Volumetric measurements of peripheral oedema in clinical conditions

Digital Volumetric Measurements Based on 3D Scans of the Lower Limb: A Valid and Reproducible Method for Evaluation in Lymphedema Therapy

BACKGROUND

Exact quantification of volumetric changes of the extremities is difficult and often error-prone. The aim of this study was to establish a standardized method based on 3-dimensional (3D) scans. Furthermore, this study tests the method in terms of reproducibility and evaluates volume changes after surgical therapy in patients suffering from lymphedema on the lower extremity.

METHODS

3D scans of the lower limb were performed with a mobile 3D scanner; "repeatability" and "interobserver reliability" of digital volumetry were tested. Furthermore, the method was applied on 31 patients suffering from chronic lymphedema.

RESULTS

Calculations of repeatability of the volume based on 20 3D scans of the same lower leg showed a mean volume of 2.488 ± 0.011 liters (range: 2.470-2.510). The mean volume of the different examiners did not differ significantly (F(2,18) = 1.579, P = 0.233). The paired t-test showed a significant mean volume decrease of 375 mL (95% confidence interval = 245/505 mL) between pretreatment and post-treatment (t (30) = 5.892, P < 0.001).

CONCLUSIONS

3D volumetry is a noninvasive, easy, and quick method to assess volume changes of the lower leg. Other than the low costs, it is reproducible and precise and therefore ideal for evolution of therapy in lymphedema.

Utilization of 3-dimensional scanner technology to measure circumference and volume of limbs in patients bitten by venomous snakes

INTRODUCTION

The objective of this study was to compare limb circumference measurements between a three-dimensional scanner and a measuring tape.

METHODS

Patients older than 18 years, who were bitten by a green pit viper and visited the emergency department between 1 October and 20 December, 2019 were included. Two physicians measured the circumference of a bitten limb and a contralateral unaffected limb twice using both a measuring tape and a three-dimensional scanner. Each patient was measured at the first emergency department visit and again at 24 h, 48 h, and 72 h post-snakebite. There were three points of measurement on both limbs.

RESULTS

There were 408 anatomical locations from 17 patients for measurement. The three-dimensional scanner and the measuring tape demonstrated a very high correlation (r-squared >0.940, P value <0.001) in measuring limb circumferences. Bland Altman plots also demonstrated the two methods measured limb circumferences with similar results with mean differences <1 cm. Intraclass correlation coefficient between the two methods was greater than 0.8 in every site for the lower limbs, but for the upper limbs, most sites had a poor agreement (ranges: 0.073-0.633). For limb volume measurement, the three-dimensional scanner provided excellent and moderate inter and intrarater reliabilities for the lower and upper limbs, respectively.

DISCUSSION

The three-dimensional scanner could be reliably used to assess limb circumference with a strong correlation and with a relatively small error compared with the conventional method. Pictures from the scan can also be constructed to calculate limb volume that could have potential for other clinical purposes such as in evaluating antivenom response for limb swelling.

CONCLUSIONS

Circumferences from the three-dimensional scanner were comparable to those from the measuring tape, especially for the lower limbs, and the three-dimensional scanner demonstrated an added value for calculating limb volume.

Review of Developed Methods for Measuring Gas Uptake and Diffusivity in Polymers Enriched by Pure Gas under High Pressure

Gas emission and diffusion through polymeric materials play crucial roles in ensuring safety and monitoring gas concentrations in technology and industry. Especially, the gas permeation characteristics for O-ring material should be investigated for sealing application in a hydrogen infrastructure. To accommodate the requirements of different environments, we first developed four complementary effective methods for measuring the gas absorption uptake from polymers enriched by pure gas under high pressure and determining the gas diffusivity. The methods included the gravimetric method, the volumetric method, the manometric method, and gas chromatography, which are based on mass, volume, pressure, and volume measurements, respectively. The representative investigated results of the developed methods, such as gas uptake, solubility, and diffusivity are demonstrated. The measuring principles, measuring procedures, measured results, and the characteristics of the methods are compared. Finally, the developed methods can be utilized for testing transport properties, such as the leakage and sealing ability, of rubber and O-ring material under high pressure for hydrogen fueling stations and gas industry.

The Reliability and Validity of a Portable Three-Dimensional Scanning System to Measure Leg Volume

(1) Background: The study examined the reliability (test-retest, intra- and inter-day) and validity of a portable 3D scanning method when quantifying human leg volume. (2) Methods: Fifteen males volunteered to participate (age, 24.6 ± 2.0 years; stature, 178.9 ± 4.5 cm; body mass, 77.4 ± 6.5 kg; mean ± standard deviation). The volume of the lower and upper legs was examined using a water displacement method (the criterion) and two consecutive 3D scans. Measurements were taken at baseline, 1 h post-baseline (intra-day) and 24 h post-baseline (inter-day). Reliability and validity of the 3D scanning method was assessed using Bland-Altman limits of agreement and Pearson's product moment correlations. (3) Results: With respect to the test-retest reliability, the 3D scanning method had smaller systematic bias and narrower limits of agreement (±1%, and 3-5%, respectively) compared to the water displacement method (1-2% and 4-7%, respectively), when measuring lower and upper leg volume in humans. The correlation coefficients for all reliability comparisons (test-retest, intra-day, inter-day) would all be regarded as 'very strong' (all 0.94 or greater). (4) Conclusions: The study's results suggest that a 3D scanning method is a reliable and valid method to quantify leg volume.

Assessment of the Efficiency of Measuring Foot and Ankle Edema with a 3D Portable Scanner

Background: To prospectively evaluate the reliability of a portable optical scanner compared to the water displacement technique for volumetric measurements of the foot and ankle and to compare the acquisition time associated with these two methods. Methods: Foot volume was measured in 29 healthy volunteers (58 feet, 24 females and 5 males) by a 3D scanner (UPOD-S 3D Laser Full-Foot Scanner®) and by water displacement volumetry. Measurements were performed on both feet, up to a height of 10 cm above the ground. The acquisition time for each method was evaluated. The Kolmogorov-Smirnov test, Lin's Concordance Correlation Coefficient, and a Student's t-test were performed. Results: Mean foot volume was 869.7 +/- 165.1 cm³ (3D scanner) versus 867.9 +/- 155.4 cm³ (water-displacement volumetry) (p < 10^-5). The concordance of measurements was 0.93, indicative of a high correlation between the two techniques. Volumes were 47.8 cm³ lower when using the 3D scanner versus water volumetry. After statistically correcting this underestimation, the concordance was improved (0.98, residual bias = -0.03 +/- 35.1 cm³). The mean examination time was 4.2 +/- 1.7 min (3D optical scanner) versus 11.1 +/- 2.9 min (water volumeter) (p < 10^-4). Conclusions: Ankle/foot volumetric measurements performed using this portable 3D scanner are reliable and fast and can be used in clinical practice and research.

