Physical rehabilitation interventions for adult patients with critical illness across the continuum of recovery: an overview of systematic reviews protocol Changing support needs of survivors of complex critical illness and their family caregivers across the care continuum: a qualitative pilot study of Towards RECOVER. Safety and Feasibility of an Exercise Prescription Approach to Rehabilitation Across the Continuum of Care for Survivors of Critical Illness Clinimetric Properties of the Motor Activity Log for the Assessment of Arm Use in Hemiparetic Patients Time to Rethink Long-Term Rehabilitation Management of Stroke Patients The foot function index with verbal rating scales (FFI-5pt): A clinimetric evaluation and comparison with the original FFI. A rehabilitation intervention to promote physical recovery following intensive care: a detailed description of construct development, rationale and content together with proposed taxonomy to capture processes in a randomised controlled trial Psychometric properties of the multiple mini-interview used for medical admissions: findings from generalizability and Rasch analyses Poor functional recovery after a critical illness: a longitudinal study. Poor functional status immediately after discharge from an intensive care unit Vitamin‐mineral treatment improves aggression and emotional regulation in children with ADHD: a fully blinded, randomized, placebo‐controlled trial Kidney failure related to broad-spectrum antibiotics in critically ill patients: secondary end point results from a 1200 patient randomised trial Early exercise in critically ill patients enhances short-term functional recovery* Physical Complications in Acute Lung Injury Survivors: A Two-Year Longitudinal Prospective Study Persistent neuromuscular and neurophysiologic abnormalities in long-term survivors of prolonged critical illness* Metrics of Arterial Hyperoxia and Associated Outcomes in Critical Care* Improving psychologic adjustment to chronic illness in cardiac patients Evaluating the teaching of evidence-based medicine. An intensive communication intervention for the critically ill. A preliminary cost effectiveness analysis of an intervention to reduce homelessness among the mentally ill A clinic-biological score for diagnosing early-onset neonatal infection in critically ill preterm infants* Bleeding during critical illness: a prospective cohort study using a new measurement tool. Neuropyschological and behavioral outcomes from a comprehensive magnetic resonance study of children with fetal alcohol spectrum disorders. Acute skeletal muscle wasting in critical illness. Which field walking test should be used to assess functional exercise capacity in lung cancer? an observational study Global Muscle Strength But Not Grip Strength Predicts Mortality and Length of Stay in a General Population in a Surgical Intensive Care Unit Prolonged cognitive dysfunction in survivors of critical illness Early mobilization in critically ill patients: patients' mobilization level depends on health care provider's profession. Analysis and Comparison of the Psychometric Properties of Three Balance Measures for Stroke Patients The Cannabis Use Problems Identification Test (CUPIT): development, reliability, concurrent and predictive validity among adolescents and adults. Insulin-like growth factor-1 and delirium in critically ill mechanically ventilated patients: a preliminary investigation. A multifactorial approach to understanding fall risk in older people. A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework Augmented renal clearance in septic and traumatized patients with normal plasma creatinine concentrations: identifying at-risk patients Relationships between upper-limb functional limitation and self-reported disability 3 months after stroke. Development of disability in chronic obstructive pulmonary disease: beyond lung function
Background Patients admitted to the intensive care unit with critical illness often experience significant physical impairments , which typically persist for many years following resolution of the original illness . Physical rehabilitation interventions that enhance restoration of physical function have been evaluated across the continuum of recovery following critical illness including within the intensive care unit , following discharge to the ward and beyond hospital discharge . Multiple systematic review s have been published appraising the exp and ing evidence investigating these physical rehabilitation interventions , although there appears to be variability in review methodology and quality . We aim to conduct an overview of existing systematic review s of physical rehabilitation interventions for adult intensive care patients across the continuum of recovery . Methods / design This protocol has been developed according to the Preferred Reporting Items for Systematic Review s and Meta-Analyses Protocol ( PRISMA -P ) guidelines . We will search the Cochrane Systematic Review Data base , Data base of Abstract s of Review s of Effectiveness , Cochrane Central Register of Controlled Trials , MEDLINE , Excerpta Medica Data base and Cumulative Index to Nursing and Allied Health Literature data bases . We will include systematic review s of r and omised controlled trials of adult patients , admitted to the intensive care unit and who have received physical rehabilitation interventions at any time point during their recovery . Data extraction will include systematic review aims and rationale , study types , population s , interventions , comparators , outcomes and quality appraisal method . Primary outcomes of interest will focus on findings reflecting recovery of physical function . Quality of reporting and method ological quality will be appraised using the PRISMA checklist and the Assessment of Multiple Systematic Review s tool . Discussion We anticipate the findings from this novel overview of systematic review s will contribute to the synthesis and interpretation of existing evidence regarding physical rehabilitation interventions and physical recovery in post-critical illness patients across the continuum of recovery . Systematic review registration PROSPERO CRD42015001068 INTRODUCTION Survivors of complex critical illness and their family caregivers require support during their recovery , rehabilitation , and return to community living ; however , the nature of these supports and how they may change over time remain unclear . Using the Timing It Right framework as a conceptual guide , this qualitative pilot study explored survivors ' and caregivers ' needs during the episode of critical illness through their return to independent living . METHODS Five survivors and seven family caregivers were recruited and consented from the main Towards RECOVER pilot study , design ed to characterize the long term outcomes of survivors of the ICU who have been mechanically ventilated for more than one week . Using the Timing It Right framework , we prospect ively conducted qualitative interviews to explore participants ' experiences and needs for information , emotional support , and training at 3 , 6 , 12 , and 24 months after intensive care unit ( ICU ) discharge . We completed 26 interviews , which were audio recorded , professionally transcribed , checked for accuracy , and analyzed using framework methodology . RESULTS In this small pilot sample , caregiver and patient perspectives were related and , therefore , are presented together . We identified 1 overriding theme : survivors do not experience continuity of medical care during recovery after critical illness . Three subthemes highlighted the following : ( 1 ) informational needs change across the care continuum , ( 2 ) fear and worry exist when families do not know what to expect , and ( 3 ) survivors transition from dependence to independence . CONCLUSIONS Interventions design ed to improve family outcomes after critical illness should address both survivors ' and caregivers ' support needs as they change across the illness and recovery trajectory . Providing early intervention and support and clarifying expectations for transitions in care and recovery may decrease fears of the unknown for both caregivers and survivors . Ongoing family-centered follow-up programs may also help survivors regain independence and help caregivers manage their perceived responsibility for the patients ' health . Using these insights for intervention development could ultimately improve long-term outcomes for both survivors and caregivers Background Survivors of critical illness can experience long-st and ing functional limitations that negatively affect their health-related quality of life . To date , no model of rehabilitation has demonstrated sustained improvements in physical function for survivors of critical illness beyond hospital discharge . Objective The aims of this study were : ( 1 ) to describe a model of rehabilitation for survivors of critical illness , ( 2 ) to compare the model to local st and ard care , and ( 3 ) to report the safety and feasibility of the program . Design This was a cohort study . Methods As part of a larger r and omized controlled trial , 74 participants were r and omly assigned , 5 days following admission to the intensive care unit ( ICU ) , to a protocol ized rehabilitation program that commenced in the ICU and continued on the acute care ward and for a further 8 weeks following hospital discharge as an outpatient program . Exercise training was prescribed based on quantitative outcome measures to achieve a physiological training response . Results During acute hospitalization , 60 % of exercise sessions were able to be delivered . The most frequently occurring barriers to exercise were patient safety and patient refusal due to fatigue . Point prevalence data showed patients were mobilized more often and for longer periods compared with st and ard care . Outpatient classes were poorly attended , with only 41 % of the patients completing more than 70 % of outpatient classes . No adverse events occurred . Limitations