Period Of Recumbency Research Articles

Assessment of time factor in managing femoral neck fractures by internal fixation in patients above 55 years of age

Background Intracapsular hip fractures account for approximately half of all hip fractures. Present treatment of an intracapsular fracture entails either replacement arthroplasty or preservation of the femoral head. In old age patients, the decision between fixation and arthroplasty becomes an issue: Although fixation is a biological solution for this fracture treatment, it has a high nonunion rate with a long postoperative recumbency period and its known complications; in contrast, arthroplasty has its advantage in early mobilization of the patient but has its well-known complications, starting with infection and ending with loosening and the need for revisions. Evidence from the literature on the effect of timing of fixation on outcomes after femoral neck fractures is conflicting. The purpose of this study was to analyze the effect of timing of surgery on the incidence of nonunion and avascular necrosis (AVN) after internal fixation of femoral neck fractures in patients above the age of 55 years. Patients and methods This study included 30 patients (13 men and 17 women) between 56–77 years of age (average 65.1 years) with femoral neck fractures who were treated by closed reduction and internal fixation and were followed up for a minimum of period of 2 years. Nineteen patients (63.33%) had displaced fractures. The average time lag between injury and surgery was 37.5 h (6–144). The patients were divided into two groups: 12 patients (40%) were treated within 12 h after injury (early fixation group) and 18 (60%) were treated more than 12 h after injury (late fixation group). All patients were treated by closed reduction and multiple screw fixation. Results The average age of the patients in the early fixation group (12 patients) was 61.9 years and that of patients in the late fixation group (18 patients) was 67.7 years. There were seven women in the early fixation group and 10 in the late fixation group. There were eight cases of displaced fractures (66.67%) in the early fixation group and 11 cases (61.1%) of the same in the late fixation group. The average time lag between injury and fixation was 10.5 h in the early fixation group and 54.78 h in the late fixation group. All fractures united within an average period of 86.8 days (range 60–128). The final results were satisfactory in 22 hips (73.33%) and unsatisfactory in eight hips (26.67%). No statistically significant difference was found in the duration of fracture union and AVN with regard to sex distribution and mechanism of injury. Variables affecting the final results of treatment were: the time factor, age at surgery and type of fracture. Conclusion Closed reduction and internal fixation is a valid contribution to the treatment of femoral neck fractures in patients above 55 years of age (56–65). The rate of nonunion and AVN was affected by a delay of more than 12 h before fixation for femoral neck fractures in this age group. The incidence of failure was significantly higher in patients aged 65 years or above and in cases of displaced fractures.

English

Thirty five patient with unstable fractures of the lower thoracic and lumbar spine managed uniformly with Hartshill fixation and sublaminar wiring were analyzed. On admission, 18 patients had complete neurologic deficit and 17 had incomplete lesions. The neurologic recovery and functional activities were assessed after an average follow up for 20.4 months. Improvement of neural function was seen in 71 % patients. Positive correlation was found between the level of injury and Frankel grades. The cord lesions tended to demonstrate more severe neurologic deficit than cauda equina lesions. A component of dislocation to the injury also resulted in a more severe neural deficit. The complications were minor. Stable fixation of thoracolumbar spine fractures was helpful in decreasing hospital stay and recumbency period, thereby facilitating early rehabilitation of the spine

The Neurologic Outcome Of Posterior Fixation Of ThoracoLumbar Spine Fractures In A Rural Tertiary Care Centre Without Help Of Image Intensifier

Thirtyfive patient with unstable fractures of the lower thoracic and lumbar spine managed uniformly with Hartshill fixation and sublaminar wiring were analyzed. On admission, 18 patients had complete neurologic deficit and 17 had incomplete lesions. The neurologic recovery and functional activities were assessed after an average follow up for 20.4 months. Improvement of neural function was seen in 71 % patients. Positive correlation was found between the level of injury and Frankel grades. The cord lesions tended to demonstrate more severe neurologic deficit than cauda equina lesions. A component of dislocation to the injury also resulted in a more severe neural deficit. The complications were minor. Stable fixation of thoracolumbar spine fractures was helpful in decreasing hospital stay and recumbency period, thereby facilitating early rehabilitation of the spine injured patients.

