Search

BackgroundLong-term cognitive impairment occurs in up to 60% of intensive care unit (ICU) survivors. Early use of functional and cognitive rehabilitation interventions, while patients are still in ICU, may reduce cognitive decline. We aim to describe the functional and cognitive interventions used during the ICU stay, the healthcare professionals providing interventions, and the potential impact on functional and cognitive rehabilitation.MethodIn this integrative systematic review, we will include empirical qualitative, quantitative, mixed- and multiple-methods studies assessing the use of functional and cognitive rehabilitation provided in ICU. We will identify studies in relevant electronic databases from 2012 to 2022, which will be screened for eligibility by at least two reviewers. Literature reported as narrative reviews and editorials will be excluded. We will assess the impact of interventions evaluating a cognitive and functional function, quality of life, and all-cause mortality at 6–12 months after ICU discharge. The Revised Cochrane risk-of-bias Tool will be used for assessing risk of bias in clinical trials. For observational studies, we will use the National Institutes of Health Quality Assessment tool for Observational Cohort and Cross-Sectional Studies. Furthermore, we will use the critical appraisal skills programme for qualitative studies and the mixed methods appraisal tool for mixed methods studies. We will construct four matrices, including results describing which ICU patients and healthcare professionals were engaged in rehabilitation, which interventions were included in early rehabilitation in ICU, the potential impact on patient outcomes of rehabilitation interventions provided in ICU and a narrative synthesis of themes. A summary of the main results will be reported using modified GRADE methodology.ImpactThis integrative review will inform the feasibility randomised clinical trial testing the development of a complex intervention targeting functional and cognitive rehabilitation for patients in ICU. Background: Long-term cognitive impairment occurs in up to 60% of intensive care unit (ICU) survivors. Early use of functional and cognitive rehabilitation interventions, while patients are still in ICU, may reduce cognitive decline. We aim to describe the functional and cognitive interventions used during the ICU stay, the healthcare professionals providing interventions, and the potential impact on functional and cognitive rehabilitation. Method: In this integrative systematic review, we will include empirical qualitative, quantitative, mixed- and multiple-methods studies assessing the use of functional and cognitive rehabilitation provided in ICU. We will identify studies in relevant electronic databases from 2012 to 2022, which will be screened for eligibility by at least two reviewers. Literature reported as narrative reviews and editorials will be excluded. We will assess the impact of interventions evaluating a cognitive and functional function, quality of life, and all-cause mortality at 6–12 months after ICU discharge. The Revised Cochrane risk-of-bias Tool will be used for assessing risk of bias in clinical trials. For observational studies, we will use the National Institutes of Health Quality Assessment tool for Observational Cohort and Cross-Sectional Studies. Furthermore, we will use the critical appraisal skills programme for qualitative studies and the mixed methods appraisal tool for mixed methods studies. We will construct four matrices, including results describing which ICU patients and healthcare professionals were engaged in rehabilitation, which interventions were included in early rehabilitation in ICU, the potential impact on patient outcomes of rehabilitation interventions provided in ICU and a narrative synthesis of themes. A summary of the main results will be reported using modified GRADE methodology. Impact: This integrative review will inform the feasibility randomised clinical trial testing the development of a complex intervention targeting functional and cognitive rehabilitation for patients in ICU.

Background: Long-term follow-up studies of COVID-19 olfactory and gustatory disorders (OGDs) are scarce. OGD, parosmia, and dysgeusia affect health-related quality of life (HRQoL) and the ability to detect potential hazards. Methods: In this study, 29 patients reporting OGD 1 month after severe-to-critical COVID-19 were tested at 3–6 months and retested at 12 months in case of hyposmia/anosmia. We used Sniffin Sticks Threshold, Discrimination, and Identification (TDI) test, Sniffin Sticks Identification Test (SIT16), Brief Smell Identification Test (BSIT), taste strips, and HRQoL. The patients were part of the prospective SECURe cohort. Results: Overall, 28% OD (TDI), 12% GD, 24% parosmia, and 24% dysgeusia (questionnaire) at 3–6 months (n = 29) and 28% OD (TDI), 38% parosmia, and 25% dysgeusia (questionnaire) at 12 months (n = 8) were observed. OGD decreased HRQoL: For 13%, it had a negative effect on daily life and, for 17%, it affected nutrition, 17% reported decreased mood, and 87–90% felt unable to navigate everyday life using their sense of smell and taste. A comparison of SIT16 and BSIT to TDI found sensitivity/specificity values of 75%/100% and 88%/86%. Conclusions: This is the first study to examine TDI, SIT16, BSIT, taste strips, and HRQoL up to 1 year after severe-to-critical COVID-19. The patients suffering from prolonged OGD, parosmia, and dysgeusia experienced severely decreasing HRQoL. We recommend including ear–nose–throat specialists in multidisciplinary post-COVID clinics.

