Cees Lucas

Poor functional status immediately after discharge from an intensive care unit

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 prospective, 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 prospective studies focusing on functional recovery to support informed decision-making concerning the care of critically ill patients after ICU discharge.

Wound Healing in Cell Studies and Animal Model Experiments by Low Level Laser Therapy; Were Clinical Studies Justified? A Systematic Review

Based on results of cell studies and animal experiments, clinical trials with Low Level Laser Therapy (LLLT) were performed, which finally did not demonstrate a beneficial effect on outcome of wound healing. The aim of this study was to investigate whether the evidence from cell studies and animal experiments with respect to wound healing was unequivocally in favour of LLLT, which would imply that these models might be adequate to predict treatment response in patients, or that the data of cell studies and animal experiments were inconclusive, which would mean that the clinical trials were based on insufficient evidence. We performed a systematic review of cell studies and animal experiment with LLLT on wound healing. Manuscripts were identified by searching Medline, Embase, and SPIE (the International Society for Optical Engineering). We assessed whether studies showed a beneficial effect of active treatment or not. The effect size was expressed in standardised mean difference [(SMD) the mean outcome measure of the treatment group minus the mean outcome measure of the control group, divided by the pooled standard deviation of these measurements]. In-depth analyses were perfomed on (1) studies in which inflicted wounds on animals were irradiated and evaluated; (2) studies with primary outcome measures on dimensions with direct reference to wound healing (ranging from acceleration of wound closure to epithelialisation, but excluding surrogate dimensions with regard to wound healing; in this case: tensile strength); (3) animal studies with ‘true controls’; (4) studies in which animals functioned as their ‘own controls’ and (5) studies with the highest methodological quality score. The 36 included studies contained 49 outcome parameters of which 30 reported a positive effect of laser irradiation and 19 did not. Eleven studies presented exact data about the effect of active treatment and controls. The pooled effect size (SMD) over 22 outcome measures of these studies was −1.05 (95% CI: −1.67 to −0.43) in favour of LLLT. Methodological quality of the studies was poor. In-depth analysis of studies showed no significant pooled effect size in studies with highest methodological quality scores [0.06 (95% CI: −0.42 to 0.53)]. Summarising the data of cell studies and animal experiments, reviewed in this manuscript, these studies failed to show unequivocal evidence to substantiate the decision for trials with LLLT in a large number of patients. In fact, there were no differences between the results of these experiments and clinical studies. Remarkably, we found that (almost from the introduction on) animal experiments and clinical studies that adress the biological effects of LLLT on wound healing, ran simultaneously, rather than in sequence. We conclude that this type of phototherapy should not be considered a valuable (adjuvant) treatment for this selected, generally therapy-refractory condition in humans.

Body weight-supported gait training for restoration of walking in people with an incomplete spinal cord injury: A systematic review

OBJECTIVE To evaluate the effect of body weight-supported gait training on restoration of walking, activities of daily living, and quality of life in persons with an incomplete spinal cord injury by a systematic review of the literature. METHODS Cochrane, MEDLINE, EMBASE, CINAHL, PEDro, DocOnline were searched and identified studies were assessed for eligibility and methodological quality and described regarding population, training protocol, and effects on walking ability, activities of daily living and quality of life. A descriptive and quantitative synthesis was conducted. RESULTS Eighteen articles (17 studies) were included. Two randomized controlled trials showed that subjects with injuries of less than one year duration reached higher scores on the locomotor item of the Functional Independence Measure (range 1-7) in the over-ground training group compared with the body weight-supported treadmill training group. Only for persons with an American Spinal Injury Association Impairment Scale C or D was the mean difference significant, with 0.80 (95% confidence interval 0.04-1.56). No differences were found regarding walking velocity, activities of daily living or quality of life. CONCLUSION Subjects with subacute motor incomplete spinal cord injury reached a higher level of independent walking after over-ground training, compared with body weight-supported treadmill training. More randomized controlled trials are needed to clarify the effectiveness of body weight-supported gait training on walking, activities of daily living, and quality of life for subgroups of persons with an incomplete spinal cord injury.

Elevated levels of a soluble form of the T cell activation antigen CD27 in cerebrospinal fluid of multiple sclerosis patients

The expression of the T cell membrane molecule CD27--a molecule that has recently been shown to belong to the nerve growth factor receptor superfamily--is strongly increased after activation of T lymphocytes via the T cell receptor/CD3 complex. In addition, activated cells release a 28-32 kDa soluble form of CD27 in their supernatant which can also be detected in serum and urine of healthy individuals. In this study we show that levels of soluble (s) CD27 are significantly elevated in cerebrospinal fluid (CSF) of multiple sclerosis (MS) patients and of patients and of suffering from other inflammatory neurological diseases (OIND), whereas increased levels of sCD25 (soluble interleukin-2 receptor) were only found in CSF of patients with OIND. In MS patients, a significant correlation was found between CSF sCD27 titer and IgG index.

Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review

QUESTION What is the inter-rater reliability for measurements of passive physiological or accessory movements in upper extremity joints? DESIGN Systematic review of studies of inter-rater reliability. PARTICIPANTS Individuals with and without upper extremity disorders. OUTCOME MEASURES Range of motion and end-feel using methods feasible in clinical practice. RESULTS Twenty-one studies were included of which 11 demonstrated acceptable inter-rater reliability. Two studies satisfied all criteria for internal validity while reporting almost perfect reliability. Overall, the methodological quality of studies was poor. ICC ranged from 0.26 (95% CI -0.01 to 0.69) for measuring the physiological range of shoulder internal rotation using vision to 0.99 (95% CI 0.98 to 1.0) for the physiological range of finger and thumb flexion/extension using a goniometer. Measurements of physiological range of motion using instruments were more reliable than using vision. Measurements of physiological range of motion were also more reliable than measurements of end-feel or of accessory range of motion. CONCLUSIONS Inter-rater reliability for the measurement of passive movements of upper extremity joints varies with the method of measurement. In order to make reliable decisions about joint restrictions in clinical practice, we recommend that clinicians measure passive physiological range of motion using goniometers or inclinometers.

The effect of visual training for patients with visual field defects due to brain damage: a systematic review.

The objective of this review was to evaluate whether systematic visual training leads to (1) a restitution of the visual field (restoration), (2) an increase in the visual search field size or an improvement in scanning strategies (compensation) and (3) a transfer of training-related improvements in activities of daily living such as reading. To retrieve relevant publications, computer-aided searches of databases (Medline, Embase, Cinahl, Cochrane Central Registers of Controlled Trials) and extensive reference tracing and hand searching were performed. Subsequently, all retrieved and blinded studies were scored on methodological quality. 14 studies were included, 2 randomised controlled trials (RCTs) and 12 within-subject repeated-measures designs (RMD). One of the two RCT studies had good quality. The internal validity of the RMD studies varied from poor to good. Five studies reported a significant effect of the vision restoration therapy (VRT), whereas two studies reported no effect using scanning laser ophthalmoscopy or Goldmann perimetry as outcome measure. All authors of the studies on scanning compensatory therapy (SCT) found a significant effect of up to 30° visual search field, a significant increase in reading speed or decrease in reading errors. It is unclear to what extent patients benefit from restoration therapy in relation to a more efficient scanning strategy which enables them to read faster or to avoid obstacles in a better way. No study has given a satisfactory answer. SCT seems to provide a more successful rehabilitation with more simple and user-friendly training techniques. Validated questionnaires provide the most reliable subjective data to assess the transfer of the relevance of training procedures to activities of daily living of the patient. Hence, SCT is recommended until the effect of the VRT is defined.

Risk Factors for Meniscal Tears: A Systematic Review Including Meta-analysis

STUDY DESIGN Systematic review with meta-analysis. OBJECTIVES To review and critically appraise the literature for factors that increase the risk for meniscal tears. BACKGROUND Meniscal tears are an important cause of disability and time lost from work, and are associated with a 4-fold increase in the long-term risk of knee osteoarthritis. Knowledge of the risk factors that lead to meniscal tears can help to correctly diagnose knee injuries and is important to the development of prevention strategies for knee osteoarthritis. METHODS A search of the Cochrane Database of Systematic Reviews, MEDLINE, and Embase, from 1950 to January 2012, and a hand search of reference lists of all initially selected studies, without restriction on language or date of publication, were conducted. Prospective, retrospective, and case-control studies that included individuals over 16 years of age, who had no previous meniscal injuries or surgeries, were selected. A meta-analysis for 17 risk factors was performed. Where considerable heterogeneity among studies was present or the data did not provide sufficient information to perform a meta-analysis, a qualitative synthesis was conducted. RESULTS Eleven studies, with a total of 7358 participants, were selected for systematic review. Data were available for meta-analysis for 10 of the 11 studies. Qualitative analysis was conducted using data from 3 of the 11 studies. Results showed strong evidence that age (older than 60 years), gender (male), work-related kneeling and squatting, and climbing stairs (greater than 30 flights) were risk factors for degenerative meniscal tears. We also found strong evidence that playing soccer and playing rugby were strong risk factors for acute meniscal tears. Waiting longer than 12 months between the anterior cruciate ligament injury and reconstructive surgery was a strong risk factor for a medial meniscal tear but not for a lateral meniscal tear. CONCLUSION The literature indicates a number of risk factors leading to either degenerative or acute meniscal tears, with some of these factors being potentially modifiable. LEVEL OF EVIDENCE Prognosis, level 2a.

