The minimal important difference of the ICU mobility scale.

BACKGROUND: The intensive care unit mobility scale (IMS) is reliable, valid and responsive. Establishing the minimal important difference (MID) of the IMS is important in order to detect clinically significant changes in mobilization. OBJECTIVE: To calculate the MID of the IMS in intensive care unit patients. METHODS: Prospective multi center observational study. The IMS was collected from admission and discharge physiotherapy assessments. To calculate the MID we used; anchor based methods (global rating of change) and two distribution-based methods (standard error of the mean and effect size). RESULTS: We enrolled 184 adult patients; mean age 62.0 years, surgical, trauma, and medical. Anchor based methods gave a MID of 3 with area under the curve 0.94 (95% CI 0.89-0.97). The two distribution based methods gave a MID between 0.89 and 1.40. CONCLUSION: These data increase our understanding of the clinimetric properties of the IMS, improving its utility for clinical practice and research.

The use of bed-dials to maintain recumbent positioning for critically ill mechanically ventilated patients (The RECUMBENT study): multicentre before and after observational study.

BACKGROUND: Observational studies continue to report poor compliance with positioning recommendations for prevention of ventilator-associated pneumonia. Inability to accurately measure backrest elevation may contribute to this poor compliance. OBJECTIVE: To determine if provision of an accurate, simple to use angle measurement device with an accompanying education program improved compliance with semirecumbency at 45 degrees over time. DESIGN: Using a prospective pre- and post-design we implemented angle measurement devices and an associated education intervention in three Australian ICUs. Backrest elevation, contraindications to semirecumbency at 45 degrees , mean arterial pressure (MAP), inotrope use, enteral feeding and weaning status were recorded 3-times daily using a pre-determined randomization schedule for 7 consecutive days prior to implementation and again at 1, 3 and 6 months post-implementation. Illness severity and a clinical pulmonary infection score were recorded for each day of ventilation. RESULTS: Backrest elevation measurements (n=1154) were recorded for 141 mechanically ventilated patients. Contraindications to semirecumbency at 45 degrees were noted for 163/1154 (14.1%) measurements the proportion of measurements at 45 degrees rose from baseline by 10.1% (P=0.03) 1-month following implementation, however this change was not sustained over time. The proportion of measurements 30 degrees increased by 43.8% at 1-month and remained above 70% 6-months after implementation (P<0.001). For measurements recorded in the absence of a contraindication to semirecumbency, and adjusted for covariates (MAP, inotropic support, sequential organ failure assessment maximum score, clinical pulmonary infection score maximum, and indication for ventilation), decreased backrest elevation was associated with higher severity of illness (0.3 degrees [95% CI 0.1-0.5] for every 1-point increase in APACHE II score). Increased mean backrest elevation was noted for older patients (0.8 degrees [95% CI 0.1-1.5] for each 10-year increment) and measurements recorded during weaning (2.7 degrees [95% CI 1.2-4.1]). CONCLUSIONS: Bedside implementation of an angle measurement device and associated educational intervention did not result in a sustained improvement to compliance with 45 degrees semirecumbency, questioning the clinical feasibility of this nursing intervention. A sustained increased in semirecumbency at 30 degrees or greater was achieved.

Semirecumbent positioning in ventilator-dependent patients: a multicenter, observational study.

BACKGROUND: Positioning of patients is a modifiable risk factor for ventilator-associated pneumonia. Current guidelines for prevention of ventilator-associated pneumonia recommend semirecumbency at 30º, with 45º preferable unless contraindicated. OBJECTIVE: To assess the use of semirecumbency for ventilator patients in Australian and New Zealand intensive care units. METHODS: In a multicenter, observational study, backrest elevation, mean arterial pressure, use of inotropic agents, enteral feeding, and weaning status were recorded 3 times per day by using a predetermined randomization schedule for 7 consecutive days (maximum 21 observation episodes). Severity of illness was recorded daily by using the Sepsis-Related Organ Failure Assessment (SOFA) score. RESULTS: Measurements (n = 2112) were recorded for 371 ventilator patients in 32 intensive care units. Backrest elevation at ≥45º was noted for 112 of 2112 (5.3%; 95% confidence interval [CI], 4.3-6.3) measurements; elevation ≥30º but <45º for 472 of 2112 (22.3%; 95% CI, 20.6-24.1). Contraindications to semirecumbency were noted during 447 measurements. Increased back-rest elevation occurred during enteral feeding (2.2º, P < .001) and weaning (3.1º, P < .001). Decreased backrest elevation was associated with inotropic support (2.8º, P < .001), decreased mean arterial pressure (0.7º/10 mm Hg, P < .001), and organ failure (0.5º/1-point increment in SOFA(max) score, P < .001). For measurements recorded with no contraindication to semirecumbency, weaning status (P = .003) and SOFA(max) score (P = .008) remained associated with the degree of backrest elevation. CONCLUSIONS: The findings of this multicenter, observational study suggest that backrest elevation was less than recommended and was influenced by clinical practices and patient condition.

Heterogeneity of nemaline myopathy cases with skeletal muscle alpha-actin gene mutations.

Nemaline myopathy (NM) is the most common of several congenital myopathies that present with skeletal muscle weakness and hypotonia. It is clinically heterogeneous and the diagnosis is confirmed by identification of nemaline bodies in affected muscles. The skeletal muscle alpha-actin gene (ACTA1) is one of five genes for thin filament proteins identified so far as responsible for different forms of NM. We have screened the ACTA1 gene in a cohort of 109 unrelated patients with NM. Here, we describe clinical and pathological features associated with 29 ACTA1 mutations found in 38 individuals from 28 families. Although ACTA1 mutations cause a remarkably heterogeneous range of phenotypes, they were preferentially associated with severe clinical presentations (p < 0.0001). Most pathogenic ACTA1 mutations were missense changes with two instances of single base pair deletions. Most patients with ACTA1 mutations had no prior family history of neuromuscular disease (24/28). One severe case, caused by compound heterozygous recessive ACTA1 mutations, demonstrated increased alpha-cardiac actin expression, suggesting that cardiac actin might partially compensate for ACTA1 abnormalities in the fetal/neonatal period. This cohort also includes the first instance of an ACTA1 mutation manifesting with adult-onset disease and two pedigrees exhibiting potential incomplete penetrance. Overall, ACTA1 mutations are a common cause of NM, accounting for more than half of severe cases and 26% of all NM cases in this series.