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Triangulating Weakness, Morbidity, and Mortality Among Acute Respiratory Distress Syndrome Survivors: A Story Emerges. Crit Care Med 2019; 45:370-371. [PMID: 28098638 DOI: 10.1097/ccm.0000000000002118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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102
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Fioretto JR, Pires RB, Klefens SO, Kurokawa CS, Carpi MF, Bonatto RC, Moraes MA, Ronchi CF. Inflammatory lung injury in rabbits: effects of high-frequency oscillatory ventilation in the prone position. J Bras Pneumol 2019; 45:e20180067. [PMID: 30916116 PMCID: PMC6715165 DOI: 10.1590/1806-3713/e20180067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 08/12/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To compare the effects that prone and supine positioning during high-frequency oscillatory ventilation (HFOV) have on oxygenation and lung inflammation, histological injury, and oxidative stress in a rabbit model of acute lung injury (ALI). METHODS Thirty male Norfolk white rabbits were induced to ALI by tracheal saline lavage (30 mL/kg, 38°C). The injury was induced during conventional mechanical ventilation, and ALI was considered confirmed when a PaO2/FiO2 ratio < 100 mmHg was reached. Rabbits were randomly divided into two groups: HFOV in the supine position (SP group, n = 15); and HFOV with prone positioning (PP group, n = 15). For HFOV, the mean airway pressure was initially set at 16 cmH2O. At 30, 60, and 90 min after the start of the HFOV protocol, the mean airway pressure was reduced to 14, 12, and 10 cmH2O, respectively. At 120 min, the animals were returned to or remained in the supine position for an extra 30 min. We evaluated oxygenation indices and histological lung injury scores, as well as TNF-α levels in BAL fluid and lung tissue. RESULTS After ALI induction, all of the animals showed significant hypoxemia, decreased respiratory system compliance, decreased oxygenation, and increased mean airway pressure in comparison with the baseline values. There were no statistically significant differences between the two groups, at any of the time points evaluated, in terms of the PaO2 or oxygenation index. However, TNF-α levels in BAL fluid were significantly lower in the PP group than in the SP group, as were histological lung injury scores. CONCLUSIONS Prone positioning appears to attenuate inflammatory and histological lung injury during HFOV in rabbits with ALI.
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Affiliation(s)
- Jose Roberto Fioretto
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | | | - Susiane Oliveira Klefens
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Cilmery Suemi Kurokawa
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Mario Ferreira Carpi
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Rossano César Bonatto
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Marcos Aurélio Moraes
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Carlos Fernando Ronchi
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
- . Departamento de Fisioterapia, Universidade Federal de Uberlândia, Uberlândia (MG) Brasil
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Kritchevsky SB, Forman DE, Callahan KE, Ely EW, High KP, McFarland F, Pérez-Stable EJ, Schmader KE, Studenski SA, Williams J, Zieman S, Guralnik JM. Pathways, Contributors, and Correlates of Functional Limitation Across Specialties: Workshop Summary. J Gerontol A Biol Sci Med Sci 2019; 74:534-543. [PMID: 29697758 PMCID: PMC6417483 DOI: 10.1093/gerona/gly093] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Indexed: 12/25/2022] Open
Abstract
Traditional clinical care models focus on the measurement and normalization of individual organ systems and de-emphasize aspects of health related to the integration of physiologic systems. Measures of physical, cognitive and sensory, and psychosocial or emotional function predict important health outcomes like death and disability independently from the severity of a specific disease, cumulative co-morbidity, or disease severity measures. A growing number of clinical scientists in several subspecialties are exploring the utility of functional assessment to predict complication risk, indicate stress resistance, inform disease screening approaches and risk factor interpretation, and evaluate care. Because a substantial number of older adults in the community have some form of functional limitation, integrating functional assessment into clinical medicine could have a large impact. Although interest in functional implications for health and disease management is growing, the science underlying functional capacity, functional limitation, physical frailty, and functional metrics is often siloed among different clinicians and researchers, with fragmented concepts and methods. On August 25-26, 2016, participants at a trans-disciplinary workshop, supported by the National Institute on Aging and the John A. Hartford Foundation, explored what is known about the pathways, contributors, and correlates of physical, cognitive, and sensory functional measures across conditions and disease states; considered social determinants and health disparities; identified knowledge gaps, and suggested priorities for future research. This article summarizes those discussions.
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Affiliation(s)
- Stephen B Kritchevsky
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel E Forman
- Department of Medicine, University of Pittsburgh, Pennsylvania
| | - Kathryn E Callahan
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - E Wesley Ely
- VA Tennessee Valley Geriatric Research Education Clinical Center (GRECC) and Department of Medicine, Vanderbilt University, Nashville
| | - Kevin P High
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Frances McFarland
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | | | - Jack M Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
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Rai S, Brown R, van Haren F, Neeman T, Rajamani A, Sundararajan K, Mitchell I. Long-term follow-up for Psychological stRess in Intensive CarE (PRICE) survivors: study protocol for a multicentre, prospective observational cohort study in Australian intensive care units. BMJ Open 2019; 9:e023310. [PMID: 30782702 PMCID: PMC6352815 DOI: 10.1136/bmjopen-2018-023310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION There are little published data on the long-term psychological outcomes in intensive care unit (ICU) survivors and their family members in Australian ICUs. In addition, there is scant literature evaluating the effects of psychological morbidity in intensive care survivors on their family members. The aims of this study are to describe and compare the long-term psychological outcomes of intubated and non-intubated ICU survivors and their family members in an Australian ICU setting. METHODS AND ANALYSIS This will be a prospective observational cohort study across four ICUs in Australia. The study aims to recruit 150 (75 intubated and 75 non-intubated) adult ICU survivors and 150 family members of the survivors from 2015 to 2018. Long-term psychological outcomes and effects on health-related quality of life (HRQoL) will be evaluated at 3 and 12 months follow-up using validated and published screening tools. The primary objective is to compare the prevalence of affective symptoms in intubated and non-intubated survivors of intensive care and their families and its effects on HRQoL. The secondary objective is to explore dyadic relations of psychological outcomes in patients and their family members. ETHICS AND DISSEMINATION The study has been approved by the relevant human research ethics committees (HREC) of Australian Capital Territory (ACT) Health (ETH.11.14.315), New South Wales (HREC/16/HNE/64), South Australia (HREC/15/RAH/346). The results of this study will be published in a peer-reviewed medical journal and presented to the local intensive care community and other stakeholders. TRIAL REGISTRATION NUMBER ACTRN12615000880549; Pre-results.
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Affiliation(s)
- Sumeet Rai
- Intensive Care Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Rhonda Brown
- Research School of Psychology, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Teresa Neeman
- Statistical Consulting Unit, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Arvind Rajamani
- Intensive Care Unit, Nepean Hospital, Penrith, New South Wales, Australia
- Discipline of Critical Care, Nepean Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Krishnaswamy Sundararajan
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Imogen Mitchell
- Intensive Care Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
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105
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Sanfilippo F, Ippolito M, Santonocito C, Martucci G, Carollo T, Bertani A, Vitulo P, Pilato M, Panarello G, Giarratano A, Arcadipane A. Long-term functional and psychological recovery in a population of acute respiratory distress syndrome patients treated with VV-ECMO and in their caregivers. Minerva Anestesiol 2019; 85:971-980. [PMID: 30665282 DOI: 10.23736/s0375-9393.19.13095-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) survivors are affected with long-term physical/mental impairments, with improvements limited mostly to the first year after intensive care (ICU) discharge. Furthermore, caregivers of ICU patients exhibit psychological problems after family-member recovery. We evaluated the long-term physical and mental recovery of ARDS survivors treated with veno-venous extracorporeal membrane oxygenation (VV-ECMO), and the long-term psychological impact on their caregivers. METHODS Single-center prospective evaluation of a retrospective cohort of 75 ARDS patients treated with VV-ECMO during a seven-year period (25.10.2009-11.08.2016). Primary outcomes were the 36-Item Short-Form Health-Survey (SF-36, patients only), and risks of depression, anxiety or post-traumatic stress disorder (PTSD), both for patients and their caregivers. We investigated correlations between outcomes and population characteristics. RESULTS Of 50 ICU-survivors, seven died later and five were not contactable. Among 38 living patients, 33 participated (87%, 31 with their caregiver) with 2.7 years of median follow-up. Physical and mental SF-36 component scores were 42 (inter-quartile range, IQR:22) and 52 (IQR:18.5), respectively. The worst domains of the SF-36 were physical-role limitations (25, IQR:100) and general-health perception (56, IQR:42.5). Psychological tests highlighted high risk of depression (39-42%, patients; 39-52%, caregivers), anxiety (42%, patients; 39%, caregivers), and PTSD (47%, patients; 61%, caregivers). Patient depression or anxiety scores were correlated to age and to the outcome reported by caregivers. CONCLUSIONS At almost three-year follow-up, ARDS survivors treated with VV-ECMO showed reduced health-related quality-of-life and high risk of psychological impairment, in particular PTSD. Caregivers of this population were at high psychological risk as well.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy -
| | - Mariachiara Ippolito
- Section of Anesthesia Analgesia Intensive Care and Emergency, Department of Biopathology and Medical Biotechnologies (DIBIMED), P. Giaccone Polyclinic, University of Palermo, Palermo, Italy
| | - Cristina Santonocito
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Tiziana Carollo
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Alessandro Bertani
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Patrizio Vitulo
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Michele Pilato
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Giovanna Panarello
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Antonino Giarratano
- Section of Anesthesia Analgesia Intensive Care and Emergency, Department of Biopathology and Medical Biotechnologies (DIBIMED), P. Giaccone Polyclinic, University of Palermo, Palermo, Italy
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
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Howard AF, Currie L, Bungay V, Meloche M, McDermid R, Crowe S, Ryce A, Harding W, Haljan G. Health solutions to improve post-intensive care outcomes: a realist review protocol. Syst Rev 2019; 8:11. [PMID: 30621770 PMCID: PMC6323758 DOI: 10.1186/s13643-018-0939-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 12/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While 80% of critically ill patients treated in an intensive care unit (ICU) will survive, survivors often suffer a constellation of new or worsening physical, cognitive, and psychiatric complications, termed post-intensive care syndrome. Emerging evidence paints a challenging picture of complex, long-term complications that are often untreated and culminate in substantial dependence on acute care services. Clinicians and decision-makers in the Fraser Health Authority of British Columbia are working to develop evidence-based community healthcare solutions that will be successful in the context of existing healthcare services. The objective of the proposed review is to provide the theoretical scaffolding to transform the care of survivors of critical illness by a synthesis of relevant clinical and healthcare service programs. METHODS Realist review will be used to develop and refine a theoretical understanding of why, how, for whom, and in what circumstances post-ICU program impact ICU survivors' outcomes. This review will follow the recommended five steps of realist review which include (1) clarifying the scope of the review and articulating a preliminary program theory, (2) searching for evidence, (3) appraising primary studies and extracting data, (4) synthesizing evidence and sharing conclusions, and (5) disseminating and implementing recommendations. DISCUSSION This realist review will provide a program theory, encompassing the contexts, mechanisms, and outcomes, to explain how clinical and health service interventions to improve ICU survivor outcomes operate in different contexts for different survivors, and with what effect. This review will be an evidentiary pillar for health service development and implementation by our knowledge user team members as well as advance scholarly knowledge relevant nationally and internationally. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018087795.
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Affiliation(s)
- A Fuchsia Howard
- Faculty of Applied Sciences, School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5, Canada.
| | - Leanne Currie
- Faculty of Applied Sciences, School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5, Canada
| | - Vicky Bungay
- Faculty of Applied Sciences, School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5, Canada
| | | | - Robert McDermid
- Fraser Health Authority, Surrey, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah Crowe
- Fraser Health Authority, Surrey, British Columbia, Canada
| | - Andrea Ryce
- Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - William Harding
- Faculty of Applied Sciences, School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5, Canada
| | - Gregory Haljan
- Fraser Health Authority, Surrey, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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107
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Shyamsundar M, O'Kane C, Perkins GD, Kennedy G, Campbell C, Agus A, Phair G, McAuley D. Prevention of post-operative complications by using a HMG-CoA reductase inhibitor in patients undergoing one-lung ventilation for non-cardiac surgery: study protocol for a randomised controlled trial. Trials 2018; 19:690. [PMID: 30563555 PMCID: PMC6299644 DOI: 10.1186/s13063-018-3078-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 11/24/2018] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative pulmonary complications (PPC) and peri-operative myocardial infarction (MI) have a significant impact on the long-term mortality of surgical patients. Patients undergoing one-lung ventilation (OLV) for surgery are at a high risk of developing these complications. These complications could be associated with intensive care unit (ICU) admissions and longer hospital stay with associated resource and economic burden. Simvastatin, a HMG-CoA reductase enzyme inhibitor has been shown to have pleiotropic anti-inflammatory effects as well as being endothelial protective. The benefits of statins have been shown in various observational studies and in small proof-of-concept studies. There is an urgent need for a well-designed, large clinical trial powered to detect clinical outcomes. The Prevention HARP 2 trial will test the hypothesis ‘simvastatin 80 mg when compared to placebo will reduce cardiac and pulmonary complications in patients undergoing elective oesophagectomy, lobectomy or pneumonectomy’. Methods/design The Prevention HARP 2 trial is a UK multi-centre, randomised, double-blind, placebo-controlled trial. Adult patients undergoing elective oesophagectomy, lobectomy or pneumonectomy will be eligible. Patients who are already on statins will be excluded from this trial. Patients will be randomised to receive simvastatin 80 mg or matched placebo for 4 days pre surgery and for up to 7 days post surgery. The primary outcome is a composite outcome of PPC and MI within 7 days post surgery. Various secondary outcome measures including clinical outcomes, safety outcomes and health economic outcomes will be collected. The study aims to recruit 452 patients in total across 12 UK sites. Discussion The results of the Prevention HARP 2 trial should add to our understanding of the benefits of peri-operative statins and influence clinical decision-making. Analysis of blood and urine samples from the patients will provide insight into the mechanism of simvastatin action. Trial registration International Standard Randomised Controlled Trials registry, ID: ISRCTN48095567. Registered on 11 November 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-3078-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Murali Shyamsundar
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK.
