1
|
Pannu S, Exline MC, Bednash JS, Englert JA, Diaz P, Bartlett A, Brock G, Wu Q, Davis IC, Crouser ED. SCARLET (Supplemental Citicoline Administration to Reduce Lung injury Efficacy Trial): study protocol for a single-site, double-blinded, placebo-controlled, and randomized Phase 1/2 trial of i.v. citicoline (CDP-choline) in hospitalized SARS CoV-2-infected patients with hypoxemic acute respiratory failure. Trials 2024; 25:328. [PMID: 38760804 PMCID: PMC11102211 DOI: 10.1186/s13063-024-08155-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 05/07/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND The SARS CoV-2 pandemic has resulted in more than 1.1 million deaths in the USA alone. Therapeutic options for critically ill patients with COVID-19 are limited. Prior studies showed that post-infection treatment of influenza A virus-infected mice with the liponucleotide CDP-choline, which is an essential precursor for de novo phosphatidylcholine synthesis, improved gas exchange and reduced pulmonary inflammation without altering viral replication. In unpublished studies, we found that treatment of SARS CoV-2-infected K18-hACE2-transgenic mice with CDP-choline prevented development of hypoxemia. We hypothesize that administration of citicoline (the pharmaceutical form of CDP-choline) will be safe in hospitalized SARS CoV-2-infected patients with hypoxemic acute respiratory failure (HARF) and that we will obtain preliminary evidence of clinical benefit to support a larger Phase 3 trial using one or more citicoline doses. METHODS We will conduct a single-site, double-blinded, placebo-controlled, and randomized Phase 1/2 dose-ranging and safety study of Somazina® citicoline solution for injection in consented adults of any sex, gender, age, or ethnicity hospitalized for SARS CoV-2-associated HARF. The trial is named "SCARLET" (Supplemental Citicoline Administration to Reduce Lung injury Efficacy Trial). We hypothesize that SCARLET will show that i.v. citicoline is safe at one or more of three doses (0.5, 2.5, or 5 mg/kg, every 12 h for 5 days) in hospitalized SARS CoV-2-infected patients with HARF (20 per dose) and provide preliminary evidence that i.v. citicoline improves pulmonary outcomes in this population. The primary efficacy outcome will be the SpO2:FiO2 ratio on study day 3. Exploratory outcomes include Sequential Organ Failure Assessment (SOFA) scores, dead space ventilation index, and lung compliance. Citicoline effects on a panel of COVID-relevant lung and blood biomarkers will also be determined. DISCUSSION Citicoline has many characteristics that would be advantageous to any candidate COVID-19 therapeutic, including safety, low-cost, favorable chemical characteristics, and potentially pathogen-agnostic efficacy. Successful demonstration that citicoline is beneficial in severely ill patients with SARS CoV-2-induced HARF could transform management of severely ill COVID patients. TRIAL REGISTRATION The trial was registered at www. CLINICALTRIALS gov on 5/31/2023 (NCT05881135). TRIAL STATUS Currently enrolling.
Collapse
Affiliation(s)
- Sonal Pannu
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Matthew C Exline
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Joseph S Bednash
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Joshua A Englert
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Philip Diaz
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Amy Bartlett
- Center for Clinical and Translational Sciences, The Ohio State University, Columbus, OH, USA
| | - Guy Brock
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Qing Wu
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Ian C Davis
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH, USA.
| | - Elliott D Crouser
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
2
|
Kohei T, Takamura D, Nonaka S, Yamada T. Association of Psoas Muscle Mass at Intensive Care Unit Admission With Physical Function and Post-discharge Destination in Survivors of Critical Illness. Cureus 2024; 16:e59609. [PMID: 38832187 PMCID: PMC11144838 DOI: 10.7759/cureus.59609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2024] [Indexed: 06/05/2024] Open
Abstract
OBJECTIVE Survivors of critical illness may have physical impairments, known as post-intensive care syndrome (PICS). Early screening for the risk of PICS is recommended to prevent PICS. Skeletal muscle mass is a clinically important indicator associated with various outcomes. This study aimed to examine the association of psoas muscle mass at intensive care unit (ICU) admission with the destination and physical function at hospital discharge. METHODS In this single-center retrospective cohort study, we reviewed the medical records of adult patients who had required emergency ICU admission and who had been intubated and mechanically ventilated. Psoas major muscle was measured as an indicator of skeletal muscle mass from abdominal computed tomography images at ICU admission. Physical function was assessed using the functional status score for the ICU and ICU mobility scale at hospital discharge. Multinomial logistic and multivariable linear regression were used to analyze the associations of the psoas muscle mass with the discharge destination and physical function at discharge. RESULTS We enrolled 124 patients (79 men and 45 women) with a median (interquartile range) age of 72.0 (62.0-80.0) years; 39 (31.5%) were discharged to home, 50 (40.3%) were transferred to rehabilitation wards, and 35 (28.2%) were transferred to long-term care settings. The psoas muscle area and volume were 16.9 (11.3-20.6) cm2 and 228.3 (180.2-282.0) cm3 in home discharge patients, 17.5 (11.5-21.5) cm2 and 248.4 (162.0-311.4) cm3 in rehabilitation ward patients, and 15.9 (10.3-19.5) cm2 and 184.0 (137.0-251.1) cm3 in long-term care patients. The areas and volumes of the psoas muscle were not significantly different in the three groups. Furthermore, psoas muscle mass was not significantly associated with the discharge destination and physical function. CONCLUSIONS Discharge destination and physical function at hospital discharge were not significantly associated with psoas muscle mass at ICU admission.
Collapse
Affiliation(s)
- Tanaka Kohei
- Department of Rehabilitation Medicine, Osaka Police Hospital, Osaka, JPN
| | - Daisuke Takamura
- Department of Rehabilitation Science, Graduate School of Health Science, Kobe University, Kobe, JPN
- Department of Rehabilitation, Kobe City Medical Center General Hospital, Kobe, JPN
| | - Shota Nonaka
- Department of Radiology Technology, Osaka Police Hospital, Osaka, JPN
| | - Tomoki Yamada
- Emergency Critical Care Medical Center, Osaka Police Hospital, Osaka, JPN
| |
Collapse
|
3
|
Taylor J, Wilcox ME. Physical and Cognitive Impairment in Acute Respiratory Failure. Crit Care Clin 2024; 40:429-450. [PMID: 38432704 DOI: 10.1016/j.ccc.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.
Collapse
Affiliation(s)
- Jonathan Taylor
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029, USA
| | - Mary Elizabeth Wilcox
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
| |
Collapse
|
4
|
Gal Y, Sapoznikov A, Lazar S, Shoseyov D, Aftalion M, Gutman H, Evgy Y, Gez R, Nevo R, Falach R. Long-Term Pulmonary Damage in Surviving Antitoxin-Treated Mice following a Lethal Ricin Intoxication. Toxins (Basel) 2024; 16:103. [PMID: 38393180 PMCID: PMC10892648 DOI: 10.3390/toxins16020103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/30/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Ricin, a highly potent plant-derived toxin, is considered a potential bioterrorism weapon due to its pronounced toxicity, high availability, and ease of preparation. Acute damage following pulmonary ricinosis is characterized by local cytokine storm, massive neutrophil infiltration, and edema formation, resulting in respiratory insufficiency and death. A designated equine polyclonal antibody-based (antitoxin) treatment was developed in our laboratory and proved efficacious in alleviating lung injury and increasing survival rates. Although short-term pathogenesis was thoroughly characterized in antitoxin-treated mice, the long-term damage in surviving mice was never determined. In this study, long-term consequences of ricin intoxication were evaluated 30 days post-exposure in mice that survived antitoxin treatment. Significant pulmonary sequelae were demonstrated in surviving antitoxin-treated mice, as reflected by prominent histopathological changes, moderate fibrosis, increased lung hyperpermeability, and decreased lung compliance. The presented data highlight, for the first time to our knowledge, the possibility of long-term damage development in mice that survived lethal-dose pulmonary exposure to ricin due to antitoxin treatment.
