Until relatively recently, critical care practitioners have focused on the survival of their patients and not on long-term outcomes. The incidence of chronic neurocognitive dysfunction has been ...underestimated and underreported, and only recently has it been studied in critically ill patients. However, neurocognitive outcomes have been the subject of extensive investigation in other medical populations for many years.
Review of the current literature regarding long-term neurocognitive outcomes following critical illness.
Data from studies to date indicate that critical illness can lead to significant neurocognitive impairments. The neurocognitive impairments persist for months and years, and may have important consequences for quality of life, the ability to return to work, overall functional ability, and substantial economic costs. The mechanisms of the neurocognitive impairments are not fully understood but likely include delirium, hypoxia, glucose dysregulation, metabolic derangements, inflammation, and the effects of sedatives and narcotics among other factors. The contributions of these factors may be particularly significant in patients with preexisting vulnerabilities for the development of cognitive impairments such as mild cognitive impairment, dementia, prior traumatic brain injury, or other comorbid disorders associated with neurocognitive impairments.
Current research indicates that neurocognitive sequelae following critical illness are common, may be permanent, and are associated with impairments in daily function, decreased quality of life, and an inability to return to work. Research needs to be done to better understand the prevalence, nature, risk factors, and nuances of the neurocognitive impairments observed in ICU survivors.
Critical illness is associated with cognitive impairment, but mental health and functional disabilities in survivors of intensive care are inadequately characterised. We aimed to assess associations ...of age and duration of delirium with mental health and functional disabilities in this group.
In this prospective, multicentre cohort study, we enrolled patients with respiratory failure or shock who were undergoing treatment in medical or surgical ICUs in Nashville, TN, USA. We obtained data for baseline demographics and in-hospital variables, and assessed survivors at 3 months and 12 months with measures of depression (Beck Depression Inventory II), post-traumatic stress disorder (PTSD, Post-Traumatic Stress Disorder Checklist-Event Specific Version), and functional disability (activities of daily living scales, Pfeffer Functional Activities Questionnaire, and Katz Activities of Daily Living Scale). We used linear and proportional odds logistic regression to assess the independent associations between age and duration of delirium with mental health and functional disabilities. This study is registered with ClinicalTrials.gov, number NCT00392795.
We enrolled 821 patients with a median age of 61 years (IQR 51-71), assessing 448 patients at 3 months and 382 patients at 12 months after discharge. At 3 months, 149 (37%) of 406 patients with available data reported at least mild depression, as did 116 (33%) of 347 patients at 12 months; this depression was mainly due to somatic rather than cognitive-affective symptoms. Depressive symptoms were common even among individuals without a history of depression (as reported by a proxy), occurring in 76 (30%) of 255 patients with data at 3 months and 62 (29%) of 217 individuals at 12 months. Only 7% of patients (27 of 415 at 3 months and 24 of 361 at 12 months) had symptoms consistent with post-traumatic distress disorder. Disabilities in basic activities of daily living (ADL) were present in 139 (32%) of 428 patients at 3 months and 102 (27%) of 374 at 12 months, as were disabilities in instrumental ADL in 108 (26%) of 422 individuals at 3 months and 87 (23%) of 372 at 12 months. Mental health and functional difficulties were prevalent in patients of all ages. Although old age was frequently associated with mental health problems and functional disabilities, we observed no consistent association between the presence of delirium and these outcomes.
Poor mental health and functional disability is common in patients treated in intensive-care units. Depression is five times more common than is post-traumatic distress disorder after critical illness and is driven by somatic symptoms, suggesting approaches targeting physical rather than cognitive causes could benefit patients leaving critical care.
National Institutes of Health AG027472 and the Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System.
Poor functional status is common after critical illness, and can adversely impact the abilities of intensive care unit (ICU) survivors to live independently. Instrumental activities of daily living ...(IADL), which encompass complex tasks necessary for independent living, are a particularly important component of post-ICU functional outcome.
To conduct a systematic review of studies evaluating IADLs in survivors of critical illness.
