Physical, Cognitive, and Psychological Disability Following Critical Illness: What Is the Risk?

Critical illnesses affect millions of individuals annually in the United States. As advances in patient care continue to improve, the number of survivors is rapidly growing. Critical illness survivors endure profoundly severe illnesses and live through often frightening experiences throughout the course of ICU hospitalization, resulting in a variety of "survivorship" challenges, expressed through a condition known as post-intensive care syndrome (PICS). Questions abound regarding the ideal protocols for ensuring the best physical, cognitive, and psychological outcomes for these survivors. Organizational change is likely to be a key factor, though the specific components have not yet been established. Throughout this article, we highlight some of the barriers and facilitators to enhancing patient care across the spectrum of critical care environments, while also highlighting the challenges inherent to studying a complex patient population. We address each of the areas potentially affected by critical illness and ICU hospitalization--physical, cognitive, and psychological functional domains--experienced by patients as well as their family caregivers.

Surveillance Practice Patterns after Curative Intent Therapy for Stage I Non-Small-Cell Lung Cancer in the Medicare Population.

OBJECTIVES: Recurrence after treatment for non-small cell lung cancer (NSCLC) is common, and routine imaging surveillance is recommended by evidence-based guidelines. Little is known about surveillance patterns after curative intent therapy for early stage NSCLC. We sought to understand recent practice patterns for surveillance of stage I NSCLC in the first two years after curative intent therapy in the Medicare population. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database we selected patients diagnosed with stage I NSCLC between 1998 and 2008. We studied adherence to surveillance guidelines based on specialty society recommendations for chest radiography and computed tomography (CT) scanning. We also tracked the use of Positron Emission Tomography (PET) scans, which are not recommended for surveillance. We calculated the percent of patients who received guideline-adherent surveillance imaging and used logistic regression to determine associations between patient and provider factors and guideline adherence. RESULTS: Overall, 61.4% of patients received guideline-adherent surveillance during the initial 2 years after treatment. Use of CT scans in the first year after treatment increased from 47.4% in 1998-78.5% in 2008, and PET use increased from 5.8% to 28.9%. Adherence with surveillance imaging was associated with younger age, higher income, more comorbidities, access to primary care, and receipt of SBRT as the primary treatment. CONCLUSIONS: Adherence to specialty society guidelines for surveillance after treatment for stage I NSCLC was poor in this population of Medicare beneficiaries, with less than two-thirds of patients receiving recommended imaging, and almost 30% receiving non-recommended PET scans.

Rare pleural tumors.

Primary pleural tumors other than mesothelioma account for fewer than 1% of all lung cancers, and consequently they pose diagnostic and management challenges. Their treatment must be targeted toward the specific tumor type and is often quite different from the treatment for mesothelioma or metastases. Despite the best efforts at diagnosing and treating these tumors, the prognosis associated with some of the benign and many of the malignant variants of these tumors remains poor. In this review, we describe the radiologic and pathologic features of the less common primary pleural tumors and propose a diagnostic approach to their evaluation.

The business of interventional pulmonology.

Interventional pulmonologists are regularly asked to perform more complicated and advanced procedures, but reimbursement for the time, effort and skill involved in these procedures has not kept up with other procedural specialties. Further changes in funding and reimbursement are likely under the Affordable Care Act. Understanding and effectively using the current system of funding for interventional pulmonology practices are imperative as we adapt to changing medical needs, legislative mandates, and reimbursement policy. This article reviews the current landscape of insurance and reimbursement in health care and anticipates some changes that might be expected from implementation of the Affordable Care Act.

Central obesity and health-related factors among middle-aged men: a comparison among native Japanese and Japanese-Brazilians residing in Brazil and Japan.

The objective of this study was to investigate the influence of different cultural environments on the development of obesity by examining the association of central obesity, lifestyle, and selected coronary risk factors among people with identical Japanese genetic backgrounds living in Japan and Brazil. One hundred and four native Japanese and 286 Japanese-Brazilians residing in Brazil and Japan aged 35 years or over were studied. Obesity, metabolic risk factors for coronary disease, and history of regular sports activity, daily physical activity, and eating habits were assessed. The results showed Japanese-Brazilians residing in Brazil with significantly higher waist circumference values, and greater prevalence of central obesity compared to native Japanese and Japanese-Brazilians residing in Japan. The risk of developing central obesity was found to be 2.8 times higher among Japanese-Brazilians residing in Brazil. However, this association was no longer found to be significant after adjusting for lifestyle factors in the logistic model. Additionally, waist circumference was found to be significantly associated with metabolic risk factors for coronary disease. These findings suggest substantial variation in measures of central obesity among the three groups of Japanese ancestry, and underscore the heterogeneity of risk factors among communities of Japanese ancestry living in different cultural environments. The results also suggest that immigrant men exposed to the Brazilian cultural environment are more susceptible to the development of central obesity, and it seems to be associated with various lifestyle items and metabolic risk factors for coronary disease.

Lower HDL-cholesterol among healthy middle-aged Japanese-Brazilians in São Paulo compared to Natives and Japanese-Brazilians in Japan.

