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Lew CCH, Lee ZY, Day AG, Jiang X, Bear D, Jensen GL, Ng PY, Tweel L, Parillo A, Heyland DK, Compher C. The Association Between Malnutrition and High Protein Treatment on Outcomes in Critically Ill Patients: A Post Hoc Analysis of the EFFORT Protein Randomized Trial. Chest 2024:S0012-3692(24)00154-5. [PMID: 38354904 DOI: 10.1016/j.chest.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Preexisting malnutrition in critically ill patients is associated with adverse clinical outcomes. Malnutrition can be diagnosed with the Global Leadership Initiative on Malnutrition using parameters such as weight loss, muscle wasting, and BMI. International critical care nutrition guidelines recommend high protein treatment to improve clinical outcomes in critically ill patients diagnosed with preexisting malnutrition. However, this recommendation is based on expert opinion. RESEARCH QUESTION In critically ill patients, what is the association between preexisting malnutrition and time to discharge alive (TTDA), and does high protein treatment modify this association? STUDY DESIGN AND METHODS This multicenter randomized controlled trial involving 16 countries was designed to investigate the effects of high vs usual protein treatment in 1,301 critically ill patients. The primary outcome was TTDA. Multivariable regression was used to identify if preexisting malnutrition was associated with TTDA and if protein delivery modified their association. RESULTS The prevalence of preexisting malnutrition was 43.8%, and the cumulative incidence of live hospital discharge by day 60 was 41.2% vs 52.9% in the groups with and without preexisting malnutrition, respectively. The average protein delivery in the high vs usual treatment groups was 1.6 g/kg per day vs 0.9 g/kg per day. Preexisting malnutrition was independently associated with slower TTDA (adjusted hazard ratio, 0.81; 95% CI, 0.67-0.98). However, high protein treatment in patients with and without preexisting malnutrition was not associated with TTDA (adjusted hazard ratios of 0.84 [95% CI, 0.63-1.11] and 0.97 [95% CI, 0.77-1.21]). Furthermore, no effect modification was observed (ratio of adjusted hazard ratio, 0.84; 95% CI, 0.58-1.20). INTERPRETATION Malnutrition was associated with slower TTDA, but high protein treatment did not modify the association. These findings challenge current international critical care nutrition guidelines. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03160547; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Charles Chin Han Lew
- Department of Dietetics & Nutrition, Ng Teng Fong General Hospital, Singapore, Singapore; Faculty of Health and Social Sciences, Singapore Institute of Technology, Singapore, Singapore
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Andrew G Day
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Xuran Jiang
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Danielle Bear
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Gordon L Jensen
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT
| | - Pauline Y Ng
- Critical Care Medicine Unit, School of Clinical Medicine, The University of Hong Kong, Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | - Lauren Tweel
- Clinical and Preventive Nutrition Sciences, Rutgers University, School of Health Professions, New Brunswick, NJ; Foothills Medical Centre, Calgary, AB, Canada
| | - Angela Parillo
- Department of Clinical Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Charlene Compher
- Department of Biobehavioral Health Science, University of Pennsylvania, School of Nursing, Philadelphia, PA.
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Neville TH, Taich Z, Walling AM, Bear D, Cook DJ, Tseng CH, Wenger NS. The 3 Wishes Program Improves Families' Experience of Emotional and Spiritual Support at the End of Life. J Gen Intern Med 2023; 38:115-121. [PMID: 35581456 PMCID: PMC9113739 DOI: 10.1007/s11606-022-07638-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 04/22/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND The end-of-life (EOL) experience in the intensive care unit (ICU) is emotionally challenging, and there are opportunities for improvement. The 3 Wishes Program (3WP) promotes the dignity of dying patients and their families by eliciting and implementing wishes at the EOL. AIM To assess whether the 3WP is associated with improved ratings of EOL care. PROGRAM DESCRIPTION In the 3WP, clinicians elicit and fulfill simple wishes for dying patients and their families. SETTING 2-hospital academic healthcare system. PARTICIPANTS Dying patients in the ICU and their families. PROGRAM EVALUATION A modified Bereaved Family Survey (BFS), a validated tool for measuring EOL care quality, was completed by families of ICU decedents approximately 3 months after death. We compared patients whose care involved the 3WP to those who did not using three BFS-derived measures: Respectful Care and Communication (5 questions), Emotional and Spiritual Support (3 questions), and the BFS-Performance Measure (BFS-PM, a single-item global measure of care). RESULTS Of 314 completed surveys, 117 were for patients whose care included the 3WP. Bereaved families of 3WP patients rated the Emotional and Spiritual Support factor significantly higher (7.5 vs. 6.0, p = 0.003, adjusted p = 0.001) than those who did not receive the 3WP. The Respectful Care and Communication factor and BFS-PM were no different between groups. DISCUSSION The 3WP is a low-cost intervention that may be a feasible strategy for improving the EOL experience.
