INTRODUCTION: Delirium in critically-ill patients is a common multifactorial disorder that is associated with various negative outcomes. It is assumed that sleep disturbances can result in an increased risk of delirium. This study hypothesized that implementing a protocol that reduces overall nocturnal sound levels improves quality of sleep and reduces the incidence of delirium in Intensive Care Unit (ICU) patients.METHODS: This interrupted time series study was performed in an adult mixed medical and surgical 24-bed ICU. A pre-intervention group of 211 patients was compared with a post-intervention group of 210 patients after implementation of a nocturnal sound-reduction protocol. Primary outcome measures were incidence of delirium, measured by the Intensive Care Delirium Screening Checklist (ICDSC) and quality of sleep, measured by the Richards-Campbell Sleep Questionnaire (RCSQ). Secondary outcome measures were use of sleep-inducing medication, delirium treatment medication, and patient-perceived nocturnal noise.RESULTS: A significant difference in slope in the percentage of delirium was observed between the pre- and post-intervention periods (-3.7% per time period, p=0.02). Quality of sleep was unaffected (0.3 per time period, p=0.85). The post-intervention group used significantly less sleep-inducing medication (p<0.001). Nocturnal noise rating improved after intervention (median: 65, IQR: 50-80 versus 70, IQR: 60-80, p=0.02).CONCLUSIONS: The incidence of delirium in ICU patients was significantly reduced after implementation of a nocturnal sound-reduction protocol. However, reported sleep quality did not improve.
ObjectiveMany patients with coronavirus disease 2019 (COVID-19) infections were admitted to an intensive care unit (ICU). Physical impairments are common after ICU stays and are associated with clinical and patient characteristics. To date, it is unknown if physical functioning and health status are comparable between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 3 months after ICU discharge. The primary objective of this study was to compare handgrip strength, physical functioning, and health status between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 3 months after ICU discharge. The second objective was to identify factors associated with physical functioning and health status in patients in the ICU with COVID-19. Methods In this observational, retrospective chart review study, handgrip strength (handheld dynamometer), physical functioning (Patient-Reported Outcomes Measurement Information System Physical Function), and health status (EuroQol 5 Dimension 5 Level) were compared between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 using linear regression. Multilinear regression analyses were used to investigate whether age, sex, body mass index, comorbidities in medical history (Charlson Comorbidity Index), and premorbid function illness (Identification of Seniors At Risk-Hospitalized Patients) were associated with these parameters in patients in the ICU with COVID-19. Results In total, 183 patients (N = 92 with COVID-19) were included. No significant between-group differences were found in handgrip strength, physical functioning, and health status 3 months after ICU discharge. The multilinear regression analyses showed a significant association between sex and physical functioning in the COVID-19 group, with better physical functioning in men compared with women. Conclusion Current findings suggest that handgrip strength, physical functioning, and health status are comparable for patients who were in the ICU with COVID-19 and patients who were in the ICU without COVID-19 3 months after ICU discharge. Impact Aftercare in primary or secondary care in the physical domain of postintensive care syndrome after ICU discharge in patients with COVID-19 and in patients without COVID-19 who had an ICU length of stay >48 hours is recommended. Lay Summary Patients who were in the ICU with and without COVID-19 had a lower physical status and health status than healthy people, thus requiring personalized physical rehabilitation. Outpatient aftercare is recommended for patients with an ICU length of stay >48 hours, and functional assessment is recommended 3 months after hospital discharge.
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Physiotherapy, Dietetics and Occupational Therapy have been collaborating over recent years to develop an optimal healthcare programme for patients with Post Intensive Care Syndrome (PICS). This case is an example of PICS symptomatology and focuses on the collaboration between Physiotherapy and Dietetics. What is PICS? Owing to healthcare improvements, more and more patients are surviving the intensive Care Unit (ICU), and recovery during and after ICU stay has been receiving more attention [1, 2]. Approximately 30% of the patients admitted to an ICU have persistent symptoms including muscle weakness, reduced walking ability, fatigue, concentration deficits, memory problems, malnutrition, sleep and mood disorders sometimes even years after discharge [3-8]. Since 2012, this combination of physical, cognitive and psychiatric manifestations and reduced quality of life after staying in an ICU has been recognised as Post Intensive Care Syndrome (PICS) [9]. The impact of PICS is often not limited to the patient as it may also impact the mental status of the patient’s immediate family. This is known as PICS-Family (PICS-F) [10-12]. Treatment of PICS: Approximately 80% of PICS patients need primary care physiotherapy. Physiotherapists and GPs are often the only primary care professionals involved in the recovery process of these patients after hospital discharge [13, 14]. Both patients and healthcare professionals report a number of difficulties, e.g. limited transmural continuity in healthcare, coordination of multidisciplinary activities, supportive treatment guidelines and specific knowledge of pathology, treatment and prognosis. Patients report that they are not adequately supported when resuming their professional activities and that medical and allied healthcare treatments do not fully meet their needs at that time [15-18]. The REACH project: In order to improve the situation, the REACH project (REhabilitation After Critical illness and Hospital discharge) was started in Amsterdam region in the Netherlands. Within REACH, a Community of Practice – consisting of professionals (physiotherapists, occupational therapists, dieticians), those who live or have lived with the condition and researchers – has developed a transmural rehab programme. A special attribute of this programme is the integration of the concept of “positive health”. The case in this article describes the treatment of a PICS patient treated within the REACH network.
