The impact on new-onset stress and PTSD in relatives of critically ill patients explored by diaries study (The "INSPIRED" study)

BACKGROUND

There is rising prevalence of post-traumatic-stress-disorder (PTSD) in patients and their relatives after ICU discharge. The impact of ICU diaries on PTSD in relatives of critically ill patients in Australia has not been fully evaluated.

OBJECTIVES

To determine if relatives of an Australian critically ill population were interested in using ICU diaries. To determine the prevalence and impact of ICU diaries upon symptoms of PTSD, depression and anxiety in relatives of an Australian critically ill population.

METHODS DESIGN

Prospective, observational, exploratory study.

SETTING

Royal Adelaide Hospital (RAH), Adelaide, Australia.

PARTICIPANTS

One hundred and eight consecutive patients, staying >48h in a level 3 ICU were identified. A survey using DASS-21, IES-R questionnaires was performed on admission followed by a repeat survey 90days post discharge from ICU. An IES-R score >33 was used to define severe PTSD symptoms. A comparison between subjects who did and did not complete their diaries was performed.

RESULTS

Forty subjects refused to participate, eight were excluded, and sixty family members were included for analysis, thirty-six of whom completed diaries. There was no statistically significant difference between PTSD symptom scores at follow-up controlling for useful diary completion (complete - see methods) and PTSD at baseline. There was a statistically significant association between PTSD and unemployment, controlling for PTSD at baseline (P value=0.0045). Family members had significantly higher odds of PTSD at baseline compared to 3 month follow up (P value=0.0092, Odds Ratio=3.3, 95% CI: 1.3, 8.2). This was independent of the completeness of the diaries and adjusted for clustering on subject. Family members with incomplete diaries were less likely to report depressive symptoms at baseline (P value=0.0218, estimate=-4.6, 95% CI: -8.5, -0.7). Diary completion was not indicative of the likelihood of family members to report PTSD symptoms (P value=0.5468, estimate=-1.6, 95% CI: -6.8, 3.6).

CONCLUSION

ICU diaries were often not completed and completion did not appear to be related to the incidence of stress, anxiety, depression and PTSD symptoms in the families of patients in the ICU. This may be because Australian families are generally not interested in maintaining a diary.

Predictors and outcomes of acute pancreatitis in critically ill patients presenting to the emergency department of a tertiary referral centre in Australia

OBJECTIVE

To provide a current review of the clinical characteristics, predictors and outcomes in critically ill patients presenting to the ED with acute pancreatitis and subsequently admitted to an intensive care unit (ICU) of a tertiary referral centre in Australia.

METHODS

A retrospective single-centre study of adult patients admitted with pancreatitis. Severe acute pancreatitis defined by Bedside Index of Severity in Acute Pancreatitis (BISAP) score ≥2.

RESULTS

Eighty-seven patients fulfilled criteria for inclusion during the study period, representing 0.9% of all ICU admissions. The median age of patients was 54. Survival was independent of patients' age, sex, aetiology and comorbidities. Mortality was 30.8% for both inpatient referrals to the ICU and for direct referrals via the ED. Higher mortality was identified among patients requiring mechanical ventilation (74.2 vs 24.6% in survivors; P < 0.0001), vasopressor support (85.7 vs 33.8% in survivors; P < 0.0001) or renal replacement therapy (60 vs 16.9% in survivors; P < 0.002). BISAP score surpasses Ranson's and Acute Physiological and Chronic Health Examination (APACHE) II scores in discriminating between survivors and non-survivors among unselected patients with acute pancreatitis admitted to ICU, whereas APACHE II discriminates better in the cohort admitted from ED.

CONCLUSION

Severe acute pancreatitis is associated with high mortality. Aetiology and comorbidity did not predict adverse outcomes in this population. BISAP score is non-inferior to APACHE II score as a prognostic tool in critically ill patients with acute pancreatitis and could be used to triage admission. Evidence of persistent organ dysfunction and requirements for organ support reliably identify patients at high-risk of death.

Phylogenetic analysis to define feline immunodeficiency virus subtypes in 31 domestic cats in South Africa

Feline immunodeficiency virus (FIV), a lentivirus, is an important pathogen of domestic cats around the world and has many similarities to human immunodeficiency virus (HIV). A characteristic of these lentiviruses is their extensive genetic diversity, which has been an obstacle in the development of successful vaccines. Of the FIV genes, the envelope gene is the most variable and sequence differences in a portion of this gene have been used to define 5 FIV subtypes (A, B, C, D and E). In this study, the proviral DNA sequence of the V3-V5 region of the envelope gene was determined in blood samples from 31 FIV positive cats from 4 different regions of South Africa. Phylogenetic analysis demonstrated the presence of both subtypes A and C, with subtype A predominating. These findings contribute to the understanding of the genetic diversity of FIV.

Immune-mediated haemolytic anaemia: possible association with Ancylostoma caninum infection in three dogs

Immune-mediated haemolytic anaemia (IMHA) may be primary or secondary. In primary IMHA, no underlying cause can be found, whereas secondary IMHA is triggered by an underlying cause, such as neoplasia, infectious diseases, or drugs. This paper describes 3 dogs with typical signs of IMHA that was possibly associated with the intestinal parasite Ancylostoma caninum. As intestinal helminths can be difficult to diagnose on faecal examination, it would be pertinent to perform multiple faecal examinations on any animal that has IMHA with no apparent underlying cause, as part of the therapy.

Feline babesiosis: signalment, clinical pathology and concurrent infections

Fifty-six cats with naturally occurring Babesia felis infection were studied. No breed or sex predilection could be identified, but there was an apparent predilection for young adult cats less than 3 years of age. Macrocytic, hypochromic, regenerative anaemia was present in 57% of the cats and in-saline agglutination tests were positive in 16%. No characteristic changes were observed in total or differential leukocyte counts. Thrombocyte counts were variable and thrombocytopaenia was an inconsistent finding. Hepatic cytosol enzyme activity and total bilirubin concentrations were elevated in the majority of cats. Serum protein values were mostly normal, but increased values were occasionally observed and polyclonal gammopathies were observed in all cats with increased total globulin concentrations. No remarkable changes in renal parameters were observed. A variety of electrolyte abnormalities occurred in a number of cats, but no consistent pattern of change could be identified. A close correlation was evident between peripheral and central parasite counts. Concurrent infections with Haemobartonella felis, feline immunodeficiency virus and/or feline leukemia virus were identified in a number of cats.

A survey of feline babesiosis in South Africa

South Africa appears to be the only country where feline babesiosis is a significant clinical entity in domestic cats. Little is known about its epidemiology or the clinical challenges facing practitioners. A questionnaire posted to 1760 South African veterinarians was returned by 16%, representing approximately 40% of practices. Just over half reported seeing feline babesiosis, with most cases occurring in the coastal areas of the Western Cape, Eastern Cape and KwaZulu-Natal Provinces. Overall incidence is highest in summer, but seasonality is less pronounced in non-seasonal and winter rainfall areas. No age, breed or sex predisposition was identified. Weight loss, weakness, anaemia, fever and icterus are common clinical findings. Complications include hepatopathy, renal failure, pulmonary oedema, cerebral signs, immune-mediated haemolytic anaemia and concurrent infections. The antibabesial drug of choice is primaquine phosphate. Response to therapy is generally good, but recurrence and chronic infections were identified as problems. The average mortality rate was 15%. Approximately 3000 cases are seen annually by the respondents, at an estimated cost of R750 000 to the owners. Feline babesiosis is a significant problem in South Africa, and further investigations of taxonomic status, concurrent infections, chemotherapy, complications and management of refractory cases are warranted.