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Affiliation(s)
- Thanh H Neville
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
| | - Zachary Taich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.,VA Greater Los Angeles Healthcare System, Veteran Affairs, Los Angeles, USA
| | - Danielle Bear
- UCLA Office of the Patient Experience, UCLA Health, Los Angeles, CA, USA
| | - Deborah J Cook
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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Turner-Stokes L, Corner EJ, Siegert RJ, Brown C, Wallace S, Highfield J, Bear D, Aitken LM, Montgomery H, Puthucheary Z. The post-ICU presentation screen (PICUPS) and rehabilitation prescription (RP) for intensive care survivors part I: Development and preliminary clinimetric evaluation. J Intensive Care Soc 2022; 23:253-263. [PMID: 36033253 PMCID: PMC9411778 DOI: 10.1177/1751143720988715] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Patients who have had prolonged stays in intensive care have ongoing rehabilitation needs. This is especially true of COVID-19 ICU patients, who can suffer diverse long-term ill effects. Currently there is no systematic data collection to guide the needs for therapy input for either of these groups nor to inform planning and development of rehabilitation services. These issues could be resolved in part by the systematic use of a clinical tool to support decision-making as patients progress from the Intensive Care Unit (ICU), through acute hospital care and onwards into rehabilitation. We describe (i) the development of such a tool (the Post-ICU Presentation Screen (PICUPS)) and (ii) the subsequent preparation of a person-centred Rehabilitation Prescription (RP) to travel with the patient as they continue down the care pathway. METHODS PICUPS development was led by a core group of experienced clinicians representing the various disciplines involved in post-ICU rehabilitation. Key constructs and item-level descriptors were identified by group consensus. Piloting was performed as part of wider clinical engagement in 26 acute hospitals across England. Development and validation of such a tool requires clinimetric analysis, and this was based on classical test theory. Teams also provided feedback about the feasibility and utility of the tool. RESULTS Initial PICUPS design yielded a 24-item tool. In piloting, a total of 552 records were collated from 314 patients, of which 121 (38.5%) had COVID-19. No obvious floor or ceiling effects were apparent. Exploratory factor analysis provided evidence of uni-dimensionality with strong loading on the first principal component accounting for 51% of the variance and Cronbach's alpha for the full-scale score 0.95 - although a 3-factor solution accounted for a further 21%. The PICUPS was responsive to change both at full scale- and item-level. In general, positive responses were seen regarding the tool's ability to describe the patients during their clinical course, engage and flag the relevant professionals needed, and to inform what should be included in an RP. CONCLUSIONS The PICUPS tool has robust scaling properties as a clinical measure and is potentially useful as a tool for identifying rehabilitation needs as patients step down from ICU and acute hospital care.
