A protocol for a pilot randomised controlled trial of an Early Psychiatric Assessment, Referral, and Intervention Study (EPARIS) for intensive care patients

BACKGROUND

Up to 80% of Intensive Care Unit patients experience physical, cognitive, and/or psychological complications post-discharge, known as 'Post Intensive Care Syndrome' (PICS). Early diagnosis and intervention are a priority, but while current post-intensive care follow-up processes endorse a multidisciplinary model, incorporating a psychiatric consultation has not been studied.

METHODS

A pilot, open-label randomised controlled trial was developed by a multidisciplinary team to evaluate the feasibility and acceptability of incorporating a psychiatric review into an existing post-ICU clinic. The study will run for 12 months and aim to recruit 30 participants. Inclusion criteria for participants: a) ICU admission greater than 48 hours, b) no cognitive impairment that prevents participation, c) ≥ 18 years old, d) residing in Australia, e) fluent in English, f) able to provide GP information, and g) likely to be contactable in 6 months. Patient recruitment will be at Redcliffe Hospital, Queensland, Australia, and will involve patients attending the Redcliffe post intensive care clinic. Participants will be allocated to intervention or control using block randomisation and allocation concealment. Participants allocated to the control arm will receive the standard cares provided by the clinic, which involves an unstructured interview about their ICU experience and a battery of surveys about their psychological, cognitive, and physical function. Those allocated to the intervention arm will receive these same cares as well as an appointment with a psychiatrist for a single session intervention. The psychiatric intervention will involve a comprehensive review, including comorbid disorders, substance use, suicidal ideation, psychosocial stressors, social/emotional supports. Psychoeducation and initial treatment will be provided as indicated and recommendations given to the patient and their GP about how to access ongoing care. In addition to surveys conducted as part of standard clinic cares, all participants will complete additional questionnaires about their history, hospital experience, mental and physical health as well as employment circumstances. All participants will be followed up 6 months after their appointment and will be invited to complete follow-up questionnaires about their mental and physical health, as well as health service use and employment circumstances. The trial has been registered with ANZCTR (ACTRN12622000894796).

RESULTS

To evaluate the feasibility and acceptability of the intervention to the patient population. Differences between groups will be assessed using an independent samples t-test. Resource requirements to administer the intervention will be evaluated by reporting the mean duration of the EPARIS assessment and approximate cost per patient to provide this service. To estimate the effect size of any treatment effects, changes in secondary outcome measures between baseline and 6 months will be compared between intervention and control groups using Analysis of Covariance regression. As this is a pilot, we will not use p-values or test a null hypothesis, but will give confidence intervals.

CONCLUSIONS

This protocol provides a pragmatic evaluation of the acceptability of introducing early psychiatric assessment into an existing post-ICU follow-up process, and if considered acceptable will inform future research into the efficacy and generalisability of the intervention. The strengths of EPARIS are the prospective, longitudinal design with a control population, and its use of validated post-ICU outcome measures.

Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study

PURPOSE

In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials.

METHODS

We carried out a prospective international cohort study of adult patients (≥ 18 years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021.

RESULTS

2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp. (20.3%), Escherichia coli (15.8%), and Pseudomonas spp. (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) was present in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24 h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alive from hospital by day-28.

CONCLUSIONS

HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes.

A cluster-controlled clinical trial of two prophylactic silicone sacral dressings to prevent sacral pressure injuries in critically ill patients

Objective Patients in the intensive care unit (ICU) have increased risk of pressure injury (PI) development due to critical illness. This study compared two silicone dressings used in the Australian ICU setting for sacral PI prevention. Design A cluster-controlled clinical trial of two sacral dressings with four alternating periods of three months' duration. Setting A 10-bed general adult ICU in outer-metropolitan Brisbane, Queensland, Australia. Participants Adult participants who did not have a sacral PI present on ICU admission and were able to have a dressing applied for more than 24 hours without repeated dislodgement or soiling in a 24-hour period (>3 times). Interventions Dressing 1 (Allevyn Gentle Border Sacrum™, Smith & Nephew) and Dressing 2 (Mepilex Border Sacrum™, Mölnlycke). Main outcomes measures The primary outcome was the incidence of a new sacral PI (stage 1 or greater) per 100 dressing days in the ICU. Secondary outcomes were the mean number of dressings per patient, the cost difference of dressings to prevent a sacral PI and product integrity. Results There was no difference in the incidence of a new sacral PI (0.44 per 100 dressing days for both products, p = 1.00), the mean number of dressings per patient per day (0.50 for both products, p = 0.51) and product integrity (85% for Dressing 1 and 84% for Dressing 2, p = 0.69). There was a dressing cost difference per patient (A$10.29 for Dressing 1 and A$28.84 for Dressing 2, p < 0.001). Conclusions Similar efficacy, product use and product integrity, but differential cost, were observed for two prophylactic silicone dressings in the prevention of PIs in the intensive care patient. We recommend the use of sacral prophylactic dressings for at-risk patients, with the choice of product based on ease of application, clinician preference and overall cost-effectiveness of the dressing.

