Prevalence and experience of fatigue in survivors of critical illness: a mixed-methods systematic review.

We conducted a mixed methods systematic review to investigate the prevalence, experience and management of fatigue in survivors of critical illness. We identified 76 studies investigating fatigue or vitality in adults discharged from an intensive care unit and split the extracted data into three datasets: vitality scores from the Short Form Health Survey-36 (n = 54); other quantitative data (n = 19); and qualitative data (n = 9). We assessed methodological quality using critical appraisal skills programme tools. We adopted a segregated approach to mixed-methods synthesis. In a final step, we attributed combined results to one of four qualitative themes: prevalence and severity; contributing factors; impacts on quality of life; and assessment and management. Prevalence of fatigue ranged from 13.8 to 80.9%. Short Form Health Survey-36 vitality scores were commonly used as a marker of fatigue. Vitality scores reached a nadir approximately one month following ICU discharge (mean (SD) 56.44 (32.30); 95%CI 52.92-59.97). They improved over time but seldom reached reference population scores. Associated biological, disease-related and psychological factors included age, poor pre-morbid status, sleep and psychological disturbance. Qualitative data highlight the profound negative impact of fatigue on survivors' quality of life. Survivors seldom had any information provided on the potential impact of fatigue. No fatigue assessment tools specific to critical illness or evidence-based interventions were reported. Fatigue is highly prevalent in survivors of critical illness, and negatively impacts recovery. Further research on developing fatigue assessment tools specifically for critically ill patients and evaluating the impact of pharmacological and non-pharmacology interventions is needed.

Evaluating the implementation of confusion assessment method-intensive care unit using a quality improvement approach.

Quality improvement (QI) is a way through which health care delivery can be made safer and more effective. Various models of quality improvement methods exist in health care today. These models can help guide and manage the process of introducing changes into clinical practice. The aim of this project was to implement the use of a delirium assessment tool into three adult critical care units within the same hospital using a QI approach. The objective was to improve the identification and management of delirium. Using the Model for Improvement framework, a multidisciplinary working group was established. A delirium assessment tool was introduced via a series of educational initiatives. New local guidelines regarding the use of delirium assessment and management for the multidisciplinary team were also produced. Audit data were collected at 6 weeks and 5 months post-implementation to evaluate compliance with the use of the tool across three critical care units within a single hospital in London. At 6 weeks, in 134 assessment points out of a possible 202, the tool was deemed to be used appropriately, meaning that 60% of patients received timely assessment; 18% of patients were identified as delirious in audit one. Five months later, only 95 assessment points out of a possible 199 were being appropriately assessed (47%); however, a greater number (32%) were identified as delirious. This project emphasizes the complexity of changing practice in a large busy critical care centre. Despite an initial increase in delirium assessment, this was not sustained over time. The use of a QI model highlights the continuous process of embedding changes into clinical practice and the need to use a QI method that can address the challenging nature of modern health care. QI models guide changes in practice. Consideration should be given to the type of QI model used.

Relationship between guideline adherence and outcomes in severe traumatic brain injury.

INTRODUCTION: Traumatic brain injury (TBI) is a leading cause of death and morbidity worldwide. Evidence-based guidelines for managing severe TBI have been available for over 25 years. However, adherence to guidelines remains variable despite evidence highlighting improvement in outcomes with individual recommendations. There is limited evidence to support a superior outcome with compliance to whole sets of recommendations. The aim of this review was to determine whether adherence to TBI guidelines as a package improves outcomes in adults and paediatric patients with severe TBI. METHODS: A structured literature search was conducted using the MEDLINE®, Embase™, PubMed and CINAHL® (Cumulative Index to Nursing and Allied Health Literature) databases. Studies were considered eligible for inclusion in this review if they were quantitative studies investigating the use of TBI guidelines in relation to one or more of the following outcomes: mortality, functional outcome and length of hospital stay. RESULTS: Nine cohort studies were identified that fulfilled the inclusion criteria and answered the clinical question. A review of these papers was conducted. CONCLUSIONS: Mortality after severe TBI improves with increasing adherence to evidence-based guidelines in both adults and children. The evidence also suggests that compliance with guideline recommendations results in improved functional outcomes and reduced length of hospital stay.

Expression and splicing of FGF receptor mRNAs during APRE-19 cell differentiation in vitro.

PURPOSE: The expression and alternative splicing of the four FGF receptor (FGFR) mRNAs are regulated in a developmental- and tissue-specific fashion. Capability of differentiation in vitro of the retinal pigment epithelial cell line ARPE-19 has been previously demonstrated. In this study, the hypothesis that FGF receptor gene expression and the alternative splicing of the FGFR1 mRNA is regulated as a function of ARPE-19 differentiation in vitro was tested. METHODS: ARPE-19 cells were plated at sparse or confluent densities and maintained in culture up to 14 months. The expression of FGF receptors and the ratio of the FGFR1beta to FGFR1alpha splice variants of the FGFR1 transcript were quantified by a published PCR technique. Two in vivo samples of human RPE served as controls. RESULTS: Sparse cultures of ARPE-19 cells predominantly express FGFR1. When these cultures are allowed to differentiate, FGFR2 is also expressed. Samples of mRNA from RPE cells in vivo exhibit FGFR1 and FGFR2 expression as well as FGFR3 expression, a form that is minimally apparent in vitro. The ratio of the FGFR1beta to FGFR1alpha splice variant decreases as a function of cell differentiation in vitro and approaches the ratio observed in human RPE cells in vivo. Stimulation of cultures in vitro with FGF2 as a prototypical differentiation agent does not regulate the ratio of the FGFR1beta to FGFR1alpha splice variant. CONCLUSIONS: Differentiation of the ARPE-19 cell line in vitro recapitulates many but not all the in vivo patterns of FGFR expression and splicing. This in vitro system may be useful for selected studies on how cellular differentiation regulates FGF receptor gene expression and splicing.

Impact of sexual and nonsexual assault on secondary victims.

Much information has been collected on the effects of crime upon victims. Experts have spoken as well about the ripple effects of crime on those close to victims. To date, however, little empirical data are available to assess the impact of crime upon "secondary victims." Our research looks at the effects of crime on a sample of persons named by victims of sexual and nonsexual assault as their primary significant others (SOs). We found that distress experienced by SOs did not vary according to victim distress or according to whether the crime was a sexual or nonsexual assault. Female SOs, however, experienced greater fear of crime than male SOs. High levels of SO distress did not interfere with the ability of SOs to lend supportive actions, but were associated with higher levels of SO unsupportive behavior. Higher levels of unsupportive behavior were also more likely among SOs of sexual assault victims than among SOs of nonsexual assault victims. Clinical implications of the findings are discussed.