Survivors Of Critical Illness Research Articles

Association of Psoas Muscle Mass at Intensive Care Unit Admission With Physical Function and Post-discharge Destination in Survivors of Critical Illness

Association of Psoas Muscle Mass at Intensive Care Unit Admission With Physical Function and Post-discharge Destination in Survivors of Critical Illness

Integrating Perspectives on Family Caregiving After Critical Illness: A Qualitative Content Analysis.

To date, no intervention has definitively improved outcomes for families of critical illness survivors. An integrated perspective on caregivers' needs after critical illness could help identify high-priority intervention targets and improve outcomes. To obtain diverse perspectives on the needs, barriers and facilitators, and social determinants of health associated with family caregiving across the critical illness continuum and assess the extent to which successful caregiving interventions in other populations may be adapted to the critical illness context. This qualitative content analysis of 31 semistructured interviews and 10 focus groups with family caregivers, health care providers, and health care administrators explored family caregivers' needs during post- intensive care unit (ICU) transitions and the barriers and facilitators associated with addressing them. Trained coders analyzed transcripts, identified patterns and categories among the codes, and generated themes. Caregivers have 3 instrumental needs: formal and informal support, involvement in care planning, and education and training. Only caregivers described their self-care and mental health needs. Social determinants of health are the key barriers and facilitators shaping the caregivers' journey, and caregiving as a social determinant of health was a prominent theme. Caregivers have instrumental, self-care, and mental health needs after critical illness. Adapting hands-on and skills training interventions to the post-ICU setting, while tailoring interventions to caregivers' health-related social context, may improve caregiver outcomes.

Effects of exercise interventions on functioning and health-related quality of life following hospital discharge for recovery from critical illness: A systematic review and meta-analysis of randomized trials.

This systematic review and meta-analysis aimed to analyze the published randomized controlled trials (RCTs) that investigated the effects of exercise interventions on functioning and health-related quality of life following hospital discharge for recovery from critical illness. Systematic review and meta-analysis of RCTs. We searched PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, PEDro data base, and SciELO (from the earliest date available to January 2023) for RCTs that evaluated the effects of physical rehabilitation interventions following hospital discharge for recovery from critical illness. Study quality was evaluated using the PEDro Scale. Mean differences (MDs), standard MDs (SMD), and 95% confidence intervals (CIs) were calculated. Fourteen studies met the study criteria, including 1259 patients. Exercise interventions improved aerobic capacity SMD 0.2 (95% CI: 0.03-0.3, I2 = 0% N = 880, nine studies, high-quality evidence), and physical component score of health-related quality of life MD 3.3 (95% CI: 1.0-5.6, I2 = 57%, six studies N = 669, moderate-quality evidence). In addition, a significant reduction in depression was observed MD -1.4 (95% CI: -2.7 to -0.1, I2 = 0% N = 148, three studies, moderate-quality evidence). No serious adverse events were reported. Exercise intervention was associated with improvement of aerobic capacity, depression, and physical component score of health-related quality of life after hospital discharge for survivors of critical illness.

Association between inflammation and post-intensive care syndrome: a systematic review.

Post-intensive care syndrome describes the physical, cognitive and emotional symptoms which persist following critical illness. At present there is limited understanding of the pathological mechanisms contributing to the development of post-intensive care syndrome. The aim of this systematic review was to synthesise current evidence exploring the association between inflammation and features of post-intensive care syndrome in survivors of critical illness. Relevant databases were systematically searched for studies of human participants exposed to critical illness. We sought studies that reported results for biomarkers with an identified role in the pathophysiology of inflammation obtained at any time-point in the patient journey and an outcome measure of any feature of post-intensive care syndrome at any point following hospital discharge. We included 32 studies, with 23 in the primary analysis and nine in a brain injury subgroup analysis. In the primary analysis, 47 different biomarkers were sampled and 44 different outcome measures were employed. Of the biomarkers which were sampled in five or more studies, interleukin-8, C-reactive protein and interleukin-10 most frequently showed associations with post-intensive care syndrome outcomes in 71%, 62% and 60% of studies, respectively. There was variability in terms of which biomarkers were sampled, time-points of sampling and outcome measures reported. Overall, there was mixed evidence of a potential association between an inflammatory process and long-term patient outcomes following critical illness. Further high-quality research is required to develop a longitudinal inflammatory profile of survivors of critical illness over the recovery period and evaluate the association with outcomes.

