Comparison of Different Ultrasound Methods to Assess Changes in Muscle Mass in Critically ill Patients.

BACKGROUND: Muscle ultrasound represents a promising approach to aid diagnoses of neuromuscular diseases in critically ill patients. Unfortunately, standardization of ultrasound measurements in clinical research is lacking, making direct comparisons between studies difficult. Protocols are required to assess qualitative muscle changes during an ICU stay in patients at high risk for the development of neuromuscular acquired weakness (ICUAW). METHODS: We conducted a retrospective, observational analysis comprised of three prospective observational studies with the aim of diagnosing muscle changes by ultrasound measurement of the quadriceps muscle. Different protocols were used in each of the three studies. In total, 62 surgical, neurocritical care and trauma intensive care patients were serially assessed by different ultrasound protocols during the first week of critical illness. The relative change in ultrasound measurements was calculated for all possible locations, methods and sides. Comparison was obtained using mixed effect models with the location, the height and the side as influencing variables and patients as fixed effect. The relationship between variables and outcomes was assessed by multivariable regression analysis. RESULTS: Ultrasound methods and measurement sites of the quadriceps muscles from all protocols were equally effective in detecting muscle changes. During the first week of an ICU stay, two groups were identified: patients with decreased muscle mass on ultrasound (n = 42) and a cohort with enlargement (n = 23). Hospital mortality was significantly increased in the cohort with muscle swelling (8 (19%) versus 12 (52%), p = .013). CONCLUSIONS: Different approaches of ultrasound measurement during critical-illness are equally able to detect muscle changes. While some patients have a decrease in muscle mass, others show swelling, which may result in a reduced probability of surviving the hospital stay. Causative reasons for these results still remain unclear.

Evaluation of cardiac function using heart-lung interactions.

Heart lung interactions can be used clinically to assist in the evaluation of cardiac function. Application of these interactions and understanding of the physiology underlying them has formed a focus of research over a number of years. The changes in preload induced by changes in intrathoracic pressure (ITP) with the respiratory cycle, have been applied to form dynamic tests of fluid responsiveness. Pulse pressure variation (PPV), stroke volume variation (SVV), end expiratory occlusion test, pleth variability index (PVI) and use of echocardiography are all clinical assessments that can be made at the bedside. However, there are limitations and pitfalls to each that restrict their use to specific situations. The haemodynamic response to treatment with continuous positive airway pressure (CPAP) in left ventricular failure is explained by the presence of heart lung interactions, and works predominately through afterload reduction. Similarly, in other disease states such as acute respiratory distress syndrome (ARDS), the effects of a change in ventilation can provide information about both the cardiac and respiratory system. This review aims to summarise how assessment of cardiac function using heart lung interactions can be performed. It introduces the underlying physiology and some of the clinical applications that are further explored in other articles within the series.

Effects of Fluids on the Macro- and Microcirculations.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2018 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .

Perioperative fluid management: From physiology to improving clinical outcomes.

Perioperative fluid management is a key component in the care of the surgical patient. It is an area that has seen significant changes and developments, however there remains a wide disparity in practice between clinicians. Historically, patients received large volumes of intravenous fluids perioperatively. The concept of goal directed therapy was then introduced, with the early studies showing significant improvements in morbidity and mortality. The current focus is on fluid therapy guided by an individual patient's physiology. A fluid challenge is commonly performed as part of an assessment of a patient's fluid responsiveness. There remains wide variation in how clinicians perform a fluid challenge and this review explores the evidence for how to administer an effective challenge that is both reliable and reproducible. The methods for monitoring cardiac output have evolved from the pulmonary artery catheter to a range of less invasive techniques. The different options that are available for perioperative use are considered. Fluid status can also be assessed by examining the microcirculation and the importance of recognising the possibility of a lack of coherence between the macro and microcirculation is discussed. Fluid therapy needs to be targeted to specific end points and individualised. Not all patients who respond to a fluid challenge will necessarily require additional fluid administration and care should be aimed at identifying those who do. This review aims to explain the underlying physiology and describe the evidence base and the changes that have been seen in the approach to perioperative fluid therapy.

Habitat selection and behaviour of a reintroduced passerine: linking experimental restoration, behaviour and habitat ecology.

