A retrospective study on the effects of illness severity and atrial fibrillation on outcomes in the intensive care unit

Introduction: Atrial fibrillation (AF) is common in patients in the intensive care unit (ICU) and has been associated with worse outcomes. However, it is unclear whether AF itself adds to the risk of death or is merely a marker of illness severity. We aimed to record the incidence and outcomes of all patients with different categories of AF and determine whether AF was an independent predictor of death.<p></p> Methods: This retrospective cohort study was undertaken in the ICU of a tertiary-referral university hospital. Category of AF, sex, C-reactive protein (CRP) level, APACHE II score, predicted hospital mortality and survival outcomes were analysed from 1084 records. Percentages, medians and interquartile ranges were used to describe the sample. Chi-square test and the non-parametric Mann–Whitney U test were used, as appropriate, for statistical analysis. Logistic regression analyses were performed to evaluate the association of AF with death in the ICU adjusting for age, sex, CRP level and APACHE II score.<p></p> Results: Overall, 13.6% of patients developed new-onset AF during their critical illness, while 4.3% had a pre-existing history. The hospital mortality rate was higher in those with AF compared with those without (47.9% vs. 30.9%, p<0.001) and higher in those with newly diagnosed AF compared with those with a prior history (53.1% vs. 31.9%, p=0.012). CRP levels were higher in those with AF (p<0.001) compared with those without and higher in those with newly diagnosed AF compared with those with a prior history (p=0.012). On multivariate logistic regression analysis, only the APACHE II score was found to be an independent predictor of death.<p></p> Conclusion: Despite the higher mortality rate in patients with AF, the APACHE II score was the only independent predictor of death within the ICU. Prospective studies are required to explore the apparently reduced risk of dying among those with a prior history of AF.<p></p&gt

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

Critical care provision after colorectal cancer surgery

Background: Colorectal cancer (CRC) is the 2nd largest cause of cancer related mortality in the UK with 40 000 new patients being diagnosed each year. Complications of CRC surgery can occur in the perioperative period that leads to the requirement of organ support. The aim of this study was to identify pre-operative risk factors that increased the likelihood of this occurring. Methods: This is a retrospective observational study of all 6441 patients who underwent colorectal cancer surgery within the West of Scotland Region between 2005 and 2011. Logistic regression was employed to determine factors associated with receiving postoperative organ support. Results: A total of 610 (9 %) patients received organ support. Multivariate analysis identified age ≥65, male gender, emergency surgery, social deprivation, heart failure and type II diabetes as being independently associated with organ support postoperatively. After adjusting for demographic and clinical factors, patients with metastatic disease appeared less likely to receive organ support (p = 0.012). Conclusions: Nearly one in ten patients undergoing CRC surgery receive organ support in the post operative period. We identified several risk factors which increase the likelihood of receiving organ support post operatively. This is relevant when consenting patients about the risks of CRC surgery

Measuring labor input on pasture-based dairy farms using a smartphone

peer-reviewedWith the cessation of milk quotas in the European Union, dairy herd sizes increased in some countries, including Ireland, with an associated increase in labor requirement. Second to feed costs, labor has been identified as one of the highest costs on pasture-based dairy farms. Compared with other European Union countries, Ireland has historically had low milk production per labor unit; thus, optimization of labor efficiency on farm should be addressed before or concurrently with herd expansion. The objective of this study was to quantify current levels of labor input and labor efficiency on commercial pasture-based dairy farms and to identify the facilities and management practices associated with increased labor efficiency. Thirty-eight dairy farms of varying herd sizes, previously identified as labor-efficient farms, were enrolled on the study and data were collected over 3 consecutive days each month over a 12-mo period, starting in May 2015 and finishing in August of 2016. This was achieved through the use of a smartphone application. For analysis purposes, farms were categorized into 1 of 3 herd size categories (HSC): farms with <150 cows (HSC 1), 150–249 cows (HSC 2), or ≥250 cows (HSC 3). Overall farm labor input increased with HSC with 3,015, 4,499, and 6,023 h worked on HSC 1, 2, and 3, respectively. A higher proportion of work was carried out by hired staff as herd size increased. Labor efficiency was measured as total hours input to the dairy enterprise divided by herd size. Labor efficiency improved as herd size increased above 250 cows with 17.3 h/cow per yr observed for HSC 3; labor efficiency was similar for HSC 1 and 2, at 23.8 and 23.3 h/cow per yr, respectively. A large range of efficiency was observed within HSC. The labor requirements had a distinct seasonal pattern across the 3 HSC with the highest input observed in springtime (February to April) primarily due to calving and calf-care duties, milking, and winter feeding. The lowest input was observed in wintertime (November to January) when cows were dry. Particular facilities and management practices were associated with efficiency within certain tasks, the most notable in regard to milking and winter feeding practices. Additionally, the most efficient farms used contractors to perform a higher proportion of machinery work on farm than the least efficient farms

A retrospective study on the effects of illness severity and atrial fibrillation on outcomes in the intensive care unit