Limitations included patient heterogeneity and delayed commencement of exercise in the ICU due to issues of consent and recruitment . Conclusions Exercise training that commences in the ICU and continues through to an outpatient program is safe and feasible for survivors of critical illness . Models of care that maximize patient participation across the continuum of care warrant further investigation Background and Purpose — The Motor Activity Log ( MAL ) is a semistructured interview for hemiparetic stroke patients to assess the use of their paretic arm and h and ( amount of use [ AOU ] ) and quality of movement [ QOM ] ) during activities of daily living . Scores range from 0 to 5 . The following clinimetric properties of the MAL were quantified : internal consistency ( Cronbach α ) , test – retest agreement ( Bl and and Altman method ) , cross-sectional construct validity ( correlation between AOU and QOM and with the Action Research Arm [ ARA ] test ) , longitudinal construct validity ( correlation of change on the MAL during the intervention with a global change rating [ GCR ] and with change on the ARA ) , and responsiveness ( effect size ) . Methods — Two baseline measurements 2 weeks apart and 1 follow-up measurement immediately after 2 weeks of intensive exercise therapy either with or without immobilization of the unimpaired arm ( forced use ) were performed in 56 chronic stroke patients . Results — Internal consistency was high ( AOU : α=0.88 ; QOM : α=0.91 ) . The limits of agreement were −0.70 to 0.85 and −0.61 to 0.71 for AOU and QOM , respectively . The correlation with the ARA score ( Spearman ρ ) was 0.63 ( AOU and QOM ) . However , the improvement on the MAL during the intervention was only weakly related to the GCR and to the improvement on the ARA , Spearman ρ was between 0.16 and 0.22 . The responsiveness ratio was 1.9 ( AOU ) and 2.0 ( QOM ) . Conclusion — The MAL is internally consistent and relatively stable in chronic stroke patients not undergoing an intervention . The cross-sectional construct validity of the MAL is reasonable , but the results raise doubt about its longitudinal construct validity Abstract Background : It has long been assumed that stroke patients plateau in their recovery within 3 to 6 months of their stroke , and evidence for rehabilitation during the chronic stage is limited . As a consequence , rehabilitation re sources for the management of chronic stroke are minimal . Objective : The primary objective was to identify r and omized controlled trials ( RCTs ) across the continuum of stroke rehabilitation for interventions initiated 6 months or more following the onset of stroke . The secondary objective was to determine whether treatments provided post 6 months are effective in improving outcomes among stroke survivors . Methods : Multiple data bases were used to identify all RCTs published from 1970 to June 2012 in the English language where the stroke rehabilitation interventions were initiated more than 6 months after the onset of the stroke . Data abstract ion was performed using a st and ardized data abstract ion form that included general citation information , study participant characteristics , methodology , outcomes assessed , and overall findings . Results : The results of our analysis revealed 339 RCTs . The mean number of subjects per study was 73 . Two hundred fifty-six RCTs were related to motor recovery , 39 to cognitive function , and only 19 to psychosocial issues and community reintegration . The majority of the RCTs demonstrated a significant positive benefit . Conclusions : There is a robust evidence -base for stroke rehabilitation interventions in chronic stroke . This research synthesis reveals a paradox , whereby an impressive evidence base contrasts with the limited optimism and re sources available for rehabilitation in chronic stroke OBJECTIVE To assess the clinimetric value of the Dutch version of the Foot Function Index ( FFI ) in comparison with the original FFI using verbal rating scales ( FFI-5pt ) rather than visual analog scales ( VAS ) . METHODS A prospect i ve study was performed on 206 patients with nontraumatic forefoot complaints . Scoring , internal consistency , and construct validity of the FFI-5pt were compared with those of the original FFI , which rates all items on VAS . We also studied agreement between the scores at baseline and after one and 8 weeks and the scale scores with regard to sex , age , presence of osteoarthritis , limitation of mobility , bodily pain , and poor physical functioning ( using SF-36 ) . RESULTS Some items were not applicable ; removal of these items left 2 scales ( Pain and Disability ) with high internal consistency ( alpha = 0.88 to 0.94 ) and good agreement between both versions ( intraclass correlation coefficient 0.64 to 0.79 ) . Principal component analysis with varimax rotation using a forced 2 factor model fitted well ( 65 % explained variance ) . Test-retest reliability was high ( ICC 0.70 to 0.83 ) , while the stability over 8 weeks was lower , but still good ( ICC 0.63 to 0.71 ) . Responsiveness to change was low to moderate . However , a small number of patients reported an overall change ( 19 % ) . Scores of patients with limited mobility and poor physical health ( SF-36 ) were higher than those of patients with fewer physical problems , indicating good concurrent validity . CONCLUSION The FFI-5pt is a suitable generic measure . Its clinimetric properties are comparable with those of the original FFI . Its administration and data entry are less time consuming . However , responsiveness has to be more exactly assessed in an intervention study Background Increasing numbers of patients are surviving critical illness , but survival may be associated with a constellation of physical and psychological sequelae that can cause ongoing disability and reduced health-related quality of life . Limited evidence currently exists to guide the optimum structure , timing , and content of rehabilitation programmes . There is a need to both develop and evaluate interventions to support and expedite recovery during the post-ICU discharge period . This paper describes the construct development for a complex rehabilitation intervention intended to promote physical recovery following critical illness . The intervention is currently being evaluated in a r and omised trial ( IS RCT N09412438 ; funder Chief Scientists Office , Scotl and ) . Methods The intervention was developed using the Medical Research Council ( MRC ) framework for developing complex healthcare interventions . We ensured representation from a wide variety of stakeholders including content experts from multiple specialties , method ologists , and patient representation . The intervention construct was initially based on literature review , local observational and audit work , qualitative studies with ICU survivors , and brainstorming activities . Iterative refinement was aided by the publication of a National Institute for Health and Care Excellence guideline ( No. 83 ) , publicly available patient stories ( Healthtalkonline ) , a stakeholder event in collaboration with the James Lind Alliance , and local piloting . Modelling and further work involved a feasibility trial and development of a novel generic rehabilitation assistant ( GRA ) role . Several rounds of external peer review during successive funding applications also contributed to development . Results The final construct for the complex intervention involved a dedicated GRA trained to pre-defined competencies across multiple rehabilitation domains ( physiotherapy , dietetics , occupational therapy , and speech/ language therapy ) , with specific training in post-critical illness issues . The intervention was from ICU discharge to 3 months post-discharge , including inpatient and post-hospital discharge elements . Clear strategies to provide information to patients /families were included . A detailed taxonomy was developed to define and describe the processes undertaken , and capture them during the trial . The detailed process measure description , together with a range of patient , health service , and economic outcomes were successfully mapped on to the modified CONSORT recommendations for reporting non-pharmacologic trial interventions . Conclusions The MRC complex intervention framework was an effective guide to developing a novel post-ICU rehabilitation intervention . Combining a clearly defined new healthcare role with a detailed taxonomy of process and activity enabled the intervention to be clearly described for the purpose of trial delivery and reporting . These data will be useful when interpreting the results of the r and omised trial , will increase internal and external trial validity , and help others implement the intervention if the intervention proves clinical ly and cost effective The multiple mini-interview ( MMI ) has become an increasingly popular admissions method for selecting prospect i ve students into professional programs ( e.g. , medical school ) . The MMI uses a series of short , labour intensive simulation stations and scenario interviews to more effectively assess applicants ’ non-cognitive qualities such as empathy , critical thinking , integrity , and communication .  