Exercise rehabilitation for recovery from critical illness (Protocol)

Queen Margaret University, Edinburgh, UK. As part of an ongoing research education programme.This is the protocol for a review and there is no abstract. The objectives are as follows: The objective of this systematic review is to assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, on improving functional exercise capacity and quality of life in adult ICU survivors who have been mechanically ventilated for more than 24 hours. We will compare an exercise intervention to any other intervention or a control or 'usual care' programme. Exercise includes any structured or taught programmes. Respiratory or inspiratory muscle training is excluded due to it being initiated within the ICU environment, for example with weaning from a ventilator, and not as post-discharge rehabilitation as required for this review.sch_phyAngus 1997 Angus, DC. Understanding the incidence and long-term outcomes of ARDS. In: Gullo, A editor(s). Anaesthesia, pain, intensive care and emergency medicine: a scientific report. Berlin Heidelberg New York: Springer, 1997:289-98. Angus 2003 Angus DC, Carlet J, Brussels Roundtable 2002 Participants. Surviving intensive care: a report from the 2002 Brussels Roundtable. Intensive Care Medicine 2003;29(3):368-77. [PUBMED: 12536269 ] Baumgartner 1999 Baumgartner WA,Walinsky PL, Salazar JD, Tseng EE, Brock MV, Doty JR, et al.Assessing the impact of cerebral injury after cardiac surgery: will determining the mechanism reduce the injury?. The Annals of Thoracic Surgery 1999;67(6):1871-3. [PUBMED: 10391329] Brown 1990 Brown AB, McCartney N, Sale DG. Positive adaptation to weightlifting in the elderly. Journal of Applied Physiology 1990;69(5): 1725-33. [PUBMED: 2272965] Burtin 2009 Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, et al.Early exercise in critically ill patients enhances short-term functional recovery. Critical Care Medicine 2009;37(9): 2499-505. [PUBMED: 19623052] Chaboyer 2003 Chaboyer W, Grace J. Following the path of ICU survivors: a quality improvement activity. Nursing in Critical Care 2003;8(4): 149-55. [PUBMED: 12940690] Eddleston 2000 Eddleston J, White P, Guthrie E. Survival, morbidity, and quality of life after discharge from intensive care. Critical Care Medicine 2000; 28(7):2293-9. [PUBMED: 10921555] Elliott 2006 Elliott D, McKinley S, Alison J, Aitken L, King M. Study protocol: Home-based rehabilitation for survivors of a critical illness. Critical Care 2006;10(3):R90. [PUBMED: 16792792 ] Fiatarone 1994 Fiatarone MA, O'Neill EF, Ryan ND, Clements KM, Solares GR, Nelson ME, et al.Exercise training and nutritional supplementation for physical frailty in very elderly people. New England Journal of Medicine 1994;330(25):1769-75. [PUBMED: 8190152] Fletcher 2003 Fletcher S, Kennedy D, Ghosh I, Misra V, Kiff K, et al.Persistant neuromuscular and neurophysiological abnormalities in long-term survivors of prolonged critical illness. Critical Care Medicine 2003; 31(4):1012-6. [PUBMED: 12682465] Frank 2000 Frank M, Schlapfer H, Otte B, Yasikoff N, Conzelmann M. Results of neurorehabilitation. An outcome study 20 months after stroke. Praxis 2000;89(44):1799-808. [PUBMED: 11109917] Gill 2002 Gill TM, Baker DI, Gottschalk M, Peduzzi PN, Allore H, Byers A. A program to prevent functional decline in physically frail, elderly persons who live at home. New England Journal of Medicine 2002; 347(14):1068-74. [PUBMED: 12362007] Grimby 1986 Grimby G. Physical activity and muscle training in the elderly. Acta Medica Scandinavica. Supplementum. 