Shoulder dysfunction in intensive care survivors:an investigation into prevalence, risk factors and impact on upper limb function

Background: Limitations in function and quality of life have been reported in intensive care unit survivors for many years after hospital discharge. Shoulder dysfunction is a cause of functional limitation in other patient populations, and has been suggested as a potential cause in intensive care unit survivors. Despite this, the prevalence of shoulder dysfunction, its impact on upper limb function and risk factors for its development are unknown in intensive care unit survivors. Methods: A cohort study of intensive care unit survivors from a single general intensive care unit was undertaken using prospective and retrospective data. Participants underwent a series of shoulder assessments up to 6 months after hospital discharge to identify shoulder dysfunction and upper limb impairment. Multivariable analysis was used to investigate the risk factors for developing shoulder dysfunction. Results: Shoulder dysfunction was present in 76% of participants, with 42% presenting with ongoing shoulder dysfunction at 6 months after hospital discharge. Functional impairment of the upper limb was present in 48% of participants and severe impairment in 18%. None of the risk factors analysed were independently associated with shoulder dysfunction. Conclusions: Shoulder dysfunction is a common problem in intensive care unit survivors, and is a source of functional impairment. Further investigation addressing risk factors for its development, and therapeutic interventions to address this problem is required

Evaluating the perceived impact and legacy of master’s degree level research in the allied health professions: a UK-wide cross-sectional survey

Background: Post graduate master’s degree qualifications are increasingly required to advance allied health profession careers in education, clinical practice, leadership, and research. Successful awards are dependent on completion of a research dissertation project. Despite the high volume of experience gained and research undertaken at this level, the benefits and impact are not well understood. Our study aimed to evaluate the perceived impact and legacy of master’s degree training and research on allied health profession practice and research activity. Methods: A cross-sectional online survey design was used to collect data from allied health professionals working in the United Kingdom who had completed a postgraduate master’s degree. Participants were recruited voluntarily using social media and clinical interest group advertisement. Data was collected between October and December 2022 and was analysed using descriptive statistics and narrative content analysis. Informed consent was gained, and the study was approved by the university research ethics committee. Results: Eighty-four responses were received from nine allied health professions with paramedics and physiotherapists forming the majority (57%) of respondents. Primary motivation for completion of the master’s degree was for clinical career progression (n = 44, 52.4%) and formation of the research dissertation question was predominantly sourced from individual ideas (n = 58, 69%). Formal research output was low with 27.4% (n = 23) of projects published in peer reviewed journal and a third of projects reporting no output or dissemination at all. Perceived impact was rated highest in individual learning outcomes, such as improving confidence and capability in clinical practice and research skills. Ongoing research engagement and activity was high with over two thirds (n = 57, 67.9%) involved in formal research projects. Conclusion: The focus of master's degree level research was largely self-generated with the highest perceived impact on individual outcomes rather than broader clinical service and organisation influence. Formal output from master’s research was low, but ongoing research engagement and activity was high suggesting master’s degree training is an under-recognised source for AHP research capacity building. Future research should investigate the potential benefits of better coordinated and prioritised research at master’s degree level on professional and organisational impact

Musculoskeletal impairments after critical illness: a protocol for a qualitative study of the experiences of patients, family and health care professionals

Background: Survivors of critical care are at risk of long-term disability from musculoskeletal (MSK) impairments. These can have a biopsychosocial impact on the patient and their families with a reduction in health-related quality of life, increased health care utilization, caregiving roles and associated psychological distress. Aims: To understand the experiences of patients living with MSK impairments following critical illness, and family and health care professionals supporting them, to inform the development of a future intervention to improve MSK health following critical illness. Study Design: A four-site qualitative case study approach will be taken, with each of the four hospital sites and associated community services representing a case site. We will conduct semi-structured interviews with 10–15 patients/family members and 10–15 health care professionals about their experiences of MSK impairment following critical illness. Interviews will be audio recorded, transcribed verbatim and analysed using reflexive thematic analysis within a descriptive phenomenological approach. Alongside interview data, analysis of publicly available policy documentation, patient-facing materials and information from service leads at the four sites will be conducted. Discourse analysis will be used for this case study documentation. Results: This protocol describes a qualitative study exploring the experiences of patients living with MSK impairments following critical illness, and the family and health care professionals supporting them. Relevance to Clinical Practice: Data analysis will illuminate their experiences and enable data richness to contribute to the qualitative body of evidence of intensive care unit (ICU) survivors. These findings will inform the development of a complex intervention for MSK rehabilitation after critical illness