MMI data from 455 medical school applicants were analyzed using : ( 1 ) Generalizability Theory to estimate the generalizability of the MMI and identify sources of error ; and ( 2 ) the Many-Facet Rasch Model , to identify misfitting examinees , items and raters . Consistent with previous research , our results support the reliability of MMI process . However , it appears that the non-cognitive qualities are not being measured as unique constructs across stations OBJECTIVE To determine the time course of functional health status , and to inventory impairments in body functions , limitations in activities , and restrictions in participation after critical illness . DESIGN Prospect i ve observational cohort study . SETTING Mixed medical and surgical closed format ; intensive care unit of an academic medical hospital . PATIENTS Consecutive patients over a period of 3 months who were ventilated in the intensive care unit for more than 48 h ( n = 116 ) . METHODS Functional health status was assessed 3 , 6 and 12 months after discharge from the intensive care unit using the Sickness Impact Profile 68 . Impairments in function , limitations in activities , and restrictions in participation , classified according to the International Classification of Functioning , Disability , and Health ( ICF ) , were evaluated after 3 and 12 months . RESULTS Due to a high mortality rate ( 48 % ) and poor health conditions , data could not be obtained from all participants at all measurement points . Physical functioning and social behaviour improved predominantly within the first 6 months , while impaired psychological functioning remained unchanged within one year after discharge from the intensive care unit . After one year , 69 % of patients were still restricted in performing daily activities and only 50 % had resumed work . CONCLUSION The extent and severity of lasting intensive care unit-related disability necessitates the development of multidisciplinary after-care to improve health status , functional independence and return to work Purpose . To evaluate the functional status of patients within the first week of discharge from an intensive care unit ( ICU ) , and to identify predictors and explanatory factors of functional status . Methods . A prospect i ve , observational , cohort study was conducted with consecutive ICU patients who had stayed in a mixed , closed-format , university-level ICU for longer than 48 h. Results . Between 3 and 7 days of discharge from the ICU , functional status ( as primary outcome ) , walking ability , muscle strength , and sensory and cognitive functioning were assessed in 69 survivors . The overall functional status was poor ( median Barthel Index 6 ) . In their ability to perform basic activities of daily living , 67 % percent were severely dependent , 15 % were moderately dependent , and 9 % were slightly dependent on other people . Independent walking was impossible for 73 % of participants , grip strength was reduced for 50 % , and 30 % had cognitive impairments . Duration of ventilation was associated with functional status after ICU discharge . Reduced grip strength and walking ability were identified as explanatory factors for poorer functional status shortly after discharge from the ICU . Conclusion . In the first week after discharge from the ICU , the majority of the patients had substantial functional disabilities in activities of daily living . These disabilities were more severe in patients who experienced ventilation for a longer period of time . There is a need for prospect i ve studies focusing on functional recovery to support informed decision-making concerning the care of critically ill patients after ICU discharge BACKGROUND Evaluation of broad-spectrum micronutrient ( vitamins and minerals ) treatment for childhood ADHD has been limited to open-label studies that highlight beneficial effects across many aspects of psychological functioning . METHOD This is the first fully blinded r and omized controlled trial of medication-free children ( n = 93 ) with ADHD ( 7 - 12 years ) assigned to either micronutrients ( n = 47 ) or placebo ( n = 46 ) in a 1:1 ratio , for 10 weeks . All children received st and ardized ADHD assessment s. Data were collected from clinicians , parents , participants and teachers across a range of measures assessing ADHD symptoms , general functioning and impairment , mood , aggression and emotional regulation . RESULTS Intent-to-treat analyses showed significant between-group differences favouring micronutrient treatment on the Clinical Global Impression-Improvement ( ES = 0.46 ) , with 47 % of those on micronutrients identified as ' much ' to ' very much ' improved versus 28 % on placebo . No group differences were identified on clinician , parent and teacher ratings of overall ADHD symptoms ( ES ranged 0.03 - 0.17 ) . However , according to clinicians , 32 % of those on micronutrients versus 9 % of those on placebo showed a clinical ly meaningful improvement on inattentive ( OR = 4.9 ; 95 % CI : 1.5 - 16.3 ) , but no group differences on improvement in hyperactive-impulsive symptoms ( OR = 1.0 ; 95 % CI : 0.4 - 2.5 ) . Based on clinician , parent and teacher report , those on micronutrients showed greater improvements in emotional regulation , aggression and general functioning compared to placebo ( ES ranged 0.35 - 0.66 ) . There were two dropouts per group , no group differences in adverse events and no serious adverse events identified . Blinding was successful with guessing no better than chance . CONCLUSIONS Micronutrients  improved overall function , reduced impairment and improved inattention , emotional regulation and aggression , but not hyperactive/impulsive symptoms , in this sample of children with ADHD . Although direct benefit for core ADHD symptoms was modest , with mixed findings across raters , the low rate of adverse effects and the benefits reported across multiple areas of functioning indicate micronutrients may be a favourable option for some children , particularly those with both ADHD and emotional dysregulation . Trial registered with the Australian New Zeal and Clinical Trials Registry ACTRN12613000896774 Objectives To explore whether a strategy of more intensive antibiotic therapy leads to emergence or prolongation of renal failure in intensive care patients . Design Secondary analysis from a r and omised antibiotic strategy trial ( the Procalcitonin And Survival Study ) . The r and omised arms were conserved from the primary trial for the main analysis . Setting Nine mixed surgical/medical intensive care units across Denmark . Participants 1200 adult intensive care patients , 18 + years , expected to stay + 24 h. Exclusion criteria : bilirubin > 40 mg/dl , triglycerides > 1000 mg/dl , increased risk from blood sampling , pregnant/breast feeding and psychiatric patients . Interventions Patients were r and omised to guideline -based therapy ( ‘ st and ard-exposure ’ arm ) or to guideline -based therapy supplemented with antibiotic escalation whenever procalcitonin increased on daily measurements ( ‘ high-exposure ’ arm ) . Main outcome measures Primary end point : estimated glomerular filtration rate ( eGFR ) < 60 ml/min/1.73 m2 . Secondary end points : ( 1 ) delta eGFR after starting/stopping a drug and ( 2 ) RIFLE criterion Risk ‘ R ’ , Injury ‘ I ’ and Failure ‘ F ’ . Analysis was by intention to treat . Results 28-day mortality was 31.8 % and comparable ( Jensen et al , Crit Care Med 2011 ) . A total of 3672/7634 ( 48.1 % ) study days during follow-up in the high-exposure versus 3016/6949 ( 43.4 % ) in the ‘ st and ard-exposure arm were spent with eGFR < 60 ml/min/1.73 m2 , p<0.001 . In a multiple effects model , 3 piperacillin/tazobactam was identified as causing the lowest rate of renal recovery of all antibiotics used : 1.0 ml/min/1.73 m2/24 h while exposed to this drug ( 95 % CI 0.7 to 1.3 ml/min/1.73 m2/24 h ) vs meropenem : 2.9 ml/min/1.73 m2/24 h ( 2.5 to 3.3 ml/min/1.73 m2/24 h ) ) ; after discontinuing piperacillin/tazobactam , the renal recovery rate increased : 2.7 ml/min/1.73 m2/24 h ( 2.3 to 3.1 ml/min/1.73 m2 /24 h ) ) . eGFR < 60 ml/min/1.73 m2 in the two groups at entry and at last day of follow-up was 57 % versus 55 % and 41 % versus 39 % , respectively . Conclusions Piperacillin/tazobactam was identified as a cause of delayed renal recovery in critically ill patients . This nephrotoxicity was not observed when using other beta-lactam antibiotics . Trial registration Clinical Trials.gov identifier : NCT00271752 Objectives : To investigate whether a daily exercise session , using a bedside cycle ergometer , is a safe and effective intervention in preventing or attenuating the decrease in functional exercise capacity , functional status , and quadriceps force that is associated with prolonged intensive care unit stay . A prolonged stay in the intensive care unit is associated with muscle dysfunction , which may contribute to an impaired functional status up to 1 yr after hospital discharge . No evidence is available concerning the effectiveness of an early exercise training intervention to prevent these detrimental complications . Design : R and omized controlled trial . Setting : Medical and surgical intensive care unit at University Hospital Gasthuisberg . Patients : Ninety critically ill patients were included as soon as their cardiorespiratory condition allowed bedside cycling exercise ( starting from day 5 ) , given they still had an expected prolonged intensive care unit stay of at least 7 more days . Interventions : Both groups received respiratory physiotherapy and a daily st and ardized passive or active motion session of upper and lower limbs . In addition , the treatment group performed a passive or active exercise training session for 20 mins/day , using a bedside ergometer . Measurements and Main Results : All outcome data are reflective for survivors . Quadriceps force and functional status were assessed at intensive care unit discharge and hospital discharge . Six-minute walking distance was measured at hospital discharge . No adverse events were identified during and immediately after the exercise training . At intensive care unit discharge , quadriceps force and functional status were not different between groups . At hospital discharge , 6-min walking distance , isometric quadriceps force , and the subjective feeling of functional well-being ( as measured with “ Physical Functioning ” item of the Short Form 36 Health Survey question naire ) were significantly higher in the treatment group ( p < .05 ) . Conclusions : Early exercise training in critically ill intensive care unit survivors enhanced recovery of functional exercise capacity , self-perceived functional status , and muscle force at hospital discharge Objective : Survivors of severe critical illness frequently develop