Acquired Neuromuscular Weakness and Early Mobilization in the Intensive Care Unit

Survival from critical illness has improved in recent years, leading to increased attention to the sequelae of such illness. Neuromuscular weakness in the intensive care unit (ICU) is common, persistent, and has significant public health implications. The differential diagnosis of weakness in the ICU is extensive and includes critical illness neuromyopathy. Prolonged immobility and bedrest lead to catabolism and muscle atrophy, and are associated with critical illness neuromyopathy and ICU-acquired weakness. Early mobilization therapy has been advocated as a mechanism to prevent ICU-acquired weakness. Early mobilization is safe and feasible in most ICU patients, and improves outcomes. Implementation of early mobilization therapy requires changes in ICU culture, including decreased sedation and bedrest. Various technologies exist to increase compliance with early mobilization programs. Drugs targeting muscle pathways to decrease atrophy and muscle-wasting are in development. Additional research on early mobilization in the ICU is needed.

Twice-daily proton pump inhibitor therapy does not decrease the frequency of reflux episodes during nocturnal recumbency in patients with refractory GERD: analysis of 200 patients using multichannel intraluminal impedance-pH testing

Over half of patients with gastroesophageal reflux disease (GERD) report nocturnal symptoms. Proton pump inhibitors (PPIs) are the main medications used to treat GERD. Multichannel intraluminal impedance with pH (MII-pH) monitoring is the most sensitive method for detection and characterization of GERD. The aim of this study was to assess and compare reflux frequency in patients with refractory GERD symptoms on and off PPI therapy during the nocturnal recumbent period, as assessed by MII-pH testing. We analyzed 24-hour MII-pH studies performed in 200 patients monitored either on twice-daily (n = 100) or off (n = 100) PPI therapy. Demographic analysis of the on-therapy group revealed a mean age of 52 years (24-78 years) with 37% males, and the off-therapy group revealed a mean age of 49 years (18-84 years) with 40% males. All studies were interpreted to assess and characterize the number of acid and nonacid reflux episodes in the nocturnal recumbent period identified by each patient on an overnight recorder (Zephyr, Sandhill Scientific, Inc., Highlands Ranch, CO, USA). The nocturnal recumbent period was the period documented by patients during which they lie in the recumbent period at night to sleep with average periods lasting 456 and 453 minutes for patients on and off PPI therapy. There were more mean recumbent reflux episodes in the on-therapy group in comparison with the off-therapy group (3.76 mean reflux episodes [mre] per patient in the recumbent vs. 2.82 mre); the difference was not statistically significant (P = 0.187). When the reflux events are classified into acid and non-acid reflux episodes, the relative occurrence of acid reflux events is less in the on-therapy group (P = 0.047), while the off-therapy group have fewer nonacid reflux episodes (P = 0.003). PPIs decrease the acidity of esophageal refluxate but do not decrease the relative frequency of reflux episodes in the recumbent position in patients with refractory GERD despite twice-a-day treatment with PPI therapy. The explanation for the finding of numerically increased, although not statistically significant, amount of reflux episodes in the PPI treatment group in this study, and previous studies is unclear and warrants further evaluation.

Advancements in the analysis of esophageal pH monitoring in GERD

Ambulatory 24 h esophageal pH monitoring enables quantification of esophageal acid exposure and assessment of the temporal relationship between symptoms and acid reflux events. Analysis of pH monitoring is currently divided into upright and recumbent periods based on the patient's body position. However, in this Review, we demonstrate that physiologic studies have shown that sleep, and not recumbency, has a greater impact on gastroesophageal reflux during night-time. The physiologic studies are further supported by clinical trials demonstrating that gastroesophageal reflux characteristics during the recumbent-awake period are similar to those in the upright rather than the recumbent-asleep period. The introduction of the integrated pH monitoring and actigraphy data analysis program offers better separation of the recumbent-awake and recumbent-asleep periods. The physiologic studies and clinical trials, as well as the availability of a better tool to measure pH during sleep, support a paradigm shift in the analysis of pH monitoring data from body position (upright or recumbent) to state of consciousness (awake or asleep).