A large proportion of patients exhibit persistently reduced pulmonary diffusion capacity after COVID-19. It is unknown whether this is due to a post-COVID restrictive lung disease and/or pulmonary vascular disease. The aim of the current study was to investigate the association between initial COVID-19 severity and haemoglobin-corrected diffusion capacity to carbon monoxide (DLco) reduction at follow-up. Furthermore, to analyse if DLco reduction could be linked to pulmonary fibrosis (PF) and/or thromboembolic disease within the first months after the illness, a total of 67 patients diagnosed with COVID-19 from March to December 2020 were included across three severity groups: 12 not admitted to hospital (Group I), 40 admitted to hospital without intensive care unit (ICU) admission (Group II), and 15 admitted to hospital with ICU admission (Group III). At first follow-up, 5 months post SARS-CoV-2 positive testing/4 months after discharge, lung function testing, including DLco, high-resolution CT chest scan (HRCT) and ventilation-perfusion (VQ) single photon emission computed tomography (SPECT)/CT were conducted. DLco was reduced in 42% of the patients; the prevalence and extent depended on the clinical severity group and was typically observed as part of a restrictive pattern with reduced total lung capacity. Reduced DLco was associated with the extent of ground-glass opacification and signs of PF on HRCT, but not with mismatched perfusion defects on VQ SPECT/CT. The severity-dependent decline in DLco observed early after COVID-19 appears to be caused by restrictive and not pulmonary vascular disease.

Background Health professionals’ attitudes towards addressing sexual health are important to promote patients’ sexual health. Therefore, measurement of health professionals’ attitudes towards addressing sexual health is essential. Aim This study aimed to adapt the questionnaire Students’ Attitudes towards Addressing Sexual Health (SA-SH-D) to health professionals working with rehabilitation in Danish municipalities and evaluated psychometric properties of the adapted questionnaire: The Danish Version of the Professionals’ Attitudes towards Addressing Sexual Health (PA-SH-D). Methods The SA-SH-D was adapted to PA-SH-D and a face validity evaluation focusing on phrasing, functionality, perception and relevance was done. In a pilot study, the PA-SH-D was answered by health professionals and internal consistency reliability and floor and ceiling effects were evaluated. Outcomes Face validity included phrasing, functionality, perception and relevance of the items in PA-SH-D, internal consistency with Cronbach's alpha in the total scale and floor and ceiling effects. Results Face validity of the PA-SH-D was acceptable. The sample size was 52 health professionals working with rehabilitation, the internal consistency reliability (Cronbach's alpha: 0.89 [lower confidence interval {CI}: 0.85]) and floor and ceiling effects (0.0%–13.7%) of the PA-SH-D were acceptable. Clinical translation As sexual health is important in human quality of life, the validation of the PA-SH-D is highly valuable as it evaluates health professionals’ attitudes towards addressing sexual health, and thereby is able to measure the need for education and training in sexual health and detect changes in attitudes following an educational intervention. Strengths and limitations Strengths were that the PA-SH-D measures both attitudes and competences and covered a need in clinical practice. The recruitment was broad and we used the work of others to orient this work. Limitations were that this study covered a preliminary psychometric evaluation and a thorough evaluation covering other aspects of psychometry should be done. We used both paper-based and online-based survey which possibly could cause bias. The study had a relatively small sample size. Comparing health professionals to students can be seen as both a limitation and a strength. Conclusion The results in face validity and internal consistency reliability indicate usefulness of the PA-SH-D to measure health professionals’ attitudes towards addressing sexual health. Further evaluation of psychometric properties of the PA-SH-D is recommended.

Background. Multidisciplinary rehabilitation including occupational therapy after COVID-19 is recommended. However, evidence on how COVID-19 affects the ability to perform activities of daily living (ADL) is sparse. Objective. The aim of this study was to explore the ability to perform ADL and cognitive status in patients with COVID-19 at time of discharge and three months postdischarge. Methods. This prospective multiple case study included adults with COVID-19, who at time of discharge had decreased ADL performance compared to habitual functional level. Data collection included Assessment of Motor and Process Skills (AMPS) and Montreal Cognitive Assessment (MoCA) at discharge and three-month follow-up. Exploratory analysis was used to identify similarities and trends within and across cases. Results. Eleven patients were included. 75% had a significant increase in motor ability measures, and 27% had a significant increase in process ability measures at follow-up. 67% of follow-up cases showed mild cognitive impairment, where executive functioning and memory were most predominant. Conclusions. The ability to perform ADL was affected at discharge and at three-month follow-up. Furthermore, mild cognitive impairment was present at both hospital discharge and follow-up in most cases. Significance. Occupational therapists can apply performance-based assessments to identify the need for rehabilitation of ADL in patients with COVID-19 during and posthospitalization.

