Caring for critically ill patients with a mental illness: A discursive paper providing an overview and case exploration of the delivery of intensive care to people with psychiatric comorbidity.

AIM: To address the need for additional education in the management of mental illness in the critical care setting by providing a broad overview of the interrelationship between critical illness and mental illness. The paper also offers practical advice to support critical care staff in managing patients with mental illness in critical care by discussing two hypothetical case scenarios involving aggressive and disorganised behaviour. People living with mental illness are over-represented among critically unwell patients and experience worse outcomes, contributing to a life expectancy up to 30 years shorter than their peers. Strategic documents call for these inequitable outcomes to be addressed. Staff working in intensive care units (ICUs) possess advanced knowledge and specialist skills in managing critical illness but have reported limited confidence in managing patients with comorbid mental illness. DESIGN & METHODS: A discursive paper, drawing on clinical experience and research of the authors and current literature. RESULTS: Like all people, patients with mental illnesses draw on their cognitive, behavioural, social and spiritual resources to cope with their experiences during critical illness. However, they may have fewer resources available due to co-morbid mental illness, a history of trauma and social disadvantage. By identifying and sensitively addressing patients' underlying needs in a trauma-informed way, demonstrating respect and maximising patient autonomy, staff can reduce distress and disruptive behaviours and promote recovery. Caring for patients who are distressed and/or display challenging behaviours can evoke strong and unpleasant emotional responses. Self-care is fundamental to maintaining a compassionate approach and effective clinical judgement. Staff should be enabled to accept and acknowledge emotional responses and access support-informally with peers and/or through formal mechanisms as needed. Organisational leadership and endorsement of the principles of equitable care are critical to creation of the environment needed to improve outcomes for staff and patients. RELEVANCE TO CLINICAL PRACTICE: ICU nurses hold an important role in the care of patients with critical illnesses and are ideally placed to empower, advocate for and comfort those patients also living with mental illness. To perform these tasks optimally and sustainably, health services have a responsibility to provide nursing staff with adequate education and training in the management of mental illnesses, and sufficient formal and informal support to maintain their own well-being while providing this care. PATIENT AND PUBLIC INVOLVEMENT: This paper is grounded in accounts of patients with mental illness and clinicians providing care to patients with mental illness in critical care settings but there was no direct patient or public contribution.

Disaster preparedness: A concept analysis and its application to the intensive care unit.

OBJECTIVES: The aim of the study is to understand the concept of disaster preparedness in relation to the intensive care unit through the review and critique of the peer-reviewed literature. REVIEW METHOD USED: Rodgers' method of evolutionary concept analysis was used in the study. DATA SOURCES: Healthcare databases included in the review were Cumulative Index to Nursing and Allied Health Literature, Public MEDLINE, Scopus, and ProQuest. REVIEW METHODS: Electronic data bases were searched using terms such as "intensive care unit" OR "critical care" AND prep∗ OR readiness OR plan∗ AND disaster∗ OR "mass casualty incidents" OR "natural disaster" OR "disaster planning" NOT paed∗ OR ped∗ OR neonat∗. Peer-reviewed articles published in English between January 2000 and April 2020 that focused on intensive care unit disaster preparedness or included intensive care unit disaster preparedness as part of a facility-wide strategy were included in the analysis. RESULTS: Eighteen articles were included in the concept analysis. Fourteen different terms were used to describe disaster preparedness in intensive care. Space, physical resources, and human resources were attributes that relied on each other and were required in sufficient quantities to generate an adequate response to patient surges from disasters. When one attribute is extended beyond normal operational capacities, the effectiveness and capacity of the other attributes will likely be limited. CONCLUSION: This concept analysis has shown the varied language used when referring to disaster preparedness relating to the intensive care unit within the research literature. Attributes including space, physical resources, and human resources were all found to be integral to a disaster response. Future research into what is required of these attributes to generate an all-hazards approach in disaster preparedness in intensive care units will contribute to optimising standards of care.

The impact of mass casualty incidents on intensive care units.

