BackgroundFollowing critical illness, family members are often required to adopt caregiving responsibilities. Anxiety and depression are common long term problems for both patients and caregivers. However, at present, it is not known how the trajectories of these symptoms compare between patients and caregivers.ObjectivesThe aim of this study was to investigate and compare the trajectories of anxiety and depression in patients and caregivers in the first year following critical illness.MethodsThis study analyses data from a prospective multicentre cohort study of patients and caregivers who underwent a complex recovery intervention following critical illness. Paired patients and caregivers were recruited. The Hospital Anxiety and Depression Scale was used to evaluate symptoms of anxiety and depression at three timepoints: baseline; 3 months; and 12 months in both patient and caregivers. A linear mixed-effects regression model was used to evaluate the trajectories of these symptoms over the first year following critical illness.Results115 paired patients and caregivers, who received the complex recovery intervention, were recruited. There was no significant difference in the relative trajectory of depressive symptoms between patients and caregivers in the first 12 months following critical illness (p = 0.08). There was, however, a significant difference in the trajectory of anxiety symptoms between patients and caregivers during this time period (p = 0.04), with caregivers seeing reduced resolution of symptoms in comparison to patients.ConclusionsFollowing critical illness, symptoms of anxiety and depression are common in both patients and caregivers. The trajectory of symptoms of depression was similar between caregivers and patients; however, there was a significantly different recovery trajectory in symptoms of anxiety. Further research is required to understand the recovery pathway of caregivers in order to design effective interventions.

Background: There is limited evidence to understand what impact, if any, recovery services might have for patients across the socioeconomic spectrum after critical illness. We analysed data from a multicentre critical care recovery programme to understand the impact of this programme across the socioeconomic spectrum. Methods: The setting for this pre-planned secondary analysis was a critical care rehabilitation programme—Intensive Care Syndrome: Promoting Independence and Return to Employment. Data were collected from five hospital sites running this programme. We utilised a Bayesian approach to analysis and explore any possible effect of the InS:PIRE intervention on Health-Related Quality of Life (HRQoL) across the socioeconomic gradient. A Bayesian quantile, non-linear mixed effects regression model, using a compound symmetry covariance structure, accounting for multiple timepoints was utilised. The Scottish Index of Multiple Deprivation (SIMD) was used to measure socioeconomic status and HRQoL was measured using the EQ-5D-5L. Results: In the initial baseline cohort of 182 patients, 55% of patients were male, the median age was 58 yr (inter-quartile range: 50–66 yr) and 129 (79%) patients had two or more comorbidities at ICU admission. Using the neutral prior, there was an overall probability of intervention benefit of 100% (β=0.71, 95% credible interval: 0.34–1.09) over 12 months to those in the SIMD≤3 cohort, and an 98.6% (β=−1.38, 95% credible interval: −2.62 to −0.16) probability of greater benefit (i.e. a steeper increase in improvement) at 12 months in the SIMD≤3 vs SIMD≥4 cohort in the EQ-visual analogue scale. Conclusions: Using multicentre data, this re-analysis suggests, but does not prove, that an integrated health and social care intervention is likely to improve outcomes across the socioeconomic gradient after critical illness, with a potentially greater benefit for those from deprived communities. Future research designed to prospectively analyse how critical care recovery programmes could potentially improve outcomes across the socioeconomic gradient is warranted.

PURPOSE:Survivors of critical illness frequently experience long-term symptoms including physical symptoms such as pain and emotional symptoms such as anxiety and depression. These symptoms frequently co-exist, however, at present there is limited understanding of these relationships. The aim of this study was to quantify the relationship between pain, anxiety and depression across the recovery trajectory. METHODS:This study is a secondary analysis of data from a multi-centre, prospective, cohort study which followed-up patients recovering from critical illness. Data was available at multiple time points and for 3 distinct cohorts. Structural equation modelling was used to investigate the relationship between outcome measures of pain, anxiety and depression. RESULTS:Data from 414 patients was analysed. Pain was significantly associated with both anxiety and depression in all cohorts and at all time points sampled. Path coefficients for the covariances between pain and depression ranged between 0.39 and 0.72 (p < 0.01). Path coefficients for the covariances between pain and anxiety ranged between 0.39 and 0.65 (p < 0.01). CONCLUSIONS:Pain, anxiety and depression are highly correlated in survivors of critical illness. Pharmacological treatments for pain management may be ineffective alone and further research is required to assess interventions targeting these symptoms in combination.

