Joint contracture following prolonged stay in the intensive care unit

Background

Prolonged immobility during a critical illness may predispose patients to the development of joint contracture. We sought to document the incidence of, the risk factors for and the reversibility of joint contractures among patients who stayed in a tertiary intensive care unit (ICU) for 2 weeks or longer.

Methods

We conducted a chart review to collect data on the presence of and risk factors for joint contractures in the shoulders, elbows, hips, knees and ankles among patients admitted to the ICU between January 2003 and March 2005.

Results

At the time of transfer out of the ICU, at least 1 joint contracture was recorded in 61 (39%) of 155 patients; 52 (34%) of the patients had joint contractures of an extent documented to impair function. Time spent in the ICU was a significant risk factor for contracture: a stay of 8 weeks or longer was associated with a significantly greater risk of any joint contracture than a stay of 2 to 3 weeks (adjusted odds ratio [OR] 7.09, 95% confidence interval (CI) 1.29–38.9; p = 0.02). Among the variables tested, only the use of steroids conferred a protective effect against joint contractures (adjusted OR 0.35, 95% CI 0.14–0.83; p = 0.02). At the time of discharge to home, which occurred a median of 6.6 weeks after transfer out of intensive care, 50 (34%) of the 147 patients not lost to follow-up still had 1 or more joint contractures, and 34 (23%) of the patients had at least 1 functionally significant joint contracture.

Interpretation

Following a prolonged stay in the ICU, a functionally significant contracture of a major joint occurred in more than one-third of patients, and most of these contractures persisted until the time of discharge to home.Joint contracture is a limitation in the passive range of motion of a joint secondary to shortening of the periarticular connective tissues and muscles.^1–7 Immobility plays a major role in the development of joint contractures.^1,2,6,8–13 Indeed, patients with conditions limiting mobility are at high risk for joint contracture.^1,9,14,15 Prolonged immobility from critical illness can also be expected to predispose patients to experience joint contractures. Herridge and colleagues¹³ evaluated the long-term consequences of acute lung injury and noticed the disabling effects of joint contractures in a small number of patients in the first year after discharge from an acute care hospital. In a systematic review, we were unable to identify any other studies characterizing joint mobility after critical illness.¹⁶Given the potentially devastating consequences of joint contracture after a prolonged stay in the intensive care unit (ICU), we sought to document the incidence of this problem among patients who remained in an ICU for 2 weeks or more. We were especially interested in mild, as well as functionally significant, limitation in the range of motion of major joints and in the number of joints affected. We also examined risk factors and the persistence or reversibility of joint contractures until discharge from hospital.     

Regulation of cellular oncosis by uncoupling protein 2

Cell death can proceed through at least two distinct pathways. Apoptosis is an energy-dependent process characterized morphologically by cell shrinkage, whereas oncosis is a form of cell death induced by energy depletion and initially characterized by cell swelling. We demonstrate in HeLa cells but not in normal diploid fibroblasts that modest increases in the expression level of uncoupling protein 2 (UCP-2) leads to a rapid and dramatic fall in mitochondrial membrane potential and to a reduction of mitochondrial NADH and intracellular ATP. In HeLa cells, increased UCP-2 expression leads to a form of cell death that is not inhibited by the anti-apoptotic gene product Bcl-2 and that morphologically resembles cellular oncosis. We further describe the creation of a dominant interfering mutant of UCP-2 whose expression increases resting mitochondrial membrane potential and selectively increases the resistance to cell death following oncotic but not apoptotic stimuli. These results suggest that distinct genetic programs may regulate the cellular response to either apoptotic or oncotic stimuli.     

Change in Adverse Events After Enrollment in the National Surgical Quality Improvement Program: A Systematic Review and Meta-Analysis

Background

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) is the first nationally validated, risk-adjusted, outcomes-based program to measure and compare the quality of surgical care across North America. Participation in this program may provide an opportunity to reduce the incidence of adverse events related to surgery.