Deltoid compartment syndrome is a surgical emergency

This report is intended to establish deltoid compartment syndrome as a true clinical entity that deserves urgent surgical management. We describe a patient who developed compartment syndrome of the deltoid after a period of prolonged recumbency. Despite emergent surgical care, finding of necrotic muscle was evident.

Increased oesophageal acid exposure at the beginning of the recumbent period is primarily a recumbent-awake phenomenon

A significant increase in oesophageal acid exposure during early recumbent period has been demonstrated. To determine if acid reflux during the early recumbent period occurs in the recumbent-asleep or recumbent-awake period using a novel integrative actigraphy and pH programme. Thirty-nine subjects with heartburn at least three times a week were included. Subjects underwent pH testing concomitantly with actigraphy. Simultaneously recorded actigraphy and pH data were incorporated using a novel integrative technique to determine sleep and awake periods. Characteristics of acid reflux were compared between the recumbent-awake and recumbent-asleep periods. Seventeen (44.7%) subjects had acid reflux events during recumbent-awake period as compared to seven (18.4%) in the corresponding recumbent-asleep period (P = 0.046). The mean number of acid reflux events in recumbent-awake period was significantly higher than in the corresponding recumbent-asleep period (8.1 +/- 4.4 vs. 3.2 +/- 1.5, P < 0.001). In the recumbent-awake period, 38.4% of acid reflux events were associated with GERD-related symptoms as compared with 3.7% of acid reflux events during the corresponding recumbent-asleep period (P = 0.01). Increased acid reflux in the early recumbent period occurs primarily during the recumbent-awake and not during the recumbent-asleep period.

Reassessment of the Principal Characteristics of Gastroesophageal Reflux During the Recumbent Period Using Integrated Actigraphy-Acquired Information

Characterization of gastroesophageal reflux (GERD) events during the sleep period has been hampered by lack of any patient-friendly technique that allows accurate assessment of sleep duration and awakening time, without confining patients to a sleep laboratory. Our aim was to compare principal reflux characteristics during the upright, recumbent-awake, and recumbent-asleep periods as well as to determine the effect of sleep awakenings on the principal reflux characteristics of the recumbent-asleep period using novel technology that allows integration of recorded actigraphy data into collected pH information. Patients with heartburn at least three times a week for the previous 3 months were invited to participate in this study. All participants were evaluated by the demographics and the GERD Symptom Checklist questionnaires. Thereafter, patients underwent ambulatory 24-h esophageal pH monitoring concomitantly with actigraphy. A novel technique was used to superimpose simultaneously recorded raw actigraphy data over pH data, resulting in more accurate information about reflux events during upright, recumbent-awake, recumbent-asleep, and conscious awakening periods as well as the relationship between symptoms and acid reflux events in the aforementioned periods. Thirty-nine subjects (M/F: 26/13, mean age 56.6+/-14 years) with an abnormal pH test were enrolled into the study. The recumbent period appeared heterogeneous and was clearly divided into recumbent-awake (123.0+/-20.2 min) and recumbent-asleep (485.6+/-23.6 min) periods. The percent total time pH<4, the mean number of acid reflux events, and the number of symptoms associated with reflux events were significantly greater in the recumbent-awake as compared with the recumbent-asleep period. The mean duration of an acid reflux event was not different among upright, recumbent-awake, and recumbent-asleep periods. However, short-duration reflux events during the sleep period were associated with conscious awakenings as compared with those during sleep (0.74+/-0.11 min vs. 1.64+/-0.3 min, P=0.01). The recumbent period is divided into recumbent-awake and recumbent-asleep periods. The recumbent-awake period has significantly different principal reflux characteristics than the recumbent-asleep period. Duration of an acid reflux event during the recumbent-asleep period is not uniformly prolonged. Short-duration acid reflux events during the sleep period are likely due to conscious awakenings.