substantial and persistent physical complications , including muscle weakness , impaired physical function , and decreased health-related quality of life . Our objective was to determine the longitudinal epidemiology of muscle weakness , physical function , and health-related quality of life and their associations with critical illness and ICU exposures . Design : A multisite prospect i ve study with longitudinal follow-up at 3 , 6 , 12 , and 24 months after acute lung injury . Setting : Thirteen ICUs from four academic teaching hospitals . Patients : Two hundred twenty-two survivors of acute lung injury . Interventions : None . Measurements and Main Results : At each time point , patients underwent st and ardized clinical evaluations of extremity , h and grip , and respiratory muscle strength ; anthropometrics ( height , weight , mid-arm circumference , and triceps skin fold thickness ) ; 6-minute walk distance , and the Medical Outcomes Short-Form 36 health-related quality of life survey . During their hospitalization , survivors also had detailed daily evaluation of critical illness and related treatment variables . Over one third of survivors had objective evidence of muscle weakness at hospital discharge , with most improving within 12 months . This weakness was associated with substantial impairments in physical function and health-related quality of life that persisted at 24 months . The duration of bed rest during critical illness was consistently associated with weakness throughout 24-month follow-up . The cumulative dose of systematic corticosteroids and use of neuromuscular blockers in the ICU were not associated with weakness . Conclusions : Muscle weakness is common after acute lung injury , usually recovering within 12 months . This weakness is associated with substantial impairments in physical function and health-related quality of life that continue beyond 24 months . These results provide valuable prognostic information regarding physical recovery after acute lung injury . Evidence -based methods to reduce the duration of bed rest during critical illness may be important for improving these long-term impairments Objective To establish the prevalence , clinical characteristics , and electrophysiologic features of residual neuromuscular dysfunction after prolonged critical illness . Design Prospect i ve follow-up study of survivors of prolonged critical illness . Setting A university hospital and two district general hospitals in the UK . Patients The study occurred for a period of 5 yrs . All patients during that time who were in the intensive care unit for > 28 days were entered in the study . Measurements and Main Results At follow-up , length of intensive care unit and hospital stay , duration of mechanical ventilation and admission Acute Physiology and Chronic Health Evaluation II score were recorded from the case notes . A clinical history was obtained , a Barthel Index disability score was calculated , and a full neurologic examination was performed . Nerve conduction studies , needle electromyography , single-fiber electromyography and thermal thresholds were performed . A total of 195 patients were identified . There were 86 survivors , of whom 47 could be contacted and 22 consented to be studied . The median time from intensive care unit discharge to follow-up was 43 months ( range , 12–57 months ) . All gave a clear history of severe weakness and functional impairment after hospital discharge and , in all , recovery was prolonged . Motor or sensory deficits were present on clinical examination in 59 % of the patients studied . Common peroneal nerve palsy was present in two patients . A total of 21 of 22 ( 95 % ) patients had electromyographic evidence of chronic partial denervation at follow-up , findings indicative of a preceding axonal neuropathy . The single-fiber electromyographic studies were also consistent with a preceding motor neuropathy . ConclusionS evere weakness requiring prolonged rehabilitation and abnormal clinical neurologic findings are extremely common in survivors of protracted critical illness . Neurophysiologic evidence of chronic partial denervation of muscle consistent with previous critical illness polyneuropathy is almost invariable and can be found up to 5 yrs after intensive care unit discharge in > 90 % of these long-stay patients . Evidence of myopathy is unusual . These findings have important implication s for the management and rehabilitation of intensive care survivors Objective : Emerging evidence has shown the potential risks of arterial hyperoxia , but the lack of a clinical definition and method ologic limitations hamper the interpretation and clinical relevance of previous studies . Our purpose was to evaluate previously used and newly constructed metrics of arterial hyperoxia and systematic ally assess their association with clinical outcomes in different subgroups in the ICU . Design : Observational cohort study . Setting : Three large tertiary care ICUs in the Netherl and s. Patients : A total of 14,441 eligible ICU patients . Interventions : None . Measurements and Main Results : In total , 295,079 arterial blood gas analyses , including the PaO2  , between July 2011 and July 2014 were extracted from the patient data management system data base . Data from all admissions with more than one PaO2 measurement were supplemented with anonymous demographic and admission and discharge data from the Dutch National Intensive Care Evaluation registry . Mild hyperoxia was defined as PaO2 between 120 and 200 mm Hg ; severe hyperoxia as PaO2 greater than 200 mm Hg . Characteristics of existing and newly constructed metrics for arterial hyperoxia were examined , and the associations with hospital mortality ( primary outcome ) , ICU mortality , and ventilator-free days and alive at day 28 were retrospectively analyzed using regression models in different subgroups of patients . Severe hyperoxia was associated with higher mortality rates and fewer ventilator-free days in comparison to both mild hyperoxia and normoxia for all metrics except for the worst PaO2 . Adjusted effect estimates for conditional mortality were larger for severe hyperoxia than for mild hyperoxia . This association was found both within and beyond the first 24 hours of admission and was consistent for large subgroups . The largest point estimates were found for the exposure identified by the average PaO2 , closely followed by the median PaO2 , and these estimates differed substantially between subsets . Time spent in hyperoxia showed a linear and positive relationship with hospital mortality . Conclusions : Our results suggest that we should limit the PaO2 levels of critically ill patients within a safe range , as we do with other physiologic variables . Analytical metrics of arterial hyperoxia should be judiciously considered when interpreting and comparing study results and future studies are needed to vali date our findings in a r and omized fashion design Abstract BACKGROUND : Poor mood adjustment to chronic medical illness is often accompanied by decrements in function . OBJECTIVE : To evaluate the effectiveness of a telephone-based intervention for psychologic distress and functional impairment in cardiac illness . DESIGN : R and omized , controlled trial . METHODS : We recruited survivors of acute coronary syndromes using the Hospital and Anxiety Depression Scale ( HADS ) with scores indicative of mood disturbances at 1-month postdischarge . Recruited patients were r and omized to experimental or control status . Intervention patients received 6 30-minute telephone counseling sessions to identify and address illness-related fears and concerns . Control patients received usual care . Patients ’ responses to the HADS and the Workplace Social Adjustment Scale ( WSAS ) were collected at baseline , 2 , 3 , and 6 months using interactive voice recognition technology . At baseline , the PRIME-MD was used to establish diagnosis of depression . We used mixed effects regression to study changes in outcomes . RESULTS : We enrolled 100 patients . Mean age was 60 ; 67 % of the patients were male . Findings confirmed that the intervention group had a 27 % improvement in depression symptoms ( P=.05 ) , 27 % in anxiety ( P=.02 ) , and a 38 % improvement in home limitations ( P=.04 ) compared with controls . Symptom improvement tracked those for WSAS measures of home function ( P=.04 ) but not workplace function . CONCLUSIONS : The intervention had a moderate effect on patient ’s emotional and functional outcomes that were observed during a critical period in patients ’ lives . Patient convenience , ease of delivery , and the effectiveness of the intervention suggest that the counseling can help patients adjust to chronic illness AN INCREASING NUMBER OF MEDICAL SCHOOLS AND residency programs are instituting curricula for teaching the principles and practice of evidence based medicine ( EBM ) . For example , 95 % of US internal medicine residency programs have journal clubs and 37 % of US and Canadian internal medicine residencies have time dedicated for EBM . Curricula based on EBM are increasingly popular in residency programs in other specialties , including family medicine , pediatrics , obstetrics/ gynecology , and surgery . Despite the widespread teaching of EBM , however , most of what is known about the outcomes of evidence -based curricula relies on observational data . Although evaluation of the quality of research evidence is a core competency of EBM , the quantity and quality of the evidence for effectively teaching EBM are poor . Ironically , if one were to develop guidelines for how to teach EBM based on these results , they would be based on the lowest level of evidence . There are several reasons why the quality of the evidence for teaching EBM is so weak . Many of these problems are related to the limitations in educational research in general . First , quantitative research methods may be inadequate to capture the complexity of an educational system . Second , students and residents change