Evaluating Physical Functioning in Survivors of Critical Illness: Development of a New Continuum Measure for Acute Care.

OBJECTIVES: Evaluation of physical functioning is central to patient recovery from critical illness-it may enable the ability to determine recovery trajectories, evaluate rehabilitation efficacy, and predict individuals at highest risk of ongoing disability. The Physical Function in ICU Test-scored is one of four recommended physical functioning tools for use within the ICU; however, its utility outside the ICU is poorly understood. The De Morton Mobility Index is a common geriatric mobility tool, which has had limited evaluation in the ICU population. For the field to be able to track physical functioning recovery, we need a measurement tool that can be used in the ICU and post-ICU setting to accurately measure physical recovery. Therefore, this study sought to: 1) examine the clinimetric properties of two measures (Physical Function in ICU Test-scored and De Morton Mobility Index) and 2) transform these measures into a single measure for use across the acute care continuum. DESIGN: Clinimetric analysis. SETTING: Multicenter study across four hospitals in three countries (Australia, Singapore, and Brazil). PATIENTS: One hundred fifty-one ICU patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Physical function tests (Physical Function in ICU Test-scored and De Morton Mobility Index) were assessed at ICU awakening, ICU, and hospital discharge. A significant floor effect was observed for the De Morton Mobility Index at awakening (23%) and minimal ceiling effects across all time points (5-12%). Minimal floor effects were observed for the Physical Function in ICU Test-scored across all time points (1-7%) and a significant ceiling effect for Physical Function in ICU Test-scored at hospital discharge (27%). Both measures had strong concurrent validity, responsiveness, and were predictive of home discharge. A new measure was developed using Rasch analytical principles, which involves 10 items (scored out of 19) with minimal floor/ceiling effects. CONCLUSIONS: Limitations exist for Physical Function in ICU Test-scored and De Morton Mobility Index when used in isolation. A new single measure was developed for use across the acute care continuum.

Comparison of Cardiac Output of Both 2-Dimensional and 3-Dimensional Transesophageal Echocardiography With Transpulmonary Thermodilution During Cardiac Surgery.

OBJECTIVES: To compare agreement and variability of cardiac output measurement of 2-dimensional (2D) and 3D transesophageal echocardiography (TEE) with thermodilution before and after bypass. DESIGN: Prospective observational study. SETTING: Two tertiary hospitals. INTERVENTIONS: Cardiac output (CO) was measured simultaneously with thermodilution and TEE by multiplying either the left ventricular outflow tract area (LVOTA) or aortic valve area (AVA), the velocity-time integral (VTI) of flow at the same site, and heart rate. The LVOTA was calculated using diameter for 2D TEE. Planimetry was used for 3D TEE. The AVA was measured using planimetry. PARTICIPANTS: The study comprised 82 adult patients undergoing coronary or valve surgery. MEASUREMENTS AND MAIN RESULTS: One hundred fifty-four complete sets of measurements were obtained (82 prebypass and 72 postbypass). All TEE methods had acceptable correlation and absence of proportional or fixed bias except for the left ventricular outflow tract (LVOT) VTI modal trace method, which had poor correlation and proportional but not fixed bias (regression coefficient [95% confidence interval], bias [percentage of mean CO]): 2D LVOT VTI modal trace 0.67 (0.54-0.80), -36.4%; 2D LVOT VTI outer edge trace 0.96 (0.80-1.12), -15.3%; 2D AVA planimetry 0.96 (0.75-1.18), +4.9%; 3D LVOT area planimetry 1.18 (0.96-1.41), +0.8%; 3D AVA planimetry 1.20 (0.93-1.46), +0.4%. All TEE methods had wide levels of agreement compared with thermodilution (-3.94 to +0.23 L/min, -2.83 to +1.28 L/min, -2.23 to +2.73 L/min, -2.35 to +2.42 L/min, and -2.57 to +2.61 L/min, respectively). Measurement variability was superior for all TEE methods compared with thermodilution before but not after bypass. CONCLUSIONS: Although limits of agreement of CO measurement with 3D TEE and thermodilution are wide, 2D planimetry of the AVA and continuous wave Doppler may be substituted for thermodilution before and after bypass.