AimThe aim of this systematic review was to assess the effectiveness of rehabilitation interventions on the secondary physical, neurological and psychological consequences of cardiac arrest (CA) for adult survivors.MethodsA literature search of electronic databases (MEDLINE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica database, Psychological Information Database, Web of Science and Cochrane Central Register of Controlled trials) was conducted for randomised controlled trials (RCTs) and observational studies up to 18 April 2021. The primary outcome was health-related quality of life (HRQoL) and main secondary outcome was neurological function with additional secondary outcomes being survival, rehospitalisation, safety (serious and non-serious adverse events), psychological well-being, fatigue, exercise capacity and physical capacity. Two authors independently screened studies for eligibility, extracted data and assessed risk of bias.ResultsThree RCTs and 11 observational studies were included (total 721 participants). Study duration ranged from 8 weeks to 2 years. Pooled data from two RCTs showed low-quality evidence for no effect on physical HRQoL (standardised mean difference (SMD) 0.19, (95% CI: −0.09 to 0.47)) and no effect on mental HRQoL (SMD 0.27 (95% CI: −0.01 to 0.55)).Regarding secondary outcomes, very low-quality evidence was found for improvement in neurological function associated with inpatient rehabilitation for CA survivors with acquired brain injury (SMD 0.71, (95% CI: 0.45 to 0.96)) from five observational studies. Two small observational studies found exercise-based rehabilitation interventions to be safe for CA survivors, reporting no serious or non-serious events.ConclusionsGiven the overall low quality of evidence, this review cannot determine the effectiveness of rehabilitation interventions for CA survivors on HRQoL, neurological function or other included outcomes, and recommend further high-quality studies be conducted. In the interim, existing clinical guidelines on rehabilitation provision after CA should be followed to meet the high burden of secondary consequences suffered by CA survivors.PROSPERO registration numberCRD42018110129.

Background One in four older adults in Denmark and almost half of the very old above 75 do not meet the World Health Organization’s recommendations for a minimum of physical activity (PA). A cost-efficient and effective way to increase focus on and motivation for daily walking might be to use Physical Activity Monitors (PAMs) in combination with behavioural change intervention. Thus, the objective of this randomized controlled study was to investigate the effect of Motivational Interviewing (MI) as an add-on intervention to a PAM-based intervention measured in community-dwelling older adults. Methods This two-arm parallel group randomized controlled effectiveness trial compared a 12-weeks PAM-based intervention with additional MI (PAM+MI group) with a PAM-based intervention alone (PAM group). The primary outcome, average daily step count, was analysed with a linear regression model, adjusted for sex and baseline daily step count. Following the intention-to-treat principle, multiple imputation based on baseline step count, sex and age was performed. Results In total, 38 participants were randomized to the PAM intervention and 32 to the PAM+MI intervention arm. During the intervention period, PAM+MI participants walked on average 909 more steps per day than PAM participants, however insignificant (95%CI: − 71; 1889) and reported 2.3 points less on the UCLA Loneliness Scale (95%CI: − 4.5; − 1.24). Conclusion The use of MI, in addition to a PAM-based intervention among older adults in PA promoting interventions hold a potential clinically relevant effect on physical activity and should thus be investigated further with adequately powered RCTs. Trial registration This study was pre-registered in the clinicaltrials.gov database with identifier: NCT03906162.

Study design: Cross-sectional study design. Background: Cardiopulmonary exercise testing (CPET) using the upper-body is an alternative to standardised CPET. A variety of test protocols has been developed for CPET performed on an arm crank for individuals with lower limb disabilities. However, no test protocol specifically designed to evaluate exercise capacity in younger adults with lower limb amputees is available. Objective: To determine test–retest reliability of VO2peak, watts, test time and max heart rate for an upper-body CPET. Methods: Males with unilateral lower limb amputation at crus-level or above, aged 18–40 years, without comorbidities preventing arm cycling were eligible. Participants completed three maximal tests with a minimum of two days between tests and maximum 14 days between the first and third test. Results: Eight participants volunteered to participate and were tested three times. Excellent and acceptable ICC values were found for power in Watts (ICC = 0.73) and test time (ICC = 0.74). Good but non-acceptable test–retest reliability was found for VO2peak (ICC = 0.51) and max heart rate (ICC = 0.64) for all three test sessions. Conclusions: Upper-body CPET shows acceptable test–retest reliability for Watts and test time in younger adult lower limb amputees, but non-acceptable reliability for VO2peak and heart rate.

Study design: A retrospective review of medical records. Objective: The objective of this study was to examine probability of survival after 90- and 180-days after surgery, to document the rehabilitation needs, patients discharge destination, and whether discharge destination, re-admission, and probability of survival among patients with metastatic spinal cord compression (MSCC) were associated with potential risk factors. Setting: Copenhagen University Hospital, Rigshospitalet that serves a population of 2.8 million people from the Eastern part of Denmark, Faroe Islands, and Greenland. Methods: Adult (≥18 years) patients with MSCC undergoing surgery in 2017–2018 were included. Descriptive statistics were used to investigate the probability of survival after 90- and 180-days, rehabilitation needs documented in the patient’s medical record, and discharge destination. Univariate logistic regression analyses were used to examine the associations between a priory defined potential risk factors for mortality and readmission. Results: Seventy-four medical records were included in final analysis. The probability of survival after 90- and 180-days post-surgery were 78% and 57%, respectively. Higher age was the only defined variable that was significantly associated with higher mortality. Ninety-three percent of the patient’s medical records described rehabilitation potential, but only 44.6% of the patients were discharged with a rehabilitation plan. Seventy-three percent of the patients were discharged to their home. None had a specialized rehabilitation plan. Conclusion: Almost all patients diagnosed with MSCC have a rehabilitation potential described in their medical records. However, only half of these patients are discharged with a rehabilitation plan indicating an unmet potential for rehabilitation.

