Exercise rehabilitation following intensive care unit discharge for recovery from critical illness

Background: Skeletal muscle wasting and weakness are significant complications of critical illness, associated with the degree of illness severity and periods of reduced mobility during mechanical ventilation. They contribute to the profound physical and functional deficits observed in survivors. These impairments may persist for many years following discharge from the intensive care unit (ICU) and may markedly influence health-related quality of life. Rehabilitation is a key strategy in the recovery of patients following critical illness. Exercise based interventions are aimed at targeting this muscle wasting and weakness. Physical rehabilitation delivered during ICU admission has been systematically evaluated and shown to be beneficial. However its effectiveness when initiated after ICU discharge has yet to be established. Objectives: To assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, on functional exercise capacity and health-related quality of life in adult ICU survivors who have been mechanically ventilated for more than 24 hours. Search methods:We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), OvidSP MEDLINE, Ovid SP EMBASE, and CINAHL via EBSCO host to 15th May 2014. We used a specific search strategy for each database. This included synonyms for ICU and critical illness, exercise training and rehabilitation. We searched the reference lists of included studies and contacted primary authors to obtain further information regarding potentially eligible studies. We also searched major clinical trials registries (Clinical Trials and Current Controlled Trials) and the personal libraries of the review authors. We applied no language or publication restriction. We reran the search in February 2015. We will deal with any studies of interest when we update the review.  Selection criteria:We included randomized controlled trials (RCTs), quasi-RCTs, and controlled clinical trials (CCTs) that compared an exercise interventioninitiated after ICU discharge to any other intervention or a control or ‘usual care’ programme in adult (≥18years) survivors ofcritical illness. Data collection and analysis:We used standard methodological procedures expected by The Cochrane Collaboration. Main results:We included six trials (483 adult ICU participants). Exercise-based interventions were delivered on the ward in two studies; both onthe ward and in the community in one study; and in the community in three studies. The duration of the intervention varied according to the length of stay in hospital following ICU discharge (up to a fixed duration of 12 weeks).Risk of bias was variable for all domains across all trials. High risk of bias was evident in all studies for performance bias, although blinding of participants and personnel in therapeutic rehabilitation trials can be pragmatically challenging. Low risk of bias was at least 50% for all other domains across all trials, although high risk of bias was present in one study for random sequence generation (selection bias), incomplete outcome data (attrition bias) and other sources. Risk of bias was unclear for remaining studies across the domains.All six studies measured effect on the primary outcome of functional exercise capacity, although there was wide variability in natureof intervention, outcome measures and associated metrics, and data reporting. Overall quality of the evidence was very low. Only two studies using the same outcome measure for functional exercise capacity, had the potential for pooling of data and assessment of heterogeneity. On statistical advice, this was considered inappropriate to perform this analysis and study findings were therefore qualitatively described. Individually, three studies reported positive results in favour of the intervention. A small benefit (versus. control)was evident in anaerobic threshold in one study (mean difference, MD (95% confidence interval, CI), 1.8 mlO2/kg/min (0.4 to 3.2),P value = 0.02), although this effect was short-term, and in a second study, both incremental (MD 4.7 (95% CI 1.69 to 7.75) Watts, P value = 0.003) and endurance (MD 4.12 (95% CI 0.68 to 7.56) minutes, P value = 0.021) exercise testing demonstrated improvement.Finally self-reported physical function increased significantly following a rehabilitation manual (P value = 0.006). Remaining studies found no effect of the intervention.Similar variability in with regard findings for the primary outcome of health-related quality of life were also evident. Only two studies evaluated this outcome. Following statistical advice, these data again were considered inappropriate for pooling to determine overall effect and assessment of heterogeneity. Qualitative description of findings was therefore undertaken. Individually, neither study reported differences between intervention and control groups for health-related quality of life as a result of the intervention. Overall quality of the evidence was very low.Mortality was reported by all studies, ranging from 0% to 18.8%. Only one non-mortality adverse event was reported across all patients in all studies (a minor musculoskeletal injury). Withdrawals, reported in four studies, ranged from 0% to 26.5% in control groups,and 8.2% to 27.6% in intervention groups. Loss to follow-up, reported in all studies, ranged from 0% to 14% in control groups, and 0% to 12.5% in intervention groups. Authors’ conclusions:We are unable, at this time, to determine an overall effect on functional exercise capacity, or health-related quality of life, of an exercise based intervention initiated after ICU discharge in survivors of critical illness. Meta-analysis of findings was not appropriate. This was due to insufficient study number and data. Individual study findings were inconsistent. Some studies reported a beneficial effect of the intervention on functional exercise capacity, and others not. No effect was reported on health-related quality of life. Methodological rigour was lacking across a number of domains influencing quality of the evidence. There was also wide variability in the characteristics of interventions, outcome measures and associated metrics, and data reporting.If further trials are identified, we may be able to determine the effect of exercise-based interventions following ICU discharge, on functional exercise capacity and health-related quality of life in survivors of critical illness.