Long-term, patient-centered, frailty-based outcomes of older critical illness survivors from the emergency department: a post hoc analysis of the LIFE Study

Background Evidence indicates frailty before intensive care unit (ICU) admission leads to poor outcomes. However, it is unclear whether quality of life (QOL) and activities of daily living (ADL) for survivors of critical illness admitted to the ICU via the emergency department remain consistent or deteriorate in the long-term compared to baseline. This study aimed to evaluate long-term QOL/ADL outcomes in these patients, categorized by the presence or absence of frailty according to Clinical Frailty Scale (CFS) score, as well as explore factors that influence these outcomes.Methods This was a post-hoc analysis of a prospective, multicenter, observational study conducted across Japan. It included survivors aged 65 years or older who were admitted to the ICU through the emergency department. Based on CFS scores, participants were categorized into either the not frail group or the frail group, using a threshold CFS score of < 4. Our primary outcome was patient-centered outcomes (QOL/ADL) measured by the five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) and the Barthel Index six months post-ICU admission, comparing results from baseline. Secondary outcomes included exploration of factors associated with QOL/ADL six months post-ICU admission using multiple linear regression analyses.Results Of 514 candidates, 390 participants responded to the EQ-5D-5L questionnaire, while 237 responded to the Barthel Index. At six months post-admission, mean EQ-5D-5L values declined in both the not frail and frail groups (0.80 to 0.73, p = 0.003 and 0.58 to 0.50, p = 0.002, respectively); Barthel Index scores also declined in both groups (98 to 83, p < 0.001 and 79 to 61, p < 0.001, respectively). Multiple linear regression analysis revealed that baseline frailty (β coefficient, -0.15; 95% CI, − 0.23 to − 0.07; p < 0.001) and pre-admission EQ-5D-5L scores (β coefficient, 0.14; 95% CI, 0.02 to 0.26; p = 0.016) affected EQ-5D-5L scores at six months. Similarly, baseline frailty (β coefficient, -12.3; 95% CI, − 23.9 to − 0.80; p = 0.036) and Barthel Index scores (β coefficient, 0.54; 95% CI, 0.30 to 0.79; p < 0.001) influenced the Barthel Index score at six months.Conclusions Regardless of frailty, older ICU survivors from the emergency department were more likely to experience reduced QOL and ADL six months after ICU admission compared to baseline.

Post-COVID-19 Clinic Utilization Among Survivors of Critical Illness in Two Waves of SARS-CoV-2 Infection

Post-COVID-19 Clinic Utilization Among Survivors of Critical Illness in Two Waves of SARS-CoV-2 Infection

New-onset mental illness and long-term survival in survivors of critical illness: population-based cohort study in South Korea.

Critical care unit (CCU) survivors have a high risk of developing mental illness. We aimed to examine the incidence and associated factors of newly developed mental illness among CCU survivors of critical illness. Moreover, we examined the association between newly developed mental illness and 2-year all-cause mortality. All adult patients (≥20 years) who were admitted to the CCU during hospitalisation between 2010 and 2018 and survived for 1 year were defined as CCU survivors and were included in this nationwide population-based cohort study. CCU survivors with a history of mental illness before CCU admission were excluded from the study. A total of 1 353 722 CCU survivors were included in the analysis; of these, 33 743 survivors (2.5%) had newly developed mental illness within 1 year of CCU admission. Old age, longer CCU stay, hospital admission through the emergency room, increased total cost of hospitalisation, mechanical ventilatory support, extracorporeal membrane oxygenation support and continuous renal replacement therapy were associated with an increased incidence of newly developed mental illness. Moreover, the newly developed mental illness group showed a 2.36-fold higher 2-year all-cause mortality rate than the no mental illness group (hazard ratio: 2.36; 95% CI: 2.30-2.42; P < 0.001). In South Korea, 2.5% of CCU survivors had newly developed mental illness within 1 year of CCU admission. Moreover, newly developed mental illness was associated with an increased 2-year all-cause mortality.