Collapse
Affiliation(s)
- Yoav Gal
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (A.S.); (M.A.); (Y.E.)
| | - Anita Sapoznikov
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (A.S.); (M.A.); (Y.E.)
| | - Shlomi Lazar
- Department of Pharmacology, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (S.L.); (H.G.); (R.G.)
| | - David Shoseyov
- Pediatric Pulmonology Unit, Hadassah Medical Center, Jerusalem P.O. Box 12000, Israel;
| | - Moshe Aftalion
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (A.S.); (M.A.); (Y.E.)
| | - Hila Gutman
- Department of Pharmacology, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (S.L.); (H.G.); (R.G.)
| | - Yentl Evgy
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (A.S.); (M.A.); (Y.E.)
| | - Rellie Gez
- Department of Pharmacology, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (S.L.); (H.G.); (R.G.)
| | - Reinat Nevo
- Department of Biomolecular Sciences, Weizmann Institute of Science, Herzel 234, Rehovot P.O. Box 26, Israel;
| | - Reut Falach
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (A.S.); (M.A.); (Y.E.)
| |
Collapse
|
5
|
Thackeray M, Mohebbi M, Orford N, Kotowicz MA, Pasco JA. Lean mass as a risk factor for intensive care unit admission: an observational study. Crit Care 2021; 25:364. [PMID: 34663393 PMCID: PMC8525013 DOI: 10.1186/s13054-021-03788-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/02/2021] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Intensive care unit (ICU) survivors have reduced physical function likely due to skeletal muscle wasting and weakness acquired during critical illness. However, the contribution of pre-morbid muscle mass has not been elucidated. We aimed to examine the association between pre-ICU muscle mass and ICU admission risk. Secondary outcomes include the relationship between muscle mass and ICU outcomes. METHODS ICU admissions between June 1, 1998, and February 1, 2019, were identified among participants of Geelong Osteoporosis Study (GOS), a population-based cohort study. Cox proportional hazard regression models estimated hazard ratios (HR) for ICU admission across T-score strata and continuous values of DXA-derived lean mass measures of skeletal mass index (SMI, lean mass/body mass %) and appendicular lean mass corrected for height (ALM/h2, kg/m2). Multivariable regression was used to determine the relationship between lean mass and ICU outcomes. RESULTS One hundred and eighty-six of 3126 participants enrolled in GOS were admitted to the ICU during the follow-up period. In adjusted models, lean mass was not predictive of ICU admission (SMI: HR 0.99 95%CI 0.97-1.01, p = 0.32; ALM/h2: HR 1.11 95%CI 0.94-1.31, p = 0.23), while greater appendicular lean mass was related to reduced 28-day mortality (ALM/h2 adjOR: 0.25, 95%CI 0.10-0.63, p = 0.003, SMI adjOR: 0.91, 95%CI 0.82-1.02, p = 0.09). CONCLUSION Lean mass was not associated with ICU admission in this population-based cohort study; however, greater appendicular lean mass was associated with reduced mortality. This suggests pre-ICU muscle status may not predict development of critical illness but is associated with better survival after critical illness occurs.
Collapse
Affiliation(s)
- Matthew Thackeray
- IMPACT (Institute of Mental and Physical Health and Clinical Translation), Deakin University, Geelong, Australia.
- Barwon Health, Geelong, Australia.
| | - Mohammadreza Mohebbi
- IMPACT (Institute of Mental and Physical Health and Clinical Translation), Deakin University, Geelong, Australia
- Faculty of Health, Biostatistics Unit, Deakin University, Geelong, Australia
| | - Neil Orford
- IMPACT (Institute of Mental and Physical Health and Clinical Translation), Deakin University, Geelong, Australia
- Barwon Health, Geelong, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, Australia
| | - Mark A Kotowicz
- IMPACT (Institute of Mental and Physical Health and Clinical Translation), Deakin University, Geelong, Australia
- Barwon Health, Geelong, Australia
- Department of Medicine-Western Health, The University of Melbourne, St Albans, Australia
| | - Julie A Pasco
- IMPACT (Institute of Mental and Physical Health and Clinical Translation), Deakin University, Geelong, Australia
- Barwon Health, Geelong, Australia
- Department of Medicine-Western Health, The University of Melbourne, St Albans, Australia
- Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, Australia
| |
Collapse
|
6
|
Qin ES, Gold LS, Hough CL, Katz PP, Bunnell AE, Wysham KD, Andrews JS. Patient-reported functional outcomes 30 days after hospitalization for COVID-19. PM R 2021; 14:173-182. [PMID: 34585858 PMCID: PMC8662144 DOI: 10.1002/pmrj.12716] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/04/2021] [Accepted: 09/10/2021] [Indexed: 01/19/2023]
Abstract
Background Many coronavirus disease 2019 (COVID‐19) survivors experience persistent symptoms, such as fatigue, dyspnea, and musculoskeletal pain. However, less is known about the impact of COVID‐19 on longer term functional outcomes. Objective To evaluate patient‐reported activity of daily living (ADL) function and fatigue symptoms 30 days after hospitalization for COVID‐19. Design Cross‐sectional study. Setting Tertiary care university hospital. Participants Adults 18 years or older hospitalized for COVID‐19 and survived to 30 days after discharge. Methods A standardized telephone questionnaire was administered 30 days after hospital discharge. Main Outcome Measures Ability to perform basic and instrumental ADLs and fatigue symptoms severity (Patient‐Reported Outcome Measurement Information System [PROMIS] Fatigue Short Form 7a) were assessed by self‐report. Results Participants (n = 55) were 22‐95 years old. Compared to pre‐COVID hospitalization, 52% developed new difficulty and 6% new dependence with performing basic ADLs (bADLs), 48% developed new difficulty and 11% new dependence with instrumental ADLs (iADLs), and 69% experienced a clinically significant worsening in their fatigue symptom severity. The average fatigue symptom severity T‐score before hospitalization was 44.2 ± 7.4 and after hospitalization was 54.5 ± 9.8. In exploratory multivariate analyses, each additional COVID symptom at presentation was associated with a predicted increase of 1.43 units (95% confidence interval [CI], 0.45–2.42) in the 30‐day fatigue symptom severity T‐score, each additional day of hospitalization was associated with an 1.2 times increased odds of worsening fatigue (95% CI, 0.98–1.5; p = .08), and each unit increase in baseline body mass index was associated with 0.8 times decreased odds of new bADL or iADL dependence at 30 days (95% CI, 0.65–0.99). Conclusions New functional impairments are common at 30 days after discharge among survivors of hospitalization for COVID‐19. Early rehabilitation, advance care planning, and referrals to appropriate therapies should be considered in postacute COVID‐19 care to maximize patients' functional outcomes. However, ongoing research is still needed regarding management of these patients.