We searched PubMed, CINAHL, Cochrane Library, SCOPUS, and Web of Science for all relevant English-language studies published through December 31, 2016. Additional articles were identified from personal files and reference lists of eligible studies. Two trained researchers independently reviewed titles and abstracts, and potentially eligible full text studies. Eligible studies included those enrolling adult ICU survivors with IADL assessments, using a validated instrument. We excluded studies involving specific ICU patient populations, specialty ICUs, those enrolling fewer than 10 patients, and those that were not peer-reviewed. Variables related to IADLs were reported using the Patient Reported Outcomes Measurement Information System (PROMIS).
Thirty of 991 articles from our literature search met inclusion criteria, and 23 additional articles were identified from review of reference lists and personal files. Sixteen studies (30%) published between 1999 and 2016 met eligibility criteria and were included in the review. Study definitions of impairment in IADLs were highly variable, as were reported rates of pre-ICU IADL dependencies (7-85% of patients). Eleven studies (69%) found that survivors of critical illness had new or worsening IADL dependencies. In three of four longitudinal studies, survivors with IADL dependencies decreased over the follow-up period. Across multiple studies, no risk factors were consistently associated with IADL dependency.
Survivors of critical illness commonly experience new or worsening IADL dependency that may improve over time. As part of ongoing efforts to understand and improve functional status in ICU survivors, future research must focus on risk factors for IADL dependencies and interventions to improve these cognitive and physical dependencies after critical illness.
Existing studies of risk factors for physical impairments in acute lung injury (ALI) survivors were potentially limited by single-center design or relatively small sample size.
To evaluate risk ...factors for three measures of physical impairments commonly experienced by survivors of ALI in the first year after hospitalization.
A prospective, longitudinal study of 6- and 12-month physical outcomes (muscle strength, 6-minute-walk distance, and Short Form SF-36 Physical Function score) for 203 survivors of ALI enrolled from 12 hospitals participating in the ARDS Network randomized trials. Multivariable regression analyses evaluated the independent association of critical illness-related variables and intensive care interventions with impairments in each physical outcome measure, after adjusting for patient demographics, comorbidities, and baseline functional status.
At 6 and 12 months, respectively, mean (± SD) values for strength (presented as proportion of maximum strength score evaluated using manual muscle testing) was 92% (± 8%) and 93% (± 9%), 6-minute-walk distance (as percent-predicted) was 64% (± 22%) and 67% (± 26%), and SF-36 Physical Function score (as percent-predicted) was 61% (± 36%) and 67% (± 37%). After accounting for patient baseline status, there was significant association and statistical interaction of mean daily dose of corticosteroids and intensive care unit length of stay with impairments in physical outcomes.
Patients had substantial impairments, from predicted values, for 6-minute-walk distance and SF-36 Physical Function outcome measures. Minimizing corticosteroid dose and implementing existing evidence-based methods to reduce duration of intensive care unit stay and associated patient immobilization may be important interventions for improving ALI survivors' physical outcomes.
Context: Epidemiological studies have identified the importance of the in utero environment in providing a healthy start to life. Previous studies have suggested that the maternal environment, in ...particular a reduction in maternal insulin sensitivity, contributes significantly to fetal growth. Regular aerobic exercise, through an effect on maternal insulin sensitivity, may influence offspring size by regulating nutrient supply to the fetus.
Objective: The aim of the study was to determine the effects of aerobic exercise training in the second half of pregnancy on maternal insulin sensitivity and neonatal outcomes.
Design and Setting: We conducted a community-based, randomized, controlled trial of exercise in pregnancy.
Participants: Eighty-four healthy nulliparous women (mean ± sd, age, 30 ± 4 yr; body mass index, 25.5 ± 4 kg/m2) participated in the study.
Intervention: Subjects participated in a home-based stationary cycling program from 20 wk gestation to delivery.
Main Outcome Measures: Maternal insulin sensitivity, neonatal auxology, body composition, and growth-related peptides in cord blood were measured.
