The Effectiveness of Hospital in Motion, a Multidimensional Implementation Project to Improve Patients' Movement Behavior During Hospitalization.

OBJECTIVE: Hospital in Motion is a multidimensional implementation project aiming to improve movement behavior during hospitalization. The purpose of this study was to investigate the effectiveness of Hospital in Motion on movement behavior. METHODS: This prospective study used a pre-implementation and post-implementation design. Hospital in Motion was conducted at 4 wards of an academic hospital in the Netherlands. In each ward, multidisciplinary teams followed a 10-month step-by-step approach, including the development and implementation of a ward-specific action plan with multiple interventions to improve movement behavior. Inpatient movement behavior was assessed before the start of the project and 1 year later using a behavioral mapping method in which patients were observed between 9:00 am and 4:00 pm. The primary outcome was the percentage of time spent lying down. In addition, sitting and moving, immobility-related complications, length of stay, discharge destination home, discharge destination rehabilitation setting, mortality, and 30-day readmissions were investigated. Differences between pre-implementation and post-implementation conditions were analyzed using the chi-square test for dichotomized variables, the Mann Whitney test for non-normal distributed data, or independent samples t test for normally distributed data. RESULTS: Patient observations demonstrated that the primary outcome, the time spent lying down, changed from 60.1% to 52.2%. For secondary outcomes, the time spent sitting increased from 31.6% to 38.3%, and discharges to a rehabilitation setting reduced from 6 (4.4%) to 1 (0.7%). No statistical differences were found in the other secondary outcome measures. CONCLUSION: The implementation of the multidimensional project Hospital in Motion was associated with patients who were hospitalized spending less time lying in bed and with a reduced number of discharges to a rehabilitation setting. IMPACT: Inpatient movement behavior can be influenced by multidimensional interventions. Programs implementing interventions that specifically focus on improving time spent moving, in addition to decreasing time spent lying, are recommended.

A Randomized Controlled Trial Comparing Flat Times Versus Standard Care in Pediatric Patients Post Cardiac Catheterization.

BACKGROUND: Pediatric patients undergoing cardiac catheterization procedures are required to lie flat for 4 hours for femoral venous access and 6 hours for femoral arterial access. Authors of research in adults suggest the flat time for the same access can be safely reduced to 1.5 to 2 hours post procedure. No literature was found that flat times could be safely reduced for pediatric patients. OBJECTIVE: The purpose of this study was to determine whether decreased flat time for the post-cardiac catheterization pediatric patient would impact the incidence of site bleeding, additional sedation, and the need for a critical care admission. METHODS: A randomized controlled trial was designed and participants were randomly assigned to experimental or control group. The experimental group reduced flat times to 2 hours for venous and 4 hours for arterial. The control group was standard care of 4 hours for venous and 6 hours for arterial. RESULTS: A total of 119 participants were enrolled, 60 in the experimental group and 59 in the control group. Results suggest no difference in the incidence of site bleeding (P = .999), additional sedation (P = .653), or need for a critical care admission. CONCLUSIONS: For pediatric patients undergoing arterial or venous cardiac catheterizations, flat times can safely be reduced without increasing site bleeding, additional sedation, or critical care admissions.

Practice Patterns for Management of Pediatric Femur Fractures in Low- and Middle-Income Countries.

BACKGROUND: Femoral shaft fractures in children are common in low and middle income countries. In high-income countries, patient age, fracture pattern, associated injuries, child/family socioeconomic status, and surgeon preference dictate fracture management. There is limited literature on treatment patterns for pediatric femur fractures in resource-limited settings. This study surveys surgeons from low (LIC), lower-middle (LMIC), and upper-middle income (UMIC) countries regarding treatment patterns for pediatric femur fractures. METHODS: Surgeons completed an electronic survey reporting surgeon demographics and treatment preference for pediatric femur fractures. Treatment preferences and indications for treatment were separated into 4 groups: infant (0 to 6 mo); toddler (7 mo to 4 y); child (5 to 12 y); adolescent (12 to 17 y). The survey was available in English, Spanish, and French. Analysis was completed with t test and χ test for continuous and categorical variables, respectively, and weighted Pearson correlation (P<0.05). RESULTS: Survey respondents consisted of 413 surgeons from 83 countries (20 LIC, 33 LMIC, 30 UMIC). The majority of respondents were fellowship trained (83%) most commonly in pediatrics (26%) and trauma (43%). Most treated >10 pediatric femur fractures per year (68%). Respondents reported treating infant femur fractures nonoperatively using Pavlik harness (19%), spica cast (60%), or traction with delayed spica cast (14%). Decreasing socioeconomic status was associated with higher nonoperative treatment rate in toddlers, children, and adolescents. Respondents commonly utilize bed rest and traction for child femur fractures in LICs (63%) and LMICs (65%) compared with UMICs (35%) (UMIC vs. LMIC P<0.001; UMIC vs. LIC P<0.001). Surgeries in children more commonly involve open reduction with internal fixation (UMIC 19%, LMIC 33%, LIC 40%; P<0.05 between UMIC-LMIC and UMIC-LIC). CONCLUSION: This is one of the largest surveys describing treatment patterns for pediatric femur fractures in low and middle income countries. Differences are evident including lower operative treatment rate in younger children and lower intramedullary fixation rates in older children. Future studies should investigate the value of treatment options in resource-limited settings. LEVEL OF EVIDENCE: Level II-prospective comparative study.