Collapse
Affiliation(s)
- Evelyn S Qin
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Laura S Gold
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Catherine L Hough
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Patricia P Katz
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Aaron E Bunnell
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Katherine D Wysham
- Department of Medicine, University of Washington, VA Puget Sound Healthcare System, Seattle, Washington, USA
| | - James S Andrews
- Department of Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
7
|
Mayer KP, Thompson Bastin ML, Montgomery-Yates AA, Pastva AM, Dupont-Versteegden EE, Parry SM, Morris PE. Acute skeletal muscle wasting and dysfunction predict physical disability at hospital discharge in patients with critical illness. Crit Care 2020; 24:637. [PMID: 33148301 PMCID: PMC7640401 DOI: 10.1186/s13054-020-03355-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/23/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients surviving critical illness develop muscle weakness and impairments in physical function; however, the relationship between early skeletal muscle alterations and physical function at hospital discharge remains unclear. The primary purpose of this study was to determine whether changes in muscle size, strength and power assessed in the intensive care unit (ICU) predict physical function at hospital discharge. METHODS Study design is a single-center, prospective, observational study in patients admitted to the medicine or cardiothoracic ICU with diagnosis of sepsis or acute respiratory failure. Rectus femoris (RF) and tibialis anterior (TA) muscle ultrasound images were obtained day one of ICU admission, repeated serially and assessed for muscle cross-sectional area (CSA), layer thickness (mT) and echointensity (EI). Muscle strength, as measured by Medical Research Council-sum score, and muscle power (lower-extremity leg press) were assessed prior to ICU discharge. Physical function was assessed with performance on 5-times sit-to-stand (5STS) at hospital discharge. RESULTS Forty-one patients with median age of 61 years (IQR 55-68), 56% male and sequential organ failure assessment score of 8.1 ± 4.8 were enrolled. RF muscle CSA decreased significantly a median percent change of 18.5% from day 1 to 7 (F = 26.6, p = 0.0253). RF EI increased at a mean percent change of 10.5 ± 21% in the first 7 days (F = 3.28, p = 0.081). At hospital discharge 25.7% of patients (9/35) met criteria for ICU-acquired weakness. Change in RF EI in first 7 days of ICU admission and muscle power measured prior to ICU were strong predictors of ICU-AW at hospital discharge (AUC = 0.912). Muscle power at ICU discharge, age and ICU length of stay were predictive of performance on 5STS at hospital discharge. CONCLUSION ICU-assessed muscle alterations, specifically RF EI and muscle power, are predictors of diagnosis of ICU-AW and physical function assessed by 5x-STS at hospital discharge in patients surviving critical illness.
Collapse
Affiliation(s)
- Kirby P Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, 900 Rose St, Wethington 204D, Lexington, KY, 40536, USA.
- Center for Muscle Biology, University of Kentucky, Lexington, USA.
| | | | - Ashley A Montgomery-Yates
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Kentucky, Lexington, USA
| | - Amy M Pastva
- Departments of Orthopedic Surgery, Medicine, Cell Biology, and Population Health Sciences, Duke University School of Medicine, Durham, USA
| | - Esther E Dupont-Versteegden
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, 900 Rose St, Wethington 204D, Lexington, KY, 40536, USA
- Center for Muscle Biology, University of Kentucky, Lexington, USA
| | - Selina M Parry
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Peter E Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Kentucky, Lexington, USA
| |
Collapse
|
8
|
Balczon R, Morrow KA, Leavesley S, Francis CM, Stevens TC, Agwaramgbo E, Williams C, Stevens RP, Langham G, Voth S, Cioffi EA, Weintraub SE, Stevens T. Cystatin C regulates the cytotoxicity of infection-induced endothelial-derived β-amyloid. FEBS Open Bio 2020; 10:2464-2477. [PMID: 33030263 PMCID: PMC7609779 DOI: 10.1002/2211-5463.12997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 08/25/2020] [Accepted: 10/05/2020] [Indexed: 02/06/2023] Open
Abstract
Infection of rat pulmonary microvascular endothelial cells with the bacterium Pseudomonas aeruginosa induces the production and release of cytotoxic oligomeric tau and beta amyloid (Aβ). Here, we characterized these cytotoxic amyloids. Cytotoxic behavior and oligomeric tau were partially resistant to digestion with proteinase K, but cytotoxicity was abolished by various denaturants including phenol, diethylpyrocarbonate (DEPC), and 1,1,1,3,3,3-hexafluoro-2-isopropanol (HFIP). Ultracentrifugation for 8 h at 150 000 g was required to remove cytotoxic activity from the supernatant. Ultracentrifugation, DEPC treatment, and immunodepletion using antibodies against Aβ also demonstrated that cytoprotective protein(s) are released from endothelial cells during P. aeruginosa infection. Mass spectrometry of endothelial cell culture media following P. aeruginosa infection allowed identification of multiple potential secreted modulators of Aβ, including cystatin C, gelsolin, and ApoJ/clusterin. Immunodepletion, co-immunoprecipitation, and ultracentrifugation determined that the cytoprotective factor released during infection of endothelial cells by P. aeruginosa is cystatin C, which appears to be in a complex with Aβ. Cytoprotective cystatin C may provide a novel therapeutic avenue for protection against the long-term consequences of infection with P. aeruginosa.
Collapse
Affiliation(s)
- Ron Balczon
- Department of Biochemistry and Molecular BiologyUniversity of South AlabamaMobileALUSA
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
| | - Kyle A. Morrow
- Department of Cell Biology and PhysiologyEdward Via College of Osteopathic MedicineMonroeLAUSA
| | - Silas Leavesley
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Chemical and Biomedical EngineeringUniversity of South AlabamaMobileALUSA
| | - Christopher M. Francis
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | - Trevor C. Stevens
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | - Ezinne Agwaramgbo
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | | | - Reece P. Stevens
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | - Geri Langham
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | - Sarah Voth
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | - Eugene A. Cioffi
- Department of PharmacologyUniversity of South AlabamaMobileALUSA
| | - Susan E. Weintraub
- Department of Biochemistry and Structural Biology and Mass Spectrometry LaboratoryUniversity of Texas at San Antonio Health Sciences CenterTXUSA
| | - Troy Stevens
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| |
Collapse
|
9
|
Mayer KP, Dhar S, Cassity E, Denham A, England J, Morris PE, Dupont-Versteegden EE. Interrater Reliability of Muscle Ultrasonography Image Acquisition by Physical Therapists in Patients Who Have or Who Survived Critical Illness. Phys Ther 2020; 100:1701-1711. [PMID: 32302406 DOI: 10.1093/ptj/pzaa068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/17/2020] [Accepted: 03/01/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Previous studies have demonstrated that muscle ultrasound (US) can be reliably performed at the patient bedside by novice assessors with minimal training. The primary objective of this study was to determine the interrater reliability of muscle US image acquisition by physical therapists and physical therapist students. Secondarily, this study was designed to elucidate the process for training physical therapists to perform peripheral skeletal muscle US. METHODS This was a cross-sectional observational study. Four novices and 1 expert participated in the study. Novice sonographers engaged in a structured training program prior to implementation. US images were obtained on the biceps brachii, quadriceps femoris, and tibialis anterior muscles in 3 groups: patients in the intensive care unit, patients on the hospital ward, and participants in the outpatient gym who were healthy. Reliability of image acquisition was analyzed compared with the expert sonographer. RESULTS Intraclass correlation coefficient values ranged from 0.76 to 0.97 with an average for all raters and all muscles of 0.903, indicating excellent reliability of image acquisition. In general, the experienced physical therapist had higher or similar intraclass correlation coefficient values compared with the physical therapist students in relation to the expert sonographer. CONCLUSIONS Excellent interrater reliability for US was observed regardless of the level of experience, severity of patient illness, or patient setting. These findings indicate that the use of muscle US by physical therapists can accurately capture reliable images in patients with a range of illness severity and different clinical practice settings across the continuum of care. IMPACT Physical therapists can utilize US to obtain images to assess muscle morphology. LAY SUMMARY Physical therapists can use noninvasive US as an imaging tool to assess the size and quality of peripheral skeletal muscle. This study demonstrates that physical therapists can receive training to reliably obtain muscle images in patients admitted to the intensive care unit who may be at risk for muscle wasting and may benefit from early rehabilitation.