Pressure Curves, Static and Dynamic Stiffness of Different Two-Component Compression Systems for the Treatment of Chronic Edema of the Lower Limbs

Background: Compression is a cornerstone modality in edema treatment. Different types of bandages are available in clinical practice. Short-stretch bandages are commonly used; however, newer technologies such as the two-component compression system are available as well. This study assesses the pressure curves and static and dynamic stiffness (Static Stiffness Index [SSI] and Dynamic Stiffness Index [DSI]) of two different two-component compression systems, Coban and CoFlex, for edema treatment. Methods and Results: For this prospective cohort study, 12 healthy volunteers were recruited. The healthy volunteers wore both two-component compression systems for 48 hours. Pressure sensors (PicoPress^®; Microlab, Italy) were placed at 10 and 25 cm above the internal malleolus and 10 pressure readings were used to obtain pressure curves. The SSI and DSI were assessed. Additionally, comfort (ICC compression questionnaire) and adverse events were assessed as well. Both two-component compression systems exert a sufficient amount of sub-bandage pressure, although CoFlex exerts systematically significantly lower pressure in comparison with Coban. This difference in sub-bandage pressure remains constant over 48 hours. Both two-component compression systems are sufficiently stiff (stiffness >15 mmHg) and remain stiff over time. Conclusions: Both two-component compression systems have pressure curves that are high enough to motivate their use in the treatment of chronic edema. Additionally, both systems were found to be comfortable and have clinically effective SSI and DSI values.

Evaluation of the Accuracy of a Video and AI Solution to Measure Lower Leg and Foot Volume

Background and Objectives

Peripheral edema, change in foot volume, is a marker of congestion which is regularly assessed in routine clinical care. A novel video and Artificial Intelligence (AI)-based solution used to measure anatomical parameters, including volume and foot length, Heartfelt HF-1, is compared to the laboratory gold standard (water displacement) and a medical disposable measuring tape.

Design Setting Participants and Measurements

58 healthy volunteers were measured with the Heartfelt device; 22 were also measured with the water displacement method and 19 with the medical tape. Bland-Altman analysis was performed for both volumes and foot lengths. Left/right foot differences provided covariance-corrected standard error of measurement (ccSEM) and minimum detectable difference (MDD) for each measurement method.

Results

Heartfelt device measured volumes displayed excellent correlation to the gold standard (water displacement), with Bland-Altman bias of +32mL ±81mL (1 std.dev). Clinically important change in foot volume is approximately 13%. Water displacement yielded ccSEM of ± 32.1mL and MDD of 90mL (6.7% of average foot volume), while the Heartfelt device measurements yielded ccSEM of ±12.6mL and MDD of 35.3mL (2.6% of average foot volume). The majority of differences were attributable to manual positioning of the patient foot in the waterbath.

Conclusion

This study finds that in clinical and non-clinical settings, the Heartfelt device measures foot volume and length more precisely than either the water displacement technique or manual foot length measurements using a medical disposable tape, while having an excellent agreement with these methods.

Comparison between bioelectrical impedance spectroscopy measurements and water volume displacement of ankle oedema variations during the course of a day

OBJECTIVE

The purpose of this study was to find relationships between variations in bioelectrical impedance spectroscopy (BIS) measurements and those obtained by water displacement (WD) and calf (C) and ankle (A) perimetry on legs of patients with venous insufficiency and lower limb oedema, some with positive pitting test (PPT), others with negative pitting test (NPT).

APPROACH

Twenty-nine (29) female subjects were clinically examined prior to inclusion in the trial. Measurements were taken once in the morning and then 6 h later, using perimetry, WD, and then BIS; subjects were standing. Leg volume was assessed using two WD volumeters, one 'Tall' (TWD) and one 'Short' (SWD). BIS was performed using a SFB7 impedance meter device (Impedimed^®).

MAIN RESULTS

Forty-three (43) legs with oedema were included. The results showed that 61% of the TWD variations variance was explained by SWD variations; less than 30% of the TWD variations variance was explained using BIS or perimetry alone, and 45% at best when used in combination. R₀, related to extracellular water, was the key BIS parameter. For NPT subpopulation (32 legs), the composite parameter (C² - A²)/R₀ explained more than 60% of the TWD variations variance. For PPT subpopulation (11 legs), small or statistically non-significant variance explanations were found.

SIGNIFICANCE

Combination of anthropometric and BIS parameters gave a better forecast of WD results than using only one or other. A novel composite parameter, (C² - A²)/R₀, better predicted TWD changes than other parameters hitherto used in literature, with improved estimates for the NPT subpopulation. Study n°ANSM 2017-A01063-50.

Measuring lower limb circumference and volume – introduction of a novel optical 3D volumetric measurement system

This study comprised two experiments: (1) the reliability of a novel optical three-dimensional (3D) volumetric measurement system (BODYTRONIC® 600) for the assessment of lower limb circumference and volume; (2) the comparison of data obtained from BODYTRONIC® 600 with that provided by computed tomography (CT) for accuracy estimation. Reliability was assessed in 20 healthy subjects. Accuracy was determined by comparing the deviations in the surface topology of two 3D models obtained from BODYTRONIC® 600 and CT. Reliability was very high for leg circumference measures [coefficient of variations (CVs) range 0.3%–1.3%] and slightly lower for foot circumference (CVs around 2.0%). Reliability of leg volume was also found to be very high (CVs ≤ 2.5%). Differences in surface topology between BODYTRONIC® 600 and CT were primarily below 1 mm indicating high accuracy. The volumes of the foot were higher (range 0.9%–1.7%) and that of the leg, lower (range 1.0%–1.3%) compared to CT. The BODYTRONIC® 600 system provides fast, highly reliable and accurate measures of lower limb circumference and volume and can be considered as a valuable measurement tool for use in various research and clinical applications.

Body volume estimation equation for male laborers in Taiwan

The purpose of this study was to develop a body volume (BV) estimation equation for male laborers in Taiwan with body weight (W) and stature height (H) as initial estimators. A three-dimensional (3D) body scanner and a 3D foot scanner were used to measure the 3D range data of 100 male laborers in this study. Subjects' BV was extracted from the 3D body model, and H and W were used as independent variables in regression analysis. The results show that the final BV estimation equation is BV = 1122.927 × W^0.972, with R² = 0.949. Thirty extra male subjects were scanned to compare this BV estimation equation with those in previous studies. The results show that this BV estimation equation had the smallest absolute mean difference at 1.1458 L and the smallest standard error of the estimate at 2.48% in comparison.