Upright time during hospitalization for older inpatients: A prospective cohort study.

BACKGROUND: The purpose of this study was to examine: a) how long and how frequently older hospitalized patients spend upright; b) whether duration and frequency of upright time change by time of the day, the day of the week, and during hospitalization; and c) whether these relationships differ based on the mobility level of patients at admission. METHODS: This prospective cohort study included 111 patients (82.2 ±â€¯8 years old, 52% female) from the Emergency Department and a Geriatric Assessment Unit who were at least 60 years old and had an anticipated length of stay of at least three days. The main outcomes were accelerometer-measured total upright time and number of bouts of upright time during awake hours. RESULTS: Patients were upright 15.9 times/day (interquartile range (IQR): 8.4-27.4) for a total of 54.2 min/day (IQR: 17.8-88.9) during awake hours. Time of day and day of week had little impact on the outcomes. Patients who walked independently at admission had 151.5 min (95% CI: 87.7-215.3) of upright time on hospital day 1 and experienced a decline of 4.5 min/day (-7.2 to -1.8). Those who needed personal mobility assistance or were bedridden had 29.5 min (-38.5-97.4) and 25 min (-48.3-100.3) of upright time on day 1, and demonstrated an increase of 3.6 (1.3-5.9) and 2.4 (0.05-4.5) min/day, respectively. CONCLUSION: Hospitalized older adults spend only 6% of their awake hours upright while in hospital. Patients who can walk independently are more active but experience a decline in their upright time during hospitalization.

Taking to Bed at the End of Life.

OBJECTIVES: To evaluate the time course of "taking to bed" at the end of life and determine whether it differs according to age, sex, and condition leading to death. DESIGN: Prospective longitudinal study. SETTING: Greater New Haven, Connecticut. PARTICIPANTS: A total of 651 decedents from a cohort of 754 community-living persons, 70+ years of age. MEASUREMENTS: During the last 2 years of life, the occurrence of bed rest and number of days in bed, two indicators of bed rest burden, were ascertained each month. Bed rest was defined as staying in bed for at least a half day due to an illness, injury, or other problem. RESULTS: The occurrence of bed rest increased modestly from 12.4% at 24 months before death to 19.0% at 5 months before death, before increasing exponentially to 51.6% at 1 month before death. The median number of days in bed fluctuated within a narrow range of 3 to 7 from 24 months to 4 months before death, before increasing substantially to a high of 14 at 1 month before death. In the last 2 years of life, the burden of bed rest did not differ by age but was significantly greater in women than men. Among the conditions leading to death, the burden of bed rest was highest among persons dying from organ failure and cancer, lowest for sudden death, and intermediate for frailty, advanced dementia, and other conditions. CONCLUSION: The burden of bed rest at the end of life is greater in women than men, does not differ by age, and is highest among persons dying from organ failure and cancer. The steep increases observed in the last 3 to 5 months of life suggest that taking to bed may be an indicator that death is approaching and should prompt discussions about referral to hospice among older persons with serious illness.

Burden of Restricted Activity and Associated Symptoms and Problems in Late Life and at the End of Life.