Collapse
Affiliation(s)
- Kirby P Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, 900 South Limestone Street, Lexington, KY 40536 USA
| | - Sanjay Dhar
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Kentucky
| | - Evan Cassity
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Kentucky
| | - Aaron Denham
- Department of Physical Therapy, College of Health Sciences, University of Kentucky
| | - Johnny England
- Department of Physical Therapy, College of Health Sciences, University of Kentucky
| | - Peter E Morris
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Kentucky
| | | |
Collapse
|
10
|
Luo F, Jiang W, Xu Y, Liu XM, Wang W, Zhang W, Luo C. The Mechanisms Involved in Mesenchymal Stem Cell Alleviation of Sepsis-Induced Acute Lung Injury in Mice: A Pilot Study. Curr Ther Res Clin Exp 2020; 93:100593. [PMID: 32760471 PMCID: PMC7393454 DOI: 10.1016/j.curtheres.2020.100593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/21/2020] [Indexed: 12/19/2022] Open
Abstract
Background Acute lung injury is a common complication of sepsis in intensive care unit patients. Inflammation is among the main mechanisms of sepsis. Therefore, suppression of inflammation is an important mechanism for sepsis treatment. Mesenchymal stem cells (MSCs) have been reported to exhibit antimicrobial properties. Objective The present study investigated the effects of MSCs on sepsis-induced acute lung injury. Methods Male C57BL/6 mice underwent a cecal ligation and puncture (CLP) operation to induce sepsis and then received either normal saline or MSCs (1 × 106 cells intravenously) at 3 hours after surgery. Survival after surgery was assessed. Lung injury was assessed by histology score, the presence of lung edema, vascular permeability, inflammatory cell infiltration, and cytokine levels in bronchoalveolar lavage fluid. Finally, we tested nuclear factor kappa-light-chain-enhancer of activated B cells activation in lung tissue. Results As expected, CLP caused lung injury as indicated by significant increases in the histopathology score, lung wet to dry weight ratio, and total protein concentration. However, mice treated with MSCs had amelioration of the lung histopathologic changes, lung wet to dry weight ratio, and total protein concentration. The levels of cytokines tumor necrosis factor alpha, interleukin 6, interleukin 1β, and interleukin 17 in bronchoalveolar lavage fluid were dramatically decreased after MSCs treatment. In contrast, expression of interleukin 10 was increased after MSCs treatment. Moreover, mice treated with MSCs had a higher survival rate than the CLP group. Neutrophil infiltration into bronchoalveolar lavage fluid was attenuated after MSCs injection, but the amounts of macrophages observed in the MSC group showed no significant differences compared with the CLP group. In addition, MSCs treatment significantly reduced nuclear factor kappa-light-chain-enhancer of activated B cells activation in lung tissue. Conclusions Based on the above findings, treatment with MSCs dampened the inflammatory response and inhibited nuclear factor kappa-light-chain-enhancer of activated B cells activation in the mouse CLP model. Thus, MSCs may be a potential new agent for the treatment of sepsis-induced acute lung injury. (Curr Ther Res Clin Exp. 2020; 81:XXX-XXX).
Collapse
Affiliation(s)
- Feng Luo
- The Affiliated Hospital of Qingdao University, Shandong, China
| | - Wei Jiang
- The Affiliated Hospital of Qingdao University, Shandong, China
| | - Yan Xu
- The Affiliated Hospital of Qingdao University, Shandong, China
| | - Xue-Mei Liu
- The Affiliated Hospital of Qingdao University, Shandong, China
| | - Wei Wang
- The Affiliated Hospital of Qingdao University, Shandong, China
| | - Wei Zhang
- The Affiliated Hospital of Qingdao University, Shandong, China
| | - Congjuan Luo
- The Affiliated Hospital of Qingdao University, Shandong, China
| |
Collapse
|
11
|
Niittyvuopio M, Liisanantti JH, Pikkupeura J, Spalding MB, Sälkiö S, Ala-Kokko TI. Factors associated with impaired physical functioning and mental health in working-age patients attending a post-intensive care follow-up clinic three months after hospital discharge. Anaesth Intensive Care 2019; 47:160-168. [PMID: 31106561 DOI: 10.1177/0310057x19838910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients recovering from critical illness are often suffering from remarkable limitations in their everyday life. The purpose of this study was to find factors associated with poor physical functioning and mental health after critical illness. The study was conducted among patients who met the inclusion criteria of our post-intensive care unit follow-up clinic. The patients were invited to the follow-up clinic three months after hospital discharge. The participants filled out a RAND-36 questionnaire, underwent a clinical examination and were stratified to those with good or poor recovery according to physical functioning and emotional wellbeing. Altogether 332 out of 351 follow-up clinic attendees had data available for analysis. In physical functioning 40% of patients achieved a poor outcome. In mental health the percentage was 8%. The patients with poor physical functioning had a longer hospital stay and were more likely to have received vasopressors. Eleven out of 16 (69%) multitrauma patients had poor physical functioning. Patients with poor physical functioning had more memories of pain, achieved worse results in a six-minute walk test and were less likely to be able to move independently. The patients with poor mental health had higher delirium incidence and fewer memories of relatives' visits and of nurses. The conclusions of this study were that the memories of pain, multitrauma and longer hospital stay were associated with a poor physical functioning outcome. Delirium and a lack of memories of relatives and nurses were associated with a poor mental health outcome.
Collapse
Affiliation(s)
- Miikka Niittyvuopio
- Department of Anaesthesiology and Intensive Care, Oulu University Hospital, Finland
| | - Janne H Liisanantti
- Department of Anaesthesiology and Intensive Care, Oulu University Hospital, Finland
| | - Jaana Pikkupeura
- Department of Anaesthesiology and Intensive Care, Oulu University Hospital, Finland
| | - Michael B Spalding
- Department of Anaesthesiology and Intensive Care, Oulu University Hospital, Finland
| | - Sinikka Sälkiö
- Department of Anaesthesiology and Intensive Care, Oulu University Hospital, Finland
| | - Tero I Ala-Kokko
- Department of Anaesthesiology and Intensive Care, Oulu University Hospital, Finland
| |
Collapse
|
12
|
Go Big: Measuring and Tackling Psychological Morbidity after Critical Illness. Ann Am Thorac Soc 2018; 13:1217-8. [PMID: 27509151 DOI: 10.1513/annalsats.201605-334ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
13
|
Langerud AK, Rustøen T, Småstuen MC, Kongsgaard U, Stubhaug A. Health-related quality of life in intensive care survivors: Associations with social support, comorbidity, and pain interference. PLoS One 2018; 13:e0199656. [PMID: 29940026 PMCID: PMC6016908 DOI: 10.1371/journal.pone.0199656] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 06/12/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Experiences during a stay in the intensive care unit (ICU), including pain, delirium, physical deterioration, and the critical illness itself, may all influence survivors' health-related quality of life (HRQOL). However, few studies have examined the influence of social support, comorbidity, and pain interference on ICU survivors' HRQOL. OBJECTIVES To investigate possible associations between social support, number of comorbidities, and pain interference on HRQOL in ICU survivors. METHODS ICU survivors responded to a survey 3 months (n = 118) and 1 year (n = 89) after ICU discharge. HRQOL was measured using the Short Form Health Survey-12 (v1), social support using the revised Social Provision Scale, pain interference using the Brief Pain Inventory-Short Form, and comorbidities using the Self-Administered Comorbidity Questionnaire. RESULTS Physical and mental HRQOL were reduced at both 3 months and 1 year in ICU survivors compared with the general population. This reduction was more pronounced at 3 months for physical HRQOL, while a small reduction in mental HRQOL was not clinically relevant. Social support was statistical significantly positively associated with mental HRQOL at 3 months, while number of comorbidities was statistical significantly associated with a reduction in physical HRQOL at 3 months and 1 year and mental HRQOL at 1 year. Lastly pain interference was significantly associated with a reduction in physical HRQOL at 3 months and 1 year. CONCLUSIONS ICU survivors primarily report reduced physical HRQOL. Social support was positively associated with mental HRQOL, while number of comorbidities, and pain interference were all significantly associated with a reduction in HRQOL. Pain interference was associated with the largest reduction in HRQOL.