Comparison of energy intake in critical illness survivors, general medical patients, and healthy volunteers: A descriptive cohort study.

Intensive care unit (ICU) survivors have reduced oral intake; it is unknown whether intake and associated barriers are unique to this group. To quantify energy intake and potential barriers in ICU survivors compared with general medical (GM) patients and healthy volunteers. A descriptive cohort study in ICU survivors, GM patients, and healthy volunteers. Following an overnight fast, participants consumed a 200 ml test-meal (213 kcal) and 180 min later an ad libitum meal to measure energy intake (primary outcome). Secondary outcomes; taste recognition, nutrition-impacting symptoms, malnutrition, and quality of life (QoL). Data are mean ± SD, median (interquartile range [IQR]) or number [percentage]). Twelve ICU survivors (57 ± 17 years, BMI: 30 ± 6), eight GM patients (69 ± 19 years, BMI: 30 ± 6), and 25 healthy volunteers (58 ± 27 years, BMI: 25 ± 4) were included. Recruitment ceased early because of slow recruitment and SARS-CoV-2. Energy intake was lower in both patient groups than in health (ICU: 289 [288, 809], GM: 426 [336, 592], health: 815 [654, 1165] kcal). Loss of appetite was most common (ICU: 78%, GM: 67%). For ICU survivors, GM patients and healthy volunteers, respectively, severe malnutrition prevalence; 40%, 14%, and 0%; taste identification; 8.5 [7.0, 11.0], 8.5 [7.0, 9.5], and 8.0 [6.0, 11.0]; and QoL; 60 [40-65], 50 [31-55], and 90 [81-95] out of 100. Energy intake at a buffet meal is lower in hospital patients than in healthy volunteers but similar between ICU survivors and GM patients. Appetite loss potentially contributes to reduced energy intake.

Psychotropic prescribing after hospital discharge in survivors of critical illness, a retrospective cohort study (2012–2019)

Background: Many people survive critical illness with the burden of new or worsened mental health issues and sleep disturbances. We examined the frequency of psychotropic prescribing after critical illness, comparing critical care to non-critical care hospitalised survivors, and whether this varied in important subgroups. Methods: This retrospective cohort study included 23,340 critical care and 367,185 non-critical care hospitalised adults from 2012 through 2019 in Lothian, Scotland, who survived to discharge. Results: One-third of critical care survivors (32%; 7527/23,340) received a psychotropic prescription within 90 days after hospital discharge (25% antidepressants; 14% anxiolytics/hypnotics; 4% antipsychotics/mania medicines). In contrast, 15% (54,589/367,185) of non-critical care survivors received a psychotropic prescription (12% antidepressants; 5% anxiolytics/hypnotics; 2% antipsychotics/mania medicines). Among patients without psychotropic prescriptions within 180 days prior to hospitalisation, after hospital discharge, the critical care group had a higher incidence of psychotropic prescription (10.3%; 1610/15,609) compared with the non-critical care group (3.2%; 9743/307,429); unadjusted hazard ratio (HR) 3.39, 95% CI: 3.22–3.57. After adjustment for potential confounders, the risk remained elevated (adjusted HR 2.03, 95% CI: 1.91–2.16), persisted later in follow-up (90–365 days; adjusted HR 1.38, 95% CI: 1.30–1.46), and was more pronounced in those without recorded comorbidities (adjusted HR 3.49, 95% CI: 3.22–3.78). Conclusions: Critical care survivors have a higher risk of receiving psychotropic prescriptions than hospitalised patients, with a significant proportion receiving benzodiazepines and other hypnotics. Future research should focus on the requirement for and safety of psychotropic medicines in survivors of critical illness, to help guide policy for clinical practice.

