Effect of sitting vs. standing on perception of provider time at bedside: a pilot study.

OBJECTIVE: Patients commonly perceive that a provider has spent more time at their bedside when the provider sits rather than stands. This study provides empirical evidence for this perception. METHODS: We conducted a prospective, randomized, controlled study with 120 adult post-operative inpatients admitted for elective spine surgery. The actual lengths of the interactions were compared to patients' estimations of the time of those interactions. RESULTS: Patients perceived the provider as present at their bedside longer when he sat, even though the actual time the physician spent at the bedside did not change significantly whether he sat or stood. Patients with whom the physician sat reported a more positive interaction and a better understanding of their condition. CONCLUSION: Simply sitting instead of standing at a patient's bedside can have a significant impact on patient satisfaction, patient compliance, and provider-patient rapport, all of which are known factors in decreased litigation, decreased lengths of stay, decreased costs, and improved clinical outcomes. PRACTICE IMPLICATIONS: Any healthcare provider may have a positive effect on doctor-patient interaction by sitting as opposed to standing during a hospital follow-up visit.

Factors affecting hospital length of stay following anterior cervical discectomy and fusion.

STUDY DESIGN: Retrospective cohort study. BACKGROUND: Several studies focus on the long-term results of anterior cervical discectomy and fusion (ACDF) surgeries, but little information exists regarding how various patient-related, procedure-related, and payer-related variables may affect postoperative hospital length of stay (LOS). OBJECTIVE: To determine what factors, if any, contribute to increased hospital LOS in patients who have had an ACDF. METHODS: Retrospective cohort study of 108 consecutive patients who underwent elective ACDF at a Midwest academic medical center. Extensive preoperative, intraoperative, and postoperative data were abstracted and analyzed to identify prognostic factors for an increased LOS. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on hospital LOS. RESULTS: 103 patients met inclusion and exclusion criteria. The mean LOS for patients undergoing ACDF was 1.98 (±1.6) days. Only 29% of patients had one level fused. The mean blood loss during surgery was 87.4 ± 99.6 mL. One subject lost 700 mL of blood. Complications, though rare, included uncontrolled postoperative pain (13%), cardiac (6%), pulmonary (4%), and urinary (3%). Covariates included in the final model were age, sex, cardiac complication, urinary complication, and pulmonary complication. Factors that contributed to increased LOS and their associated adjusted mean days were: ≥50 years of age (2.5 ± 1.2 days), female gender (2.3 ± 1.2 days), and three particular types of complications. The complications that had the largest effect on increased LOS from least to most severe were cardiac (3.5 ± 1.3 days), urinary (4.7 ± 1.3 days), and pulmonary (5.3 ± 1.3 days). CONCLUSIONS: The information presented in this study may be useful for patients, clinicians, and insurance companies, including precertification and case-management services. Our results can be instrumental in designing future prospective studies using more detailed analyses with more patients, more surgeons, and multiple institutions. [Table: see text].

Threaded interbody fusion cage for adjacent segment degenerative disease after previous anterior cervical fusion.

BACKGROUND: Anterior discectomy and fusion have been used for over 50 years in the treatment of degenerative disease of the cervical spine. However, as these procedures become more common, the long-term consequences are becoming more evident. One such consequence is degeneration of an adjacent segment, which can occur in up to 17% of patients undergoing cervical fusion. A threaded interbody fusion cage has often been used in a primary degenerative disorder of the cervical spine. However, there have been no studies in which these cages have been used in adjacent segments after previous cervical fusion. This is a retrospective review of 7 patients to determine the fusion rate, operative utility, and clinical outcomes using a threaded fusion cage construct in the treatment of cervical adjacent segment degeneration. METHODS: A standard low-profile interbody fusion cage was implanted after standard discectomy and local vertebral body bone graft in 7 patients with documented radiographic adjacent segment degeneration and clinical disease after anterior cervical fusion. Each patient underwent clinical and radiographic evaluation, and all 7 patients demonstrated signs of radiculopathy and/or myelopathy as well as radiographic signs of degeneration referable to a motion segment adjacent to previous cervical arthrodesis. These evaluations were repeated postoperatively. Patients were also asked to fill a preoperative and postoperative VAS, NDI, Prolo Economic-Functional Rating System, and CNDS for evaluation of outcome. RESULTS: Each procedure was performed without complication. The mean VAS pain scale decreased 58% as a result of the surgery. The CNDS improved in all patients by an average of 42%. The NDI improved in all patients, with an average increase of 42%. The Prolo Economic-Function Status showed that 4 patients had an excellent outcome and 3 patients had a good outcome. There was no incidence of pseudoarthrosis in any procedure at the 24-month follow-up. CONCLUSION: These preliminary results support the use of threaded interbody cages in adjacent segment degeneration of the cervical spine after previous anterior cervical fusion. Pain and functional scores improved in all cases. This technique should be among the possibilities for surgical treatment of degeneration of adjacent segments in patients with previous cervical spinal fusion.

