A randomized controlled trial of supervised versus unsupervised exercise programs for ambulatory stroke survivors.
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BACKGROUND AND PURPOSE: Little is known about the relative efficacy of supervised versus unsupervised community exercise programs for stroke survivors. This study compared the effectiveness of a 10-week supervised strengthening and conditioning program (supervised) with a 1-week supervised instruction program followed by a 9-week unsupervised home program (unsupervised) and evaluated retention of changes at 6 months and 1 year after program completion. METHODS: Seventy-two subjects retained at baseline (27 women, 45 men; mean+/-SD age, 64.6+/-11.8 years) were randomly allocated to receive the supervised or unsupervised program. The primary outcome was walking speed over 6 minutes, and secondary outcome measures were Human Activity Profile, Medical Outcome Study 36-Item Short-Form survey (SF-36), Physiological Cost Index, and lower extremity muscle strength. RESULTS: The 6-minute walking speed increased significantly in both groups and remained significantly improved by 1 year. The Human Activity Profile demonstrated an increasing trend only in the supervised group that was significant by 1 year. The SF-36 Physical Component summary score increased significantly in the supervised group and remained improved by 1 year; the unsupervised group showed significant improvement at 1 year. Women made greater gains in supervised programs, but men made greater gains in unsupervised programs. CONCLUSIONS: Supervised exercise programs and unsupervised programs after initial supervised instruction were both associated with physical benefits that were retained for 1 year, although supervised programs showed trends to greater improvements in self-reported gains. Gender differences require further research. (+info)
A randomized trial of home oxygen therapy from the emergency department for acute bronchiolitis.
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OBJECTIVE: Hypoxia is a common reason for hospital admission in infants and children with acute bronchiolitis. No study has evaluated discharge from the emergency department (ED) on home oxygen. This study evaluated the feasibility and safety of ED discharge on home oxygen in the treatment of acute bronchiolitis. METHODS: This was a prospective, randomized trial of infants and children with acute bronchiolitis and hypoxia (room-air saturations of < or =87%) aged 2 to 24 months presenting to an urban, academic, tertiary care children's hospital ED from December 1998 to April 2001. Subjects received inpatient admission or home oxygen after an 8-hour observation period in the ED. We measured the failure to meet discharge criteria during the observation period, return for hospital admission, and incidence of serious complications. RESULTS: Ninety-two patients were enrolled. Fifty three (58%) were randomly assigned to home and 39 (42%) to inpatient admission. There were no differences between the groups in age, initial room-air saturation, and respiratory distress severity score. Of 53 patients, 37 (70%) randomly assigned to home oxygen completed the observation period and were discharged from the hospital. The remaining 16 patients were excluded from the study (6), resolved their oxygen requirement (5), or failed to meet the discharge criteria and were admitted (5). One discharged patient (2.7%) returned to the hospital and was admitted for a cyanotic spell at home after the 24-hour follow-up appointment. The patient had an uncomplicated hospital course with a length of stay of 45 hours. The remaining 36 patients (97%) were treated successfully as outpatients with home oxygen. Satisfaction with home oxygen was high from the caregiver and the primary care provider. CONCLUSIONS: Discharge from the ED on home oxygen after a period of observation is an option for patients with acute bronchiolitis. Secondary to the low incidence of complications, the safety of this practice will require a larger study. (+info)
The epidemiology of meconium aspiration syndrome: incidence, risk factors, therapies, and outcome.
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OBJECTIVE: We sought to examine, in a large cohort of infants within a definable population of live births, the incidence, risk factors, treatments, complications, and outcomes of meconium aspiration syndrome (MAS). DESIGN: Data were gathered on all of the infants in Australia and New Zealand who were intubated and mechanically ventilated with a primary diagnosis of MAS (MASINT) between 1995 and 2002, inclusive. Information on all of the live births during the same time period was obtained from perinatal data registries. RESULTS: MASINT occurred in 1061 of 2,490,862 live births (0.43 of 1000), with a decrease in incidence from 1995 to 2002. A higher risk of MASINT was noted at advanced gestation, with 34% of cases born beyond 40 weeks, compared with 16% of infants without MAS. Fetal distress requiring obstetric intervention was noted in 51% of cases, and 42% were delivered by cesarean section. There was a striking association between low 5-minute Apgar score and MASINT. In addition, risk of MASINT was higher where maternal ethnicity was Pacific Islander or indigenous Australian and was also increased after planned home birth. Uptake of exogenous surfactant, high-frequency ventilation, and inhaled nitric oxide increased considerably during the study period, with >50% of infants receiving > or =1 of these therapies by 2002. Risk of air leak was 9.6% overall, with an apparent reduction to 5.3% in 2001-2002. The duration of intubation remained constant throughout the study period (median: 3 days), whereas duration of oxygen therapy and length of hospital stay increased. Death related to MAS occurred in 24 infants (2.5% of the MASINT cohort; 0.96 per 100,000 live births). CONCLUSIONS: The incidence of MASINT in the developed world is low and seems to be decreasing. Risk of MASINT is significantly greater in the presence of fetal distress and low Apgar score, as well as Pacific Islander and indigenous Australian ethnicity. The increased use of innovative respiratory supports has not altered the duration of mechanical ventilation. (+info)
Preschool healthcare utilisation related to home oxygen status.