Collapse
Affiliation(s)
- Anne Kathrine Langerud
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Department of Post-operative and Critical Care, Division of Emergencies and Critical Care Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tone Rustøen
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Health and Society, Department of Nursing science, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Ulf Kongsgaard
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Audun Stubhaug
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
14
|
Perioperative Research into Memory (PRiMe): Cognitive impairment following a severe burn injury and critical care admission, part 1. Burns 2018; 44:1167-1178. [PMID: 29752016 DOI: 10.1016/j.burns.2018.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 03/20/2018] [Accepted: 04/10/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION An investigation into long-term cognitive impairment and Quality of Life (QoL) after severe burns. METHODS A proof of principle, cohort design, prospective, observational clinical study. Patients with severe burns (>15% TBSA) admitted to Burns ICU for invasive ventilation were recruited for psychocognitive assessment with a convenience sample of age and sex-matched controls. Participants completed psychological and QoL questionnaires, the Cogstate® electronic battery, Hopkins Verbal Learning, Verbal Fluency and Trail making tasks. RESULTS 15 patients (11M, 4F; 41±14 years; TBSA 38.4%±18.5) and comparators (11M, 4F; 40±13 years) were recruited. Burns patients reported worse QoL (Neuro-QoL Short Form v2, patient 30.1±8.2, control 38.7±3.2, p=0.0004) and cognitive function (patient composite z-score 0.01, IQR -0.11 to 0.33, control 0.13, IQR 0.47-0.73, p=0.02). Compared to estimated premorbid FSIQ, patients dropped an equivalent of 8 IQ points (p=0.002). Cognitive function negatively correlated with burn severity (rBaux score, p=0.04). QoL strongly correlated with depressive symptoms (Rho=-0.67, p=0.009) but not cognitive function. CONCLUSIONS Severe burns injuries are associated with a significant, global, cognitive deficit. Patients also report worse QoL, depression and post-traumatic stress. Perceived QoL from cognitive impairment was more closely associated with depression than cognitive impairment.
Collapse
|
15
|
Betters KA, Hebbar KB, Farthing D, Griego B, Easley T, Turman H, Perrino L, Sparacino S, deAlmeida ML. Development and implementation of an early mobility program for mechanically ventilated pediatric patients. J Crit Care 2017; 41:303-308. [PMID: 28821360 DOI: 10.1016/j.jcrc.2017.08.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Early mobility (EM) is being used in adult ICUs in an effort to treat and prevent intensive care unit acquired weakness (ICU-AW) and Post-Intensive Care Syndrome (PICS). Data supports children suffer from ICU-AW and PICS as well. Our objective was to create and implement an EM protocol for pediatric patients receiving invasive mechanical ventilation. METHODS A multidisciplinary EM committee was formed to create and implement an EM protocol in a quarternary care PICU. A quality database was used to prospectively monitor patient tolerance of EM sessions and for serious adverse events, defined as unplanned extubation, hemodynamic instability, loss of central venous line, loss of arterial line, displacement of ECMO cannula, or cardiopulmonary arrest. RESULTS Between December 2013 and October 2016, 74 patients received EM for a total of 130 unique sessions. No serious adverse events occurred. Two patients had an oxygen desaturation episode during mobility that resolved with ventilator modifications, and one patient had nasogastric tube displacement during mobility. CONCLUSIONS Early mobility is attainable in a quaternary care PICU population without serious adverse events, using a multidisciplinary approach and appropriate staff education. Further research is needed to understand the physical and neurocognitive benefits of EM in children.
Collapse
Affiliation(s)
- Kristina A Betters
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA 30322, United States; Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322, United States.
| | - Kiran B Hebbar
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA 30322, United States; Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322, United States
| | - David Farthing
- Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322, United States
| | - Brittany Griego
- Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322, United States
| | - Tricia Easley
- Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322, United States
| | - Hartley Turman
- Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322, United States
| | - Lauren Perrino
- Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322, United States
| | - Stephanie Sparacino
- Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322, United States
| | - Mary L deAlmeida
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA 30322, United States; Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322, United States
| |
Collapse
|
16
|
[Depressive, anxiety and posttraumatic stress disorders as long-term sequelae of intensive care treatment]. DER NERVENARZT 2016; 87:253-63. [PMID: 26908007 DOI: 10.1007/s00115-016-0070-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Modern intensive care medicine has led to increased survival rates even after severe life-threatening medical conditions. In self-critical and multidimensional outcome research, however, it must be considered that beyond survival rates treatment on intensive care units (ICU) can also be associated with high long-term rates of depressive, anxiety and posttraumatic stress disorders. Significant correlations with increased somatic morbidity and mortality, persisting cognitive impairments and significant deficits in health-related quality of life must also be taken into consideration. Empirical analysis of the risk factors reveals that a history of premorbid depression, sociodemographic and socioeconomic variables, age, female sex, personality traits, the underlying pathophysiological condition requiring ICU treatment, mode of sedation and analgesia, life support measures, such as mechanical ventilation, manifold traumatic experiences and memories during the stay in the ICU are all of particular pathogenetic importance. In order to reduce principally modifiable risk factors several strategies are illustrated, including well-reflected intensive care sedation and analgesia, special prophylactic medication regarding the major risk of traumatic memories and posttraumatic stress disorder (PTSD), psychological and psychotherapeutic interventions in states of increased acute stress symptoms and aids for personal memories and reorientation.