| | - Cecilia O'Kane
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - Gavin D Perkins
- Warwick Trials Unit, University of Warwick, Coventry, CV4 7AL, UK
| | - Gavin Kennedy
- Northern Ireland Clinical Trials Unit, 1st Floor Elliott Dynes Building, Royal Hospitals, Belfast, BT12 6BA, UK
| | - Christina Campbell
- Northern Ireland Clinical Trials Unit, 1st Floor Elliott Dynes Building, Royal Hospitals, Belfast, BT12 6BA, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, 1st Floor Elliott Dynes Building, Royal Hospitals, Belfast, BT12 6BA, UK
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, 1st Floor Elliott Dynes Building, Royal Hospitals, Belfast, BT12 6BA, UK
| | - Danny McAuley
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
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Toufen Junior C, De Santis Santiago RR, Hirota AS, Carvalho ARS, Gomes S, Amato MBP, Carvalho CRR. Driving pressure and long-term outcomes in moderate/severe acute respiratory distress syndrome. Ann Intensive Care 2018; 8:119. [PMID: 30535520 PMCID: PMC6286297 DOI: 10.1186/s13613-018-0469-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 12/03/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) patients may present impaired in lung function and structure after hospital discharge that may be related to mechanical ventilation strategy. The aim of this study was to evaluate the association between functional and structural lung impairment, N-terminal-peptide type III procollagen (NT-PCP-III) and driving pressure during protective mechanical ventilation. It was a secondary analysis of data from randomized controlled trial that included patients with moderate/severe ARDS with at least one follow-up visit performed. We obtained serial measurements of plasma NT-PCP-III levels. Whole-lung computed tomography analysis and pulmonary function test were performed at 1 and 6 months of follow-up. A health-related quality of life survey after 6 months was also performed. RESULTS Thirty-three patients were enrolled, and 21 patients survived after 6 months. In extubation day an association between driving pressure and NT-PCP-III was observed. At 1 and 6 months forced vital capacity (FVC) was negatively correlated to driving pressure (p < 0.01). At 6 months driving pressure was associated with lower FVC independently on tidal volume, plateau pressure and baseline static respiratory compliance after adjustments (r2 = 0.51, p = 0.02). There was a significant correlation between driving pressure and lung densities and nonaerated/poorly aerated lung volume after 6 months. Driving pressure was also related to general health domain of SF-36 at 6 months. CONCLUSION Even in patients ventilated with protective tidal volume, higher driving pressure is associated with worse long-term pulmonary function and structure.
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Affiliation(s)
- Carlos Toufen Junior
- Divisão de Pneumologia, Cardiopulmonary Department, Heart Institute (InCor) University of São Paulo, INCOR Av. Dr. Enéas de Carvalho Aguiar, 44 Pinheiros, São Paulo, SP, CEP 05403-900, Brazil.
| | - Roberta R De Santis Santiago
- Divisão de Pneumologia, Cardiopulmonary Department, Heart Institute (InCor) University of São Paulo, INCOR Av. Dr. Enéas de Carvalho Aguiar, 44 Pinheiros, São Paulo, SP, CEP 05403-900, Brazil
| | - Adriana S Hirota
- Divisão de Pneumologia, Cardiopulmonary Department, Heart Institute (InCor) University of São Paulo, INCOR Av. Dr. Enéas de Carvalho Aguiar, 44 Pinheiros, São Paulo, SP, CEP 05403-900, Brazil
| | - Alysson Roncally S Carvalho
- Laboratory of Pulmonary Engineering, Biomedical Engineering Program, Alberto Luiz Coimbra Institute of Post-Graduation and Research in Engineering, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Laboratory of Respiration Physiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Susimeire Gomes
- Divisão de Pneumologia, Cardiopulmonary Department, Heart Institute (InCor) University of São Paulo, INCOR Av. Dr. Enéas de Carvalho Aguiar, 44 Pinheiros, São Paulo, SP, CEP 05403-900, Brazil
| | - Marcelo Brito Passos Amato
- Respiratory Intensive Care Unit, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - Carlos Roberto Ribeiro Carvalho
- Divisão de Pneumologia, Cardiopulmonary Department, Heart Institute (InCor) University of São Paulo, INCOR Av. Dr. Enéas de Carvalho Aguiar, 44 Pinheiros, São Paulo, SP, CEP 05403-900, Brazil
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Williams CN, Piantino J, McEvoy C, Fino N, Eriksson CO. The Burden of Pediatric Neurocritical Care in the United States. Pediatr Neurol 2018; 89:31-38. [PMID: 30327237 PMCID: PMC6349248 DOI: 10.1016/j.pediatrneurol.2018.07.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/23/2018] [Accepted: 07/31/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Disorders requiring pediatric neurocritical care (PNCC) affect thousands of children annually. We aimed to quantify the burden of PNCC through generation of national estimates of disease incidence, utilization of critical care interventions (CCI), and hospital outcomes. METHODS We performed a retrospective cohort analysis of the Kids Inpatient Database over three years to evaluate pediatric traumatic brain injury, neuro-infection or inflammatory diseases, status epilepticus, stroke, hypoxic ischemic injury after cardiac arrest, and spinal cord injury. We evaluated use of CCI, death, length of stay, hospital charges, and poor functional outcome defined as receipt of tracheostomy or gastrostomy or discharge to a medical care facility. RESULTS At least one CCI was recorded in 67,058 (23%) children with a primary neurological diagnosis, and considered a PNCC admission. Over half of PNCC admissions had at least one chronic condition, and 23% were treated in children's hospitals. Mechanical ventilation was the most common CCI, but utilization of CCIs varied significantly by diagnosis. Among PNCC admissions, 8110 (12%) children died during hospitalization and 14,067 (21%) children had poor functional outcomes. PNCC admissions cumulatively accounted for over 1.5 million hospital days and over $4 billion in hospital costs in the study years. Most PNCC admissions, across all diagnoses, had prolonged hospitalizations (more than one week) with an average cost of $39.9 thousand per admission. CONCLUSIONS This large, nationally representative study shows PNCC diseases are a significant public health burden with substantial risk to children's health. More research is needed to improve outcomes in these vulnerable children.
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Affiliation(s)
- Cydni N. Williams
- Oregon Health and Science University, Department of Pediatrics, Division of Pediatric Critical Care
| | - Juan Piantino
- Division of Pediatric Neurology, Oregon Health and Science University
| | - Cynthia McEvoy
- Division of Neonatology, Oregon Health and Science University
| | - Nora Fino
- Biostatistics and Design Program, Oregon Health and Science University
| | - Carl O. Eriksson
- Oregon Health and Science University, Department of Pediatrics, Division of Pediatric Critical Care
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110
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Keim G, Watson RS, Thomas NJ, Yehya N. New Morbidity and Discharge Disposition of Pediatric Acute Respiratory Distress Syndrome Survivors. Crit Care Med 2018; 46:1731-1738. [PMID: 30024428 PMCID: PMC6185805 DOI: 10.1097/ccm.0000000000003341] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Much of the research related to pediatric acute respiratory distress syndrome has focused on inhospital mortality and interventions affecting this outcome. Limited data exist on survivors' morbidity, hospital disposition, and 1-year survival. The aim of this study was to determine new morbidity rate, discharge disposition, and 1-year mortality for survivors of pediatric acute respiratory distress syndrome. DESIGN Secondary analysis of prospective cohort study. SETTING Quaternary children's hospital. PATIENTS Three-hundred sixteen mechanically ventilated children with pediatric acute respiratory distress syndrome (Berlin and Pediatric Acute Lung Injury Consensus Conference criteria) between July 2011 and December 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We performed secondary analysis of a prospectively recruited cohort of 316 mechanically ventilated children with pediatric acute respiratory distress syndrome between July 2011, and December 2014. Preillness and hospital discharge Functional Status Scale score were determined via chart review, and factors associated with new morbidity, defined as an increase of Functional Status Scale score of 3 or more, were analyzed. Demographic variables, pediatric acute respiratory distress syndrome characteristics, and ventilator management were tested for association with development of new morbidity, discharge disposition, and 1-year mortality. Inhospital mortality of pediatric acute respiratory distress syndrome was 13.3% (42/316). Of 274 survivors to hospital discharge, new morbidity was seen in 63 patients (23%). Discharge to rehabilitation rate was 24.5% (67/274) and associated with development of new morbidity. One- and 3-year mortality of survivors was 5.5% (15 deaths) and 8% (22 deaths) and was associated with baseline Functional Status Scale, immunocompromised status, Pediatric Risk of Mortality III, and organ failures at pediatric acute respiratory distress syndrome onset, but not with pediatric acute respiratory distress syndrome severity. CONCLUSIONS New morbidity was common after pediatric acute respiratory distress syndrome and appears to be intermediate phenotype between survival without morbidity and death, making it a useful metric in future interventional and outcome studies in pediatric acute respiratory distress syndrome.
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Affiliation(s)
- Garrett Keim
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Neal J. Thomas
- Pennsylvania State University College of Medicine, Hershey, PA
| | - Nadir Yehya
- Children’s Hospital of Philadelphia, Philadelphia, PA
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Pediatric Acute Respiratory Distress Syndrome Survivors—What Happens After the PICU?*. Crit Care Med 2018; 46:1866-1867. [DOI: 10.1097/ccm.0000000000003375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Al-Nassan S, Alshammari F, Al-Bostanji S, Modhi Mansour Z, Hawamdeh M. Physical therapy practice in intensive care units in Jordanian hospitals: A national survey. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2018; 24:e1749. [PMID: 30230143 DOI: 10.1002/pri.1749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/02/2018] [Accepted: 08/15/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE A national survey was conducted to determine the current status of physical therapy practice in the intensive care units (ICUs) of Jordanian hospitals. METHODS An online survey was sent via email to physical therapists working at Jordanian hospitals. Questions of the survey addressed the physical therapy demographics, staffing, education, training, and barriers of practice. The responses were compared among four different hospital sectors in the country. RESULTS The response rate was 31% (50/161). Thirty-six percent of participants had more than 10 years of experience in physical therapy, and 26% had less than 1 year of experience in the intensive care practice. Staffing of physical therapists working in ICUs relative to the total ICU beds was the highest in public hospitals compared with other hospital sectors. Among all participants, only 4% had received specialized postgraduate ICU training. The barriers to ICU physical therapy practice in Jordan included insufficient staffing, inadequate training, and lack of understanding of physical therapy role for ICU patients. CONCLUSION The study showed the main barriers to ICU physical therapy practice in Jordan. There is a need for well-structured strategies to overcome these barriers to help improve the delivery of physical therapy services in Jordan.
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Affiliation(s)
- Saad Al-Nassan
- Department of Physical and Occupational Therapy, Faculty of Allied Health Sciences, Hashemite University, Zarqa, Jordan
| | - Faris Alshammari
- Department of Physical and Occupational Therapy, Faculty of Allied Health Sciences, Hashemite University, Zarqa, Jordan
| | - Shaden Al-Bostanji
- Department of Physical and Occupational Therapy, Faculty of Allied Health Sciences, Hashemite University, Zarqa, Jordan
| | - Zaid Modhi Mansour
- Department of Physical and Occupational Therapy, Faculty of Allied Health Sciences, Hashemite University, Zarqa, Jordan
| | - Mohannad Hawamdeh
- Department of Physical and Occupational Therapy, Faculty of Allied Health Sciences, Hashemite University, Zarqa, Jordan
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Kamo T, Aoki Y, Fukuda T, Kurahashi K, Yasuda H, Sanui M, Nango E, Abe T, Lefor AK, Hashimoto S. Optimal duration of prone positioning in patients with acute respiratory distress syndrome: a protocol for a systematic review and meta-regression analysis. BMJ Open 2018; 8:e021408. [PMID: 30206081 PMCID: PMC6144408 DOI: 10.1136/bmjopen-2017-021408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Several systematic reviews and meta-analyses have demonstrated that prolonged (≥16 hours) prone positioning can reduce the mortality associated with acute respiratory distress syndrome (ARDS). However, the effectiveness and optimal duration of prone positioning was not fully evaluated. To fill these gaps, we will first investigate the effectiveness of prone positioning compared with the conventional management of patients with ARDS, regarding outcomes using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Second, if statistical heterogeneity in effectiveness with regard to short-term mortality (intensive care unit death or ≤30-day mortality) is shown, we will conduct a meta-regression analysis to explore the association between duration and effectiveness, and determine the optimal duration of prone positioning. METHOD AND ANALYSIS Relevant studies are collected using PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials and the WHO International Clinical Trials Platform Search Portal. Randomised controlled trials comparing prone and supine positioning in adults with ARDS will be included in the meta-analysis. Two independent investigators will screen trials obtained by search eligibility and extract data from selected studies to standardised data recording forms. For each selected trial, the risk of bias and quality of evidence will be evaluated using the GRADE system. Meta-regression analyses will be performed to identify the most important factors associated with short-term mortality, and subgroup analysis will be used to analyse the following: duration of mechanical ventilation in the prone position per day, patient severity, tidal volume and cause of ARDS. If heterogeneity or inconsistency among the studies is detected, subgroup analysis will be conducted on factors that may cause heterogeneity. ETHICS AND DISSEMINATION This study requires no ethical approval. The results obtained from this systematic review and meta-analysis will be disseminated through international conference presentations and publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42017078340.