MicroRNA-centered theranostics for pulmoprotection in critical COVID-19

Elucidating the pathobiological mechanisms underlying post-acute pulmonary sequelae following SARS-CoV-2 infection is essential for early interventions and patient stratification. Here, we investigated the potential of microRNAs (miRNAs) as theranostic agents for pulmoprotection in critical illness survivors. Multicenter study including 172 ICU survivors. Diffusion impairment was defined as a lung diffusing capacity for carbon monoxide (DLCO)<80% within 12 months post-discharge. A disease-associated 16-miRNA panel was quantified in plasma samples collected at ICU admission. Bioinformatic analyses were conducted using KEGG, Reactome, GTEx and Drug-Gene Interaction databases. The results were validated using an external RNA-seq dataset. A 3-miRNA signature linked to diffusion impairment (miR-27a-3p, miR-93a-5p, and miR-199a-5p) was identified using Random Forest. Levels of miR-93a-5p and miR-199a-5p were independently associated with the outcome, improving patient classification provided by the electronic heatlh record. The experimentally-validated targets of these miRNAs exhibited enrichment across diverse pathways, with telomere length quantification in an additional set samples (n=83) supporting the role of cell senescence in sequelae. Analysis of an external dataset refined the pathobiological fingerprint of pulmonary sequelae. Gene-drug interaction analysis revealed four FDA-approved drugs. Overall, this study advances our understanding of lung recovery in post-acute respiratory infections, highlighting the potential of miRNAs and their targets for pulmonoprotection.

Determinants of Subjective Mental and Functional Health of Critical Illness Survivors: Comparing Pre-ICU and Post-ICU Status.

To compare ICU survivors' subjective mental and functional health before ICU admission and after discharge and to assess determinants of subjective health decline or improvement. Secondary analysis of the multicenter cluster-randomized Enhanced Recovery after Intensive Care trial (ClinicalTrials.gov: NCT03671447). Ten ICU clusters in Germany. Eight hundred fifty-five patients with 1478 follow-up assessments. None. At two patient follow-ups scheduled 3 and 6 months after ICU discharge, patients rated their subjective mental and functional/physical health on two separate visual analog scales from 0 (worst) to 10 (best) in the previous week and before ICU admission. We compared pre-ICU and post-ICU subjective health and used mixed-effects regression to assess determinants of a health decline or improvement. At the first follow-up, 20% (n = 165/841) and 30% (n = 256/849) of patients reported a decline in subjective mental and functional health of at least three points, respectively; 16% (n = 133/841 and n = 137/849) outlined improvements of mental and functional health. For 65% (n = 543/841) and 54% (n = 456/849), mental and functional health did not change three points or more at the first follow-up. Multivariable mixed-effects logistic regressions revealed that the ICU length of stay was a predictor of mental (adjusted odds ratio [OR] per ICU day, 1.04; 95% CI, 1.00-1.09; p = 0.038) and functional health (adjusted OR per ICU day, 1.06; 95% CI, 1.01-1.12; p = 0.026) decline. The odds of a mental health decline decreased with age (adjusted OR per year, 0.98; 95% CI, 0.96-0.99; p = 0.003) and the odds of a functional health decline decreased with time after discharge (adjusted OR per month, 0.86; 95% CI, 0.79-0.94; p = 0.001). The majority of ICU survivors did not experience substantial changes in their subjective health status, but patients with long ICU stays were prone to subjective mental and functional health decline. Hence, post-ICU care in post-ICU clinics could focus on these patients.

Critical illness survivors' experiences of attending an intensive care unit follow-up service: a systematic review protocol.

The objective of this review is to explore critical illness survivors' experiences of attending an intensive care unit (ICU) follow-up service. A significant proportion of critical illness survivors will require ICU follow-up care to support adverse symptoms in health domains, including cognition, mental health, and physical and social function. While there is consensus on the need for ICU follow-up services, systematic reviews to date have not identified any significant impact of ICU follow-up services on clinical health outcomes. An understanding of survivors' experiences of attending an ICU follow-up service may improve the effectiveness and design of such services. This review will include studies that explore the experiences of adult ( 18 years of age) critical illness survivors who attended an ICU follow-up service following discharge from an ICU, regardless of the admitting diagnosis or ICU length of stay. This review will be conducted in line with the JBI methodological framework for qualitative systematic reviews. Electronic databases, including MEDLINE, CINAHL, PsycINFO, Embase, and Web of Science Core Collection, will be searched to identify relevant studies for inclusion in the review. Studies will be screened by 2 independent reviewers. Critical appraisal, data extraction, and data synthesis will be completed by 2 independent reviewers using a meta-aggregation method for data synthesis. Confidence in the research findings will be assessed and assigned a ConQual score. PROSPERO CRD42023404585.