Results: Offspring of exercisers had lower birth weight (sd score, control, 0.23 ± 0.8; exercise, −0.19 ± 0.9; P = 0.03) and body mass index at birth (sd score, control, 0.40 ± 0.9; exercise, −0.01 ± 0.09; P = 0.04). The reduction in maternal insulin sensitivity in late gestation was not affected by exercise (P = 0.45) and was unrelated to offspring size. Exercise offspring had lower cord serum IGF-I (P = 0.03) and IGF-II (P = 0.04).
Conclusions: Regular exercise was associated with lower birth weights and reduced cord concentrations of growth-related peptides, suggesting an influence of exercise on endocrine regulation of fetal growth. These effects on offspring growth were not associated with an exercise training effect on maternal insulin sensitivity.
Regular exercise during pregnancy is associated with lower birth weight and reduced cord IGF concentrations, without exercise-associated alterations in maternal insulin sensitivity.
Post-traumatic stress disorder (PTSD) is a potentially serious psychiatric disorder that has traditionally been associated with traumatic stressors such as participation in combat, violent assault, ...and survival of natural disasters. Recently, investigators have reported that the experience of critical illness can also lead to PTSD, although details of the association between critical illness and PTSD remain unclear.
We conducted keyword searches of MEDLINE and Psych Info and investigations of secondary references for all articles pertaining to PTSD in medical intensive care unit (ICU) survivors.
From 78 screened papers, 16 studies (representing 15 cohorts) and approximately 920 medical ICU patients met inclusion criteria. A total of 10 investigations used brief PTSD screening tools exclusively as opposed to more comprehensive diagnostic methods. Reported PTSD prevalence rates varied from 5% to 63%, with the three highest prevalence estimates occurring in studies with fewer than 30 patients. Loss to follow-up rates ranged from 10% to 70%, with average loss to follow-up rates exceeding 30%.
Exact PTSD prevalence rates cannot be determined due to methodological limitations such as selection bias, loss to follow-up, and the wide use of screening (as opposed to diagnostic) instruments. In general, the high prevalence rates reported in the literature are likely to be overestimates due to the limitations of the investigations conducted to date. Although PTSD may be a serious problem in some survivors of critical illness, data on the whole population are inconclusive. Because the magnitude of the problem posed by PTSD in survivors of critical illness is unknown, there remains a pressing need for larger and more methodologically rigorous investigations of PTSD in ICU survivors.
In contrast to other clinical outcomes, long-term cognitive function in critical care survivors has not been deeply studied. In this narrative review, we summarize the existing literature on the ...prevalence, mechanisms, risk factors, and prediction of cognitive impairment after surviving critical illness. Depending on the exact clinical subgroup, up to 100% of critical care survivors may suffer some degree of long-term cognitive impairment at hospital discharge; in approximately 50%, decrements in cognitive function will persist years later. Although the mechanisms of acquiring this impairment are poorly understood, several risk factors have been identified. Unfortunately, no easy means of predicting long-term cognitive impairment exists. Despite this barrier, research is ongoing to test possible treatments for cognitive impairment. In particular, the potential role of exercise on cognitive recovery is an exciting area of exploration. Opportunities exist to incorporate physical and cognitive rehabilitation strategies across a spectrum of environments (in the ICU, on the hospital ward, and at home, posthospital discharge).
An estimated 14.1 million patients survive sepsis each year. Many survivors experience poor long-term outcomes, including new or worsened neuropsychological impairment; physical disability; and ...vulnerability to further health deterioration, including recurrent infection, cardiovascular events, and acute renal failure. However, clinical trials and guidelines have focused on shorter-term survival, so there are few data on promoting longer-term recovery. To address this unmet need, the International Sepsis Forum convened a colloquium in February 2018 titled "Understanding and Enhancing Sepsis Survivorship." The goals were to identify gaps and limitations of current research and shorter- and longer-term priorities for understanding and enhancing sepsis survivorship. Twenty-six experts from eight countries participated. The top short-term priorities identified by nominal group technique culminating in formal voting were to better leverage existing databases for research, develop and disseminate educational resources on postsepsis morbidity, and partner with sepsis survivors to define and achieve research priorities. The top longer-term priorities were to study mechanisms of long-term morbidity through large cohort studies with deep phenotyping, build a harmonized global sepsis registry to facilitate enrollment in cohorts and trials, and complete detailed longitudinal follow-up to characterize the diversity of recovery experiences. This perspective reviews colloquium discussions, the identified priorities, and current initiatives to address them.