Commencing Out-of-Bed Rehabilitation in Critical Care-What Influences Clinical Decision-Making?

OBJECTIVES: To develop a decision tree that objectively identifies the most discriminative variables in the decision to provide out-of-bed rehabilitation, measure the effect of this decision and to identify the factors that intensive care unit (ICU) practitioners think most influential in that clinical decision. DESIGN: A prospective 3-part study: (1) consensus identification of influential factors in mobilization via survey; (2) development of an early rehabilitation decision tree; (3) measurement of practitioner mobilization decision-making. Treating practitioners of patients expected to stay >96 hours were asked if they would provide out-of-bed rehabilitation and rank factors that influenced this decision from an a priori defined list developed from a literature review and expert consultation. SETTING: Four tertiary metropolitan ICUs. PARTICIPANTS: Practitioners (ICU medical, nursing, and physiotherapy staff) (N=507). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A decision tree was constructed using binary recursive partitioning to determine the factor that best classified patients suitable for out-of-bed rehabilitation. Descriptive statistics were used to describe practitioner and patient samples as well as patient adverse events associated with out-of-bed rehabilitation and the factors prioritized by ICU practitioners. RESULTS: There were 1520 practitioner decisions representing 472 individual patient decisions. Practitioners classified patients suitable for out-of-bed rehabilitation on 149 occasions and not suitable on 323 occasions. Decision tree analysis showed the presence of an endotracheal tube (ETT) and sedation state were the only discriminative variables that predicted patient suitability for rehabilitation. In contrast, medical staff and nurses reported that ventilator status was the most influential factor in their decision not to provide rehabilitation while physiotherapists ranked sedation most highly. The presence of muscle weakness did not inform the decision to provide rehabilitation. CONCLUSION: These results confirm previous observational reports that the presence of an ETT remains a major obstacle to the provision of rehabilitation for critically ill patients. Despite rehabilitation being effective for improving muscle strength, the presence of muscle weakness did not influence the decision to provide rehabilitation.

Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy ('SMART' Trial): a randomised trial.

QUESTION: In people who have undergone cardiac surgery via median sternotomy, does modifying usual sternal precautions to make them less restrictive improve physical function, pain, kinesiophobia and health-related quality of life? DESIGN: Two-centre, randomised, controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS: Seventy-two adults who had undergone cardiac surgery via a median sternotomy were included. INTERVENTION: Participants were randomly allocated to one of two groups at 4 (SD 1) days after surgery. The control group received the usual advice to restrict their upper limb use for 4 to 6 weeks (ie, restrictive sternal precautions). The experimental group received advice to use pain and discomfort as the safe limits for their upper limb use during daily activities (ie, less restrictive precautions) for the same period. Both groups received postoperative individualised education in hospital and via weekly telephone calls for 6 weeks. OUTCOME MEASURES: The primary outcome was physical function assessed by the Short Physical Performance Battery. Secondary outcomes included upper limb function, pain, kinesophobia, and health-related quality of life. Outcomes were measured before hospital discharge and at 4 and 12 weeks postoperatively. Adherence to sternal precautions was recorded. RESULTS: There were no statistically significant differences in physical function between the groups at 4 weeks (MD 1.0, 95% CI -0.2 to 2.3) and 12 weeks (MD 0.4, 95% CI -0.9 to 1.6) postoperatively. There were no statistically significant between-group differences in secondary outcomes. CONCLUSION: Modified (ie, less restrictive) sternal precautions for people following cardiac surgery had similar effects on physical recovery, pain and health-related quality of life as usual restrictive sternal precautions. Similar outcomes can be anticipated regardless of whether people following cardiac surgery are managed with traditional or modified sternal precautions. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ANZCTRN12615000968572. [Katijjahbe MA, Granger CL, Denehy L, Royse A, Royse C, Bates R, Logie S, Nur Ayub MA, Clarke S, El-Ansary D (2018) Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy ('SMART' Trial): a randomised trial. Journal of Physiotherapy 64: 97-106].