Collapse
|
17
|
Abstract
OBJECTIVE ICU-acquired weakness, comprised critical illness myopathy and critical illness neuropathy, occurs in a significant proportion of critically ill adults and is associated with high morbidity and mortality. Little is known about ICU-acquired weakness among critically ill children. We investigated the incidence of ICU-acquired weakness among PICUs participating in the Virtual PICU Systems database. We also sought to identify associated risk factors for ICU-acquired weakness and evaluate the hypothesis that ICU-acquired weakness is associated with poor clinical outcomes. DESIGN Retrospective cohort study. SETTING PICU. MEASUREMENTS AND MAIN RESULTS Virtual PICU System was queried for critical illness myopathy and critical illness neuropathy between January 2009 and November 2013. Demographic, admission, and clinical outcome variables including mechanical ventilation days, PICU length of stay, and discharge disposition were analyzed. The Pediatric Index of Mortality-2 was used to evaluate and control for illness severity and risk of mortality. Among 203,875 admissions, there were 55 cases of critical illness myopathy reported and no cases of critical illness neuropathy, resulting in an incidence of 0.02%. Mechanical ventilation days were higher among patients with ICU-acquired weakness versus those who did not develop ICU-acquired weakness (31.6 ± 28.9 vs 9.3 ± 20.6; p < 0.001). In our multivariable analysis, when controlling for Pediatric Index of Mortality-2, ICU-acquired weakness was more frequently reported in those with admission diagnoses of respiratory illness and infection and the need for mechanical ventilation, renal replacement therapy, extracorporeal life support, and tracheostomy. ICU-acquired weakness was associated with a longer PICU length of stay, episodes requiring mechanical ventilation, and discharge to an intermediate, chronic care, and rehabilitation care unit. ICU-acquired weakness was not independently associated with mortality. CONCLUSIONS ICU-acquired weakness is uncommonly diagnosed among PICU patients reported in Virtual PICU System. ICU-acquired weakness is associated with critical care therapies, invasive procedures, and resource utilization. Limitations of our retrospective study include underrecognition of ICU-acquired weakness and lack of standardized diagnostic criteria within Virtual PICU System. Prospective studies are needed to better understand the true incidence, risk factors, and clinical course for patients who develop ICU-acquired weakness.
Collapse
|
18
|
Abstract
BACKGROUND Acute hypoxaemia de novo or on a background of chronic hypoxaemia is a common reason for admission to intensive care and for provision of mechanical ventilation. Various refinements of mechanical ventilation or adjuncts are employed to improve patient outcomes. Mortality from acute respiratory distress syndrome, one of the main contributors to the need for mechanical ventilation for hypoxaemia, remains approximately 40%. Ventilation in the prone position may improve lung mechanics and gas exchange and could improve outcomes. OBJECTIVES The objectives of this review are (1) to ascertain whether prone ventilation offers a mortality advantage when compared with traditional supine or semi recumbent ventilation in patients with severe acute respiratory failure requiring conventional invasive artificial ventilation, and (2) to supplement previous systematic reviews on prone ventilation for hypoxaemic respiratory failure in an adult population. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), Ovid MEDLINE (1950 to 31 January 2014), EMBASE (1980 to 31 January 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 31 January 2014) and Latin American Caribbean Health Sciences Literature (LILACS) (1992 to 31 January 2014) in Ovid MEDLINE for eligible randomized controlled trials. We also searched for studies by handsearching reference lists of relevant articles, by contacting colleagues and by handsearching published proceedings of relevant journals. We applied no language constraints, and we reran the searches in CENTRAL, MEDLINE, EMBASE, CINAHL and LILACS in June 2015. We added five new studies of potential interest to the list of "Studies awaiting classification" and will incorporate them into formal review findings during the review update. SELECTION CRITERIA We included randomized controlled trials (RCTs) that examined the effects of prone position versus supine/semi recumbent position during conventional mechanical ventilation in adult participants with acute hypoxaemia. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed all trials identified by the search and assessed them for suitability, methods and quality. Two review authors extracted data, and three review authors reviewed the data extracted. We analysed data using Review Manager software and pooled included studies to determine the risk ratio (RR) for mortality and the risk ratio or mean difference (MD) for secondary outcomes; we also performed subgroup analyses and sensitivity analyses. MAIN RESULTS We identified nine relevant RCTs, which enrolled a total of 2165 participants (10 publications). All recruited participants suffered from disorders of lung function causing moderate to severe hypoxaemia and requiring mechanical ventilation, so they were fairly comparable, given the heterogeneity of specific disease diagnoses in intensive care. Risk of bias, although acceptable in the view of the review authors, was inevitable: Blinding of participants and carers to treatment allocation was not possible (face-up vs face-down).Primary analyses of short- and longer-term mortality pooled from six trials demonstrated an RR of 0.84 to 0.86 in favour of the prone position (PP), but findings were not statistically significant: In the short term, mortality for those ventilated prone was 33.4% (363/1086) and supine 38.3% (395/1031). This resulted in an RR of 0.84 (95% confidence interval (CI) 0.69 to 1.02) marginally in favour of PP. For longer-term mortality, results showed 41.7% (462/1107) for prone and 47.1% (490/1041) for supine positions, with an RR of 0.86 (95% CI 0.72 to 1.03). The quality of the evidence for both outcomes was rated as low as a result of important potential bias and serious inconsistency.Subgroup analyses for mortality identified three groups consistently favouring PP: those recruited within 48 hours of meeting entry criteria (five trials; 1024 participants showed an RR of 0.75 (95% CI 0.59 to 94)); those treated in the PP for 16 or more hours per day (five trials; 1005 participants showed an RR of 0.77 (95% CI 0.61 to 0.99)); and participants with more severe hypoxaemia at trial entry (six trials; 1108 participants showed an RR of 0.77 (95% CI 0.65 to 0.92)). The quality of the evidence for these outcomes was rated as moderate as a result of potentially important bias.Prone positioning appeared to influence adverse effects: Pressure sores (three trials; 366 participants) with an RR of 1.37 (95% CI 1.05 to 1.79) and tracheal tube obstruction with an RR of 1.78 (95% CI 1.22 to 2.60) were increased with prone ventilation. Reporting of arrhythmias was reduced with PP, with an RR of 0.64 (95% CI 0.47 to 0.87). AUTHORS' CONCLUSIONS We found no convincing evidence of benefit nor harm from universal application of PP in adults with hypoxaemia mechanically ventilated in intensive care units (ICUs). Three subgroups (early implementation of PP, prolonged adoption of PP and severe hypoxaemia at study entry) suggested that prone positioning may confer a statistically significant mortality advantage. Additional adequately powered studies would be required to confirm or refute these possibilities of subgroup benefit but are unlikely, given results of the most recent study and recommendations derived from several published subgroup analyses. Meta-analysis of individual patient data could be useful for further data exploration in this regard. Complications such as tracheal obstruction are increased with use of prone ventilation. Long-term mortality data (12 months and beyond), as well as functional, neuro-psychological and quality of life data, are required if future studies are to better inform the role of PP in the management of hypoxaemic respiratory failure in the ICU.
Collapse
Affiliation(s)
- Roxanna Bloomfield
- Intensive Care Unit and Department of Anaesthesia, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZN
| | | | | |
Collapse
|
19
|
Bunnell A, Ney J, Gellhorn A, Hough CL. Quantitative neuromuscular ultrasound in intensive care unit-acquired weakness: A systematic review. Muscle Nerve 2015; 52:701-8. [PMID: 26044880 DOI: 10.1002/mus.24728] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2015] [Indexed: 12/20/2022]
Abstract
Intensive care unit-acquired weakness (ICU-AW) causes significant morbidity and impairment in critically ill patients. Recent advances in neuromuscular ultrasound (NMUS) allow evaluation of neuromuscular pathology early in critical illness. Here we review application of ultrasound in ICU-AW. MEDLINE-indexed articles were searched for terms relevant to ultrasound and critical illness. Two reviewers evaluated the resulting abstracts (n = 218) and completed full-text review (n = 13). Twelve studies and 1 case report were included. Ten studies evaluated muscle thickness or cross-sectional area (CSA): 8 reported a decrease, and 2 reported no change. Two studies reported preservation of muscle thickness in response to neuromuscular electrical stimulation, and 1 found no preservation. One study found decreases in gray-scale standard deviation, but no change in echogenicity. One study described increases in echogenicity and fasciculations. Ultrasound reliability in ICU-AW is not fully established. Further investigation is needed to identify ultrasound measures that reliably predict clinical, electrodiagnostic, and pathologic findings of ICU-AW.