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OBJECTIVE: To determine, in prematurely born children who had bronchopulmonary dysplasia (BPD), if respiratory morbidity, healthcare utilisation, and cost of care during the preschool years were influenced by use of supplementary oxygen at home after discharge from the neonatal intensive care unit. DESIGN: Observational study. SETTING: Four tertiary neonatal intensive care units. PATIENTS: 190 children, median gestational age 27 weeks (range 22-31), 70 of whom received supplementary oxygen when discharged home. INTERVENTIONS: Review of hospital and general practitioner records together with a parent completed respiratory questionnaire. MAIN OUTCOME MEASURES: Healthcare utilisation, cost of care, cough, wheeze, and use of an inhaler. RESULTS: Seventy children had supplementary oxygen at home (home oxygen group), but only one had a continuous requirement for home oxygen beyond 2 years of age. There were no significant differences in the gestational age or birth weight of the home oxygen group compared with the rest of the cohort. However, between 2 and 4 years of age inclusive, the home oxygen group had more outpatient attendances (p = 0.0021) and specialist attendances (p = 0.0023), and, for respiratory problems, required more prescriptions (p<0.0001). Their total cost of care was higher (p<0.0001). In addition, more of the home oxygen group wheezed more than once a week (p = 0.0486) and were more likely to use an inhaler (p<0.0001). CONCLUSIONS: Children with BPD who have supplementary oxygen at home after discharge have increased respiratory morbidity and healthcare utilisation in the preschool years. (+info)
Study protocol: home-based physical rehabilitation for survivors of a critical illness [ACTRN12605000166673].
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INTRODUCTION: Numerous primary studies and several review papers have highlighted delayed physical and psychological recovery for survivors of critical illness, often beyond 6 months after discharge. This randomized controlled trial with blinded assessment aims to test the effects of an 8-week, home-based, individually tailored physical rehabilitation programme on physical and psychological recovery for survivors of a critical illness after discharge from hospital. METHOD: Participants are survivors of a critical illness discharged from nine intensive care units (ICUs) in Australia, who are aged 18 years or older, in an ICU longer than 48 hours, discharged home to self-care or carer (non-institutional care), able to participate in physical rehabilitation, and within the hospitals' local geographical areas for home visits. The study is based in participants' home environments. Blinded assessments at weeks 1, 8 and 26 after hospital discharge examine physical functioning, exercise capacity, health-related quality of life and psychological well being. The intervention is graded, individualized endurance and strength training prescribed by a pulmonary rehabilitation physiotherapist over an 8-week period, with three home visits, five follow-up phone calls, and a printed exercise manual supporting the training. Initial focus is on lower limb exercises and walking, with warm-up stretches, and progresses to the addition of core stabilization and upper limb exercises. RESULTS: The burden of a critical illness is well documented. This novel study will determine whether a home-based physical rehabilitation programme improves the recovery trajectory for survivors of critical illness. The projected sample size of 200 patients aims to detect a clinically important 10% improvement in physical functioning. The study will also examine whether other important physical and psychological measures are improved. CONCLUSION: This multicentre, randomized controlled trial will examine outcomes that are meaningful to patients, their family and society, namely functional ability and well being. The study will also target a health problem that is likely to increase as the population ages. If the programme is effective, it will provide a model that can be easily adapted and adopted by existing primary care or community services to improve the recovery of individuals following critical illness. (+info)
Lifestyle intervention development study to improve physical function in older adults with cancer: outcomes from Project LEAD.
