Strict Bed Rest Research Articles

How long is strict bed rest necessary after renal biopsy?

No consensus exists on the amount of bed rest required after renal biopsy. Moreover, forced prolonged bed rest can be uncomfortable in patients undergoing renal biopsy. To evaluate whether the length of strict bed rest affects the incidence of pain and other complications after renal biopsy. STUDY DESIGN, FACILITY, AND PATIENTS: This single-center retrospective observational study was conducted in 94 consecutive patients undergoing biopsy of a native kidney between November 2005 and December 2006 at Mie University Hospital. The control group was composed of 317 patients who underwent biopsy of a native kidney between January 2001 and October 2005. The incidence of biopsy-related complications was compared between two periods of strict bed rest: 2 h of strict bed rest with no abdominal bandage (November 2005 to December 2006) and 7 h of strict bed rest with an abdominal bandage (January 2001 to October 2005). The primary outcome was the incidence of back pain requiring analgesics. The secondary outcomes were: need for transfusion or hemostatic intervention, decrease of >/=10% in hemoglobin (Hb) after biopsy, macroscopic hematuria, infection possibly related to biopsy, need for single or indwelling bladder catheterization, and other biopsy-related complications. The incidence of back pain requiring analgesics decreased with a shorter period of strict bed rest [7.5% versus 21.1%, odds ratio (OR) 0.30, 95% confidence interval (95% CI) 0.12-0.64, p = 0.004]. Even after adjustment for age, sex, perinephric hematoma size, and number of biopsy punctures, the incidence of back pain decreased significantly (OR 0.34, 95% CI 0.14-0.73, p = 0.01). With a shorter period of strict bed rest, there were no significant differences in bleeding complications (need for transfusion or other hemostatic intervention), decrease of >or=10% in Hb or macroscopic hematuria. However, the need for indwelling bladder catheterization decreased significantly (36.2% versus 50.5%, OR 0.55, 95% CI 0.34-0.88, p = 0.013). Shortening the period of strict bed rest after renal biopsy from 7 h to 2 h decreased the incidence of back pain, but there was no increase in bleeding or other biopsy-related complications. Our findings suggest that a shorter period of strict bed rest can safely reduce discomfort in renal biopsy patients.

Orthopedics in the Graeco - Roman era

In this study the evolutionary development of orthopedics (management of diseases of bones and joints), which commenced in early Mesopotamia and Egypt, is followed through Classical times.The Greek infl uence probably commenced in the 6thcentury BC with Democedes of Croton who cured the Persian king’s dislocated ankle. The Corpus Hippocraticum laid the foundation of orthopedic practice in antiquity. Although knowledge of anatomy was limited, its four books on orthopedics (The Nature of Bones, Mochlicon, On Fractures, On Joints) count amongst the outstanding contributions of Hippocratic writers. In systematic manner the general recognition and management of fractures and dislocations are covered, followed by the handling of individual lesions. Hippocrates differentiated between closed and open fractures (with overlaying skin wounds). Closed fractures were reduced to as normal a position as possible – manually where possible, but with large bones and in the presence of formidable muscle mass, mechanical traction was often employed (e.g. the Hippocratic bench and the bizarre succusion ladder for spinal deformities). There is no mention of the use of analgetic drugs. After application of cerate (mixture of olive oil, soda and pitch) to the skin, the fracture was immobilized by a combination of plasters and compresses (often fi rmed up with gum-mixtures) – but never very fi rmly. On the 3rd, 6/7th, 9thand 12th days the bandaging was removed, the lesion inspected and if considered necessary, re-aligned, A variety of splints were then applied. Strict bed rest was enforced, as well as a light diet (no wine or meat for 10 days). It was believed that fractures of the feet, clavicle, ribs and jaw healed after 20 days, of the forearm after 30 days, and fractures of the upper arm and leg after 40 days. Open fractures were considered very serious injuries, and reduced very carefully. Protruding bone fragments were removed (sawn off if necessary) and the wound was covered with black cerate, compresses and light bandages. Pressure and heavy splints were thought to induce infection and gangrene and thus avoided. Dislocations were reduced as soon and as effectively as possible, before muscle spasm set in. As with fractures manual reduction was, where necessary, complemented by mechanical traction. After extensive washing of the joint area with warm water, cerate was applied to the wound and specialised bandaging (even splints) ensured immobilization. Open dislocations like open fractures were considered very serious and reduction was not attempted. Again all pressure bandaging was avoided. A non-functional joint was commonly the end result. The management of 18 specifi c fractures is described in detail. Jaw fractures were fi xed by the binding of contiguous teeth. Fractures of the spinal column clearly presented a major problem. Although knowledge of spinal anatomy was surprisingly good, the diagnosis of fractures was very difficult and its association with spinal curvatures presented almost insurmountable problems of management. It was recognized that rib fractures could cause serious damage to the lung and pleura. Complex problems caused by arm fractures involving the elbow or shoulder joints, and combined radius and ulna fractures, are addressed. Femur fractures presented major problems and permanent leg deformity was very common. Open femur fractures were extremely serious and Hippocrates even stated that a physician who could ethically avoid becoming involved in treating such an injury, should do so. Fractures of femur necks were not recognised. The Hippocratic work, Wounds of the head, dealing with fractures of the skull, is not covered in this study.Management of the major joints are individually described. Seven different techniques of reducing a dislocated shoulder joint are mentioned The original description of the management of the dislocation of the wrist and hand is lost. Proper reduction of hip-dislocation was essential to avoid muscle atrophy and life-long limping, and was achieved by intricate mechanical suspension. Strangely enough, lateral dislocation of the knee was a common occurrence and not seen as a serious problem. Congenital club feet were effectively treated by prolonged fi xation in the correct position by way of tight bandaging with compresses stiffened in glue-mixtures.There is abundant skeletal evidence of osteo-arthritis in Neolithic man, but no clear description of it in the Corpus Hippocraticum. Gout is repeatedly mentioned in the Corpus but without detailed descriptions of the disease. In the Roman era authors like Heliodorus, Antyllus and Celsus in particular, wrote authoritatively on orthopedic subjects, Osteo-archaeological evidence is that fractures were treated expertly in the Roman army. Conditions consistent with degenerative osteoarthritis and true gout (as podagra and chiragra) were described by Celsus and Aretaeus of Cappadocia. Soranus, Rufus of Ephesus and Galen also wrote on orthopedic subjects. We will today differ from many statements made in the Corpus Hippocraticum, but it is clear that the orthopedic basis laid by those documents was not seriously challenged for 1 000 years.