Aims Infective endocarditis is a complex and highly mortal disease requiring lengthy treatment. Physical and mental deconditioning is common. Nonetheless, rehabilitation is virtually unexplored in this population. The aim of this trial was therefore to investigate the effects of cardiac rehabilitation in patients following endocarditis. Methods and results In a randomized trial, adults with left-sided or cardiac device endocarditis were randomized 1:1 to 12 weeks of physical exercise training and five psycho-educational consultations (cardiac rehabilitation) vs. usual care without rehabilitation (control). Primary outcome was mental health measured by SF-36 Mental Component Summary (MCS) at 6 months. Secondary outcome was physical capacity measured by peak oxygen uptake (VO2) at 4 months. Exploratory outcomes were investigated. Low inclusion rate resulted in trial termination before reaching the target sample size. A total of 117 participants (mean age: 60 years, 81% male) were randomized to cardiac rehabilitation (n = 58) or to control (n = 59). Mental health and physical capacity at baseline were generally poor (MCS: 38.9–42.2 points, VO2 peak: 16.1–16.6 mL/kg/min). Cardiac rehabilitation compared with control showed no effect on mental health (MCS: 44.6 points vs. 48.8 points, P = 0.41) or physical capacity (VO2 peak: 19.9 mL/kg/min vs. 18.0 mL/kg/min, P = 0.09). Effects favouring the intervention were identified in exploratory outcomes including general fatigue (P = 0.005), and physical capacity as maximal power (W) (P = 0.005). Adherence to the intervention was 28%. Conclusions Results indicate no effect of cardiac rehabilitation in patients following endocarditis; however, lack of statistical power and poor adherence render findings inconclusive. Valuable insight into patients’ capabilities and safety was gained, and further investigations into rehabilitation needs and modes of delivery in this high-need population should be a future priority. Registration The trial is registered at ClinicalTrials.gov, NCT01512615

Background: Patient participation in treatment and care is often encouraged and is desirable because of its proven positive impact on treatment, quality of care and patient safety. Aims: To develop an instrument to measure patient participation in health care and to investigate the measurement properties of the Patient Participation Questionnaire (PPQ). Methods: A literature review was conducted to develop a model of patient participation. The PPQ was constructed consisting of 17 items organized into four subscales. Psychometric evaluation of factor structure, convergent construct validity by hypothesis testing and analyses of internal consistency using Cronbach’s alpha were performed on data from a hospitalised mixed group of patients with cardiac disease, pulmonary disease and cancer ( N=378 patients). Results: Confirmatory factor analysis did not show a clear model fit, which is why an exploratory factor analysis was performed, suggesting a different four subscale structure consisting of a total of 16 items. The four subscales were labelled Shared decision power, Adapted and individualized knowledge, Collaboration and Human approach. There were strong ceiling effects on all items. Analysis of convergent construct validity showed a moderate correlation (0.59) between the PPQ and another instrument measuring patient participation. Internal consistency for the total PPQ score was high: 0.89. Conclusion: In a mixed group of patients with cardiac disease, pulmonary disease and cancer, the PPQ showed promising psychometric properties in terms of factor structure, convergent construct validity and internal consistency. The PPQ may be used to shed light on the experience of patient participation and guide quality improvements.

Purpose: Exercise-based cardiac rehabilitation improves physical performance and health-related quality of life (HRQoL). However, whether improvements in physical performance are associated with changes in HRQoL has not been adequately investigated in a nonischemic cardiac population. Methods: Patients who were ablated for atrial fibrillation, who underwent heart valve surgery or who were treated for infective endocarditis, and who participated in 1 of 3 randomized controlled rehabilitation trials were eligible for the current study. Change in physical performance and HRQoL were measured before and after a 12-wk exercise intervention. Physical performance was assessed using a cardiopulmonary exercise test, a 6-min walk test, and a sit-to-stand test. Health-related quality of life was assessed using the generic 36-Item Short Form Health Survey and the disease-specific HeartQoL questionnaire. Spearman correlation coefficient (ρ) and linear regressions quantified the association between changes in physical outcome measures and changes in HRQoL. Results: A total of 344 patients were included (mean age: 60.8 ± 11.6 yr and 77% males). Associations between changes in physical outcome measures and HRQoL ranged from very weak to weak (ρ = -0.056 to 0.228). The observed associations were more dominant within physical dimensions of the HRQoL compared with mental or emotional dimensions. After adjusting for sex, age, and diagnosis, changes in physical performance explained no more than 20% of the variation in the HRQoL. Conclusion: The findings show that the positive improvement in HRQoL from exercise-based cardiac rehabilitation cannot simply be explained by an improvement in physical performance.

Background: Previously published studies have reported injury rates ranging from 0.74 to 3.3 per 1000 h of exposure in CrossFit participants. However, the existing body of evidence is mainly based on experienced participants, therefore, the injury incidence and injury rate within novice CrossFit participants remains relatively unknown. The aim of this study wasto investigate the injury incidence and injury rate among novice participants in an eight-week CrossFit program. Methods: This survey-based prospective cohort study included CrossFit Copenhagen&rsquo, s novice members who began an eight-week, free-of-charge membership period. A questionnaire was distributed at baseline and at eight-week follow-up. Information about exposure was retrieved through the online booking system. Injury incidence, defined as proportion of participants who sustained an injury, and injury rates per 1000 h of exposure were calculated. Results: Among the 168 included participants, a total of 28 injuries (14.9%) were reported. The number of injured participants and total exposure time resulted in an injury rate per 1000 h of exposure of 9.5. Conclusions: Compared to the existing body of evidence, the findings in this study indicate that the risk of injuries is higher among novice participants than among experienced CrossFit participants.