NLite laser: nonablative wrinkle reduction

The NLite laser is promoted as a tool for painless wrinkle reduction without side effects, posttreatment care, "downtime," or complications. However, with only 1 published study, limited scientific data are available. The authors report generally disappointing clinical results based on personal experience and a survey of 8 physicians who were among the first in Dallas to incorporate NLite technology into their practices. (Aesthetic Surg J 2001;21:371-372.).

Progressive tension sutures: a technique to reduce local complications in abdominoplasty

Abdominoplasty has evolved as a very effective and satisfactory procedure, especially when combined with liposuction and the repair of diastasis recti. However, local complications, including hematoma and seroma formation, flap necrosis, and hypertrophic scars, continue to plague this procedure. The authors present a relatively simple and reproducible technique that allows extensive liposuction in conjunction with abdominoplasty; they think this technique reduces the incidence of local complications. This technique, the use of progressive tension sutures, has been used in their practice for more than 15 years. A retrospective review of 65 consecutive abdominoplasty patients demonstrates a very low local complication rate when compared with historical controls. In this series of both full and modified abdominoplasty patients who were followed for an average of 18 months, the authors had no hematomas, seromas, or skin flap necrosis.

Perivascular spaces in the basal ganglia of the human brain: their relationship to lacunes

There is evidence for lymphatic drainage of interstitial fluid from the brain along perivascular spaces in a number of mammalian species. Ultrastructural studies suggest that there are similar drainage pathways in the human cerebral cortex. Perivascular spaces in the basal ganglia, however, differ from those in the cortex in that they dilate to form lacunes and rarely accumulate beta-amyloid (amyloid angiopathy) in Alzheimer's disease; in the cortex, lacunes are rare but amyloid angiopathy is common. The aim of the present study is to compare the structure of perivascular spaces in the basal ganglia and at the anterior perforated substance with perivascular spaces in the cerebral cortex. Eight postmortem brains from patients aged 23-80 years (mean 68 y) were examined by light microscopy, by scanning and transmission electron microscopy and by direct visualisation of etched paraffin blocks. The results show that arteries in the basal ganglia are surrounded by 2 distinct coats of leptomeninges separated by a perivascular space which is continuous with the perivascular space around arteries in the subarachnoid space. The inner layer of leptomeninges closely invests the adventitia of the vessel wall and the outer layer is continuous with the pia mater on the surface of the brain at the anterior perforated substance. Veins in the basal ganglia have no outer layer of leptomeninges and thus the perivascular space is continuous with the subpial space. The anatomy of the periarterial spaces in the basal ganglia differs significantly from that in the cerebral cortex where there is only a single periarterial layer of leptomeninges. Differences in structure of perivascular spaces around arteries may reflect relative efficiencies in the drainage of interstitial fluid from different sites in the brain. Furthermore, the structure of the perivascular spaces may contribute to the relatively high frequency of lacunes in the basal ganglia, and the low frequency of amyloid angiopathy at this site in Alzheimer's disease.

Fine-needle aspiration cytology and thyroid surgery in the community hospital

BACKGROUND

To assess the use and usefulness of fine-needle aspiration cytologic biopsy (FNAB) of the thyroid in our hospital.

METHODS

All cytology slides and charts of patients who had FNAB of the thyroid done in our hospital in 1993 were reviewed. Charts of all patients having thyroid surgery in our hospital in 1993 were reviewed to determine the pathological diagnosis and whether FNAB had been performed preoperatively. Finally, we reviewed all consecutive thyroid surgery cases for an 8-year period, and we calculated the yearly percentage of malignancy.