Factors influencing audiologists' perception of moral climate in the workplace.

OBJECTIVE: The purpose of this study was to assess audiologists' perceptions of ethics and moral climate in the workplace. DESIGN: The Ethics Environmental Questionnaire (EEQ) was sent out to all audiologists registered with the professional body Audiology Australia. Participants were also invited to undertake a semi-structured interview. STUDY SAMPLE: A total of 301 audiologists completed the questionnaire. Eight of these participants also agreed to complete the interview. RESULTS: The overall mean on the EEQ was approximately equivalent to that of a positive ethical environment, with the exception of those working in adult rehabilitation settings who scored significantly poorer. Scores were significantly associated with state and age. Qualitative analysis from the interviews found that sales pressure from employers was the dominant cause for concern amongst the group. CONCLUSIONS: For those working in adult rehabilitation, moral distress is most likely to occur as the result of conflicting goals between the organisation and the audiologist. There is a need to regulate the practice at an organisational as well as individual level to ensure the focus remains on ethical practice.

Speech intelligibility benefits of frequency-lowering algorithms in adult hearing aid users: a systematic review and meta-analysis.

OBJECTIVE: This systematic review evaluated the effectiveness of two frequency-lowering schemes, non-linear frequency compression and frequency transposition, at improving speech intelligibility for adult hearing-impaired populations. DESIGN: A systematic search of 10 electronic databases was carried out using pre-defined inclusion criteria. Accepted articles were then critically appraised using the Effective Public Health Practice Project (EPHPP) Critical Appraisal Tool. Outcome results were further synthesised where possible using random effects meta-analysis to provide overall combined estimates of the treatment differences along with 95% confidence intervals. STUDY SAMPLE: A total of 20 articles were accepted for final review. RESULTS: Overall, study quality was of moderate strength. Meta-analysis found a statistically significant benefit in favour of frequency-lowering for consonant recognition testing in quiet across 145 participants with both algorithms providing comparable gains. Equivalent results were found between frequency-lowering and conventional processing on all other speech measures. CONCLUSIONS: Based on the available data, frequency-lowering does seem to provide some improvement in an individual's speech intelligibility dependant on the stimulus type, although the benefits were modest. This improvement was not seen across all measures, however those who do not benefit from the technology will also not be harmed by trialling it.

Electroconvulsive therapy in the continuation and maintenance treatment of depression: Systematic review and meta-analyses.

OBJECTIVE: Acute course of electroconvulsive therapy is effective in inducing remission from depression, but recurrence rate is unacceptably high following termination of electroconvulsive therapy despite continued pharmacotherapy. Continuation electroconvulsive therapy and maintenance electroconvulsive therapy have been studied for their efficacy in preventing relapse and recurrence of depression. The purpose of this meta-analysis was to examine the efficacy of continuation electroconvulsive therapy and maintenance electroconvulsive therapy in preventing relapse and recurrence of depression in comparison to antidepressant pharmacotherapy alone. METHODS: We searched MEDLINE, Embase, PsycINFO, clinicaltrials.gov and Cochrane register of controlled trials from the database inception to December 2016 without restriction on language or publication status for randomized trials of continuation electroconvulsive therapy and maintenance electroconvulsive therapy. Two independent Cochrane reviewers extracted the data in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews and meta-analyses. The risk of bias was assessed using four domains of the Cochrane Collaboration Risk of Bias Tool. Outcomes were pooled using random effect model. The primary outcome was relapse or recurrence of depression. RESULTS: Five studies involving 436 patients were included in the meta-analysis. Analysis of the pooled data showed that continuation electroconvulsive therapy and maintenance electroconvulsive therapy, both with pharmacotherapy, were associated with significantly fewer relapses and recurrences than pharmacotherapy alone at 6 months and 1 year after a successful acute course of electroconvulsive therapy (risk ratio = 0.64, 95% confidence interval = [0.41, 0.98], p = 0.04, risk ratio = 0.46, 95% confidence interval = [0.21, 0.98], p = 0.05, respectively). There was insufficient data to perform a meta-analysis of stand-alone continuation electroconvulsive therapy or maintenance electroconvulsive therapy beyond 1 year. CONCLUSION: There are only a few randomized trials of continuation electroconvulsive therapy and maintenance electroconvulsive therapy. The preliminary and limited evidence suggests the modest efficacy of continuation electroconvulsive therapy and maintenance electroconvulsive therapy with concomitant pharmacotherapy in preventing relapse and recurrence of depressive episodes for 1 year after the remission of index episode with the acute course of electroconvulsive therapy.