Habitat restoration can play an important role in recovering functioning ecosystems and improving biodiversity. Restoration may be particularly important in improving habitat prior to species reintroductions. We reintroduced seven brown treecreeper (Climacteris picumnus) social groups into two nature reserves in the Australian Capital Territory in south-eastern Australia. This study provided a unique opportunity to understand the interactions between restoration ecology, behavioural ecology and habitat ecology. We examined how experimental restoration treatments (addition of coarse woody debris, variations in ground vegetation cover and nest box installation) influenced the behaviour and microhabitat use of radio-tracked individuals to evaluate the success of restoration treatments. The addition of coarse woody debris benefited the brown treecreeper through increasing the probability of foraging on a log or on the ground. This demonstrated the value of using behaviour as a bio-indicator for restoration success. Based on previous research, we predicted that variations in levels of ground vegetation cover would influence behaviour and substrate use, particularly that brown treecreepers would choose sites with sparse ground cover because this allows better access to food and better vigilance for predators. However, there was little effect of this treatment, which was likely influenced by the limited overall use of the ground layer. There was also little effect of nest boxes on behaviour or substrate use. These results somewhat confound our understanding of the species based on research from extant populations. Our results also have a significant impact regarding using existing knowledge on a species to inform how it will respond to reintroduction and habitat restoration. This study also places great emphasis on the value of applying an experimental framework to ecological restoration, particularly when reintroductions produce unexpected outcomes.

Habitat selection and post-release movement of reintroduced brown treecreeper individuals in restored temperate woodland.

It is essential to choose suitable habitat when reintroducing a species into its former range. Habitat quality may influence an individual's dispersal decisions and also ultimately where they choose to settle. We examined whether variation in habitat quality (quantified by the level of ground vegetation cover and the installation of nest boxes) influenced the movement, habitat choice and survival of a reintroduced bird species. We experimentally reintroduced seven social groups (43 individuals) of the brown treecreeper (Climacteris picumnus) into two nature reserves in south-eastern Australia. We radio-tracked 18 brown treecreepers from release in November 2009 until February 2010. We observed extensive movements by individuals irrespective of the release environment or an individual's gender. This indicated that individuals were capable of dispersing and actively selecting optimum habitat. This may alleviate pressure on wildlife planners to accurately select the most optimum release sites, so long as the species' requirements are met. There was significant variation in movement between social groups, suggesting that social factors may be a more important influence on movement than habitat characteristics. We found a significant effect of ground vegetation cover on the likelihood of settlement by social groups, with high rates of settlement and survival in dry forests, rather than woodland (where the species typically resides), which has implications for the success of woodland restoration. However, overall the effects of variation in habitat quality were not as strong as we had expected, and resulted in some unpredicted effects such as low survival and settlement in woodland areas with medium levels of ground vegetation cover. The extensive movement by individuals and unforeseen effects of habitat characteristics make it difficult to predict the outcome of reintroductions, the movement behaviour and habitat selection of reintroduced individuals, particularly when based on current knowledge of a species' ecology.

Histological subtype of lung cancer in relation to socio-economic deprivation in South East England.

BACKGROUND: Previous studies have found differences in the histological subtypes of lung cancers affecting males and females. Our objective was to investigate trends in the incidence of histological subtypes of lung cancer in males and females in relation to socio-economic deprivation in South East England. METHODS: Data on 48,031 males and 30,454 females diagnosed with lung cancer between 1995 and 2004 were extracted from the Thames Cancer Registry database. Age-standardised incidence rates for histological subtypes were calculated for each year, using the European standard population. Using the Income Domain of the Multiple Index of Deprivation 2004, patients diagnosed between 2000 and 2004 were classified into quintiles of socio-economic deprivation based on their postcode of residence. Age-standardised rates for each histological subtype were then calculated for each deprivation quintile. A Poisson regression model was fitted to the data for males and females separately to test the hypothesis that the relationship between socio-economic deprivation and adenocarcinoma was less strong than for other subtypes. RESULTS: In males all specific histological subtypes except adenocarcinoma declined in incidence. Squamous cell carcinoma remained the most common specific subtype and large cell carcinoma the least common. In females squamous cell carcinoma was initially most common, but its incidence declined slightly and that for adenocarcinoma increased. In both sexes the overall age-standardised incidence rate of lung cancer increased with increasing deprivation. However, these trends were less strong for adenocarcinoma than for the other subtypes in both males (p < 0.001) and females (p = 0.003). CONCLUSION: The temporal trends and distribution of histological subtypes of lung cancer in males and females are similar to that reported from other western populations. In both males and females, adenocarcinoma was less strongly related to deprivation than other subtypes. This may be because its development is less strongly linked to individual smoking history.