frequently , making it difficult to retain a consistent sample . Third , the time allotted for a given intervention may be brief in the context of the overall medical curriculum . Fourth , educational institutions may be hesitant to pay students as research participants or to allocate them to unproved educational interventions . Fifth , because most educational interventions are unique to specific institutions , assessment of their effectiveness is usually limited by small sample sizes . Furthermore , even if such interventions could be instituted across multiple institutions , the problems of st and ardization and cointervention would be particularly challenging . Sixth , perhaps because they are simplest to measure , the most frequently reported outcomes are subjective variables such as satisfaction or self-reported changes in attitudes or knowledge , rather than more important assessment s of objective ly measured clinical skills or improved patient outcomes . Finally , granting agencies do not give priority to educational investigations , making it difficult to undertake definitive multicenter studies . Educators who have struggled to evaluate educational interventions will find these issues all too familiar . With the increasing prevalence of EBM teaching , however , high quality evidence is more important than ever . Assessment of EBM teaching has also presented some unique problems . For instance , we originally defined evidence -based practice in terms of 4 basic competencies : ( 1 ) recognition of a patient problem and construction of a structured clinical question ; ( 2 ) ability to efficiently and effectively search the medical literature to retrieve the best available evidence to answer the clinical question ; ( 3 ) critical appraisal of the evidence ; and ( 4 ) integration of the evidence with all aspects of individual patient decision making to determine the best clinical care for the patient . Although these 4 skills were the most commonly reported curricular objectives in 99 internal medicine residencies that teach EBM , almost all the research on EBM education has focused exclusively on the third item : teaching critical appraisal skills . Examining this literature may yield useful insights into the difficulties of EBM educational research . Since critical appraisal skills involve the ability to differentiate strong from weak research methods , one might expect that this research would be of relatively high quality . In fact , most of these studies are method ologically weak . Using broad criteria to identify any reports of a graduate ( residency ) EBM curricula , Green identified 18 reports published between 1980 and 1997 . Of these , 72 % used a traditional journal club format to teach critical appraisal skills . Only 7 of the 18 studies evaluated the effectiveness of their intervention . Five of these 7 studies compared intervention with control ( only 1 with r and omized design ) ; only 2 of 7 studies used any blinding . Of these 5 controlled studies , 2 used a vali date d outcome measure to evaluate  critical appraisal skills .  Measurement of behavioral change relied on self-report in all 5 studies , and none examined patient outcomes . Most reports did not evaluate their PURPOSE We sought to determine the effects of a communication process that was design ed to encourage the use of advanced supportive technology when it is of benefit , but to limit its burdens when it is ineffective . We compared usual care with a proactive , multidisciplinary method of communicating that prospect ively identified for patients and families the criteria that would determine whether a care plan was effective at meeting the goals of the patient . This process allowed caregivers to be informed of patient preferences about continued advanced supportive technology when its continuation would result in a compromised functional outcome or death . MATERIAL S AND METHODS We performed a before- and -after study in 530 adult medical patients who were consecutively admitted to a university tertiary care hospital for intensive care .  Multidisciplinary meetings were held within 72 hours of critical care admission . Patients , families , and the critical care team discussed the care plan and the patients ' goals and expectations for the outcome of critical care . Clinical " milestones " indicative of recovery were identified with time frames for their occurrence . Follow-up meetings were held to discuss palliative care options when continued advanced supportive technology was not achieving the patient 's goals . We measured length of stay , mortality , and provider team and family consensus in 134 patients before the intensive communication intervention and in 396 patients after the intervention . RESULTS Intensive communication significantly reduced the median length of stay from 4 days ( interquartile range , 2 to 11 days ) to 3 days ( 2 to 6 days , P = 0.01 by survival analysis ) . This reduction remained significant after adjustment for acute physiology and chronic health evaluation ( APACHE ) 3 score [ risk ratio ( RR ) = 0.81 ; 95 % confidence interval ( CI ) , 0.66 to 0.99 ; P = 0.04 ) . Subgroup analysis revealed that this reduction occurred in our target group , patients with acuity scores in the highest quartile who died ( RR = 0.60 ; 95 % CI , 0.38 to 0.92 ; P = 0.02 ) . The intervention , which allowed dying patients earlier access to palliative care , was not associated with increased mortality . CONCLUSIONS Intensive communication was associated with a reduction in critical care use by patients who died . Our multidisciplinary process targeted advanced supportive technology to patients who survived and allowed the earlier withdrawal of advanced supportive technology when it was ineffective The Critical Time Intervention Project is a three-year clinical trial which tests a time-limited , supportive intervention to reduce recurrent homelessness among mentally ill men moving from a shelter to the community . Along with a comparison of nights spent homeless and other outcomes , the evaluation of the Critical Time Intervention includes a comparison of the relative costs of the intervention , compared to usual treatment . Such cost effectiveness analyses are difficult to perform and are rarely applied to mental health treatments . This paper presents the general scheme of this analysis and discusses critical issues in the construction and measurement of cost variables . Preliminary results which have implication s for the cost analysis are presented Objective : To identify the best combination of serum cytokines and clinical parameters to diagnose rapidly early-onset neonatal infection ( EONI ) in critically ill preterm infants . At birth , most critically ill neonates are receiving broad-spectrum antibiotics pending bacterial culture results , because distinguishing infected from noninfected infants at birth is difficult . Design : Prospect i ve study . Setting : Neonatal intensive care unit in a tertiary care hospital . Patients : Two hundred thirteen infants , born before 33 wks ’ gestation , admitted to the neonatal intensive care unit within 6 hrs of life with a presumptive diagnosis of EONI . Intervention : A presumptive diagnosis of EONI was associated with a 300-&mgr;L blood sample to measure six cytokine ( interleukin [IL]-1&bgr ; , IL-6 , IL-8 , IL-10 , IL-12 , tumor necrosis factor-&agr ; ) concentrations  , using the cytometric bead array technique . Measurements and Main Results : Of the 213 infants included , 31 had a definite or possible EONI and 182 were not infected . Concentrations of IL-6 , IL-8 , and IL-10 were significantly increased in infected neonates , in comparison with infants without EONI . In contrast , IL-1&bgr ; , IL-12 , and tumor necrosis factor-&agr ; concentrations were not . Logistic regression analyses were performed to construct multivariate predictive models that could distinguish infected from noninfected infants at birth . A clinical score was based on three parameters independently associated with EONI ( i.e. , interval of > 12 hrs between the membranes rupture and delivery , prenatal maternal colonization and mechanical ventilation at birth ) . This score was compared with scores including clinical parameters and serum cytokines , alone or in combination . The best predictive model combined the three clinical parameters , IL-6 ( positive threshold , 300 pg/mL ) and IL-8 ( positive threshold , 300 pg/mL ) concentrations . Conclusion : A predictive model combining serum IL-6 and IL-8 measurements and selected clinical variables could distinguish infected from noninfected preterm infants at birth and should help the clinician in reducing or shortening the unnecessary use of antibiotics PURPOSE To estimate the incidence , severity , duration and consequences of bleeding during critical illness , and to test the performance characteristics of a new bleeding assessment tool . METHODS Clinical bleeding assessment s were performed prospect ively on 100 consecutive patients admitted to a medical-surgical intensive care unit ( ICU ) using a novel bleeding measurement tool called HEmorrhage MEasurement ( HEME ) . Bleeding assessment s were done daily in duplicate and independently by blinded , trained assessors . Inter-rater agreement and construct validity of the HEME tool were calculated using phi . Risk factors for major bleeding were identified using a multivariable Cox proportional hazards model . RESULTS Overall , 90 % of patients experienced a total of 480 bleeds of which 94.8 % were minor and 5.2 % were major . Inter-rater reliability of the HEME tool was excellent ( phi = 0.98 , 95 % CI : 0.96 to 0.99 ) . A decrease in platelet count and a prolongation of partial thromboplastin time were independent risk factors for major bleeding but neither were renal failure nor prophylactic anticoagulation . Patients with major bleeding received more blood transfusions and had longer ICU stays compared to patients with minor or no bleeding . CONCLUSIONS Bleeding , although primarily minor , occurred in the majority of ICU patients . One of five patients experienced a major bleed which was associated with abnormal coagulation tests but not with prophylactic anticoagulants . These baseline bleeding rates can inform the design of future clinical trials in critical care that use bleeding as an outcome and HEME is a useful tool to measure bleeding in critically ill patients BACKGROUND Clinical and research advancements in the field of fetal alcohol spectrum disorders ( FASD ) require accurate and valid identification of FASD clinical subgroups . OBJECTIVES A comprehensive neuropsychological battery , coupled with magnetic resonance imaging , ( MRI ) , MR spectroscopy ( MRS ) , and functional MRI ( fMRI ) were administered to children with fetal alcohol spectrum disorders ( FASD ) to determine if global and /or focal abnormalities could be identified across the spectrum , and distinguish diagnostic subclassifications within the spectrum . The neuropsychological outcomes of the comprehensive neuroimaging study are presented here . METHODS The study groups included : 1 ) FAS/Partial FAS ; 2 ) Static Encephalopathy/Alcohol Exposed ( SE/AE ) ; 3 ) Neurobehavioral Disorder/Alcohol Exposed ( ND/AE ) as diagnosed by an interdisciplinary team using the FASD 4-Digit Code ; and 4 ) healthy peers with no prenatal alcohol .  