Closure of Large Percutaneous Femoral Venous Access Using a Modified "Figure-of-Eight" Suture.

Recent advances in different percutaneous treatments made insertion of large-caliber sheaths in the femoral veins more common. Venous punctures are historically managed by initial manual compression with subsequent application of a compression bandage and bed rest. We describe a modified "figure-of-eight" suture technique for minimizing the risk of accidental puncture of the vein while grabbing the subcutaneous tissue. We examined the safety and feasibility of this technique combined with early mobilization in a real-world setting. We performed a retrospective analysis on 56 consecutive patients undergoing percutaneous mitral valve repair using large femoral venous access. The patient population was heterogeneous and bleeding risk characteristics were common. Bleeding Academic Research Consortium Consensus (BARC)-classifiable bleeding complications occurred in eight patients (14%), BARC of two events or more in five patients (8.9%), and BARC of three or more event in only one patient (1.8%), which is a comparable success rate to large venous access closure with suture-mediated closure devices. No BARC Type 3b or BARC Type 5 bleeding occurred. During routine clinical follow-up, no groin-related problems were reported in all patients. Closure of large femoral venous access using a modified temporary subcutaneous figure-of-eight suture in combination of a light compression bandage and bed rest for 2 to 4 hours provides a safe and low-cost alternative to closure devices for early mobilization.

Indirect costs in chronic obstructive pulmonary disease: a review of the economic burden on employers and individuals in the United States.

OBJECTIVE: To review and summarize existing literature on the indirect burden of chronic obstructive pulmonary disease (COPD) in the US. METHODS: Medline, Scopus, and OvidSP databases were searched using defined search terms to identify relevant studies. Eligible studies were published in English between January 2000 and April 2012 and calculated the indirect burden of COPD in a US population in terms of prevalence, incidence or costs of productivity loss, disability, morbidity, or mortality. RESULTS: Of 53 studies identified, eleven met eligibility criteria, with data years spanning 1987-2009. Estimates of workforce participation range from 56% to 69% among individuals with COPD and from 65% to 77% among individuals without COPD. Approximately 13%-18% of those with COPD are limited in the amount or type of work they can do and one-third or more experience general activity limitation. Estimates of restricted activity days range from 27-63 days per year. Estimates of mean annual sick leave and/or disability days among employed individuals with COPD range from 1.3-19.4 days. Estimates of bed confinement range from 13-32 days per year. Estimated mean annual indirect costs were $893-$2,234/person (US dollars) with COPD ($1,521-$3,348 in 2010 [US dollars]) and varied with the population studied, specific cost outcomes, and economic inputs. In studies that assessed total (direct and indirect) costs, indirect costs accounted for 27%-61% of total costs, depending on the population studied. CONCLUSIONS: COPD is associated with substantial indirect costs. The disease places a burden on employers in terms of lost productivity and associated costs and on individuals in terms of lost income related to absenteeism, activity limitation, and disability. Consideration of indirect as well as direct costs is necessary to gain a more complete view of the societal burden of COPD.

Rest easy? Is bed rest really necessary after surgical repair of an ankle fracture?

INTRODUCTION: Bed rest with elevation of the affected limb is commonly prescribed postoperatively following ankle fracture fixation although there is no evidence that this is necessary. AIM: The aim of this prospective, randomised study was to investigate the effects of early mobilisation following surgical fixation of an ankle fracture on wound healing and length of stay (LOS). METHOD: A total of 104 patients underwent primary internal fixation of an ankle fracture at The Alfred hospital, Melbourne between July 2008 and January 2010. INTERVENTION: The strategy included either early mobilisation group (first day post surgery) or control group (bed rest with elevation until day 2 post surgery). OUTCOME MEASURES: Data collected included demographic, injury type and surgical procedure. Outcome data included inpatient LOS, wound condition at 10-14 days, opioid use and re-admission rate. RESULTS: Groups were comparable at baseline. Wound breakdown rate was 2.9% (3 patients in the control group). Median LOS of the early mobilisation group was 55 h compared with 71 h in the control group (p<0.0001). Opioid use for the control group was an average of 90 mg morphine equivalent in the first 24 h post surgery compared with 67 mg morphine equivalent for the early mobilisation group (p=0.32). CONCLUSION: This study indicates that early mobilisation following surgical fixation of an ankle fracture results in a shorter hospital stay without evidence of an increased risk of re-admission or wound complication.

Disability days in Canada associated with dental problems: a pilot study.