OBJECTIVES: To compare rates of restricted activity and associated symptoms and problems in the last 6 months of life with those in the period before the last 6 months of life. DESIGN: Prospective cohort study. SETTING: Greater New Haven, Connecticut. PARTICIPANTS: Community-living persons aged 70 and older (N=754). MEASUREMENTS: The occurrence of restricted activity (staying in bed for at least half the day or cutting down on usual activities) and 24 prespecified symptoms and problems leading to restricted activity was ascertained monthly for nearly 19 years. RESULTS: Rates of restricted activity per 100 person-months were 36.5 in the last 6 months of life versus 16.1 in the period before the last 6 months of life (P<.001). Of 737 participants with 1 month or more of restricted activity, rates of restricting symptoms per 100 person-months of restricted activity ranged from 8.0 for frequent or painful urination to 65.6 for been fatigued, and rates of restricting problems ranged from 0.1 for problem with alcohol to 23.4 for been afraid of falling. Rates were significantly higher in the last 6 months of life than in the prior period for 13 of the 24 restricting symptoms and problems (P<.05), most notably for shortness of breath (38.6 vs 21.8), weakness (37.3 vs 18.9), and confusion (31.2 vs 9.8). Mean (standard error) number of restricting symptoms and problems was significantly higher in the last 6 months of life (6.1 (0.1)) than in the prior period (4.7 (0.03)) (P<.001). CONCLUSION: Rates of restricted activity and associated symptoms and problems are substantially greater in the last 6 months of life than in the period before the last 6 months of life. Enhanced palliative care strategies may be needed to diminish the burden of distressing symptoms and problems at the end of life. J Am Geriatr Soc 66:2282-2288, 2018.

Activity restriction and risk of preterm delivery.

PURPOSE: We sought to determine whether activity restriction (AR) in a cohort of women at high risk for preterm delivery is associated with the risk of preterm delivery. MATERIALS AND METHODS: This is a secondary analysis of the Maternal-Fetal Medicine Units MFMU's Preterm Prediction Study; a multicenter prospective cohort study designed to identify risk factors of preterm birth (PTB). The study group consisted of women with a singleton gestation that at their first study visit (23-24 weeks) had at least one of the following criteria: patient reported contractions, severe back pain, a cervical length <15 mm, spotting, protruding membranes, or positive fetal fibronectin. Women were assessed for AR at a 27- to 29-week study visit. Associations between AR and preterm delivery (<37 weeks) were examined through logistic regression models before and after adjustment for confounders. RESULTS: Of the 1086 women that met the inclusion criteria, 16.5% (n = 179) delivered preterm. In this cohort, 9.7% (n = 105) of women were recommended AR, with 37.1% (n = 39) having a PTB. In the group not recommended AR (n = 981), 14.3% (n = 140) delivered preterm. CONCLUSION: In this cohort of women at high risk for PTB, activity restriction was associated with an increased risk of PTB. The use of AR in this population should be discouraged.

Decreased bed rest post-percutaneous coronary intervention with a 7-French arterial sheath and its effects on vascular complications.

AIMS AND OBJECTIVES: To compare the incidence of femoral access puncture site complications in the control group, who underwent 6 hr of bed rest, with patients in the case group, who underwent 4 hr of bed rest. BACKGROUND: The ideal bed rest length after percutaneous coronary intervention with a 7-French arterial sheath has been investigated by nursing practice. However, in this larger-sheath-size group, best practices have not been determined, and bed rest time continues to vary markedly among institutions. DESIGN: Retrospective study. METHODS: Data were retrieved from the National Cardiovascular Data Registry and electronic health records in this retrospective study. Sample size was 401 patients: 152 case patients with 4-hr bed rest and 249 controls with 6-hr bed rest. Case group data were obtained from 20 May 2013-31 December 2014; and control group data, 15 June 2011-20 May 2013. RESULTS: National Cardiovascular Data Registry event rates were generally low in both groups: Only three patients in each group had a bleeding event within 72 hr (2% vs. 1%) and no patient and only two controls had arteriovenous fistula (0% vs. 1%). Complications documented in the electronic health records with institutional femoral access puncture site complication definitions identified bleeding at the access site in eight case patients (5%) and nine controls (4%). Haematoma at the access site occurred in 21 case patients (14%) and 25 controls (10%). CONCLUSIONS: The practice change of decreasing bed rest from 6-4 hr for patients with 7-French arterial sheaths post-percutaneous coronary intervention was associated with no significant change in femoral access puncture site complications in either National Cardiovascular Data Registry data or institutional electronic health records data. RELEVANCE TO CLINICAL PRACTICE: This introduces expanded evidence of safety in decreasing bed rest length in larger (7-French) arterial sheaths post-percutaneous coronary intervention.