Introduction Pain is a common and debilitating symptom in survivors of critical illness. The ‘Core Outcome Set for Survivors of Acute Respiratory Failure’ proposes that the pain and discomfort question of the EuroQol 5 Dimension 5 Level (EQ-5D-5L) could be used to assess pain in this group, however, it was recognised that further research is required to evaluate how this single question compares to other more detailed pain tools. This study aims to evaluate the relationship between the pain and discomfort question of the EQ-5D-5L and the Brief Pain Inventory (BPI) in survivors of critical illness.Methods This study retrospectively analysed paired EQ-5D-5L and BPI data extracted from a prospective, multicentre study evaluating the impact of a critical care recovery programme. 172 patients who received a complex recovery intervention and 108 patients who did not receive this intervention were included. Data were available for the intervention cohort at multiple time points, namely, baseline, 3 months and 12 months. While, data were available for the usual care cohort at a single time point (12 months). We assessed the correlation between the pain and discomfort question of the EQ-5D-5L and two separate components of the BPI: severity of pain and pain interference.Results Correlation coefficients comparing the pain and discomfort question of the EQ-5D-5L and the BPI pain severity score ranged between 0.73 (95% CI 0.63 to 0.80) and 0.80 (95% CI 0.72 to 0.86). Correlation coefficients comparing the pain and discomfort question of the EQ-5D-5L and the BPI pain interference score ranged between 0.71 (95% CI 0.62 to 0.79) and 0.83 (95% CI 0.76 to 0.88) across the various time points.Conclusions The pain and discomfort question of the EQ-5D-5L correlates moderately well with a more detailed pain tool and may help to streamline assessments in survivorship studies. More in-depth tools may be of use where pain is the primary study outcome or a patient-reported concern.

Background: Caregivers and family members of Intensive Care Unit (ICU) survivors can face emotional problems following patient discharge from hospital. We aimed to evaluate the impact of a multi-centre integrated health and social care intervention, on caregiver and family member outcomes. Methods: This study evaluated the impact of the Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) programme across 9 sites in Scotland. InS:PIRE is an integrated health and social care intervention. We compared caregivers who attended this programme with a contemporary control group of ICU caregivers (usual care cohort), who did not attend. Results: The primary outcome was anxiety measured via the Hospital Anxiety and Depression Scale at 12 months post hospital discharge. Secondary outcome measures included, depression, carer strain and clinical insomnia. A total of 170 caregivers had data available at 12 months for inclusion in this study. 81 caregivers attended the InS:PIRE intervention and completed outcome measures at 12 months post-hospital discharge. In the usual care cohort of caregivers, 89 completed measures. The two cohorts had similar baseline demographics. After adjustment, those caregivers who attended InS:PIRE demonstrated a significant improvement in symptoms of anxiety (OR: 0.42, 95% CI: 0.20-0.89, p =0.02), carer strain (OR: 0.39; 95% CI:0.16-0.98 p =0.04) and clinical insomnia (OR: 0.40; 95% CI:0.17-0.77 p <0.001). There was no significant difference in symptoms of depression at 12 months. Conclusions: This multicentre evaluation has shown that caregivers who attended an integrated health and social care intervention, reported improved emotional health and less symptoms of insomnia, 12 months after the delivery of the intervention.