Introduction: Atrial fibrillation (AF) is common in patients in the intensive care unit (ICU) and has been associated with worse outcomes. However, it is unclear whether AF itself adds to the risk of death or is merely a marker of illness severity. We aimed to record the incidence and outcomes of all patients with different categories of AF and determine whether AF was an independent predictor of death.&lt;p&gt;&lt;/p&gt; Methods: This retrospective cohort study was undertaken in the ICU of a tertiary-referral university hospital. Category of AF, sex, C-reactive protein (CRP) level, APACHE II score, predicted hospital mortality and survival outcomes were analysed from 1084 records. Percentages, medians and interquartile ranges were used to describe the sample. Chi-square test and the non-parametric Mann–Whitney U test were used, as appropriate, for statistical analysis. Logistic regression analyses were performed to evaluate the association of AF with death in the ICU adjusting for age, sex, CRP level and APACHE II score.&lt;p&gt;&lt;/p&gt; Results: Overall, 13.6% of patients developed new-onset AF during their critical illness, while 4.3% had a pre-existing history. The hospital mortality rate was higher in those with AF compared with those without (47.9% vs. 30.9%, p&lt;0.001) and higher in those with newly diagnosed AF compared with those with a prior history (53.1% vs. 31.9%, p=0.012). CRP levels were higher in those with AF (p&lt;0.001) compared with those without and higher in those with newly diagnosed AF compared with those with a prior history (p=0.012). On multivariate logistic regression analysis, only the APACHE II score was found to be an independent predictor of death.&lt;p&gt;&lt;/p&gt; Conclusion: Despite the higher mortality rate in patients with AF, the APACHE II score was the only independent predictor of death within the ICU. Prospective studies are required to explore the apparently reduced risk of dying among those with a prior history of AF.&lt;p&gt;&lt;/p&gt

The Effect of Calcium Alginate Entrapment on the Stability of Novel Lipases from P. Reinekei and P. brenneri

The high cost of soluble enzymes can limit their use for commercial and industrial purposes. Immobilization can enhance enzyme reusability, thereby reducing product isolation costs and overcoming this economic barrier. In the current study, two novel, purified lipases from Pseudomonas sp. (Pseudomonas reinekei and Pseudomonas brenneri) were entrapped in a calcium alginate matrix, with the aim of simultaneously enhancing enzyme reusability and stability. Following entrapment, the retained activity of the enzyme-alginate composite was verified by an enzymatic hydrolysis reaction of a p-nitrophenol palmitate substrate. The effect of the enzyme-alginate entrapment against various physiochemical parameters such as pH, temperature, metal ions, and solvents were subsequently examined. The entrapment was found to have minimal beneficial stability gains. However, enhanced enzyme reusability (up to 3 cycles) and stability (up to 18 days at 4°C) of the calcium alginate entrapped lipase, as indicated by residual hydrolysis of p-nitrophenol palmitate, was observed, suggesting potential roles for calcium alginate entrapped lipases in cost efficient enzyme catalysis. HIGHLIGHTS•Two novel lipases have been entrapped in calcium alginate for the first time.•A statistically enhanced stability in 1M EDTA was observed following entrapment.•The novel entrapped lipases display excellent storage stability and reusability

β-glucosidase from Streptomyces griseus: ester hydrolysis and alkyl glucoside synthesis in the presence of Deep Eutectic Solvents

Deep Eutectic Solvents (DES) are ionic liquid analogs that have attracted considerable attention as green solvents for biocatalytic transformations. The use of DES as part of a ‘solvent engineering’ approach to enhance enzyme stability holds great promise since they are biodegradeable, relatively inexpensive and environmentally safe media for enzyme reactions. However, the behaviour of specific enzymes in such solvents is complex; some enzymes are inhibited in DES, while others appear to be activated. Glucosidases are among the most widely used enzymes for commercial chemoenzymatic synthesis. In particular, their application in the synthesis of biodegradable alkyl glucosides by reverse hydrolysis is of great interest. Previous work in this laboratory identified Streptomyces griseus glucosidase (Sgβgl) as an interesting enzyme for biotechnological applications. In this study, we examined its behaviour in the presence of DES as a co-solvent using choline chloride as hydrogen bond donor and using glycerol, glucose and urea as hydrogen bond acceptors. We show that Sgβgl activity depends on both the nature of DES components, and their ratio in the eutectic mixture, as well as the water content of the reaction medium. A choline chloride/glycerol DES eutectic mixture at a level of 40% (v/v) caused activation of Sgβgl and increased its optimum temperature from 70 to 80oC: it also led to a striking increase in its thermostability, doubling its half-life at 60oC and almost tripling its half-life at 80oC. The synthesis of alkyl glucosides was explored using DES as a co-solvent. In the presence of DES, Sgβgl catalysed the formation of a range of alkyl glucosides. The presence of DES resulted in enhanced product yield, which was observed to increase with increasing temperature, up to 60oC. These studies show that the application of DES at relatively low % (v/v) levels can dramatically effect enzyme activity and stability. Specifically, enhanced thermostability can significantly increase the operating range for glucosidases for biocatalytic applications. Solvent engineering offers a simple and effective way to enhance glucosidase stability and will be useful as an alternative and/or adjunct to more complex methods such as immobilisation or protein engineering

Cutinase from Amycolatopsis mediterannei: marked activation and stabilisation in Deep Eutectic Solvents

Amycolatopsis mediterranei cutinase (AmCut) has potential biocatalytic applications in plastics degradation and ester synthesis. Deep Eutectic Solvents (DES) are next generation biodegradable solvents for biocatalysis. However, the behaviour of cutinase enzymes in DES is little studied. Herein, we examine the effect of selected DES, and their components, on AmCut activity and stability. Low amounts (10% v/v) of DES (choline chloride:glycerol; 1:1 mole ratio) caused striking activation of AmCut (over 2-fold). Further examination showed that the choline chloride component of DES caused the observed activation. This is the first report of activation of a cutinase by a small molecule. At higher concentrations (50% v/v), DES composed of a choline chloride with glycerol as hydrogen bond donor dramatically increased the thermostability of AmCut - the enzyme lost no activity after incubation at 50oC for 2 hours. The biotechnological utility and physiological relevance of choline chloride activation and stabilisation is discussed