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Affiliation(s)
- Lynne Turner-Stokes
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute. Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
- UK Rehabilitation Outcomes Collaborative, Northwick Park Hospital, London, UK
| | - Evelyn J Corner
- Department of Health Sciences, College of Health, Medicine and Life Sciences, Brunel University, UK
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Richard J Siegert
- Auckland University of Technology, School of Public Health & Psychosocial Studies and School of Clinical Sciences, New Zealand
| | | | - Sarah Wallace
- Wythenshawe Hospital Manchester, Manchester University NHS Foundation Trust, UK
| | | | - Danielle Bear
- Department of Nutrition and Dietetics, St Thomas’ NHS Foundation Trust, London, UK
- Department of Critical Care, Guy’s and St. Thomas’ NHS Foundation & King’s College London NIHR Biomedical Research Centre, London, UK
| | - Leanne M Aitken
- School of Health Sciences, City, University of London, London, UK
| | - Hugh Montgomery
- Centre for Human Health and Performance, Department of Medicine, University College London, London, UK
| | - Zudin Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London
- Adult Critical Care Unit, Royal London Hospital, Whitechapel, London, UK
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Puthucheary Z, Brown C, Corner E, Wallace S, Highfield J, Bear D, Rehill N, Montgomery H, Aitken L, Turner-Stokes L. The Post-ICU presentation screen (PICUPS) and rehabilitation prescription (RP) for intensive care survivors part II: Clinical engagement and future directions for the national Post-Intensive care Rehabilitation Collaborative. J Intensive Care Soc 2022; 23:264-272. [PMID: 36033242 PMCID: PMC9411763 DOI: 10.1177/1751143720988708] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Many Intensive Care Unit (ICU) survivors suffer from a multi- system disability, termed the post-intensive care syndrome. There is no current national coordination of either rehabilitation pathways or related data collection for them. In the last year, the need for tools to systematically identify the multidisciplinary rehabilitation needs of severely affected COVID-19 survivors has become clear. Such tools offer the opportunity to improve rehabilitation for all critical illness survivors through provision of a personalised Rehabilitation Prescription (RP). The initial development and secondary refinement of such an assessment and data tools is described in the linked paper. We report here the clinical and workforce data that was generated as a result. METHODS Prospective service evaluation of 26 acute hospitals in England using the Post-ICU Presentation Screen (PICUPS) tool and the RP. The PICUPS tool comprised items in domains of a) Medical and essential care, b) Breathing and nutrition; c) Physical movement and d) Communication, cognition and behaviour. RESULTS No difference was seen in total PICUPS scores between patients with or without COVID-19 (77 (IQR 60-92) vs. 84 (IQR 68-97); Mann-Whitney z = -1.46, p = 0.144. A network analysis demonstrated that requirements for physiotherapy, occupational therapy, speech and language therapy, dietetics and clinical psychology were closely related and unaffected by COVID-19 infection status. A greater proportion of COVID-19 patients were referred for inpatient rehabilitation (13% vs. 7%) and community-based rehabilitation (36% vs.15%). The RP informed by the PICUPS tool generally specified a greater need for multi-professional input when compared to rehabilitation plans instituted. CONCLUSIONS The PICUPS tool is feasible to implement as a screening mechanism for post-intensive care syndrome. No differences are seen in the rehabilitation needs of patients with and without COVID-19 infection. The RP could be the vehicle that drives the professional interventions across the transitions from acute to community care. No single discipline dominates the rehabilitation requirements of these patients, reinforcing the need for a personalised RP for critical illness survivors.