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Affiliation(s)
- Tetsuro Kamo
- Department of Pulmonary Medicine, Intensive Care Medicine, Keio University School of Medicine, Tochigi, Japan
- Department of Pulmonary Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kiyoyasu Kurahashi
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Hideto Yasuda
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Eishu Nango
- Department of General Medicine, Tokyo-Kita Medical Center, Tokyo, Japan
| | - Takayuki Abe
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
- Biostatistics Unit at Clinical and Translational Research Center, Keio University Hospital, Tokyo, Japan
| | | | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Arias-Fernández P, Romero-Martin M, Gómez-Salgado J, Fernández-García D. Rehabilitation and early mobilization in the critical patient: systematic review. J Phys Ther Sci 2018; 30:1193-1201. [PMID: 30214124 PMCID: PMC6127491 DOI: 10.1589/jpts.30.1193] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/29/2018] [Indexed: 12/23/2022] Open
Abstract
[Purpose] To review the literature that examines rehabilitation and early mobilization
and that involves different practices (effects of interventions) for the critically ill
patient. [Materials and Methods] A PRISMA-Systematic review has been conducted based on
different data sources: Biblioteca Virtual en Salud, CINHAL, Pubmed, Scopus, and Web of
Science were used to identify randomized controlled trials, crossover trials, and
case-control studies. [Results] Eleven studies were included. Early rehabilitation had no
significant effect on the length of stay and number of cases of Intensive Care Unit
Acquired Weaknesses. However, early rehabilitation had a significant effect on the
functional status, muscle strength, mechanical ventilation duration, walking ability at
discharge, and health quality of life. [Conclusion] Rehabilitation and early mobilization
are associated with an increased probability of walking more distance at discharge. Early
rehabilitation is associated with an increase in functional capacity and muscle strength,
an improvement in walking distance and better perception of the health-related quality of
life. Cycloergometer and electrical stimulation can be used to maintain muscle strength.
Further research is needed to establish stronger evidences.
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Affiliation(s)
- Patricia Arias-Fernández
- Health Sciences School, Department of Nursing and Physiotherapy, Intensive Care Unit, University Hospital of León, Spain
| | | | - Juan Gómez-Salgado
- Nursing School, University of Huelva: 21071 Huelva, Spain.,University Espiritu Santo, Ecuador
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Wesselink E, Koekkoek WAC, Grefte S, Witkamp RF, van Zanten ARH. Feeding mitochondria: Potential role of nutritional components to improve critical illness convalescence. Clin Nutr 2018; 38:982-995. [PMID: 30201141 DOI: 10.1016/j.clnu.2018.08.032] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 08/03/2018] [Accepted: 08/25/2018] [Indexed: 12/30/2022]
Abstract
Persistent physical impairment is frequently encountered after critical illness. Recent data point towards mitochondrial dysfunction as an important determinant of this phenomenon. This narrative review provides a comprehensive overview of the present knowledge of mitochondrial function during and after critical illness and the role and potential therapeutic applications of specific micronutrients to restore mitochondrial function. Increased lactate levels and decreased mitochondrial ATP-production are common findings during critical illness and considered to be associated with decreased activity of muscle mitochondrial complexes in the electron transfer system. Adequate nutrient levels are essential for mitochondrial function as several specific micronutrients play crucial roles in energy metabolism and ATP-production. We have addressed the role of B vitamins, ascorbic acid, α-tocopherol, selenium, zinc, coenzyme Q10, caffeine, melatonin, carnitine, nitrate, lipoic acid and taurine in mitochondrial function. B vitamins and lipoic acid are essential in the tricarboxylic acid cycle, while selenium, α-tocopherol, Coenzyme Q10, caffeine, and melatonin are suggested to boost the electron transfer system function. Carnitine is essential for fatty acid beta-oxidation. Selenium is involved in mitochondrial biogenesis. Notwithstanding the documented importance of several nutritional components for optimal mitochondrial function, at present, there are no studies providing directions for optimal requirements during or after critical illness although deficiencies of these specific micronutrients involved in mitochondrial metabolism are common. Considering the interplay between these specific micronutrients, future research should pay more attention to their combined supply to provide guidance for use in clinical practise. REVISION NUMBER: YCLNU-D-17-01092R2.
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Affiliation(s)
- E Wesselink
- Division of Human Nutrition and Health, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
| | - W A C Koekkoek
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, The Netherlands.
| | - S Grefte
- Human and Animal Physiology, Wageningen University, De Elst 1, 6708 DW, Wageningen, The Netherlands.
| | - R F Witkamp
- Division of Human Nutrition and Health, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
| | - A R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, The Netherlands.
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Orhun G, Tüzün E, Özcan PE, Ulusoy C, Yildirim E, Küçükerden M, Gürvit H, Ali A, Esen F. Association Between Inflammatory Markers and Cognitive Outcome in Patients with Acute Brain Dysfunction Due to Sepsis. ACTA ACUST UNITED AC 2018; 56:63-70. [PMID: 30911240 DOI: 10.29399/npa.23212] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 06/01/2018] [Indexed: 12/13/2022]
Abstract
Introduction Sepsis-induced brain dysfunction (SIBD) has been neglected until recently due to the absence of specific clinical or biological markers. There is increasing evidence that sepsis may pose substantial risks for long term cognitive impairment. Methods To find out clinical and inflammatory factors associated with acute SIBD serum levels of cytokines, complement breakdown products and neurodegeneration markers were measured by ELISA in sera of 86 SIBD patients and 33 healthy controls. Association between these biological markers and cognitive test results was investigated. Results SIBD patients showed significantly increased IL-6, IL-8, IL-10 and C4 d levels and decreased TNF-α, IL-12, C5a and iC3b levels than healthy controls. No significant alteration was observed in neuronal loss and neurodegeneration marker [neuron specific enolase (NSE), amyloid β, tau] levels. Increased IL-1β, IL-6, IL-8, IL-10, TNF-α and decreased C4 d, C5a and iC3b levels were associated with septic shock, coma and mortality. Transient mild cognitive impairment was observed in 7 of 21 patients who underwent neuropsychological assessment. Cognitive dysfunction and neuronal loss were associated with increased duration of septic shock and delirium but not baseline serum levels of inflammation and neurodegeneration markers. Conclusion Increased cytokine levels, decreased complement activity and increased neuronal loss are indicators of poor prognosis and adverse events in SIBD. Cognitive dysfunction and neuronal destruction in SIBD do not seem to be associated with systemic inflammation factors and Alzheimer disease-type neurodegeneration but rather with increased duration of neuronal dysfunction and enhanced exposure of the brain to sepsis-inducing pathogens.
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Affiliation(s)
- Günseli Orhun
- Department of Anesthesiology and Reanimation, İstanbul University Faculty of Medicine, İstanbul, Turkey
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Experimental Medicine Research Institute, İstanbul University, İstanbul, Turkey
| | - Perihan Ergin Özcan
- Department of Anesthesiology and Reanimation, İstanbul University Faculty of Medicine, İstanbul, Turkey
| | - Canan Ulusoy
- Department of Neuroscience, Aziz Sancar Experimental Medicine Research Institute, İstanbul University, İstanbul, Turkey
| | - Elif Yildirim
- Department of Neurology, İstanbul University Faculty of Medicine, İstanbul, Turkey
| | - Melike Küçükerden
- Department of Neuroscience, Aziz Sancar Experimental Medicine Research Institute, İstanbul University, İstanbul, Turkey
| | - Hakan Gürvit
- Department of Neurology, İstanbul University Faculty of Medicine, İstanbul, Turkey
| | - Achmet Ali
- Department of Anesthesiology and Reanimation, İstanbul University Faculty of Medicine, İstanbul, Turkey
| | - Figen Esen
- Department of Anesthesiology and Reanimation, İstanbul University Faculty of Medicine, İstanbul, Turkey
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Robles AJ, Kornblith LZ, Hendrickson CM, Howard BM, Conroy AS, Moazed F, Calfee CS, Cohen MJ, Callcut RA. Health care utilization and the cost of posttraumatic acute respiratory distress syndrome care. J Trauma Acute Care Surg 2018; 85:148-154. [PMID: 29958249 PMCID: PMC6029709 DOI: 10.1097/ta.0000000000001926] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Posttraumatic acute respiratory distress syndrome (ARDS) is associated with prolonged mechanical ventilation and longer hospitalizations. The relationship between posttraumatic ARDS severity and financial burden has not been previously studied. We hypothesized that increasing ARDS severity is associated with incrementally higher health care costs. METHODS Adults arriving as the highest level of trauma activation were enrolled in an ongoing prospective cohort study. Patients who survived 6 hours or longer are included in the analysis. Blinded review of chest radiographs was performed by two independent physicians for any intubated patient with PaO2:FIO2 ratio of 300 mmHg or lower during the first 8 days of admission. The severity of ARDS was classified by the Berlin criteria. Hospital charge data were used to perform standard costing analysis. RESULTS Acute respiratory distress syndrome occurred in 13% (203 of 1,586). The distribution of disease severity was 33% mild, 42% moderate, and 25% severe. Patients with ARDS were older (41 years vs. 35 years, p < 0.01), had higher median Injury Severity Score (30 vs. 10, p < 0.01), more chest injury (Abbreviated Injury Scale score, ≥ 3: 51% vs. 21%, p < 0.01), and blunt mechanisms (85% vs. 53%, p < 0.01). By ARDS severity, there was no significant difference in age, mechanism, or rate of traumatic brain injury. Increasing ARDS severity was associated with higher Injury Severity Score and higher mortality rates. Standardized total hospital charges were fourfold higher for patients who developed ARDS compared with those who did not develop ARDS (US $434,000 vs. US $96,000; p < 0.01). Furthermore, the daily hospital charges significantly increased across categories of worsening ARDS severity (mild, US $20,451; moderate, US $23,994; severe, US $33,316; p < 0.01). CONCLUSION The development of posttraumatic ARDS is associated with higher health care costs. Among trauma patients who develop ARDS, total hospital charges per day increase with worsening severity of disease. Prevention, early recognition, and treatment of ARDS after trauma are potentially important objectives for efforts to control health care costs in this population. LEVEL OF EVIDENCE Economic and value-based evaluations, level IV.
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Affiliation(s)
- Anamaria J Robles
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Lucy Z Kornblith
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Carolyn M Hendrickson
- Department of Medicine, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Benjamin M Howard
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Amanda S Conroy
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Farzad Moazed
- Department of Medicine, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Carolyn S Calfee
- Department of Medicine, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Mitchell J Cohen
- Department of Surgery, Denver Health Medical Center and the University of Colorado; Denver, Colorado
| | - Rachael A Callcut
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
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Abstract
With the emerging interest in documenting and understanding muscle atrophy and function in critically ill patients and survivors, ultrasonography has transformational potential for measurement of muscle quantity and quality. We discuss the importance of quantifying skeletal muscle in the intensive care unit setting. We also identify the merits and limitations of various modalities that are capable of accurately and precisely measuring muscularity. Ultrasound is emerging as a potentially powerful tool for skeletal muscle quantification; however, there are key challenges that need to be addressed in future work to ensure useful interpretation and comparability of results across diverse observational and interventional studies. Ultrasound presents several methodological challenges, and ultimately muscle quantification combined with metabolic, nutritional, and functional markers will allow optimal patient assessment and prognosis. Moving forward, we recommend that publications include greater detail on landmarking, repeated measures, identification of muscle that was not assessable, and reproducible protocols to more effectively compare results across different studies.
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Six-Month Morbidity and Mortality among Intensive Care Unit Patients Receiving Life-Sustaining Therapy. A Prospective Cohort Study. Ann Am Thorac Soc 2018. [PMID: 28622004 DOI: 10.1513/annalsats.201611-875oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
RATIONALE Understanding long-term outcomes of critically ill patients may inform shared decision-making in the intensive care unit (ICU). OBJECTIVES To quantify 6-month functional outcomes of general ICU patients, and develop a multivariable model comprising factors present during the first ICU day to predict which patients will return to their baseline function 6 months later. METHODS We conducted a prospective cohort study in three medical ICUs and two surgical ICUs in three hospitals. We enrolled patients who spent at least 3 days in the ICU and received mechanical ventilation for more than 48 hours and/or vasoactive infusions for more than 24 hours. RESULTS We measured 6-month outcomes including survival, return to original place of residence, and physical and cognitive function. Of 303 enrolled patients, 299 (98.7%) had complete follow-up at 6 months. Among the 169 patients (56.5%) who survived to 6 months, 82.8% returned home, 81.9% were able to toilet, 71.3% were able to ambulate 10 stairs, and 62.4% reported normal cognition. Overall, 31.1% of patients returned to their baseline status on these measures. Factors associated with not returning to baseline included higher APACHE III score, being a medical patient, older age, nonwhite race, recent hospitalization, prior transplantation, and a history of cancer or of neurologic or liver disease. A model including only these Day 1 factors had good discrimination (area under receiver operating characteristic curve, 0.778; 95% confidence interval, 0.724-0.832) and calibration (difference between observed and expected P value, 0.36). CONCLUSIONS Among patients spending at least 3 days in an ICU and requiring even brief periods of life-sustaining therapy, nearly one-half will be dead and less than one-third will have returned to their baseline status at 6 months. Of those who survive, the majority of patients will be back at home at 6 months. Future research is needed to validate this multivariable model, including readily available patient characteristics available on the first ICU day, that seems to identify patients who will return to baseline at 6 months.