Acute effect of wearing compression stockings on lower leg swelling and muscle stiffness in healthy young women

Compression stockings are known to be effective in reducing peripheral oedema or leg swelling by increasing tissue pressure and venous blood flow. While previous studies on compression stockings have focused on its prolonged, preventive effect on leg swelling, the aim of this study was to investigate an acute effect of wearing compression stockings on lower leg swelling and muscle stiffness. Twenty healthy women aged 18-23 years participated in the experiment conducted in the evening, in which they wore below-knee graduated compression stockings and rested in a seated position for 30 min. Before and after the application of stockings, maximum calf circumference, volume, extracellular water resistance (RECW ) and muscle stiffness of the right lower leg were determined by tape measure, water displacement volumetry, segmental bioelectrical impedance spectroscopy and ultrasound shear-wave elastography, respectively. The maximum calf circumference and the reciprocal of RECW (an index of extracellular fluid volume) significantly decreased after the application of stockings, whereas the total lower leg volume and the stiffness (shear modulus) of the medial gastrocnemius muscle tended to decrease. These changes, except for that in the medial gastrocnemius muscle stiffness, were opposite to those from morning to evening studied in the subgroup of participants (n = 8). However, partial correlation analysis failed to detect significant associations among these changes. These results suggest that even for a short period of application, compression stockings have some positive effects against lower leg swelling.

Limb volume measurements: comparison of accuracy and decisive parameters of the most used present methods

Limb volume measurements are used for evaluating growth of muscle mass and effectivity of strength training. Beside sport sciences, it is used e.g. for detection of oedemas, lymphedemas or carcinomas or for examinations of muscle atrophy. There are several commonly used methods, but there is a lack of clear comparison, which shows their advantages and limits. The accuracy of each method is uncertainly estimated only. The aim of this paper is to determine and experimentally verify their accuracy and compare them among each other. Water Displacement Method (WD), three methods based on circumferential measures—Frustum Sign Model (FSM), Disc Model (DM), Partial Frustum Model (PFM) and two 3D scan based methods Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) were compared. Precise reference cylinders and limbs of two human subjects were measured 10 times by each method. Personal dependency of methods was also tested by measuring 10 times the same object by 3 different people. Accuracies: WD 0.3 %, FSM 2–8 % according person, DM, PFM 1–8 %, MRI 2 % (hand) or 8 % (finger), CT 0.5 % (hand) or 2 % (finger);times: FSM 1 min, CT 7 min, WD, DM, PFM 15 min, MRI 19 min; and more. WD was found as the best method for most of uses with best accuracy. The CT disposes with almost the same accuracy and allows measurements of specific regions (e.g. particular muscles), as same as MRI, which accuracy is worse though, but it is not harmful. Frustum Sign Model is usable for very fast estimation of limb volume, but with lower accuracy, Disc Model and Partial Frustum Model is useful in cases when Water Displacement cannot be used.

Kinesio Taping does not decrease swelling in acute, lateral ankle sprain of athletes: a randomised trial

QUESTION

Does Kinesio Taping reduce swelling in athletes who have suffered an acute, lateral ankle sprain?

DESIGN

Randomised controlled trial with concealed allocation, intention-to-treat analysis and blinded assessment.

PARTICIPANTS

Thirty-six athletes who participated regularly in one of seven different sports modalities and suffered an acute ankle sprain.

INTERVENTION

The experimental group received Kinesio Taping application for 3 days, which was designed to treat swelling. The control group received an inert Kinesio Taping application.

OUTCOME MEASURES

For the comparison between groups, the swelling was measured via volumetry, perimetry, relative volumetry and two analyses of the difference in volume and perimetry between ankles of each participant. Data were collected immediately after the 3 days of intervention and at follow-up, which was 15 days post intervention.

RESULTS

At 3 days after intervention, there were no differences between groups for swelling in volumetry (MD -2 ml, 95% CI -28 to 32); perimetry (MD 0.2 cm, 95% CI -0.6 to 1.0); relative volumetry (MD 0.0 cm, 95% CI -0.1 to 0.1); and the other analyses. At day 15 follow-up, there were no significant between-group differences in outcomes.

CONCLUSION

The application of Kinesio Taping, with the aim of stimulating the lymphatic system, is ineffective in decreasing acute swelling after an ankle sprain in athletes.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials, RBR-32sctf.

Diurnal and twenty-four hour patterning of human diseases: cardiac, vascular, and respiratory diseases, conditions, and syndromes

Various medical conditions, disorders, and syndromes exhibit predictable-in-time diurnal and 24 h patterning in the signs, symptoms, and grave nonfatal and fatal events, e.g., respiratory ones of viral and allergic rhinorrhea, reversible (asthma) and non-reversible (bronchitis and emphysema) chronic obstructive pulmonary disease, cystic fibrosis, high altitude pulmonary edema, and decompression sickness; cardiac ones of atrial premature beats and tachycardia, paroxysmal atrial fibrillation, 3rd degree atrial-ventricular block, paroxysmal supraventricular tachycardia, ventricular premature beats, ventricular tachyarrhythmia, symptomatic and non-symptomatic angina pectoris, Prinzmetal vasospastic variant angina, acute (non-fatal and fatal) incidents of myocardial infarction, sudden cardiac arrest, in-bed sudden death syndrome of type-1 diabetes, acute cardiogenic pulmonary edema, and heart failure; vascular and circulatory system ones of hypertension, acute orthostatic postprandial, micturition, and defecation hypotension/syncope, intermittent claudication, venous insufficiency, standing occupation leg edema, arterial and venous branch occlusion of the eye, menopausal hot flash, sickle cell syndrome, abdominal, aortic, and thoracic dissections, pulmonary thromboembolism, and deep venous thrombosis, and cerebrovascular transient ischemic attack and hemorrhagic and ischemic stroke. Knowledge of these temporal patterns not only helps guide patient care but research of their underlying endogenous mechanisms, i.e., circadian and others, and external triggers plus informs the development and application of effective chronopreventive and chronotherapeutic strategies.

Working conditions at hospital food service and the development of venous disease of lower limbs

The present study assesses some factors that may influence the development of lower limb venous disease in workers of a hospital food service unit. An Ergonomic analysis of work was carried out at a hospital located in the south of Brazil. As for data collection, the following were used: interviews and body mass index assessment; specific clinical examination to diagnose venous disease, water displacement volumetry of the lower limbs. The activities performed at the workplace were followed by direct observation with image registration, use of pedometers, stopwatches, decibel meter, and digital thermo-hygrometer. It was observed different degrees of venous disease in 78% of the cases investigated. The volumetric variation of the lower limbs was 5.13%, showing the presence of edema. Working in hospital food service is associated with circulatory disorders of lower limbs, such as edema and venous disease. The following risk factors were identified: standing activities at work during a long period of time, high temperature, and humidity and carrying heavy weights.

Kinesio taping and the circulation and endurance ratio of the gastrocnemius muscle

CONTEXT

Kinesio Tex tape is a therapeutic tape that is applied with the Kinesio-taping (KT) method and is theorized to increase circulation and subsequently improve muscle function. However, little research has been conducted to determine how KT affects performance.

OBJECTIVE

To determine the effect of KT on muscular endurance ratio, blood flow, circumference, and volume of the gastrocnemius muscle.

DESIGN

Randomized controlled clinical trial.