Huntington’s disease (HD) and various spinocerebellar ataxias (SCA) are autosomal dominantly inherited neurodegenerative disorders caused by a CAG repeat expansion in the disease-related gene1. The impact of HD and SCA on families and individuals is enormous and far reaching, as patients typically display first symptoms during midlife. HD is characterized by unwanted choreatic movements, behavioral and psychiatric disturbances and dementia. SCAs are mainly characterized by ataxia but also other symptoms including cognitive deficits, similarly affecting quality of life and leading to disability. These problems worsen as the disease progresses and affected individuals are no longer able to work, drive, or care for themselves. It places an enormous burden on their family and caregivers, and patients will require intensive nursing home care when disease progresses, and lifespan is reduced. Although the clinical and pathological phenotypes are distinct for each CAG repeat expansion disorder, it is thought that similar molecular mechanisms underlie the effect of expanded CAG repeats in different genes. The predicted Age of Onset (AO) for both HD, SCA1 and SCA3 (and 5 other CAG-repeat diseases) is based on the polyQ expansion, but the CAG/polyQ determines the AO only for 50% (see figure below). A large variety on AO is observed, especially for the most common range between 40 and 50 repeats11,12. Large differences in onset, especially in the range 40-50 CAGs not only imply that current individual predictions for AO are imprecise (affecting important life decisions that patients need to make and also hampering assessment of potential onset-delaying intervention) but also do offer optimism that (patient-related) factors exist that can delay the onset of disease.To address both items, we need to generate a better model, based on patient-derived cells that generates parameters that not only mirror the CAG-repeat length dependency of these diseases, but that also better predicts inter-patient variations in disease susceptibility and effectiveness of interventions. Hereto, we will use a staggered project design as explained in 5.1, in which we first will determine which cellular and molecular determinants (referred to as landscapes) in isogenic iPSC models are associated with increased CAG repeat lengths using deep-learning algorithms (DLA) (WP1). Hereto, we will use a well characterized control cell line in which we modify the CAG repeat length in the endogenous ataxin-1, Ataxin-3 and Huntingtin gene from wildtype Q repeats to intermediate to adult onset and juvenile polyQ repeats. We will next expand the model with cells from the 3 (SCA1, SCA3, and HD) existing and new cohorts of early-onset, adult-onset and late-onset/intermediate repeat patients for which, besides accurate AO information, also clinical parameters (MRI scans, liquor markers etc) will be (made) available. This will be used for validation and to fine-tune the molecular landscapes (again using DLA) towards the best prediction of individual patient related clinical markers and AO (WP3). The same models and (most relevant) landscapes will also be used for evaluations of novel mutant protein lowering strategies as will emerge from WP4.This overall development process of landscape prediction is an iterative process that involves (a) data processing (WP5) (b) unsupervised data exploration and dimensionality reduction to find patterns in data and create “labels” for similarity and (c) development of data supervised Deep Learning (DL) models for landscape prediction based on the labels from previous step. Each iteration starts with data that is generated and deployed according to FAIR principles, and the developed deep learning system will be instrumental to connect these WPs. Insights in algorithm sensitivity from the predictive models will form the basis for discussion with field experts on the distinction and phenotypic consequences. While full development of accurate diagnostics might go beyond the timespan of the 5 year project, ideally our final landscapes can be used for new genetic counselling: when somebody is positive for the gene, can we use his/her cells, feed it into the generated cell-based model and better predict the AO and severity? While this will answer questions from clinicians and patient communities, it will also generate new ones, which is why we will study the ethical implications of such improved diagnostics in advance (WP6).