Background Few studies have investigated the measurement properties of consumer-grade physical activity monitors (PAMs) in older adults. Therefore, we investigated the criterion validity of consumer-grade PAMs in older adults and whether the measurement properties differed between older adults with and without rollators and whether worn on the hip or at the wrist. Methods Consumer-grade PAMs were eligible for inclusion in this study if they: 1) could be fastened at the hip as well as on the wrist, 2) were simple in function and design and thus easy to use for participants with minimal technical skills, 3) included step-counting as outcome measure and 4) were powered by a button cell battery. Participants performed self-paced walking for six minutes while two physiotherapists counted their steps with a click-counter. The average of the two counts was used as criterion. The participants wore 16 monitors, four located bilaterally on both hips and wrists. Our prior expectation was that all monitors would have at least moderate criterion validity for all participants, good criterion validity for participants walking without a rollator and poor criterion validity for participants walking with a rollator. Results Four physical activity monitors were included in this study; Misfit Shine, Nokia GO, Jawbone UP Move and Garmin Vivofit 3. A total of 103 older adults participated. Nokia GO was excluded from this study due to technical issues. Therefore, we present results on the frequency of data loss, ICC (1, 2) and percentage measurement error for Misfit Shine, Garmin Vivofit 3 and Jawbone UP Move located on four different positions. Conclusions The hip-worn PAMs did not differ significantly in terms of measurement error or criterion validity. Wrist-worn monitors cannot adequately measure number of steps in a population of older adults using rollators. The hip-worn PAMs were superior to wrist-worn PAMs among older adults with and without rollators.

ObjectiveTo estimate the effectiveness of physical activity monitor (PAM) based interventions among adults and explore reasons for the heterogeneity.DesignSystematic review and meta-analysis.Study selectionThe electronic databases MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched on 4 June 2021. Eligible randomised controlled trials compared interventions in which adults received feedback from PAMs with control interventions in which no feedback was provided. No restrictions on type of outcome measurement, publication date, or language were applied.Data extraction and synthesisTwo reviewers independently extracted data and assessed risk of bias. Random effects meta-analyses were used to synthesise the results. The certainty of evidence was rated by the Grading of Recommendations Assessment and Evaluation (GRADE) approach.Main outcome measuresThe three primary outcomes of interest were physical activity, moderate to vigorous physical activity, and sedentary time.Results121 randomised controlled trials with 141 study comparisons, including 16 743 participants, were included. The PAM based interventions showed a moderate effect (standardised mean difference 0.42, 95% confidence interval 0.28 to 0.55) on physical activity, equivalent to 1235 daily steps; a small effect (0.23, 0.16 to 0.30) on moderate to vigorous physical activity, equivalent to 48.5 weekly minutes; and a small insignificant effect (−0.12, −0.25 to 0.01) on sedentary time, equal to 9.9 daily minutes. All outcomes favoured the PAM interventions.ConclusionsThe certainty of evidence was low for the effect of PAM based interventions on physical activity and moderate for moderate to vigorous physical activity and sedentary time. PAM based interventions are safe and effectively increase physical activity and moderate to vigorous physical activity. The effect on physical activity and moderate to vigorous physical activity is well established but might be overestimated owing to publication bias.Study registrationPROSPERO CRD42018102719.

Objective: To review the evidence concerning the effects of postoperative exercise interventions on exercise capacity and health-related quality of life following resection for non-small cell lung cancer, and to review whether different initiation times of exercise produce different effects on exercise capacity. Data sources: Comprehensive literature search of MEDLINE, Embase, CENTRAL, CINAHL and PEDro. Study selection: Randomized controlled trials examining the effects of exercise interventions were eligible for inclusion. Data extraction: Postoperative outcome measurements were extracted and the quality of evidence was graded using Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group. Data synthesis: Four randomized controlled trials were identified involving 262 participants. Short-term follow-up (12–20 weeks) showed significantly higher exercise capacity and physical component of health-related quality of life in the intervention group (standardized mean difference (SMD) 0.48; 95% confidence interval (CI) 0.04–0.93) compared with the control group (SMD 0.50; 95% CI 0.19–0.82). There was no difference between the effect of late- and early-initiated exercise intervention. Conclusion: Exercise has a small-to-moderate effect at short-term follow-up on exercise capacity and the physical component of health-related quality of life in patients operated for lung cancer. The long-term effects of exercise capacity are unknown. Early-initiated exercise programmes (2 weeks post-operation) did not show an effect on exercise capacity. These findings should be interpreted with caution.