Fracture of the Long Bones

Fracture management in alpacas and llamas presents a unique and interesting challenge to the veterinary surgeon. The increasing popularity of camelids in North America means veterinarians are more likely to see them as patients; therefore, dealing with camelid fractures is quickly becoming part of the normal caseload. Because of the relatively high commercial value of most camelids, clients will usually be willing to pursue treatment.&#x0D; Camelids are considered to be excellent patients for the treatment of orthopedic injuries because of their relative low body weight, their ability to ambulate on three legs postoperatively, and tolerate external coaptation devices and prolonged periods of recumbency for recuperation after surgery. For these reasons, the veterinary surgeon has a full repertoire of repair techniques available to choose from when determining the ideal repair option. Not surprisingly, the scientific literature has lagged behind the relatively rapid rise in camelid popularity; there are currently 62 case reports on camelid long bone fracture fixation. This paper will review the published literature on the management of long bone fractures. Fracture management includes the preoperative, intraoperative and postoperative time periods. Emergency treatment, clinical workup, principles of fracture repair, treatment, and prognosis for specific long bone fractures and their complications will be discussed.

Increased distensibility in dependent veins following prolonged bedrest

Displacement of blood to the lower portion of the body that follows a postural transition from recumbent to erect is augmented by a prolonged period of recumbency (bedrest). Information is scarce as to what extent this augmented blood-volume shift to dependent veins is attributable to increased distensibility of the veins. Accordingly, we studied the effect of 5 weeks of horizontal bedrest on the pressure-distension relationship in limb veins. Elevation of venous distending pressure was induced by exposure of the body except the tested limb to supra-atmospheric pressure with the subject seated in a pressure chamber with one arm, or supine with a lower leg, protruding through a hole in the chamber door. Diameter changes in response to an increase of intravenous pressure (distensibility) from 60 to about 140 mmHg were measured in the brachial and posterior tibial veins using ultrasonographic techniques. Prior to bedrest, the distensibility was substantially less in the tibial than in the brachial vein. Bedrest increased (P < 0.01) pressure distension in the tibial vein by 86% from 7 +/- 3% before to 13 +/- 3% after bedrest. In the brachial vein, bedrest increased (P < 0.05) pressure distension by 36% from 14 +/- 5% before to 19 +/- 5% after bedrest. Thus, removal of the gravity-dependent pressure components that act along the blood vessels in erect posture increases the distensibility of dependent veins.

Cerebral Injury from Intracarotid Injection in an Alpaca (Vicugna Pacos)

A mixture of ketamine, xylazine, and butorphanol was inadvertently injected into the right carotid artery of a 1-year-old alpaca. Injection was followed by a brief period of recumbency and seizure activity. The alpaca recovered, but was euthanatized 72 hr later because of development of progressive neurologic deficits. Pathologic findings were confined to the right cerebrum, meninges, thalamus, and hippocampus. Cerebrocortical edema with astrocytic reaction, perivascular hemorrhage and neutrophilic infiltration, and fibrinoid necrosis of vasculature within the meninges and thalamus were the most prominent lesions. Neuronal necrosis was mild. Astrocytic reaction within the right cerebral cortex was confirmed with immunohistochemistry for glial fibrillary acidic protein.

Anesthesia in xylazine premedicated donkeys with ketamine and ketamine-propofol mixture: A comparative study