OBJECTIVES: Mass casualty incidents occur worldwide and have the capacity to overwhelm local healthcare facilities. There has been much research into how these events are managed in the prehospital environment and in the emergency department. However, there is a paucity in research addressing the impact that mass casualty incidents have on adult intensive care units. This review seeks to identify what literature is available that addresses the impact that mass casualty incidents have on intensive care units. REVIEW METHOD USED: Integrative Review Data sources: Electronic databases MEDLINE, CINAHL, PubMed and Scopus. REVIEW METHODS: Electronic databases were searched using terms such as "Intensive Care Unit" OR "Intensive Care" OR "Critical Care" OR "ICU" AND "Mass Casualty Incidents" OR "MCI" OR "Mass Casualty Event" OR "Mass Casualty Management" OR "Disaster". Articles that were published in the preceding 10 years in English as case studies or addressing real world events were included. Editorials, theoretical papers and research involving paediatrics were excluded from the results. RESULTS: Seven articles met the search criteria. Results identified four key areas in ICU that were impacted by mass casualty incidents. These areas include the impact on facilities, on resources, on staff and of training on the management of mass casualty incidents. CONCLUSIONS: This review has demonstrated a paucity in research and reporting practices on the impact that mass casualty incidents have on intensive care units. The returned articles have identified four areas that were seen as influencing management of real-world mass casualty incidents. By increasing reporting and research into factors that impact mass casualty incident management in intensive care units, policy and training can be enhanced to ensure better preparedness for future incidents.

Analogues with fluorescent leaving groups for screening and selection of enzymes that efficiently hydrolyze organophosphorus nerve agents.

Enzymes that efficiently hydrolyze highly toxic organophosphorus nerve agents could potentially be used as medical countermeasures. As sufficiently active enzymes are currently unknown, we synthesized twelve fluorogenic analogues of organophosphorus nerve agents with the 3-chloro-7-oxy-4-methylcoumarin leaving group as probes for high-throughput enzyme screening. This set included analogues of the pesticides paraoxon, parathion, and dimefox, and the nerve agents DFP, tabun, sarin, cyclosarin, soman, VX, and Russian-VX. Data from inhibition of acetylcholinesterase, in vivo toxicity tests of a representative analogue (cyclosarin), and kinetic studies with phosphotriesterase (PTE) from Pseudomonas diminuta, and a mammalian serum paraoxonase (PON1), confirmed that the analogues mimic the parent nerve agents effectively. They are suitable tools for high-throughput screens for the directed evolution of efficient nerve agent organophosphatases.

Simplified kinetic analysis of tumor 18F-FDG uptake: a dynamic approach.

UNLABELLED: Standardized uptake value (SUV) is often used to quantify (18)F-FDG tumor use. Although useful, SUV suffers from known quantitative inaccuracies. Simplified kinetic analysis (SKA) methods have been proposed to overcome the shortcomings of SUV. Most SKA methods rely on a single time point (SKA-S), not on tumor uptake rate. We describe a hybrid between Patlak analysis and existing SKA-S methods, using multiple time points (SKA-M) but reduced imaging time and without measurement of an input function. We compared SKA-M with a published SKA-S method and with Patlak analysis. METHODS: Twenty-seven dynamic (18)F-FDG scans were performed on 11 cancer patients. A population-based (18)F-FDG input function was generated from an independent patient population. SKA-M was calculated using this population input function and either a short, late, dynamic acquisition over the tumor (starting 25-35 min after injection and ending approximately 55 min after injection) or dynamic imaging 10 or 25 min to approximately 55 min after injection but using only every second or third time point, to permit a 2- or 3-field-of-view study. SKA-S was also calculated. Both SKA-M and SKA-S were compared with the gold standard, Patlak analysis. RESULTS: Both SKA-M (1 field of view) and SKA-S correlated well with Patlak slope (r > 0.99, P < 0.001, and r = 0.96, P < 0.001, respectively), as did multilevel SKA-M (r > 0.99 and P < 0.001 for both). Mean values of SKA-M (25-min start time) and SKA-S were statistically different from Patlak analysis (P < 0.001 and P < 0.04, respectively). One-level SKA-M differed from the Patlak influx constant by only -1.0% +/- 1.4%, whereas SKA-S differed by 15.1% +/- 3.9%. With 1-level SKA-M, only 2 of 27 studies differed from K(i) by more than 20%, whereas with SKA-S, 10 of 27 studies differed by more than 20% from K(i). CONCLUSION: Both SKA-M and SKA-S compared well with Patlak analysis. SKA-M (1 or multiple levels) had lower variability and bias than did SKA-S, compared with Patlak analysis. SKA-M may be preferred over SUV or SKA-S when a large unmetabolized (18)F-FDG fraction is expected and 1-3 fields of view are sufficient.