Inter-rater reliability for measurement of passive physiological movements in lower extremity joints is generally low: a systematic review

QUESTION What is the inter-rater reliability for measurements of passive physiological or accessory movements in lower extremity joints? DESIGN Systematic review of studies of inter-rater reliability. PARTICIPANTS Individuals with and without lower extremity disorders. OUTCOME MEASURES Range of motion and end-feel using methods feasible in daily practice. RESULTS 17 studies were included of which 5 demonstrated acceptable inter-rater reliability. Reliability of measurements of physiological range of motion ranged from Kappa -0.02 for measuring knee extension using a goniometer to ICC 0.97 for measuring knee flexion using vision. Measuring range of knee flexion consistently yielded acceptable reliability using either vision or instruments. Measurements of end-feel were unreliable for all hip and knee movements. Two studies satisfied all criteria for internal validity while reporting acceptable reliability for measuring physiological range of knee flexion and extension. Overall,however, methodological quality of included studies was poor. CONCLUSION Inter-rater reliability of measurement of passive movements in lower extremity joints is generally low. We provide specific recommendations for the conduct and reporting of future research. Awaiting new evidence, clinicians should be cautious when relying on results from measurements of passive movements in joints for making decisions about patients with lower extremity disorders.

Early Wound Complications After Inguinal Lymphadenectomy in Penile Cancer: A Historical Cohort Study and Risk-factor Analysis

BACKGROUND Complication rates after inguinal lymph node dissection (ILND) are high. Risk factors for early wound complications after ILND in patients with penile carcinoma have not yet been studied. OBJECTIVES To assess the frequency of early wound complications in a contemporary series and to identify clinical risk factors for early wound complications after ILND for penile carcinoma. DESIGN, SETTING, AND PARTICIPANTS We evaluated 237 ILNDs in 163 patients with penile cancer treated between 2003 and 2012 at the Netherlands Cancer Institute. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We assessed the occurrence of wound infection, skin-flap problems, and seroma formation and graded complications using the modified Clavien system. Univariable and multivariable penalised mixed effects logistic regression was used to identify clinical risk factors for occurrence of any complication (grade ≥ 1) and of moderate to severe complications (grade ≥ 2). RESULTS AND LIMITATIONS One complication or more occurred in 58% of the procedures, and 10% of those complications were severe. Wound infection occurred in 43%, seroma formation occurred in 24%, and skin-flap problems occurred in 16%. Palpable disease was the only factor associated with grade ≥ 1 complications in the univariable analysis (odds ratio [OR]: 0.43; p=0.02). In the multivariable model, after penalisation, no statistically significant risk factors remained. Univariable associations for grade ≥ 2 complications were present for body mass index (BMI; OR of 1.66 for a 5.8-point change in BMI; p=0.05) and sartorius muscle transposition (OR: 2.64; p=0.04). In the reduced multivariable model, the OR for sartorius muscle transposition was 2.12 (p=0.06) and for BMI was 1.76 (p=0.03). In addition, bilateral dissection approached significance in the multivariable model (OR: 2.17; p=0.06). This study is limited by its observational nature. CONCLUSIONS Wound complication rates after ILND are high in this cohort. BMI, sartorius muscle transposition, and bilateral dissection were the factors most strongly associated with the occurrence of grade ≥ 2 wound complications.

Obesity: a systematic review on parental involvement in long-term European childhood weight control interventions with a nutritional focus

In Europe, about 20% of children are overweight. Focus on parental responsibility is an effective method in weight control interventions in children. In this systematic review we describe the intensity of parental involvement and behaviour change aimed at parents in long‐term European childhood weight control interventions. We include European Union studies targeting parents in order to improve childrens weight status in multi‐component (parental, behaviour change and nutrition) health promotion or lifestyle interventions. The included studies have at least one objectively measured anthropometric outcome in the weight status of the child. Parental involvement was described and categorized based on the intensity of parental involvement and coded using a validated behaviour change taxonomy specific to childhood obesity. Twenty‐four studies were analysed. In effective long‐term treatment studies, medium and high intensity parental involvement were identified most frequently; whereas in prevention studies low intensity parental involvement was identified most frequently. Parenting skills, generic and specific to lifestyle behaviour, scored frequently in effective weight control interventions. To list parental skills in generic and specific to lifestyle, descriptions of the included studies were summarized. We conclude that intensity of parental involvement and behaviour change techniques are important issues in the effectiveness of long‐term childhood weight control interventions.