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Affiliation(s)
- Zudin Puthucheary
- William Harvey Research Institute,
Barts and The London School of Medicine & Dentistry, Queen Mary University
of London, London, UK
- Adult Critical Care Unit, Royal
London Hospital, Whitechapel, London, UK
| | - Craig Brown
- Imperial College Health Partners
(ICHP), London, UK
| | - Evelyn Corner
- Department of Heath Sciences, Brunel
University London, London, UK
- Charing Cross Hospital, Imperial
College Healthcare NHS Trust, London, UK
| | - Sarah Wallace
- Wythenshawe Hospital Manchester,
Manchester University NHS Foundation Trust, Manchester, UK
| | - Julie Highfield
- Critical Care Directorate,
University Hospital Wales, Wales, UK
| | - Danielle Bear
- Department of Nutrition and
Dietetics St Thomas’ NHS Foundation Trust, London, UK
- Department of Critical Care, Guy's
and St. Thomas' NHS Foundation & King's College London NIHR Biomedical
Research Centre, London, UK
| | | | - Hugh Montgomery
- Centre for Human Health and
Performance, Dept Medicine, Anthropogenic Emissions, University College London,
London, UK
| | - Leanne Aitken
- School of Health Sciences, City,
University of London, London, UK
| | - Lynne Turner-Stokes
- Department of Palliative Care,
Policy and Rehabilitation, Cicely Saunders Institute, Florence Nightingale
Faculty of Nursing, Midwifery and Palliative Care, King’s College London,
London, UK
- Regional Hyper-acute
Rehabilitation Unit, Northwick Park Hospital, London, UK
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5
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Day G, Bear D, Swinton M, Karlin D, Phung P, McCann K, Bell A, McParlane R, Granone MC, Cook DJ, Neville TH. End-of-life transitions for family member on the solid tumour oncology ward: the 3 Wishes Project. BMJ Support Palliat Care 2021:bmjspcare-2021-003138. [PMID: 34470773 DOI: 10.1136/bmjspcare-2021-003138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/12/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Although death is not uncommon for hospitalised patients with cancer, there are few interventions in oncology that are designed to create a dignified, compassionate end-of-life (EOL) experience for patients and families. The 3 Wishes Project (3WP), a programme in which clinicians elicit and implement final wishes for dying patients, has been shown effective in intensive care units (ICUs) at improving the EOL experience. The objective was to initiate 3WP on an oncology ward and evaluate its effect on family member experiences of their loved one's EOL. We hypothesised that the 3WP can be implemented in the non-ICU setting and help oncological patients and their families with transition to the EOL. METHODS When the patient's probability of dying is greater than 95%, patients and families were invited to participate in the 3WP. Wishes were elicited, implemented and categorised. Audiorecorded, semistructured interviews were conducted with family members, transcribed and analysed using content analysis. RESULTS 175 wishes were implemented for 52 patients with cancer (average cost of US$34). The most common wish (66%) was to personalise the environment. Qualitative analysis of 11 family member interviews revealed that the 3WP facilitates three transitions at the EOL: (1) the transition from multiple admissions to the final admission, (2) the transition of a predominantly caregiver role to a family member role and (3) the transition from a focus on the present to a focus on legacy. CONCLUSION The 3WP can be implemented on the oncology ward and enhance the EOL experience for hospitalised patients with cancer.
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Affiliation(s)
- Gwenyth Day
- Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Danielle Bear
- Office of Patient Experience, UCLA Health System, Los Angeles, California, USA
| | - Marilyn Swinton
- Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Karlin
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Peter Phung
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Kelly McCann
- Department of Medicine, Division of Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Allegra Bell
- Nursing, UCLA Health System, Los Angeles, California, USA
| | | | - Maria Carmela Granone
- Department of Medicine, Division of Pulmonary and Critical Care, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Deborah J Cook
- Departments of Medicine and Health Research Methods, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Thanh H Neville
- Department of Medicine, Division of Pulmonary and Critical Care, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
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Abstract
Intensive care unit-acquired weakness (ICUAW) is common and prolongs the duration of mechanical ventilation and ICU length of stay and is also a leading cause of physical restriction up to five years later. Developing diagnostic tools that allow early identification and risk stratification in all critically ill patients is vital. Ultrasound is a cheap, reproducible and noninvasive imaging modality that can be used to assess multiple muscle groups. It has advantages over other imaging techniques that entail risks of radiation as well as the logistical concerns of moving critically ill patients. Ultrasound muscle indices can be monitored over time and may serve as predictors for ventilatory weaning and long-term outcomes. The diaphragm is frequently perturbed during critical illness, specifically when mechanical ventilation is initiated. Diaphragm thickness and excursion have been shown to support extubation strategy with the former serving as a marker of inspiratory effort in the absence of more specialist tests. The techniques are reproducible with appropriate training and practice and have been applied in clinical trials. Peripheral skeletal muscle ultrasound has been the subject of intense research in ICU-acquired muscle weakness. The technique has also been found to be reproducible and can serve as a surrogate marker to current volitional and non-volitional tests in the assessment of muscle ICUAW. This article outlines the application of musculoskeletal ultrasound and its role in the early recognition of ICUAW in three distinct muscle groups: (1) diaphragm (2) rectus femoris and introduces the potential of (3) parasternal muscles.