This study was conducted to evaluate the anesthetic quality produced by ketamine hydrochloride (K) (3 mg/kg, I.V.) and ketamine–propofol (K-P) mixture (2 mg/kg-1 mg/kg, I.V., respectively) in six donkeys premedicated with xylazine (X), (1 mg/kg, I.V.). Each donkey was anesthetized one time with each dose of (K) and (K-P), five minutes after (X) administration, in random order at (1) week intervals. The anesthetic parameters; induction and sleeping time, abolishment of the swallowing reflex, recumbencey period, cardiopulmonary responses, were qualitatively and quantitatively assessed. The results revealed presence of significant difference (p< 0.05) in the induction and sleeping time between (K) and (K-P) protocols. Neither the swallowing reflex, nor recumbency period represented statistical difference between (K) and (K-P) protocols. But clinically, anesthesia with (K-P) produced shorter and smoother recovery to recumbency than with (K), and the swallowing reflex was abolished while persisted with (K) anesthesia. The excellent anesthesia produced with K-P was characterized by smooth, calm, gradual and free of excitement induction (23.75±1.75 sec), good narcosis (22.50±3.57 minutes) and muscle relaxation. The swallowing reflex was abolished for (15.75±5.61 minutes). The recumbency period was characteristically smooth and featured by its rapidness (10.50±2.62 minutes). While on the other hand, induction of anesthesia with (K) protocol was characterized by rough, slow and excitement (56.25±8.44 sec), muscle rigidity, and persistence of the swallowing reflex (not disappeared or slightly disappeared). The shorter sleeping time (10.5±0.95 minutes) and the longer recumbencey (14.75±2.28 minutes) periods that was associated with violent convulsion and excitement, were clinically an obvious associate with (K) anesthesia. The intubations with (K-P) anesthetic protocol was easily performed, but was difficult or failed during (K) anesthesia.In conclusion, anesthesia with (K-P) protocol produced an excellent anesthetic mixture for induction of general anesthesia in donkeys, and up to our knowledge this the first report on the use of this mixture for total intravenous anesthesia in donkeys.

Determinants of Abnormal Supine Reflux in 24-Hour pH Recordings

A previous study showed that supine gastroesophageal reflux occurs mainly in the early nighttime period and is greater if the patient retires within 2 hr of a meal. We analyzed 306 consecutive esophageal pH studies between January and July 2003. Ninety-two patients had abnormal supine reflux. The recumbent period was divided into quarters (Q1-Q4) and reflux parameters were calculated for each period. Reflux was maximal in Q1, and decreased progressively from Q1 to Q4 (P<0.001). Median time between evening meal and retiring was no different from that for 44 upright gastroesophageal reflux patients. Patients retiring within 2 hr of a meal had a higher percentage supine reflux time (P=0.012), but no increase in reflux was observed in those retiring within 3 hr. Supine reflux occurs maximally in the early nighttime period. Although not fully explained as a postprandial phenomenon, these patients should avoid going to bed within 3 hr of a meal.

Comparison of recoveries from anesthesia of horses placed on a rapidly inflating-deflating air pillow or the floor of a padded stall

To compare recoveries from anesthesia of horses placed on a conventional padded stall floor or on a specially designed air pillow. Prospective study. 409 horses (> 1 year old) that were anesthetized for surgical procedures during a 37-month period. By random allocation, horses were allowed to recover from anesthesia in either a foammat-padded recovery stall or an identical recovery stall equipped with a rapidly inflating-deflating air pillow. All recoveries were videotaped for subsequent analysis by an independent evaluator. Times to first movement, first attempt to attain sternal recumbency, attainment of sternal recumbency, first attempt to stand, and successful standing were recorded. The numbers of attempts before achieving sternal recumbency and standing were counted, and scores for quality of standing and overall recovery were assigned. Recovery-related variables were compared between groups. Compared with horses allowed to recover in a conventional manner, horses that recovered from anesthesia on the air pillow had a significantly longer rest period before attempting to attain sternal recumbency and rise to standing. Once the pillow was deflated, horses were able to stand after significantly fewer attempts and the quality of their standing was significantly better. Between the 2 groups of horses, there was no significant difference in overall recovery quality scores. The air pillow and padded floor systems were equally safe. Results suggested that use of a rapidly inflating-deflating air pillow promotes a longer period of recumbency and a better quality of standing after anesthesia in horses.

