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.

Gauge transformations in the Lagrangian and Hamiltonian formalisms of generally covariant theories

We study spacetime diffeomorphisms in Hamiltonian and Lagrangian formalisms of generally covariant systems. We show that the gauge group for such a system is characterized by having generators which are projectable under the Legendre map. The gauge group is found to be much larger than the original group of spacetime diffeomorphisms, since its generators must depend on the lapse function and shift vector of the spacetime metric in a given coordinate patch. Our results are generalizations of earlier results by Salisbury and Sundermeyer. They arise in a natural way from using the requirement of equivalence between Lagrangian and Hamiltonian formulations of the system, and they are new in that the symmetries are realized on the full set of phase space variables. The generators are displayed explicitly and are applied to the relativistic string and to general relativity.Comment: 12 pages, no figures; REVTeX; uses multicol,fancyheadings,eqsecnum; to appear in Phys. Rev.

Evaluation of radiometric and geometric characteristics of LANDSAT-D imaging system

With vegetation masked and noise sources eliminated or minimized, different carbonate facies could be discriminated in a south Florida scene. Laboratory spectra of grab samples indicate that a 20% change in depth of the carbonate absorption band was detected despite the effects of atmospheric absorption. Both bright and dark hydrothermally altered volcanic rocks can be discriminated from their unaltered equivalents. A previously unrecognized altered area was identified on the basis of the TM images. The ability to map desert varnish in semi-arid terrains has economic significance as it defines areas that are less susceptible desert erosional process and suitable for construction development

Temporal and spatial dynamics of CO2 air-sea flux in the Gulf of Maine

Ocean surface layer carbon dioxide (CO2) data collected in the Gulf of Maine from 2004 to 2008 are presented. Monthly shipboard observations are combined with additional higher‐resolution CO2 observations to characterize CO2 fugacity ( fCO2) and CO2 flux over hourly to interannual time scales. Observed fCO2 andCO2 flux dynamics are dominated by a seasonal cycle, with a large spring influx of CO2 and a fall‐to‐winter efflux back to the atmosphere. The temporal results at inner, middle, and outer shelf locations are highly correlated, and observed spatial variability is generally small relative to the monthly to seasonal temporal changes. The averaged annual flux is in near balance and is a net source of carbon to the atmosphere over 5 years, with a value of +0.38 mol m−2 yr−1. However, moderate interannual variation is also observed, where years 2005 and 2007 represent cases of regional source (+0.71) and sink (−0.11) anomalies. We use moored daily CO2 measurements to quantify aliasing due to temporal undersampling, an important error budget term that is typically unresolved. The uncertainty of our derived annual flux measurement is ±0.26 mol m−2 yr−1 and is dominated by this aliasing term. Comparison of results to the neighboring Middle and South Atlantic Bight coastal shelf systems indicates that the Gulf of Maine exhibits a similar annual cycle and range of oceanic fCO2 magnitude but differs in the seasonal phase. It also differs by enhanced fCO2 controls by factors other than temperature‐driven solubility, including biological drawdown, fall‐to‐winter vertical mixing, and river runoff

Cost-effectiveness modelling of telehealth for patients with raised cardiovascular disease risk: evidence from a cohort simulation conducted alongside the Healthlines randomised controlled trial

OBJECTIVES: To investigate the long-term cost-effectiveness (measured as the ratio of incremental NHS cost to incremental quality-adjusted life years) of a telehealth intervention for patients with raised cardiovascular disease (CVD) risk. DESIGN: A cohort simulation model developed as part of the economic evaluation conducted alongside the Healthlines randomised controlled trial. SETTING: Patients recruited through primary care, and intervention delivered via telehealth service. PARTICIPANTS: Participants with a 10-year CVD risk ≥20%, as measured by the QRISK2 algorithm, and with at least 1 modifiable risk factor, individually randomised from 42 general practices in England. INTERVENTION: A telehealth service delivered over a 12-month period. The intervention involved a series of responsive, theory-led encounters between patients and trained health information advisors who provided access to information resources and supported medication adherence and coordination of care. PRIMARY AND SECONDARY OUTCOME MEASURES: Cost-effectiveness measured by net monetary benefit over the simulated lifetime of trial participants from a UK National Health Service perspective. RESULTS: The probability that the intervention was cost-effective depended on the duration of the effect of the intervention. The intervention was cost-effective with high probability if effects persisted over the lifetime of intervention recipients. The probability of cost-effectiveness was lower for shorter durations of effect. CONCLUSIONS: The intervention was likely to be cost-effective under a lifetime perspective. TRIAL REGISTRATION NUMBER: ISRCTN27508731; Results

Complex consultations in primary care: a tool for assessing the range of health problems and issues addressed in general practice consultations

Background: There is an increasing recognition that many consultations in general practice involve several problems covering multiple disease domains. However there is a paucity of reliable tools and techniques to understand and quantify this phenomenon. The objective was to develop a tool that can be used to measure the number and type of problems discussed in primary care consultations. Methods: Thirteen consultations between general practitioners and patients were initially videoed and reviewed to identify the problems and issues discussed. An iterative process involving a panel of clinicians and researchers and repeated cycles of testing and development was used to develop a measurement proforma and coding manual for assessment of video recorded consultations. The inter-rater reliability of this tool was assessed in 60 consultations. Results: The problems requiring action were usually readily identified. However the different dimensions of the problem and how they were addressed required the identification and definition of ‘issues’. A coding proforma was developed that allowed quantification of the numbers and types of health problems and issues discussed. Ten categories of issues were identified and defined. At the consultation level, inter-rater agreements for the number of problems discussed (within ±1), types of problems and issues were 98.3%, 96.5% and 90% respectively. The tool has subsequently been used to analyse 229 consultations. Conclusion: The iterative approach to development of the tool reflected the complexity of doctor-patient interactions. A reliable tool has been developed that can be used to analyse the number and range of problems managed in primary care consultations