Balance and Falls in Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Prospective Study.

Individuals with chronic obstructive pulmonary disease (COPD) have demonstrated balance impairment and a higher fall incidence. However, these have not been investigated in acute exacerbations of the disease (ECOPD). This study evaluates balance in patients during an ECOPD compared to stable COPD and healthy controls, and examines the fall incidence rate after hospitalisation due to ECOPD compared to individuals with stable COPD. Balance performance of 26 hospitalised patients with ECOPD was compared to 26 community-dwelling participants with stable COPD and 25 matched healthy controls. Balance was evaluated using computerised posturography and the Berg Balance Scale (BBS). Prospective falls were monitored by monthly calendars for 12 months in both COPD groups. Compared to controls, greater balance impairment was observed during ECOPD for most posturography variables across standing conditions (p ≤ 0.05). Both COPD groups had worse BBS scores (p ≤ 0.05) compared to controls. Increased dyspnoea and reduced quadriceps' strength were associated with impaired balance performance. A higher fall incidence (1.76 falls/person/year) was observed following hospitalisation in patients with ECOPD compared to stable COPD (0.53 falls/person/year) at 12 months. Patients with ECOPD demonstrate balance impairments which are associated with increased dyspnoea and reduced muscle strength. Balance impairment during ECOPD may contribute to a high incidence of falls following hospitalisation.

The Sternal Management Accelerated Recovery Trial (S.M.A.R.T) - standard restrictive versus an intervention of modified sternal precautions following cardiac surgery via median sternotomy: study protocol for a randomised controlled trial.

BACKGROUND: The routine implementation of sternal precautions to prevent sternal complications that restrict the use of the upper limbs is currently worldwide practice following a median sternotomy. However, evidence is limited and drawn primarily from cadaver studies and orthopaedic research. Sternal precautions may delay recovery, prolong hospital discharge and be overly restrictive. Recent research has shown that upper limb exercise reduces post-operative sternal pain and results in minimal micromotion between the sternal edges as measured by ultrasound. The aims of this study are to evaluate the effects of modified sternal precautions on physical function, pain, recovery and health-related quality of life after cardiac surgery. METHODS/DESIGN: This study is a phase II, double-blind, randomised controlled trial with concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. Patients (n = 72) will be recruited following cardiac surgery via a median sternotomy. Sample size calculations were based on the minimal important difference (two points) for the primary outcome: Short Physical Performance Battery. Thirty-six participants are required per group to counter dropout (20%). All participants will be randomised to receive either standard or modified sternal precautions. The intervention group will receive guidelines encouraging the safe use of the upper limbs. Secondary outcomes are upper limb function, pain, kinesiophobia and health-related quality of life. Descriptive statistics will be used to summarise data. The primary hypothesis will be examined by repeated-measures analysis of variance to evaluate the changes from baseline to 4 weeks post-operatively in the intervention arm compared with the usual-care arm. In all tests to be conducted, a p value <0.05 (two-tailed) will be considered statistically significant, and confidence intervals will be reported. DISCUSSION: The Sternal Management Accelerated Recovery Trial (S.M.A.R.T.) is a two-centre randomised controlled trial powered and designed to investigate whether the effects of modifying sternal precautions to include the safe use of the upper limbs and trunk impact patients' physical function and recovery following cardiac surgery via median sternotomy. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry identifier: ACTRN12615000968572 . Registered on 16 September 2015 (prospectively registered).