OBJECTIVE: The aim of this study was to explore disability days, or bed days and cut-down days, associated with dental problems in Canada. METHODS: Data were collected through a national telephone interview survey of 1005 Canadians aged 18 years and over using random digit dialling. Participants were asked to enumerate the number of disability days associated with dental problems in the previous 2-week period. Descriptive and bivariate logistic regression analyses were undertaken. RESULTS: In the previous 2-week period, 33 people, or 3.3% of the sample, reported spending a day in bed because of a dental problem. Of these, 22 people also reported having to cut down on their normal activity because of the dental problem. It appears that younger age groups, those with the lowest incomes, college educations, no dental insurance, oral pain and a history of visiting a hospital emergency room for a dental problem, were all more likely to report a dental disability day. CONCLUSIONS: These data demonstrate the potential economic impacts of dental problems in Canada, yet they must be interpreted with caution because of the very low prevalence of the main outcome measure, the potential for selection bias and the relative inconsistency with existing historical estimates.

Bed rest in pregnancy.

The use of bed rest in medicine dates back to Hippocrates, who first recommended bed rest as a restorative measure for pain. With the formalization of prenatal care in the early 1900s, maternal bed rest became a standard of care, especially toward the end of pregnancy. Antepartum bed rest is a common obstetric management tool, with up to 95% of obstetricians utilizing maternal activity restriction in some way in their practice. Bed rest is prescribed for a variety of complications of pregnancy, from threatened abortion and multiple gestations to preeclampsia and preterm labor. Although the use of bed rest is pervasive, there is a paucity of data to support its use. Additionally, many well-documented adverse physical, psychological, familial, societal, and financial effects have been discussed in the literature. There have been no complications of pregnancy for which the literature consistently demonstrates a benefit to antepartum bed rest. Given the well-documented adverse effects of bed rest, disruption of social relationships, and financial implications of this intervention, there is a real need for scientific investigation to establish whether this is an appropriate therapeutic modality. Well-designed randomized, controlled trials of bed rest versus normal activity for various complications of pregnancy are required to lay this debate to rest once and for all.

Cost of hospital care for elderly at risk of falling.

The variables that relate to cost of hospital care for a large sample of elderly patients at risk for falling are examined. The chief predictors of cost of hospitalization were medical, pharmacy, and nursing interventions. Use of nursing interventions, on average, raised the median hospital cost less than use of medical or pharmacy interventions. Using a standardized nursing language with the hospital's information system can provide nurses with information that demonstrates the cost effectiveness of their interventions.

Antepartum bed rest: effect upon the family.

OBJECTIVE: To identify the effects of antepartum bed rest upon the family. DESIGN: Descriptive, retrospective survey. PARTICIPANTS: A national random selection of 89 women who had been prescribed antepartum bed rest in the hospital or at home and who contacted a high-risk pregnancy support group for information. MAIN OUTCOME MEASURE: An open-ended questionnaire. RESULTS: Families experienced difficulty assuming maternal responsibilities, anxiety about maternalfetal outcomes, and adverse emotional effects on the children. Child care was managed by various people across time. Child care problems included negative reactions from the children, concern about the quality of the provider, and maternal worry about care. Families also experienced financial difficulties, the majority of which were not compensated by insurance or work benefits. Almost all, 96.6%, families received some type of support during bed rest. Instrumental support was the most commonly received; however, emotional support was considered the most helpful. The least helpful type of support was that which was unreliable. The primary providers of support to the family were parents and family, followed by friends. The women reported that health care providers offered minimal support to the family. CONCLUSION: Despite support, antepartum bed rest creates difficulties that affect the entire family and its finances.

Effects of continuous lateral rotation therapy on pulmonary complications in liver transplant patients.

BACKGROUND: When liver transplant candidates and recipients suffer from pulmonary complications of immobility, the results can be life-threatening. Continuous lateral rotation therapy has been reported to decrease complications of immobility. OBJECTIVES: To determine whether continuous lateral rotation therapy decreases the duration of mechanical ventilation, intensive care unit length of stay, incidence or resolution of atelectasis, incidence or onset time of lower respiratory tract infection and pneumonia. METHODS: Sixty-nine subjects admitted to a liver transplant intensive care unit at a university teaching hospital were randomly assigned to continuous lateral rotation therapy or a stationary bed. All subjects were mechanically ventilated for 24 hours and had a Glasgow Coma Scale score of 11 or less upon admission to the study. Subjects were followed until out of bed, unable to rotate for 3 consecutive days, or transferred from the intensive care unit. Data and chest roentgenogram results were collected on admission and daily during the study. Sputum culture results were obtained if available as part of normal patient care. RESULTS: Incidence of lower respiratory tract infection was significantly lower and length of time to occurrence of lower respiratory tract infection was significantly longer in the continuous lateral rotation therapy group than in the stationary bed group. CONCLUSIONS: Although continuous lateral rotation therapy did not affect duration of mechanical ventilation, length of stay, or incidence of atelectasis, it was effective in decreasing the incidence of, and increasing onset time to, lower respiratory tract infection in the liver transplantation population.