In vitro and in vivo percutaneous absorption of 14C-octamethylcyclotetrasiloxane (14C-D4) and 14C-decamethylcyclopentasiloxane (14C-D5).

Octamethylcyclotetrasiloxane (D4) and decamethylcyclopentasiloxane (D5) are cyclic siloxanes used as chemical intermediates with some applications in consumer products. The in vitro percutaneous absorption of 14C-D4 and 14C-D5 was studied in flow-through diffusion cells. Single doses were applied neat and in antiperspirant formulations to dermatomed human skin for 24h. The majority of applied D4 and D5 ( approximately 90%) volatilized before being absorbed. Only 0.5% of applied D4 was absorbed while the absorption of D5 (0.04%) was one order of magnitude lower. The largest percentage (>90%) of the absorbed D4 and D5 was found in the skin. The fate of D4 and D5 absorbed in the skin was studied in rat in vivo. A single dose of 14C-D4 (10, 4.8 and 2mg/cm2) and 14C-D5 (10mg/cm2) was topically applied inside a dosing chamber attached to the dorsal area. Rats were housed in metabolism cages up to 24h to enable collection of urine, feces, expired/escaped volatiles. The majority of applied D4 or D5 had volatilized from the skin surface. Less than 1.0% of the applied D4 and only 0.2% of applied D5 was absorbed with approximately 60% of absorbed D4 and 30% of absorbed D5 reaching systemic compartments. The amount absorbed into the skin decreased with time showing that residual D4 and D5 diffused back to the skin surface and continued to evaporate. Overall, a low tendency to pass through the skin into systemic compartments was demonstrated for both D4 (< or = 0.5% of applied dose) and D5 (<0.1% of applied dose).

In vitro and in vivo evaluation of the estrogenic, androgenic, and progestagenic potential of two cyclic siloxanes.

The purpose of these experiments was to determine the potential estrogenic, androgenic, and progestagenic activity of two cyclic siloxanes, octamethylcyclotetrasiloxane (D4) and decamethylcyclopentasiloxane (D5). Receptor-binding experiments and a luciferase reporter gene assay were used to determine if the materials were able to bind and activate either the estrogen receptors (ERs) or progesterone receptors (PRs)-alpha or beta. The rat uterotrophic assay (RUA) for estrogenic activity and the Hershberger assay for androgenic activity were utilized as the in vivo assays. For the ER-binding studies, D4 was shown to bind to ERalpha but not to ERbeta. D5 did not bind to either of the two receptors. D4 activated the reporter gene at 10 microM, while D5 was considered negative in the estrogen reporter gene assay. Neither material was a ligand for the PRs. Both the RUA and Hershberger assays were conducted using whole-body inhalation of the two materials for 16 h/day. D4 resulted in a small but significant increase in both wet and blotted uterine weight as well as increases in both luminal and glandular epithelial cell height in both Sprague Dawley and Fischer 344 rats. D5 was negative in both rat strains, indicating that D5 does not possess estrogenic activity. Neither material possessed any significant antiestrogenic activity. Both materials were negative in the Hershberger assay indicating that neither material possesses any significant androgenic activity. Our studies have shown that D4 exhibits a low affinity for ERalpha in vitro and a weakly estrogenic response in vivo.