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PURPOSE: Declines in physical functioning (PF) among elderly cancer patients threaten quality of life and the ability to maintain independence. Adherence to healthy lifestyle behaviors may prevent functional decline. PATIENTS AND METHODS: Project Leading the Way in Exercise and Diet (LEAD), an intervention development study of the Pepper Older Americans Independence Center, aimed to determine whether breast and prostate cancer survivors (age 65+ years) assigned to a 6-month home-based diet and exercise intervention experienced improvements in PF when compared with an attention control arm receiving general health information. An accrual target was set at 420, and PF (Short Form-36 subscale), physical activity (Community Healthy Activities Models Program for Seniors), and diet quality (index from 3-day recalls) were assessed at baseline and at 6 and 12 months (6 months after intervention). RESULTS: This developmental project did not achieve its accrual target (N = 182); however, PF change scores were in the direction and of the magnitude projected. Baseline to 6-month change scores in the intervention versus the control arms were as follows: PF, +3.1 v -0.5 (P = .23); physical activity energy expenditure, +111 kcal/wk v -400 kcal/wk (P = .13); and diet quality index, +2.2 v -2.9 (P = .003), respectively. Differences between arms diminished during the postintervention period. CONCLUSION: These findings suggest that home-based diet and exercise interventions hold promise in improving lifestyle behaviors among older cancer survivors, changes that trend toward improved PF. Future studies should incorporate larger sample sizes and interventions that sustain long-term effects and also take into account secular trends; these efforts will require adequate planning and resources to overcome the numerous barriers to intervening in this difficult to reach yet vulnerable population. (+info)
Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure.
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BACKGROUND: There are logistical and financial advantages to undertaking shoulder surgery in a day case setting. However, this approach is limited by postoperative pain being inadequately controlled by oral medication alone. We describe a pilot study investigating the feasibility and acceptance of community based continuous interscalene brachial plexus blockade (CIBPB) to provide effective analgesia for day case shoulder surgery. METHODS: Phase 1 consisted of five patients who received CIBPB for shoulder surgery. Following an overnight hospital stay they were assessed for discharge home with the interscalene catheter in situ. Once the safety and feasibility of the approach was documented, five more patients were recruited to Phase 2. These patients had the adequacy of analgesia assessed in the postoperative period and were discharged home on the same day as surgery. A district nurse visited twice daily and removed the catheter on the third day. Patient satisfaction was assessed using a discovery interview. RESULTS: Nine of the 10 patients experienced good analgesia. One patient was re-admitted because the catheter fell out. No patient experienced complications and the discovery interviews showed that the patients were satisfied with their management and pleased to be treated as a day case. CONCLUSIONS: POSSI proved that it was feasible to manage these patients in the community with support and training of the district nurses. Although extra community nursing hours are required, this technique has the potential for significant cost benefits with at least three bed days saved per patient. (+info)
Outcome of non-invasive domiciliary ventilation in elderly patients.
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STUDY OBJECTIVES: To analyze the short- and long-term effects of domiciliary non-invasive ventilation (NIV) in the elderly. METHODS: From 1990 to 2005 all patients who initiated NIV at age 75 or older were included in the study. The mean follow-up period was 36 (24) months. Data were obtained from a database record. RESULTS: Forty-three patients, mean age 77 (1.9) years and hypercapnic respiratory failure secondary to restrictive, neuromuscular or hypoventilatory disease were included. The short-term effects included a significant improvement in arterial blood gases and nocturnal desaturations during NIV compared to baseline: PaO(2) increased a mean of 19 mmHg (P<0.0001), PaCO(2) decreased a mean of 16 mmHg (P<0.0001) and nocturnal time with SaO(2)<90% decreased a mean of 72% (P<0.0001). Arterial blood gases while breathing room air also improved significantly at 6 months after NIV initiation. Five patients (11%) discontinued treatment; this group did not differ from patients who continued NIV. Mean compliance was 8.3 (3.1)h/day. In the long-term effects, we observed that the initial improvement of arterial blood gases breathing room air was maintained throughout the followup period. The number of hospital admissions and days of hospital stay decreased significantly (P<0.0001 and 0.001, respectively) after NIV initiation. The poorest survival was observed in ALS patients (median 10.9 (2.3) months) significantly lower than the survival for the other diagnostic groups (median 58.5 (4.8) months), P=0.0013. CONCLUSIONS: NIV is an effective treatment in the elderly. It improves arterial blood gases and nocturnal desaturations, decreases hospital admissions and is associated with long survival. So advanced age should not be considered as an exclusion criteria to prescribe NIV. (+info)