Comparison of the effects of local anesthesia and epidural anesthesia for percutaneous transforaminal endoscopic discectomy in elderly patients over 65 years old.

BACKGROUND: Local anesthesia (LA) is recommended for percutaneous transforaminal endoscopic discectomy (PTED) but clinical practice indicates that LA cannot achieve satisfactory pain management during PTED. OBJECTIVES: The study aimed to investigate the comparisons between LA and EA for PTED in elderly population over 65 years old. METHODS: We performed a retrospective analysis of patients over 65 years old received PTED from May 2013 to December 2014. And patients were divided into two groups according to the anesthesia method. The data collected for analysis including operative time, fluoroscopy time, postoperative bed time, visual analog scale (VAS), Oswestry Back Pain Disability Index (ODI), the global outcome based on the Macnab outcome criteria, satisfaction rate of anesthesia, and complications. RESULTS: A total of 132 consecutive patients were enrolled in this study. There were 65 patients in LA group and 67 patients in EA group. Compared to LA group, EA group had longer operative time (P < 0.001) and postoperative bed time (P < 0.001) but shorter fluoroscopy time, (P < 0.001), smaller VAS score of lumbar pain intraoperatively (P < 0.001), 1-h postoperatively (P < 0.001) and 1-week postoperatively (P < 0.001). Similarly, EA group had lower VAS score of leg pain intraoperatively (P < 0.001) and 1-h postoperatively (P < 0.001). In additions, higher satisfaction rate of anesthesia was observed in EA group (P = 0.029). CONCLUSIONS: EA and LA for PTED achieved comparable clinical outcomes in elderly population over 65 years old. However, compared to LA for PTED, EA had a better performance in pain management.

Immobilization versus immediate mobilization after intrauterine insemination: A systematic review and meta-analysis.

INTRODUCTION: The objective of this systematic review and meta-analysis was to investigate a possible association between immobilization and pregnancy rate in patients undergoing intrauterine insemination. MATERIAL AND METHODS: To ensure the quality of the methodology, the PRISMA criteria were met at all stages of the development of this meta-analysis. We searched the Cochrane Library, EMBASE, PubMed MEDLINE, ScienceDirect and reference lists of eligible studies from inception to March 2017, without any restriction. We also interviewed the ClinicalTrials.gov database for unpublished articles. Finally, we sought potentially eligible studies in meeting abstracts. Two reviewers independently extracted study characteristics and outcome data. Estimates were pooled using random effects models and sensitivity analyses. We selected studies that compared bed rest to immediate mobilization after intrauterine insemination. The primary outcome was the ongoing pregnancy rate per couple. RESULTS: Of 176 identified abstracts, four primary studies, all of them randomized controlled trials, met the inclusion criteria, including 1361 couples. The overall relative risk of ongoing pregnancy rate in bed rest versus immediate immobilization was 1.67 95% CI [0.86; 3.22]. The overall relative risk of the live birth rate was 1.11 95% CI [0.56; 2.20]. CONCLUSION: This systematic review and meta-analysis was not able to demonstrate that bed rest after intrauterine insemination effectively increases in pregnancy rate. For everyday practice, no specific strategy, bed rest or immediate mobilization, can be recommended at this time.

En enfermos ingresados en cuidados intensivos, ¿es efectiva la rehabilitación y la movilización activa en la mortalidad y capacidad funcional? / For patients in intensive care, are rehabilitation and active mobilisation effective in terms of mortality and functional capacity?

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Revolving door respiratory patients: A rehabilitative perspective.

Rehabilitation is an integral component of care for patients affected by either acute or chronic pulmonary diseases. The key elements of rehabilitation treatment for critical respiratory patients are as follows: weaning from mechanical ventilation, respiratory therapy, physical reconditioning, and occupational therapy. It should be noted that patients affected by pulmonary diseases are prone to hospital re-admission due to frequent exacerbations, especially in cases with more severe stages of chronic obstructive pulmonary disease. A periodical worsening of clinical conditions is common in asthma, acute respiratory distress syndrome survivors, obstructive sleep apnea syndrome, and pulmonary fibrosis, as well as in patients with severe neuromuscular diseases. These patients are often identified as "revolving door patients". Pulmonary patients are typically forced to maintain bed rest, or at least spend most of their waking hours dealing with mobility limitations, due to various pathological conditions including dyspnea, fatigue, and poor tolerance of movements. Alterations in mood are common in pulmonary patients who experience a decreased quality of life and limited social interactions. These negative emotional and cognitive aspects can be a major limitation to the provision of care, because to enhance and facilitate a degree of autonomy, the patient must be cooperative and pro-active.