Prevention of bone loss during 56 days of strict bed rest by side-alternating resistive vibration exercise

Bed rest is a recognized model for muscle atrophy and bone loss in space flight and in clinical medicine. We hypothesized that whole body vibration in combination with resistive exercise (RVE) would be an effective countermeasure. Twenty healthy male volunteers underwent horizontal bed rest for 56 days and were randomly assigned either to a group that performed RVE 11 times per week or to a group that underwent bed rest only (Ctrl). Bone mineral content (BMC) was assessed by peripheral quantitative computed tomography (pQCT) in the tibia and the radius and by dual x-ray absorptiometry (DXA) in the hip and lumbar spine at baseline and at regular intervals during bed rest and a 12-month follow-up. RVE appeared to protect muscle size and function, and it also prevented bone loss ( p-values between < 0.001 and 0.01). Bone losses were largest in the distal tibia epiphysis, where BMC declined from 421.8 mg/mm (SD 51.3) to 406.6 mg/mm (SD 52.7) in Ctrl, but only from 411.1 mg/mm (SD 56.6) to 409.6 mg/mm (SD 66.7) in RVE. Most of the BMC losses were recovered by 12-month follow-up. Analyses showed that the epiphyseal cortex, rather than spongiosa, depicted the most pronounced changes during bed rest and recovery. These results suggest that the combined countermeasure applied in this study is effective to prevent bone losses from the tibia. This underlines the importance of mechanical usage for the maintenance of the human skeleton.

Early mobilization after total knee replacement reduces the incidence of deep venous thrombosis

Both chemical and mechanical methods of prophylaxis have reduced the incidence of thromboembolic complications following total knee replacement (TKR). Only a few studies have shown that mobilization on the first post-operative day further reduces the incidence of thromboembolic phenomena. We conducted a prospective study to verify not only if early mobilization but also whether the distance mobilized on the first post-operative day after TKR reduced the incidence of thromboembolic complications. The incidence of deep venous thrombosis and pulmonary embolism were compared in 50 consecutive patients who underwent TKR from July 2006 following a change in the mobilization protocol with 50 consecutive patients who underwent TKR before the protocol was instigated. The mobilization protocol changed from strict bed rest the first post-operative day to mobilization on the first post-operative day. Mobilization was defined as sitting out of bed or walking for at least 15-30 min twice a day. The distance mobilized was accurately recorded by the physiotherapists. All patients underwent duplex scans of both lower limbs on the fourth post-operative day. There was a significant reduction in the incidence of thromboembolic complications in the mobilization group (seven in total) compared with the control group (16 in total) (P= 0.03). Furthermore, in the mobilization group the odds of developing a thromboemobloic complication was significantly reduced the greater the distance the patient mobilized (Chi-squared linear trend = 8.009, P= 0.0047). Early mobilization in the first 24 h after TKR is a cheap and effective way to reduce the incidence of post-operative deep venous thrombosis.

