with exposure to surgical smoke. SINCE THE MID 1970s, the body of evidence documenting the hazardous components of surgical smoke has continued to grow. Despite the evidence and recommendations of a variety of organizations, there are no uniform requirements mandating surgical smoke evacuation. THIS ARTICLE REVIEWS current research to identify the potential health hazards as well as the current recommendations related to the filtration and evacuation of surgical smoke. AORN J 87 (April 2008) 721-734. © AORN, Inc, 2008.

Cytogenetic and molecular genetic techniques have been used in demonstrating the chromosomal abnormalities which characterize specific subtypes of renal cell carcinoma (RCC). The aim of this study was to determine the efficiency of fluorescent in situ hybridization (FISH) technique in characterizing various subtypes of RCC based on the presence of specific chromosome abnormalities found in each RCC subtype.FISH was performed on touch imprint smears from eight renal cell carcinomas histologically confirmed by established criteria.In four tumors with histologic features of chromophobe renal cell carcinoma (ChRCC), interphase FISH was performed using centromeric probes for chromosomes 1, 2, 6, 10, 12, 17 and 21. All four ChRCC tumors showed one FISH signal corresponding to one copy number for each of these chromosomes. Two papillary RCCs included in this study showed trisomy 7 and 17, and loss of chromosome Y, using the corresponding chromosome centromeric probes. Similarly, we tested two clear cell RCCs for chromosome 3 short arm deletion with DNA probe 3p21.3. Both tumors showed loss of 3p21.3 signal.We conclude that interphase FISH performed on touch imprint smears is a relatively simple, rapid and reliable method for detecting chromosome abnormalities which are specific for various subtypes of RCC.

Der prognostisch bedeutsame Lymphknotenstatus beim Kolon- und Rektumkarzinom wird durch die Auswahl und die Anzahl der untersuchten Lymphknoten sowie durch die Qualitat der Untersuchung beeinflusst. Die Vielzahl moglicher Einflusse bringt dabei ein hohes Risiko fur Qualitatsschwankungen mit sich. Die Sentinel-Lymphknoten-Biopsie (SLNB) wird derzeit auf ihre Wertigkeit hin untersucht, die Bestimmung des Nodalstatus beim Kolon- und Rektumkarzinom zu verbessern bzw. zu vereinfachen. Weltweit liegen derzeit die Daten von 800–1000 Patienten aus ca. 20 kleineren Untersuchungen uberwiegend mit Kolonkarzinom vor. Wahrend eine mogliche praktische Bedeutung der Methode fur das Rektumkarzinom derzeit noch unklar ist, zeichnet sich anhand der verfugbaren Daten ab, dass das Potenzial fur eine praktische Anwendung der SLNB beim kolorektalen Karzinom in einer Verbesserung des Staging zu liegen scheint. Moglicherweise kann durch die intensivierte histopathologische Untersuchung des SLN und dem dadurch erfolgenden Nachweis von Mikrometastasen oder isolierter Tumorzellverbande eine zusatzliche Patientengruppe identifiziert werden, die von einer adjuvanten Chemotherapie profitiert, was einen wichtigen Einfluss auf die Therapie und Prognose der Patienten bedeuten wurde.