Effects of mobility training on severe burn patients in the BICU: A retrospective cohort study.

PURPOSE: To assess the effects of mobility training on severe burn patients in the Burn Intensive Care Unit (BICU). METHODS: This was a retrospective cohort study. Severe burn patients with equal to or more than 50% Total Body Surface Area (TBSA) burns who received early rehabilitation in the BICU were included in this study. Based on the different early rehabilitation strategies during the two periods, patients admitted to the BICU from January 2011 to April 2013 were identified as the passive training cohort (n=49) while patients admitted to the BICU from May 2013 to December 2013 were identified as the mobility training cohort (n=24). Data on length of BICU stay, length of hospital stay, length of rehabilitation in the BICU, ventilator dependent days, strict bed rest time, range of motion (ROM), the Barthel Index (BI) and the Functional Independence Measure (FIM) were collected. RESULTS: Compared with the passive training cohort, patients in the mobility training cohort had significantly shorter length of BICU stay (p=0.002), length of hospital stay (p=0.010), strict bed rest time (p<0.001) and length of rehabilitation in the BICU (p=0.026) with improved ROM of shoulder, wrist, hip, knee and ankle joints. CONCLUSIONS: Mobility training in the BICU was shown to be feasible and effective in achieving better outcomes than passive training for severe burn patients.

Reducing bed rest time from five to three hours does not increase complications after cardiac catheterization: the THREE CATH Trial.

OBJECTIVE: to compare the incidence of vascular complications in patients undergoing transfemoral cardiac catheterization with a 6F introducer sheath followed by 3-hour versus 5-hour rest. METHODS: randomized clinical trial. Subjects in the intervention group (IG) ambulated 3 hours after sheath removal, versus 5 hours in the control group (CG). All patients remained in the catheterization laboratory for 5 hours and were assessed hourly, and were contacted 24, 48, and 72 h after hospital discharge. RESULTS: the sample comprised 367 patients in the IG and 363 in the GC. During cath lab stay, hematoma was the most common complication in both groups, occurring in 12 (3%) IG and 13 (4%) CG subjects (P=0.87). Bleeding occurred in 4 (1%) IG and 6 (2%) CG subjects (P=0.51), and vasovagal reaction in 5 (1.4%) IG and 4 (1.1%) CG subjects (P=0.75). At 24-h, 48-h, and 72-h bruising was the most commonly reported complication in both groups. None of the comparisons revealed any significant between-group differences. CONCLUSION: the results of this trial show that reducing bed rest time to 3 hours after elective cardiac catheterization is safe and does not increase complications as compared with a 5-hour rest. ClinicalTrials.gov Identifier: NCT-01740856.

Retention in Care among HIV-Infected Adults in Ethiopia, 2005- 2011: A Mixed-Methods Study.

BACKGROUND: Poor retention in HIV care challenges the success of antiretroviral therapy (ART). This study assessed how well patients stay in care and explored factors associated with retention in the context of an initial ART rollout in Sub-Saharan Africa. METHODS: We conducted a mixed-methods study at a teaching hospital in Addis Ababa, Ethiopia. A cohort of 385 patients was followed for a median of 4.6 years from ART initiation to lost-to-follow-up (LTFU-missing appointments for more than three months after last scheduled visit or administrative censoring). We used Kaplan-Meier plots to describe LTFU over time and Cox-regression models to identify factors associated with being LTFU. We held six focus group discussions, each with 6-11 patients enrolled in care; we analyzed data inductively informed by grounded theory. RESULTS: Patients in the cohort were predominantly female (64%) and the median age was 34 years. Thirty percent were LTFU by study's end; the median time to LTFU was 1,675 days. Higher risk of LTFU was associated with baseline CD4 counts <100 and >200 cells/µL (HR = 1.62; 95% CI:1.03-2.55; and HR = 2.06; 95% CI:1.15-3.70, respectively), compared with patients with baseline CD4 counts of 100-200 cells/µL. Bedridden participants at ART initiation (HR = 2.05; 95% CIs [1.11-3.80]) and those with no or only primary education (HR = 1.50; 95% CIs [1.00-2.24]) were more likely to be LTFU. Our qualitative data revealed that fear of stigma, care dissatisfaction, use of holy water, and economic constraints discouraged retention in care. Social support and restored health and functional ability motivated retention. CONCLUSION: Complex socio-cultural, economic, and health-system factors inhibit optimum patient retention. Better tracking, enhanced social support, and regular adherence counseling addressing stigma and alternative healing options are needed. Intervention strategies aimed at changing clinic routines and improving patient-provider communication could address many of the identified barriers.