The impact of critical illness on patients’ physical function and recovery: An explanatory mixed-methods analysis

ObjectivesTo determine how the perception of physical function 6-months following critical illness compares to objectively measured function, and to identify key concerns for patients during recovery from critical illness. Research methodology and designA nested convergent parallel mixed methods study assessed physical function during a home visit 6-months following critical illness, with semi-structured interviews conducted at the same time. SettingParticipants were recruited from two hospitals at one healthcare network in Melbourne, Australia from September 2017 to October 2018 with follow-up data completed in April 2019. Main Outcome MeasuresPhysical function was assessed through four objective outcomes: the functional independence measure, six-minute walk test, functional reach test, and grip strength. Semi structured interviews focused on participants function, memories of the intensive care and hospital stay, assistance required on discharge, ongoing limitations, and the recovery process. FindingsAlthough many participants (12/20, 60%) stated they had recovered from their critical illness, 14 (70%) had function below expected population norms. Decreased function on returning home was commonly reported, although eleven participants were described as independent and safe for discharge from hospital-based staff. The importance of family and social networks to facilitate discharge was highlighted, however participants often described wanting more support and issues accessing services. The effect of critical illness on the financial well-being of the family network was confirmed, with difficulties accessing financial support identified. ConclusionSurvivors of critical illness perceived a better functional state than measured, but many report new limitations 6-months after critical illness. Family and friends play a crucial role in facilitating transition home and providing financial support. Implications for clinical practiceImplementation of specific discharge liaison personnel to provide education, support and assist the transition from hospital-based care to home, particularly in those without stable social supports, may improve the recovery process for survivors of critical illness.

Iron and erythropoietin to heal and recover after intensive care (ITHRIVE): A pilot randomised clinical trial

ObjectiveTo determine the feasibility of a pivotal randomised clinical trial of intravenous (IV) iron and erythropoietin in adult survivors of critical illness with anaemia requiring treatment in the intensive care unit. DesignAn investigator-initiated, parallel group, placebo-controlled, randomised feasibility trial. SettingA tertiary intensive care unit (ICU) in Perth, Western Australia. ParticipantsAdults with anaemia (haemoglobin <100 g/L), requiring ICU-level care for more than 48 h, and likely to be ready for ICU discharge within 24 h. InterventionsA single dose of IV ferric carboxymaltose and Epoetin alfa (active group) or an equal volume of 0.9% saline (placebo group). Main outcome measuresStudy feasibility was considered met if the pilot achieved a recruitment rate of ≥2 participants per site per month, ≥90% of participants received their allocated study treatment, and≥ 90% of participants were followed up for the proposed pivotal trial primary outcome - days alive and at home to day 90 (DAH90). ResultsThe 40-participant planned sample size included twenty in each group and was enrolled between 1/9/2021 and 2/3/2022. Participants spent a median of 3.4 days (interquartile range 2.8–5.1) in the ICU prior to enrolment and had a mean baseline haemoglobin of 83.7 g/L (standard deviation 6.7). The recruitment rate was 6.7 participants per month [95% confidence interval (CI) 4.8–9.0], DAH90 follow-up was 100% (95% CI 91.2%–100%), and 39 (97.5%, 95% CI 86.8%–99.9%) participants received the allocated study intervention. No serious adverse events were reported. ConclusionThe iron and erythropoietin to heal and recover after intensive care (ITHRIVE) pilot demonstrated feasibility based on predefined participant recruitment, study drug administration, and follow-up thresholds.