Lack of effect of subject posture on intravenous midazolam clearance: implications for hepatic cytochrome P450 3A phenotyping

Intravenous (i.v.) midazolam is used to phenotype hepatic cytochrome P450 (CYP) 3A [1]. Midazolam clearance (CL) is believed to correlate with the intrinsic hepatic CL (CLint) of midazolam and thus acts as a surrogate for hepatic CYP3A activity. Midazolam is a moderate extraction ratio drug [2]. Based on the well-stirred model of hepatic clearance [3], midazolam CL depends on CLintand hepatic blood flow. Subject posture alters hepatic blood flow, is often not controlled during blood sample collection [1], and impacts pharmacokinetic studies [4]. The magnitude of posture-induced blood flow changes has been seen in a study of six subjects. Plasma midazolam CL decreased 48% in an ambulant (sitting/walking) posture compared with a supine posture [5] and suggests that changes in midazolam CL may be dependent on hepatic blood flow and not exclusively CYP3A activity. This study evaluated the effect of subject posture on midazolam CL to confirm previous findings. We quantified posture-induced hepatic blood flow changes with i.v. indocyanine green as a biomarker. Results are published elsewhere [6]. The Institutional Review Board of Bassett Healthcare (Cooperstown, NY, USA) approved the study. Written informed consent was obtained. Healthy adults 18–55 years old who were not on any medications were enrolled. Subjects were randomized to a 7-h supine or ambulant posture. A minimum of 7 days passed between study phases. Subjects maintained strict horizontal bed rest during supine posture. During ambulant posture, subjects were seated for the first 3 h and then allowed to stand, walk, or sit. Sessions began between 06.00 h and 07.00 h to minimize temporal variation [5]. Subjects fasted (except water) overnight and for the duration of each posture. To stabilize hepatic blood flow, subjects were in the assigned posture for 1 h prior to midazolam 0.025 mg kg−1 i.v. (midazolam hydrochloride, 1 mg ml−1 injection, North Chicago, IL, USA) administration. Eight blood samples were obtained over 6 h. Samples were centrifuged and stored at −80°C. Plasma concentrations were analysed by liquid chromatography/mass spectrometry/mass spectrometry as described elsewhere [7]. The linear range of the assay was 0.50–100 ng ml−1, with intra- and interday coefficients of variation of ≤7.9% at 0.75, 7.5 and 75 ng ml−1. Midazolam pharmacokinetics was determined by noncompartmental analysis (WinNonlin v3.1; Pharsight, Cary, NC, USA). Sample size calculations were based on previously published data [5, 8–10]. Using an α= 0.05 and β= 0.20, a sample size of 12 would detect a 25% difference in midazolam CL. Bioequivalence testing was used by calculating the least squares geometric mean ratios (LS-GMR; CLambulant/CLsupine) and 90% confidence intervals (CI). Bioequivalence was concluded if the 90% CIs were within the 80–125% interval. Thirteen (seven female) subjects completed both postures. Plasma midazolam concentrations vs. time are shown in Figure 1. Bioequivalence was observed for the geometric mean midazolam CLs in the supine and ambulant phases (595.6 vs. 565.1 ml min−1; LS-GMR 0.95, 90% CI 0.88, 1.02). Intersubject variation of midazolam CL was small, varying 1.7- and two-fold in the supine and ambulant postures, respectively. The volume of distribution (Vd) decreased 18% in the ambulant posture. The difference in Vd may be due to changes in tissue binding, but for CYP3A phenotyping in healthy adults this change is unlikely to be of clinical significance. Figure 1 Mean ± SD midazolam plasma concentrations vs. time in the ambulant (closed squares) and supine (open circles) postures (n= 13) Studies have observed posture-induced changes in hepatic blood flow of 17–37% for several medications [11, 12]. In the current study, subject posture did not affect midazolam CL. In contrast to the study of Klotz et al. [5], the current study used a smaller midazolam i.v. dose (0.025 vs. 0.075 mg kg−1), had a larger sample size (13 vs. 6), and had subjects remain fasting during the entire sampling period. Food intake increases hepatic blood flow and lasts up to 190 min [13]. We speculate that the small sample size and food intake may have affected midazolam CL in the Klotz et al. study [5]. Neither study reported the exact amount of time during the ambulant posture that subjects were in a sitting, walking and standing posture, and potential differences between subjects and studies may have existed in the amount of time spent in a specific ambulant position. Phenotyping studies using i.v. midazolam as a hepatic CYP3A probe do not need to control for subject posture during blood sample collection. These findings are not applicable when using oral midazolam to phenotype intestinal and hepatic CYP3A activity, as i.v. midazolam exclusively measures hepatic CYP3A.