Reducing bed rest time from five to three hours does not increase complications after cardiac catheterization: the THREE CATH Trial / Redução do repouso de cinco para três horas não aumenta complicações após cateterismo cardíaco: THREE CATH Clinical Trial / La reducción del reposo de cinco para tres horas no aumenta las complicaciones después del Clinical Trial Three Cath

Abstract Objective: to compare the incidence of vascular complications in patients undergoing transfemoral cardiac catheterization with a 6F introducer sheath followed by 3-hour versus 5-hour rest. Methods: randomized clinical trial. Subjects in the intervention group (IG) ambulated 3 hours after sheath removal, versus 5 hours in the control group (CG). All patients remained in the catheterization laboratory for 5 hours and were assessed hourly, and were contacted 24, 48, and 72 h after hospital discharge. Results: the sample comprised 367 patients in the IG and 363 in the GC. During cath lab stay, hematoma was the most common complication in both groups, occurring in 12 (3%) IG and 13 (4%) CG subjects (P=0.87). Bleeding occurred in 4 (1%) IG and 6 (2%) CG subjects (P=0.51), and vasovagal reaction in 5 (1.4%) IG and 4 (1.1%) CG subjects (P=0.75). At 24-h, 48-h, and 72-h bruising was the most commonly reported complication in both groups. None of the comparisons revealed any significant between-group differences. Conclusion: the results of this trial show that reducing bed rest time to 3 hours after elective cardiac catheterization is safe and does not increase complications as compared with a 5-hour rest. ClinicalTrials.gov Identifier: NCT-01740856

Resumo Objetivo: comparar a incidência de complicações vasculares em pacientes submetidos a cateterismo cardíaco com introdutor 6 French sob abordagem transfemoral com repouso de 3 horas e de 5 horas Método: ensaio clínico randomizado. Os sujeitos incluídos no grupo intervenção (GI) deambularam 3 horas após a retirada do introdutor versus 5 horas para os do grupo controle (GC). Todos os pacientes permaneceram 5 horas no laboratório de hemodinâmica (LH), onde foram avaliados a cada hora, e foram contatados em 24, 48 e 72 h após a alta hospitalar. Resultados: a amostra foi composta por 367 pacientes no GI e 363 no GC. Durante a permanência no LH, hematoma foi a complicação mais observada em ambos os grupos, ocorrendo em 12 (3%) pacientes do GI e 13 (4%) do GC (P=0,87). Sangramento ocorreu em 4 (1%) pacientes do GI e 6 (2%) do GC (P=0,51), e reação vasovagal em 5 (1,4%) pacientes do GI e 4 (1,1%) do GC (P=0,75). Em 24, 48 e 72 h, equimose foi a complicação mais relatada por ambos os grupos, seguida por dor no local da punção. Nenhuma das comparações revelou significância estatística entre os grupos. Conclusão: as resultados deste estudo demonstram que a redução do tempo de repouso para 3 horas após cateterismo cardíaco eletivo mostrou-se segura, não ocasionando um aumento de complicações quando comparada ao repouso de 5 horas. Registro Clinical Trials: NCT-01740856.