Slaap is essentieel voor het herstellen van ziekte en om verwardheid te voorkomen en verminderen. Ernstig zieke patiënten, op de Intensive Care (IC), Medium Care (MC) of Cardiac Care Unit (CCU), slapen vaak onvoldoende door de aanwezigheid van veel externe prikkels (licht, geluid, alarmen, aanwezigheid personeel). Hierdoor is de leefomgeving op deze afdelingen erg onrustig. Patiënten vinden deze onrust en het gebrek aan privacy een groot probleem. Voor verpleegkundigen veroorzaken patiënten die ’s nachts wakker zijn een verhoging van de werkdruk. De startup Micro-Cosmos wil ernstig zieke patiënten in staat te stellen om een ‘micro-omgeving’ te creëren, waarin zij in eigen regie externe prikkels zoals licht en geluid buiten kunnen sluiten. Dit gebeurt via een innovatieve kap, de Maya, die aan het hoofdeinde van het bed wordt geplaatst. De Maya heeft als doel de slaapkwaliteit te verbeteren, en verwardheid, angst en stress te reduceren. Ook maakt de Maya het mogelijk om te ‘cocoonen’ en zorgt daarmee voor comfort en privacy. Door de ziekenhuis leefomgeving positief te beïnvloeden draagt de Maya bij aan een verbetering van de kwaliteit van zorg voor kritisch zieke en kwetsbare patiënten. In een pilot studie gaan we de haalbaarheid, de effecten (effect size) en de ervaringen van 20 patiënten en van zorgverleners in een gerandomiseerde cross-over design studie op de IC, MC en CCU testen. Hierbij wordt de Maya om de dag ingezet waarbij de volgorde gerandomiseerd is. Op de dagen dat de Maya niet wordt gebruikt, wordt standaard zorg geleverd. Objectieve en subjectieve informatie wordt gebruikt voor verdere optimalisatie van het Maya prototype en voor effectmaat bepaling voor aanvullend onderzoek. De netwerken van het Radboudumc en Micro-Cosmos worden gebruikt voor kennisverspreiding en toekomstig aanvullend onderzoek in groter verband. Opgedane resultaten worden door het Radboudumc na afloop overgedragen aan Micro-Cosmos.
Zorg op maat voor patiënten met het post-intensive care syndroom: Dankzij verbeteringen in de zorg overleven steeds meer Intensive Care (IC) patiënten een levensbedreigende ziekte. De keerzijde is dat steeds meer patiënten met langdurige lichamelijke en mentale klachten als gevolg van het Post-Intensive Care Syndroom (PICS) uit het ziekenhuis worden ontslagen. Positieve gezondheid: een nieuw concept met focus op de kracht en eigen regie van mensen: In 2012 introduceerde arts onderzoeker Huber een nieuwe definitie van gezondheid, namelijk “Gezondheid als het vermogen van mensen zich aan te passen en een eigen regie te voeren in het licht van fysieke, emotionele en sociale uitdagingen van het leven”. Het concept Positieve gezondheid bevordert persoonsgerichte zorg en sluit goed aan bij wat voor de patiënt belangrijk is. Patiënten na een IC opname willen thuis een eigen regie kunnen voeren: De meeste patiënten met PICS ontvangen na ontslag uit het ziekenhuis fysiotherapie bij een 1e lijns fysiotherapeut. Deze ontvangen niet alle noodzakelijke informatie van het ziekenhuis over het ziekteverloop van de patiënt en zijn onvoldoende bekend met de gevolgen van PICS. Feitelijk heeft het zorgveld te maken met een nieuw ziektebeeld waarvoor nog geen revalidatiebehandeling bestaat. De diversiteit aan klachten worden niet op een juiste manier geïnterpreteerd en/of in een logische volgorde geadresseerd in een behandelplan. Bij PICS komen de dimensies van het concept van Huber naar voren en zal de zorgverlener – primair de fysiotherapeut - in overleg met de patiënt de terreinen moeten identificeren waarop ondersteuning noodzakelijk is. Het doel van dit RAAK project is om in een Community of Practice van professionals, studenten en patiënten een transmuraal fysiotherapieprogramma te ontwikkelen om patiënten die met PICS naar huis worden ontslagen optimaal te ondersteunen. Aan het einde van het project is een fysiotherapieprogramma ontwikkeld voor PICS en geïmplementeerd volgens het concept ‘Positieve gezondheid’. Daarnaast is kennis over de behandeling van patiënten met PICS gedissemineerd binnen de 1e lijns fysiotherapie en het (post)HBO onderwijs.