RATIONALE:At present, clinicians aiming to support patients through the challenges after critical care have limited evidence to base interventions. OBJECTIVES:Evaluate a multicentre integrated health and social care intervention for critical care survivors. A process evaluation assessed factors influencing the programme implementation. METHODS:This study evaluated the impact of the Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) programme. We compared patients who attended this programme with a usual care cohort from the same time period across nine hospital sites in Scotland. The primary outcome was health-related quality of life (HRQoL) measured via the EuroQol 5-dimension 5-level instrument, at 12 months post hospital discharge. Secondary outcome measures included self-efficacy, depression, anxiety and pain. RESULTS:137 patients who received the InS:PIRE intervention completed outcome measures at 12 months. In the usual care cohort, 115 patients completed the measures. The two cohorts had similar baseline demographics. After adjustment, there was a significant absolute increase in HRQoL in the intervention cohort in relation to the usual care cohort (0.12, 95% CI 0.04 to 0.20, p=0.01). Patients in the InS:PIRE cohort also reported self-efficacy scores that were 7.7% higher (2.32 points higher, 95% CI 0.32 to 4.31, p=0.02), fewer symptoms of depression (OR 0.38, 95% CI 0.19 to 0.76, p=0.01) and similar symptoms of anxiety (OR 0.58, 95% CI 0.30 to 1.13, p=0.11). There was no significant difference in overall pain experience. Key facilitators for implementation were: integration with inpatient care, organisational engagement, flexibility to service inclusion; key barriers were: funding, staff availability and venue availability. CONCLUSIONS:This multicentre evaluation of a health and social care programme designed for survivors of critical illness appears to show benefit at 12 months following hospital discharge.

and severity of pulmonary hypertension in asymptomatic rural residents with schistosomal infection in the Nile Delta. Trop Med Int Health 2012; 17:112–118. 7 Chen MG. Assessment of morbidity due to Schistosoma japonicum infection in China. Infect Dis Poverty 2014;3:6. 8 Li FY, Hou XY, Tan HZ, Williams GM, Gray DJ, Gordon CA, et al. Current status of schistosomiasis control and prospects for elimination in the Dongting Lake Region of the People’s Republic of China. Front Immunol 2020;11:574136. 9 LoganOT. A case of dysentery in HunanProvince caused by the trematode Schistosoma japonicum 1905. Chin Med J 1905;19:243–245. 10 ZhouXN,Guo JG,WuXH, JiangQW, Zheng J, DangH, et al.Epidemiology of schistosomiasis in the People’s Republic of China, 2004. Emerg Infect Dis 2007;13:1470–1476. 11 Raso G, Li Y, Zhao Z, Balen J, Williams GM, McManus DP. Spatial distribution of human Schistosoma japonicum infections in the Dongting Lake Region, China. PLoS One 2009;4:e6947. 12 VezozzoDC, Farias AQ, Cerri GG, DaSilva LC,Carrilho FJ. Assessment of portal hemodynamics by Doppler ultrasound and of liver morphology in the hepatosplenic and hepatointestinal forms of schistosomiasis mansoni. Dig Dis Sci 2006;51:1413–1419. 13 de Cleva R, Herman P, Pugliese V, Zilberstein B, Saad WA, Rodrigues JJ, et al. Prevalence of pulmonary hypertension in patients with hepatosplenic Mansonic schistosomiasis–prospective study. Hepatogastroenterology 2003;50:2028–2030. 14 Ferreira RC, Domingues AL, Bandeira AP, Markman Filho B, Albuqerque Filho ES, Correiade de Ara ujo AC, et al. Prevalence of pulmonary hypertension in patients with schistosomal liver fibrosis. Ann Trop Med Parasitol 2009;103:129–143. 15 Botoni FA, Marinho CC, Carvalho VT, Mickael CS, Graham BB. A retrospective study of schistosomiasis-associated pulmonary hypertension from an endemic area in Brazil. Int J Cardiol Heart Vasc 2019;24:100387. 16 Mohamed-AliQ,Elwali NE, AbdelhameedAA,Mergani A, RahoudS, Elagib KE, et al. Susceptibility to periportal (Symmers) fibrosis in human Schistosoma mansoni infections: evidence that intensity and duration of infection, gender, and inherited factors are critical in disease progression. J Infect Dis 1999;180:1298–1306. 17 SimonneauG,Gali e N,Rubin LJ, LanglebenD,SeegerW,Domenighetti G, et al. Clinical classification of pulmonary hypertension. J Am Coll Cardiol 2004;43(12, Suppl S)5S–12S. 18 Knafl D, Gerges C, King CH, Humbert M, Bustinduy AL. Schistosomiasisassociated pulmonary arterial hypertension: a systematic review. Eur Respir Rev 2020;29:190089. 19 Mauad T, Pozzan G, Lanças T, Overbeek MJ, Souza R, Jardim C, et al. Immunopathological aspects of schistosomiasis-associated pulmonary arterial hypertension. J Infect 2014;68:90–98. 20 Mickael CS, Graham BB. The role of type 2 inflammation in Schistosomainduced pulmonary hypertension. Front Immunol 2019;10:27. 21 Sibomana JP, Campeche A, Carvalho-Filho RJ, Correa RA, Duani H, Pacheco Guimaraes V, et al. Schistosomiasis pulmonary arterial hypertension. Front Immunol 2020;11:608883. 22 Knafl D, Gerges C, King CH, Humbert M, Bustinduy AL. Schistosomiasisassociated pulmonary arterial hypertension: a systematic review. Eur Respir Rev 2020;29:190089. 23 Mendes AA, Roncal CGP, Oliveira FRA, Albuquerque ES, G oes GHB, Piscoya ICV, et al. Demographic and clinical characteristics of pulmonary arterial hypertension caused by schistosomiasis are indistinguishable from other etiologies.Rev SocBrasMed Trop 2020;53: e20190418. 24 Barbosa MM, Lamounier JA, Oliveira EC, Souza MV, Marques DS, Silva AA, et al. Pulmonary hypertension in schistosomiasis mansoni. Trans R Soc Trop Med Hyg 1996;90:663–665. 25 Strange G, Stewart S, Celermajer DS, Prior D, Scalia GM, Marwick TH, et al.; NEDA Contributing Sites. Threshold of pulmonary hypertension associated with increased mortality. J Am Coll Cardiol 2019;73:2660– 2672.