Arachnids are the second most successful terrestrial animal group after insects 1 and were one of the first arthropod clades to successfully invade land 2. Fossil evidence for this transition is ...limited, with the majority of arachnid clades first appearing in the terrestrial fossil record. Furthermore, molecular clock dating has suggested a Cambrian-Ordovician terrestrialization event for arachnids 3, some 60 Ma before their first fossils in the Silurian, although these estimates assume that arachnids evolved from a fully aquatic ancestor. Eurypterids, the sister clade to terrestrial arachnids 4–6, are known to have undergone major macroecological shifts in transitioning from marine to freshwater environments during the Devonian 7, 8. Discoveries of apparently subaerial eurypterid trackways 9, 10 have led to the suggestion that eurypterids were even able to venture on land and possibly breathe air 11. However, modern horseshoe crabs undertake amphibious excursions onto land to reproduce 12, rendering trace fossil evidence alone inconclusive. Here, we present details of the respiratory organs of Adelophthalmus pyrrhae sp. nov. from the Carboniferous of Montagne Noire, France 13, revealed through micro computed tomography (μ-CT) imaging. Pillar-like trabeculae on the dorsal surface of each gill lamella indicate eurypterids were capable of subaerial breathing, suggesting that book gills are the direct precursors to book lungs while vascular ancillary respiratory structures known as Kiemenplatten represent novel air-breathing structures. The discovery of air-breathing structures in eurypterids indicates that characters permitting terrestrialization accrued in the arachnid stem lineage and suggests the Cambrian-Ordovician ancestor of arachnids would also have been semi-terrestrial.
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•A three-dimensionally preserved eurypterid, Adelophthalmus pyrrhae, is described•Computed tomography reveals the presence of trabeculae on the respiratory lamellae•Occurrence of trabeculae indicates eurypterids were capable of breathing air•Data from eurypterids suggest horseshoe crabs were not secondarily aquatic
Lamsdell et al. use computed tomography to study the respiratory organs of a three-dimensional Carboniferous eurypterid. Trabeculae on the respiratory lamellae indicate that the animal was capable of breathing air. Evidence from spermatophores in Silurian species and amphibious trackways demonstrates air breathing was common to all eurypterids.
We hypothesized that providing patients with acute lung injury two different protein/calorie nutritional strategies in the intensive care unit may affect longer-term physical and cognitive ...performance.
To assess physical and cognitive performance 6 and 12 months after acute lung injury, and to evaluate the effect of trophic versus full enteral feeding, provided for the first 6 days of mechanical ventilation, on 6-minute-walk distance, cognitive impairment, and secondary outcomes.
A prospective, longitudinal ancillary study of the ARDS Network EDEN trial evaluating 174 consecutive survivors from 5 of 12 centers. Blinded assessments of patients' arm anthropometrics, strength, pulmonary function, 6-minute-walk distance, and cognitive status (executive function, language, memory, verbal reasoning/concept formation, and attention) were performed.
At 6 and 12 months, respectively, the mean (SD) percent predicted for 6-minute-walk distance was 64% (22%) and 66% (25%) (P = 0.011 for difference between assessments), and 36 and 25% of survivors had cognitive impairment (P = 0.001). Patients performed below predicted values for secondary physical tests with small improvement from 6 to 12 months. There was no significant effect of initial trophic versus full feeding for the first 6 days after randomization on survivors' percent predicted for 6-minute-walk distance, cognitive impairment status, and all secondary outcomes.
EDEN trial survivors performed below predicted values for physical and cognitive performance at 6 and 12 months, with some improvement over time. Initial trophic versus full enteral feeding for the first 6 days after randomization did not affect physical and cognitive performance.
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