Background The value of sentinel node biopsy in visceral cancers is uncertain. We evaluated the feasibility and utility of radiocolloid lymphatic mapping and selective lymph node sampling in patients with rectal cancer. Methods Forty-eight patients with rectal cancer were investigated. Thirty-seven patients had already undergone preoperative radiochemotherapy for locally advanced tumors. Eleven patients underwent primary surgery. An endoscopic injection of 1 mL technetium 99m–sulfur-colloid into the peritumoral submucosa was performed 15 to 17 hours before surgery. Ex vivo identification of the nuclide-enriched “sentinel lymph nodes” (SLNs) was performed using a hand-held γ-probe. The selected SLNs were then carefully and systematically examined using serial sections and immunohistochemistry. Results One or more SLNs were found in 46 of the 48 patients. The SLN detection rate was 96%. Sixteen of the 48 patients had lymph node metastases (35%). In 7 of the 16 patients, the SLNs correctly represented the nodal status. In 9 of the 16 patients, the SLN was tumor-free whereas non-SLN harbored metastases. This result represents a sensitivity of only 44%, and a false-negative rate of 56%. Further analysis showed that the method correctly predicted the nodal status only in the small subgroup of 5 patients with early cancer without preoperative radiation. In 4 patients, juxtaregional lymph nodes were excised on the basis of intraoperative radiocolloid detection, leading to upward staging in 1 patient. Conclusions Sentinel lymph node biopsy using the radiocolloid technique with ex vivo lymph node identification shows a relatively high detection rate; however, the sensitivity in patients with locally advanced/irradiated rectal cancer is low. Nevertheless, the detection of juxtaregional metastases can improve staging in some patients. Further studies should focus on patients with early rectal cancers where the data were more promising.

Background: The purpose of this study was to investigate the ability of transcutaneous three-dimensional US cholangiography to depict the biliary tree in malignant obstruction, compared with that of MRCP and direct cholangiography. Methods: Three-dimensional US and MRCP and direct cholangiography were performed in 40 patients with suspected malignant biliary obstruction. Diagnostic quality of the images, presence, level, and cause of ductal obstruction were assessed in a prospective, blinded fashion. The results were correlated with consensus interpretation (3 investigators), intra-operative findings, and histopathology or clinical follow-up. Results: Three-dimensional US produced cholangiographic images of diagnostic quality. The appearance of these images was similar to that of MRCP or ERCP/percutaneous transhepatic cholangiography images. All modalities were highly sensitive in the detection of biliary dilatation. The accuracy of 3-dimensional US, MRCP, and ERCP/percutaneous transhepatic cholangiography in determining the level of obstruction was, respectively, 92%, 95%, and 98%. Transcutaneous 3-dimensional US and MRCP accurately identified the cause of obstruction in, respectively, 90% and 95% of cases. Direct cholangiography revealed the correct diagnosis in 95% of the patients. Conclusions: Three-dimensional US cholangiography is a new, noninvasive method with the capability to produce diagnostic cholangiograms. Three-dimensional US cholangiography may be used increasingly as an initial test to select patients who require further diagnostic evaluation by MRCP or therapeutic ERCP.

ISSUE: To prevent the transmission of influenza to persons at risk of complications and death from influenza, the Advisory Committee on Immunization Practices (ACIP) recommends annual vaccination of healthcare workers (HCWs). National data demonstrates HCW vaccination coverage of 36%. BJC HealthCare has had an average rate of 47% (range 40–52%) over the past 6 years. However, our goal was to improve influenza vaccination coverage for our 24,300 employees. PROJECT: A vaccination program assessment was conducted using a 14-question survey of 13 (100%) occupational health departments covering employees at 11 hospitals, five long-term-care facilities, home care, and multiple outpatient entities. Based on the survey results, an influenza vaccination program “best practices” was developed. These best practices were implemented at 100% of BJC HealthCare occupational health departments in the fall of 2003. RESULTS: The key aspects identified by the survey assessment included: readily accessible vaccination opportunities such as cafeteria campaigns; key partnerships with Administration, Infection Control, and Safety; educational materials; and incentives for getting vaccinated including gift certificates, event tickets, cafeteria coupons, and a cash drawing. One important aspect identified was effective marketing that included the use of multiple methods such as organizational and entity newspaper articles, paycheck flyers, poster displays, mass e-mails, and management meeting announcements. A vaccination rate of 52.7% (12,797 vaccinations/24,300 employees) demonstrates an increase of 6.7%. In addition, the increased vaccination rates occurred over a shorter period of time (7 weeks during 2003 versus 12 weeks during 2002). LESSONS LEARNED: Implementation of best practices for influenza vaccination programs increased vaccination coverage for HCWs. Ongoing evaluation of vaccination efforts, rate analysis, and recommendations for best practices should continue to increase influenza vaccination coverage for HCWs.