Objectives: To describe the long-term outcomes of cardiac intensive care unit patients and their primary caregivers, and to explore the feasibility of implementing a complex intervention, designed to support problems associated with post-intensive care syndrome and post-intensive care syndrome- family, in the year following discharge from the cardiac intensive care unit. Design: A complex multidisciplinary rehabilitation programme, delivered as a quality improvement initiative, in a single centre in the West of Scotland. Outcomes were measured using surveys of health related quality of life, self efficacy, anxiety, depression, pain, caregiver strain, and insomnia. Participants: Patients and their caregivers were invited to participate 12 weeks after hospital discharge. Twenty-seven patients and 23 caregivers attended the programme. Results: Over 90% of patients had problems in at least one quality of life domain at baseline, 41% of patients had symptoms of anxiety and 22% had symptoms of depression. During the baseline visit, caregiver strain was present in 20% of caregivers, 57% had symptoms of anxiety, and 35% had symptoms of depression. Improvements in outcomes were seen in both patients and caregivers at 1-year follow-up. The programme was implement ed, and iterative learning obtained about the content and the operationalization of the service, in order to understand feasibility. Conclusion: This small-scale quality improvement project has demonstrated that this complex multidisciplinary rehabilitation programme is feasible and has positive implications for patients following discharge from the cardiac intensive care unit, and their caregivers.