Resumen Objetivo: comparar la incidencia de complicaciones vasculares en pacientes sometidos a cateterismo cardíaco con introductor 6 French bajo abordaje transfemoral con reposo de 3 horas y de 5 horas Método: ensayo clínico aleatorio. Los sujetos incluidos en el grupo intervención (GI) deambularon 3 horas después de la retirada del introductor versus 5 horas para los del grupo control (GC). Todos los pacientes permanecieron 5 horas en el laboratorio de hemodinámica (LH), en donde fueron evaluados a cada hora, y fueron contactados en 24, 48 y 72 h después del alta hospitalaria. Resultados: la muestra estuvo compuesta por 367 pacientes en el GI y 363 en el GC. Durante la permanencia en el LH, el hematoma fue la complicación más observada en los dos grupos, ocurriendo en 12 (3%) pacientes del GI y 13 (4%) del GC (P=0,87). La hemorragia ocurrió en 4 (1%) pacientes del GI y 6 (2%) del GC (P=0,51), y la reacción vasovagal en 5 (1,4%) pacientes del GI y 4 (1,1%) del GC (P=0,75). En 24, 48 y 72 h, la equimosis fue la complicación más relatada por los dos grupos, seguida por dolor en el local de la punción. Ninguna de las comparaciones reveló tener significación estadística entre los grupos. Conclusión: los resultados de este estudio demuestran que la reducción del tiempo de reposo para 3 horas después del cardíaco electivo se mostró segura, no ocasionando un aumento de complicaciones cuando comparada al reposo de 5 horas. Registro Clinical Trials: NCT-01740856

Medical and neurologic complications of the current management strategy of angiographically negative nontraumatic subarachnoid hemorrhage patients.

PURPOSE: Common management of angionegative subarachnoid hemorrhage includes mandatory intensive care unit stay for up to 14 days with strict bedrest, constant neurologic serial examination, invasive arterial and central line monitoring, and aneurysm rupture precautions. We evaluated the frequency of neurologic and nonneurologic complications in this patient population. METHODS: This was a retrospective chart review from July 2008 to 2011. Adult patients with International Classification of Diseases, Ninth Revision code for nontraumatic subarachnoid hemorrhage who had angiograms and cranial cat scans (CTs) were evaluated as the first screening measure. Negative screening angiograms constituted our study population and were divided into 2 groups (aneurysmal or perimesencephalic) based on the CT blood pattern. RESULTS: Fifty-one patients met the study criteria (aneurysmal CT, n = 26; perimesencephalic CT pattern, n = 25). There were no incidences of rebleeding or mortality, and patients were discharged after a mean of 15.24 hospital days and a mean of 11 bedrest days. Seventeen patients (65%) in the aneurysmal group developed at least 1 nonneurologic complication compared with 2 patients (8%) in the perimesencephalic group (P = .001). Eleven patients in the aneurysmal group (42.3%) developed at least 1 neurologic complication compared with 1 patient (4%) in the perimesecephalic group (P = .001). CONCLUSION: Based on our results, we propose admission to the medical floor for patients with World Federation of Neurosurgical Societies score 1 to 3, perimesencephalic CT pattern, and no hydrocephalus.

Prospective evaluation of the optimal duration of bed rest after vascular interventions using a 3-French introducer sheath.

PURPOSE: To assess optimal bed-rest duration after vascular intervention by way of the common femoral artery using 3F introducer sheaths. MATERIALS AND METHODS: Eligibility criteria for this single-center, prospective study included clinically necessary angiography, no coagulopathy or anticoagulant therapy, no hypersensitivity to contrast medium, age >20 years, and written, informed consent. Enrolled patients were assigned to one of three groups (105/group) with the duration of bed rest deceased sequentially. A sheath was inserted by way of the common femoral artery using the Seldinger technique. The first group (level 1) received 3 h of bed rest after the vascular intervention. If no bleeding or hematomas developed, the next group (level 2) received 2.5 h of bed rest. If still no bleeding or hematomas developed, the final group (level 3) received 2 h of bed rest. If any patient had bleeding or hematomas after bed rest, the study was terminated, and the bed rest of the preceding level was considered the optimal duration. RESULTS: A total of 105 patients were enrolled at level 1 between November 2010 and September 2011. Eight patients were excluded from analysis because cessation of bed rest was delayed. None of the remaining subjects experienced postoperative bleeding; therefore, patient enrollment at level 2 began in September 2011. However, puncture site bleeding occurred in the 52nd patient immediately after cessation of bed rest, necessitating study termination. CONCLUSION: To prevent bleeding, at least 3 h of postoperative bed rest is recommended for patients undergoing angiography using 3F sheaths.

Sicurezza e comfort dei pazienti con impianto di pacemaker mobilizzati dopo 24 e 48 ore: studio retrospettivo.