Double-electron above threshold ionization of helium

We present calculations of intense-field multiphoton ionization processes in helium at XUV wavelengths. The calculations are obtained from a full-dimensional integration of the two-electron time-dependent Schrödinger equation. A momentum-space analysis of the ionizing two-electron wavepacket reveals the existence of double-electron above threshold ionization (DATI). In momentum-space two distinct forms of DATI are resolved, namely non-sequential and sequential. In non-sequential DATI correlated electrons resonantly absorb and share energy in integer units of Ïlaser.

Secondary threshold laws for multiple ionization of atoms

We propose a physical mechanism that leads to the emergence of secondary threshold laws in processes of multiple ionization of atoms. We argue that the removal of n electrons (n>2) from a many-electron atom may proceed via intermediate resonant states of the corresponding doubly charged ion. For atoms such as rare gases, the density of such resonances in the vicinity of subsequent ionization thresholds is high. As a result, the appearance energies for multiply charged ions are close to these thresholds, while the effective power indices mu in the near-threshold energy dependence of the cross section, sigmaproportional toE(mu), are lower compared to those from the Wannier theory. This provides a possible explanation of the recent experimental results of B. Gstir [Nucl. Instrum. Methods Phys. Res. B 205, 413 (2003)].

Electron-impact ionization of atomic hydrogen close to threshold

A systematic study of the ionization of atomic hydrogen by electron impact from 0.3 eV to a few eV above the ionization threshold has been carried out using a semiclassical-quantal calculation. Differential and integrated cross sections are presented at 0.3 eV above the energy threshold. Triple- differential cross sections (TDCS) are presented at constant theta(12) geometry where theta(12)=180degrees and 150degrees. Good agreement is achieved with the measurement [Roder, Phys. Rev. Lett. 79, 1666 (1997)] and calculations based on exterior complex scaling at 2 eV and 4 eV above threshold. Results of triple-differential cross sections are also presented at 0.3, 0.5, and 1.0 eV above threshold at both theta(12)=180degrees and 150degrees. At theta(12)=180degrees the small local maximum in the TDCS around theta(1)=90degrees reported by Pan and Starace [Phys. Rev. A 45, 4588 (1992)] at 0.5 eV above threshold is not observed in our calculation at energies down to 0.3 eV above threshold. The shape of our double differential cross sections seems to disagree qualitatively with the available calculations as we found two local maxima around 15degrees and 165degrees in our calculation. Single differential cross sections in our formulation appear naturally as a function of total excess energy E and, therefore, constant for all combinations of individual electron energies E-1 and E- 2 with E=E-1+E-2. Total ionization cross sections are also compared with measurement and available theoretical calculations and found to be in reasonably good agreement up to 10 eV above ionization threshold.

Semiclassical-quantal approach to the near-threshold ionization of hydrogen

A recent improved version of the semiclassical-quantal approach has been applied to the e(-)-H near-threshold ionization for theta (12) = 180 degrees geometry. It is found, that unlike other sophisticated theoretical methods such as distorted wave theory or convergent close-coupling calculation, the present relatively simpler approach produces correct behavior and numerical values for the triple-differential cross sections. We compare our results with recent absolute measurements and accurate numerical calculations at 2 eV and 4 eV above the threshold at constant theta (12) geometry.

Electron impact ionization of He above the threshold

Near-threshold ionization of He has been studied by using a uniform semiclassical wavefunction for the two outgoing electrons in the final channel. The quantum mechanical transition amplitude for the direct and exchange scattering derived earlier by using the Kohn variational principle has been used to calculate the triple differential cross sections. Contributions from singlets and triplets are critically examined near the threshold for coplanar asymmetric geometry with equal energy sharing by the two outgoing electrons. It is found that in general the tripler contribution is much smaller compared to its singlet counterpart. However, at unequal scattering angles such as theta (1) = 60 degrees, theta (2) = 120 degrees the smaller peaks in the triplet contribution enhance both primary and secondary TDCS peaks. Significant improvements of the primary peak in the TDCS are obtained for the singlet results both in symmetric and asymmetric geometry indicating the need to treat the classical action variables without any approximation. Convergence of these cross sections are also achieved against the higher partial waves. Present results are compared with absolute and relative measurements of Rosel et al (1992 Phys. Rev. A 46 2539) and Selles et al (1987 J. Phys. B. At. Mel. Phys. 20 5195) respectively.