BackgroundAccurate measurement of quality of life in older ICU survivors is difficult but critical for understanding the long-term impact of our treatments. Activities of daily living (ADLs) are important components of functional status and more easily measured than quality of life (QOL). We sought to determine the cross-sectional associations between disability in ADLs and QOL as measured by version one of the Short Form 12-item Health Survey (SF-12) at both one month and one year post-ICU discharge.MethodsData was prospectively collected on 309 patients over age 60 admitted to the Yale-New Haven Hospital Medical ICU between 2002 and 2004. Among survivors an assessment of ADL's and QOL was performed at one month and one-year post-ICU discharge. The SF-12 was scored using the version one norm based scoring with 1990 population norms. Multivariable regression was used to adjust the association between ADLs and QOL for important covariates.ResultsOur analysis of SF-12 data from 110 patients at one month post-ICU discharge showed that depression and ADL disability were associated with decreased QOL. Our model accounted for 17% of variability in SF12 physical scores (PCS) and 20% of variability in SF12 mental scores (MCS). The mean PCS of 37 was significantly lower than the population mean whereas the mean MCS score of 51 was similar to the population mean. At one year mean PCS scores improved and ADL disability was no longer significantly associated with QOL. Mortality was 17% (53 patients) at ICU discharge, 26% (79 patients) at hospital discharge, 33% (105 patients) at one month post ICU admission, and was 45% (138 patients) at one year post ICU discharge.ConclusionsIn our population of older ICU survivors, disability in ADLs was associated with reduced QOL as measured by the SF-12 at one month but not at one year. Although better markers of QOL in ICU survivors are needed, ADLs are a readily observable outcome. In the meantime, clinicians must try to offer realistic estimates of prognosis based on available data and resources are needed to assist ICU survivors with impaired ADLs who wish to maintain their independence. More aggressive diagnosis and treatment of depression in this population should also be explored as an intervention to improve quality of life.

Malnutrition is underrecognized by physicians. However, further research is needed to determine if physician recognition and treatment of malnutrition can improve outcomes. The most important criteria for identifying malnourished patients in our cohort were weight loss and reduced energy intake.

Objectives: The aims of this study were, first, to compare the predicted (calculated) energy requirements based on standard equations with target energy requirement based on indirect calorimetry (IC) in critically ill, obese mechanically ventilated patients; and second, to compare actual energy intake to target energy requirements. Methods: We conducted a prospective cohort study of mechanically ventilated critically ill patients with body mass index ≥30.0 kg/m 2 for whom enteral feeding was planned. Clinical and demographic data were prospectively collected. Resting energy expenditure was measured by open-circuit IC. American Society of Parenteral and Enteral Nutrition (APSPEN)/Society of Critical Care Medicine (SCCM) 2016 equations were used to determine predicted (calculated) energy requirements. Target energy requirements were set at 65% to 70% of measured resting energy expenditure as recommended by ASPEN/SCCM. Nitrogen balance was determined via simultaneous measurement of 24-h urinary nitrogen concentration and protein intake. Results: Twenty-five patients (mean age: 64.5 ± 11.8 y, mean body mass index: 35.2 ± 3.6 kg/m 2 ) underwent IC. The mean predicted energy requirement was 1227 kcal/d compared with mean measured target energy requirement of 1691 kcal/d. Predicted (calculated) energy requirements derived from ASPEN/SCCM equations were less than the target energy requirements in most cases. Actual energy intake from enteral nutrition met 57% of target energy requirements. Protein intake met 25% of target protein requirement and the mean nitrogen balance was −2.3 ± 5.1 g/d. Conclusions: Predictive equations underestimated target energy needs in this population. Further, we found that feeding to goal was often delayed resulting in failure to meet both protein and energy intake goals.

429 Surgery and radiation can be curative in stage I nonsmall cell lung cancer (NSCLC); untreated patients with stage I NSCLC have a 5-year survival of only 6% compared with an overall survival of 43% to 73% for all patients with stage I cancer. [1][2][3] Curative therapy should be offered to all patients for whom it is clinically appropriate. However, up to 20% of patients with early stage NSCLC have been described as medically inoperable. 4 Although new technologies have disseminated into clinical practice over the past decade, it is unknown whether these have led to increased access to treatment.Video-assisted thoracoscopic surgery (VATS) reduces the morbidity of lung cancer surgery and improves quality of life for patients with lung cancer. 5,6 It is unknown how adoption of VATS is affecting access to surgical resection in older persons with NSCLC; that is, VATS may have been adopted primarily for the treatment of patients who traditionally would have received open surgery, resulting in no net increase in the use of surgical resection. Alternatively, the adoption of VATS on the population level may have increased the proportion of patients receiving surgery.Stereotactic body radiation therapy (SBRT) uses multiple radiation beams and sophisticated accounting for motion to deliver biologically effective doses of radiation several times higher than standard external beam radiation therapy (EBRT). 7 Intensity-modulated claims and the following hierarchy: surgery, SBRT/proton therapy, IMRT, and EBRT. We selected the following patient variables a priori as factors that might infl uence decisions regarding treatment: age, sex, race, urban vs rural residence, marital status, and income. Clinical variables included comorbidity, tumor size, histology (e-Appendix 1), receipt of chemotherapy or invasive mediastinal staging, prior receipt of the infl uenza vaccine, admission for COPD exacerbation in the year prior to diagnosis, and life expectancy. We used Healthcare Common Procedure Coding System and International Classifi cation of Diseases, Ninth Revision , codes to identify treatments and invasive staging (e-Appendix 2). US Department of Agriculture rural-urban continuum codes were used to classify patient area of residence. Comorbidity was assessed in two ways. First, Medicare claims for service in the previous 24 months through 3 months prior to diagnosis were used to identify the comorbid conditions recommended by Elixhauser et al, 10 which we pre viously determined to be signifi cantly associated with survival. International Classifi cation of Diseases, Ninth Revision , codes were used if they appeared on an inpatient claim or two or more outpatient or physician claims billed . 30 days apart. Second, we created a variable to indicate whether a patient had been admitted for a COPD exacerbation in the year prior to diagnosis. A dichotomous variable to indicate whether a claim had been submitted for infl uenza vaccine for service in the previous 24 months through 3 months prior to diagnosis was created; this variab...

Background Malnutrition remains an important yet under‐recognised problem among hospitalised adults. Although interventions exist aiming to improve nutritional status beyond hospitalisation, few studies examine how often and what type of nutrition care instructions are given at discharge. The present study sought to review nutrition‐focused discharge care provided to malnourished adults. Methods We reviewed the electronic medical record for discharge nutrition care instructions provided to adult patients identified by dietitians as malnourished over a 4‐month period. Results Seventy‐six eligible patients were identified during the study period. More than half of malnutrition cases (64.5%) were attributed to chronic illness. According to electronic medical record documentation, 6.6% received discharge instructions to consume oral nutrition supplements and 30.3% received new or changed prescriptions for vitamins/noncaloric supplements. Almost half of patients (47.4%) received general diet instructions that did not address malnutrition and 44.8% received inappropriate instructions to limit caloric intake. Conclusions A majority of malnourished adult patients receive inappropriate or inadequate nutrition care instructions at the time of discharge. Clinician education and redesign of nutrition care options in the electronic medical record may improve the provision of post‐discharge nutrition care instructions.