A proactive approach to prevention of health care-acquired Legionnaires' disease: the Allegheny County (Pittsburgh) experience.

BACKGROUND: The Allegheny County Health Department (ACHD) in Pennsylvania distributed the first guidelines for prevention and control of health care-acquired Legionnaires' disease (LD) by 1995. The proactive approach advocated in the guidelines differed notably from that of the Centers for Disease Control and Prevention (CDC) by recommending routine environmental testing of the hospital water distribution system even when cases of health care-acquired Legionnaires' disease had never been identified. OBJECTIVES: Our purpose was to (1) evaluate the impact of the ACHD guidelines on the Legionella diagnostic and preventive practices of health care facilities in Allegheny and surrounding counties and (2) compare the incidence of health care-acquired LD before and after issuance of the ACHD guidelines. METHODS: CDC case reports of LD from 1991 to 2001 were tabulated and compiled by the ACHD Infectious Disease Unit and the Association for Professionals in Infection Control and Epidemiology, Inc, Three Rivers Chapter. A survey was distributed to 110 hospitals and long-term care facilities in the region. The results were analyzed as occurring either in the preguideline period (1991-1994) or postguideline period (1995-2001). RESULTS: A significant decrease in the number of health care-acquired cases was demonstrated between the preguideline (33%) and postguideline (9%) periods (P=.0001). In contrast, community-acquired cases increased from 67% pre guideline to 91% post guideline. A total of 71% of the facilities were colonized with Legionella. Disinfection of the water distribution system was initiated by 44% of facilities. Use of urinary antigen testing significantly increased from 40% pre guideline to 79% post guideline (P=.0001). CONCLUSIONS: Health care-acquired LD declined significantly after the issuance of guidelines for prevention and control of health care-acquired LD. The decline was associated with health care facilities performing routine environmental monitoring of their water distribution systems followed by the initiation of disinfection methods if indicated. Two unanticipated benefits were (1) cases of LD in the community and long-term care facilities were uncovered as a result of increased availability of Legionella tests and (2) litigation and unfavorable publicity involving ACHD hospitals ceased.

Chondromyxoid fibroma of the upper thoracic spine in a 7-year-old patient. A case report and review of the literature.

BACKGROUND: We report a case of a 7-year-old white female who presented with acute, progressive bilateral lower extremity weakness over 48 h. METHODS: Case report and presentation of clinical, radiological and pathological data on a single case of chondromyxoid fibroma (CMF) of the T2 vertebral body. RESULTS: Magnetic resonance imaging of the thoracic spine revealed an extensive mass invading the lamina of the second thoracic vertebra, causing extensive cord compression and progressive neurological deterioration. Surgical resection and pathologic study of the mass revealed a CMF. CONCLUSIONS: A thorough Medline search has revealed that only 25 cases of spinal CMF have been reported, making this lesion an extremely rare bone tumor.

Influenza immunizations provided by EMS agencies: the MEDICVAX Project.

OBJECTIVE: Emergency medical services (EMS) agencies may be an underutilized resource for provision of preventive health services. This study sought to demonstrate the feasibility for EMS agencies to provide influenza immunizations. METHODS: This prospective, observational cohort study was conducted with urban, suburban, and rural EMS agencies that volunteered to participate. EMS managers and paramedics attended an orientation program, and then developed and implemented recruitment strategies. Adult volunteer subjects who met Centers for Disease Control and Prevention criteria for influenza vaccination were enrolled. Paramedics obtained informed consent, determined subject eligibility, administered the vaccine, and observed each subject for 10 minutes. Paramedics, EMS managers, and subjects completed surveys; EMS managers reported costs and resource utilization. Data were analyzed descriptively. RESULTS: Ninety paramedics from 15 EMS agencies in three counties participated. Subjects were recruited by print and broadcast media and enrolled at 73 events held at retail establishments, community events, EMS stations, churches, senior citizen complexes, and private residences. Of the 2,075 adults immunized, 1,014 (49%) did not receive influenza vaccination in the previous year. Seven hundred five (34%) reported that they probably would not have been vaccinated elsewhere. Fixed cost for each immunization was $3.42. The EMS managers estimated their variable costs to range from zero dollars (volunteer agencies with all donated expenses) to $15.31 per immunization. No adverse events were reported. Subjects, paramedics, and EMS managers indicated a high level of satisfaction with the project. CONCLUSION: The MEDICVAX Project demonstrated the feasibility of EMS agencies to safely provide influenza immunizations. The project reached some adults who likely would not have been immunized.