Safety and comfort of patients mobilized 24 and 48 hours after a pacemaker implantation: a retrospective study. Background. In Italy bed rest times after a pacemaker implantation (PI) may vary between 24 and 72 hours, although previous studies showed that early mobilization does not increase the risk of complications. Objective. To observe the safety and comfort of mobilization 24 and 48 hours after PI. Methods. Observational retrospective study on clinical records of consecutive patients undergoing PI from January 2009 to April 2012 in Monzino Hospital in Milan and with a bed rest of 24 or 48 hours. Results. A total of 411 patients were included (Group 48h n=251, Group 24h: n=160). Complications occurred more frequently in the Group 48h: haematomas (3.2% vs 1.9% OR:1.71, p=0.4269); lead dislocations (1.9% vs. 0.6%; OR:3.23 p=0.2863). Patients with longer bed rest received more analgesics for back pain (BP) or pacemaker pocket pain (PPP) (BP: 12% vs 3.1%; OR:4.21; p=0.0036; PPP 13.1% vs 3.7% OR:3.88; p=0.0029). Conclusions. The mobilization after 24 hours to PI increased patients' comfort without increasing risks. Future studies are warranted to explore the effects of a bed rest shorter than 24 hours.

Post-embryo transfer interventions for assisted reproduction technology cycles.

BACKGROUND: In women undergoing in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI), embryos transferred into the uterine cavity can be expelled due to many factors including uterine peristalsis and contractions, low site of deposition and negative pressure generated when removing the transfer catheter. Techniques to reduce the risk of embryo loss following embryo transfer (ET) have been described but are not standard in all centres conducting ET. OBJECTIVES: To evaluate the efficacy of interventions used to prevent post-transfer embryo expulsion in women undergoing IVF and ICSI. SEARCH METHODS: We searched the Menstrual Disorders and Subfertility Group Specialised Register of controlled trials to June 2014 and PubMed, MEDLINE, EMBASE, CENTRAL, PsycINFO, CINAHL, World Health Organization ICTRP, and trial registers from inception to June 2014, with no language restrictions. Additionally, we handsearched reference lists of relevant articles, and ESHRE and ASRM conference abstracts. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of interventions used to prevent post-transfer embryo expulsion in women undergoing IVF and ICSI. Two review authors independently screened titles and abstracts and reviewed the full-texts of all potentially eligible citations to determine whether they met our inclusion criteria. Disagreements were resolved by consensus. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed the risk of bias of included trials using standardised, piloted data extraction forms. Data were extracted to allow intention-to-treat analyses. Disagreements were resolved by consensus. The overall quality of the evidence was rated using GRADE methods. MAIN RESULTS: We included four RCTs (n = 1392 women) which administered the following interventions: bed rest (two trials), fibrin sealant (one trial), and mechanical closure of the cervix (one trial). Our primary outcome, live birth rate, was not reported in any of the included trials; nor were the data available from the corresponding authors. For the ongoing pregnancy rate, two trials comparing more bed rest with less bed rest showed no evidence of a difference between groups (odds ratio (OR) 0.88; 95% confidence interval (CI) 0.60 to 1.31, 542 women, I(2) = 0%, low quality evidence). Secondary outcomes were sporadically reported with the exception of the clinical pregnancy rate, which was reported in all of the included trials. There was no evidence of a difference in clinical pregnancy rate between more bed rest and less bed rest (OR 0.88; 95% CI 0.60 to 1.31, 542 women, I(2) = 0%, low quality evidence) or between fibrin sealant and usual care (OR 0.98; 95% CI 0.54 to 1.78, 211 women, very low quality evidence). However, mechanical closure of the cervix was associated with a higher clinical pregnancy rate than usual care (OR 1.92; 95% CI 1.40 to 2.63, very low quality evidence). The quality of the evidence was rated as low or very low for all outcomes. The main limitations were failure to report live births, imprecision and risk of bias. Overall, the risk of bias of the included trials was high. The use of a proper method of randomisation and allocation concealment was fairly well reported, while only one trial clearly reported blinding. There was no evidence that any of the interventions had an effect on adverse event rates but data were too few to reach any conclusions. AUTHORS' CONCLUSIONS: There is insufficient evidence to support any specific length of time for women to remain recumbent, if at all, following embryo transfer, nor is there sufficient evidence to recommend the use of fibrin sealants added to the embryo transfer fluid. There is very limited evidence to support the use of mechanical pressure to close the cervical canal following embryo transfer. Further well-designed and powered studies are required to determine the true effectiveness and safety of these interventions.