Contribution of both B cell intrinsic alterations as well as non-hematopoietic derived factors in the enhanced immune response of the NOD mouse

Background Physical Activity Monitors (PAMs) have been shown to effectively enhance level of physical activity (PA) in older adults. Motivational interviewing is a person-centred model where participants are guided using self-reflection and counselling, and addresses the behavioural and psychological aspects of why people initiate health behaviour change by prompting increases in motivation and self-efficacy. The addition of motivational interviewing to PA interventions may increase the effectiveness of PAMs for older adults. Methods This motivational interviewing and PA monitoring trial is designed as an investigator-blinded, two arm parallel group, randomized controlled superiority trial with primary endpoint after 12 weeks of intervention. The intervention group will receive a PAM-based intervention and motivational interviewing and the control group will only receive the PAM-based intervention. The primary outcome is PA, objectively measured as the average daily number of steps throughout the intervention period. Secondary outcome measures include self-reported PA health-related quality of life, loneliness, self-efficacy for exercise, outcome expectancy for exercise, and social relations. The outcomes will be analysed with a linear regression model investigating between-group differences, adjusted for baseline scores. Following the intention to treat principle, multiple imputation will be performed to handle missing values. Discussion A moderate effect of daily PA measured using PAMs is expected in this superiority RCT investigating the effect of adding motivational interviewing to a PAM intervention. According to the World Health Organization, walking and cycling are key activities in regular PA and should be promoted. To increase the general public health and lower the burden of inactivity in older adults, cost-beneficial solutions should be investigated further. If this RCT shows that motivational interviewing can enhance the effect of PAM-based interventions, it might be included as an add-on intervention when appropriate. No matter what the results of this study will be, the conclusions will be relevant for clinicians as the dependence on technology is increasing, especially in relation to public health promotion. Trial registration NCT03906162, April 1, 2019.

Objectives To investigate use of data from a clinical quality registry for cardiac rehabilitation in Denmark, considering the extent to which data are used for local quality improvement and what facilitates the use of these data, with a particular focus on whether there are differences between frontline staff and managers. Design Cross-sectional nationwide survey study. Setting, methods and participants A previously validated, Swedish questionnaire regarding use of data from clinical quality registries was translated and emailed to frontline staff, mid-level managers and heads of departments (n=175) in all 30 hospital departments participating in the Danish Cardiac Rehabilitation Database. Data were analysed descriptively and through multiple linear regression. Results Survey response rate was 58% (101/175). Reports of registry use at department level (measured through an index comprising seven items; score min 0, max 7, where a low score indicates less use of data) varied significantly between groups of respondents: frontline staff mean score 1.3 (SD=2.0), mid-level management mean 2.4 (SD=2.3) and heads of departments mean 3.0 (SD=2.5), p=0.006. Overall, department level use of data was positively associated with higher perceived data quality and usefulness (regression coefficient=0.22, p=0.019), management request for data (regression coefficient=0.40, p=0.008) and personal motivation of the respondent (regression coefficient=1.63, pamp;lt;0.001). Among managers, use of registry data was associated with data quality and usefulness (regression coefficient=0.43, p=0.027), and among frontline staff, reported data use was associated with management involvement in quality improvement work (regression coefficient=0.90, p=0.017) and personal motivation (regression coefficient=1.66, pamp;lt;0.001). Conclusions The findings suggest relatively sparse use of data in local quality improvement work. A complex interplay of factors seem to be associated with data use with varying aspects being of importance for frontline staff and managers. Funding Agencies|Unit for Production, Research and Innovation, Region Zealand; Department of Medicine, Holbaek University Hospital; Danish Knowledge Centre for Rehabilitation and Palliative Care, University of Southern Denmark; Odense University Hospital, Southern Region of Denmark; Region Zealand Regional Research Fund

Objective The use of physical activity monitors (PAMs) in the adult population is increasing rapidly and previous systematic reviews are outdated. The objective of this systematic review and meta-analysis is to estimate the effect of PAM-based interventions on physical activity behavior in adults. Furthermore, the impact of intervention, study, and participants characteristics will be investigated. Methods and design Randomized controlled trials and randomized cross-over trials including adult participants will be included if the study compares any PAM-based intervention where the participants receive feedback on their physical activity level measured by PAMs, to control interventions where participants do not receive feedback from PAMs. This protocol is detailed according to the recommendations of the Cochrane Handbook, and it is reported according to the preferred reporting items for systematic reviews and meta-analyses protocols statement. The results from the literature search will be presented in a PRISMA flow chart. The effects from individual studies will be summarized in a random effects meta-analysis and the impact of diagnosis of the participants, type of feedback, type of intervention, and control intervention will be investigated in stratified meta-analysis and meta-regressions analysis. The results on daily physical activity, moderate to vigorous physical activity, sedentary time, and adverse events will be presented in a summary of findings table. Discussion The results will be useful to researchers, policy makers, and health care professionals when the intention is to increase physical activity in the adult population. PROSPERO registration CRD42018102719 Electronic supplementary material The online version of this article (10.1186/s13643-019-0970-3) contains supplementary material, which is available to authorized users.