A st and ardized neuropsychological battery was administered to each child and their primary caregiver by a psychologist . RESULTS Use of the 4-Digit Code produced three clinical ly and statistically distinct FASD clinical subgroups . The three subgroups ( ND/AE , SE/AE and FAS/PFAS ) reflected a linear continuum of increasing neuropsychological impairment and physical abnormality , representing the full continuum of FASD . Behavioral and psychiatric disorders were comparably prevalent across the three FASD groups , and significantly more prevalent than among the Controls . All three FASD subgroups had comparably high levels of prenatal alcohol exposure . CONCLUSIONS Although ND/AE , SE/AE , and FAS/PFAS are distinct FASD subgroups , these groups are not distinguishable solely by their neuropsychological profiles . While all children within a group shared the same magnitude of neuropsychological impairment , the patterns of impairment showed considerable individual variability . MRI , MRS and fMRI further distinguished these FASD subgroups IMPORTANCE Survivors of critical illness demonstrate skeletal muscle wasting with associated functional impairment . OBJECTIVE To perform a comprehensive prospect i ve characterization of skeletal muscle wasting , defining the pathogenic roles of altered protein synthesis and breakdown . DESIGN , SETTING , AND PARTICIPANTS Sixty-three critically ill patients ( 59 % male ; mean age : 54.7 years [ 95 % CI , 50.0 - 59.6 years ] ) with an Acute Physiology and Chronic Health Evaluation II score of 23.5 ( 95 % CI , 21.9 - 25.2 ) were prospect ively recruited within 24 hours following intensive care unit ( ICU ) admission from August 2009 to April 2011 at a university teaching and a community hospital in Engl and . Patients were recruited if older than 18 years and were anticipated to be intubated for longer than 48 hours , to spend more than 7 days in critical care , and to survive ICU stay . MAIN OUTCOMES AND MEASURES Muscle loss was determined through serial ultrasound measurement of the rectus femoris cross-sectional area ( CSA ) on days 1 , 3 , 7 , and 10 . In a subset of patients , the fiber CSA area was quantified along with the ratio of protein to DNA on days 1 and 7 . Histopathological analysis was performed . In addition , muscle protein synthesis , breakdown rates , and respective signaling pathways were characterized . RESULTS There were significant reductions in the rectus femoris CSA observed at day 10 ( −17.7 % [ 95 % CI , −25.9 % to 8.1 % ] ; P < .001 ) . In the 28 patients assessed by all 3 measurement methods on days 1 and 7 , the rectus femoris CSA decreased by 10.3 % ( 95 % CI , 6.1 % to 14.5 % ) , the fiber CSA by 17.5 % ( 95 % CI , 5.8 % to 29.3 % ) , and the ratio of protein to DNA by 29.5 % ( 95 % CI , 13.4 % to 45.6 % ) . Decrease in the rectus femoris CSA was greater in patients who experienced multiorgan failure by day 7 ( −15.7 % ; 95 % CI , −27.7 % to 11.4 % ) compared with single organ failure ( −3.0 % ; 95 % CI , −5.3 % to 2.1 % ) ( P < .001 ) , even by day 3 ( −8.7 % [ 95 % CI , −59.3 % to 50.6 % ] vs −1.8 % [ 95 % CI , −12.3 % to 10.5 % ] , respectively ; P = .03 ) . Myofiber necrosis occurred in 20 of 37 patients ( 54.1 % ) . Protein synthesis measured by the muscle protein fractional synthetic rate was depressed in patients on day 1 ( 0.035%/hour ; 95 % CI , 0.023 % to 0.047%/hour ) compared with rates observed in fasted healthy controls ( 0.039%/hour ; 95 % CI , 0.029 % to 0.048%/hour ) ( P = .57 ) and increased by day 7 ( 0.076 % [ 95 % CI , 0.032%-0.120%/hour ] ; P = .03 ) to rates associated with fed controls ( 0.065%/hour [ 95 % CI , 0.049 % to 0.080%/hour ] ; P = .30 ) , independent of nutritional load . Leg protein breakdown remained elevated throughout the study ( 8.5 [ 95 % CI , 4.7 to 12.3 ] to 10.6 [ 95 % CI , 6.8 to 14.4 ] μmol of phenylalanine/min/ideal body weight × 100 ; P = .40 ) . The pattern of intracellular signaling supported increased breakdown ( n = 9 , r = −0.83 , P = .005 ) and decreased synthesis ( n = 9 , r = −0.69 , P = .04 ) . CONCLUSIONS AND RELEVANCE Among these critically ill patients  , muscle wasting occurred early and rapidly during the first week of critical illness and was more severe among those with multiorgan failure compared with single organ failure . These findings may provide insights into skeletal muscle wasting in critical illness Background There is emerging evidence regarding the efficacy of exercise training to improve exercise capacity for individuals with non-small cell lung cancer ( NSCLC ) .  Cardiopulmonary exercise testing ( CPET ) is the gold st and ard measure of exercise capacity ; however this laboratory test has limitations for use in research and clinical practice . Alternative field walking tests are the six-minute walk test ( 6MWT ) , incremental-shuttle walk test ( ISWT ) and endurance-shuttle walk test ( ESWT ) ; however there is limited information about their clinimetric properties in NSCLC . Aims : In NSCLC to determine the 1 ) criterion validity of the 6MWT , ISWT and ESWT against CPET ; 2 ) construct validity of the 6MWT , ISWT and ESWT against measures of function , strength , respiratory function and health-related quality of life ( HRQoL ) ; and 3 ) clinical applicability of the tests . Methods Twenty participants ( 40 % male , mean ± SD age 66.1 ± 6.5 years ) with stage I-IIIb NSCLC completed the 6MWT , ISWT , ESWT and CPET within six months of treatment . Testing order was r and omised . Additional measures included Eastern Cooperative Oncology Group Performance-Status ( ECOG-PS , function ) , respiratory function , h and -grip dynamometry and HRQoL. Correlations and regression analyses were used to assess relationships . Results The ISWT demonstrated criterion validity with a moderate relationship between ISWT distance and CPET peak oxygen consumption ( r = 0.61 , p = 0.007 ) . Relationships between CPET and six minute walk distance ( 6MWD ) ( r = 0.24 , p = 0.329 ) or ESWT time ( r = 0.02 , p = 0.942 ) were poor . Moderate construct validity existed for the 6MWD and respiratory function ( forced vital capacity % predicted r = 0.53 , p = 0.019 ; forced expiratory volume in the first second % predicted r = 0.55 , p = 0.015 ) . There were no relationships between the walking tests and measures of function , strength or HRQoL. The ESWT had a ceiling effect with 18 % reaching maximum time . No floor effects were seen in the tests . The mean ± SD time required to perform the individual 6MWT , ISWT and ESWT was 12.8 ± 2.5 , 14.7 ± 3.7 and 16.3 ± 5.0 min respectively ; in comparison to CPET which was 51.2 ± 12.7 min . Only one assessor was required to perform all field walking tests and no adverse events occurred . Conclusions The ISWT is a promising measure of functional exercise capacity in lung cancer . Findings need to be confirmed in a larger sample prior to translation into practice Background Paresis acquired in the intensive care unit ( ICU ) is common in patients who are critically ill and independently predicts mortality and morbidity . Manual muscle testing ( MMT ) and h and grip dynamometry assessment s have been used to evaluate muscle weakness in patients in a medical ICU , but similar data for patients in a surgical ICU ( SICU ) are limited . Objective The purpose of this study was to evaluate the predictive value of strength measured by MMT and h and grip dynamometry at ICU admission for in-hospital mortality , SICU length of stay ( LOS ) , hospital LOS , and duration of mechanical ventilation . Design This investigation was a prospect i ve , observational study . Methods One hundred ten patients were screened for eligibility for testing in the SICU of a large , academic medical center . The Acute Physiology and Chronic Health Evaluation ( APACHE ) II score , diagnoses , and laboratory data were collected . Measurements were obtained by MMT quantified with the sum ( total ) score on the Medical Research Council Scale and by h and grip dynamometry . Outcome data , including in-hospital mortality , SICU LOS , hospital LOS , and duration of mechanical ventilation , were collected for all participants . Results One hundred seven participants were eligible for testing ; 89 % were tested successfully at a median of 3 days ( 25th–75th percentiles=3–6 days ) after admission . Sedation was the most frequent barrier to testing ( 70.6 % ) . Manual muscle testing  was identified as an independent predictor of mortality , SICU LOS , hospital LOS , and duration of mechanical ventilation . Grip strength was not independently associated with these outcomes . Limitations This study did not address whether muscle weakness translates to functional outcome impairment . Conclusions