The Effect of Bed Rest on Bone Turnover in Young Women Hospitalized for Anorexia Nervosa: A Pilot Study

Malnourished adolescents with anorexia nervosa (AN) requiring medical hospitalization are at high risk for skeletal insults. Even short-term bed rest may further disrupt normal patterns of bone turnover. The objective of the study was to determine the effect of relative immobilization on bone turnover in adolescents hospitalized for AN. This was a short-term observational study. The study was conducted at a tertiary care pediatric hospital. Twenty-eight adolescents with AN, aged 13-21 yr with a mean body mass index of 15.9 +/- 1.8 kg/m(2), were enrolled prospectively on admission. As per standard care, all subjects were placed on bed rest and graded nutritional therapy. Markers of bone formation (bone specific alkaline phosphatase), turnover (osteocalcin), and bone resorption (urinary N-telopeptides NTx) were measured. During the 5 d of hospitalization, serum osteocalcin increased by 0.24 +/- 0.1 ng/ml . d (P = 0.02). Urine N-telopeptides reached a nadir on d 3, declining -6.9 +/- 2.8 nm bone collagen equivalent per millimole creatinine (P = 0.01) but returned to baseline by d 5 (P > 0.05). Bone-specific alkaline phosphatase exhibited a decline that was strongly age dependent, being highly significant for younger subjects only [age 14 yr: -0.42 +/- 0.11 (P = 0.0002); age 18 yr: -0.03 +/- 0.08 (P = 0.68)]. Age had no effect on other outcome measures. Limitation of physical activity during hospitalization for patients with AN is associated with suppressed bone formation and resorption and an imbalance of bone turnover. Future interventional studies involving mechanical stimulation and/or weight-bearing activity are needed to determine whether medical protocols prescribing strict bed rest are appropriate.

A Forty-Year Follow-Up of the Dallas Bed Rest and Training Study: The Effect of Age on the Cardiovascular Response to Exercise in Men

In 1966, five 20-year-old men underwent a comprehensive physiological evaluation of the capacity for adaptation of the cardiovascular system in response to 3 weeks of bed rest and 8 weeks of heavy endurance training; these same participants were reevaluated before and after training at the age of 50. The aim of the present study was to reexamine these same men 40 years following the original assessments. In all three studies, minute ventilation and expired gases were analyzed during exercise testing with Douglas bag collection. Cardiac output (CO) was determined using the acetylene rebreathing technique. Compared with the original 30-year interval, the decline in maximal oxygen uptake (VO(2max)) (-11% vs -25%), maximal CO (+6% vs -11%), and maximal stroke volume (+10% vs -10%) were greater between 50 and 60 years of age. The annualized decline in VO(2max) (55 mL/min/y) between ages 50 and 60 was approximately fourfold higher than the decline between 20 and 50 years (12 mL/min/y). In the original five participants of the Dallas Bed Rest and Training Study, VO(2max) declined after 40 years of living due to a balanced decrease in central and peripheral determinants of oxygen uptake. The rate of decline in VO(2max) and its components accelerated after the age of 50 years secondary to age and clinical comorbidities. The net proportional decline in VO(2max) for a period of 40 years of life was comparable with that experienced after 3 weeks of strict bed rest at the age of 20 (27% vs 26%, respectively).

Bone loss in the lower leg during 35 days of bed rest is predominantly from the cortical compartment

Immobilization-induced bone loss is usually greater in the epiphyses than in the diaphyses. The larger fraction of trabecular bone in the epiphyses than in the diaphyses offers an intuitive explanation to account for this phenomenon. However, recent evidence contradicts this notion and suggests that immobilization-induced bone loss from the distal tibia epiphysis is mainly from the cortical compartment. The aim of this study was to establish whether this pattern of bone loss was a general rule during immobilization. We monitored various skeletal sites with different tissue composition during 5 weeks of immobilization.Ten healthy male volunteers with mean age of 24.3 years (SD 2.6 years) underwent strict horizontal bed rest. Bone scans were obtained during baseline data collection, at the end of bed rest and after 14 days of recovery by peripheral Quantitative Computed Tomography (pQCT). Sectional images were obtained from the distal tibia epiphysis (at 4% of the tibia's length), from the diaphysis (at 38%), from the proximal metaphysis (at 93%) and from the proximal epiphysis (at 98%), as well as from the distal femur epiphysis (at 4% of the femur's length) and from the patella.Relative bone losses were largest at the patella, where they amounted to −3.2% (SD 1.8%, p<0.001) of the baseline values, and smallest at the tibia diaphysis, where they amounted to −0.7% (SD 1.0%, p=0.019). The relative losses were generally larger from cortical than from trabecular compartments (p=0.004), and whilst all skeletal sites depicted such cortical losses, substantial trabecular losses were found only from the proximal tibia epiphysis.Results confirm that the differential losses from the various skeletal sites cannot be explained on the basis of trabecular vs. cortical tissue composition differences, but that endocortical circumference can account for the different amounts of bone loss in the tibia. The present study therefore supports the suggestion of the subendocortical layer as a transitional zone, which can readily be transformed into trabecular bone in response to immobilization. The latter will lead to cortical thinning, a factor that has been associated with the risk of fracture and with osteoarthritis.

Is spontaneous spinal epidural hematoma in elderly patients an emergency surgical case ?