Purpose: Most veterans live for many years after their war-related traumatic lower-limb amputation, which is why understanding which factors influence health-related quality of life (HRQoL) remains important to their long-term management. The objective of this study was to perform a review of the literature to summarize any evidence on the physical and social determinants for HRQoL in veterans with uni- or bilateral lower-limb amputation(s). Method: MEDLINE, EMBASE, PEDro, CINAHL, Scopus and Cochrane databases were searched systematically for eligible studies. Inclusion criteria were: traumatic lower-limb amputation(s), HRQoL outcome and veterans. Physical and social factors that influence HRQoL were extracted. Results: The literature search identified 2073 citations, leading to the inclusion of 10 studies in the systematic review. Physical activity level, sport participation, level of amputation, back pain, years of education, as well as duration and severity of phantom pain were found to be determining factors for HRQoL among veterans with lower-limb amputation. Conclusions: The identified physical and social determinants were similar to those found in civilian traumatic amputees. More high quality research designs, interventions and complex statistical analyses are warranted to identify the physical and social factors that influence the HRQoL of veteran amputees. Implications for Rehabilitation Rehabilitation staff should promote physical activity and participation in sport among veterans with lower-limb amputation(s). Level of amputation, back pain severity, years of education, duration of phantom pain and severity of phantom pain have been found to be determining factors for HRQoL and should be taken into consideration when planning rehabilitation programs for veterans with lower-limb amputations.

Purpose: Alternative modes of cardiopulmonary exercise testing are needed and an arm cycle (AC) is a promising alternative to the gold standard of the leg cycle (LC). The aim of this study was to undertake a systematic review comparing maximal oxygen consumption (VO2max) obtained from AC and LC in patient populations with cardiovascular disease (CVD) and pulmonary disease (PD).Methods: A systematic review was undertaken with literature searches on December 5, 2016. Studies were included if they directly compared aerobic capacity values obtained from AC and LC in patients with CVD or PD. Results across studies were pooled using random effects meta-analysis and univariate meta-regression were used to assess potential associations between variables.Results: A total of 14 studies in 411 patients were included. On average, VO2max of LC exceeded AC mean difference by 3.48 mL·kg−1·min−1, (95% confidence interval [CI]: 1.94, 5.03) and a mean AC/LC ratio of 0.83, (95% CI: 0.77, 0.90). VO2max differences between AC and LC were similar in patients with CVD compared with PD but were found to be higher in older individuals and those with higher VO2max.Conclusions: Although AC offers an important alternative form of exercise testing for patients with CVD or PD, clinicians must take into account that VO2max values obtained from AC are consistently lower than those obtained on LC. However, the results of this article offer an evidence-based estimation for the proportional differences between AC values and LC values for groups with CVD or groups with PD.

Background To investigate the use of physical activity monitors (PAMs) for the elderly, the scientific literature should be systematically reviewed and the effect quantified, as the evidence seems inconclusive. Methods and design Randomized controlled trials and randomized crossover trials, with participants with a mean age above 65 years, comparing any PAM intervention with other control interventions or no intervention, will be included. This protocol is detailed according to the recommendations of the Cochrane Handbook, and it is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols statement. Results We will present results from the search in a flow diagram. The results from the analyses will include regular meta-analyses, stratified analyses, and meta-regressions. The results on each outcome of interest will be presented in a summary of findings table. Discussion This paper will explore and analyze the heterogeneity of the results and try to identify variables that will enhance the effect of PAMs in elderly. The results will be useful to researchers working with elderly and/or PAMs, health care professionals working with elderly, and relatives together with the elderly themselves. Systematic review registration PROSPERO CRD42018083648. Electronic supplementary material The online version of this article (10.1186/s13643-018-0733-6) contains supplementary material, which is available to authorized users.

Background: Knowledge about the organization and factors of importance to rehabilitation of veterans with lower limb amputation is sparse. The aim of this study was, therefore, to improve understanding of the influences of “military identity” on the organization of rehabilitation services and to investigate those factors influential in achieving successful rehabilitation, including interprofessional collaboration between different sectors involved in the rehabilitation of veterans with lower limb amputations. Methods: We used a qualitative exploratory design, triangulating interviews and participant observation. Data were generated using in-depth semi-structured interviews (n = 6) exploring in-hospital and post-hospital rehabilitation in Danish veterans after unilateral lower limb amputation due to trauma. We conducted four sessions of participant observation, during weekly post-hospitalization rehabilitation and included field notes in the dataset. Results: Two main themes emerged: “experiencing different identities” and “experiencing discontinuity in rehabilitation.” The first theme illustrated how veterans actively shift between the identities of disabled person, wounded veteran and athlete according to the context. The second theme illustrated the frustration of negotiating military versus civilian mindsets during rehabilitation and lack of coordination between the public healthcare system, municipal services and the military. Conclusion: Veterans live with shifting identities after returning to civilian life, increasing their awareness of the transition from active service to a new life as a civilian. During rehabilitation, it is important to acknowledge the disparities between the military and civilian mindsets and to integrate the different sets of values, such as structure versus autonomy. IMPLICATIONS FOR REHABILITATION Recommendations for the improvement of rehabilitation of amputated veterans include: Rehabilitation professionals working with veterans should focus on abilities instead of disabilities, in order to support their active identity. Rehabilitation professionals working with veterans should understand and integrate military key components, such as autonomy, structure, clear expectations, goal setting and ongoing testing and adjustment of goals. Rehabilitation professionals working with veterans should facilitate collaboration between civilian and military rehabilitation services, in order to secure both physical and psychosocial reintegration. Keywords: Qualitative, interviews, participant observation, amputation, lower limb, trauma