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Efron PA, Mohr AM, Bihorac A, Horiguchi H, Hollen MK, Segal MS, Baker HV, Leeuwenburgh C, Moldawer LL, Moore FA, Brakenridge SC. Persistent inflammation, immunosuppression, and catabolism and the development of chronic critical illness after surgery. Surgery 2018; 164:178-184. [PMID: 29807651 DOI: 10.1016/j.surg.2018.04.011] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/19/2018] [Accepted: 04/03/2018] [Indexed: 12/12/2022]
Abstract
As early as the 1990s, chronic critical illness, a distinct syndrome of persistent high-acuity illness requiring management in the ICU, was reported under a variety of descriptive terms including the "neuropathy of critical illness," "myopathy of critical illness," "ICU-acquired weakness," and most recently "post-intensive care unit syndrome." The widespread implementation of targeted shock resuscitation, improved organ support modalities, and evidence-based protocolized ICU care has resulted in significantly decreased in-hospital mortality within surgical ICUs, specifically by reducing early multiple organ failure deaths. However, a new phenotype of multiple organ failure has now emerged with persistent but manageable organ dysfunction, high resource utilization, and discharge to prolonged care facilities. This new multiple organ failure phenotype is now clinically associated with the rapidly increasing incidence of chronic critical illness in critically ill surgery patients. Although the underlying pathophysiology driving chronic critical illness remains incompletely described, the persistent inflammation, immunosuppression, and catabolism syndrome has been proposed as a mechanistic framework in which to explain the increased incidence of chronic critical illness in surgical ICUs. The purpose of this review is to provide a historic perspective of the epidemiologic evolution of multiple organ failure into persistent inflammation, immunosuppression, and catabolism syndrome; describe the mechanism that drives and sustains chronic critical illness, and review the long-term outcomes of surgical patients who develop chronic critical illness.
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Affiliation(s)
- Philip A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville.
| | - Alicia M Mohr
- Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Azra Bihorac
- Department of Medicine, University of Florida College of Medicine, Gainesville
| | - Hiroyuki Horiguchi
- Department of Surgery, University of Florida College of Medicine, Gainesville
| | - McKenzie K Hollen
- Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Mark S Segal
- Department of Medicine, University of Florida College of Medicine, Gainesville
| | - Henry V Baker
- Department of Molecular Genetics & Microbiology, University of Florida College of Medicine, Gainesville
| | - Christiaan Leeuwenburgh
- Institute on Aging and the Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainseville
| | - Lyle L Moldawer
- Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Frederick A Moore
- Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Scott C Brakenridge
- Department of Surgery, University of Florida College of Medicine, Gainesville
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Connolly B, Denehy L, Hart N, Pattison N, Williamson P, Blackwood B. Physical Rehabilitation Core Outcomes In Critical illness (PRACTICE): protocol for development of a core outcome set. Trials 2018; 19:294. [PMID: 29801508 PMCID: PMC5970518 DOI: 10.1186/s13063-018-2678-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/08/2018] [Indexed: 01/07/2023] Open
Abstract
Background Existing data on physical rehabilitation interventions in critical illness are challenged by outcome heterogeneity that limits data synthesis and translation of research findings into clinical practice. This protocol describes the PRACTICE study to develop a core outcome set (COS) for trials of physical rehabilitation interventions delivered across the continuum of a patient’s recovery from the intensive care unit until reintegration in the community following hospital discharge. Methods Mixed methods will be used including: systematic reviews of quantitative and qualitative literature; qualitative interviews with patients and caregivers; a modified Delphi consensus process with researcher, clinician and patient/caregiver stakeholder groups; and consensus meetings for ratification of findings, resolving uncertainty, or developing an action plan for COS implementation. Discussion The PRACTICE COS will inform relevant stakeholders about important outcomes regarding physical rehabilitation in critical illness, and may enhance the future design and conduct of trials in this area. Trial registration COMET database (www.comet-initiative.org/, Record ID 288, 01/03/13). PROSPERO database (CRD42014008908, CRD42017078549). Electronic supplementary material The online version of this article (10.1186/s13063-018-2678-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bronwen Connolly
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK. .,NIHR Biomedical Research Centre at Guy's and St. Thomas' NHS Foundation and King's College London, London, UK. .,Centre for Human and Applied Physiological Sciences, King's College London, London, UK. .,Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, 3010, Australia.
| | - Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Natalie Pattison
- School of Health and Social Work, University of Hertfordshire and East & North Hertfordshire NHS Trust, Hertfordshire, UK.,School of Health and Social Work, College Lane Campus, University of Hertfordshire, Hatfield, Hertfordshire, AL10 9AB, UK
| | - Paula Williamson
- MRC North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, UK.,Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool, L69 3BX, UK
| | - Bronagh Blackwood
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland, UK.,Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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Abstract
RATIONALE Poor functional status is common after critical illness, and can adversely impact the abilities of intensive care unit (ICU) survivors to live independently. Instrumental activities of daily living (IADL), which encompass complex tasks necessary for independent living, are a particularly important component of post-ICU functional outcome. OBJECTIVES To conduct a systematic review of studies evaluating IADLs in survivors of critical illness. METHODS We searched PubMed, CINAHL, Cochrane Library, SCOPUS, and Web of Science for all relevant English-language studies published through December 31, 2016. Additional articles were identified from personal files and reference lists of eligible studies. Two trained researchers independently reviewed titles and abstracts, and potentially eligible full text studies. Eligible studies included those enrolling adult ICU survivors with IADL assessments, using a validated instrument. We excluded studies involving specific ICU patient populations, specialty ICUs, those enrolling fewer than 10 patients, and those that were not peer-reviewed. Variables related to IADLs were reported using the Patient Reported Outcomes Measurement Information System (PROMIS). RESULTS Thirty of 991 articles from our literature search met inclusion criteria, and 23 additional articles were identified from review of reference lists and personal files. Sixteen studies (30%) published between 1999 and 2016 met eligibility criteria and were included in the review. Study definitions of impairment in IADLs were highly variable, as were reported rates of pre-ICU IADL dependencies (7-85% of patients). Eleven studies (69%) found that survivors of critical illness had new or worsening IADL dependencies. In three of four longitudinal studies, survivors with IADL dependencies decreased over the follow-up period. Across multiple studies, no risk factors were consistently associated with IADL dependency. CONCLUSIONS Survivors of critical illness commonly experience new or worsening IADL dependency that may improve over time. As part of ongoing efforts to understand and improve functional status in ICU survivors, future research must focus on risk factors for IADL dependencies and interventions to improve these cognitive and physical dependencies after critical illness.
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Chapple LAS, Weinel LM, Abdelhamid YA, Summers MJ, Nguyen T, Kar P, Lange K, Chapman MJ, Deane AM. Observed appetite and nutrient intake three months after ICU discharge. Clin Nutr 2018; 38:1215-1220. [PMID: 29778511 DOI: 10.1016/j.clnu.2018.05.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 04/12/2018] [Accepted: 05/02/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Oral intake is diminished immediately after ICU discharge, yet factors affecting nutritional intake after hospital discharge have not been evaluated. The aim of this study was to evaluate dietary intake and factors which may influence intake - appetite and gastric emptying - 3-months after ICU discharge. METHODS Inception cohort study with ICU survivors compared to healthy subjects. Following an overnight fast, all participants consumed a standardized carbohydrate drink, containing 13C-octanoic acid, to measure gastric emptying. Dietary intake was assessed by recall of the preceding day and a standard weighed buffet meal 4-h post-drink. Appetite was assessed pre-drink (fasting) and pre- and post-buffet using visual analogue scales. RESULTS Fifty-one ICU survivors (82% male; 70 ± 9 y; BMI 28 ± 6 kg/m2) and 25 healthy subjects (60% male; 67 ± 12 y; BMI 27 ± 4 kg/m2) were evaluated. From the 24-h recall ICU survivors consumed less calories (ICU 1876 (708) vs. healthy subjects 2291 (834) kcal; p = 0.025) with no difference in macronutrient intake, however reported a lower preference for fat (p < 0.001). Calorie and macronutrient intake from the weighed buffet was similar between groups: calories (ICU: 658 (301) vs. healthy subjects: 736 (325) kcal; p = 0.149); protein (ICU: 37 (19) vs. healthy subjects: 40 (17) g; p = 0.275); fat (ICU: 23 (12) vs healthy subjects: 26 (13) g; p = 0.261); and carbohydrates (ICU: 69 (35) vs. healthy subjects: 79 (42) g; p = 0.141). ICU survivors reported feeling less full regardless of time-point (p = 0.041). There was no difference in the rate of gastric emptying between the two groups (p = 0.216). CONCLUSIONS ICU survivors reported less preference for fat and less calorie consumption than healthy subjects. However, intake of calories and macronutrients at a weighed meal was similar in the two groups, as was the rate of gastric emptying. ICU survivors reported being less full after the test meal, suggesting factors other than appetite may influence intake.
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Affiliation(s)
- Lee-Anne S Chapple
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia; Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, Australia; National Health and Medical Research Council of Australia Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia.
| | - Luke M Weinel
- Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Yasmine Ali Abdelhamid
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Matthew J Summers
- Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Thu Nguyen
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia
| | - Palash Kar
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia; Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Kylie Lange
- National Health and Medical Research Council of Australia Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia; Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, Australia; National Health and Medical Research Council of Australia Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Adam M Deane
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia; National Health and Medical Research Council of Australia Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
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Anabolic Steroid Use for Weight and Strength Gain in Critically Ill Patients: A Case Series and Review of the Literature. Case Rep Crit Care 2018; 2018:4545623. [PMID: 29854477 PMCID: PMC5964539 DOI: 10.1155/2018/4545623] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/26/2018] [Accepted: 04/02/2018] [Indexed: 11/26/2022] Open
Abstract
Background An important long-term complication of critical illness is significant weakness and its resulting functional impairment. Recent advances have aimed to prevent critical illness weakness via early mobilisation of patients, minimising sedation, and optimising nutrition. One other potential treatment may be to provide anabolic support in the recovery phase, especially as patients have decreased levels of anabolic hormones. Case Presentation We describe a case series of 4 patients who had either (1) profound critical illness myopathy and (2) profound weight loss. All patients were already receiving appropriate nutritional support and physiotherapy. All patients had functional improvements in their muscle strength. Conclusions For patients in the recovery phase of critical illness, we provide examples of when anabolic steroid supplementation may assist the treating clinicians in rehabilitating their patients who are still in the Intensive Care Unit. We discuss patient selection and the current supporting literature for anabolic supplementation in critically ill patients.
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Gao Y, Wang N, Li RH, Xiao YZ. The Role of Autophagy and the Chemokine (C-X-C Motif) Ligand 16 During Acute Lung Injury in Mice. Med Sci Monit 2018; 24:2404-2412. [PMID: 29677174 PMCID: PMC5928852 DOI: 10.12659/msm.906016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Acute lung injury (ALI) is responsible for mortality in hospitalized patients. Autophagy can negatively regulate inflammatory response, and CXCL16 (chemokine (C-X-C motif) ligand 16) is a kind of chemokine, which is closely related to the inflammatory response. However, the relationship between autophagy and CXCL16 in ALI is still unclear. This study aimed to investigate the role of autophagy and chemokine CXCL16 in ALI in mice. Material/Methods Thirty-two male C57BL/6 mice were divided into four groups. The control group (C group) was given normal saline through intraperitoneal injection. The L group was given LPS (lipopolysaccharide) at 30 mg/kg to construct an ALI model. The 3-MA group received an intraperitoneal injection of inhibitor of autophagy 3-methyladenine at 15 mg/kg, 30 minutes before LPS injection. The anti-CXCL16 group was given 20 mg/kg of CXCL16 monoclonal antibody 30 minutes before the LPS injection. Results In the 3-MA Group, the level of histological analysis, lung wet/dry ratio, total protein of BAL (bronchoalveolar lavage fluid) and TNF-α level were higher than the L group (p<0.05), the level of autophagy was lower than the L group (p<0.05), and the level of CXCL16 was higher than the L group (p<0.05). In the anti-CXCL16 group, the level of histological analysis, lung wet/dry ratio, BAL protein, and TNF-α level were declined compared to the L group (p<0.05), but there was no statistically significant difference in expression of CXCL16 detected by ELISA between the anti-CXCL16 group and the L group (p>0.05). Conclusions Autophagy played a protective role in ALI induced by LPS in mice. Autophagy could regulate the level of CXCL16. The chemokine CXCL16 could exacerbate ALI.
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Affiliation(s)
- Ye Gao
- Department of Emergency Anesthesia, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China (mainland)
| | - Ni Wang
- Department of Emergency Anesthesia, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China (mainland)
| | - Rui H Li
- Department of Emergency Anesthesia, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China (mainland)
| | - Yang Z Xiao
- Department of Emergency Anesthesia, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China (mainland)
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Healthcare costs of ICU survivors are higher before and after ICU admission compared to a population based control group: A descriptive study combining healthcare insurance data and data from a Dutch national quality registry. J Crit Care 2018; 44:345-351. [DOI: 10.1016/j.jcrc.2017.12.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 11/24/2017] [Accepted: 12/10/2017] [Indexed: 11/24/2022]
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Biehl M, Ahmed A, Kashyap R, Barwise A, Gajic O. The Incremental Burden of Acute Respiratory Distress Syndrome: Long-term Follow-up of a Population-Based Nested Case-Control Study. Mayo Clin Proc 2018; 93:445-452. [PMID: 29499971 DOI: 10.1016/j.mayocp.2017.11.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the long-term survival of patients at similar risk for hospital-acquired acute respiratory distress syndrome (ARDS) who did and did not develop ARDS. METHODS We conducted long-term follow-up of a population-based nested case-control study in a consecutive cohort of adult Olmsted County, Minnesota, patients admitted from January 1, 2001, through December 31, 2010. Patients in whom ARDS developed during their hospital stay (cases) were matched to similar-risk patients without ARDS (controls) by 6 characteristics: age, sex, sepsis, high-risk surgery, ratio of oxygen saturation to fraction of inspired oxygen, and ARDS risk according to the Lung Injury Prediction Score. Hospital mortality, discharge disposition, and long-term survival were compared. RESULTS Patients who developed hospital-acquired ARDS (n=400) had higher hospital mortality than at-risk controls (n=400) (35% vs 5%; P<.001). Among hospital survivors (252 matched pairs), ARDS cases were more likely to be discharged to rehabilitation (13% vs 4%) and long-term care (30% vs 15%) facilities, whereas more controls were discharged home (71% vs 41%). After discharge, differences in survival persisted beyond 90 days (adjusted hazard ratio [HR], 1.76; 95% CI, 1.2-2.5; P=.002) and 6 months (adjusted HR, 1.73; 95% CI, 1.2-2.6; P<.001). CONCLUSION These results suggest that in a population-based matched case-control study of patients with similar characteristics at the time of hospital admission, those who developed hospital-acquired ARDS had worse long-term survival.