Spontaneous spinal epidural hematoma (SSEH) is a rare condition requiring urgent diagnosis and treatment. Patients with SSEH typically present with acute onset of severe back pain and rapidly develop signs of compression of the spinal cord. The authors present a case with spontaneous resolution of SSEH which is extremely rare. We discuss a man who presented to our clinic with mild paraparesis at the seventh day of his symptoms. He had a history of poorly controlled hypertension and hypercholestrolemia requiring an antihyperlipidemic agent and anticoagulation. His upper level of hypoesthesia was at the third thoracic segment. Cervicothoracic SSEH was diagnosed by magnetic resonance imaging. Since there was a gradual recovery of the neurological deficits beginning 12 hours after the onset of symptoms, surgery was obviated and strict bed rest, serial neurological examinations, and pain controls with opiates were instituted. The neurological deficits showed complete recovery on the 25th day of the clinical course. SSEH is rare and immediate surgical decompression is suggested. Rapid neurological deterioration followed by early and progressive neurological recovery, confirmed by radiological resolution of the lesion, may indicate nonoperative treatment.

Need for a National Database for Splenic Trauma?

We would agree with the authors that the incidence of blunt splenic injury seen in district general hospitals seems to be decreasing and there is an increasing move towards non-operative management in such cases. We note in their paper that mean in-hospital stay for patients not undergoing surgery was 13 days but this ranged widely from 3–25 days. We have similar experiences in our practice and comparable dilemmas surrounding the management of such patients. We wonder what criteria were used to allow the patients to be safely discharged from hospital and why there was such a wide range of hospital stay. We also wonder what general advice was given to patients following discharge from hospital and specifically what advice was given around resumption of driving, daily activities and contact sports, etc. Several published papers and traditional advice recommend strict bed rest for up to 7 days following non-operative management of splenic trauma, 6 weeks before return to physical activity and 6 months before contact sports should be recommenced.1,2. However, these protocols are based on little evidence. In their large case series, Crawford et al.3 found only a 2% ‘late’ failure rate of a non-operative management strategy (failure occurring 3 days or more after admission) but all of these patients were still in hospital as a result of associated injuries. They concluded, therefore, that ‘in-hospital observation beyond the third day after injury is not necessary for most patients with splenic injury, who have no other reason to remain hospitalised’. However, other authors have reported failure rates of between 5–37%,4–7 Sanders and Civil8 finding the failures occurring on average on the fourth hospitalised day. Advice to remain free from physical activity for 6 weeks is largely based on in vitro experiments that have shown splenic wounds allowed to heal by secondary intention develop a ‘wound break strength’ (the physiological index of wound healing) equal to that of a normal spleen at 6 weeks following initial insult.9 Detrimental effects of an earlier return to physical activity before 6 weeks has yet to be shown in vivo. Advice to remain free from contact sports for 6 months is based on level 3 evidence and professional opinion rather than any scientific evidence. Interestingly, Pachter et al.10 recommended obtaining a follow-up computed tomography (CT) scan at 8 weeks' post-injury in patients keen to return to contact sports, only permitting a return to sport if the CT demonstrated complete resolution. Were there any cases of delayed rupture in the patients from the Royal Glamorgan Hospital? Radiological follow-up following non-operative management of splenic injury remains controversial. In this series, the authors followed up 6 patients with ultrasound and 4 patients with a varying number of CT scans. Although they comment on the significant radiation exposure to these patients, we wonder what criteria were used for determining which imaging modality to use and the timing and number of follow-up imaging in their patients. Follow-up imaging aims to exclude the development of progressive haematomas and pseudo-aneurysms of the splenic hilar vessels. Lyass et al.,11 in their published series, found only 1 patient (3%) whose splenic injury had deteriorated; however, a conservative management strategy in this case was continued and was ultimately successful. They concluded that: ‘follow-up imaging can be omitted in clinically stable patients with blunt splenic trauma of grades 1–3’. These findings correspond with those of Shafi et al.,12 who found a deterioration in radiological findings in 5% of patients, only one of whom required intervention. Sinha and colleagues did not comment on the outcome of the follow-up radiological investigations in their reported series or if there were any cases of late rupture in the non-operative group. Thus the role of follow-up imaging remains controversial. A number of bodies recommend a vaccination programme for asplenic patients and those undergoing elective splenectomy, so as to reduce the risks of sepsis.13 It is recommended that pneumococcal vaccine should be given at least 2 weeks prior to elective splenectomy, if possible, to allow for a peak functional antibody response, as hyposplenic/asplenic patients have been found to have a reduced ability to mount an antibody response to vaccines.14 As rates of failure of non-operative management of splenic trauma vary between 5–40%, we speculate whether all patients admitted with splenic trauma and treated conservatively should undergo routine vaccination immediately, as up to 40% may eventually require a splenectomy. As single-unit experience in the management of splenic trauma is likely to be limited, we wonder if a national database should be established, for patients with splenic injuries managed non-operatively, to allow surgeons both to manage and advise these patients, based on an increasingly established evidence base.

