Physical outcome measure for critical care patients following intensive care discharge

Introduction: The aim of this study was to evaluate the most suitable physical outcome measures to be used with critical care patients following discharge. ICU survivors experience physical problems such as reduced exercise capacity and intensive care acquired weakness. NICE guideline ‘Rehabilitation after critical illness’ (1) recommends the use of outcome measures however does not provide any specific guidance. A recent Cochrane review noted wide variability in measures used following ICU discharge (2). Methods: Discharged ICU patients attended a five week multidisciplinary programme. Patients’ physical function was assessed during the programme, at 6 months and 12 months post discharge. Three outcome measures were included in the initial two cohorts. The Six Minute Walk Test (6MWT) and the Incremental Shuttle Walk test (ISWT) were chosen as they have been used within the critical care follow up setting (2). The Chester Step Test (CST) is widely thought to be a good indicator of ability to return to work (one of the programmes primary aims). Ethics approval was waived as the programme was part of a quality improvement initiative. Results: Data was collected for the initial patients attending the programme (n = 13), median age was 52 (IQR = 38-72), median ICU LOS was 19 days (IQR = 4-91), median APACHE II was 23 (IQR = 19-41) and 11 were men. One patient was so physically debilitated that the CST or ISWT could not be completed however a score was achieved using the 6MWT. Another patient almost failed to achieve level 1 of the ISWT. Subsequent patients for this project (total n = 47) have all therefore been tested using the 6MWT. Good inter-rater and intrarater reliability and validity have been reported for the 6MWT (3). Conclusions: Exercise capacity measurement is not achievable for some patients with either the ISWT or the CST due to the severity of their physical debilitation. Anxiety, post-traumatic stress disorder and depression are common psychological problems post discharge (4), therefore using a test with a bleep is not appropriate. Therefore, the 6MWT is the most appropriate physical outcome measure to be used with critical care patients post discharge

Classification of pain and its treatment at an intensive care rehabilitation clinic

Introduction Treatment in an Intensive Care Unit (ICU) often necessitates uncomfortable and painful procedures for patients throughout their admission. There is growing evidence to suggest that chronic pain is becoming increasingly recognised as a long term problem for patients following an ICU admission [1]. Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) is a five week rehabilitation programme for patients and their caregivers after ICU discharge at Glasgow Royal Infirmary. This study investigated the incidence and location of chronic pain in patients discharged from ICU and classified the analgesics prescribed according to the World Health Organization analgesic Methods The InS:PIRE programme involved individual sessions for patients and their caregivers with a physiotherapist and a pharmacist along with interventions from medical, nursing, psychology and community services. The physiotherapist documented the incidence and pain location during the assessment. The pharmacist recorded all analgesic medications prescribed prior to admission and at their clinic visit. The patient’s analgesic medication was classified according to the WHO pain ladder from zero to three, zero being no pain medication and three being treatment with a strong opioid. Data collected was part of an evaluation of a quality improvement initiative, therefore ethics approval was waived. Results Data was collected from 47 of the 48 patients who attended the rehabilitation clinic (median age was 52 (IQR, 44-57) median ICU LOS was 15 (IQR 9-25), median APACHE II was 23 (IQR 18-27) and 32 of the patients were men (67 %)). Prior to admission to ICU 43 % of patients were taking analgesics and this increased to 81 % at the time of their clinic visit. The number of patients at step two and above on the WHO pain ladder also increased from 34 % to 56 %. Conclusions Of the patients seen at the InS:PIRE clinic two-thirds stated that they had new pain since their ICU admission. Despite the increase in the number and strength of analgesics prescribed, almost a quarter of patients still complained of pain at their clinic visit. These results confirm that pain continues to be a significant problem in this patient group. Raising awareness in primary care of the incidence of chronic pain and improving its management is essential to the recovery process following an ICU admission

Pharmacy intervention at an intensive care rehabilitation clinic

Introduction: During an intensive care stay, patients often have their chronic medications withheld for a variety of reasons and new drugs commenced [1]. As patients are often under the care of a number of different medical teams during their admission there is potential for these changes to be inadvertently continued [2]. Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) is a five week rehabilitation programme for patients and their caregivers after ICU (Intensive Care Unit) discharge at Glasgow Royal Infirmary. Within this programme a medication review by the critical care pharmacist provided an opportunity to identify and resolve any pharmaceutical care issues and also an opportunity to educate patients and their caregivers about changes to their medication. Methods: During the medication review we identified ongoing pharmaceutical care issues which were communicated to the patient’s primary care physician (GP) by letter or a telephone call. The patients were also encouraged to discuss any issues raised with their GP. The significance of the interventions was classified from those not likely to be of clinical benefit to the patient, to those which prevented serious therapeutic failure. Results: Data was collected from 47 of the 48 patients who attended the clinic (median age was 52 (IQR, 44-57) median ICU LOS was 15 (IQR 9-25), median APACHE II was 23 (IQR 18-27) and 32 of the patients were men (67%). The pharmacist made 69 recommendations; including 20 relating to drugs which had been withheld and not restarted, dose adjustments were suggested on 13 occasions and new drug recommendations were made for 10 patients. Duration of treatment for new medications started during hospital admission was clarified on 12 occasions. Lastly adverse drug effects were reported on 4 occasions and the incorrect drug was prescribed on 2 occasions. Of the interventions made 58% were considered to be of moderate to high impact. Conclusions: The pharmacist identified pharmaceutical care issues with 18.6% of the prescribed medications. Just over half of the patients reported that they were not made aware of any alterations to their prescribed medication on discharge. Therefore a pharmacy intervention is an essential part of an intensive care rehabilitation programme to address any medication related problems, provide education and to ensure patients gain optimal benefit from their medication