Fracture management in llamas and alpacas

Fracture management in llamas and alpacas present a unique and interesting challenge to the veterinary surgeon compared to other species. Camelids are considered to be excellent patients for the treatment of orthopedic injuries because they have a relative low body weight, tolerate external coaptation devices, are able to ambulate on three legs post-operatively, and can tolerate prolonged periods of recumbency for recuperation after surgery. Reports in the literature on camelid fractures (28 cases) and the authors’ experiences with an additional 38 fractures are reviewed. There are a number of repair techniques that can be employed, depending primarily on fracture configuration and the surgeon's experience. Complications to fracture repair include mal-union, delayed union, non-union, osteomyelitis, sequestrum formation, and implant failure. Complications are associated with damage to the neurovascular bundle, damage to adjacent soft tissue at the fracture site, and compound fractures. Complications may be managed through the use antibiotics, surgical debridement, and staged destabilization of the fixation device. When irreversible damage to the neurovascular bundle has occurred, limb amputation with or without a prosthetic device may be alternatives to euthanatizing the patient.

Nighttime Reflux Is Primarily an Early Event

Our clinical impression gleaned from reading large numbers of ambulatory pH studies is that recumbent reflux episodes mostly occur in the early part of the nighttime period. In this study, we propose to test this hypothesis. A total of 201 consecutive pH studies performed in our laboratory between November 2001 and October 2002 were analyzed. Population characteristics: 75 males and 126 females; mean age, 50.4 yrs (range, 16-88 years). Reflux was defined by a drop in pH to less than 4. Abnormal total recumbent reflux was defined as >1.2% time pH < 4. For patients with abnormal recumbent reflux, the recumbent period was divided into two halves and the reflux time in each period was calculated. In all patients, ingestion of a meal within 2 hours of retiring was also identified. A total of 59 patients had abnormal recumbent reflux: 24 males and 35 females; mean age, 48.9 years. In patients with abnormal recumbent reflux, acid reflux was significantly more frequent in the first half of the recumbent period compared with the second half (median, 6.3%; vs. 0.3%, respectively; P < 0.001; Wilcoxon signed rank test, two-tailed analysis). Those patients (N = 118) having had a meal within 2 hours of retiring were 2.46 times more likely to develop recumbent reflux than those whose last meal was more than 2 hours earlier (N = 83). These results support our hypothesis that nighttime reflux occurs primarily during the first half of the recumbent period. In addition, they reinforce the concept of maintaining control of early nighttime reflux and the importance of counseling patients with nocturnal symptoms against late meals and snacks.

Evaluation of Kidney Anomalies in Congenital Scoliosis

Evaluation of Kidney Anomalies in Congenital Scoliosis

Perioperative Considerations in the Geriatric Patient With a Hip Fracture

Summary: Geriatric fracture patients deserve special considerations in the perioperative period. The goal of geriatric fracture management is restoring mobility and limiting a prolonged recumbency period. A comprehensive multidisciplinary approach involving surgical, medical, rehabilitation, and social work specialists is advocated. Indications, surgical timing, and optimization of comorbid conditions are important issues to be addressed. In addition, anesthesia and postoperative pain control require individual attention in this population. Serving as the background to all these issues are the varied social needs of the elderly who could have a limited support network. This review focuses on the current recommendations for perioperative management of the geriatric patient with a hip fracture.

The influence of bedding on the time horses spend recumbent

To determine if bedding has any influence on the time horses spend recumbent, 8 horses kept on straw and 8 kept on wood shavings were observed from 10:00 pm to 5:30 am for two successive nights. Observations were conducted using time-lapse video recordings. Lying down and rising behavior, as well as frequency and duration of bouts spent in lateral and sternal recumbency, was registered. The results showed that horses on straw were lying in lateral recumbency three times longer than horses on shavings (P < .001), whereas the time horses spent in sternal recumbency did not differ. The longest period of noninterrupted lateral recumbency was longer for horses on straw than for those on shavings. Because horses must lie down, preferably in lateral recumbency, to achieve paradoxical sleep, the reduced time spent in lateral recumbency in horses on wood shavings may affect their welfare and performance. Independent of the bedding, we further observed that, as the horses got up from recumbency, most of them made attempts to roll over before rising. This behavior appeared to be caused by some difficulty in rising, possibly due to the box size, and might have a connection with the fact that horses sometimes get stuck against the box wall.