Collapse
Affiliation(s)
- Aaron Bunnell
- Department of Physical Medicine and Rehabilitation, University of Washington, Harborview Medical Center, Seattle, Box, 359740, 325, 9th Avenue, Washington, 98104, USA
| | - John Ney
- School of Oral Health Sciences, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Alfred Gellhorn
- Department of Physical Medicine and Rehabilitation, University of Washington, Harborview Medical Center, Seattle, Box, 359740, 325, 9th Avenue, Washington, 98104, USA
| | - Catherine L Hough
- Department of Pulmonary Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| |
Collapse
|
20
|
[Neurological and psychological long-term effects of sepsis]. Med Klin Intensivmed Notfmed 2014; 109:596-603. [PMID: 25326073 DOI: 10.1007/s00063-014-0380-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 09/04/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND In addition to the limitations to the health-related quality of life that have been compiled with validated test instruments, a number of former sepsis patients suffer from functional impairments, which are categorized under the terms critical illness polyneuropathy (CIP) or critical illness myopathy (CIM), which have been in existence for over 20 years now. CURRENT FOCUS The issues of delirium during intensive therapy and persistent residual neurocognitive impairments, posttraumatic stress disorder (PTSD) and states of depression related to perihospital functional development have increasingly attracted notice. FUTURE The degree of functional deficits resulting from sepsis and the actual quality of life of those affected may, however, be influenced by taking appropriate rehabilitation measures. However, neither therapeutic rehabilitation standards nor any rehabilitation facilities tailored to the needs of these patients currently exist.
Collapse
|
21
|
Pelosi P, Sutherasan Y. Bone marrow-derived mononuclear cell therapy in sepsis-induced acute respiratory distress syndrome: different insults, different effects! Stem Cell Res Ther 2014; 4:143. [PMID: 24279925 PMCID: PMC4055016 DOI: 10.1186/scrt354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is one of the devastating sequelae of sepsis, and so far no specific promising pharmacotherapies have been proven to decrease mortality from it. Stem cell therapy is a novel therapy that can promote earlier and more effective remodeling and repair of damaged lung tissue. Bone marrow-derived mononuclear cells are an alternative stem cell therapy that is safely and easily administered on the day of harvesting and yields benefits in acute disease processes like ARDS. In a recent issue of Stem Cell Research and Therapy, Maron-Gutierrez and colleagues demonstrated that the effects of transfused bone marrow-derived mononuclear cells on lung mechanics, inflammation and mortality might be different in different septic ARDS models due to different insults.
Collapse
|
22
|
Jones C. Recovery post ICU. Intensive Crit Care Nurs 2014; 30:239-45. [PMID: 25065538 DOI: 10.1016/j.iccn.2014.06.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 06/06/2014] [Accepted: 06/12/2014] [Indexed: 11/19/2022]
Abstract
Many ICU patients struggle to recovery following critical illness and may be left with physical, cognitive and psychological problems, which have a negative impact on their quality of life. Gross muscle mass loss and weakness can take some months to recover after the patients' Intensive Care Unit (ICU) discharge, in addition critical illness polyneuropathies can further complicate physical recovery. Psychological problems such as anxiety, depression and post traumatic stress disorder (PTSD) are common and have an negative impact on the patients' ability to engage in rehabilitation after ICU discharge. Finally cognitive deficit affecting memory can be a significant problem. The first step in helping patients to recover from such a devastating illness is to recognise those who have the greatest need and target interventions. Research now suggests that there are interventions that can accelerate physical recovery and reduce the incidence of psychological problems such as anxiety, depression and PTSD. Cognitive rehabilitation, however, is still in its infancy. This review will look at the research into patients' recovery and what can be done to improve this where needed.
Collapse
Affiliation(s)
- Christina Jones
- Critical Care Rehabilitation, Whiston Hospital, Prescot L35 5DR, UK; Institute of Ageing & Chronic Disease, Faculty of Health & Life Sciences, University of Liverpool, Liverpool, UK.
| |
Collapse
|
23
|
Connolly BA, Jones GD, Curtis AA, Murphy PB, Douiri A, Hopkinson NS, Polkey MI, Moxham J, Hart N. Clinical predictive value of manual muscle strength testing during critical illness: an observational cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R229. [PMID: 24112540 PMCID: PMC4057053 DOI: 10.1186/cc13052] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/13/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Impaired skeletal muscle function has important clinical outcome implications for survivors of critical illness. Previous studies employing volitional manual muscle testing for diagnosing intensive care unit-acquired weakness (ICU-AW) during the early stages of critical illness have only provided limited data on outcome. This study aimed to determine inter-observer agreement and clinical predictive value of the Medical Research Council sum score (MRC-SS) test in critically ill patients. METHODS Study 1: Inter-observer agreement for ICU-AW between two clinicians in critically ill patients within ICU (n = 20) was compared with simulated presentations (n = 20). Study 2: MRC-SS at awakening in an unselected sequential ICU cohort was used to determine the clinical predictive value (n = 94) for outcomes of ICU and hospital mortality and length of stay. RESULTS Although the intra-class correlation coefficient (ICC) for MRC-SS in the ICU was 0.94 (95% CI 0.85-0.98), κ statistic for diagnosis of ICU-AW (MRC-SS <48/60) was only 0.60 (95% CI 0.25-0.95). Agreement for simulated weakness presentations was almost complete (ICC 1.0 (95% CI 0.99-1.0), with a κ statistic of 1.0 (95% CI 1.0-1.0)). There was no association observed between ability to perform the MRC-SS and clinical outcome and no association between ICU-AW and mortality. Although ICU-AW demonstrated limited positive predictive value for ICU (54.2%; 95% CI 39.2-68.6) and hospital (66.7%; 95% CI 51.6-79.6) length of stay, the negative predictive value for ICU length of stay was clinically acceptable (88.2%; 95% CI 63.6-98.5). CONCLUSIONS These data highlight the limited clinical applicability of volitional muscle strength testing in critically ill patients. Alternative non-volitional strategies are required for assessment and monitoring of muscle function in the early stages of critical illness.
Collapse
|
24
|
|
25
|
Denehy L, Skinner EH, Edbrooke L, Haines K, Warrillow S, Hawthorne G, Gough K, Hoorn SV, Morris ME, Berney S. Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up. Crit Care 2013; 17:R156. [PMID: 23883525 PMCID: PMC4056792 DOI: 10.1186/cc12835] [Citation(s) in RCA: 277] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 07/09/2013] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The purpose of this trial was to investigate the effectiveness of an exercise rehabilitation program commencing during ICU admission and continuing into the outpatient setting compared with usual care on physical function and health-related quality of life in ICU survivors. METHODS We conducted a single-center, assessor-blinded, randomized controlled trial. One hundred and fifty participants were stratified and randomized to receive usual care or intervention if they were in the ICU for 5 days or more and had no permanent neurological insult. The intervention group received intensive exercises in the ICU and the ward and as outpatients. Participants were assessed at recruitment, ICU admission, hospital discharge and at 3-, 6- and 12-month follow-up. Physical function was evaluated using the Six-Minute Walk Test (6MWT) (primary outcome), the Timed Up and Go Test and the Physical Function in ICU Test. Patient-reported outcomes were measured using the Short Form 36 Health Survey, version 2 (SF-36v2) and Assessment of Quality of Life (AQoL) Instrument. Data were analyzed using mixed models. RESULTS The a priori enrollment goal was not reached. There were no between-group differences in demographic and hospital data, including acuity and length of acute hospital stay (LOS) (Acute Physiology and Chronic Health Evaluation II score: 21 vs 19; hospital LOS: 20 vs 24 days). No significant differences were found for the primary outcome of 6MWT or any other outcomes at 12 months after ICU discharge. However, exploratory analyses showed the rate of change over time and mean between-group differences in 6MWT from first assessment were greater in the intervention group. CONCLUSIONS Further research examining the trajectory of improvement with rehabilitation is warranted in this population. TRIAL REGISTRATION The trial was registered with the Australian New Zealand Clinical Trials Registry ACTRN12605000776606.