Conceptual model of sport-specific classification for para-athletes with intellectual impairment

The present paper describes the conceptual basis of evidence-based classification of para-athletes with intellectual impairment (II). An extensive description of the theoretical and conceptual foundation of the system as currently conceived is provided, as are examples of its applications in the three sports included in the Paralympic programme for II-athletes in 2020 (i.e., athletics, swimming and table tennis). Evidence based classification for II-athletes is driven by two central questions: i. How can intellectual impairment be substantiated in a valid and reliable way, and ii. Does intellectual impairment limit optimal sport proficiency? Evolution of the system and current best practice for addressing these questions are described, and suggestions for future research and development are provided. Challenges of understanding and assessing a complex (multifaceted and intersectional) impairment in the context of sport also are considered

EChOSim: The Exoplanet Characterisation Observatory software simulator

EChOSim is the end-to-end time-domain simulator of the Exoplanet Characterisation Observatory (EChO) space mission. EChOSim has been developed to assess the capability EChO has to detect and characterize the atmospheres of transiting exoplanets, and through this revolutionize the knowledge we have of the Milky Way and of our place in the Galaxy. Here we discuss the details of the EChOSim implementation and describe the models used to represent the instrument and to simulate the detection. Software simulators have assumed a central role in the design of new instrumentation and in assessing the level of systematics affecting the measurements of existing experiments. Thanks to its high modularity, EChOSim can simulate basic aspects of several existing and proposed spectrometers for exoplanet transits, including instruments on the Hubble Space Telescope and Spitzer, or ground-based and balloon borne experiments. A discussion of different uses of EChOSim is given, including examples of simulations performed to assess the EChO mission

Cosmic Microwave Background Polarization

Cosmic microwave background (CMB) anisotropy is our richest source of cosmological information; the standard cosmological model was largely established thanks to study of the temperature anisotropies. By the end of the decade, the Planck satellite will close this important chapter and move us deeper into the new frontier of polarization measurements. Numerous ground--based and balloon--borne experiments are already forging into this new territory. Besides providing new and independent information on the primordial density perturbations and cosmological parameters, polarization measurements offer the potential to detect primordial gravity waves, constrain dark energy and measure the neutrino mass scale. A vigorous experimental program is underway worldwide and heading towards a new satellite mission dedicated to CMB polarization.Comment: Review given at TAUP 2005; References added; Additional reference

Cosmological Parameters from the 2003 flight of BOOMERANG

We present the cosmological parameters from the CMB intensity and polarization power spectra of the 2003 Antarctic flight of the BOOMERANG telescope. The BOOMERANG data alone constrains the parameters of the $\Lambda$CDM model remarkably well and is consistent with constraints from a multi-experiment combined CMB data set. We add LSS data from the 2dF and SDSS redshift surveys to the combined CMB data set and test several extensions to the standard model including: running of the spectral index, curvature, tensor modes, the effect of massive neutrinos, and an effective equation of state for dark energy. We also include an analysis of constraints to a model which allows a CDM isocurvature admixture.Comment: 18 pages, 10 figures, submitted to Ap

A Measurement of the Angular Power Spectrum of the CMB Temperature Anisotropy from the 2003 Flight of Boomerang

We report on observations of the Cosmic Microwave Background (CMB) obtained during the January 2003 flight of Boomerang . These results are derived from 195 hours of observation with four 145 GHz Polarization Sensitive Bolometer (PSB) pairs, identical in design to the four 143 GHz Planck HFI polarized pixels. The data include 75 hours of observations distributed over 1.84% of the sky with an additional 120 hours concentrated on the central portion of the field, itself representing 0.22% of the full sky. From these data we derive an estimate of the angular power spectrum of temperature fluctuations of the CMB in 24 bands over the multipole range (50 < l < 1500). A series of features, consistent with those expected from acoustic oscillations in the primordial photon-baryon fluid, are clearly evident in the power spectrum, as is the exponential damping of power on scales smaller than the photon mean free path at the epoch of last scattering (l > 900). As a consistency check, the collaboration has performed two fully independent analyses of the time ordered data, which are found to be in excellent agreement.Comment: 11 pages, 7 figures, 3 tables. High resolution figures and data are available at http://cmb.phys.cwru.edu/boomerang/ and http://oberon.roma1.infn.it/boomerang/b2

Some FRW Models of Accelerating Universe with Dark Energy

The paper deals with a spatially homogeneous and isotropic FRW space-time filled with perfect fluid and dark energy components. The two sources are assumed to interact minimally, and therefore their energy momentum tensors are conserved separately. A special law of variation for the Hubble parameter proposed by Berman (1983) has been utilized to solve the field equations. The Berman's law yields two explicit forms of the scale factor governing the FRW space-time and constant values of deceleration parameter. The role of dark energy with variable equation of state parameter has been studied in detail in the evolution of FRW universe. It has been found that dark energy dominates the universe at the present epoch, which is consistent with the observations. The physical behavior of the universe is discussed in detail.Comment: 10 pages, 5 figure

Searching for non Gaussian signals in the BOOMERanG 2003 CMB maps

We analyze the BOOMERanG 2003 (B03) 145 GHz temperature map to constrain the amplitude of a non Gaussian, primordial contribution to CMB fluctuations. We perform a pixel space analysis restricted to a portion of the map chosen in view of high sensitivity, very low foreground contamination and tight control of systematic effects. We set up an estimator based on the three Minkowski functionals which relies on high quality simulated data, including non Gaussian CMB maps. We find good agreement with the Gaussian hypothesis and derive the first limits based on BOOMERanG data for the non linear coupling parameter f_NL as -300<f_NL<650 at 68% CL and -800<f_NL<1050 at 95% CL.Comment: accepted for publication in ApJ. Letter