Passive Movements Do not Appear to Prevent or Reduce Joint Stiffness in Medium to Long-Stay ICU Patients: A Randomized, Controlled, Within-Participant Trial.

OBJECTIVES: ICU patients have an increased risk of joint stiffness because of their critical illness and reduced mobility. There is a paucity of evidence evaluating the efficacy of passive movements (PMs). We investigated whether PMs prevent or reduce joint stiffness in ICU patients. DESIGN: A randomized, controlled, within-participant, assessor-blinded study. SETTING: A 48-bed tertiary care adult ICU. PATIENTS: Intubated patients who were expected to be invasively mechanically ventilated for greater than 48 hours with an ICU length of stay greater than or equal to 5 days, and unable to voluntarily move their limbs through full range of motion (ROM). INTERVENTIONS: The ankle and elbow on one side of each participant's body received PMs (10 min each joint, morning and afternoon, 5 d/wk). The other side acted as the control. The PMs intervention continued for as long as clinically indicated to a maximum of 4 weeks. MEASUREMENTS: The primary outcome was ankle dorsiflexion ROM at cessation of PMs. Plantarflexion, elbow flexion and extension ROM, and participant-reported joint pain and stiffness (verbal analog scale [VAS]) were also measured. Outcomes were recorded at baseline and cessation of PMs. For participants whose PMs intervention ceased early due to recovery, additional post-early-cessation of PMs review measurements were undertaken as near as possible to 4 weeks. MAIN RESULTS: We analyzed data from 25 participants with a median (interquartile range) ICU stay of 15.6 days (11.3-25.4). The mean (95% CI) between-side difference for dorsiflexion ROM (with knee extension) at cessation of PMs was 0.4 degrees (-4.4 to 5.2; p = 0.882), favoring the intervention side, indicating there was not a clinically meaningful effect of 5 degrees. No statistically significant differences were found between the intervention and control sides for any ROM or VAS data. CONCLUSIONS: PMs, as provided to this sample of medium to long-stay ICU patients, did not prevent or reduce joint stiffness.

Inspiratory muscle training is feasible and safe for patients with acute spinal cord injury.

OBJECTIVE: To investigate the feasibility and safety and, to a lesser extent efficacy, of inspiratory muscle training (IMT) for patients with acute complete cervical or thoracic spinal cord injury (SCI). DESIGN: Prospective, observational pilot study comprising a series of case reports. SETTING: Tertiary care, public hospital. PARTICIPANTS: Seven adult subjects with an acute complete cervical or thoracic SCI. INTERVENTIONS: Participants received IMT as soon as their respiratory condition was stable. A high-resistance, low-repetition program of IMT using a POWERbreathe KH1 device was instituted. Training comprised 3-6 sets of 6 breaths, commenced at 50% maximum inspiratory pressure with the training load progressively increased. OUTCOME MEASURES: Feasibility (number of sessions when the criteria to participate in IMT were met/not met), safety (symptoms and physiological stability) before, during and after IMT sessions and efficacy (lung function) were measured. RESULTS: There were 50 sessions in total where participants met the criteria to receive IMT, with a mean (range) of 7.1 (3-11) IMT sessions per participant delivered over 10.7 (4-17) days. IMT was feasible, with all 50 planned sessions of IMT able to be delivered, and safe, with stable physiological parameters and no adverse symptoms or events recorded before, during or after IMT. Maximal inspiratory pressure increased for four participants and forced vital capacity increased for three participants over the duration of their IMT sessions. CONCLUSION: A high-resistance, low-repetition program of IMT was feasible and safe in adults with an acute complete cervical or thoracic SCI whose respiratory status was stable. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN 12614000975695).

Chlorination of Source Water Containing Iodinated X-ray Contrast Media: Mutagenicity and Identification of New Iodinated Disinfection Byproducts.

