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

When to invest in carbon capture and storage technology in the presence of uncertainty: A mathematical model

We present a model for determining analytically the critical threshold for investment in carbon capture and storage technology in a region where carbon costs are volatile and assuming the cost of investment decreases. We first study a deterministic model with quite general dependence on carbon price and then analyse the effect of carbon price volatility on the optimal investment decision by solving a Bellman equation with an infinite planning horizon. We find that increasing the expected carbon price volatility increases the critical investment threshold and that adoption of this technology is not optimal at current prices, in agreement with other works. However, reducing carbon price volatility by switching from carbon permits to taxes or by introducing a carbon floor as in Great Britain would accelerate the optimal adoption of this technology. Our deterministic model provides a good description of this decision problem

Does tiny-scale atomic structure exist in the interstellar medium ?

We report on preliminary results from the recent multi-epoch neutral hydrogen absorption measurements toward three pulsars, B0823+26, B1133+16 and B2016+28, using the Arecibo telescope. We do not find significant variations in optical depth profiles over periods of 0.3 and 9--10 yr, or on spatial scales of 10--20 and 70--85 AU. The large number of non detections of the tiny scale atomic structure suggests that the AU-sized structure is not ubiquitous in the interstellar medium and could be quite a rare phenomenon.Comment: Accepted by ApJ Letters, 5 pages, 2 figure

Gene expression profile of Scardovia spp. in the metatranscriptome of root caries

A few investigations of caries biofilms have identified Scardovia spp.; however, little is known about its involvement in caries pathogenesis. The purpose of this study was to assess the gene expression profile of Scardovia spp. in root caries, and compare it with other microorganisms. Clinical samples from active root caries lesions were collected. Microbial mRNA was isolated and cDNA sequenced. The function and composition of the Scardovia were investigated using two methods: a) de novo assembly of the read data and mapping to contigs, and b) reads mapping to reference genomes. Pearson correlation was performed (p < 0.05). Proportion of Scardovia inopinata and Scardovia wiggsiae sequences ranged from 0-6% in the root caries metatranscriptome. There was a positive correlation between the transcriptome of Lactobacillus spp. and Scardovia spp. (r = 0.70; p = 0.03), as well as with other Bifidobacteriaceae (r = 0.91; p = 0.0006). Genes that code for fructose 6-phosphate phosphoketolase (the key enzyme for “Bifid shunt”), as well as ABC transporters and glycosyl-hydrolases were highly expressed. In conclusion, “Bifid shunt” and starch metabolism are involved in carbohydrate metabolism of S. inopinata and S. wiggsiae in root caries. There is a positive correlation between the metabolism abundance of Lactobacillus spp., Bifidobacteriaceae members, and Scardovia in root caries

Actinomyces spp. gene expression in root caries lesions

Background: studies of the distribution of Actinomyces spp. on carious and non-carious root surfaces have not been able to confirm the association of these bacteria with root caries, although they were extensively implicated as a prime suspect in root caries. Objective: the aim of this study was to observe the gene expression of Actinomyces spp. in the microbiota of root surfaces with and without caries. Design: the oral biofilms from exposed sound root surface (SRS; n=10) and active root caries (RC; n=30) samples were collected. The total bacterial RNA was extracted and the mRNA was isolated. Samples with low RNA concentration were pooled, yielding a final sample size of SRS=10 and RC=9. cDNA libraries were prepared and sequenced on the Illumina Hi-Seq2500. Sequence reads were mapped to eight Actinomyces genomes. Count data were normalized using DESeq2 to analyse differential gene expression applying the Benjamini-Hochberg correction (FDR0.05), except for Actinomyces OT178 (p=0.001) and A. gerencseriae (p=0.004), which had higher read count in the SRS. Genes that code for stress proteins (clp, dnaK and groEL), enzymes of glycolysis pathways (including, enolase and phosphoenolpyruvate carboxykinase), adhesion (Type-2 fimbrial and collagen-binding protein) and cell growth (EF-Tu) were highly, but not differentially (p>0.001) expressed in both groups. Genes with the most significant up-regulation in RC were those coding for hypothetical proteins and uracil DNA glycosylase (p=2.61E-17). The gene with the most significant up-regulation in SRS was a peptide ABC transporter substrate-binding protein (log2FC= -6.00, FDR= 2.37E-05). Conclusion: there were similar levels of Actinomyces gene expression in both sound and carious root biofilms. These bacteria can be commensal in root surface sites, but may be cariogenic due to survival mechanisms allowing them to exist in acid environment and metabolize sugars saving energy

The metatranscriptomes of root caries and sound root surface biofilms

There is limited knowledge of bacterial metabolism in root caries lesions. The aim of this study was to describe the bacterial metatranscriptomes associated with root caries and sound root surfaces using an RNA-seq analysis approach. The biofilms from exposed root surfaces were sampled from caries-free volunteers (n=10), and from the infected dentine of volunteers with root caries (n=30). Total bacterial RNA was extracted; cDNA libraries were prepared and sequenced on the Illumina Hi-Seq2500. The function and composition of the metabolically active microbiota were investigated using: a) MG-RAST, and b) denovo assembly of the read data and mapping to contigs. Differential gene expression analysis was done using the R package DESeq2 (padj <10−3). Transcripts with the highest expression levels were those coding for membrane transport systems, ribosomal proteins, enolase and glycolytic pathways in both groups. Differential analysis indicated that genes coding for the OmpA domain protein and metalloprotease domain protein were over-expressed in the caries samples (log2FoldChange = –12.2; padj= 3.5 × 10−13), whereas genes in the samples from healthy sites over-expressed pilus biosynthesis protein, thiamine diphosphokinase and transporter protein (log2FoldChange = 16.5; padj = 2.2 × 10−21). Metatranscriptomic analyses show unique gene expression profiles in sound root surface and carious biofilms