The treatment of acute low back pain--bed rest, exercises, or ordinary activity?

BACKGROUND: Bed rest and back-extension exercises are often prescribed for patients with acute low back pain, but the effectiveness of these two competing treatments remains controversial. METHODS: We conducted a controlled trial among employees of the city of Helsinki, Finland, who presented to an occupational health care center with acute, nonspecific low back pain. The patients were randomly assigned to one of three treatments: bed rest for two days (67 patients), back-mobilizing exercises (52 patients), or the continuation of ordinary activities as tolerated (the control group; 67 patients). Outcomes and costs were assessed after 3 and 12 weeks. RESULTS: After 3 and 12 weeks, the patients in the control group had better recovery than those prescribed either bed rest or exercises. There were statistically significant differences favoring the control group in the duration of pain, pain intensity, lumbar flexion, ability to work as measured subjectively, the Oswestry back-disability index, and number of days absent from work. Recovery was slowest among the patients assigned to bed rest. The overall costs of care did not differ significantly among the three groups. CONCLUSIONS: Among patients with acute low back pain, continuing ordinary activities within the limits permitted by the pain leads to more rapid recovery than either bed rest or back-mobilizing exercises.

Bed rest in pregnancy.

OBJECTIVE: To summarize existing data about the effectiveness of bed rest when used to improve various pregnancy outcomes and to determine how often bed rest is used and the cost associated with its use. DATA SOURCES: We used the MEDLINE data base to search for all English language papers evaluating the effectiveness of bed rest in pregnancy. We also reviewed a number of textbooks and the 1988 National Infant Mortality Survey. METHODS OF STUDY SELECTION: We reviewed these sources for recommendations about using bed rest in various obstetric conditions. We used the 1988 National Infant Mortality Survey to determine how often bed rest was used either to prevent or to treat various obstetric conditions and estimated the costs associated with its use. DATA EXTRACTION AND SYNTHESIS: Bed rest is used in nearly 20% of all pregnancies to prevent or treat a wide variety of conditions, including spontaneous abortion, preterm labor, fetal growth retardation, edema, chronic hypertension, and preeclampsia. There is little evidence of effectiveness. The estimated costs associated with bed rest, including hospitalization, lost wages, and lost domestic productivity, range from more than $250 million to billions of dollars per year. CONCLUSIONS: Bed rest is used extensively to treat a wide variety of pregnancy conditions, at substantial cost but with little proof of effectiveness. We recommend that because this intervention has failed the test of effectiveness, its use during pregnancy should be curtailed unless randomized trials demonstrate improvement in a specific outcome.

The Northwestern University Triplet Study. II: Fourteen triplet pregnancies delivered between 1981 and 1986.

Fourteen triplet deliveries conducted between 1 January 1981 and 30 June 1986 at the principal teaching hospitals of Northwestern University Medical School are reviewed. Maternal demographic characteristics are listed, as are the obstetric outcomes, including mode of delivery, and the fetal outcome. The recent literature of triplet delivery is reviewed. The rate of triplet delivery in our study was 0.37 per 1,000 live births. About two-thirds of the pregnancies resulted from the use of fertility-inducing agents. Ultrasonic confirmation was available in all cases. The majority of women were delivered by cesarean section (85%). No consistent pattern of presentation was seen. The mean weight of all 42 infants was 1,779 g (+/- 594). Unlike-sex triplets accounted for most of the sets (77%). The mean 5-min Apgar score of all infants was 9 and had no association with the order of deliveries. The weight differences by sex regardless of birth order were clinically insignificant. Neonatal mortality was 2.3%.

Bed rest in twin pregnancy: identification of a critical period and its cost implications.

Since twin pregnancies often result in poor perinatal outcomes, many physicians advise prolonged bed rest. Recommendations concerning the timing of bed rest conflict and are made with little assessment of costs. This review of twin pregnancies in the North Central Illinois perinatal region establishes that twins are most vulnerable if they are born between 27 and 34 weeks' gestation. If bed rest is to be imposed, it probably should be timed so as to influence this vulnerable period. Intervention (bed rest in the hospital from 27 to 34 weeks' gestation) would cost between $5,720 and $6,909 per twin pregnancy, whereas nonintervention (intensive care nursery charges for infants born before 34 weeks' completed gestation) would cost $1,689 per twin pregnancy. Before intervention can be universally advocated and costs of this magnitude incurred, a prospective controlled trial to determine the efficacy of bed rest in twin pregnancy is mandatory.