Blood lipid levels are determined by a combination of genetic and environmental factors. Higher than average values of high-density lipoprotein cholesterol (HDL-cholesterol) have been observed in people of Japanese ethnicity. The aim of this study was to investigate whether Japanese immigrants to Brazil and subsequent generations maintain the protective benefits associated with higher levels of HDL-cholesterol, and to examine the potential associations between HDL-cholesterol and a variety of other blood lipids, anthropometric and lifestyle factors. Healthy men and women aged 35 years and older who were Native Japanese (n = 198) or Japanese-Brazilians (JB) living in São Paulo, Brazil (n = 198) and in some Japanese cities (n = 246) were investigated. Anthropometric variables, blood lipids including HDL-cholesterol, and lifestyle factors were assessed. Serum HDL-cholesterol was observed to be lower for JB in São Paulo (both women and men) compared with Natives and JB in Japan. Among the groups, triglycerides, waist circumference, LDL-cholesterol, meat intake, stress, and smoking were observed to be independently negatively associated with HDL-cholesterol, whereas total cholesterol, fish intake, and physical activity were positively associated. Lower levels of HDL-cholesterol among both men and women of JB in São Paulo compared with both other groups were confirmed even after lifestyle adjustments. Our findings highlight the significantly lower levels of HDL-cholesterol among Japanese-Brazilians living in São Paulo city compared to Japanese-Brazilians and Native Japanese residing in Japan. Although several lifestyle factors were found to be significantly associated with HDL-cholesterol, they cannot adequately explain the role of the Brazilian cultural environment on HDL-cholesterol levels.

A comparison of the prevalence of the metabolic syndrome and its components among native Japanese and Japanese Brazilians residing in Japan and Brazil.

BACKGROUND: This study investigated the prevalence of risk factors associated with the metabolic syndrome (MetSyn) among individuals of Japanese descent exposed to different cultural environments. DESIGN: A cross-sectional study to assess component risk factors for the diagnosis of MetSyn was undertaken in urban areas in Japan and Brazil. A total of 773 men and women aged 35 years or over were included in three groups: 249 native Japanese, 269 Brazilian individuals of Japanese ancestry residing in Japan, and 255 Brazilian individuals of Japanese ancestry residing in Brazil. RESULTS: Higher rates of metabolic abnormalities with respect to central obesity and serum lipid profiles were observed among Brazilian individuals of Japanese ancestry residing in Brazil compared with those residing in Japan and native Japanese. Likewise, an increased risk of hypertension was observed among Japanese Brazilian individuals residing in Japan. The prevalence of MetSyn in men was significantly higher among Brazilians of Japanese ancestry residing in Brazil (37.5%) compared with those residing in Japan (25.3%) or native Japanese (21.4%), whereas no significant difference was observed among women. In the logistic model, Brazilian individuals of Japanese ancestry residing in Brazil were twice as likely to develop MetSyn compared with native Japanese, whereas no significant differences were found among those residing in Japan. CONCLUSIONS: These findings underscore the significant heterogeneity in risk factors among communities of Japanese ancestry residing in Brazil and Japan, and suggest that immigrants exposed to the Brazilian cultural environment are more susceptible to the development of risk factors associated with MetSyn than native Japanese.

Effects of protein supplementation on fat-free mass in response to different weight loss programs in obese women

The aim of this study was to investigate whether protein supplementation helps prevent the loss of fat-free mass during weight loss. The sample was composed of seventy-eight obese adult Japanese women, assigned into four different programs: diet-alone (D, n=24), diet-alone with protein supplementation (DP, n=16), diet-plusexercise (DE, n=17), and diet-plus-exercise with protein supplementation (DEP, n=21). All participants restricted their energy intakes to 1200 kcal/day, and participants in DE and DEP had the exercise session including aerobicexercise of approximately 90 min/day, 3 day/week. Participants enrolled in protein supplementation groups receivedan additional 14 g/day of protein. Measures on body composition were conducted before and after the program by DXA. All programs yielded significant weight (6.9 to 9.5 kg) and fat (4.1 to 7.6%) reduction. Total fat-free masssignificantly decreased in D, DP and DE groups, whereas for DEP group the decrease was not significant. Regionalfat-free mass lowered for D and DP groups in leg, arms and trunk. For those in DE group, fat-free mass in trunkwas not significantly decreased, and for those in DEP group, fat-free mass in leg and trunk did not differ significantlyafter the program. However, no significant differences of changes in fat-free mass were observed in comparisonsamong all groups. Our results confirmed the efficiency of weight loss intervention on fat-mass reduction through diet and exercise. However, fat-free mass does not appear to be preserved by protein supplementation, suggesting that its influence on a short-term weight reduction program is not apparent.

O objetivo deste estudo foi investigar a influência da suplementação protéica na preservação da massa magra durante programas de emagrecimento. Setenta e oito mulheres adultas japonesas e obesas foram submetidas a quatro programas diferentes: dieta (D, n=24), dieta com suplementação proteica (DP, n=16), dieta com exercício físico (DE, n=17) e dieta com exercício físico e suplementação protéica (DEP, n=21). A dieta restringiu-se a 1200 kcal/dia e o programa de exercício físico compreendeu atividade aeróbica durante 90 minutos/dia, 3 dias/semana. Os participantes em suplementação proteica receberam 14 gramas/dia de proteína. A avaliação da composição corporal foi conduzida antes e depois de 14 semanas utilizando DXA. Todos os programas resultaram significante redução de massa corporal (6,9 a 9,5kg) e gordura (4,1 a 7,6%), sendo que a massa magra total diminuiu significativamente nos grupos D, DP e DE. No entanto, a redução não foi significativa para o grupo DEP. A massa magra localizada nas pernas, braços e tronco sofreu redução significativa nos grupos D e DP. Para o grupo DE, a massa magra do tronco não reduziu significativamente, assim como para o grupo DEP, a massa magra das pernas e do tronco não alterou significativamente. Entretanto, não foram observadas diferenças significantes na comparação entre os grupos com relação às mudanças obtidas na massa magra. Os resultados confirmam a eficiência da dieta e exercício físico na redução de gordura corporal. Entretanto, este estudo sugere que a suplementação proteica durante programas de emagrecimento de curta duração não se associa à preservação de massa magra.