Pregnant women maintain body temperatures within safe limits during moderate-intensity aqua-aerobic classes conducted in pools heated up to 33 degrees Celsius: an observational study.

QUESTION: What is the body temperature response of healthy pregnant women exercising at moderate intensity in an aqua-aerobics class where the water temperature is in the range of 28 to 33 degrees Celsius, as typically found in community swimming pools? DESIGN: An observational study. PARTICIPANTS: One hundred and nine women in the second and third trimester of pregnancy who were enrolled in a standardised aqua-aerobics class. OUTCOME MEASURES: Tympanic temperature was measured at rest pre-immersion (T1), after 35minutes of moderate-intensity aqua-aerobic exercise (T2), after a further 10minutes of light exercise while still in the water (T3) and finally on departure from the facility (T4). The range of water temperatures in seven indoor community pools was 28.8 to 33.4 degrees Celsius. RESULTS: Body temperature increased by a mean of 0.16 degrees Celsius (SD 0.35, p<0.001) at T2, was maintained at this level at T3 and had returned to pre-immersion resting values at T4. Regression analysis demonstrated that the temperature response was not related to the water temperature (T2 r = -0.01, p = 0.9; T3 r = -0.02, p=0.9; T4 r=0.03, p=0.8). Analysis of variance demonstrated no difference in body temperature response between participants when grouped in the cooler, medium and warmer water temperatures (T2 F=0.94, p=0.40; T3 F=0.93, p=0.40; T4 F=0.70, p=0.50). CONCLUSIONS: Healthy pregnant women maintain body temperatures within safe limits during moderate-intensity aqua-aerobic exercise conducted in pools heated up to 33 degrees Celsius. The study provides evidence to inform guidelines for safe water temperatures for aqua-aerobic exercise during pregnancy.

Falls by individuals with chronic obstructive pulmonary disease: a preliminary 12-month prospective cohort study.

BACKGROUND AND OBJECTIVE: Despite evidence of an increased fall risk in people with chronic obstructive pulmonary disease (COPD), there is a paucity of prospective fall data in this population. This preliminary study aimed to prospectively examine the prevalence rate, incidence rate and associated risk factors for falls in a sample of community-dwelling people with COPD over 1 year. METHODS: Forty-one participants with stable COPD (mean ± SD) aged 71 ± 8 years with a forced expiratory volume in 1 s of 45.1 ± 16.2% predicted were included. At baseline, participants' demographic, physical function and fall-related measures were documented. Falls were monitored for 12 months following initial assessments. RESULTS: The prevalence of people having falls was 40% (95% CI: 24-56%); amongst these, 75% had frequent falls. The overall fall incidence rate was 1.17 falls/person-year. Risk factors associated with a higher fall incidence rate ratio (IRR) in COPD were: number of pack-years (IRR: 1.02; 95%CI: 1.00,1.04), comorbidities (IRR: 2.02; 95%CI: 1.42,3.06), number of medications (IRR: 1.15; 95%CI: 1.00,1.34), history of falls in the previous year (IRR: 1.89; 95%CI: 1.10,3.34), fear of falling (IRR: 1.08; 95% CI: 1.02,1.14) and higher score in a fall risk assessment questionnaire for older adults (IRR: 1.14; 95% CI: 1.05,1.25); P ≤ 0.05. When adjusted for age, only pack-years (P = 0.01), number of comorbidities (P < 0.001) and history of falls (P = 0.03) were related to an increased fall incidence. CONCLUSIONS: These preliminary findings demonstrated the fall prevalence and incidence rate in community-dwelling people with stable COPD and identified prospective risk factors for an increased fall incidence, which suggest potential mitigation strategies.

Interatrial septum motion but not Doppler assessment predicts elevated pulmonary capillary wedge pressure in patients undergoing cardiac surgery.