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Affiliation(s)
- Sunil Patel
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, United Kingdom of Great Britain and Northern Ireland
| | - Danielle Bear
- Department of Dietetics, Guy's and Saint Thomas' Hospitals NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Brijesh Patel
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, United Kingdom of Great Britain and Northern Ireland
| | - Zudin Puthucheary
- Barts & The London School of Medicine & Dentistry, William Harvey Research Institute, London, United Kingdom of Great Britain and Northern Ireland
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Heyland DK, Patel J, Bear D, Sacks G, Nixdorf H, Dolan J, Aloupis M, Licastro K, Jovanovic V, Rice TW, Compher C. The Effect of Higher Protein Dosing in Critically Ill Patients: A Multicenter Registry-Based Randomized Trial: The EFFORT Trial. JPEN J Parenter Enteral Nutr 2018; 43:326-334. [PMID: 30260486 DOI: 10.1002/jpen.1449] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 08/22/2018] [Indexed: 01/22/2023]
Abstract
Current randomized trials and observational studies evaluating higher versus lower protein doses in critically ill patients yield inconclusive results. Because of few studies and methodologic limitations, clinical guidelines suggest a wide range of protein intake based on weak evidence. Clinical equipoise about protein dosing exists. The purpose of the current manuscript is to provide the rationale and protocol for a randomized controlled trial (RCT) of 4000 critically ill patients randomly allocated to receive a higher or lower protein dose. We propose a global, volunteer-driven, registry-based RCT involving >100 intensive care units (ICUs). We will enroll mechanically ventilated patients with high nutrition risk, identified by low (≤25) or high (≥35) body mass index, moderate to severe malnutrition, frailty, sarcopenia, or when >96-hour duration of mechanical ventilation is expected. Exclusion criteria include patients who are >96 hours since initiation of mechanical ventilation, moribund, or pregnant, and where the clinician lacks clinical equipoise regarding protein dose. The intervention consists of higher (≥2.2 g/kg/d) or lower (≤1.2 g/kg/d) protein dose, achieved by enteral nutrition, parenteral nutrition, or both. The primary outcome will be 60-day mortality. Key secondary outcomes include time-to-discharge alive from hospital, ICU and hospital survival, and length of stay. As this is research based on existing medical practice, we will apply for a waiver of informed consent, where possible. The large sample size is a reflection of the small signal we expect to see in this large, pragmatic trial.
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Affiliation(s)
- Daren K Heyland
- Department of Critical Care Medicine and Department of Public Health Sciences, Queen's University, and the Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Jayshil Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Danielle Bear
- Department of Critical Care, Department of Nutrition and Dietetics, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Gordon Sacks
- Auburn University Harrison School of Pharmacy, Auburn, Alabama, USA
| | - Heidi Nixdorf
- Trillium Health Partners, Credit Valley Hospital, Mississauga, Canada
| | - Jennifer Dolan
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Marianne Aloupis
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Kate Licastro
- Trillium Health Partners, Mississauga Hospital, Mississauga, Canada
| | - Vera Jovanovic
- Trillium Health Partners, Mississauga Hospital, Mississauga, Canada
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Charlene Compher
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Mandal S, Suh ES, Harding R, Vaughan-France A, Ramsay M, Connolly B, Bear D, McLaughlin H, Greenwood S, Polkey M, Elliott M, Douiri A, Moxham J, Hart N. S30 Nutrition and Exercise Rehabilitation in Obesity Hypoventilation Syndrome (NERO): A Pilot Randomised Controlled Trial. Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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9
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Canè F, Bear D, Phillips DF, Rosen MS, Smallwood CL, Stoner RE, Walsworth RL, Kostelecký VA. Bound on Lorentz and CPT violating boost effects for the neutron. Phys Rev Lett 2004; 93:230801. [PMID: 15601138 DOI: 10.1103/physrevlett.93.230801] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2003] [Indexed: 05/14/2023]
Abstract
A search for an annual variation of a daily sidereal modulation of the frequency difference between colocated 129Xe and 3He Zeeman masers sets a stringent limit on boost-dependent Lorentz and CPT violation involving the neutron, consistent with no effect at the level of 150 nHz. In the framework of the general standard-model extension, the present result provides the first clean test for the fermion sector of the symmetry of spacetime under boost transformations at a level of 10(-27) GeV.