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Affiliation(s)
- Michelle Biehl
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Sanford USD Medical Center, Sioux Falls, SD
| | - Adil Ahmed
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Wichita Falls Family Practice Residency Program, North Central Texas Medical Foundation, Wichita Falls, TX
| | - Rahul Kashyap
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN
| | - Amelia Barwise
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Williams CN, Eriksson C, Piantino J, Hall T, Moyer D, Kirby A, McEvoy C. Long-term Sequelae of Pediatric Neurocritical Care: The Parent Perspective. J Pediatr Intensive Care 2018; 7:173-181. [PMID: 31073491 DOI: 10.1055/s-0038-1637005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/07/2018] [Indexed: 02/06/2023] Open
Abstract
Critical neurologic disease and injury affect thousands of children annually with survivors suffering high rates of chronic morbidities related directly to the illness and to critical care hospitalization. Postintensive care syndrome (PICS) in patients and families encompasses a variety of morbidities including physical, cognitive, emotional, and psychological impairments following critical care. We conducted a focus group study with parents of children surviving pediatric neurocritical care (PNCC) for traumatic brain injury, stroke, meningitis, or encephalitis to determine outcomes important to patients and families, identify barriers to care, and identify potential interventions to improve outcomes. Sixteen parents participated in four groups across Oregon. Three global themes were identified: (1) PNCC is an intense emotional experience for the whole family; (2) PNCC survivorship is a chronic illness; and (3) PNCC has a significant psychological and social impact. Survivors and their families suffer physical, emotional, psychological, cognitive, and social impairments for many years after discharge. Parents in this study highlighted the emotional and psychological distress in survivors and families after PNCC, in contrast to most PNCC research focusing on physical outcomes. Several barriers to care were identified with potential implications on survivor outcomes, including limited pediatric resources in rural settings, perceived lack of awareness of PICS among medical providers, and the substantial financial burden on families. Parents desire improved education surrounding PICS morbidities for families and medical providers, improved communication with primary care providers after discharge, access to educational materials for patients and families, direction to mental health providers, and family support groups to assist them in dealing with morbidities and accessing appropriate resources. Clinicians and researchers should consider the parent perspectives reported here when caring for and evaluating outcomes for children requiring PNCC.
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Affiliation(s)
- Cydni N Williams
- Division of Pediatric Critical Care, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, United States
| | - Carl Eriksson
- Division of Pediatric Critical Care, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, United States
| | - Juan Piantino
- Division of Pediatric Neurology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, United States
| | - Trevor Hall
- Division of Pediatric Psychology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, United States
| | - Danielle Moyer
- Division of Pediatric Psychology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, United States
| | - Aileen Kirby
- Division of Pediatric Critical Care, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, United States
| | - Cindy McEvoy
- Division of Neonatology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, United States
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Wang ZY, Li T, Wang CT, Xu L, Gao XJ. Assessment of 1-year Outcomes in Survivors of Severe Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation or Mechanical Ventilation: A Prospective Observational Study. Chin Med J (Engl) 2018; 130:1161-1168. [PMID: 28485315 PMCID: PMC5443021 DOI: 10.4103/0366-6999.205847] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: Little is known about the long-term outcomes of severe acute respiratory distress syndrome (ARDS) patients requiring extracorporeal membrane oxygenation (ECMO). This study aimed to investigate the 1-year outcomes of these patients or patients receiving mechanical ventilation (MV) and compare their health-related quality of life (HRQoL) to the general population. Methods: Severe ARDS survivors admitted to two ICUs in China between January 2012 and January 2014 were enrolled. Of the severe ARDS survivors enrolled, 1-year postdischarge, HRQoL assessment using the Short-Form 36 (SF-36) and EuroQol questionnaire dimensions, 6-min walking distance, chest computed tomography scan, pulmonary function, and arterial blood gas analysis were compared for ARDS patients with or without ECMO. Results: ARDS patients receiving ECMO had a significantly higher Acute Physiology and Chronic Health Evaluation II score (30.3 ± 6.7 vs. 26.5 ± 7.3, P = 0.036), lung injury score (3.3 ± 0.4 vs. 2.8 ± 0.5, P = 0.000), Sequential Organ Failure Assessment score (10.8 ± 3.5 vs. 7.9 ± 3.1, P = 0.000), lower PaO2/FiO2 ratio ([mmHg, 1 mmHg = 0.133 kPa], 68.3 ± 16.1 vs. 84.8 ± 16.5, P = 0.000), and increased extrapulmonary organ failure (2 [1, 3] vs. 1 [1, 1], P = 0.025) compared with patients not receiving ECMO. ECMO and non-ECMO survivors showed similar pulmonary function, morphological abnormalities, resting arterial blood gas values, and 6-min walking distance. Mild pulmonary dysfunction and abnormal morphology were observed in a few survivors. In addition, ECMO and non-ECMO survivors showed a similar quality of life. ECMO survivors showed lower SF-36 physical functioning and role-physical domain scores (minimum clinically significant difference at least 5 points), and non-ECMO survivors had similar outcome. Conclusions: One-year posthospital discharge, severe ARDS survivors receiving ECMO or MV demonstrated comparable outcomes. Compared with the general population, ARDS survivors showed reduced HRQoL. Pulmonary function and lung morphology revealed sufficient recovery with minor lung impairment.
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Affiliation(s)
- Zhi-Yong Wang
- Department of Critical Care Medicine, Tianjin Third Central Hospital, Artificial Cells Key Laboratory of Tianjin, Tianjin 300170, China
| | - Tong Li
- Heart Center, Tianjin Third Central Hospital, Tianjin 300170, China
| | - Chun-Ting Wang
- Department of Critical Care Medicine, Shandong Provincial Hospital, Jinan, Shandong 250021, China
| | - Lei Xu
- Department of Critical Care Medicine, Tianjin Third Central Hospital, Artificial Cells Key Laboratory of Tianjin, Tianjin 300170, China
| | - Xin-Jing Gao
- Department of Critical Care Medicine, Tianjin Third Central Hospital, Artificial Cells Key Laboratory of Tianjin, Tianjin 300170, China
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Bakhru RN, Davidson JF, Bookstaver RE, Kenes MT, Welborn KG, Morris PE, Clark Files D. Physical function impairment in survivors of critical illness in an ICU Recovery Clinic. J Crit Care 2018; 45:163-169. [PMID: 29494941 DOI: 10.1016/j.jcrc.2018.02.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/08/2018] [Accepted: 02/02/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE The aims were to 1) determine feasibility of measuring physical function in our ICU Recovery Clinic (RC), 2) determine if physical function was associated with 6-month re-hospitalization and 1-year mortality and 3) compare ICU survivors' physical function to other comorbid populations. MATERIALS AND METHODS We established the Wake Forest ICU RC. Patients were seen in clinic 1month following hospital discharge. Testing included the Short Form-36 questionnaire and Short Physical Performance Battery (SPPB). We related these measures to 6month re-hospitalizations and 1year mortality, and compared patients' functional performance with other comorbid populations. RESULTS Thirty-six patients were seen in clinic from July 2014 to June 2015; the median SPPB score was 5 (IQR 5). The median SF-36 physical component summary score was 21.8 (IQR 28.8). Mortality was 14% at 1year. Of those who did not die by 1year, 35% were readmitted to our hospital within 6months of hospital discharge. SPPB scores demonstrated a non-significant trend with both mortality (p=0.06) and readmissions (p=0.09). ICU survivors' SPPB scores were significantly lower than those of other chronically ill populations (p<0.001). CONCLUSIONS Physical function measurement in a recovery clinic is feasible and may inform subsequent morbidity and mortality.
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Affiliation(s)
- Rita N Bakhru
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA; Critical Illness Injury and Recovery Research Center, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA.
| | - James F Davidson
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Rebecca E Bookstaver
- Department of Pharmacy, Wake Forest Baptist Medical Center, Medical Center Blvd, Winston-Salem, NC 27157, USA.
| | - Michael T Kenes
- Department of Pharmacy, Wake Forest Baptist Medical Center, Medical Center Blvd, Winston-Salem, NC 27157, USA.
| | - Kristin G Welborn
- Department of Pharmacy, Wake Forest Baptist Medical Center, Medical Center Blvd, Winston-Salem, NC 27157, USA.
| | - Peter E Morris
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, 740 S. Limestone, Lexington, KY 40536, USA.
| | - D Clark Files
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA; Critical Illness Injury and Recovery Research Center, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA; Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA.
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Kim D. Rehabilitation and Intensive Care Unit. Acute Crit Care 2018; 33:43-45. [PMID: 31723859 PMCID: PMC6848999 DOI: 10.4266/acc.2018.00080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Deokkyu Kim
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Hospital, Jeonju, Korea
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Abstract
RATIONALE Limited data are available to characterize the long-term outcomes and associated costs for patients who require prolonged mechanical ventilation (PMV; defined here as mechanical ventilation for longer than 21 d). OBJECTIVES To examine the association between PMV and mortality, health care utilization, and costs after critical illness. METHODS Population-based cohort study of adults who received mechanical ventilation in an intensive care unit (ICU) in Ontario, Canada between 2002 and 2013. MEASUREMENT AND MAIN RESULTS We used linked administrative databases to determine discharge disposition, and ascertain 1-year mortality (primary outcome), readmissions to hospital and ICU, and health care costs for hospital survivors. Overall, 11,594 (5.4%) patients underwent PMV, with 42.4% of patients dying in the hospital (vs. 27.6% of patients who did not undergo prolonged ventilation; P < 0.0001). Patients on prolonged ventilation were more frequently discharged to other facilities or home with health care support (84.8 vs. 43.5%, P < 0.0001). Among hospital survivors, estimated mortality was higher for patients who underwent PMV: 16.6 versus 11% at 1 year and 42.0 versus 30.4% at 5 years. At 1 year after hospital discharge, patients on prolonged ventilation had higher rates of hospital readmission (47.2 vs. 37.7%; adjusted odds ratio = 1.20; 95% confidence interval = 1.14-1.26), ICU readmission (19.0 vs. 11.6%; adjusted odds ratio = 1.49; 95% confidence interval: 1.39, 1.60), and total health care costs: median (interquartile range) Can $32,526 ($20,821-$56,102) versus Can $13,657 ($5,946-$38,022). Increasing duration of mechanical ventilation was associated with higher mortality and health care utilization. CONCLUSIONS Critically ill patients who undergo mechanical ventilation in an ICU for longer than 21 days have high in-hospital mortality and greater postdischarge mortality, health care utilization, and health care costs compared with patients who undergo mechanical ventilation for a shorter period of time.
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Persistent Inflammation, Immunosuppression and Catabolism after Severe Injury or Infection. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [DOI: 10.1007/978-3-319-73670-9_3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Herridge MS. Fifty Years of Research in ARDS. Long-Term Follow-up after Acute Respiratory Distress Syndrome. Insights for Managing Medical Complexity after Critical Illness. Am J Respir Crit Care Med 2017; 196:1380-1384. [PMID: 28767270 DOI: 10.1164/rccm.201704-0815ed] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Critical illness is not a discrete disease state or syndrome. It is the culmination of a multiplicity of heterogeneous disease states and their varied health trajectories leading to extreme illness that requires advanced life support in a distinct geographic location in the hospital. It is a marker of newly acquired or worsened medical complexity and multimorbidities. Fifty years ago, distinguished critical care colleagues identified a syndrome of severe lung injury that united a group of patients with disparate admitting diagnoses. Acute respiratory distress syndrome continues to represent an important, incremental insult and risk modifier of acute and longer-term outcome, but it does not solely define our patients or their outcomes in isolation. Over the next 50 years, our research and clinical agenda needs to sharpen our lens on the fundamental importance of our patients' pre-critical illness health status, their intrinsic susceptibilities to tissue injury, and their innate and varied resiliencies. We need to take responsibility for the contribution that we make to morbidity through our practice in the intensive care unit each day. Engagement in frank and transparent communication with our patients and their caregivers about the very real and morbid consequences of being this sick is essential. We must enforce explicit consent about the morbidity of innovative, experimental, or high-risk medical and surgical procedures and ensure that our ongoing level of treatment aligns with patients' and caregivers' goals and values. Interprofessional and multidisciplinary collaboration is crucial to modify existing complex care pathways for our patients and their families to foster optimal rehabilitation and reintegration into the workplace and community.