BACKGROUND: Left atrial pressure and its surrogate, pulmonary capillary wedge pressure (PCWP), are important for determining diastolic function. The role of transthoracic echocardiography (TTE) in assessing diastolic function is well established in awake subjects. The objective was to assess the accuracy of predicting PCWP by TTE and transesophageal echocardiography (TEE) during coronary artery surgery. METHODS: In 27 adult patients undergoing on-pump coronary artery surgery, simultaneous echocardiographic and hemodynamic measurements were obtained immediately before anesthesia (TTE), after anesthesia and mechanical ventilation (TTE and TEE), during conduit harvest (TEE), and after separation from cardiopulmonary bypass (TEE). RESULTS: Twenty patients had an ejection fraction (EF) of 0.5 or greater. With the exception of E/e' and S/D ratios, echocardiographic values changed over the echocardiographic studies. In patients with low EF, E velocity, deceleration time, pulmonary vein D, S/D, and E/e' ratios correlated well with PCWP before anesthesia. After induction of anesthesia using TTE or TEE, correlations were poor. In normal EF patients, correlations were poor for both TEE and TTE at all five stages. The sensitivity and specificity of echocardiographic values were not high enough to predict raised PCWP except for a fixed curve pattern of interatrial septum (area under the curve 0.89 for PCWP ≥ 17, and 0.98 for ≥ 18 mmHg) and S/D less than 1 (area under the curve 0.74 for PCWP ≥ 17, and 0.78 for ≥ 18 mmHg). CONCLUSION: Doppler assessment of PCWP was neither sensitive nor specific enough to be clinically useful in anesthetized patients with mechanical ventilation. The fixed curve pattern of the interatrial septum was the best predictor of raised PCWP.

Investigation of forelimb hoof wall strains and hoof shape in unshod horses exercised on a treadmill at various speeds and gaits.

OBJECTIVE: To investigate forelimb hoof wall strains and shape changes in unshod horses undergoing regular moderate exercise on a treadmill at selected speeds and gaits. ANIMALS: 6 horses of various body types. PROCEDURES: Each horse was exercised on a treadmill (walking, trotting, and cantering, with or without galloping at 12.5 m/s) 3 times a week for 4 consecutive weeks; duration of each exercise session ranged from 10 to 14 minutes. During the 4-week period, the proximal hoof circumference (PHC) and toe angle (TA) of each forelimb hoof were measured weekly with a flexible measuring tape and a hoof gauge, respectively. Forelimb hoof wall strains were measured bilaterally at the toe and each quarter (3 strain gauges) immediately before the first and after the last exercise session. RESULTS: Strain measurements revealed a consistent pattern of deformation of the hoof wall in both forelimbs at all gaits; strains increased during the stance phase of the stride. Strain values were dependent on site and gait. Compared with initial findings, mean TA increased significantly, whereas mean PHC did not, after the 4-week exercise period. A relationship between TA changes and hoof wall strains could not be established. CONCLUSIONS AND CLINICAL RELEVANCE: In unshod horses, forelimb hoof wall strains were affected by site and gait, but not by discrete changes in TA; PHC did not change in response to moderate regular exercise. The pattern of hoof loading was consistent despite significant changes in TA.

Epigenetic changes in response to tai chi practice: a pilot investigation of DNA methylation marks.

Tai chi exercise has been shown to improve physiological and psychosocial functions, well-being, quality of life, and disease conditions. The biological mechanisms by which tai chi exerts its holistic effects remain unknown. We investigated whether tai chi practice results in positive epigenetic changes at the molecular level. Design. The DNA methylation profiles of sixty CpG-dinucleotide marks in female tai chi practitioners (N = 237; 45-88 years old) who have been practising tai chi for three or more years were compared with those of age-matched control females (N = 263) who have never practised tai chi. Results. Six CpG marks originating from three different chromosomes reveal a significant difference (P < 0.05) between the two cohorts. Four marks show losses while two marks show gains in DNA methylation with age in the controls. In the tai chi cohort all six marks demonstrate significant slowing (by 5-70%) of the age-related methylation losses or gains observed in the controls, suggesting that tai chi practice may be associated with measurable beneficial epigenetic changes. Conclusions. The results implicate the potential use of DNA methylation as an epigenetic biomarker to better understand the biological mechanisms and the health and therapeutic efficacies of tai chi.