Patient harm and institutional avoidability of out-of-hours discharge from intensive care: An analysis using mixed methods

© [2022] The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY). https://creativecommons.org/licenses/by/4.0/Objective: Out-of-hours discharge from ICU to the ward is associated with increased in-hospital mortality and ICU readmission. Little is known about why this occurs. We map the discharge process and describe the consequences of out-of-hours discharge to inform practice changes to reduce the impact of discharge at night. Design: This study was part of the REFLECT mixed methods study. We defined out-of-hours discharge as 16:00 - 07:59h. We undertook 20 in-depth case record reviews where in-hospital death after ICU discharge had been judged ‘probably avoidable’ in previous retrospective structured judgement reviews, and 20 where patients survived. We conducted semi-structured interviews with 55 patients, family members and staff with experience of ICU discharge processes. These, along with a stakeholder focus group, informed ICU discharge process mapping using the Human Factors-based Functional Analysis Resonance Method (FRAM). Setting: Three UK NHS hospitals, chosen to represent different hospital settings. Subjects: Patients discharged from ICU, their families and staff involved in their care. Interventions None. Measurements and Main Results: Out-of-hours discharge was common. Patients and staff described out-of-hours discharge as unsafe due to a reduction in staffing and skill mix at night. Patients discharged out-of-hours were commonly discharged prematurely, had inadequate handover, were physiologically unstable and did not have deterioration recognised or escalated appropriately. We identified five interdependent functions key to facilitating timely ICU discharge: multi-disciplinary team decision for discharge; patient prepared for discharge; bed meeting; bed manager allocation of beds; and ward bed made available. Conclusion: We identified significant limitations in out-of-hours care provision following overnight discharged from ICU. Transfer to the ward before 16:00 should be facilitated where possible. Our work highlights changes to help make day time discharge more likely. Where discharge after 16:00 is unavoidable, support systems should be implemented to ensure the safety of patients discharged from ICU at night.Peer reviewedFinal Published versio

The effects of inspiratory muscle training on inspiratory muscle strength, lung function and quality of life in adults with spinal cord injuries: A systematic review and Meta-analysis

Purpose: This systematic review and meta-analysis aimed to evaluate the effectiveness of inspiratory muscle training (IMT) on respiratory muscle strength, lung function and quality of life (QOL) in adults with spinal cord injuries (SCI). Methods: Databases were searched up to June 2022; CENTRAL, CINAHL, MEDLINE, PEDRo, and PubMed. Following PRISMA reporting guidelines, two independent reviewers selected studies and extracted data. Study quality and levels of evidence were assessed. Results: Following selection from 624 initial search results, six randomised controlled trials were identified, comprising 124 participants. Quality of Evidence was very low to moderate. Meta-analysis showed that post intervention, IMT significantly improved maximal inspiratory pressure (MD 15.72 cmH2O, 95% CI 5.02, 26.41, p ¼ 0.004) when compared with a control intervention. There was no significant benefit for physical QOL (SMD 0.12, 95% CI 1.01, 1.25, p ¼ 0.84), mental QOL (SMD 0.2, 95% CI 1.72, 1.33, p ¼ 0.80), maximal expiratory pressure (MD 5.19 cmH2O, 95% CI 4.16, 14.55, p ¼ 0.80), or FEV1 (MD 0.26 L, 95% CI 0.19, 0.7, p ¼ 0.26). Sensitivity analyses found larger effects for studies with 8 week interventions (MD 17.5 cmH2O (95% CI 3.36 to 31.66)) and spring loaded devices alone (MD 21.18 cmH2O, 95% CI 9.65 to 32.72). Conclusion: Moderate quality evidence suggests IMT improves respiratory strength in adults with an SCI. The mental and physical QOL outcomes provided very low quality of evidence, with considerable heterogeneity between study results, leading to inconsistency. Further research is warranted to investigate medium and long-term impact of robust IMT protocols, accounting for patient motivation and adherence t

Mobilisation in the EveNing to TreAt deLirium (MENTAL):protocol for a mixed-methods feasibility randomised controlled trial