Metabolites of hexamethyldisiloxane and decamethylcyclopentasiloxane in Fischer 344 rat urine--a comparison of a linear and a cyclic siloxane.

Hexamethyldisiloxane (MM or HMDS) and decamethylcylclopentasiloxane (D(5)) are examples of a linear and a cyclic siloxane, respectively. These volatile low molecular weight siloxanes are of significant commercial importance. To aid in the pharmacokinetic investigations, major metabolites of MM and D(5) were identified in urine collected from Fischer (F-344) rats administered [(14)C]MM and [(14)C]D(5) orally and via intravenous injection. The metabolite profiles were obtained using a high-pressure liquid chromatography (HPLC) system equipped with a radioisotope detector. The metabolite elution was carried out on a C(18) column using an acetonitrile/water mobile phase. The structural assignments were based on GC-MS analysis of the tetrahydrofuran extract of urine containing the metabolites. Some of the metabolites in the extracts were first protected with trimethylsilyl groups prior to GC-MS analysis using bis(trimethylsiloxy)trifluoroacetamide or highly purified hexamethyldisiloxane. The structures were also confirmed by comparisons with synthetic (14)C-labeled metabolite standards. The following are among the major metabolites identified in the case of MM: Me(2)Si(OH)(2), HOMe(2)SiCH(2)OH, HOCH(2)Me(2)SiOSiMe(2)CH(2)OH, HOMe(2)SiOSiMe(2)CH(2)-OH, HOCH(2)Me(2)SiOSiMe(3), and Me(3)SiOH. The metabolites of D(5) are as follows: Me(2)Si(OH)(2), MeSi(OH)(3), MeSi(OH)(2)OSi(OH)(3), MeSi(OH)(2)OSi(OH)(2)Me, MeSi(OH)(2)OSi(OH)Me(2), Me(2)Si(OH)OSi(OH)Me(2), Me(2)Si(OH)OSiMe(2)OSi(OH)Me(2), nonamethylcyclopentasiloxanol, and hydroxymethylnonamethylcyclopentasiloxane. No parent MM or D(5) was present in urine The presence of certain metabolites such as HOMe(2)SiCH(2)OH and Me(2)Si(OH)(2) in MM and D(5), respectively, clearly established the occurrence of demethylation at the silicon-methyl bonds. Metabolites of the linear siloxane are structurally different from that obtained for cyclic siloxane except for the commonly present Me(2)Si(OH)(2). Mechanistic pathways for the formation of the metabolites were proposed.

Automatic electronic laboratory-based reporting of notifiable infectious diseases at a large health system.

Electronic laboratory-based reporting, developed by the UPMC Health System, Pittsburgh, Pennsylvania, was evaluated to determine if it could be integrated into the conventional paper-based reporting system. We reviewed reports of 10 infectious diseases from 8 UPMC hospitals that reported to the Allegheny County Health Department in southwestern Pennsylvania during January 1-November 26, 2000. Electronic reports were received a median of 4 days earlier than conventional reports. The completeness of reporting was 74% (95% confidence interval [CI] 66% to 81%) for the electronic laboratory-based reporting and 65% (95% CI 57% to 73%) for the conventional paper-based reporting system (p>0.05). Most reports (88%) missed by electronic laboratory-based reporting were caused by using free text. Automatic reporting was more rapid and as complete as conventional reporting. Using standardized coding and minimizing free text usage will increase the completeness of electronic laboratory-based reporting.