RESULTS

Fifty-five FNAB were done in 53 patients. In 21 patients the FNAB gave indication for thyroid surgery, yet surgery was done in only 12 (57.1%). Forty-two patients had surgery for a thyroid nodule, but only 20 patients (47.6%) had a preoperative FNAB. There were 3 malignancies among the 20; 2 were correctly predicted by FNAB. The FNAB was correct in 18 of 20. In all, 378 thyroid operations were done from 1987 to 1994. The yearly proportion of thyroid malignancy ranged from 11% to 29%, but showed no change corresponding with increasing diagnostic sophistication.

CONCLUSIONS

Fine-needle aspiration cytologic biopsy in the workup of patients with thyroid masses is strikingly underutilized in our institution. While accurate in 90% of cases where used, FNAB appears to play a minor role in the surgeon's decision regarding surgery. As a result of these findings, we developed a grading system for better communication of the FNAB report and a clinical guideline to improve the evaluation of patients with thyroid masses.

Breast capsular contracture: a retrospective study of textured versus smooth silicone implants

Recent media attention has transformed breast augmentation, a routine surgical procedure, into a highly controversial one. Capsular contracture is cited in both the lay press and scientific literature as the most frequent complication of breast augmentation. This retrospective study compares two similar groups of breast augmentation patients. The first group consists of 98 consecutive patients utilizing smooth-surface silicone implants, and the second group consists of 99 consecutive augmentations using textured-surface silicone implants. The operative technique and postoperative care were identical--with the surface differences being the only significant variable. Textured-surface silicone implants are shown statistically to reduce capsular contracture to 4 percent, compared with a 21 percent incidence with smooth-surface silicone implants.

Evaluation of a maternity cushion (Ozzlo pillow) for backache and insomnia in late pregnancy

The effect of a wedge-shaped pillow (Ozzlo pillow) was compared with a standard hospital pillow, used to support the abdomen of a pregnant woman while lying on her side, in preventing or alleviating backache and backache-related insomnia; 92 women at 36 weeks' gestation completed the study. Backache was found to be very common (87%), the onset of pain occurring before 29 weeks in 59%. Age, parity, previous backache and type of bed used did not correlate with the backache scores during the period of study. Lower scores for backache were recorded by women in the week they used the Ozzlo pillow compared with the week they used the standard pillow. Sleeping was deemed better by the patient with the Ozzlo pillow, though actual sleeping scores did not corroborate this. While significantly more felt the Ozzlo pillow was superior to a standard pillow for backache and sleeping, some found both methods helpful. The simple measure of supporting the abdomen with a pillow when in lateral recumbency is likely to benefit many women in late pregnancy. A wedge-shaped pillow of the Ozzlo type, conforming to the shape of the abdomen and supporting it more closely, may be of greater help than a standard cushion or pillow.

Enzymes of glucose and fatty acid metabolism of liver, kidney, skeletal muscle, adipose tissue and mammary gland of lactating and non-lactating sheep

The effect of peak lactation on the activities of a number of enzymes of glucose and lipid metabolism of perirenal and subcutaneous adipose tissue, skeletal muscle, liver, kidney cortex and mammary parenchyma of sheep are described. Enzymes studied included hexokinase (glucose utilization), pyruvate carboxylase (gluconeogenesis), pyruvate dehydrogenase (glucose oxidation and production of acetyl CoA for fatty acid synthesis), acetyl CoA carboxylase (fatty acid synthesis) and glycerol-3-phosphate acyltransferase (fatty acid esterification). Major changes that were found include a decrease in activities of enzymes of fatty acid synthesis and esterification in adipose tissues, decreased activity of pyruvate dehydrogenase in muscle and adipose tissues and increased pyruvate carboxylase; there was no change in activities of enzyme of fatty acid esterification in liver. Activities of hexokinase, acetyl CoA carboxylase and glycerol-3-phosphate acyltransferase have been estimated per tissue; this shows the quantitative importance of limiting glucose utilization by muscle and of suppression of fatty acid synthesis in adipose tissue for efficient partitioning of nutrients for milk production.