The optimal dose of mobilisation therapy in the ICU: a prospective cohort study

BackgroundThis study aimed to assess the impact of duration of early mobilisation on survivors of critical illness. The hypothesis was that interventions lasting over 40 min, as per the German guideline, positively affect the functional status at ICU discharge.MethodsProspective single-centre cohort study conducted in two ICUs in Germany. In 684 critically ill patients surviving an ICU stay > 24 h, out-of-bed mobilisation of more than 40 min was evaluated.ResultsDaily mobilisation ≥ 40 min was identified as an independent predictor of an improved functional status upon ICU discharge. This effect on the primary outcome measure, change of Mobility-Barthel until ICU discharge, was observed in three different models for baseline patient characteristics (average treatment effect (ATE), all three models p < 0.001). When mobilisation parameters like level of mobilisation, were included in the analysis, the average treatment effect disappeared [ATE 1.0 (95% CI − 0.4 to 2.4), p = 0.16].ConclusionsA mobilisation duration of more than 40 min positively impacts functional outcomes at ICU discharge. However, the maximum level achieved during ICU stay was the most crucial factor regarding adequate dosage, as higher duration did not show an additional benefit in patients with already high mobilisation levels.Trial registration: Prospective Registry of Mobilization-, Routine- and Outcome Data of Intensive Care Patients (MOBDB), NCT03666286. Registered 11 September 2018—retrospectively registered,https://classic.clinicaltrials.gov/ct2/show/NCT03666286.

Early weight measures and long-term neuropsychological outcome of critically ill neonates and infants: a secondary analysis of the PEPaNIC trial

Neonates and infants surviving critical illness show impaired growth during critical illness and are at risk for later neuropsychological impairments. Early identification of individuals most at risk is needed to provide tailored long-term follow-up and care. The research question is whether early growth during hospitalization is associated with growth and neuropsychological outcomes in neonates and infants after pediatric intensive care unit admission (PICU). This is a secondary analysis of the PEPaNIC trial. Weight measurements upon PICU admission, at PICU discharge, at hospital discharge, at 2- and 4-year follow-up, and of different subgroups were compared using (paired) t-tests. Multiple linear regression analyses were performed to investigate the association between early growth in weight measures and neuropsychological outcomes at 4-year follow-up. One hundred twenty-one infants were included, and median age upon admission was 21 days. Growth in weight per week was less than the age-appropriate norm, resulting in a decrease in weight-for-age Z-score during hospitalization. Weight is normalized at 2- and 4-year follow-up. Weight gain in kilograms per week and change in weight Z-score were not associated with neurodevelopmental outcome measures at 4-year follow-up. Lower weight-for-age Z-score at PICU admission and at hospital discharge was associated only with lower weight and height Z-scores at 4-year follow-up.Conclusion: Growth in weight during hospital stay of young survivors of critical illness is impaired. Worse early growth in weight is associated with lower weight and height but not with neuropsychological outcomes at 4-year follow-up.What is Known:• Critically ill neonates and infants show impaired early growth during admission and are at risk for later neuropsychological impairments.• Unraveling the association between early growth and later neuropsychological impairments is crucial since the first year of life is critical for brain development.What is New:• Critically ill neonates and infants had age appropriate weight measures at 4-year follow-up.• Poor growth in weight during hospital stay was not associated with poorer cognitive, emotional, or behavioral functioning four years after critical illness.

Functional recovery of chronically critically ill patients in the first days after discharge from the intensive care unit: Feasibility of the 6-minute step test.

Survivors of chronic critical illness often experience weakness and functional dependence to various degrees after their intensive care unit (ICU) stay. Evaluating their functional status with the traditional six-minute walk test is challenging due to space constraints or patient intolerance. Our aim was to evaluate the feasibility of using the six-minute step test (6MST) as a measure of functional capacity in chronically critically ill patients early after ICU discharge. This prospective study was undertaken in a private Brazilian hospital. From July 2019 to July 2020, all chronically critically ill patients were asked to participate 48 hours after ICU discharge. On the day of study inclusion and a week later, those who consented underwent functional assessment comprised of the 6MST, peripheral muscle strength using handgrip strength (HGS), and mobility using the ICU mobility scale (IMS). A total of 40 patients were included. The 6MST was feasible in 40% on the first evaluation and 57% on the second. The median 6MST was 0 [0-5] on the first evaluation and 3.5 [0-7.75] on the second (P = 0.005). The median HGS increased from 11.50 [9.25-18] on the first evaluation to 14.5 [10-20] on the second (P = 0.006). The median IMS was 4.5 [3.25-7] on the first evaluation and 6 [3.25-7] on the second (P<0.001). Despite the significant improvement, all parameters measured remained well below normal. The 6MST was a feasible measure of functional capacity in chronically critically ill patients early after ICU discharge. Patients had functional capacity well below predicted values.