Iodinated contrast media (ICM) are nonmutagenic agents administered for X-ray imaging of soft tissues. ICM can reach µg/L levels in surface waters because they are administered in high doses, excreted largely unmetabolized, and poorly removed by wastewater treatment. Iodinated disinfection byproducts (I-DBPs) are highly genotoxic and have been reported in disinfected waters containing ICM. We assessed the mutagenicity in Salmonella of extracts of chlorinated source water containing one of four ICM (iopamidol, iopromide, iohexol, and diatrizoate). We quantified 21 regulated and nonregulated DBPs and 11 target I-DBPs and conducted a nontarget, comprehensive broad-screen identification of I-DBPs. We detected one new iodomethane (trichloroiodomethane), three new iodoacids (dichloroiodoacetic acid, chlorodiiodoacetic acid, bromochloroiodoacetic acid), and two new nitrogenous I-DBPs (iodoacetonitrile and chloroiodoacetonitrile). Their formation depended on the presence of iopamidol as the iodine source; identities were confirmed with authentic standards when available. This is the first identification in simulated drinking water of chloroiodoacetonitrile and iodoacetonitrile, the latter of which is highly cytotoxic and genotoxic in mammalian cells. Iopamidol (5 µM) altered the concentrations and relative distribution of several DBP classes, increasing total haloacetonitriles by >10-fold. Chlorination of ICM-containing source water increased I-DBP concentrations but not mutagenicity, indicating that such I-DBPs were either not mutagenic or at concentrations too low to affect mutagenicity.

Orthopedic inpatients' ability to accurately reproduce partial weight bearing orders.

Partial weight bearing is often prescribed for patients with orthopedic injuries. Patients' ability to accurately reproduce partial weight bearing orders is variable, and its impact on clinical outcomes is unknown. This observational study measured patients' ability to reproduce partial weight bearing orders, factors influencing this, patients' and physiotherapists' ability to gauge partial weight bearing accuracy, and the effect of partial weight bearing accuracy on long-term clinical outcomes. Fifty-one orthopedic inpatients prescribed partial weight bearing were included. All received standard medical/nursing/physiotherapy care. Physiotherapists instructed patients in partial weight bearing using the hand-under-foot, bathroom scales, and/or verbal methods of instruction. Weight bearing was measured on up to 3 occasions during hospitalization using a force-sensitive insole. Factors that had the potential to influence partial weight bearing accuracy were recorded. Patients and their physiotherapists rated their perception of partial weight bearing accuracy. Three-month clinical follow-up data were retrieved from medical records. The majority of patients (72% or more) exceeded their target load, with mean peak weight bearing as high as 19.3 kg over target load (285% of target load). Weight bearing significantly increased over the 3 measurement occasions (P<.001) and was significantly associated with greater body weight (P=.04). Patients and physiotherapists were unable to accurately gauge partial weight bearing accuracy. The incidence of clinically important complications at 3 months was 9% and not significantly associated with partial weight bearing accuracy during hospitalization (P≥.45). Patients are unable to accurately reproduce partial weight bearing orders when trained with the hand-under-foot, bathroom scales, or verbal methods of instruction.

Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms.

BACKGROUND: Most disability produced by psychotic illnesses, especially schizophrenia, develops during the prepsychotic period, creating a case for intervention during this period. However, only recently has it been possible to engage people in treatment during this phase. METHODS: A randomized controlled trial compared 2 interventions in 59 patients at incipient risk of progression to first-episode psychosis. We termed this group ultra-high risk to emphasize the enhanced risk vs conventional genetic high-risk studies. Needs-based intervention was compared with specific preventive intervention comprising low-dose risperidone therapy (mean dosage, 1.3 mg/d) and cognitive behavior therapy. Treatment was provided for 6 months, after which all patients were offered ongoing needs-based intervention. Assessments were performed at baseline, 6 months, and 12 months. RESULTS: By the end of treatment, 10 of 28 people who received needs-based intervention progressed to first-episode psychosis vs 3 of 31 from the specific preventive intervention group (P=.03). After 6-month follow-up, another 3 people in the specific preventive intervention group became psychotic, and with intention-to-treat analysis, the difference was no longer significant (P=.24). However, for risperidone therapy-adherent patients in the specific preventive intervention group, protection against progression extended for 6 months after cessation of risperidone use. CONCLUSIONS: More specific pharmacotherapy and psychotherapy reduces the risk of early transition to psychosis in young people at ultra-high risk, although their relative contributions could not be determined. This represents at least delay in onset (prevalence reduction), and possibly some reduction in incidence.