Physical outcome measure for critical care patients following intensive care discharge

Introduction: The aim of this study was to evaluate the most suitable physical outcome measures to be used with critical care patients following discharge. ICU survivors experience physical problems such as reduced exercise capacity and intensive care acquired weakness. NICE guideline ‘Rehabilitation after critical illness’ (1) recommends the use of outcome measures however does not provide any specific guidance. A recent Cochrane review noted wide variability in measures used following ICU discharge (2). Methods: Discharged ICU patients attended a five week multidisciplinary programme. Patients’ physical function was assessed during the programme, at 6 months and 12 months post discharge. Three outcome measures were included in the initial two cohorts. The Six Minute Walk Test (6MWT) and the Incremental Shuttle Walk test (ISWT) were chosen as they have been used within the critical care follow up setting (2). The Chester Step Test (CST) is widely thought to be a good indicator of ability to return to work (one of the programmes primary aims). Ethics approval was waived as the programme was part of a quality improvement initiative. Results: Data was collected for the initial patients attending the programme (n = 13), median age was 52 (IQR = 38-72), median ICU LOS was 19 days (IQR = 4-91), median APACHE II was 23 (IQR = 19-41) and 11 were men. One patient was so physically debilitated that the CST or ISWT could not be completed however a score was achieved using the 6MWT. Another patient almost failed to achieve level 1 of the ISWT. Subsequent patients for this project (total n = 47) have all therefore been tested using the 6MWT. Good inter-rater and intrarater reliability and validity have been reported for the 6MWT (3). Conclusions: Exercise capacity measurement is not achievable for some patients with either the ISWT or the CST due to the severity of their physical debilitation. Anxiety, post-traumatic stress disorder and depression are common psychological problems post discharge (4), therefore using a test with a bleep is not appropriate. Therefore, the 6MWT is the most appropriate physical outcome measure to be used with critical care patients post discharge

Classification of pain and its treatment at an intensive care rehabilitation clinic

Introduction Treatment in an Intensive Care Unit (ICU) often necessitates uncomfortable and painful procedures for patients throughout their admission. There is growing evidence to suggest that chronic pain is becoming increasingly recognised as a long term problem for patients following an ICU admission [1]. Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) is a five week rehabilitation programme for patients and their caregivers after ICU discharge at Glasgow Royal Infirmary. This study investigated the incidence and location of chronic pain in patients discharged from ICU and classified the analgesics prescribed according to the World Health Organization analgesic Methods The InS:PIRE programme involved individual sessions for patients and their caregivers with a physiotherapist and a pharmacist along with interventions from medical, nursing, psychology and community services. The physiotherapist documented the incidence and pain location during the assessment. The pharmacist recorded all analgesic medications prescribed prior to admission and at their clinic visit. The patient’s analgesic medication was classified according to the WHO pain ladder from zero to three, zero being no pain medication and three being treatment with a strong opioid. Data collected was part of an evaluation of a quality improvement initiative, therefore ethics approval was waived. Results Data was collected from 47 of the 48 patients who attended the rehabilitation clinic (median age was 52 (IQR, 44-57) median ICU LOS was 15 (IQR 9-25), median APACHE II was 23 (IQR 18-27) and 32 of the patients were men (67 %)). Prior to admission to ICU 43 % of patients were taking analgesics and this increased to 81 % at the time of their clinic visit. The number of patients at step two and above on the WHO pain ladder also increased from 34 % to 56 %. Conclusions Of the patients seen at the InS:PIRE clinic two-thirds stated that they had new pain since their ICU admission. Despite the increase in the number and strength of analgesics prescribed, almost a quarter of patients still complained of pain at their clinic visit. These results confirm that pain continues to be a significant problem in this patient group. Raising awareness in primary care of the incidence of chronic pain and improving its management is essential to the recovery process following an ICU admission