In contrast to h and grip strength , MMT reliably predicted in-hospital mortality , duration of mechanical ventilation , SICU LOS , and hospital LOS A prospect i ve study using neuropsychological testing explored cognitive performance , and specifically executive function , in survivors of critical illness during the first year of recovery . Fifty‐one patients who had survived 3 days or more in the intensive care unit were studied approximately 3 months after discharge ; 45 of them were studied again 6 months later . General health was assessed using the Short‐Form 36 . Cognitive and executive functions were measured using  Raven 's Progressive Matrices ,  the Hayling Sentence completion test and the Six‐Element Test . Three months after discharge from intensive care , all eight domains of Short‐Form 36 were impaired among survivors ; by 9 months , four of the eight domains showed significant improvement . At 3 months , 35 % of patients scored at or below a level equivalent to the lowest performing 5 % of a normal population ( i.e. the fifth percentile ) on two or more tests of cognitive function ; by 9 months only 4 % of patients were impaired to this extent . Although cognitive performance improved with time , it remained below normal OBJECTIVE To evaluate whether the level of mobilization achieved and the barriers for progressing to the next mobilization level differ between nurses and physical therapists . DESIGN Prospect i ve , observational study . SETTING Twenty-bed surgical intensive care unit ( SICU ) of the Massachusetts General Hospital . PARTICIPANTS Sixty-three critically ill patients . METHODS Physical therapists and nurses performed 179 mobilization therapies with 63 patients . OUTCOME MEASUREMENT Mobilization was defined as the process of enhancing mobility in the SICU , including bed mobility , edge of bed activities , transfers out of bed to a chair , and gait training ; the mobilization level was measured on the SICU optimal mobilization scale , a 5-point ( 0 - 4 ) numerical rating scale . RESULTS Patients ' level of mobilization achieved by physical therapists was significantly higher compared with that achieved by nurses ( 2.3 ± 1.2 mean ± SD versus 1.2 ± 1.2 , respectively P < .0001 ) . Different barriers for mobilization were identified by physical therapists and nurses : hemodynamic instability ( 26 % versus 12 % , P = .03 ) and renal replacement therapy ( 12 % versus 1 % , P = .03 ) were barriers rated higher by nurses , whereas neurologic impairment was rated higher by physical therapists providers ( 18 % versus 38 % , P = .002 ) . No mobilization-associated adverse events were observed in this study . CONCLUSIONS This study showed that physical therapists mobilize their critically ill patients to higher levels compared with nurses . Nurse and physical therapists identify different barriers for mobilization . Routine involvement of physical therapists in directing mobilization treatment may promote early mobilization of critically ill patients Background and Purpose — This study compared the psychometric properties of 3 clinical balance measures , the  Berg Balance Scale ( BBS ) , the Balance subscale of the Fugl-Meyer test ( FM-B ) , and the Postural Assessment Scale for Stroke Patients ( PASS ) , in stroke patients with a broad range of neurological and functional impairment from the acute stage up to 180 days after onset . Methods — One hundred twenty-three stroke patients were followed up prospect ively with the 3 balance measures 14 , 30 , 90 , and 180 days after stroke onset ( DAS ) . Reliability ( interrater reliability and internal consistency ) and validity ( concurrent validity , convergent validity , and predictive validity ) of each measure were examined . A comparison of the responsiveness of each of the 3 measures was made on the basis of the entire group of patients and 3 separate groups classified by degree of neurological severity . Results — The FM-B and BBS showed a significant floor or ceiling effect at some DAS points , whereas the PASS did not show these effects . The BBS , FM-B , and PASS all had good reliability and validity for patients at different recovery stages after stroke . The results of effect size demonstrated fair to good responsiveness of all 3 measures within the first 90 DAS but , as expected , only a low level of responsiveness at 90 to 180 DAS . The PASS was more responsive to changes in severe stroke patients at the earliest period after stroke onset , 14 to 30 DAS . Conclusions — All 3 measures tested showed very acceptable levels of reliability , validity , and responsiveness for both clinicians and research ers . The PASS showed slightly better psychometric characteristics than the other 2 measures AIMS To describe the empirical construction and initial validation of the Cannabis Use Problems Identification Test ( CUPIT ) , a brief self-report screening instrument for detection of currently and potentially problematic cannabis use . DESIGN In a three-phase prospect i ve design an item pool of c and i date questions was generated from a literature review and extensive expert consultation . The CUPIT internal structure , cross-sectional and longitudinal psychometric properties were then systematic ally tested among heterogeneous past-year users . PARTICIPANTS Volunteer participants were 212 high-risk adolescents ( n = 138 ) and adults ( n = 74 ) aged 13 - 61 years from multiple community setting s. MEASUREMENTS The comprehensive assessment battery included several established measures of cannabis-related pathology for CUPIT validation , with DSM-IV/ICD-10 diagnoses of cannabis use disorders as criterion st and ard . FINDINGS Sixteen items loading highly on two subscales derived from principal components analysis exhibited good to excellent test-retest ( 0.89 - 0.99 ) and internal consistency reliability ( 0.92 , 0.83 ) , and highly significant ability to discriminate diagnostic subgroups along the severity continuum ( non-problematic , risky , problematic use ) . Twelve months later , baseline CUPIT scores demonstrated highly significant longitudinal predictive utility for respondents ' follow-up diagnostic group membership . Receiver operating characteristic ( ROC ) analysis identified a  CUPIT score of 12 to be the optimal cut-point for maximizing sensitivity for both currently diagnosable cannabis use disorder and those at risk of meeting diagnostic criteria in the following 12 months . CONCLUSIONS The CUPIT is a brief cannabis screener that is reliable , valid and acceptable for use across diverse community setting s and consumers of all ages . The CUPIT has clear potential to assist with achievement of public health goals to reduce cannabis-related harms in the community BACKGROUND Delirium occurs frequently in the intensive care unit ( ICU ) , but its pathophysiology is still unclear . Low levels of insulin-like growth factor 1 ( IGF-1 ) , a hormone with neuroprotective properties , have been associated with delirium in some non-ICU studies , but this relationship has not been examined in the ICU . We sought to test the hypothesis that low IGF-1 concentrations are associated with delirium during critical illness . METHODS Mechanically ventilated medical ICU patients were prospect ively enrolled , and blood was collected after enrollment for measurement of IGF-1 using radioimmunometric assay .  Delirium and coma were identified daily using the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale , respectively . The association between IGF-1 and delirium was evaluated with logistic regression . In addition , the association between IGF-1 and duration of normal mental state , measured as days alive without delirium or coma , was assessed using multiple linear regression . RESULTS Among 110 patients , the median age was 65 years ( IQR , 52 - 75 ) and APACHE II was 27 ( IQR , 22 -32 ) .  IGF-1 levels were not a risk factor for delirium on the day after IGF-1 measurement ( p = 0.97 ) , at which time 65 % of the assessable patients were delirious . No significant association was found between IGF-1 levels and duration of normal mental state ( p = 0.23 ) . CONCLUSIONS This pilot study , the first to investigate IGF-1 and delirium in critically ill patients , found no association between IGF-1 and delirium . Future studies including serial measurements of IGF-1 and IGF-1 binding proteins are needed to determine whether this hormone has a role in delirium during critical illness OBJECTIVE To identify the interrelationships and discriminatory value of a broad range of objective ly measured explanatory risk factors for falls . DESIGN Prospect i ve cohort study with 12-month follow-up period . SETTING Community sample . PARTICIPANTS Five hundred community-dwelling people aged 70 to 90 . MEASUREMENTS All participants underwent assessment s on medical , disability , physical , cognitive , and psychological measures .  