INTRODUCTION: Delirium is common in critically ill patients and is associated with longer hospital stays, increased mortality and higher healthcare costs. A number of risk factors have been identified for the development of delirium in intensive care, two of which are sleep disturbance and immobilisation. Non-pharmacological interventions for the management of intensive care unit (ICU) delirium have been advocated, including sleep protocols and early mobilisation. However, there is a little published evidence evaluating the feasibility and acceptability of evening mobilisation. METHODS AND ANALYSIS: Mobilisation in the EveNing to TreAt deLirium (MENTAL) is a two-centre, mixed-methods feasibility randomised controlled trial (RCT). Sixty patients will be recruited from ICUs at two acute NHS trusts and randomised on a 1:1 basis to receive additional evening mobilisation, delivered between 19:00 and 21:00, or standard care. The underpinning hypothesis is that the physical exertion associated with evening mobilisation will promote better sleep, subsequently having the potential to reduce delirium incidence. The primary objective is to assess the feasibility and acceptability of a future, multicentre RCT. The primary outcome measures, which will determine feasibility, are recruitment and retention rates, and intervention fidelity. Acceptability of the intervention will be evaluated through semi-structured interviews of participants and staff. Secondary outcome measures include collecting baseline, clinical and outcome data to inform the power calculations of a future definitive trial. ETHICS AND DISSEMINATION: Ethical approval has been obtained through the Wales Research and Ethics Committee 6 (22/WA/0106). Participants are required to provide written informed consent. We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media. TRIAL REGISTRATION NUMBER: NCT05401461

Effect of Silicon Content on Carbide Precipitation and Low-Temperature Toughness of Pressure Vessel Steels

Cr – Mn – Mo – Ni pressure vessel steels containing 0.54 and 1.55% Si are studied. Metallographic and fractographic analyses of the steels after tempering at 650 and 700°C are performed. The impact toughness at – 30°C and the hardness of the steels are determined. The mass fraction of the carbide phase in the steels is computed with the help of the J-MatPro 4.0 software

Investigating the impact of physical activity interventions on delirium outcomes in intensive care unit patients: A systematic review and meta-analysis

Background. To investigate the impact of physical activity interventions, including early mobilisation, on delirium outcomes in critically ill patients. Methods. Electronic database literature searches were conducted, and studies were selected based on pre-specified eligibility criteria. Cochrane Risk of Bias-2 and Risk Of Bias In Non-randomised Studies-of Interventions quality assessment tools were utilised. Grading of Recommendations, Assessment, Development and Evaluations was used to assess levels of evidence for delirium outcomes. The study was prospectively registered on PROSPERO (CRD42020210872). Results. Twelve studies were included; ten randomised controlled trials one observational case-matched study and one before-after quality improvement study. Only five of the included randomised controlled trial studies were judged to be at low risk of bias, with all others, including both non-randomised controlled trials deemed to be at high or moderate risk. The pooled relative risk for incidence was 0.85 (0.62–1.17) which was not statistically significant in favour of physical activity interventions. Narrative synthesis for effect on duration of delirium found favour towards physical activity interventions reducing delirium duration with median differences ranging from 0 to 2 days in three comparative studies. Studies comparing varying intervention intensities showed positive outcomes in favour of greater intensity. Overall levels of evidence were low quality. Conclusions. Currently there is insufficient evidence to recommend physical activity as a stand-alone intervention to reduce delirium in Intensive Care Units. Physical activity intervention intensity may impact on delirium outcomes, but a lack of high-quality studies limits the current evidence base

The effectiveness of prehabilitation interventions on biopsychosocial and service outcomes pre and post upper gastrointestinal surgery : a systematic review

Purpose. This review synthesised the evidence for the effect of prehabilitation interventions on biopsychosocial and service outcomes. Materials and Methods. A systematic review was conducted. 10 databases were searched to December 2023. Prospective experimental studies exploring prehabilitation interventions in adults undergoing upper gastrointestinal surgery were included. Prehabilitation was any preoperative intervention to improve physical or psychological outcomes. Included studies required a comparator group or alternative preoperative intervention as well as baseline, presurgical and postoperative assessment points. Study quality was assessed using the Cochrane risk of bias tool (v.2). Data synthesis was narrative (SWiM guidance). Results. 6028 studies were screened, with 25 studies included. Prehabilitation interventions were: inspiratory muscle training (five studies n = 450); exercise (nine studies n = 683); psychological (one study n = 400); and nutritional (ten studies n = 487). High quality studies showed preoperative improvements in impairments directly targeted by the interventions. Generally, these did not translate into functional or postoperative improvements, but multimodal interventions were more promising. Conclusion. Current evidence supports prehabilitation as safe to preserve or improve preoperative function. Heterogeneity in outcomes and variable study quality means definitive conclusions regarding interventions are not yet possible, limiting implementation. Agreement of clinical outcomes and cost effectiveness evaluation is required