Pharmacy intervention at an intensive care rehabilitation clinic

Introduction: During an intensive care stay, patients often have their chronic medications withheld for a variety of reasons and new drugs commenced [1]. As patients are often under the care of a number of different medical teams during their admission there is potential for these changes to be inadvertently continued [2]. Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) is a five week rehabilitation programme for patients and their caregivers after ICU (Intensive Care Unit) discharge at Glasgow Royal Infirmary. Within this programme a medication review by the critical care pharmacist provided an opportunity to identify and resolve any pharmaceutical care issues and also an opportunity to educate patients and their caregivers about changes to their medication. Methods: During the medication review we identified ongoing pharmaceutical care issues which were communicated to the patient’s primary care physician (GP) by letter or a telephone call. The patients were also encouraged to discuss any issues raised with their GP. The significance of the interventions was classified from those not likely to be of clinical benefit to the patient, to those which prevented serious therapeutic failure. Results: Data was collected from 47 of the 48 patients who attended the clinic (median age was 52 (IQR, 44-57) median ICU LOS was 15 (IQR 9-25), median APACHE II was 23 (IQR 18-27) and 32 of the patients were men (67%). The pharmacist made 69 recommendations; including 20 relating to drugs which had been withheld and not restarted, dose adjustments were suggested on 13 occasions and new drug recommendations were made for 10 patients. Duration of treatment for new medications started during hospital admission was clarified on 12 occasions. Lastly adverse drug effects were reported on 4 occasions and the incorrect drug was prescribed on 2 occasions. Of the interventions made 58% were considered to be of moderate to high impact. Conclusions: The pharmacist identified pharmaceutical care issues with 18.6% of the prescribed medications. Just over half of the patients reported that they were not made aware of any alterations to their prescribed medication on discharge. Therefore a pharmacy intervention is an essential part of an intensive care rehabilitation programme to address any medication related problems, provide education and to ensure patients gain optimal benefit from their medication

My country or my planet? Exploring the influence of multiple place attachments and ideological beliefs upon climate change attitudes and opinions

This is the author accepted manuscript. The final version is available from Elsevier via the DOI in this record.Research on people-place relations, specifically place attachment and place identity, is beginning to make an important contribution to understanding human responses to climate change. However, to date there has been a dearth of research on how place attachments at multiple scales, particularly the global, and individual level ideological beliefs combine to influence climate change attitudes and opinions. To address these gaps, survey data was collected from a representative sample of Australian citizens (. N=. 1147), capturing attachments at neighbourhood, city/town, state/territory, country and global scales, as well as a range of climate change belief and individual difference measures. Results show the importance of the interplay between national and global place attachments. Individuals expressing stronger global than national attachments were more likely to attribute climate change to anthropogenic causes, to oppose hierarchy-enhancing myths that legitimize climate inaction, and to perceive positive economic impacts arising from climate change responses, in comparison to individuals indicating stronger national over global place attachments. Individuals with stronger global than national attachments were more likely to be female, younger, and self-identify as having no religion, to be more likely to vote Green and to be characterized by significantly lower levels of right wing authoritarian and social dominance beliefs. Right wing authoritarian and social dominance beliefs mediated the effects of place attachments upon climate change skepticism. Explanations for the findings and implications for future research are discussed.This study was funded by the Climate Adaptation Flagship of the Commonwealth Scientific and Industrial Research Organisation (CSIRO), Australia. Patrick Devine-Wright received a Distinguished Visiting Scientist award from CSIRO, which enabled this collaboration to take place. The authors would like to thank Iain Walker for helpful comments on a draft, as well as peer reviewers

Ibuprofen Ameliorates Fatigue- And Depressive-Like Behavior in Tumor-Bearing Mice

Aims: Cancer-related fatigue (CRF) is often accompanied by depressed mood, both of which reduce functional status and quality of life. Research suggests that increased expression of pro-inflammatory cytokines is associated with skeletal muscle wasting and depressive- and fatigue-like behaviors in rodents and cancer patients. We have previously shown that treatment with ibuprofen, a nonsteroidal anti-inflammatory drug, preserved muscle mass in tumor-bearing mice. Therefore, the purpose of the present study was to determine the behavioral effects of ibuprofen in a mouse model of CRF. Main methods: Mice were injected with colon-26 adenocarcinoma cells and treated with ibuprofen (10 mg/kg) in the drinking water. Depressive-like behavior was determined using the forced swim test (FST). Fatigue-like behaviors were determined using voluntary wheel running activity (VWRA) and grip strength. The hippocampus, gastrocnemius muscle, and serum were collected for cytokine analysis. Key findings: Tumor-bearing mice showed depressive-like behavior in the FST, which was not observed in mice treated with ibuprofen. VWRA and grip strength declined in tumor-bearing mice, and ibuprofen attenuated this decline. Tumor-bearing mice had decreased gastrocnemius muscle mass and increased expression of IL-6, MAFBx and MuRF mRNA, biomarkers of protein degradation, in the muscle. Expression of IL-1β and IL-6 was also increased in the hippocampus. Treatment with ibuprofen improved muscle mass and reduced cytokine expression in both the muscle and hippocampus of tumor-bearing mice. Significance: Ibuprofen treatment reduced skeletal muscle wasting, inflammation in the brain, and fatigue- and depressive-like behavior in tumor-bearing mice. Therefore, ibuprofen warrants evaluation as an adjuvant treatment for CRF