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Affiliation(s)
- Margaret S Herridge
- 1 Critical Care and Respiratory Medicine.,2 Toronto General Research Institute.,3 Institute of Medical Sciences, and.,4 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Cherian RA, P P, Panda BK. Direct medical costs in management of preterm neonates with respiratory distress syndrome in an Indian tertiary care teaching hospital. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2017. [DOI: 10.1111/jphs.12192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Reshma Alice Cherian
- Department of Clinical Pharmacy; Poona College of Pharmacy; Bharati Vidyapeeth Deemed University; Pune India
| | - Prabhadevi P
- Department of Clinical Pharmacy; Poona College of Pharmacy; Bharati Vidyapeeth Deemed University; Pune India
| | - Bijoy Kumar Panda
- Department of Clinical Pharmacy; Poona College of Pharmacy; Bharati Vidyapeeth Deemed University; Pune India
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Bellingan G, Brealey D, Mancebo J, Mercat A, Patroniti N, Pettilä V, Quintel M, Vincent JL, Maksimow M, Jalkanen M, Piippo I, Ranieri VM. Comparison of the efficacy and safety of FP-1201-lyo (intravenously administered recombinant human interferon beta-1a) and placebo in the treatment of patients with moderate or severe acute respiratory distress syndrome: study protocol for a randomized controlled trial. Trials 2017; 18:536. [PMID: 29132404 PMCID: PMC5683224 DOI: 10.1186/s13063-017-2234-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 10/04/2017] [Indexed: 11/11/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) results in vascular leakage, inflammation and respiratory failure. There are currently no approved pharmacological treatments for ARDS and standard of care involves treatment of the underlying cause, and supportive care. The vascular leakage may be related to reduced concentrations of local adenosine, which is involved in maintaining endothelial barrier function. Interferon (IFN) beta-1a up-regulates the cell surface ecto-5′-nucleotidase cluster of differentiation 73 (CD73), which increases adenosine levels, and IFN beta-1 may, therefore, be a potential treatment for ARDS. In a phase I/II, open-label study in 37 patients with acute lung injury (ALI)/ARDS, recombinant human IFN beta-1a was well tolerated and mortality rates were significantly lower in treated than in control patients. Methods/design In this phase III, double-blind, randomized, parallel-group trial, the efficacy and safety of recombinant human IFN beta-1a (FP-1201-lyo) will be compared with placebo in adult patients with ARDS. Patients will be randomly assigned to receive 10 μg FP-1201-lyo or placebo administered intravenously once daily for 6 days and will be monitored for 28 days or until discharged from the intensive care unit. Follow-up visits will then take place at days 90, 180 and 360. The primary endpoint is a composite endpoint including any cause of death at 28 days and days free of mechanical ventilation within 28 days among survivors. Secondary endpoints include: all-cause mortality at 28, 90, 180 and 360 days; organ failure-free days; length of hospital stay; pharmacodynamic assessment including measurement of myxovirus resistance protein A concentrations; and measures of quality of life, respiratory and neurological function at 180 and 360 days. The estimated sample size to demonstrate a reduction in the primary outcome between groups from 30% to 15% is 300 patients, and the study will be conducted in 70–80 centers in nine countries across Europe. Discussion There are no effective specific treatments for patients with ARDS and mortality rates remain high. The results from this study will provide evidence regarding the efficacy of a potential new therapeutic agent, FP-1201-lyo, in improving the clinical course and outcome for patients with moderate/severe ARDS. Trial registration European Union Clinical Trials Register, no: 2014-005260-15. Registered on 15 July 2017. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2234-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Geoff Bellingan
- Division of Critical Care, University College London Hospitals, NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK
| | - David Brealey
- Division of Critical Care, University College London Hospitals, NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK.,The NIHR University College London Hospitals Biomedical Research Centre, University College London Hospitals, NHS Foundation Trust, 235 Euston Road, London, NW1 2BU, UK
| | - Jordi Mancebo
- Department of Intensive Care, Hospital de la Santa Creu I Sant Pau, Carrer de Sant Quintí, 89, 08026, Barcelona, Spain
| | - Alain Mercat
- Service de Réanimation, CHU D'Angers, 4 Rue Larrey, 49100, Angers, France
| | - Nicolò Patroniti
- Dipartimento di Emergenza e Urgenza, Azienda Ospedaliera San Gerardo, Via Giambattista Pergolesi 33, 20052, Monza, Italy
| | - Ville Pettilä
- Department of Intensive Care, Helsinki University Hospital, Haartmaninkatu 4, Helsinki, 00290, Finland
| | - Michael Quintel
- Anesthesiology and Operative Intensive Care Medicine, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Mikael Maksimow
- Faron Pharmaceuticals Oy, Joukahaisenkatu 6, 20520, Turku, Finland
| | - Markku Jalkanen
- Faron Pharmaceuticals Oy, Joukahaisenkatu 6, 20520, Turku, Finland
| | - Ilse Piippo
- Faron Pharmaceuticals Oy, Joukahaisenkatu 6, 20520, Turku, Finland
| | - V Marco Ranieri
- Department of Anesthesia and Critical Care Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161, Rome, Italy
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137
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Wilcox ME, Jaramillo-Rocha V, Hodgson C, Taglione MS, Ferguson ND, Fan E. Long-Term Quality of Life After Extracorporeal Membrane Oxygenation in ARDS Survivors: Systematic Review and Meta-Analysis. J Intensive Care Med 2017; 35:233-243. [PMID: 29050526 DOI: 10.1177/0885066617737035] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE Extracorporeal membrane oxygenation (ECMO) is an increasingly prevalent treatment for acute respiratory failure (ARF). To evaluate the impact of ECMO support on long-term outcomes for critically ill adults with ARF. METHODS We searched electronic databases 1948 through to November 30 2016; selected controlled trials or observational studies of critically ill adults with acute respiratory distress syndrome, examining long-term morbidity specifically health-related quality of life (HRQL); 2 authors independently selected studies, extracted data, and assessed methodological quality. ANALYSIS Of the 633 citations, 1 randomized controlled trial and 5 observational studies met the selection criteria. Overall quality of observational studies was moderate to high (mean score on Newcastle-Ottawa scale, 7.2/9; range, 6-8). In 3 studies (n = 245), greater decrements in HRQL were seen for survivors of ECMO when compared to survivors of conventional mechanical ventilation (CMV) as measured by the Short Form 36 (SF-36) scores ([ECMO-CMV]: 5.40 [95% confidence interval, CI, 4.11 to 6.68]). As compared to CMV survivors, those who received ECMO experienced significantly less psychological morbidity (2 studies; n = 217 [ECMO-CMV]: mean weighted difference [MWD], -1.31 [95% CI, -1.98 to -0.64] for depression and MWD, -1.60 [95% CI, -1.80 to -1.39] for anxiety). CONCLUSIONS Further studies are required to confirm findings and determine prognostic factors associated with more favorable outcomes in survivors of ECMO.
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Affiliation(s)
- M Elizabeth Wilcox
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Valente Jaramillo-Rocha
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Carol Hodgson
- Australia and New Zealand Intensive Care-Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,The Alfred Hospital, Melbourne, Australia
| | - Michael S Taglione
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eddy Fan
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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138
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Tokarz DA, Heffelfinger AK, Jima DD, Gerlach J, Shah RN, Rodriguez-Nunez I, Kortum AN, Fletcher AA, Nordone SK, Law JM, Heber S, Yoder JA. Disruption of Trim9 function abrogates macrophage motility in vivo. J Leukoc Biol 2017; 102:1371-1380. [PMID: 29021367 DOI: 10.1189/jlb.1a0816-371r] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 09/01/2017] [Accepted: 09/26/2017] [Indexed: 11/24/2022] Open
Abstract
The vertebrate immune response comprises multiple molecular and cellular components that interface to provide defense against pathogens. Because of the dynamic complexity of the immune system and its interdependent innate and adaptive functionality, an understanding of the whole-organism response to pathogen exposure remains unresolved. Zebrafish larvae provide a unique model for overcoming this obstacle, because larvae are protected against pathogens while lacking a functional adaptive immune system during the first few weeks of life. Zebrafish larvae were exposed to immune agonists for various lengths of time, and a microarray transcriptome analysis was executed. This strategy identified known immune response genes, as well as genes with unknown immune function, including the E3 ubiquitin ligase tripartite motif-9 (Trim9). Although trim9 expression was originally described as "brain specific," its expression has been reported in stimulated human Mϕs. In this study, we found elevated levels of trim9 transcripts in vivo in zebrafish Mϕs after immune stimulation. Trim9 has been implicated in axonal migration, and we therefore investigated the impact of Trim9 disruption on Mϕ motility and found that Mϕ chemotaxis and cellular architecture are subsequently impaired in vivo. These results demonstrate that Trim9 mediates cellular movement and migration in Mϕs as well as neurons.
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Affiliation(s)
- Debra A Tokarz
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Amy K Heffelfinger
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Dereje D Jima
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA.,Center for Human Health and the Environment, North Carolina State University, Raleigh, North Carolina, USA.,Bioinformatics Research Center, North Carolina State University, Raleigh, North Carolina, USA
| | - Jamie Gerlach
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Radhika N Shah
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Ivan Rodriguez-Nunez
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Amanda N Kortum
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Ashley A Fletcher
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Shila K Nordone
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| | - J McHugh Law
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA.,Department of Population Health and Pathobiology, North Carolina State University, Raleigh, North Carolina, USA; and
| | - Steffen Heber
- Department of Computer Science, North Carolina State University, Raleigh, North Carolina, USA
| | - Jeffrey A Yoder
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA; .,Center for Human Health and the Environment, North Carolina State University, Raleigh, North Carolina, USA.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
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139
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Bear DE, Wandrag L, Merriweather JL, Connolly B, Hart N, Grocott MPW. The role of nutritional support in the physical and functional recovery of critically ill patients: a narrative review. Crit Care 2017; 21:226. [PMID: 28841893 PMCID: PMC6389279 DOI: 10.1186/s13054-017-1810-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The lack of benefit from randomised controlled trials has resulted in significant controversy regarding the role of nutrition during critical illness in terms of long-term recovery and outcome. Although methodological caveats with a failure to adequately appreciate biological mechanisms may explain these disappointing results, it must be acknowledged that nutritional support during early critical illness, when considered alone, may have limited long-term functional impact.This narrative review focuses specifically on recent clinical trials and evaluates the impact of nutrition during critical illness on long-term physical and functional recovery.Specific focus on the trial design and methodological limitations has been considered in detail. Limitations include delivery of caloric and protein targets, patient heterogeneity, short duration of intervention, inappropriate clinical outcomes and a disregard for baseline nutritional status and nutritional intake in the post-ICU period.With survivorship at the forefront of critical care research, it is imperative that nutrition studies carefully consider biological mechanisms and trial design because these factors can strongly influence outcomes, in particular long-term physical and functional outcome. Failure to do so may lead to inconclusive clinical trials and consequent rejection of the potentially beneficial effects of nutrition interventions during critical illness.
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Affiliation(s)
- Danielle E. Bear
- Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Division of Asthma, Allergy, and Lung Biology, King’s College London, London, UK
- National Institute for Health Research (NIHR), Guy’s and St Thomas’ NHS Foundation Biomedical Research Centre, London, UK
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Liesl Wandrag
- Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Judith L. Merriweather
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Bronwen Connolly
- National Institute for Health Research (NIHR), Guy’s and St Thomas’ NHS Foundation Biomedical Research Centre, London, UK
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Centre for Human and Aerospace Physiological Sciences, King’s College London, London, UK
- Department of Physiotherapy, The University of Melbourne, Melbourne, VIC Australia
| | - Nicholas Hart
- Division of Asthma, Allergy, and Lung Biology, King’s College London, London, UK
- National Institute for Health Research (NIHR), Guy’s and St Thomas’ NHS Foundation Biomedical Research Centre, London, UK
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Michael P. W. Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Southampton, UK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research Centre, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - on behalf of the Enhanced Recovery After Critical Illness Programme Group (ERACIP) investigators
- Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Division of Asthma, Allergy, and Lung Biology, King’s College London, London, UK
- National Institute for Health Research (NIHR), Guy’s and St Thomas’ NHS Foundation Biomedical Research Centre, London, UK
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Human and Aerospace Physiological Sciences, King’s College London, London, UK
- Department of Physiotherapy, The University of Melbourne, Melbourne, VIC Australia
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Southampton, UK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research Centre, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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140
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Rückert F, Steinke T, Flöther L, Bucher M, Metz D, Frantz S, Charitos EI, Treede H, Raspé C. Predictors for quality of life of patients with a portable out-of-centre-implanted extracorporeal membrane oxygenation device. Interact Cardiovasc Thorac Surg 2017; 24:542-548. [PMID: 28040752 DOI: 10.1093/icvts/ivw398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 09/19/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives Despite progress in the treatment of cardiopulmonary organ failure, the mortality rate for patients with acute respiratory distress syndrome (ARDS) and cardiogenic shock remains high. Extracorporeal membrane oxygenation (ECMO) is a promising treatment option, but long-term outcomes and health-related quality of life (HRQOL) are unknown. Methods Detailed information related to pre- and post-device data and outcomes from a consecutive sample of 71 patients treated with ECMO was analysed. Long-term survivors were given a detailed follow-up examination after a median time of 31 months that included multiple scoring systems for HRQOL assessment. Results Seventy-one patients received a portable out-of-centre-implanted ECMO system. The survival rate at hospital discharge was 48%. Median HRQOL scores were 80% on the Karnofsky index (normal ≥80%), 80% on the Euroqol-5D (normal ≥75%) and 73.1% on the quality-of-life index (normal ≥70%). Mental scores were 96.7% on the Mini-Mental State Examination (normal ≥90.0%), 77.8% on the DemTect (normal ≥72.0%), 87.0% on the test for early detection of dementia with depression demarcation (TFDD; normal ≥74.0%) and confirmed good mental state and HRQOL for patients at follow-up. Univariate analysis for in-hospital mortality indicated that ventilation time before device implantation, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, higher lactate level at the time of ECMO implantation and female gender were associated with adverse outcomes. Conclusions In our cohort of patients, survivors of out-of-hospital ECMO implantation demonstrated good mental and quality-of-life conditions with well-recovered cardiopulmonary function during long-term follow-up. The indicators for adverse outcomes, pre-implantation lactate levels, pre-ventilation time and APACHE II score, should be considered before implantation of an ECMO device. Clinical trial This study is registered at DRKS (Deutsches Register Klinischer Studien) under the code DRKS00009735 and was submitted to the WHO.