1986;711:233-7. [PUBMED: 3535411] Guyatt 2008 Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schunemann HJ, et al.What is quality of evidence- and why is it important to clinicians?. BMJ 2008;336:995-8. [PUBMED: 18456631] Higgins 2008 Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 [updated September 2008]. Available from www.cochrane-handbook.org: The Cochrane Collaboration, 2008. Iversen 2003 Iversen MD, Fossel AH, Katz JN. Enhancing function in older adults with chronic low back pain: a pilot study of endurance training. Archives of Physical Medicine and Rehabilitation 2003;84 (9):1324-31. [PUBMED: 13680569] Jolliffe 2001 Jolliffe J, Rees K, Taylor RRS, Thompson DR, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2001, Issue 1. [DOI: 10.1002/14651858.CD001800.] King 1998 King J, Crowe J. Mobilisation practices in Canadian critical care units. Physiotherapy Canada 1998;50(3):206-11. [MEDLINE: 0346574] Kouidi 2002 Kouidi E. Exercise training in dialysis patients: why, when, and how?. Artificial Organs 2002;26(12):1009-13. [PUBMED: 12460377] Krishnan 2002 Krishnan KR, Delong M, Kraemer H, Carney R, Spiegel D, Gordon C, et al.Comorbidity of depression with other medical diseases in the elderly. Biological Psychiatry 2002;52(6):559-88. [PUBMED: 12361669] Lavie 2009 Lavie CJ, Thomas RJ, Squires RW, Allison TG, Milani RV. Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease. Mayo Clinic Proceedings 2009; 84(4):373-83. [PUBMED: 19339657] Lewis 2003 Lewis M. Intensive care unit rehabilitation within the United Kingdom: a review. Physiotherapy 2003;89(9):531-8. [DOI: 10.1016/S0031-9406(05)60179-4] Martin 2005 Martin M, Salim A, Murray J, Demetriades D, Belzberg H, Rhee P. The decreasing incidence and mortality of acute respiratory distress syndrome after injury: a 5-year observational study. Journal of Trauma 2005;50(5):1107-13. [PUBMED: 16385287] Mazzeo 2001 Mazzeo RS, Tanaka H. Exercise prescription for the elderly: current recommendations. Sports Medicine 2001;31(11):809-18. [PUBMED: 11583105] Miller 2002 Miller MD, Crotty M, Giles LC, Bannerman E, Whitehead C, Cobiac L, et al.Corrected arm muscle area: an independent predictor of long-term mortality in community dwelling older adults?. Journal of the America Geriatrics Society 2002;50(7): 1272-7. [PUBMED: 12133024] Paffenbarger 1986 Paffenbarger RS, Hyde RT, Wing AL, Hseih CC. Physical activity, all-cause mortality, and longevity of college alumni. New England Journal of Medicine 1986;314(10):605-13. [PUBMED: 3945246] Puhan 2006 Puhan MA, Busching G, Schunemann HJ, VanOort E, Zaugg C, Frey M. Interval versus continuous high-intensity exercise in chronic obstructive pulmonary disease: a randomized trial. Annals of Internal Medicine 2006;145(11):816-25. [PUBMED: 17146066] Rantanen 2000 Rantanen T, Harris T, Leveille SG, Visser M, Foley D, et al.Muscle strength and body mass index as long-term predictors of mortality in initially healthy men. Journal of Gerontology. Series A: Biological Sciences and Medical Sciences 2000;55(3):M168-73. [PUBMED: 10795731] RevMan 5.0 The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008. Schweickert 2009 Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al.Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373(epub):1874-82. [PUBMED: 19446324] Smith 2006 Smith TP, Kennedy SL, Smith M, Orent S, Fleshner M. Physiological improvements and health benefits during an exercisebased comprehensive rehabilitation program in medically complex patients. Exercise Immunology Review 2006;12:86-96. [PUBMED: 17201074] Stiller 2000 Stiller K. Physiotherapy in intensive care: toward an evidence-based practice. Chest 2000;118(6):1801-13. [PUBMED: 11115476] Storch 2008 Storch EK, Kruszynski DM. From rehabilitation to optimal function: role of clinical exercise therapy. Current Opinion in Critcal Care 2008;14(4):451-5. [PUBMED: 18614911] Wiles 2009 Wiles L, Stiller K. Passive limb movements for patients in an intensive care unit: A survey of physiotherapy practice in Australia. Journal of Critical Care 2009;epub:ahead of print. [PUBMED: 19819105] Yoshida 1999 Yoshida T, Kohzuki M, Yoshida K, Hiwatari M, Kamimoto M, Yamamoto C, et al.Physical and psychological improvements after phase II cardiac rehabilitation in patients with myocardial infarction. Nursing & Health Sciences 1999;1(3):163-70. [PUBMED: 10894639] Indicates the major publication for the study8pub1756pubArt.