Collapse
Affiliation(s)
- Linda Denehy
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia
| | | | - Lara Edbrooke
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia
| | | | | | - Graeme Hawthorne
- Department of Psychiatry, The University of Melbourne, Melbourne, Australia
| | - Karla Gough
- Cancer Nursing Research Centre, Peter MacCallum Cancer Institute, Melbourne, Australia
| | - Steven Vander Hoorn
- Department of Mathematics and Statistics, The University of Melbourne, Melbourne, Australia
| | - Meg E Morris
- School of Allied Health, Latrobe University Melbourne, Melbourne, Australia
| | - Sue Berney
- Physiotherapy Department, Austin Health, Melbourne, Australia
| |
Collapse
|
26
|
Jones C. What's new on the post-ICU burden for patients and relatives? Intensive Care Med 2013; 39:1832-5. [PMID: 23856950 DOI: 10.1007/s00134-013-3015-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 06/27/2013] [Indexed: 12/01/2022]
Affiliation(s)
- Christina Jones
- Nurse Consultant Critical Care Rehabilitation, Ward 4E (Critical Care), Whiston Hospital, Prescot, L34 5DR, UK,
| |
Collapse
|
27
|
Waterer GW, Rello J. Acute respiratory distress syndrome and stem cells: a small beginning or a strategy doomed to never gestate? Am J Respir Crit Care Med 2013; 187:674-5. [PMID: 23540875 DOI: 10.1164/rccm.201301-0170ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
28
|
Abstract
PURPOSE OF REVIEW As numbers of patients who survive a critical illness increase, often within a context of comorbidities and acquired physical, mental or cognitive sequelae [postintensive care syndrome (PICS)], identifying effective recovery and rehabilitation strategies is paramount. In this review, we discuss recent studies that inform our developing understanding for improving the recovery trajectory for survivors of a critical illness during the postintensive care and posthospital periods. RECENT FINDINGS New studies, although at this stage often presented as pilot work, provide important beginning messages for improving recovery from a critical illness. Some pilot studies demonstrate promise of effective interventions, whereas other studies offer useful baseline information for improving the power of tested interventions. SUMMARY Innovative rehabilitation and recovery strategies during the postintensive care and posthospital periods are now being published. Further research with larger sample sizes, well-documented usual care and intervention arms and in different critical illness cohorts is required to demonstrate the optimal approaches for screening, implementation, outcome assessment and follow-up periods for rehabilitation interventions in the postintensive care phase of a patient's recovery.
Collapse
|
29
|
Hodgson CL, Hayes K, Everard T, Nichol A, Davies AR, Bailey MJ, Tuxen DV, Cooper DJ, Pellegrino V. Long-term quality of life in patients with acute respiratory distress syndrome requiring extracorporeal membrane oxygenation for refractory hypoxaemia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R202. [PMID: 23082772 PMCID: PMC3682304 DOI: 10.1186/cc11811] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 09/28/2012] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The purpose of the study was to assess the long term outcome and quality of life of patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) for refractory hypoxemia. METHODS A retrospective observational study with prospective health related quality of life (HRQoL) assessment was conducted in ARDS patients who had ECMO as a rescue therapy for reversible refractory hypoxemia from January 2009 until April 2011 in a tertiary Australian centre. Survival and long-term quality of life assessment, using the Short-Form 36 (SF-36) and the EuroQol health related quality of life questionnaire (EQ5D) were assessed and compared to international data from other research groups. RESULTS Twenty-one patients (mean age 36.3 years) with ARDS receiving ECMO for refractory hypoxemia were studied. Eighteen (86%) patients were retrieved from external intensive care units (ICUs) by a dedicated ECMO retrieval team. Eleven (55%) had H1N1 influenza A-associated pneumonitis. Eighteen (86%) patients survived to hospital discharge. Of the 18 survivors, ten (56%) were discharged to other hospitals and 8 (44%) were discharged directly home. Sequelae and health related quality of life were evaluated for 15 of the 18 (71%) long-term survivors (assessment at median 8 months). Mean SF-36 scores were significantly lower across all domains compared to age and sex matched Australian norms. Mean SF-36 scores were lower (minimum important difference at least 5 points) than previously described ARDS survivors in the domains of general health, mental health, vitality and social function. One patient had long-term disability as a result of ICU acquired weakness. Only 26% of survivors had returned to previous work levels at the time of follow-up. CONCLUSIONS This ARDS cohort had a high survival rate (86%) after use of ECMO support for reversible refractory hypoxemia. Long term survivors had similar physical health but decreased mental health, general health, vitality and social function compared to other ARDS survivors and an unexpectedly poor return to work.
Collapse
|
30
|
Woon FL, Dunn CB, Hopkins RO. Predicting cognitive sequelae in survivors of critical illness with cognitive screening tests. Am J Respir Crit Care Med 2012; 186:333-40. [PMID: 22700858 DOI: 10.1164/rccm.201112-2261oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE Survivors of critical illness have a high rate of cognitive impairments that may persist years after hospital discharge. Data are lacking regarding whether cognitive screening tests administered at hospital discharge can be used to predict which critically ill patients are likely to have long-term cognitive sequelae. OBJECTIVES This prospective study assessed whether two cognitive screening tests, the Mini-Mental State Examination (MMSE) and Mini-Cog, administered at hospital discharge, predict cognitive sequelae in survivors of critical illness 6 months after hospital discharge. METHODS Seventy critically ill patients completed the MMSE and Mini-Cog just before hospital discharge. Of these 70 patients, 53 completed a neuropsychological battery 6 months after hospital discharge. MEASUREMENTS AND MAIN RESULTS At hospital discharge, 45 patients (64%) had impaired performance on the MMSE (score < 27, mean = 24.4) and 32 (45%) on the Mini-Cog. Twenty-seven patients (39%) were impaired on both the MMSE and Mini-Cog, whereas only 20 patients (28%) had scores in the normal range on both tests. Cognitive sequelae occurred in 57% of survivors (30 of 53) at 6 months, with predominant dysfunction in the memory (38%) and executive (36%) domains. Logistic regression analyses showed that neither the MMSE nor the Mini-Cog predicted cognitive sequelae at 6 months. CONCLUSIONS A large number of critically ill survivors had cognitive impairments, as assessed by the MMSE and Mini-Cog, at hospital discharge. However, the MMSE and Mini-Cog scores did not predict long-term cognitive sequelae at 6-month follow-up and cannot be used as surrogate endpoints for long-term cognitive impairment.
Collapse
Affiliation(s)
- Fu L Woon
- Neuropsychology Section, Department of Psychiatry, University of Michigan, 2101 Commonwealth Boulevard, Suite C, Ann Arbor, MI 48105, USA.
| | | | | |
Collapse
|