SETTING

Research laboratory. Patients or Other Participants: Sixty-one healthy, active people (23 men, 38 women; age = 19.99 ± 8.01 years, height = 169.42 ± 23.62 cm, mass = 71.53 ± 36.77 kg) volunteered to participate. They were assigned randomly to 1 of 3 groups: treatment KT, sham KT, and control.

INTERVENTION(S)

Tape was applied based on group assignment. The treatment KT group received the ankle-tape technique as described in the KT manual. The sham KT group received 1 strip of Kinesio Tex tape around the circumference of the proximal gastrocnemius muscle. The control group did not receive tape application.

MAIN OUTCOME MEASURE(S)

The dependent variables were blood flow in blood perfusion units, volume of water displacement in milliliters, circumference of the gastrocnemius muscle in centimeters, and endurance ratio in joules measured before, 24 hours after, and 72 hours after the intervention. Separate repeated-measures analyses of variance were conducted for each dependent variable.

RESULTS

We found no group-by-test day interaction for endurance ratios (F(4,116) = 1.99, P = .10). Blood flow, circumference, and volume measurements also yielded no differences among groups (F(2,58) range, 0.02-0.51; P > .05) or test days (F(2,116) range, 0.05-2.33; P > .05).

CONCLUSIONS

We found KT does not enhance anaerobic muscle function measured by endurance ratio. The KT also did not affect circulation or volume of the gastrocnemius muscle in a healthy population.

Segmental bioimpedance for measuring amlodipine-induced pedal edema: a placebo-controlled study

BACKGROUND

The development of antihypertensives requires efficient and accurate tools for identifying pedal edema. Methodologies used to gauge the potential of an agent to induce pedal edema in short-term (<4-week) clinical trials have not been reported in the literature.

OBJECTIVE

The purpose of this study was to identify a robust and practical method for measuring drug-induced pedal edema for use in the clinical development of antihypertensives. The efficacy of segmental bioimpedance in the detection of increased pedal edema was compared with that of clinical pitting assessment, ankle circumference, and water displacement volumetry.

METHODS

The study population consisted of male and female healthy subjects and patients with stage 1 or 2 hypertension who were otherwise healthy. Participants were randomly assigned to receive amlodipine 10 mg or placebo once daily in this 6-week, double-blind, parallel-group study. Amlodipine was used as a means of inducing ankle edema, and not for the treatment of hypertension. Patients with hypertension were required to undergo a washout of antihypertensive therapies. Edema was evaluated using segmental bioimpedance at 10 kHz, clinical pitting assessment, ankle circumference, and water displacement at weeks 2, 4, and 6. The ANOVA model used included treatment and baseline values as covariates, with treatment pairs compared via t tests derived from the model.

RESULTS

A total of 47 individuals were randomized (49% male; 29 [62%] with hypertension; mean [SD] age, 59 [5.9] years; baseline body mass index, 28.6 kg/m(2) [2.8]; blood pressure 146.6 [10.7]/93.5 [6.5] and 139.3 [8.3]/89.5 [4.5] in individuals with and without hypertension, respectively; amlodipine 10 mg, n = 24; placebo, n = 23). At weeks 2, 4, and 6, statistically significant treatment differences in changes from baseline were detected using water displacement (mean [90% CI] treatment differences, +39.0 g [+17.9 to +60.1], +61.9 g [+36.1 to +87.6], and +72.2 g [+42.3 to +102.1], respectively; all, P ≤ 0.001), ankle circumference (+4.74 mm [+2.38 to +7.11; P < 0.001], +2.92 mm [+0.33 to +5.49; P = 0.032], and +5.16 mm [+2.21 to +8.11; P = 0.002]), and bioimpedance (-11.7 Ω [-18.1 to -5.4], -18.3 Ω [-26.2 to -10.4], and -20.9 Ω [-29.7 to -12.0]; all, P≤0.001), but no significant differences were detected using clinical assessment of pitting.

CONCLUSION

In this population of healthy subjects and patients with hypertension, segmental bioimpedance was comparable to water displacement and ankle circumference and outperformed clinical assessment of pitting for the detection of ankle edema, supporting the use of segmental bioimpedance as a drug-development tool to objectively quantify amlodipine-induced pedal edema.

Compression stockings with moderate pressure are able to reduce chronic leg oedema

Aim

To compare the efficacy of compression stockings and inelastic, high-pressure bandages concerning leg volume reduction in patients with chronic leg oedema.

Material and methods

Forty-two legs of 30 patients with chronic leg oedema caused by venous stasis were randomized to receive a strong inelastic bandage (IB) or an elastic stocking (ES) exerting a pressure of 23–32 mmHg. Changes in leg oedema were assessed after two and seven days by water displacement volumetry, measurements of leg circumferences and of skin thickness by using Duplex ultrasound. Interface pressure was registered under the compression devices for seven days.

Results

There was no significant difference between stockings and bandages, which both produced a significant reduction in leg volume after two days (−9.6% [95% CI 7.5–11.8] by ES and −11.5% [95% CI 9.9–13.2%] by IB) and after seven days (−13.2% [95% CI 10.4–16.2] by ES and −15.6% [95% CI 12.8–18.4] by IB). Bandages showed a more pronounced reduction in leg circumference and in skin thickness in the calf region. The pressure of IB in the lying position fell from initially 63 to 22 mmHg after two days, but only from 33 to 26 mmHg under ES (median values). The optimal pressure range concerning oedema reduction was found between 40 and 60 mmHg, while higher pressures produced by bandages showed a negative correlation with volume reduction.

Conclusions

Compression stockings exerting a pressure of around 30 mmHg are nearly as effective as high-pressure bandages with an initial pressure over 60 mmHg in reducing chronic leg oedema.

Reproducibility and day time bias correction of optoelectronic leg volumetry: a prospective cohort study

BACKGROUND

Leg edema is a common manifestation of various underlying pathologies. Reliable measurement tools are required to quantify edema and monitor therapeutic interventions. Aim of the present work was to investigate the reproducibility of optoelectronic leg volumetry over 3 weeks' time period and to eliminate daytime related within-individual variability.

METHODS

Optoelectronic leg volumetry was performed in 63 hairdressers (mean age 45 ± 16 years, 85.7% female) in standing position twice within a minute for each leg and repeated after 3 weeks. Both lower leg (legBD) and whole limb (limbBF) volumetry were analysed. Reproducibility was expressed as analytical and within-individual coefficients of variance (CVA, CVW), and as intra-class correlation coefficients (ICC).

RESULTS

A total of 492 leg volume measurements were analysed. Both legBD and limbBF volumetry were highly reproducible with CVA of 0.5% and 0.7%, respectively. Within-individual reproducibility of legBD and limbBF volumetry over a three weeks' period was high (CVW 1.3% for both; ICC 0.99 for both). At both visits, the second measurement revealed a significantly higher volume compared to the first measurement with a mean increase of 7.3 ml ± 14.1 (0.33% ± 0.58%) for legBD and 30.1 ml ± 48.5 ml (0.52% ± 0.79%) for limbBF volume. A significant linear correlation between absolute and relative leg volume differences and the difference of exact day time of measurement between the two study visits was found (P < .001). A therefore determined time-correction formula permitted further improvement of CVW.