Interventions for improving adherence to iron chelation therapy in people with sickle cell disease or thalassaemia

Background Regularly transfused people with sickle cell disease (SCD) and people with thalassaemia are at risk of iron overload. Iron overload can lead to iron toxicity in vulnerable organs such as the heart, liver and endocrine glands, which can be prevented and treated with iron‐chelating agents. The intensive demands and uncomfortable side effects of therapy can have a negative impact on daily activities and wellbeing, which may affect adherence. Objectives To identify and assess the effectiveness of different types of interventions (psychological and psychosocial, educational, medication interventions, or multi‐component interventions) and interventions specific to different age groups, to improve adherence to iron chelation therapy compared to another listed intervention, or standard care in people with SCD or thalassaemia. Search methods We searched CENTRAL (Cochrane Library), MEDLINE, PubMed, Embase, CINAHL, PsycINFO, ProQuest Dissertations & Global Theses, Web of Science & Social Sciences Conference Proceedings Indexes and ongoing trial databases (13 December 2021). We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register (1 August 2022). Selection criteria For trials comparing medications or medication changes, only randomised controlled trials (RCTs) were eligible for inclusion. For studies including psychological and psychosocial interventions, educational interventions, or multi‐component interventions, non‐randomised studies of interventions (NRSIs), controlled before‐after studies, and interrupted time series studies with adherence as a primary outcome were also eligible for inclusion. Data collection and analysis For this update, two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. Main results We included 19 RCTs and one NRSI published between 1997 and 2021. One trial assessed medication management, one assessed an education intervention (NRSI) and 18 RCTs were of medication interventions. Medications assessed were subcutaneous deferoxamine, and two oral chelating agents, deferiprone and deferasirox. We rated the certainty of evidence as very low to low across all outcomes identified in this review. Four trials measured quality of life (QoL) with validated instruments, but provided no analysable data and reported no difference in QoL. We identified nine comparisons of interest. 1. Deferiprone versus deferoxamine We are uncertain whether or not deferiprone affects adherence to iron chelation therapy (four RCTs, unpooled, very low‐certainty evidence), all‐cause mortality (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.18 to 1.21; 3 RCTs, 376 participants; very low‐certainty evidence), or serious adverse events (SAEs) (RR 1.43, 95% CI 0.83 to 2.46; 1 RCT, 228 participants; very low‐certainty evidence). Adherence was reported as "good", "high" or "excellent" by all seven trials, though the data could not be analysed formally: adherence ranged from 69% to 95% (deferiprone, mean 86.6%), and 71% to 93% (deferoxamine, mean 78.8%), based on five trials (474 participants) only. 2. Deferasirox versus deferoxamine We are uncertain whether or not deferasirox affects adherence to iron chelation therapy (three RCTs, unpooled, very low‐certainty evidence), although medication adherence was high in all trials. We are uncertain whether or not there is any difference between the drug therapies in serious adverse events (SAEs) (SCD or thalassaemia) or all‐cause mortality (thalassaemia). 3. Deferiprone versus deferasirox We are uncertain if there is a difference between oral deferiprone and deferasirox based on a single trial in children (average age 9 to 10 years) with any hereditary haemoglobinopathy in adherence, SAEs and all‐cause mortality. 4. Deferasirox film‐coated tablet (FCT) versus deferasirox dispersible tablet (DT) One RCT compared deferasirox in different tablet forms. There may be a preference for FCTs, shown through a trend for greater adherence (RR 1.10, 95% CI 0.99 to 1.22; 1 RCT, 88 participants), although medication adherence was high in both groups (FCT 92.9%; DT 85.3%). We are uncertain if there is a benefit in chelation‐related AEs with FCTs. We are uncertain if there is a difference in the incidence of SAEs, all‐cause mortality or sustained adherence. 5. Deferiprone and deferoxamine combined versus deferiprone alone We are uncertain if there is a difference in adherence, though reporting was usually narrative as triallists report it was "excellent" in both groups (three RCTs, unpooled). We are uncertain if there is a difference in the incidence of SAEs and all‐cause mortality. 6. Deferiprone and deferoxamine combined versus deferoxamine alone We are uncertain if there is a difference in adherence (four RCTs), SAEs (none reported in the trial period) and all‐cause mortality (no deaths reported in the trial period). There was high adherence in all trials. 7. Deferiprone and deferoxamine combined versus deferiprone and deferasirox combined There may be a difference in favour of deferiprone and deferasirox (combined) in rates of adherence (RR 0.84, 95% CI 0.72 to 0.99) (one RCT), although it was high (> 80%) in both groups. We are uncertain if there is a difference in SAEs, and no deaths were reported in the trial, so we cannot draw conclusions based on these data (one RCT). 8. Medication management versus standard care We are uncertain if there is a difference in QoL (one RCT), and we could not assess adherence due to a lack of reporting in the control group. 9. Education versus standard care One quasi‐experimental (NRSI) study could not be analysed due to the severe baseline confounding. Authors' conclusions The medication comparisons included in this review had higher than average adherence rates not accounted for by differences in medication administration or side effects, though often follow‐up was not good (high dropout over longer trials), with adherence based on a per protocol analysis. Participants may have been selected based on higher adherence to trial medications at baseline. Also, within the clinical trial context, there is increased attention and involvement of clinicians, thus high adherence rates may be an artefact of trial participation. Real‐world, pragmatic trials in community and clinic settings are needed that examine both confirmed or unconfirmed adherence strategies that may increase adherence to iron chelation therapy. Due to lack of evidence this review cannot comment on intervention strategies for different age groups

Resistance (exercise) training in non-dialysis dependent chronic kidney disease (ckd stage 3) and validation of ultrasound in the measurement of muscle size and structure in haemodialysis patients (ckd stage 5)