Using positron emission tomography 2-deoxy-2-[18F]fluoro-D-glucose, 11CO, and 15O-water for monitoring androgen independent prostate cancer.

PURPOSE: Monitoring of androgen independent prostate cancer (AIPC) therapy involves monitoring prostate specific antigen (PSA) blood serum concentrations; however, the reliability of small changes in PSA values has been questioned. We performed a small pilot study to determine whether PET might be a useful monitor of changes during anti-angiogenic therapy in AIPC. PROCEDURES: Changes in tumor blood flow ([15O] water), blood volume ([11C]CO), 2-deoxy-2-[18F]fluoro-D-glucose (FDG) uptake and metabolic volume were measured before and during thalidomide treatment and compared with changes in PSA in six patients with AIPC. RESULTS: The percent change in PSA correlated with the FDG Delta%SUV(mean) (r=0.94, P<0.01) and Delta%metabolic tumor volume (r=0.91, P<0.01) but less well with Delta%blood volume (r=0.65, P=0.14). Percent change blood flow values showed an inverse correlation with percent changes in PSA (r=-0.83, P=0.032). CONCLUSIONS: PET measures of tumor blood flow and metabolism may have use in monitoring the physiologic changes occurring during anti-angiogenic therapy in AIPC.

Line staff use of the behavioral observation system: assessment of depression scale validity and cut scores.

The Behavioral Observation System (BOS) is an objective behavioral tool used by non-degreed line staff to assess depression, mania, psychosis, and acting out in psychiatric inpatients. The current study uses the Beck Depression Inventory (BDI)-1A to provide evidence for convergent validity for the BOS Depression Scale and to determine effective cut-scores to assist in BOS interpretation. Findings support substantial correlational agreement between the BOS Depression Scale and the BDI. A discriminant function analysis established a "hit rate" of 82% using a Depression Scale score of 7 or greater to identify those with at least moderate levels of depression. The study data lend further credibility to the use of non-degreed line staff as a source of data that can aid in treatment decisions.

Comparison of SUV and Patlak slope for monitoring of cancer therapy using serial PET scans.

The standardized uptake value (SUV) and the slope of the Patlak plot ( K) have both been proposed as indices to monitor the progress of disease during cancer therapy. Although a good correlation has been reported between SUV and K, they are not equivalent, and may not be equally affected by metabolic changes occurring during disease progression or therapy. We wished to compare changes in tumor SUV with changes in K during serial positron emission tomography (PET) scans for monitoring therapy. Thirteen patients enrolled in a protocol to treat renal cell carcinoma metastases were studied. Serial dynamic fluorodeoxyglucose (FDG) PET scans and computed tomography (CT) and magnetic resonance (MR) scans were performed once prior to treatment, once at 36+/-2 days after the start of treatment, and (in 7/13 subjects, 16/27 lesions) a third time at 92+/-9 days after the start of treatment. This resulted in a total of 33 scans, and 70 tumor Patlak and SUV values (one value for each lesion at each time point). SUV and K were measured over one to four predefined tumors/patient at each time point. The input function was obtained from regions of interest over the heart, combined, if necessary, with late blood samples. Over all tumors and scans, SUV and K correlated well ( r=0.97, P<0.0001). However, change in SUV with treatment over all tumor scan pairs was much less well correlated with the corresponding change in K ( r=0.73, P<0.0001). The absolute difference in % change was outside the 95% confidence limits expected from previous variability studies in 6 of 43 pairs of tumor scans, and greater than 50% in 2 of 43 tumor scan pairs. In four of the six cases, the two indices predicted opposing therapeutic outcomes. Similar results were obtained for SUV normalized by body weight or body surface area and for SUVs using mean or maximum count. Changes in CT and MR tumor cross-product dimensions correlated poorly with each other ( r=0.47, P=NS), and so could not be used to determine the "correct" PET index. Absolute values of SUV and K correlated well over the patient population. However, when monitoring individual patient therapy serially, large differences in the % changes in the two indices were occasionally found, sometimes sufficient to produce opposing conclusions regarding the progression of disease.