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Complete inactivity no longer encouraged

I'm a school nurse. Recently I cared for a teenager who suffered a concussion playing basketball. I was surprised when her physician allowed her to return to school the next week. Shouldn't patients be encouraged to rest their brains until all symptoms resolve?-L.K., MASS.

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Although complete rest and physical inactivity following a sports-related concussion (SRC) was once recommended, the American Academy of Pediatrics (AAP) has modified this approach; current research indicates that complete physical and cognitive inactivity may actually prolong recovery. Recently released AAP guidelines discourage prolonged absence from school, instead recommending that teachers and school staff make academic adjustments to reduce the returning student's workload and avoid environmental triggers that may exacerbate symptoms.


In addition, although the student should be removed from sports play and avoid strenuous activities following an SRC, light cardiovascular activity, such as brisk walking, may be beneficial after the acute phase (24 to 48 hours following the injury), provided the activity does not provoke or exacerbate symptoms. The AAP notes that more research is needed to determine the optimal type and duration of exercise.


Sources: Halstead ME, Walter KD, Moffatt K, Council on sports medicine and fitness. Sport-related concussion in children and adolescents. Pediatrics. 2018;142(6). McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838-847.



Wondering about water

Some of my home healthcare patients have problems with recurrent cystitis. I usually advise them to increase their water intake to help flush bacteria from the bladder. It seems like common sense, but does the evidence support this approach?-C.N., CONN.


Although little research on this issue has been done, a recent 12-month study of 140 premenopausal women supports the value of increasing water intake to prevent recurrent cystitis, particularly in women whose fluid intake is low. The study participants were all in good general health and reported drinking less than 1.5 L fluid daily. They were randomly assigned to the water group (1.5 L fluid daily in addition to their usual fluid intake) and the control group (usual fluid intake with no additional fluids). Assessments of daily fluid intake, urinary hydration, and cystitis symptoms were performed at baseline, 6- and 12-month visits, and monthly telephone calls.


During the study period, the researchers documented 327 cystitis episodes, 111 in the water group and 216 in the control group. The mean number of cystitis episodes was 1.7 for women in the water group compared with 3.2 for those in the control group.


Overall, the mean number of antimicrobial regimens used to treat cystitis episodes was 1.9 for the water group and 3.6 for the control group. The researchers concluded that "increased water intake is an effective antimicrobial-sparing strategy to prevent recurrent cystitis in premenopausal women at high risk for recurrence who drink low volumes of fluid daily."


Source: Hooton TM, Vecchio M, Iroz A, et al. Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections: a randomized clinical trial. JAMA Intern Med. [e-pub Oct. 1, 2018].



Pregnancy doesn't bar hyperbaric oxygen

A pregnant woman I cared for recently was diagnosed with mild carbon monoxide poisoning resulting from a malfunctioning heater in her home. One of the prescribed treatments was hyperbaric oxygen therapy. Is this treatment safe during pregnancy?-U.Y., ILL.


According to the CDC, hyperbaric oxygen (HBO) is not only safe, it is the treatment of choice for pregnant women, even those who are less severely poisoned. International consensus favors it as part of a more aggressive role in treating pregnant women.


In nonpregnant patients, indications for HBO include a carboxyhemoglobin (COHgb) level of more than 25%, evidence of cardiac involvement, severe acidosis, transient or prolonged unconsciousness, neurologic impairment, abnormal neuropsychiatric testing, or patient age 36 or older. Depending on the patient's clinical condition and history of exposure, HBO may also be indicated in patients whose COHgb is less than 25%.


Source: Centers for Disease Control and Prevention. Clinical guidance for carbon monoxide (CO) poisoning after a disaster. 2017. http://www.cdc.gov/disasters/co_guidance.html.