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Affiliation(s)
- Florian Rückert
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle (Saale), Germany.,Department of Cardiac Surgery, Halle-Wittenberg University, Halle (Saale), Germany
| | - Thomas Steinke
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle (Saale), Germany
| | - Lilit Flöther
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle (Saale), Germany
| | - Michael Bucher
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle (Saale), Germany
| | - Dietrich Metz
- Department of Cardiac Surgery, Halle-Wittenberg University, Halle (Saale), Germany
| | - Stefan Frantz
- Department of Internal Medicine III, Halle-Wittenberg University, Halle (Saale), Germany
| | | | - Hendrik Treede
- Department of Cardiac Surgery, Halle-Wittenberg University, Halle (Saale), Germany
| | - Christoph Raspé
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle (Saale), Germany
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141
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Mei SHJ, Dos Santos CC, Stewart DJ. Advances in Stem Cell and Cell-Based Gene Therapy Approaches for Experimental Acute Lung Injury: A Review of Preclinical Studies. Hum Gene Ther 2017; 27:802-812. [PMID: 27531647 DOI: 10.1089/hum.2016.063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Given the failure of pharmacological interventions in acute respiratory distress syndrome (ARDS), researchers have been actively pursuing novel strategies to treat this devastating, life-threatening condition commonly seen in the intensive care unit. There has been considerable research on harnessing the reparative properties of stem and progenitor cells to develop more effective therapeutic approaches for respiratory diseases with limited treatment options, such as ARDS. This review discusses the preclinical literature on the use of stem and progenitor cell therapy and cell-based gene therapy for the treatment of preclinical animal models of acute lung injury (ALI). A variety of cell types that have been used in preclinical models of ALI, such as mesenchymal stem cells, endothelial progenitor cells, and induced pluripotent stem cells, were evaluated. At present, two phase I trials have been completed and one phase I/II clinical trial is well underway in order to translate the therapeutic benefit gleaned from preclinical studies in complex animal models of ALI to patients with ARDS, paving the way for what could potentially develop into transformative therapy for critically ill patients. As we await the results of these early cell therapy trials, future success of stem cell therapy for ARDS will depend on selection of the most appropriate cell type, route and timing of cell delivery, enhancing effectiveness of cells (i.e., potency), and potentially combining beneficial cells and genes (cell-based gene therapy) to maximize therapeutic efficacy. The experimental models and scientific methods exploited to date have provided researchers with invaluable knowledge that will be leveraged to engineer cells with enhanced therapeutic capabilities for use in the next generation of clinical trials.
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Affiliation(s)
- Shirley H J Mei
- 1 Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Claudia C Dos Santos
- 2 The Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada.,3 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Duncan J Stewart
- 1 Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,4 Department of Medicine, University of Ottawa , Ottawa, Ontario, Canada
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142
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Healthcare utilization and costs in ARDS survivors: a 1-year longitudinal national US multicenter study. Intensive Care Med 2017; 43:980-991. [DOI: 10.1007/s00134-017-4827-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 04/28/2017] [Indexed: 10/19/2022]
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143
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Healthcare Resource Use and Costs in Long-Term Survivors of Acute Respiratory Distress Syndrome: A 5-Year Longitudinal Cohort Study. Crit Care Med 2017; 45:196-204. [PMID: 27748659 DOI: 10.1097/ccm.0000000000002088] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the time-varying relationship of annual physical, psychiatric, and quality of life status with subsequent inpatient healthcare resource use and estimated costs. DESIGN Five-year longitudinal cohort study. SETTING Thirteen ICUs at four teaching hospitals. PATIENTS One hundred thirty-eight patients surviving greater than or equal to 2 years after acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Postdischarge inpatient resource use data (e.g., hospitalizations, skilled nursing, and rehabilitation facility stays) were collected via a retrospective structured interview at 2 years, with prospective collection every 4 months thereafter, until 5 years postacute respiratory distress syndrome. Adjusted odds ratios for hospitalization and relative medians for estimated episode of care costs were calculated using marginal longitudinal two-part regression. The median (interquartile range) number of inpatient admission hospitalizations was 4 (2-8), with 114 patients (83%) reporting greater than or equal to one hospital readmission. The median (interquartile range) estimated total inpatient postdischarge costs over 5 years were $58,500 ($19,700-157,800; 90th percentile, $328,083). Better annual physical and quality of life status, but not psychiatric status, were associated with fewer subsequent hospitalizations and lower follow-up costs. For example, greater grip strength (per 6 kg) had an odds ratio (95% CI) of 0.85 (0.73-1.00) for inpatient admission, with 23% lower relative median costs, 0.77 (0.69-0.87). CONCLUSIONS In a multisite cohort of long-term acute respiratory distress syndrome survivors, better annual physical and quality of life status, but not psychiatric status, were associated with fewer hospitalizations and lower healthcare costs.
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Agus A, Hulme C, Verghis RM, McDowell C, Jackson C, O'Kane CM, Laffey JG, McAuley DF. Simvastatin for patients with acute respiratory distress syndrome: long-term outcomes and cost-effectiveness from a randomised controlled trial. Crit Care 2017; 21:108. [PMID: 28511660 PMCID: PMC5434552 DOI: 10.1186/s13054-017-1695-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/02/2017] [Indexed: 11/17/2022] Open
Abstract
Background Simvastatin therapy for patients with acute respiratory distress syndrome (ARDS) has been shown to be safe and associated with minimal adverse effects, but it does not improve clinical outcomes. The aim of this research was to report on mortality and cost-effectiveness of simvastatin in patients with ARDS at 12 months. Methods This was a cost-utility analysis alongside a multicentre, double-blind, randomised controlled trial carried out in the UK and Ireland. Five hundred and forty intubated and mechanically ventilated patients with ARDS were randomly assigned (1:1) to receive once-daily simvastatin (at a dose of 80 mg) or identical placebo tablets enterally for up to 28 days. Results Mortality was lower in the simvastatin group (31.8%, 95% confidence interval (CI) 26.1–37.5) compared to the placebo group (37.3%, 95% CI 31.6–43.0) at 12 months, although this was not significant. Simvastatin was associated with statistically significant quality-adjusted life year (QALY) gain (incremental QALYs 0.064, 95% CI 0.002–0.127) compared to placebo. Simvastatin was also less costly (incremental total costs –£3601, 95% CI –8061 to 859). At a willingness-to-pay threshold of £20,000 per QALY, the probability of simvastatin being cost-effective was 99%. Sensitivity analyses indicated that the results were robust to changes in methodological assumptions with the probability of cost-effectiveness never dropping below 90%. Conclusion Simvastatin was found to be cost-effective for the treatment of ARDS, being associated with both a significant QALY gain and a cost saving. There was no significant reduction in mortality at 12 months, Trial registration ISRCTN, 88244364. Registered 26 November 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1695-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A Agus
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK.
| | - C Hulme
- Academic Unit of Health Economics, University of Leeds, Charles Thackrah Building, Clarendon Road, Leeds, LS2 9LJ, UK
| | - R M Verghis
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK.,Centre for Infection and Immunity, Queen's University of Belfast, Belfast, BT9 7AE, UK
| | - C McDowell
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK
| | - C Jackson
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK
| | - C M O'Kane
- Centre for Infection and Immunity, Queen's University of Belfast, Belfast, BT9 7AE, UK
| | - J G Laffey
- Department of Anaesthesia, School of Medicine, HRB Galway Clinical Research Facility, Clinical Sciences Institute, National University of Ireland, Galway, Ireland.,Department of Anesthesia, Centre for Critical Care Research, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - D F McAuley
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK.,Centre for Infection and Immunity, Queen's University of Belfast, Belfast, BT9 7AE, UK.,Regional Intensive Care Unit, The Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, UK
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145
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Herrup EA, Wieczorek B, Kudchadkar SR. Characteristics of postintensive care syndrome in survivors of pediatric critical illness: A systematic review. World J Crit Care Med 2017; 6:124-134. [PMID: 28529914 PMCID: PMC5415852 DOI: 10.5492/wjccm.v6.i2.124] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 02/25/2017] [Accepted: 03/24/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To synthesize the available evidence focusing on morbidities in pediatric survivors of critical illness that fall within the defined construct of postintensive care syndrome (PICS) in adults, including physical, neurocognitive and psychological morbidities.
METHODS A comprehensive search was conducted in MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and CINAHL using controlled vocabulary and key word terms to identify studies reporting characteristics of PICS in pediatric intensive care unit (PICU) patients. Two reviewers independently screened all titles and abstracts and performed data extraction. From the 3176 articles identified in the search, 252 abstracts were identified for full text review and nineteen were identified for inclusion in the review. All studies reporting characteristics of PICS in PICU patients were included in the final synthesis.
RESULTS Nineteen studies meeting inclusion criteria published between 1995 and 2016 were identified and categorized into studies reporting morbidities in each of three categories-physical, neurocognitive and psychological. The majority of included articles reported prospective cohort studies, and there was significant variability in the outcome measures utilized. A synthesis of the studies indicate that morbidities encompassing PICS are well-described in children who have survived critical illness, often resolving over time. Risk factors for development of these morbidities include younger age, lower socioeconomic status, increased number of invasive procedures or interventions, type of illness, and increased benzodiazepine and narcotic administration.
CONCLUSION PICS-related morbidities impact a significant proportion of children discharged from PICUs. In order to further define PICS in children, more research is needed using standardized tools to better understand the scope and natural history of morbidities after hospital discharge. Improving our understanding of physical, neurocognitive, and psychological morbidities after critical illness in the pediatric population is imperative for designing interventions to improve long-term outcomes in PICU patients.
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146
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Club cell protein 16 and cytokeratin fragment 21-1 as early predictors of pulmonary complications in polytraumatized patients with severe chest trauma. PLoS One 2017; 12:e0175303. [PMID: 28380043 PMCID: PMC5381917 DOI: 10.1371/journal.pone.0175303] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 03/23/2017] [Indexed: 01/11/2023] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) and pneumonia have a great impact on the treatment regimen of polytraumatized patients with severe chest trauma. The objective of our study was to determine whether biomarker levels assessed shortly after multiple trauma may predict the occurrence of these conditions. Methods and findings Our patient population included 71 men and 30 women (mean age, 40.3 ± 15.8 years) with an Injury Severity Score that ranged from 17 to 59 and an Abbreviated Injury Scale Thorax of at least 3. They were admitted to our level I trauma center within one post-traumatic hour and survived for at least 24 hours after the trauma occurred. Thirty-five patients developed ARDS, 30 patients pneumonia and 21 patients both. Five individuals died during hospitalization. The levels of five selected biomarkers, which were identified by a literature search, were assessed at admission (initial levels) and on day 2 after trauma. We performed comparisons of medians, logistic regression analyses and receiver operating characteristic analyses for initial and day-2 levels of each biomarker. With regard to ARDS, initial levels of cytokeratin fragment 21–1, the soluble fragment of cytokeratin 19 (CYFRA21-1) and of the club cell protein 16 (CC16) provided significant results in each statistical analysis. With regard to pneumonia, each statistical analysis supplied significant results for both initial and day-2 levels of CYFRA21-1 and CC16. Consistently, initial CYFRA21-1 levels were identified as the most promising predictor of ARDS, whereas day-2 CC16 levels have to be considered as most appropriate for predicting pneumonia. Conclusions CYFRA21-1 levels exceeding cut-off value of 1.85 ng/ml and 2.49 ng/ml in the serum shortly after multiple injury occurred may identify polytraumatized patients at risk for ARDS and pneumonia, respectively. However, CC16 levels exceeding 30.51 ng/ml on day 2 may allow a firmer diagnosis for the development of pneumonia.
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147
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Hopkins RO, Mitchell L, Thomsen GE, Schafer M, Link M, Brown SM. Implementing a Mobility Program to Minimize Post-Intensive Care Syndrome. AACN Adv Crit Care 2017; 27:187-203. [PMID: 27153308 DOI: 10.4037/aacnacc2016244] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Immobility in the intensive care unit (ICU) is associated with neuromuscular weakness, post-intensive care syndrome, functional limitations, and high costs. Early mobility-based rehabilitation in the ICU is feasible and safe. Mobility-based rehabilitation varied widely across 5 ICUs in 1 health care system, suggesting a need for continuous training and evaluation to maintain a strong mobility-based rehabilitation program. Early mobility-based rehabilitation shortens ICU and hospital stays, reduces delirium, and increases muscle strength and the ability to ambulate. Long-term effects include increased ability for self-care, faster return to independent functioning, improved physical function, and reduced hospital readmission and death. Factors that influence early mobility-based rehabilitation include having an interdisciplinary team; strong unit leadership; access to physical, occupational, and respiratory therapists; a culture focused on patient safety and quality improvement; a champion of early mobility; and a focus on measuring performance and outcomes.