Objective:\ud \ud To assess patient preference for exercise setting and examine if choice of setting influences the long-term health benefit of exercise-based cardiac rehabilitation.\ud Methods:\ud \ud Patients participating in a randomised controlled trial following either heart valve surgery, or radiofrequency ablation for atrial fibrillation were given the choice to perform a 12-week exercise programme in either a supervised centre-based, or a self-management home-based setting. Exercise capacity and physical and mental health outcomes were assessed for up to 24 months after hospital discharge. Outcomes between settings were compared using a time × setting interaction using a mixed effects regression model.\ud Results:\ud \ud Across the 158 included patients, an equivalent proportion preferred to undertake exercise rehabilitation in a centre-based setting (55%, 95% CI: 45% to 63%) compared to a home-based setting (45%, 95% CI: 37% to 53%, p = 0.233). At baseline, those who preferred a home-based setting reported better physical health (mean difference in physical component score: 5.0, 95% CI 2.3 to 7.4; p = 0.001) and higher exercise capacity (mean between group difference 15.9 watts, 95% CI 3.7 to 28.1; p = 0.011). With the exception of the depression score in the Hospital Anxiety and Depression Score (F(3.65), p = 0.004), there was no evidence of a significant difference in outcomes between settings.\ud Conclusion:\ud \ud The preference of patients to participate in home-based and centre-based exercise programmes appears to be equivalent and provides similar health benefits. Whilst these findings support that patients should be given the choice between exercise-settings when initiating cardiac rehabilitation, further confirmatory evidence is needed.

Many low and middle income countries (LMICs) struggle to provide the investment required for life-saving Congenital Heart Disease (CHD) surgery. As poverty and infectious diseases decrease, CHD remains an important contributor to mortality. We linked risk-adjusted CHD surgical mortality from 15

BACKGROUND: Uraemia and chronical haemodialysis are associated with an abnormal growth hormone (GH)-insulin-like growth factor (IGF) axis which may contribute to malnutrition and renal bone disease. Short-term studies have shown a beneficial effect of treatment with recombinant human growth hormone (rhGH) on nutritional status in patients on haemodialysis. In the present study, we evaluated the effect of rhGH on bone and mineral metabolism. METHODS: Twenty chronic malnourished patients on haemodialysis took part in a double-blind, placebo controlled trial with subcutaneous injections of rhGH (4 IU/m2/day) or placebo for 6 months. RESULTS: During rhGH treatment, serum IGF-1 increased 264 +/- 52% (mean +/- SEM) (P < 0.008). There were no significant changes in biochemical markers of mineral metabolism (serum ionized calcium, phosphate and parathyroid hormone). Among markers of bone metabolism, there was a significant increase in serum procollagen type I C-terminal propeptide (maximum 155 +/- 8%, P < 0.001) and no significant changes in serum alkaline phosphatase. Bone densitometry showed a significant decrease in whole body bone mineral content (95.7 +/- 1.2%) after 6 months treatment. The effects on the proximal femur were not significant. CONCLUSION: The effects of 6 months treatment with rhGH seen in this study are best explained by a GH- or IGF-1-induced increased bone turnover. Long-term treatment in larger cohorts followed by bone densitometry and, preferentially, bone histomorphometry are needed to evaluate whether this is a beneficial effect in haemodialysis patients.

An increasing focus on hospital productivity has rendered a need for more thorough knowledge of cost drivers in hospitals, including a need for quantification of the impact of age, case-mix and other characteristics of patients, as well as establishment of the cost-quality relationship. The aim of this study is to identify cost drivers for vascular surgery in Danish hospitals with a specific view to quality of the treatment: Is higher quality associated with increased costs, when all other cost drivers are accounted for? We analyse cost drivers in a register-based study, using patient level data from three sources: The Vascular Register, the hospital cost database, and the National Patient Register with added DRG-information. The analysis follows a multilevel set-up, where cost drivers at patient level are analysed in a set of general linear regression models including complications and mortality as quality measures. At the hospital level of the analysis, we analyse deviations of observed costs from risk-adjusted costs and compare these to deviations of observed quality from risk-adjusted quality. We find, not surprisingly, that a number of patient characteristics, including case-mix and severity, have a major impact on treatment costs. At patient level, both complications and mortality are associated with increased costs. At hospital department level, results are not straightforward, but could indicate a U-shaped association. We conclude that the relation between costs and quality is not straightforward, at least not at department level. Our results indicate, albeit vaguely, a U-shaped relation between quality, in terms of fewer surgical complications than expected, and costs at department level, since our results suggest that increasing costs for vascular departments are associated with increased quality when costs are high and decreased quality when costs are low. For mortality however, we have not been able to establish a clear relation to costs. JEL codes: I12- health production; C33 - Models with Panel Data; Longitudinal Data; Spatial Time Series; D24 - Production; Cost; Capital; Capital, Total Factor, and Multifactor Productivity; Capacity