Instant Two-Body Equation in Breit Frame

A quasipotential formalism for elastic scattering from relativistic bound states is based on applying an instant constraint to both initial and final states in the Breit frame. This formalism is advantageous for the analysis of electromagnetic interactions because current conservation and four momentum conservation are realized within a three-dimensional formalism. Wave functions are required in a frame where the total momentum is nonzero, which means that the usual partial wave analysis is inapplicable. In this work, the three-dimensional equation is solved numerically, taking into account the relevant symmetries. A dynamical boost of the interaction also is needed for the instant formalism, which in general requires that the boosted interaction be defined as the solution of a four-dimensional equation. For the case of a scalar separable interaction, this equation is solved and the Lorentz invariance of the three-dimensional formulation using the boosted interaction is verified. For more realistic interactions, a simple approximation is used to characterize the boost of the interaction.Comment: 20 pages in revtex 3, 3 figures. Fixed reform/tex errors

Fluoxetine Prevents the Development of Depressive-like Behavior in a Mouse Model of Cancer Related Fatigue

Cancer patients frequently suffer from fatigue, a complex syndrome associated with tiredness and depressed mood. Cancer-related fatigue (CRF) can be present at the time of diagnosis, escalates during treatment, and can persist for years after treatment. CRF negatively influences quality of life, limits functional independence, and is associated with decreased survival in patients with incurable disease. We have previously shown that increased pro-inflammatory cytokine expression in the brain contributes to depressive- and fatigue-like behaviors in a mouse model of CRF. Inflammatory cytokines increase the activity of indoleamine 2,3-dioxygenase (IDO) and kynurenine 3-monooxygenase (KMO), which competitively reduce serotonin synthesis. Reduced serotonin availability in the brain and increased production of alternative neuroactive metabolites of tryptophan are thought to contribute to the development of depression and fatigue. The purpose of this study was to determine the effects of fluoxetine, a selective serotonin reuptake inhibitor (SSRI), on brain cytokines and behavioral measures of fatigue and depression in tumor-bearing mice. Here we show that tumor growth increased brain expression of pro-inflammatory cytokines and KMO. Treatment with fluoxetine had no effect on tumor growth, muscle wasting, fatigue behavior, or cytokine expression in the brain. Fluoxetine, however, reduced depressive-like behaviors in tumor bearing mice. In conclusion, our data confirm that increased brain expression of pro-inflammatory cytokines is associated with tumor-induced fatigue- and depressive-like behaviors. However, it is possible to separate the effects of tumor growth on mood and fatigue-like behaviors using SSRIs such as fluoxetine

Rogue wave spectra of the Sasa–Satsuma equation

We analyze the rogue wave spectra of the Sasa–Satsuma equation and their appearance in the spectra of chaotic wave fields produced through modulation instability. Chaotic wave fields occasionally produce high peaks that result in a wide triangular spectrum, which could be used for rogue wave detection.The authors acknowledge the support from the Volkswagen Stiftung. N. D. and N. A. acknowledge the support of the Australian Research Council (Discovery Project DP140100265). N. A. is a recipient of the Alexander von Humboldt Award (Germany). The work of JMSC is supported by the MINECO under contracts FIS2009- 09895 and TEC2012-37958-C02-02, and by C.A.M. under contract S2013/MIT-2790

Memetic Multilevel Hypergraph Partitioning

Hypergraph partitioning has a wide range of important applications such as VLSI design or scientific computing. With focus on solution quality, we develop the first multilevel memetic algorithm to tackle the problem. Key components of our contribution are new effective multilevel recombination and mutation operations that provide a large amount of diversity. We perform a wide range of experiments on a benchmark set containing instances from application areas such VLSI, SAT solving, social networks, and scientific computing. Compared to the state-of-the-art hypergraph partitioning tools hMetis, PaToH, and KaHyPar, our new algorithm computes the best result on almost all instances