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Affiliation(s)
- F Canè
- Harvard-Smithsonian Center for Astrophysics, Cambridge, Massachusetts 02138, USA
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10
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Canè F, Bear D, Phillips DF, Rosen MS, Smallwood CL, Stoner RE, Walsworth RL, Kostelecký VA. Bound on Lorentz and CPT violating boost effects for the neutron. Phys Rev Lett 2004. [PMID: 15601138 DOI: 10.1103/phys-revlett.93.230801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
A search for an annual variation of a daily sidereal modulation of the frequency difference between colocated 129Xe and 3He Zeeman masers sets a stringent limit on boost-dependent Lorentz and CPT violation involving the neutron, consistent with no effect at the level of 150 nHz. In the framework of the general standard-model extension, the present result provides the first clean test for the fermion sector of the symmetry of spacetime under boost transformations at a level of 10(-27) GeV.
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Affiliation(s)
- F Canè
- Harvard-Smithsonian Center for Astrophysics, Cambridge, Massachusetts 02138, USA
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11
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Bear D, Stoner RE, Walsworth RL, Kostelecky VA, Lane CD. Limit on lorentz and CPT violation of the neutron using a two-species noble-Gas maser. Phys Rev Lett 2000. [PMID: 11102181 DOI: 10.1103/physrevlett.89.209902] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
A search for sidereal variations in the frequency difference between co-located 129Xe and 3He Zeeman masers sets the most stringent limit to date on leading-order Lorentz and CPT violation involving the neutron, consistent with no effect at the level of 10(-31) GeV.
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Affiliation(s)
- D Bear
- Harvard-Smithsonian Center for Astrophysics, Cambridge, Massachusetts 02138, USA
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12
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Bear D, Stoner RE, Walsworth RL, Kostelecky VA, Lane CD. Limit on lorentz and CPT violation of the neutron using a two-species noble-Gas maser. Phys Rev Lett 2000; 85:5038-5041. [PMID: 11102181 DOI: 10.1103/physrevlett.85.5038] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2000] [Indexed: 05/23/2023]
Abstract
A search for sidereal variations in the frequency difference between co-located 129Xe and 3He Zeeman masers sets the most stringent limit to date on leading-order Lorentz and CPT violation involving the neutron, consistent with no effect at the level of 10(-31) GeV.
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Affiliation(s)
- D Bear
- Harvard-Smithsonian Center for Astrophysics, Cambridge, Massachusetts 02138, USA
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14
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Keller RW, Keller DJ, Bear D, Vasenka J, Bustamante C. Electrodeposition procedure of E. coli RNA polymerase onto gold and deposition of E. coli RNA polymerase onto mica for observation with scanning force microscopy. Ultramicroscopy 1992; 42-44 ( Pt B):1173-80. [PMID: 1413255 DOI: 10.1016/0304-3991(92)90420-o] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Molecules of the transcriptional enzyme E. coli RNA polymerase (RNAP) have been deposited using three different deposition methods: (1) passive adsorption onto gold, (2) electrochemical adsorption onto gold and (3) adsorption onto mica. In all cases SFM imaging was straightforward and reliable, and surface coverage by the protein varied with deposition conditions as expected. To determine the nature of the electrochemical treatment on the gold substrate, cyclic voltammetry was performed with various chemical solutions. Finally, a comparison is made between the SFM images of RNAP obtained with these methods and STM images obtained earlier. Both STM and SFM show strikingly similar results; however, heights and widths of individual molecules differ.