BACKGROUND:There are limited data describing the long-term outcomes of severe COVID-19. We aimed to evaluate the long-term psychosocial and physical consequences of severe COVID-19 for patients.METHODS:We conducted a multicentre observational cohort study; between 3 and 7 months posthospital discharge, patients who had been admitted to critical care due to severe COVID-19 were invited to an established recovery service. Standardised questionnaires concerning emotional, physical and social recovery, including information on employment, were completed by patients. Using propensity score matching, we explored outcomes between patients admitted to critical care with and without COVID-19, using data from the same recovery programme.RESULTS:Between July 2020 and December 2020, 93 patients who had been admitted to critical with COVID-19 participated. Emotional dysfunction was common: 46.2% of patients had symptoms of anxiety and 34.4% symptoms of depression. At follow-up 53.7% of previously employed patients had returned to employment; there was a significant difference in return to employment across the socio-economic gradient, with lower numbers of patients from the most deprived areas returning to employment (p=0.03). 91 (97.8%) COVID-19 patients were matched with 91 non-COVID-19 patients. There were no significant differences in any measured outcomes between the two cohorts.INTERPRETATION:Emotional and social problems are common in survivors of severe COVID-19 infection. Coordinated rehabilitation is required to ensure patients make an optimal recovery.

Few data measure the problems critically ill patients have with medications after hospital discharge, whichmedications are involved, and how severe the consequences are (1–3). We sought to assess the prevalence and severity of medication-related problems in intensive care unit (ICU) survivors and explore pain management strategies. We did so among patients attending a five-site post-ICU program in Scotland between September 2016 and June 2018.

BACKGROUND:Intensive care unit survivors experience significant physical and psychological problems, including chronic pain following discharge. The aim of this study was to observe the incidence, anatomical sites, intensity, and interference of chronic pain in intensive care unit survivors over a 1-year period. In addition, potential predictors of chronic pain were analysed. METHODS:Data were collected during an intensive care unit follow-up programme as part of a quality improvement initiative. Data from the Brief Pain Inventory and from musculoskeletal assessment were examined, alongside demographic data from the patient. Data were collected from patients at baseline and at a 1-year follow-up appointment. RESULTS:Data from 47 intensive care unit survivors were included in this study. In 66% (n = 31) of the patients a "new" chronic pain that did not exist before their stay in the intensive care, was reported. Pain intensity in this patient group was "moderate"' and did not improve significantly over the 1-year period. Although pain interference with life decreased over the study period, it was still the most common cause of reduced enjoyment of life and reduced employment at 1-year follow-up. CONCLUSION:Chronic pain is associated with morbidity in intensive care unit survivors. Pain interference, but not pain intensity, improved significantly in the first year after discharge. Further multi-centre research is required to elucidate the chronic pain experience.

BACKGROUND The number of patients surviving critical care is increasing. Quality of life after critical care is known to be poor for some patients. The evidence base for effective rehabilitation interventions in the period following a stay in an intensive care unit is limited. OBJECTIVES To understand what rehabilitation goals are important to patients after critical care discharge. METHODS This prospective study, which was undertaken during an intensive care unit recovery program, explored the recovery goals of 43 patients. Framework analysis was used to extract prevalent themes and identify the important components of recovery from the patients' perspective. RESULTS Participants described diverse goals for their post-intensive care unit recovery. Most goals were about health-related quality of life, including physical goals and rehabilitation. Although health was central to many of the participants' individual recovery aims, themes of family and social engagement and adopting appropriate goal trajectories also emerged within patient goals. Individual strategies for reaching these goals varied, and patients had different aspirations about what they could achieve. CONCLUSIONS Patients' aspirations for their intensive care unit recovery are diverse. Design of postdischarge care can be informed by this greater understanding of the heterogeneous starting points and goal trajectories of survivors of critical illness.