Safety of Early Mobilization of Patients With Blunt Solid Organ Injuries

Many surgeons believe that early mobilization of patients with blunt solid organ injuries increases the risk of delayed hemorrhage. To determine whether there is an association between the day of mobilization and rates of delayed hemorrhage from blunt solid organ injuries. Retrospective cohort study. Univariate and multivariate analyses were performed to determine the association of mobilization with delayed hemorrhage of a solid organ requiring laparotomy. Level I trauma center. Adults with blunt renal, hepatic, or splenic injuries were identified from a trauma registry. Medical records were used to determine the day of mobilization and to identify patients with delayed hemorrhage requiring laparotomy. Four hundred fifty-four patients with blunt solid organ injuries were admitted to the hospital for nonoperative management. Failure rates of nonoperative management were 4.0%, 1.0%, and 7.1% for renal, hepatic, and splenic injuries, respectively. No patients with renal or hepatic injuries failed secondary to delayed hemorrhage. Ten patients (5.5%) with splenic injuries failed secondary to delayed hemorrhage. Eighty-four percent of patients with renal injuries, 80% with hepatic injuries, and 77% with splenic injuries were mobilized within 72 hours of admission. Day of mobilization was not associated with delayed splenic rupture in multivariate analysis (odds ratio, 0.97; 95% confidence interval, 0.90-1.05). The timing of mobilization of patients with blunt solid organ injuries does not seem to contribute to delayed hemorrhage requiring laparotomy. Protocols incorporating periods of strict bed rest are unnecessary.

Metabolic Effects of 2 Days of Strict Bed Rest

To examine the possibility of whether 2 days of strict hospitalized bed rest would alter the metabolic profile (including insulin resistance as calculated by the quantitative insulin sensitivity check index or QUICKI) in both normal subjects and patients with type 2 diabetes in comparison with 2 days of normal activity. The design of this pilot study was a randomized, crossover protocol that evaluated the effects of strict bed rest versus normal activity in 5 healthy normal subjects and 5 healthy patients with type 2 diabetes. All study participants completed a screening visit for assessment of baseline health. All 10 study subjects completed the protocol without adverse events. Fasting plasma glucose, insulin, and C-peptide levels as well as several known risk factors for atherosclerosis were unchanged in both the subjects without diabetes and the patients with type 2 diabetes after 2 days of hospitalized bed rest. Insulin resistance demonstrated no significant change during the 48 hours of bed rest when compared with the mean value at baseline. This study demonstrates that 48 hours of bed rest has no significant effect on insulin resistance or standard metabolic variables in normal subjects and patients with type 2 diabetes. Therefore, achieving good glucose control in patients hospitalized for a period of 2 days or less does not necessitate early ambulation to prevent an increase in insulin resistance.

The Management of Heart Failure

It is an honor to contribute to this inaugural issue of Circulation: Heart Failure and to provide some personal reflections on the management of heart failure (HF). I will comment on the past and the present and will venture to make some predictions about the future of this important subject. In 1950, as a medical student, I first learned about the management of congestive HF from the first edition of Harrison’s Principles of Internal Medicine ,1 which had just been published. Management consisted of strict bed rest, sedation, dietary sodium restriction, digitalis, venesection, and administration of morphine and mercurial diuretics; the latter were only modestly effective and were administered by painful intramuscular injection. All of these measures (other than mercurial diuretics) had not changed for about a half century. I replaced Harrison as the cardiology editor of Harrison’s Principles of Internal Medicine for the sixth edition,2 which was published in 1970. The management of HF, while still adhering to the principles set forth in the first edition, included 3 new aspects: (1) control of fluid retention with the (then) new orally effective diuretics—thiazides, the powerful new loop diuretics, as well as potassium-retaining diuretics (because of the widespread use of these agents, the adjective “congestive” was gradually eliminated from the name of the condition); (2) recognition and vigorous treatment of the precipitating causes of HF, such as infection, pulmonary embolism, and arrhythmias; and (3) intravenous dopamine, the powerful new β-adrenergic agonist for the management of acute, decompensated HF, including cardiogenic shock. If we move forward 35 years and 10 editions of Harrison’s Principles of Internal Medicine , we come to the 16th edition, in which my chapter called attention to the importance of attempting to prevent HF in patients who were at risk for this condition but without overt …

Infekte der Hand

Delayed or insufficient surgical intervention of hand infections can lead to long periods of being unfit for work as well as severe functional disabilities of the hand. The reasons that surgery is delayed for too long can be due to trivialization of injuries or incorrect primary treatment. In order to avoid such severe complications following hand injuries the same diagnostic procedure must be implemented including examination of the case history must be carried out with patients who present with so-called trivial hand injuries as with patients with severe injuries. The operative planning and techniques are carried out much further than the edges of the assumed infection limits far into the healthy tissue without consideration of possible functional loss or residual defects. Plastic surgery and other reconstructive surgical measures are often subsequently necessary to correct defects. Antibiotic treatment is only implemented after adequate débridement and according to an antibiogram. In addition to sufficient immobilization and strict bed rest, early exercise, physiotherapeutic and ergotherapeutic mobilization are absolutely necessary.

