Sleeping with Elevated Upper Body Does Not Attenuate Acute Mountain Sickness: Pragmatic Randomized Clinical Trial.

PURPOSE: Acute mountain sickness commonly occurs following ascent to high altitude and is aggravated following sleep. Cephalad fluid shifts have been implicated. We hypothesized that sleeping with the upper body elevated by 30º reduces the risk of acute mountain sickness. METHODS: In a pragmatic, randomized, observer-blinded field study at 4554 meters altitude, we investigated 134 adults aged 18-70 years with a Lake Louise score between 3 and 12 points on the evening of their arrival at the altitude. The individuals were exposed to sleeping on an inflatable cushion elevating the upper body by 30º or on a sham pillow in a horizontal position. The primary endpoint was the change in the Acute Mountain Sickness-Cerebral (AMS-C) score in the morning after sleeping at an altitude of 4554 meters compared with the evening before. Sleep efficiency was the secondary endpoint. RESULTS: Among 219 eligible mountaineers, 134 fulfilled the inclusion criteria and were randomized. The AMS-C score increased by 0.250 ± 0.575 in the control group and by 0.121 ± 0.679 in the intervention group (difference 0.105; 95% confidence interval, -0.098-0.308; P = .308). Oxygen saturation in the morning was 79% ± 6% in the intervention group and 78% ± 6% in the control group (P = .863). Sleep efficiency did not differ between groups (P = .115). CONCLUSIONS: Sleeping with the upper body elevated by 30° does not lead to relevant reductions in acute mountain sickness symptoms or hypoxemia at high altitude.

The financial burden of mandibular trauma.

PURPOSE: Patients with mandibular trauma in the greater Seattle region are frequently transferred to Harborview Medical Center (HMC) despite trained providers in the surrounding communities. HMC receives poor reimbursement for these services, creating a disproportionate financial burden on the hospital. In this study we aim to identify the variables associated with increased cost of care, measure the relative financial impact of these variables, and quantify the revenue loss incurred from the treatment of isolated mandibular fractures. MATERIALS AND METHODS: A retrospective chart review was conducted of patients treated at HMC for isolated mandibular fractures from July 1999 through June 2010, using International Classification of Diseases, Ninth Revision and Current Procedural Terminology coding. Data collected included demographics, injury, hospital course, treatment, outcomes, and billing. RESULTS: The study included 1,554 patients. Total billing was $22.1 million. Of this, $6.9 million was recovered. We found that there are multiple variables associated with the increased cost of treating mandibular fractures; 4 variables--length of hospital stay, treatment modality, service providing treatment, and method of arrival--accounted for 49.1% of the total variance in the amount billed. In addition, we found that the unsponsored portion of our patient population grew from 6.7% to 51.4% during the study period. CONCLUSIONS: Our results led to specific cost-efficiency recommendations: 1) perform closed reduction whenever possible; 2) encourage performing procedures with patients under local anesthesia (closed reductions and arch bar removals); 3) provide improved and shared training among the services treating craniofacial trauma; 4) encourage arrival by privately owned vehicle; 5) provide outpatient treatment, when applicable; 6) offer provider incentives to take trauma call; and 7) offer hospital incentives to treat patients and not transfer them.