Fallers were defined as people who had at least one injurious fall or at least two noninjurious falls during a 12-month follow-up period . RESULTS Univariate regression analyses identified the following fall risk factors : disability , poor performance on physical tests , depressive symptoms , poor executive function , concern about falling , and previous falls . Classification and regression tree analysis revealed that balance-related impairments were critical predictors of falls . In those with good balance , disability and exercise levels influenced future fall risk-people in the lowest and the highest exercise tertiles were at greater risk . In those with impaired balance , different risk factors predicted greater fall risk-poor executive function , poor dynamic balance , and low exercise levels . Absolute risks for falls ranged from 11 % in those with no risk factors to 54 % in the highest-risk group . CONCLUSIONS A classification and regression tree approach highlighted interrelationships and discriminatory value of important explanatory fall risk factors . The information may prove useful in clinical setting s to assist in tailoring interventions to maximize the potential benefit of falls prevention strategies Background The Promoting Action on Research Implementation in  Health Services framework  , or PARIHS , is a conceptual framework that posits key , interacting elements that influence successful implementation of evidence -based practice s. It has been widely cited and used as the basis for empirical work ; however , there has not yet been a literature review to examine how the framework has been used in implementation projects and research . The purpose of the present article was to critically review and synthesize the literature on PARIHS to underst and how it has been used and operationalized , and to highlight its strengths and limitations . Methods We conducted a qualitative , critical synthesis of peer- review ed PARIHS literature published through March 2009 . We synthesized findings through a three-step process using semi-structured data abstract ion tools and group consensus . Results Twenty-four articles met our inclusion criteria : six core concept articles from original PARIHS authors , and eighteen empirical articles ranging from case reports to quantitative studies . Empirical articles generally used PARIHS as an organizing framework for analyses . No studies used PARIHS prospect ively to design implementation strategies , and there was generally a lack of detail about how variables were measured or mapped , or how conclusions were derived . Several studies used findings to comment on the framework in ways that could help refine or vali date it . The primary issue identified with the framework was a need for greater conceptual clarity regarding the definition of sub-elements and the nature of dynamic relationships . Strengths identified included its flexibility , intuitive appeal , explicit acknowledgement of the outcome of ' successful implementation , ' and a more expansive view of what can and should constitute ' evidence . ' Conclusions While we found studies reporting empirical support for PARIHS , the single greatest need for this and other implementation models is rigorous , prospect i ve use of the framework to guide implementation projects . There is also need to better explain derived findings and how interventions or measures are mapped to specific PARIHS elements ; greater conceptual discrimination among sub-elements may be necessary first . In general , it may be time for the implementation science community to develop consensus guidelines for reporting the use and usefulness of theoretical frameworks within implementation studies See related commentary by De Waele and Carlier , http://ccforum.com/content/17/2/130 Introduction Improved methods to optimize drug dosing in the critically ill are urgently needed . Traditional prescribing culture involves recognition of factors that m and ate dose reduction ( such as renal impairment ) , although optimizing drug exposure , through more frequent or augmented dosing , represents an evolving strategy . Elevated creatinine clearance ( CLCR ) has been associated with sub-therapeutic antibacterial concentrations in the critically ill , a concept termed augmented renal clearance ( ARC ) . We aim ed to determine the prevalence of ARC in a cohort of septic and traumatized critically ill patients , while also examining demographic , physiological and illness severity characteristics that may help identify this phenomenon . Methods This prospect i ve observational study was performed in a 30-bed tertiary level , university affiliated , adult intensive care unit . Consecutive traumatized and septic critically ill patients , receiving antibacterial therapy , with a plasma creatinine concentration ≤110 μmol/L , were eligible for enrolment . Pulse contour analysis ( Vigileo / Flo Trac ® system , Edwards Lifesciences , Irvine , CA , USA ) , was used to provide continuous cardiac index ( CI ) assessment over a single six-hour dosing interval . Urinary CLCR measures were obtained concurrently . Results Seventy-one patients contributed data ( sepsis n = 43 , multi-trauma n = 28 ) . Overall , 57.7 % of the cohort manifested ARC , although there was a greater prevalence in trauma ( 85.7 % versus 39.5 % , P < 0.001 ) . In all patients , a weak correlation was noted between CI and CLCR ( r = 0.346 , P = 0.003 ) . This was mostly driven by septic patients ( r = 0.508 , P = 0.001 ) , as no correlation ( r = -0.012 , P = 0.951 ) was identified in trauma . Those manifesting ARC were younger ( P<0.001 ) , male ( P = 0.012 ) , with lower acute physiology and chronic health evaluation ( APACHE ) II ( P= 0.008 ) and modified sequential organ failure assessment ( SOFA ) scores ( P = 0.013 ) , and higher cardiac indices ( P = 0.013 ) . In multivariate analysis , age ≤50 years , trauma , and a modified SOFA score ≤4 , were identified as significant risk factors . These had greater utility in predicting ARC , compared with CI assessment alone . Conclusions Diagnosis , illness severity and age , are likely to significantly influence renal drug elimination in the critically ill , and must be regularly considered in future study design and daily prescribing practice This study explored relationships between upper-limb ( UL ) functional limitations and self-reported disability in stroke patients with relatively pure motor hemiparesis who were enrolled in an acute rehabilitation treatment trial . All participants were enrolled in the VECTORS ( Very Early Constraint Treatment for Recovery from Stroke ) study . VECTORS is a single-center pilot clinical trial of early application of constraint-induced movement therapy ( CIMT ) . All 39 subjects who completed 90 days of VECTORS  were included in this analysis . Trained study personnel who were blinded to the treatment type performed all evaluations . Data in this article examine relationships between assessment s performed 90 days after stroke . Functional limitation measures included the Action Research Arm ( ARA ) test and Wolf Motor Function Test ( WMFT ) , and self-reported disability measures included the Functional Independence Measure ( FIM ) and Motor Activity Log ( MAL ) ( by telephone ) . Mean plus or minus st and ard deviation time from stroke onset to r and omization was 9.4 plus or minus 4.3 days , and median time to follow-up was 99 days ( range 68 - 178 ) . Subjects with perfect or near-perfect scores on the ARA test or WMFT reported residual disability on the FIM and MAL . Quality of movement on the WMFT ( functional ability score ) was not strongly associated with self-reported frequency , and speed of movement on the WMFT ( timed score ) was not associated with self-reported frequency ( MAL amount of use ) . In this early UL intervention trial , we found that perceived disability measures captured information that was not assessed by functional limitation and impairment scales . Our results indicate that excellent motor recovery as measured by functional limitation and impairment scales did not equal restoration of everyday productive UL use and speed of task completion did not translate to actual use . Our results confirm the need for a measurement strategy that is sensitive to change , assesses a broad performance range , and detects meaningful clinical improvements in early rehabilitation intervention trials Background COPD is a major cause of disability , but little is known about how disability develops in this condition . Methods The authors analysed data from the Function , Living , Outcomes and Work ( FLOW ) Study which enrolled 1202 Kaiser Permanente Northern California members with COPD at baseline and re-evaluated 1051 subjects at 2-year follow-up . The authors tested the specific hypothesis that the development of specific non-respiratory impairments ( abnormal body composition and muscle strength ) and functional limitations ( decreased lower extremity function , poor balance , mobility-related dyspnoea , reduced exercise performance and decreased cognitive function ) will determine the risk of disability in COPD , after controlling for respiratory impairment ( FEV1 and oxygen saturation ) . The  Valued Life Activities Scale  was used to assess disability in terms of a broad range of daily activities . The primary disability outcome measure was defined as an increase in the proportion of activities that can not be performed of 3.3 % or greater from baseline to 2-year follow-up ( the estimated minimal important difference ) . Multivariable logistic regression was used for analysis . Results Respiratory impairment measures were related to an increased prospect i ve risk of disability ( multivariate OR 1.75 ; 95 % CI 1.26 to 2.44 for 1 litre decrement of FEV1 and OR 1.57 per 5 % decrement in oxygen saturation ; 95 % CI 1.13 to 2.18 ) . Non-respiratory impairment ( body composition and lower extremity muscle strength ) and functional limitations ( lower extremity function , exercise performance , and mobility-related dyspnoea ) were all associated with an increased longitudinal risk of disability after controlling for respiratory impairment ( p<0.05 in all cases ) . Non-respiratory impairment and functional limitations were predictive of prospect i ve disability , above- and -beyond sociodemographic characteristics , smoking status and respiratory impairment ( area under the receiver operating characteristic curve increased from 0.65 to 0.75 ; p<0.001 ) . Conclusions Development of non-respiratory impairment and functional limitations , which reflect the systemic nature of COPD , appear to be critical determinants of disablement . Prevention and treatment of disability require a comprehensive approach to the COPD patient
Conclusions There is considerable variability in the type of measures utilized to measure physical impairments and limitations in survivors of critical illness .
Purpose To identify measures used to evaluate the broad constructs of functional impairment and limitations in the critically ill across the continuum of recovery , and to evaluate , synthesis e and compare the clinimetric properties of the measures identified .