Fibrin sealant for control of cerebrospinal fluid otorrhea

Cerebrospinal fluid (CSF) otorrhea is a potentially common complication of trauma or surgery involving the temporal bone and skull base. Traditional methods of controlling CSF otorrhea include observation with or without subarachnoid lumbar drainage of CSF, reinforcement of the incision, or surgical exploration with operative obliteration of the drainage pathway. In recent years, fibrin sealants have been demonstrated to prevent intraoperative bleeding and fluid leaks in a variety of surgical specialties. Here we describe 2 cases in which application of fibrin sealant to a CSF fistula resulted in closure of the fistula without requiring surgical exploration or repair. We believe that the in-office use of fibrin sealant is a safe and costeffective method to obliterate small CSF leaks arising from the temporal bone. 2. Case 1 A 54-year-old man presented with a 4-month history of gradually decreasing hearing and increasing tinnitus in his right ear. An audiogram revealed a right profound sensorineural hearing loss with a 0% speech discrimination score. Vestibular testing revealed a right vestibulopathy, with caloric responses of the right ear 44% weaker than those of the left ear. Magnetic resonance imaging scan demonstrated an enhancing mass within the right internal auditory canal consistent with an intracanalicular acoustic neuroma. The patient subsequently underwent resection of the acoustic neuroma through a right translabyrinthine approach. The eustachian tube was packed with a plug of muscle and the incus. The operative cavity was obliterated with an abdominal fat graft, and the lateral aspect of the defect was closed with hydroxyapatite cement. On the evening of postoperative day 1, the patient experienced clear drainage from his right ear canal. A computed tomographic scan of the head was obtained, which showed complete obliteration of the mastoid cavity with fat. There was no evidence of airfluid level to suggest CSF leak, and there was no evidence of ventricular dilation. Examination of the ear failed to demonstrate a tympanic membrane (TM) perforation. The drainage was collected for analysis and subsequently tested positive for the presence of β2-transferrin, indicating a CSF leak. On postoperative day 2, the patient was given stool softeners to prevent straining and was placed on strict bed rest, with the head of his bed at 45°. A lumbar drain was placed and set to midbrain with 50 to 80 cc drainage every 8 hours. Cerebrospinal fluid otorrhea persisted despite a functioning lumbar drain. A microscope was brought to the bedside. Again, no obvious perforation in the TM was identified. The source was thought to be through the medial posterior canal wall near the annulus. The TM was covered with a layer of EpiFilm (Medtronic Xomed Inc, Jacksonville, FL), and the external auditory canal (EAC) was filled with 2 to 3 cc of Tisseel fibrin sealant (Baxter Healthcare Corp, Deerfield, IL). No further otorrhea was noted after these interventions. The lumbar drain was kept at midbrain level for 72 hours, clamped for an additional 24 hours, and then discontinued. There was no further evidence of otorrhea and no evidence of fluid accumulation under the wound. The patient was then discharged home and had no evidence of recurrent CSF leak with more than 4 years of follow-up.

Analysis of the factors influencing headache and backache following lumbar puncture

= Abstract = Purpose :This study aimed to examine the factors influencing the appearance of headache and backache following diag nostic lumbar puncture in children, focusing on the need for strict bed rest after lumbar puncture. Methods :We studied 70 two-fifteen-year-old pediatric patients who underwent diagnostic lumbar puncture from July 2005 to July 2007 at Konkuk University Hospital. We divided them into two groups. Patients in the first group (n=24) were allowed free mobility and patients in the second group (n=46) were to have strict bed rest for four hours after puncture. Data were analyzed by age, sex, number of puncture attempts, cell counts and pressure in the cerebrospinal fluid (CSF), duration of bed rest, and occurrence of headache and backache. Results :The rate of complications was not significantly related to sex, age, presence of enterovirus, CSF pressure, or postural headache. The occurrence of headache was significantly correlated with white blood cell (WBC) count in CSF (P= 0.043). Symptom frequency did not differ significantly between the groups. Backache was significantly related to the frequency of puncture attempts (P=0.046). Conclusion :Strict bed rest following diagnostic lumbar puncture in children does not influence headaches and backaches. These are respectively related to the WBC count on the CSF profile and the frequency of attempts. Therefore, after lumbar puncture, absolute bed rest is not necessary and patients are more comfortable with free mobility. (Korean J Pediatr 2008;51:856-860)

Spontaneous intracranial hypotension: The syndrome and its complications

Spontaneous intracranial hypotension (SIH) is a syndrome that was largely unknown until the advent of MRI. The incidence of SIH is estimated at 5 per 100,000, which is half the incidence of subarachnoid hemorrhage. The major feature is a postural headache of acute or subacute onset. This headache is absent or minimal when the patient is lying down and rapidly worsens to great intensity when the patient sits or stands. Other features may include nausea, vomiting, vertigo, tinnitus, and marked exacerbation by Valsalva maneuver. SIH is due to a leak of cerebrospinal fluid from a tear in the dural membrane, which occurs most often at the exit zones where the cervical spinal roots leave the subarachnoid space. Other leak sites may be the vestibular system, the cribriform plate, or the pituitary fossa. If the leak continues, the brain loses buoyancy within the cranial space and sags toward the foramen magnum. This, in turn, may produce subdural hygroma or hematoma, brainstem compression, focal cranial nerve palsies, or cerebellar tonsillar herniation. The initial therapy is generally strict bed rest. If this fails, an epidural blood patch is usually successful in sealing the leak and restoring brain buoyancy. A significant minority of patients require a repeat epidural blood patch. If the blood patch fails, a surgical approach may be needed. Repair of the leak and restoration of brain buoyancy will stop the postural headache and, in most cases, will reverse the complications.