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Affiliation(s)
- R W Keller
- Department of Chemistry, University of New Mexico, Albuquerque 87131
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Bear D. Neurological perspectives on aggressive behavior. J Neuropsychiatry Clin Neurosci 1991; 3:S3-8. [PMID: 1821218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- D Bear
- Department of Psychiatry, University of Massachusetts Medical Center, Worcester 01655
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Abstract
Organic illnesses may produce alterations in behavior that closely resemble personality disorders. Careful differential diagnosis is necessary in formulating appropriate treatment.
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Affiliation(s)
- L W Welch
- Vanderbilt University Medical Center, Nashville, Tennessee
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Affiliation(s)
- R G Vasile
- Department of Psychiatry, Harvard Medical School, Boston, MA
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Affiliation(s)
- D Bear
- Vanderbilt University Hospital, Nashville, Tennessee
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Abstract
Four patients with left-sided posterior cerebral artery infarction developed acute confusional states. Fifteen additional patients with confusion following unilateral posterior cerebral artery infarction were identified from a review of the literature; in 14 the lesion was left sided. Destruction or disconnection of dominant hemisphere neocortex from limbic structures, resulting in impairment of focal attention, loss of linguistically organized memory, and/or disruption of temporal sequencing may be responsible for this syndrome.
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Affiliation(s)
- O Devinsky
- Department of Neurology, Cornell University Medical Center, New York
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Bear D, Schiff D, Saver J, Greenberg M, Freeman R. Quantitative analysis of cerebral asymmetries. Fronto-occipital correlation, sexual dimorphism and association with handedness. Arch Neurol 1986; 43:598-603. [PMID: 3718289 DOI: 10.1001/archneur.1986.00520060060019] [Citation(s) in RCA: 141] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To investigate the biological and functional significance of cerebral asymmetries, we measured lateral differences of the frontal and occipital poles on computed tomographic scans of 66 adult outpatients with no diagnosed abnormalities. In addition to confirming the greater average sizes of the right frontal and left occipital poles, we found a significant linear correlation relating anterior and posterior difference measures. Men showed greater degrees of frontal and occipital asymmetries than women; reversals of the typical asymmetries were more common among women. Reduction or reversal of the usual left occipital predominance in the presence of typical right frontal predominance was associated with non-right-handedness. These findings clarify and extend prior qualitative observations and relate to the possible role of testosterone in modulation of cortical asymmetries. Reduced structural asymmetries among women and non-right-handers may provide an anatomical basis for clinical and laboratory findings of lessened functional lateralization in these groups.
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Abstract
While an increase in aggression has frequently been reported in association with temporal lobe epilepsy, the validity of this behavioral observation and the relationship of specific aggressive behavior to electrophysiologic abnormality in the human limbic system remain unclear. Case reports of five patients document the clinical importance of aggressive behavior, especially during the interictal period, in patients with temporal lobe epilepsy. Aggressiveness was often encountered together with other deepened emotions and changes in behavior previously described as an interictal behavior syndrome. Variations among the individual patients may clarify the neuroanatomical mechanisms leading to aggression and suggest specific therapeutic interventions.
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Finklestein S, Benowitz LI, Baldessarini RJ, Arana GW, Levine D, Woo E, Bear D, Moya K, Stoll AL. Mood, vegetative disturbance, and dexamethasone suppression test after stroke. Ann Neurol 1982; 12:463-8. [PMID: 6960804 DOI: 10.1002/ana.410120509] [Citation(s) in RCA: 129] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Assessments of mood disturbance and "vegetative" (appetite or sleep) disturbance as well as a single-dose dexamethasone suppression test (DST) were carried out in 25 randomly selected stroke patients and in 13 nonstroke control patients hospitalized in a rehabilitation center. Prevalence rates of moderate-to-serve depression of mood and vegetative disturbance were significantly higher in stroke patients than controls (48% and 52% versus 0% and 8%, respectively), as was the prevalence of abnormal DST results (52% versus 8%). Abnormal DST results were associated with the occurrence of moderate to severe mood, appetite, and sleep disturbances among all patients. in 2 stroke patients, repeated DST results paralleled the clinical course. The DST may be useful as an adjunct to the diagnosis and in monitoring the progress of the common and potentially reversible mood and vegetative disturbances occurring after stroke.