AIM: This thesis set out to make an original contribution to knowledge with regard to methods of assessing muscle size and architecture in the CKD and ESRD population, and to assess the ability to improve the muscle size and architecture, and symptoms of uraemia, by implementing an anabolic intervention (resistance exercise training) in the CKD population. OUTCOME MEASURES: Ultrasound was shown to have high validity (against gold standard MRI measures; ICCs: VLACSA 0.96, VL depth 0.99, fat depth 0.98) and intra-rater reliability (ICCs: VL depth 0.98, total muscle depth 0.97, fat depth 0.99; MDC: VL depth 0.14cm, total muscle depth 0.19cm, fat depth 0.22cm) in measuring regional body composition at the mid-VL site in the CKD population. There were significant (p<0.01) correlations between US-derived measures of (mid-VL) muscle size and architecture with strength and function (larger muscle mass and/or pennation angle positively correlated with higher strength and/or functional performance). Patient-reported uraemic symptoms were worse (p<0.01) in those with reduced strength and/or function. INTERVENTION RESULTS: An anabolic (resistance training) intervention (12-weeks, randomized to once [RT1 n=7] or three times [RT3 n=10] per week, 80%1RM) brought about significant improvements over time (p<0.01) in all measures of muscle size and architecture (VL depth, total muscle depth, VLACSA, pennation angle). Interaction effects (group*time) were only seen in pennation angle (p<0.05) and VLACSA (p<0.01) where RT3 gains were greater than RT1 from week 8 onwards. All measures of strength, function, and uraemic symptoms improved over time (p<0.01) with no interaction effects (no difference from greater training frequency/ volume). CLINICAL AND RESEARCH IMPLICATIONS: The intervention results suggest implementing a RT form of “prehabilitation” in early stage (CKD3) patients just once per week is sufficient to bring about statistically and clinically important changes in strength and function that benefit the patient through reduced frequency and/or intrusiveness of uraemic symptoms (improved health-related quality of life), with minimal time-commitment. Further research should examine if there is additional benefit to the significantly greater increases in VLACSA and pennation angle observed in RT3, with regards to long-term maintenance of functional improvements, and whether an RT1 or RT3 programme delays the progression of CKD, the need for RRT, and patient mortality.sub_phyunpub1807_ethesesunpu

From product dispensing to patient care: The role of the pharmacist in providing pharmaceutical care as part of an integrated disease management approach

During the past decade, the profession of pharmacy has changed dramatically. The Doctor of Pharmacy degree has replaced the Bachelor of Science degree as the first professional degree offered at most accredited U.S. pharmacy schools. Advanced clinical training is now a mainstay of pharmacy training, and this has enabled pharmacists to contribute to disease management efforts. In addition, technological improvements in prescription processing have afforded pharmacists more time to participate in disease management activities. This paper describes how the role of the pharmacist has changed and reviews the results of programs involving pharmacists as disease management providers in the areas of asthma, hypertension, diabetes, and hyperlipidemia. Pharmacists\u27 contributions in various practice settings are also discussed

Validity and reliability of high-resolution ultrasound imaging for the assessment of regional body composition in stage 5 chronic kidney disease patients undergoing continuous ambulatory peritoneal dialysis

Tom Mercer - ORCID: 0000-0002-5078-4769 https://orcid.org/0000-0002-5078-4769Tobia Zanotto - ORCID 0000-0002-6571-4763 https://orcid.org/0000-0002-6571-4763Background: Accurate measurement of muscle mass is an important research and clinical tool. High-resolution ultrasound (US) has shown potential as a method to assess muscle and fat mass at specific anatomical sites. However, there is limited evidence for the reliability of US to measure muscle size in patients receiving continuous ambulatory peritoneal dialysis (CAPD). Therefore, we examined the validity and reliability of an US method compared to a gold standard comparison for the assessment of a quadriceps muscle in this clinical population. Methods: Twenty people receiving CAPD (mean age = 56.5 ± 16.7 years) at a single dialysis unit were assessed on two occasions, 7 days apart. Measures of the mid-thigh, such as vastus lateralis (VL) anatomical cross-sectional area (ACSA), VL muscle thickness and subcutaneous fat thickness were compared for US reliability and validity compared to magnetic resonance imaging (MRI) measures. Results: US had high validity against gold standard MRI measures, with intraclass correlation coefficients (ICC) equating to VL ACSA of 0.95, VL thickness of 0.99 and fat thickness of 0.98. The US measurements also exhibited high intra-rater reliability (ICCs: VL thickness = 0.98, total muscle thickness = 0.97 and fat thickness = 0.99) in measuring body composition at the mid-VL site in the study population. Conclusions: Valid assessment of regional body composition can be achieved via high-resolution US in patients receiving CAPD. The validity and reliability of the US in repeated measures (in comparison to the gold standard MRI) warrant further investigation in the wider chronic kidney disease population.42pubpub