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Affiliation(s)
- Ramona O Hopkins
- Ramona O. Hopkins is Professor, Department of Psychology and Neuroscience Center, Brigham Young University, Provo, Utah, and Clinical Research Investigator, Center for Humanizing Critical Care, and Department of Medicine, Pulmonary and Critical Care Division, Intermountain Healthcare, 5121 South Cottonwood St, Murray, UT 84107 . Lorie Mitchell is Nurse Manager, Shock Trauma Intensive Care Unit, Department of Medicine, Intermountain Medical Center. George E. Thomsen is Medical Director, Coronary Intensive Care Unit, Department of Medicine, Intermountain Medical Center. Michele Schafer is Member, Intensive Care Unit Patient-Family Advisory Council, Intermountain Medical Center. Maggie Link is Physical Therapist, Shock Trauma Intensive Care Unit, Intermountain Medical Center. Samuel M. Brown is Director, Center for Humanizing Critical Care, Assistant Professor of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Healthcare, and University of Utah School of Medicine, Salt Lake City, Utah
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148
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Statin therapy for acute respiratory distress syndrome: an individual patient data meta-analysis of randomised clinical trials. Intensive Care Med 2016; 43:663-671. [PMID: 28004129 DOI: 10.1007/s00134-016-4649-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 12/08/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE We performed an individual patient data meta-analysis to assess the possible benefits and harms of statin therapy in adults with acute respiratory distress syndrome (ARDS) and to investigate effects in specific ARDS subgroups. METHODS We identified randomised clinical trials up to 31 October 2016 that had investigated statin therapy versus placebo in patients with ARDS. Individual patient data from each trial were compiled. Conventional two-stage meta-analyses were performed for primary and secondary outcomes, and one-stage regression models with single treatment-covariate interactions for subgroup analyses. Risk of bias was assessed using the Cochrane Risk of Bias Tool. RESULTS Six trials with a total of 1755 patients were included. For the primary outcomes, there was no significant effect of statin therapy on 28-day mortality [relative risk (RR) 1.03, 95% CI 0.86-1.23], ventilator-free days (mean difference 0.34 days, 95% CI -0.68 to 1.36) or serious adverse events (RR 1.14, 95% CI 0.84-1.53). There was a significantly increased incidence of raised serum creatine kinase or transaminase levels with statin therapy (106/879; 12.1%) versus control (78/876; 8.9%) (RR 1.40, 95% CI 1.07-1.83, p = 0.015). There were no significant treatment-covariate interactions in the predefined subgroups investigated. CONCLUSIONS We found no clinical benefit from initiation of statin therapy in adult patients with ARDS, either overall or in predefined subgroups. While there was an increased incidence of raised serum creatine kinase and transaminase levels, there was no difference in serious adverse events among groups. Therefore, we do not recommend initiation of statin therapy for the treatment of ARDS.
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149
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Connolly B, Salisbury L, O'Neill B, Geneen L, Douiri A, Grocott MPW, Hart N, Walsh TS, Blackwood B. Exercise rehabilitation following intensive care unit discharge for recovery from critical illness: executive summary of a Cochrane Collaboration systematic review. J Cachexia Sarcopenia Muscle 2016; 7:520-526. [PMID: 27891297 PMCID: PMC5114628 DOI: 10.1002/jcsm.12146] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/02/2016] [Indexed: 01/26/2023] Open
Abstract
Skeletal muscle wasting and weakness are major complications of critical illness and underlie the profound physical and functional impairments experienced by survivors after discharge from the intensive care unit (ICU). Exercise-based rehabilitation has been shown to be beneficial when delivered during ICU admission. This review aimed to determine the effectiveness of exercise rehabilitation initiated after ICU discharge on primary outcomes of functional exercise capacity and health-related quality of life. We sought randomized controlled trials, quasi-randomized controlled trials, and controlled clinical trials comparing an exercise intervention commenced after ICU discharge vs. any other intervention or a control or 'usual care' programme in adult survivors of critical illness. Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database, and Cumulative Index to Nursing and Allied Health Literature databases were searched up to February 2015. Dual, independent screening of results, data extraction, and quality appraisal were performed. We included six trials involving 483 patients. Overall quality of evidence for both outcomes was very low. All studies evaluated functional exercise capacity, with three reporting positive effects in favour of the intervention. Only two studies evaluated health-related quality of life and neither reported differences between intervention and control groups. Meta-analyses of data were precluded due to variation in study design, types of interventions, and selection and reporting of outcome measurements. We were unable to determine an overall effect on functional exercise capacity or health-related quality of life of interventions initiated after ICU discharge for survivors of critical illness. Findings from ongoing studies are awaited. Future studies need to address methodological aspects of study design and conduct to enhance rigour, quality, and synthesis.
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Affiliation(s)
- Bronwen Connolly
- Lane Fox Clinical Respiratory Physiology Research UnitGuy's and St Thomas' NHS Foundation TrustLondonUK
- Division of Asthma, Allergy, and Lung BiologyKing's College LondonLondonUK
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | - Lisa Salisbury
- Edinburgh Critical Care Research Group MRC Centre for Inflammation ResearchUniversity of EdinburghEdinburghUK
| | - Brenda O'Neill
- Institute of Nursing and Health Research, School of Health SciencesUlster UniversityNewtownabbeyUK
| | - Louise Geneen
- School of Medicine, College of Medicine, Dentistry, and NursingUniversity of DundeeDundeeUK
| | - Abdel Douiri
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
- Department of Public Health Sciences, Division of Health and Social Care ResearchKing's College LondonLondonUK
| | - Michael P. W. Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental SciencesUniversity of SouthamptonSouthamptonUK
- Critical Care Research AreaSouthampton NIHR Respiratory Biomedical Research UnitSouthamptonUK
- Anaesthesia and Critical Care Research UnitUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Research UnitGuy's and St Thomas' NHS Foundation TrustLondonUK
- Division of Asthma, Allergy, and Lung BiologyKing's College LondonLondonUK
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | | | - Bronagh Blackwood
- Health Sciences, School of Medicine, Dentistry, and Biomedical Sciences, Centre for Infection and ImmunityQueen's University BelfastBelfastUK
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150
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Herridge MS, Chu LM, Matte A, Tomlinson G, Chan L, Thomas C, Friedrich JO, Mehta S, Lamontagne F, Levasseur M, Ferguson ND, Adhikari NKJ, Rudkowski JC, Meggison H, Skrobik Y, Flannery J, Bayley M, Batt J, Santos CD, Abbey SE, Tan A, Lo V, Mathur S, Parotto M, Morris D, Flockhart L, Fan E, Lee CM, Wilcox ME, Ayas N, Choong K, Fowler R, Scales DC, Sinuff T, Cuthbertson BH, Rose L, Robles P, Burns S, Cypel M, Singer L, Chaparro C, Chow CW, Keshavjee S, Brochard L, Hebert P, Slutsky AS, Marshall JC, Cook D, Cameron JI. The RECOVER Program: Disability Risk Groups and 1-Year Outcome after 7 or More Days of Mechanical Ventilation. Am J Respir Crit Care Med 2016; 194:831-844. [PMID: 26974173 DOI: 10.1164/rccm.201512-2343oc] [Citation(s) in RCA: 243] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE Disability risk groups and 1-year outcome after greater than or equal to 7 days of mechanical ventilation (MV) in medical/surgical intensive care unit (ICU) patients are unknown and may inform education, prognostication, rehabilitation, and study design. OBJECTIVES To stratify patients for post-ICU disability and recovery to 1 year after critical illness. METHODS We evaluated a multicenter cohort of 391 medical/surgical ICU patients who received greater than or equal to 1 week of MV at 7 days and 3, 6, and 12 months after ICU discharge. Disability risk groups were identified using recursive partitioning modeling. MEASUREMENTS AND MAIN RESULTS The 7-day post-ICU Functional Independence Measure (FIM) determined the recovery trajectory to 1-year after ICU discharge and was an independent risk factor for 1-year mortality. The 7-day post-ICU FIM was predicted by age and ICU length of stay. By 2 weeks of MV, ICU patients could be stratified into four disability groups characterized by increasing risk for post ICU disability, ICU and post-ICU healthcare use, and disposition. Patients less than 42 years with ICU length of stay less than 2 weeks had the best function and fewest deaths at 1 year compared with patients greater than 66 years with ICU length of stay greater than 2 weeks who sustained the worst disability and 40% 1-year mortality. Depressive symptoms (17%) and post-traumatic stress disorder (18%) persisted at 1 year. CONCLUSIONS ICU survivors of greater than or equal to 1 week of MV may be stratified into four disability groups based on age and ICU length of stay. These groups determine 1-year recovery and healthcare use and are independent of admitting diagnosis and illness severity. Clinical trial registered with www.clinicaltrials.gov (NCT 00896220).
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Affiliation(s)
- Margaret S Herridge
- 1 Department of Medicine.,2 Medical-Surgical Intensive Care.,4 Institute of Medical Science.,5 Toronto General Research Institute.,3 Interdepartmental Division of Critical Care Medicine
| | | | | | - George Tomlinson
- 1 Department of Medicine.,6 Institute of Health Policy, Management and Evaluation.,7 Dalla Lana School of Public Health.,8 Department of Medicine
| | | | | | - Jan O Friedrich
- 3 Interdepartmental Division of Critical Care Medicine.,9 Department of Medicine.,10 Division of Critical Care Medicine, and.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Sangeeta Mehta
- 3 Interdepartmental Division of Critical Care Medicine.,12 Department of Medicine and Anesthesia, Mount Sinai Hospital, Toronto, Canada
| | - Francois Lamontagne
- 13 Centre de Recherche du CHU de Sherbrooke, Sherbrooke, Canada.,14 Ecole de Réadaptation, Institut Universitaire de Gériatrie de Sherbrooke, University of Sherbrooke, Sherbrooke, Canada
| | - Melanie Levasseur
- 14 Ecole de Réadaptation, Institut Universitaire de Gériatrie de Sherbrooke, University of Sherbrooke, Sherbrooke, Canada
| | - Niall D Ferguson
- 1 Department of Medicine.,2 Medical-Surgical Intensive Care.,4 Institute of Medical Science.,5 Toronto General Research Institute.,3 Interdepartmental Division of Critical Care Medicine
| | - Neill K J Adhikari
- 3 Interdepartmental Division of Critical Care Medicine.,15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jill C Rudkowski
- 16 Department of General Internal Medicine and.,17 Department of Critical Care, St. Joseph's Healthcare
| | - Hilary Meggison
- 18 Department of Critical Care, University of Ottawa, Ottawa, Canada
| | - Yoanna Skrobik
- 19 Department of Medicine and.,20 Division of Critical Care, Maisonneuve Rosemont Hospital, University of Montreal, Montreal, Canada
| | - John Flannery
- 21 Toronto Rehabilitation Institute.,22 Interdepartmental Division of Physiatry
| | - Mark Bayley
- 21 Toronto Rehabilitation Institute.,22 Interdepartmental Division of Physiatry
| | - Jane Batt
- 9 Department of Medicine.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Claudia Dos Santos
- 3 Interdepartmental Division of Critical Care Medicine.,9 Department of Medicine.,10 Division of Critical Care Medicine, and.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Susan E Abbey
- 1 Department of Medicine.,23 Department of Psychiatry, and
| | - Adrienne Tan
- 1 Department of Medicine.,23 Department of Psychiatry, and
| | - Vincent Lo
- 2 Medical-Surgical Intensive Care.,24 Department of Physical Therapy
| | - Sunita Mathur
- 24 Department of Physical Therapy.,25 Rehabilitation Science Institution, and
| | - Matteo Parotto
- 1 Department of Medicine.,2 Medical-Surgical Intensive Care.,3 Interdepartmental Division of Critical Care Medicine
| | | | | | - Eddy Fan
- 1 Department of Medicine.,2 Medical-Surgical Intensive Care.,4 Institute of Medical Science.,5 Toronto General Research Institute.,3 Interdepartmental Division of Critical Care Medicine
| | - Christie M Lee
- 3 Interdepartmental Division of Critical Care Medicine.,12 Department of Medicine and Anesthesia, Mount Sinai Hospital, Toronto, Canada
| | - M Elizabeth Wilcox
- 1 Department of Medicine.,2 Medical-Surgical Intensive Care.,3 Interdepartmental Division of Critical Care Medicine
| | - Najib Ayas
- 26 Department of Medicine, St. Paul's Hospital, British Columbia, Vancouver, Canada
| | - Karen Choong
- 27 Department of Clinical Epidemiology and Biostatistics, and
| | - Robert Fowler
- 3 Interdepartmental Division of Critical Care Medicine.,6 Institute of Health Policy, Management and Evaluation.,7 Dalla Lana School of Public Health.,15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Damon C Scales
- 3 Interdepartmental Division of Critical Care Medicine.,15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Tasnim Sinuff
- 3 Interdepartmental Division of Critical Care Medicine.,15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Brian H Cuthbertson
- 3 Interdepartmental Division of Critical Care Medicine.,15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Louise Rose
- 15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Priscila Robles
- 5 Toronto General Research Institute.,24 Department of Physical Therapy.,25 Rehabilitation Science Institution, and
| | | | - Marcelo Cypel
- 4 Institute of Medical Science.,5 Toronto General Research Institute.,28 Division of Thoracic Surgery and Lung Transplant, University Health Network, Toronto, Canada
| | - Lianne Singer
- 1 Department of Medicine.,4 Institute of Medical Science.,5 Toronto General Research Institute
| | - Cecelia Chaparro
- 1 Department of Medicine.,4 Institute of Medical Science.,5 Toronto General Research Institute.,28 Division of Thoracic Surgery and Lung Transplant, University Health Network, Toronto, Canada
| | - Chung-Wai Chow
- 1 Department of Medicine.,4 Institute of Medical Science.,5 Toronto General Research Institute
| | - Shaf Keshavjee
- 1 Department of Medicine.,4 Institute of Medical Science.,5 Toronto General Research Institute.,28 Division of Thoracic Surgery and Lung Transplant, University Health Network, Toronto, Canada
| | - Laurent Brochard
- 3 Interdepartmental Division of Critical Care Medicine.,9 Department of Medicine.,10 Division of Critical Care Medicine, and.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Paul Hebert
- 29 Centre de recherche du Centre hospitalier de l'Université de Montreal, Montreal, Canada; and.,30 Department of Medicine of the Université de Montréal, Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Arthur S Slutsky
- 3 Interdepartmental Division of Critical Care Medicine.,9 Department of Medicine.,10 Division of Critical Care Medicine, and.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - John C Marshall
- 3 Interdepartmental Division of Critical Care Medicine.,9 Department of Medicine.,10 Division of Critical Care Medicine, and.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Deborah Cook
- 27 Department of Clinical Epidemiology and Biostatistics, and.,31 Department of Medicine and Pediatrics, McMaster University, Hamilton, Canada
| | - Jill I Cameron
- 32 Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada
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