CONCLUSIONS

Leg volume changes can be reliably assessed by optoelectronic leg volumetry at a single time point and over a 3 weeks' time period. However, volumetry results are biased by orthostatic and daytime-related volume changes. The bias for day-time related volume changes can be minimized by a time-correction formula.

Estudo da confiabilidade e validade da utilização do hidropletismômetro para medida de edema no tornozelo

Instrumentos confiáveis e válidos são necessários para avaliar a efetividade das técnicas de reabilitação. O objetivo deste estudo foi avaliar a confiabilidade e a validade do Hidropletismômetro. Quatorze sujeitos com idade entre 18 e 59 anos foram selecionados para participar do estudo. Os tornozelos foram avaliados por dois examinadores treinados com o Hidropletismômetro. Três medidas de cada tornozelo foram obtidas pelos examinadores de forma aleatória para investigar a confiabilidade intra e inter-examinadores. Foram também obtidas vinte e seis medidas com o Hidropletismômetro e comparadas com as medidas obtidas com o Deslocador de Água considerado "padrão ouro", através de provetas de vidro graduadas de 10 ml a 1000 ml. A confiabilidade intra e inter-examinadores foi realizada através do Coeficiente de Correlação Intraclasse (CCI) e a validade através do teste t pareado. O Coeficiente de Correlação de Pearson foi utilizado para estabelecer a associação entre os dois instrumentos. Os dados demonstraram níveis de confiabilidade intra e inter-examinadores com (CCI)3,1 = 0,99 e (CCI)3,2 = 0,99, respectivamente. Nenhuma diferença foi encontrada entre as medidas obtidas com o Hidropletismômetro e as obtidas com as provetas (p=0,404). A Correlação de Coeficiente de Pearson mostrou alta magnitute e nível de significância entre as medidas (r=1,0; p<0,0001). Os resultados evidenciaram que o Hidropletismômetro é um instrumento confiável e válido para medida de volume do tornozelo/pé.

Ankle manual therapy for individuals with post-acute ankle sprains: description of a randomized, placebo-controlled clinical trial

BACKGROUND

Ankle sprains are common within the general population and can result in prolonged disablement. Limited talocrural dorsiflexion range of motion (DF ROM) is a common consequence of ankle sprain. Limited talocrural DF ROM may contribute to persistent symptoms, disability, and an elevated risk for re-injury. As a result, many health care practitioners use hands-on passive procedures with the intention of improving talocrural joint DF ROM in individuals following ankle sprains. Dosage of passive hands-on procedures involves a continuum of treatment speeds. Recent evidence suggests both slow- and fast-speed treatments may be effective to address disablement following ankle sprains. However, these interventions have yet to be longitudinally compared against a placebo study condition.

METHODS/DESIGN

We developed a randomized, placebo-controlled clinical trial designed to test the hypotheses that hands-on treatment procedures administered to individuals following ankle sprains during the post-acute injury period can improve short-, intermediate-, and long-term disablement, as well as reduce the risk for re-injury.

DISCUSSION

This study is designed to measure the clinical effects of hands-on passive stretching treatment procedures directed to the talocrural joint that vary in treatment speed during the post-acute injury period, compared to hands-on placebo control intervention.

TRIAL REGISTRATION

http://www.clinicaltrials.gov identifier NCT00888498.

Effects of intensive insulin therapy alone and with added pioglitazone on renal salt/water balance and fluid compartment shifts in type 2 diabetes

OBJECTIVE

To evaluate the effects of intensive insulin therapy alone or with added pioglitazone on renal salt/water balance and body fluid compartment shifts in type 2 diabetes.

METHODS

A total of 25 insulin-treated, obese patients with type 2 diabetes were randomized to pioglitazone 45 mg (n = 12) or placebo (n = 13) and treated intensively for 12-16 weeks to achieve equivalent glycaemic control. We measured total body water (TBW) and extracellular/intracellular fluid by bioimpedance analysis; plasma/RBC volume with I(131)albumin; sodium handling by fractional excretion of sodium/lithium (FeNa/FeLi) and other renal/hormonal parameters.

RESULTS

Intensification of insulin therapy and the addition of pioglitazone significantly improved glycaemia (HbA1C 7.8-7.2% and 7.6-7.1%) and increased body weight (1.7 and 4.9 kg) respectively. TBW increased 1.7 l with insulin alone (65% intracellular) and 1.6 l with added pioglitazone (75% extracellular) (p = 0.06 and 0.09 respectively). Plasma volume increased 0.2 +/- 0.1 l with insulin alone (p = 0.05) and 0.4 +/- 0.1 l with added pioglitazone (p < 0.05). Extravascular, extracellular (interstitial) fluid increased significantly and more with added pioglitazone (0.8 +/- 0.2 l, p < 0.01) than with insulin alone (0.4 +/- 0.2 l, p = ns). At steady-state, FeLi (marker of proximal-tubular sodium delivery to the distal nephron) increased significantly with added pioglitazone (12.4 +/- 1.3 to 18.0 +/- 3.2%) vs. no significant change with insulin alone (15.4 +/- 1.2 to 14.5 +/- 2.3%). There were no significant changes in the other parameters.

CONCLUSION

In intensively insulin-treated obese type 2 diabetic patients, at equivalent glycaemic control, the addition of pioglitazone causes greater weight gain, but a similar increase in body water that is mainly extracellular and interstitial compared with intracellular increase with insulin therapy alone. Pioglitazone also increases the filtered load of sodium reabsorbed at the distal nephron with no net change in FeNa.

Water displacement leg volumetry in clinical studies--a discussion of error sources

Background

Water displacement leg volumetry is a highly reproducible method, allowing the confirmation of efficacy of vasoactive substances. Nevertheless errors of its execution and the selection of unsuitable patients are likely to negatively affect the outcome of clinical studies in chronic venous insufficiency (CVI).

Discussion

Placebo controlled double-blind drug studies in CVI were searched (Cochrane Review 2005, MedLine Search until December 2007) and assessed with regard to efficacy (volume reduction of the leg), patient characteristics, and potential methodological error sources. Almost every second study reported only small drug effects (≤ 30 mL volume reduction). As the most relevant error source the conduct of volumetry was identified. Because the practical use of available equipment varies, volume differences of more than 300 mL - which is a multifold of a potential treatment effect - have been reported between consecutive measurements. Other potential error sources were insufficient patient guidance or difficulties with the transition from the Widmer CVI classification to the CEAP (Clinical Etiological Anatomical Pathophysiological) grading.

Summary

Patients should be properly diagnosed with CVI and selected for stable oedema and further clinical symptoms relevant for the specific study. Centres require a thorough training on the use of the volumeter and on patient guidance. Volumetry should be performed under constant conditions. The reproducibility of short term repeat measurements has to be ensured.