OBJECTIVE:While disruptions in medications are common among patients who survive critical illness, there is limited information about specific medication-related problems among survivors of critical care. This study sought to determine the prevalence of specific medication-related problems detected in patients, seen after critical care discharge.DESIGN:Consecutive patients attending an intensive care unit (ICU) follow-up programme were included in this single-centre service evaluation.SETTING:Tertiary care regional centre in Scotland (UK).PARTICIPANTS:47 patients reviewed after critical care discharge at an ICU follow-up programme.INTERVENTIONS:Pharmacists conducted a full medication review, including: medicines reconciliation, assessing the appropriateness of each prescribed medication, identification of any medication-related problems and checking adherence.MEASUREMENTS:Medication-related problems in patients following critical care discharge. Interventions and medication-related problems were systematically graded and risk factors were identified using an adapted version of the National Patient Safety Agency Risk Matrix.MAIN RESULTS:69 medication-related problems were identified in 38 (81%) of the 47 patients. The most common documented problem was drug omission (29%). 64% of the medication-related problems identified were classified as either moderate or major. The number of pain medications prescribed at discharge from intensive care was predictive of medication-related problems (OR 2.02, 95% CI 1.14 to 4.26, p=0.03).CONCLUSIONS:Medication problems are common following critical care. Better communication of medication changes both to patients and their ongoing care providers may be beneficial following a critical care admission. In the absence of highly effective communication, a pharmacy intervention may contribute substantially to an intensive care rehabilitation or recovery programme.

We report the case of a self-employed builder aged 58-years, with a medical history of ischaemic heart disease and type II diabetes. He was transferred to our intensive care unit (ICU) from another local hospital for treatment of gallstone pancreatitis. He stayed in critical care for 19 days, with a total hospital stay of 9 weeks. He and his wife have consented to the presentation of their case. This patient required level three care (ICU care) for 3 days. He required level two care (high dependency care) for a further 16 days due to complications related to his acute kidney injury and pancreatitis. He was mechanically ventilated for 3 days with a worst P/F ratio of 150 mmHg and underwent renal replacement therapy for 8 days. As per standard practice in the ICU at the time, he was visited by physical therapy on 17 of his 19 ICU days. This patient has two children and a wife who works as a Nursery Teacher. After discharge from hospital, he returned to his own home. At discharge from hospital, aerobic capacity was assessed using the incremental shuttle walk test. The patient scored a metabolic equivalent of 2.4 on this test (this represents an ability to undertake a low intensity exercise programme).1 Grip strength measurements were obtained and were 16 kg (right hand) and 12 kg (left hand), less than half of expected when compared with the population norm.2 At home, further nutritional support from a nasogastric tube (NGT) was required. The patient also had significant fatigue, limb weakness, lethargy, decreased balance and shortness of breath. At 2 months post-discharge from hospital, neither he nor his wife had returned to work. In light of these problems, at 2 months post-ICU discharge, both the patient and his wife were invited to participate in Intensive Care Syndrome: Promoting Independence and Return to Employment …

Background Many patients suffer significant physical, social and psychological problems in the months and years following critical care discharge. At present, there is minimal evidence of any effective interventions to support this patient group following hospital discharge. The aim of this project was to understand the impact of a complex intervention for ICU survivors. Methods Quality improvement project conducted between September 2014 and June 2016, enrolling 49 selected patients from one ICU in Scotland. To evaluate the impact of this programme outcomes were compared to an existing cohort of patients from the same ICU from 2008-2009. Patients attended a five week peer supported rehabilitation programme. This multidisciplinary programme included pharmacy, physiotherapy, nursing, medical, and psychology input. The primary outcome in this evaluation was the EQ-5D, a validated measure of health-related quality of life. The minimally clinically important difference (MCID) in the EQ-5D is 0.08. We also measured change in self-efficacy over the programme duration. Based on previous research, this study utilised a 2.4 (6%) point change in self-efficacy scores as a MCID. Results 40 patients (82%) completed follow-up surveys at 12 months. After regression adjustment for those factors known to impact recovery from critical care, there was a 0.07-0.16 point improvement in quality of life for those patients who took part in the intervention compared to historical controls from the same institution, depending on specific regression strategy used. Self-efficacy scores increased by 2.5 points (6.25%) over the duration of the five week programme (p = 0.003), and was sustained at one year post intervention. In the year following ICU, 15 InS:PIRE patients returned to employment or volunteering roles (88%) compared with 11 (46%) in the historical control group (p = 0.15). Conclusions and relevance This historical control study suggests that a complex intervention may improve quality of life and self-efficacy in survivors of ICU. A larger, multi-centre study is needed to investigate this intervention further.