Study on critical illness and bone turnover

Purpose: Critical illness has been recognized to acutely influence bone metabolism and, consequently, bone mineral density. The main purpose of this study was to describe bone metabolism changes in adult survivors of critical illness in an attempt to correlate them with severity scores. Methods: An open, prospective, observational, monocentric study in patients admitted to the intensive care unit (ICU) was conducted, evaluating bone metabolism at baseline (within 72 hours of ICU admission), 6 months, and 12 months. Results: Fifty-nine patients admitted to the ICU (63% males), mean age 58 ± 16 years, were enrolled. Of these, 20 patients (34%) completed the one-year follow up. At baseline, bone resorption showed an increase, which was maintained at 6 months, and followed by normalization at 12 months. Patients showed, in the majority of cases, hypovitaminosis D with hyperparathyroidism at baseline with subsequent normalization. A trend towards a correlation was described between severity scores and serum 25(OH) vitamin D and bone turnover marker levels. Conclusions: These results help to confirm a positive association between critical illness requiring ICU admission and bone metabolism changes. This study lays the foundations for further studies evaluating bone health in ICU patients. KEY WORDS: Critical illness, osteoporosis, bone turnover, bone metabolism, treatment.

Palliative Care in Survivors of Critical Illness: A Qualitative Study of Post-Intensive Care Unit Program Clinicians.

Background: Survivors of critical illness experience high rates of serious health-related suffering. The delivery of palliative care may assist in decreasing this burden for survivors and their families. Objectives: To understand beliefs, attitudes, and experiences of post-intensive care unit (ICU) program clinicians regarding palliative care and explore barriers and facilitators to incorporating palliative care into critical illness survivorship care. Design: Qualitative inquiry using semistructured interviews and framework analysis. Results were mapped using the Consolidated Framework for Implementation Research. Setting/Subjects: We interviewed 29 international members (United States, United Kingdom, Canada) of the Critical and Acute Illness Recovery Organization post-ICU clinic collaborative. Results: All interprofessional clinicians described components of palliative care as essential to post-ICU clinic practice, including symptom management, patient/family support, facilitation of goal-concordant care, expectation management and anticipatory guidance, spiritual support, and discussion of future health care wishes and advance care planning. Facilitators promoting palliative care strategies were clinician level, including first-hand experience, perceived value, and a positive attitude regarding palliative care. Clinician-level barriers were reciprocals and included insufficient palliative care knowledge, lack of self-efficacy, and a perceived need to protect ICU survivors from interventions the clinician felt may adversely affect recovery or change the care trajectory. System-level barriers included time constraints, cost, and lack of specialty palliative care services. Conclusion: Palliative care may be an essential element of post-ICU clinic care. Implementation efforts focused on tailoring strategies to improve post-ICU program clinicians' palliative care knowledge and self-efficacy could be a key to enhanced care delivery for survivors of critical illness.

Accounting for Competing Events When Evaluating Long-Term Outcomes in Survivors of Critical Illness.

The clinical trajectory of survivors of critical illness after hospital discharge can be complex and highly unpredictable. Assessing long-term outcomes after critical illness can be challenging because of possible competing events, such as all-cause death during follow-up (which precludes the occurrence of an event of particular interest). In this perspective, we explore challenges and methodological implications of competing events during the assessment of long-term outcomes in survivors of critical illness. In the absence of competing events, researchers evaluating long-term outcomes commonly use the Kaplan-Meier method and the Cox proportional hazards model to analyze time-to-event (survival) data. However, traditional analytical and modeling techniques can yield biased estimates in the presence of competing events. We present different estimands of interest and the use of different analytical approaches, including changes to the outcome of interest, Fine and Gray regression models, cause-specific Cox proportional hazards models, and generalized methods (such as inverse probability weighting). Finally, we provide code and a simulated dataset to exemplify the application of the different analytical strategies in addition to overall reporting recommendations.