Identification of potential neuromotor mechanisms of manual therapy in patients with musculoskeletal disablement: rationale and description of a clinical trial

Background

Many health care practitioners use a variety of hands-on treatments to improve symptoms and disablement in patients with musculoskeletal pathology.

Research to date indirectly suggests a potentially broad effect of manual therapy on the neuromotor processing of functional behavior within the supraspinal central nervous system (CNS) in a manner that may be independent of modification at the level of local spinal circuits. However, the effect of treatment speed, as well as the specific mechanism and locus of CNS changes, remain unclear.

Methods/Design

We developed a placebo-controlled, randomized study to test the hypothesis that manual therapy procedures directed to the talocrural joint in individuals with post-acute ankle sprain induce a change in corticospinal excitability that is relevant to improve the performance of lower extremity functional behavior.

Discussion

This study is designed to identify potential neuromotor changes associated with manual therapy procedures directed to the appendicular skeleton, compare the relative effect of treatment speed on potential neuromotor effects of manual therapy procedures, and determine the behavioral relevance of potential neuromotor effects of manual therapy procedures.

Trial Registration

identifier NCT00847769.

Rate of occupational leg swelling is greater in the morning than in the afternoon

The aim of this study was to investigate the rate of occupational leg swelling depending on the time period of the working day. Volumetric variations of the legs of 70 hospital employees, enrolled in three groups, were evaluated. Group I: 35 morning shift workers; Group II: 35 afternoon shift workers; and Group III: 15 individuals randomly selected from Groups I and II, who were evaluated on the day they worked 12 hours consecutively. Volumetry was performed before and after each shift for both legs of the participants in Groups I and II. For Group III volumetry was performed early in the morning, at noon and in the evening. For statistical analysis, the Student's t-test and Mann-Whitney test were used with an alpha error of 5% being considered acceptable ( P value < 0.05). Significant increases in volume were recorded for the limbs in all three groups ( P value < 0.001). On comparing Groups I and II, the accumulation of fluids was significantly higher in the morning than in the afternoon ( P value < 0.003). Asymptomatic workers may present with oedema of the legs during their work with the rate of oedema being different for morning and afternoon shifts. The possibility of wearing compression stockings should be considered for this type of work.

Metabolic stress-like condition can be induced by prolonged strenuous exercise in athletes

Few studies have examined energy metabolism during prolonged, strenuous exercise. We wanted therefore to investigate energy metabolic consequences of a prolonged period of continuous strenuous work with very high energy expenditure. Twelve endurance-trained athletes (6 males and 6 females) were recruited. They performed a 7-h bike race on high work-load intensity. Physiological, biochemical, endocrinological, and anthropometric muscular compartment variables were monitored before, during, and after the race. The energy expenditure was high, being 5557 kcal. Work-load intensity (% of VO(2) peak) was higher in females (77.7%) than in men (69.9%). Muscular glycogen utilization was pronounced, especially in type I fibres (>90%). Additionally, muscular triglyceride lipolysis was considerably accelerated. Plasma glucose levels were increased concomitantly with an unchanged serum insulin concentration which might reflect an insulin resistance state in addition to proteolytic glyconeogenesis. Increased reactive oxygen species (malondialdehyde (MDA)) were additional signs of metabolic stress. MDA levels correlated with glycogen utilization rate. A relative deficiency of energy substrate on a cellular level was indicated by increased intracellular water of the leg muscle concomitantly with increased extracellular levels of the osmoregulatory amino acid taurine. A kindred nature of a presumed insulin-resistant state with less intracellular availability of glucose for erythrocytes was also indicated by the findings of decreased MCV together with increased MCHC (haemoconcentration) after the race. This strenuous energy-demanding work created a metabolic stress-like condition including signs of insulin resistance and deteriorated intracellular glucose availability leading to compromised fuelling of ion pumps, culminating in a disturbed cellular osmoregulation indicated by taurine efflux and cellular swelling.

Influência do turno laboral na formação de edema dos membros inferiores em indivíduos normais

CONTEXTO: A presença de edema vespertino nos membros inferiores de indivíduos normais, após jornada habitual de trabalho, foi demonstrada na literatura nacional e internacional. O ritmo de formação e o acúmulo desse edema variam de acordo com os distintos turnos laborais. OBJETIVO: O edema de membros inferiores tem sido descrito após jornadas habituais de trabalho e representa uma queixa freqüente na prática vascular. O objetivo deste estudo foi avaliar a evolução do edema em indivíduos normais durante os distintos turnos laborais. MÉTODO: Foram feitas avaliações volumétricas de ambos os membros inferiores em 20 profissionais da área da saúde do Hospital e Maternidade São Marcos de Maringá, no Paraná. A escolha dos participantes foi por ordem de chegada, e as volumetrias foram feitas por técnica de deslocamento de água às 7, 13 e 19 h. Para análise estatística foi utilizado o teste t de Student, considerando erro alfa de 5%. RESULTADO: Dos 20 participantes, 19 eram do sexo feminino e 1 do masculino, sem evidência de doença venosa nos membros inferiores e pertencentes a C0 e C1 da classificação CEAP (C = clínica, E = etiologia, A = segmento anatômico, P = fisiopatologia). As idades dos participantes variaram entre 20 e 53 anos. Detectou-se aumento significativo de volume nos membros inferiores entre os distintos períodos avaliados, com p = 0,0001 e 0,0001, respectivamente. A maior variação ocorreu no período da manhã, com média ± desvio padrão de 107,2±63,5 mL, enquanto que à tarde, a variação foi de 44,5±35,4 mL. CONCLUSÃO: O edema é uma constante durante atividades laborais, mesmo em pessoas sem doença venosa manifesta e sofre influência do turno laboral ao qual o trabalhador se encontra exposto.

Adaptation to altitude as a vehicle for experiential learning of physiology by university undergraduates

In this article, an experiential learning activity is described in which 19 university undergraduates made experimental observations on each other to explore physiological adaptations to high altitude. Following 2 wk of didactic sessions and baseline data collection at sea level, the group ascended to a research station at 12,500-ft elevation. Here, teams of three to four students measured the maximal rate of oxygen uptake, cognitive function, hand and foot volume changes, reticulocyte count and hematocrit, urinary pH and 24-h urine volume, athletic performance, and nocturnal blood oxygen saturation. Their data allowed the students to quantify the effect of altitude on the oxygen cascade and to demonstrate the following altitude-related changes: 1) impaired performance on selected cognitive function tests, 2) mild peripheral edema, 3) rapid reticulocytosis, 4) urinary alkalinization and diuresis, 5) impaired aerobic but not anaerobic exercise performance, 6) inverse relationship between blood oxygen saturation and resting heart rate, and 7) regular periodic nocturnal oxygen desaturation events accompanied by heart rate accelerations. The students learned and applied basic statistical techniques to analyze their data, and each team summarized its results in the format of a scientific paper. The students were uniformly enthusiastic about the use of self-directed experimentation to explore the physiology of altitude adaptation and felt that they learned more from this course format than a control group of students felt that they learned from a physiology course taught by the same instructor in the standard classroom/laboratory format.