Study Design

A systematic review of the literature was performed. MedLine, EMBASE and PubMed were searched for studies relevant to NSQIP. Patient characteristics, intervention, and primary outcome measures were abstracted. The intervention was participation in NSQIP and monitoring of Individual Site Summary Reports with or without implementation of a quality improvement program. The outcomes of interest were change in peri-operative adverse events and mortality represented by pooled risk ratios (pRR) and 95% confidence intervals (CI).

Results

Eleven articles reporting on 35 health care institutions were included. Nine (82%) of the eleven studies implemented a quality improvement program. Minimal improvements in superficial (pRR 0.81; 95% CI 0.72–0.91), deep (pRR 0.82; 95% CI0.64–1.05) and organ space (pRR 1.15; 95% CI 0.96–1.37) infections were observed at centers that did not institute a quality improvement program. However, centers that reported formal interventions for the prevention and treatment of infections observed substantial improvements (superficial pRR 0.55, 95% CI 0.39–0.77; deep pRR 0.61, 95% CI 0.50–0.75, and organ space pRR 0.60, 95% CI 0.50–0.71). Studies evaluating other adverse events noted decreased incidence following NSQIP participation and implementation of a formal quality improvement program.

Conclusions

These data suggest that NSQIP is effective in reducing surgical morbidity. Improvement in surgical quality appears to be more marked at centers that implemented a formal quality improvement program directed at the reduction of specific morbidities.     

On the occurence of a short period of delayed implantation in Schreibers'long-fingered bat (Miniopterus schreibersii) from a tropical latitude in Zimbabwe

Mating in Schrcibers'long-fingered bat ( Miniopterus schreibersii ) from central Zimbabwe (18°S) occurred between mid-April and mid-May, after a five-month period of spermatogenesis. Implantation was delayed until early July and parturition occurred between late October and mid-November, about four months after implantation and six to seven months after fertilization. The timing and length of gestation at 18°S are similar to that described for M. schreibersii from Zaire (11σS) and when these date are compared with those for the same species from higher latitudes in Africa, it is apparent that there is a small, but distinct, increase in the total length of pregnancy and the length of delayed implantation with increasing latitude. The reproductive bilogy of Miniopterus schreibersii from Africa and France differs fundamentally from that of the same species from Australia and Japan, and it is suggested that studies of the relationship between latitude and duration of delayed implantation should be based on comparisons within single species from different latitudes on the same continent, and that comparisons between species and between continents should be avoided.     

Radioisotopic Bone Scintigraphy with the Gamma Camera in the Investigation of Prostatic Cancer

Experience with x-rays, strontium-87m scintigraphy, and technetium-99m polyphosphate scintigraphy in the identification of bone metastases in 201 patients with prostatic cancer is reviewed. About 40% of the patients had demonstrable metastases in bone at the time of first presentation.Comparative studies of 247 x-ray and ^87mSr surveys indicated that x-rays failed to detect metastases in 10% of cases where they were identified by ^87mSr but that the isotopic survey similarly failed to detect radiologically evident deposits in 7% of cases.Similar studies comparing ^99mTc polyphosphate surveys with x-ray scans showed that x-rays missed isotopically detected metastases in 12% of cases, but in only one survey out of 67 did the isotope miss radiologically evident deposits. In a series of 32 patients investigated by both isotopic techniques ^99mTc polyphosphate did not fail to detect any metastases and identified deposits in one patient in whom they were missed by ^87mSr scintigraphy. About 15% of both x-ray and ^87mSr surveys gave equivocal results, but only 3% (2 out of 67) of ^99mTc polyphosphate surveys were equivocal.We concluded that ^99mTc polyphosphate bone scintigraphy with the gamma camera was the most reliable of the techniques used for the identification of bone metastases in patients with carcinoma of the prostate. The results of scintigraphy with ^87mSr suggested that serial surveys may provide early evidence of hormone resistance in prostatic cancer.