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

A study to explore the experiences of patient and family volunteers in a critical care environment: a phenomenological analysis

Introduction: ICU survivors suffer persistent physical, psychological and social problems in the months and years after discharge from critical care (1). Caregivers of these patients also suffer similar problems (2). As a result, an innovative, peer supported rehabilitation programme- Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) was created in Glasgow Royal Infirmary. This 5 week multi disciplinary programme, which is co facilitated by patient and family volunteers further along the recovery trajectory, aims to empower patients and caregivers to take control of their health and wellbeing. The objective of this study was to explore the experiences of the volunteers who participated in InS:PIRE. It also sought to identify the support required by volunteers from healthcare professionals involved in the project. Methods: Six in depth semi structured interviews were undertaken with volunteers (both patients and family members) involved in the InS:PIRE clinic by an assistant psychologist. A predetermined topic guide was utilised to guide interviews. Interviews were audio recorded and transcribed verbatim. Interpretative Phenomenological Analysis was used to analyse the transcripts (3). Peer Review was undertaken to ensure credibility of the findings. Results: Findings: Six key themes were identified from these interviews: the social impact of volunteering, shared experiences; supporting others; personal boundaries; support needs and personal gain. The importance of peer support and having a shared understanding of participants needs were key themes for the volunteers. Volunteers described the need for further support in areas such as: confidentiality; listening skills and understanding boundaries. Conclusions: The use of peer volunteers in this ICU rehabilitation service has been successful within this local context. Further, larger scale research studies, which explore further the impact of volunteering for ICU survivors are required

Deposit-feeding sea cucumbers enhance mineralization and nutrient cycling in organically-enriched coastal sediments

Bioturbators affect multiple biogeochemical interactions and have been suggested as suitable candidates to mitigate organic matter loading in marine sediments. However, predicting the effects of bioturbators at an ecosystem level can be difficult due to their complex positive and negative interactions with the microbial community

Enhancement of vaccinia virus based oncolysis with histone deacetylase inhibitors

Histone deacetylase inhibitors (HDI) dampen cellular innate immune response by decreasing interferon production and have been shown to increase the growth of vesicular stomatitis virus and HSV. As attenuated tumour-selective oncolytic vaccinia viruses (VV) are already undergoing clinical evaluation, the goal of this study is to determine whether HDI can also enhance the potency of these poxviruses in infection-resistant cancer cell lines. Multiple HDIs were tested and Trichostatin A (TSA) was found to potently enhance the spread and replication of a tumour selective vaccinia virus in several infection-resistant cancer cell lines. TSA significantly decreased the number of lung metastases in a syngeneic B16F10LacZ lung metastasis model yet did not increase the replication of vaccinia in normal tissues. The combination of TSA and VV increased survival of mice harbouring human HCT116 colon tumour xenografts as compared to mice treated with either agent alone. We conclude that TSA can selectively and effectively enhance the replication and spread of oncolytic vaccinia virus in cancer cells. © 2010 MacTavish et al

Instrumental and Analytic Methods for Bolometric Polarimetry

We discuss instrumental and analytic methods that have been developed for the first generation of bolometric cosmic microwave background (CMB) polarimeters. The design, characterization, and analysis of data obtained using Polarization Sensitive Bolometers (PSBs) are described in detail. This is followed by a brief study of the effect of various polarization modulation techniques on the recovery of sky polarization from scanning polarimeter data. Having been successfully implemented on the sub-orbital Boomerang experiment, PSBs are currently operational in two terrestrial CMB polarization experiments (QUaD and the Robinson Telescope). We investigate two approaches to the analysis of data from these experiments, using realistic simulations of time ordered data to illustrate the impact of instrumental effects on the fidelity of the recovered polarization signal. We find that the analysis of difference time streams takes full advantage of the high degree of common mode rejection afforded by the PSB design. In addition to the observational efforts currently underway, this discussion is directly applicable to the PSBs that constitute the polarized capability of the Planck HFI instrument.Comment: 23 pages, 11 figures. for submission to A&

Cosmic Microwave Background Polarization

Cosmic microwave background (CMB) anisotropy is our richest source of cosmological information; the standard cosmological model was largely established thanks to study of the temperature anisotropies. By the end of the decade, the Planck satellite will close this important chapter and move us deeper into the new frontier of polarization measurements. Numerous ground--based and balloon--borne experiments are already forging into this new territory. Besides providing new and independent information on the primordial density perturbations and cosmological parameters, polarization measurements offer the potential to detect primordial gravity waves, constrain dark energy and measure the neutrino mass scale. A vigorous experimental program is underway worldwide and heading towards a new satellite mission dedicated to CMB polarization.Comment: Review given at TAUP 2005; References added; Additional reference

Probing for cosmological parameters with LAMOST measurement

In this paper we study the sensitivity of the Large Sky Area Multi-Object Fiber Spectroscopic Telescope (LAMOST) project to the determination of cosmological parameters, employing the Monte Carlo Markov Chains (MCMC) method. For comparison, we first analyze the constraints on cosmological parameters from current observational data, including WMAP, SDSS and SN Ia. We then simulate the 3D matter power spectrum data expected from LAMOST, together with the simulated CMB data for PLANCK and the SN Ia from 5-year Supernovae Legacy Survey (SNLS). With the simulated data, we investigate the future improvement on cosmological parameter constraints, emphasizing the role of LAMOST. Our results show the potential of LAMOST in probing for the cosmological parameters, especially in constraining the equation-of-state (EoS) of the dark energy and the neutrino mass.Comment: 7 pages and 3 figures. Replaced with version accepted for publication in JCA

Cosmological Parameters from the 2003 flight of BOOMERANG

We present the cosmological parameters from the CMB intensity and polarization power spectra of the 2003 Antarctic flight of the BOOMERANG telescope. The BOOMERANG data alone constrains the parameters of the $\Lambda$CDM model remarkably well and is consistent with constraints from a multi-experiment combined CMB data set. We add LSS data from the 2dF and SDSS redshift surveys to the combined CMB data set and test several extensions to the standard model including: running of the spectral index, curvature, tensor modes, the effect of massive neutrinos, and an effective equation of state for dark energy. We also include an analysis of constraints to a model which allows a CDM isocurvature admixture.Comment: 18 pages, 10 figures, submitted to Ap