Volumetric evaluation of upper extremities in 250 healthy persons

BACKGROUND AND PURPOSE

Upper extremity oedema frequently occurs as a complication of several diseases. The aim of this study was to establish normative data for upper extremity volumes with a modified water displacement method. These data were used to develop predictive formulas helpful in detecting abnormal swelling.

SUBJECTS AND METHODS

Upper extremities of 250 healthy subjects (138 men and 112 women) were measured by water displacement.

RESULTS

A mean difference of 3.0% (3.2%) between right and left arm (forearm) was found. Intra-class correlation coefficients were 0.99 for intra-rater and inter-rater reliabilities. Coefficient of variation was 0.23%. To predict the premorbid volume of an oedematous arm, prediction formulas were constructed.

DISCUSSION AND CONCLUSION

Water displacement as used in this study is a highly reliable technique for volume measurement of upper extremities. This technique was applied to gather normative data for upper extremity volumes. We suggest that this technique can be used in daily clinical practice for the evaluation of upper extremity oedema or atrophy caused by various diseases as well as for volume monitoring. Prediction formulas can be used to define abnormal swelling.

Response of pregnancy leg edema to a single immersion exercise session

BACKGROUND

To quantify the effect of a single immersion exercise session on uncomplicated dependent edema in pregnancy.

METHODS

Lower leg volume was measured by water displacement volumetry and limb circumference in nine women with marked dependent edema, but otherwise normal second or third trimester pregnancy, before and after upright water immersion exercise session (Aqua-Fit) for 45 min. Maternal heart rate was monitored continuously throughout the session. Blood pressure was measured before and after the session.

RESULTS

Mean left leg volume decreased by 112 ml from 1665 to 1553 ml, and right leg volume by 84 ml from 1665 to 1581 ml (P = 0.007). Cardiovascular parameters fluctuated within the normal range, well below the upper limits recommended in pregnancy.

CONCLUSIONS

A single immersion exercise session is a safe, effective, and enjoyable complement, or alternative, to compression stockings for reduction of gestational dependent edema. Further study is required to determine its duration of effect and the optimum interval between sessions.

Relationship between ankle-foot swelling and self-assessed function after ankle sprain

PURPOSE

Decreasing swelling after ankle sprain is a main focus of treatment, as it is believed that swelling is related to function. The purpose of this study was to evaluate the relationship between ankle-foot swelling and self-assessed ankle function in the early period after ankle sprain.

METHODS

Thirty-six individuals were tested for ankle-foot volume and self-assessed ankle function within days of spraining their ankle. Volumetric measurements of the injured and uninjured ankle-foot segment were taken with a foot and ankle volumeter. Stepwise linear regression analysis was performed, with function being the dependent variable, and the following variables included as independent variables: gender, age, body mass index, previous history of sprain in the injured ankle, and the volume difference between the injured and uninjured ankle-foot segment.

RESULTS

None of the independent variables were significantly related to self-assessed function. Pearson's correlation coefficient for the injured minus uninjured ankle-foot volume and self-assessed ankle function was -0.003.

CONCLUSION

The results indicate that there is no relationship between ankle-foot swelling and self-assessed ankle function in the early period after ankle sprain injury.

Effect of body position on foot and ankle volume in healthy subjects

Physical therapy treatments for and evaluation of lower limb swelling are usually performed in supine lying position. However, the limb is usually treated or assessed in the dependent position, i.e. sitting or standing. The purpose of this study was to determine the possible confounding effect of subject positioning on foot and ankle volume. Sixty healthy individuals were randomly positioned into motionless standing, sitting or supine lying for 30 min. Volumetric measurements of the dominant leg were taken with a foot and ankle volumeter before and after 30 min of positioning. A significant difference between the three groups for foot and ankle volume change (F(2,53) = 35.41, P<0.001) was found. A post-hoc Tukey HSD test revealed that the difference was statistically significant between sitting and standing as well as supine lying and standing (P<0.001). No statistical significance was found between sitting and supine lying (P = 0.90). Standing caused the greatest increase in foot and ankle volume followed by sitting then supine lying. The results indicate that treating or assessing a limb with the subject in a sitting position would not be significantly different from a subject who is positioned in supine lying. However, it is not known whether the height and the distance from the heart to the feet were comparable between the groups, and so it is recommended that, where possible, treatment and assessment of lower leg swelling should be undertaken with the leg in a non-dependent position and definitely not in standing.

Therapeutic profile of manidipine and lercanidipine in hypertensive patients

Manidipine and lercanidipine are considered effective and safe in the treatment of chronic arterial hypertension and are equipotent in reducing blood pressure (BP) levels. Their main side effect is ankle-foot edema. After a 2-week placebo run-in period, these 2 drugs were compared in a controlled parallel-group study lasting 3 months, involving 53 patients with mild-to-moderate essential hypertension (26 assigned to manidipine and 27 to lercanidipine). At the end of the active treatment period, BP was significantly reduced in comparison with the end of the placebo phase in both the manidipine and the lercanidipine groups, without significant differences between the 2 drugs. Daytime BP was significantly reduced by 5.5%/5.6% with manidipine and by 3.8%/6.6% with lercanidipine, while smaller reductions were seen at nighttime. The smoothness index was the same with both drugs. Unlike lercanidipine, manidipine significantly reduced both basal (-30%) and minimal vascular resistance (-39%), qualifying it as a potent vasodilator. Despite vasodilation, heart rate was not increased but was even slightly reduced by treatment. Ankle-foot edema was observed with both drugs but was less pronounced with manidipine, probably because of greater postcapillary dilatation. In conclusion, manidipine and lercanidipine are both effective and safe in mild-to-moderate essential hypertension, although the former seems to have a more favorable tolerability profile than the latter.

The validity and reliability of the Perometer in evaluating human knee volume

BACKGROUND

Accurate knee swelling evaluation is important in monitoring the progress of a patient's condition and rehabilitation. Water volumetry is the current gold standard of volume assessment but can be time consuming and unsuitable for assessing patients with open wounds. No previous study has reported the potential use of an optoelectronic device in assessing knee volume.

OBJECTIVES

To evaluate an optoelectronic device, the Perometer in knee volume assessment in uninjured subjects and compare it to the current gold standard of volume assessment - water displacement.

MATERIALS AND METHODS

Bilateral knee measurements were measured in 20 uninjured individuals with both methods on two separate days using a one-way repeated measures design. A cylindrical object was also measured 10 times with both tools.

RESULTS

The mathematically calculated volume of the cylinder was 1568 ml. The mean volume obtained by the Perometer was 1602 and 1620 ml by the volumeter. This represented an over-estimation of the true volume of 2.2% by the Perometer and 3.4% by the volumeter. A high correlation was found for repeated measures of knee volumes with both methods (r = 0.94, P<0.01). Limits of agreement (LOA) were calculated to assess the amount of agreement between the two methods and these ranged from -130 to 207 ml indicating a low degree of agreement.