Complication rare de l’acidocétose diabétique : le pneumomédiastin

Pneumomediastinum is a rare condition with an incidence of 1/33,000. It can be a rare complication of diabetic acidoketosis. We present the cases of two diabetic patients and review the literature, focusing our analysis on the interrelationships between these two diseases. Both patients were young subjects, a 21-year-old woman and an 18-year-old man with type 1 diabetes who were admitted for acidoketosis. Clinically, the patients presented the cardinal signs of diabetes and a flu-like syndrome associated with dyspnea and chest pain. Physical examination revealed a poor general health status, tachycardia and polymnea, as well as a painful diffuse tumefaction of the neck with subcutaneous emphysema. Blood tests disclosed elevated glycemia and urine was positive for acetone. The diagnosis of severe metabolic acidosis was retained. The chest x-ray demonstrated the subcutaneous emphysema and air in the anterior mediastinum. On the computed tomography scan obtained in the second patient, the heart was silhouetted with a hyperlucent zone laterally. Treatment consisted in strict bed rest with oxygen therapy, fluid replacement, insulin and heparin. The pneumomediastinum resolved in both patients within three days on average. The causal effect of diabetic acidoketosis in the development of pneumomediastinum in our two patients was retained after ruling out all other potential causes, including chest trauma and asthma.

Acute Intracranial Subdural Hematoma After Epidural Steroid Injection: A Case Report

Objective Conservative treatment of lumbar radiculopathy includes bed rest, oral medications, physical therapy, spinal manipulation, mobilization, and epidural steroid injections. Intracranial subdural hematoma after accidental dural puncture is a rare and life-threatening complication of epidural steroid injections. In this report, we present a case of subacute intracranial subdural hematoma that developed after epidural steroid injection. Clinical Features A 40-year-old man was admitted to our clinic with severe persistent headache and vomiting for 2 days after epidural steroid injection for right leg pain. Intervention and Outcome The patient was hospitalized for epidural steroid injection for right leg pain in our pain clinic and was discharged the same day. Twenty-four hours later, he started having a headache. Despite the use of oral analgesics, his headache worsened, and he began to vomit particularly in the upright position. Magnetic resonance imaging of the brain displayed a right frontal subdural hematoma. The headache was relieved after strict bed rest, intravenous hydration, and analgesics. The patient was discharged with full recovery after 1 week. Conclusion Intracranial subdural hematoma after accidental dural puncture during epidural steroid injection is a rare complication. Persistent headache should be evaluated carefully for possible intracranial hematomas.

Reduction of Renal Stone Risk by Potassium-Magnesium Citrate During 5 Weeks of Bed Rest

Exposure to the microgravity environment of space increases the risk of kidney stone formation, particularly for calcium oxalate and uric acid stones. This study was performed to evaluate the efficacy of potassium alkali as potassium-magnesium citrate in reducing renal stone risk and bone turnover. This study was performed as a double-blind, placebo controlled trial. We studied 20 normocalciuric subjects randomized to either placebo or potassium-magnesium citrate (42 mEq potassium, 21 mEq magnesium, 63 mEq citrate per day) before and during 5 weeks of strict bed rest. The study was performed in the General Clinical Research Center and under a controlled dietary regimen composed of 100 mEq of sodium, 800 mg of calcium, 0.8 gm/kg animal protein and 2,200 kcal per day. Two 24-hour urine collections were obtained under oil each week for assessment of stone risk parameters and relative saturation of calcium oxalate, brushite and undissociated uric acid. Blood was also collected for determination of serum immunoreactive parathyroid hormone and vitamin D metabolites. Bed rest promoted a rapid increase in urinary calcium excretion of approximately 50 mg per day in both groups. Despite this increase subjects treated with potassium-magnesium citrate demonstrated significant decreases in the relative saturation of calcium oxalate and in the concentration of undissociated uric acid compared to placebo. Immunoreactive parathyroid hormone, serum 1,25-dihydroxyvitamin D and intestinal calcium absorption all decreased in both groups with no difference in response between the 2 treatment arms. Provision of alkali as potassium-magnesium citrate is an effective countermeasure for the increased risk of renal stone disease associated with immobilization. Despite an increase in urine calcium concentration, the relative saturation of calcium oxalate decreased due to citrate chelation of calcium and the concentration of undissociated uric acid decreased due to the significant increase in urine pH.