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Bear D, Levin K, Blumer D, Chetham D, Ryder J. Interictal behaviour in hospitalised temporal lobe epileptics: relationship to idiopathic psychiatric syndromes. J Neurol Neurosurg Psychiatry 1982; 45:481-8. [PMID: 7119811 PMCID: PMC491423 DOI: 10.1136/jnnp.45.6.481] [Citation(s) in RCA: 87] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Temporal lobe epileptics undergoing psychiatric hospitalisation were contrasted with patients suffering idiopathic psychiatric syndromes or other epilepsies. Quantitative ratings from blind interviews conducted according to a protocol confirmed the appearance of a statistically distinctive behavioural profile, including the desire for social affiliation, circumstantiality, religious and philosophic interests, and deepened affects, among the temporal lobe epileptics.
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Abstract
Many patients with temporal lobe epilepsy also experience dissociative episodes. Three patients with multiple personality exhibited alterations in speech pattern, personality, handedness, and sense of personal identity and claimed amnesia for the dissociative episodes. Another 10 patients identified alternative personalities or demons as motivators of ego-alien behavior. Of clinic patients with temporal lobe epilepsy, 33% exhibited some dissociative phenomena, which had no apparent association with individual seizures but always followed the development of the seizure disorder. The authors propose that intensified, dystonic affects, characteristic of the interictal period in temporal lobe epilepsy, may predispose some individuals to dissociative reactions.
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Geschwind N, Shader RI, Bear D, North B, Levin K, Chetham D. Case 2: Behavioral changes with temporal lobe epilepsy: assessment and treatment. J Clin Psychiatry 1980; 41:89-95. [PMID: 7354021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Pacheco P, Bear D, Ervin FR. Functional interpretation of the flash-evoked response in the chiasma of the monkey (Cebus albifrons). Brain Res 1973; 50:63-76. [PMID: 4632233 DOI: 10.1016/0006-8993(73)90594-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Wiesner P, MacGregor R, Bear D, Berman S, Holmes K, Turck M. Evaluation of a new cephalosporin antibiotic, cephapirin. Antimicrob Agents Chemother 1972; 1:303-9. [PMID: 4208896 PMCID: PMC444212 DOI: 10.1128/aac.1.4.303] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Cephapirin sodium, a parenterally administered derivative of cephalosporanic acid, was tested in vitro against 150 stock cultures of Enterobacteriaceae and 30 stock cultures each of Pseudomonas aeruginosa and Staphylococcus aureus. Both broth- and agar-dilution techniques were employed with two sizes of inocula of organisms. At a concentration of 7.5 mug or less/ml, cephapirin inhibited and killed 100% of strains of Escherichia coli and Proteus mirabilis and more than 80% of Klebsiella species when tested against an inoculum of 10(5) bacterial cells/ml. However, even at 100 mug/ml, only a few isolates of other Enterobacteriaceae and Pseudomonas were inhibited. A 100-fold increase in the inoculum resulted in decreased susceptibility of organisms. All penicillin-susceptible as well as penicillin-resistant S. aureus isolates were inhibited and killed by 5 mug or less of cephapirin/ml when tested with an inoculum of either 10(4) or 10(6) organisms/ml. The drug also was studied in various doses in the treatment of 77 patients with diverse infections. Cephapirin was effective in the treatment of 27 of 32 patients with pulmonary infection, as well as in 6 of 7 patients with staphylococcal or streptococcal soft tissue infection. Of 25 patients with urinary-tract infections, 19 developed a negative culture during therapy. A single 4-g intramuscular dose of cephapirin was effective in only 2 of 11 patients with gonococcal urethritis or endocervicitis. Two patients with gonococcal urethritis treated with multiple injections were cured. The drug was well tolerated except for pain at the site of injection in 14 patients and phlebitis in 4 patients. No abnormalities in renal or hepatic function could be attributed to cephapirin. In addition, no abnormalities were found in the renal tubules of rabbits challenged with 500 mg of cephapirin/kg. If further studies document that cephapirin is well tolerated by the parenteral route, it may have advantages over cephalothin or cephaloridine.
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