CONCLUSIONS

The results indicate that the Perometer is as reliable as the knee volumeter in assessing knee volume. However, the wide LOA suggest the two methods should not be used interchangeably.

Effect of manual lymph drainage after hindfoot operations

BACKGROUND AND PURPOSE

Manual lymph drainage therapy is often prescribed following hindfoot operations. However, the relative efficacy of this treatment component has not yet been determined.

METHOD

A two-group pre-test-post-test study design was used in this preliminary randomized clinical trial of 23 subjects who underwent hindfoot surgery. Patients were randomly assigned into two groups: an intervention group of 11 patients who received standard physiotherapy plus manual lymph drainage; and a control group of 12 patients who received standard physiotherapy but no lymph drainage. The main outcome measure was the percentage reduction in excess limb volume, measured by the water displacement method at the second post-operative day (t1) and at the day of discharge (t2).

RESULTS

Compared to the control group, a significant reduction in post-operative swelling was measured in the intervention group only (p = 0.011).

CONCLUSIONS

Application of lymph drainage techniques after hindfoot operations, in combination with standard physiotherapy exercises, achieves greater limb volume reduction than exercise alone. The present study offers an insight into a treatment that may shorten rehabilitation and thereby control the cost of caring for post-operative treatment complicated by post-operative swelling.

The effect of different knee angles on knee volume measured with the Perometer device in uninjured subjects

The Perometer is an optoelectronic device used to calculate limb volume. However, knee angle effect on knee volume during a Perometer measurement has not been reported. This could be a potential confounding factor in assessing knee volume in subjects with impaired knee mobility and where volume measurements are taken over time. To address this issue, bilateral knee volume measurements were recorded from 20 uninjured subjects in seven different knee angles from 0-60 degrees flexion. All 40 knees were not measured in all seven angles because of obstruction of the measurement frame when some knees were in 50 degrees and 60 degrees flexion. Thus, the volume data was separated into three subgroups for analysis: 40 knees at knee flexion angles 0, 10, 20, 30 and 40 degrees; 36 knees at 50 degrees; and 16 knees at 60 degrees. Repeated measures analysis of variance showed a statistically significant difference between the volume measurements in the three subgroups: 0-40 degrees knee flexion [F(4,156) = 35.146, P<0.001], 50 degrees knee flexion (F(5,175) = 56.826, P<0.001] and 60 degrees knee flexion, [F(6,90) = 45.825, P<0.001]. Subsequent paired t-tests showed statistically significant [P<0.001] differences in knee volume for all angle comparisons except for 0 and 10 degrees (absolute volume difference of 1.2 ml; P = 0.772) and 0 and 20 degrees (absolute volume difference of 10.9 ml; P = 0.036) (Bonferroni adjustment applied). The absolute values of the differences that were shown to be statistically significantly different ranged from 12-47 ml for the 0-40 degrees subgroup; 39-85 ml for the 50 degrees subgroup and 35-107 ml for the 60 degrees subgroup. In conclusion, knee angle affects Perometer knee volume measurements and statistically significant differences occur as knee flexion exceeds 20 degrees with greater differences occurring as the knee is more flexed. Hence, knee angle should be reproduced in re-testing and in side-to-side comparisons when evaluating knee volume with the Perometer.

Intraoperative colloid administration reduces postoperative nausea and vomiting and improves postoperative outcomes compared with crystalloid administration

The debate over colloid versus crystalloid as the best solution for intraoperative fluid resuscitation is not resolved. Published studies have shown that mortality is not related to the specific fluid used for resuscitation. In addition, the quality of postoperative recovery between colloid and crystalloid has not been well investigated. In a prospective, blinded fashion, we investigated the effects of colloid and crystalloid resuscitation on nausea and vomiting and on the postoperative patient recovery profile. Patients undergoing major elective noncardiac surgery were randomized to receive 6% hetastarch in saline (HS-NS), 6% hetastarch in balanced salt (HS-BS), or lactated Ringer's solution (LR) on the basis of a fluid administration algorithm. The anesthetic was standardized. Hemodynamic targets included maintenance of arterial blood pressure, heart rate, and urine output within a predefined range. A postoperative morbidity survey was performed at baseline and daily after surgery. Ninety patients participated in the study, with 30 patients in each group. The amounts of study fluid (mean +/- SD) administered were 1301 +/- 1079 mL, 1448 +/- 759 mL, and 5946 +/- 1909 mL for the HS-NS, HS-BS, and LR groups, respectively (P < 0.05, HS-NS and HS-BS versus LR). Both the HS-NS and HS-BS (colloid) groups had a significantly less frequent incidence of nausea and vomiting, use of rescue antiemetics, severe pain, periorbital edema, and double vision. We concluded that intraoperative fluid resuscitation with colloid, when compared with crystalloid administration, is associated with an improvement in the quality of postoperative recovery.

Discontinuation of furosemide decreases PaCO(2) in patients with COPD

STUDY OBJECTIVE

To evaluate whether the discontinuation of furosemide treatment resulted in a decrease in PaCO(2) and an increase in daytime and nocturnal oxygenation.

BACKGROUND

Furosemide is widely prescribed in patients with COPD for the treatment of peripheral edema. It is known that furosemide causes a metabolic alkalosis. A diminished chemoreceptor stimulation may cause a decreased alveolar ventilation.

DESIGN

Randomized, double-blind, placebo-controlled, crossover trial.

SETTING

Department of Pulmonology, Rijnstate Hospital Arnhem, the Netherlands.

PATIENTS

Twenty patients with stable COPD (10 men; median age, 70 years [range, 58 to 81 years]; FEV(1) 35% predicted [range, 19 to 70% predicted]). Subjects were included if they had received furosemide, 40 mg/d, for the treatment of peripheral edema for at least a month and if they had a mean nocturnal arterial oxygen saturation (SaO(2)) < 92%. Patients with cardiac left and/or right ventricular dysfunction, sleep apneas, and patients receiving other diuretics, angiotensin-converting enzyme inhibitors, potassium or chloride replacement therapy, or long-term oxygen treatment were excluded.

INTERVENTION

Furosemide was discontinued for 1 week and replaced by placebo treatment in the first or the second week.

MEASUREMENTS AND RESULTS

Ventilation, daytime arterial blood gas levels, and nocturnal SaO(2) were measured at baseline, after 1, and after 2 weeks. Sixteen subjects completed the study. Ventilation increased from 10.4 L/min (range, 6.7 to 15.4 L/min) at baseline to 11.6 L/min (range, 8.7 to 14.0 L/min) after discontinuation of furosemide (p < 0.05). PaCO(2) decreased from 45 mm Hg (range, 35 to 64 mm Hg) to 41 mm Hg (range, 32 to 61 mm Hg; p < 0.01). Daytime and nocturnal oxygenation did not improve.

CONCLUSIONS

Although it does not improve oxygenation, the discontinuation of furosemide decreases PaCO(2) in patients with COPD.