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Abstract Background COVID-19 disproportionately impacted marginalized populations early in the pandemic. Families of patients admitted to the intensive care unit (ICU) experienced significant psychological effects. Little is known about whether individual and patient psychological outcomes after a loved ones stay in the ICU differs by socioeconomic status, as measured by the area deprivation index (ADI). Methods Family members of patients with COVID-19 respiratory failure admitted to the ICU at twelve hospitals in five US states were enrolled in a larger study looking at rates of symptoms of post-traumatic stress disorder (PTSD), anxiety, and depression in the months following their loved one's ICU stay. This secondary data analysis includes eight of the twelve hospitals in four of the five states. Each participant was assigned a number indicating a level of neighborhood disadvantage based on the patient’s zip code. Patient and family level characteristics as well as symptoms of anxiety, depression, and PTSD were assessed among each neighborhood. Results Patients from the most disadvantaged neighborhoods had the highest proportion of patients that needed to be intubated (p = 0.005). All the patients in the most disadvantaged neighborhoods were a race other than white (p = 0.17). At 12 months post-hospitalization, there was a statistically significant difference in the proportion of family members who experienced symptoms of PTSD, anxiety, and depression between the ADI groups. Conclusions ADI may be a predictor of COVID-19 disease severity for patients on presentation to the ICU. Patients and family members experience psychological effects after a loved one’s admission to the ICU, and these outcomes vary among individuals of different socioeconomic status’, as measured by the ADI. A larger study of family members’ incidence of anxiety, depression, and post-traumatic stress disorder is needed to understand the extent to which these symptoms are impacted by neighborhood level factors as measured by the ADI.

Abstract Skeletal muscle dysfunction in critical illnesses leaves survivors weak and functionally impaired. Macrophages infiltrate muscles; however, their functional role is unclear. We aim to examine muscle leukocyte composition and the effect of macrophages on muscle mass and function in the murine acute lung injury (ALI)‐associated skeletal muscle wasting model. We performed flow cytometry of hindlimb muscle to identify myeloid cells pre‐injury and time points up to 29 days after intratracheal lipopolysaccharide ALI. We evaluated muscle force and morphometrics after systemic and intramuscular clodronate‐induced macrophage depletions between peak lung injury and recovery (day 5–6) versus vehicle control. Our results show muscle leukocytes changed over ALI course with day 3 neutrophil infiltration (130.5 ± 95.6cells/mg control to 236.3 ± 70.6cells/mg day 3) and increased day 10 monocyte abundance (5.0 ± 3.4%CD45+CD11b+ day 3 to 14.0 ± 2.6%CD45+CD11b+ day 10, p = 0.005). Although macrophage count did not significantly change, pro‐inflammatory (27.0 ± 7.2% day 3 to 7.2 ± 3.8% day 10, p = 0.02) and anti‐inflammatory (30.5 ± 11.1% day 3 to 52.7 ± 9.7% day 10, p = 0.09) surface marker expression changed over the course of ALI. Macrophage depletion following peak lung injury increased muscle mass and force generation. These data suggest muscle macrophages beyond peak lung injury limit or delay muscle recovery. Targeting macrophages could augment muscle recovery following lung injury.

Introduction Survivors of critical illness often experience significant morbidities, including muscle weakness and impairments in physical functioning. This muscle weakness is associated with longer duration mechanical ventilation, greater hospital costs and increased postdischarge impairments in physical function, quality of life and survival. Compared with standard of care, the benefits of greater protein intake combined with structured exercise started early after the onset of critical illness remain uncertain. However, the combination of protein supplementation and exercise in other populations has demonstrated positive effects on strength and function. In the present study, we will evaluate the effects of a combination of early implementation of intravenous amino acid supplementation and in-bed cycle ergometry exercise versus a ‘usual care’ control group in patients with acute respiratory failure requiring mechanical ventilation in an intensive care unit (ICU).Methods and analysis In this multicentre, assessor-blinded, randomised controlled trial, we will randomise 142 patients in a 1:1 ratio to usual care (which commonly consists of minimal exercise and under-achievement of guideline-recommended caloric and protein intake goals) versus a combined intravenous amino acid supplementation and in-bed cycle ergometery exercise intervention. We hypothesise that this novel combined intervention will (1) improve physical functioning at hospital discharge; (2) reduce muscle wasting with improved amino acid metabolism and protein synthesis in-hospital and (3) improve patient-reported outcomes and healthcare resource utilisation at 6 months after enrolment. Key cointerventions will be standardised. In-hospital outcome assessments will be conducted at baseline, ICU discharge and hospital discharge. An intent-to-treat analysis will be used to analyse all data with additional per-protocol analyses.Ethics and dissemination The trial received ethics approval at each institution and enrolment has begun. These results will inform both clinical practice and future research in the area. We plan to disseminate trial results in peer-reviewed journals, at national and international conferences, and via nutritional and rehabilitation-focused electronic education and knowledge translation platforms.Trial registration number NCT03021902; Pre-results.

Patients who survive an index lung cancer (ILC) after surgical resection continue to be at significant risk for a metachronous lung cancer (MLC). Indeed, this risk is much higher than the risk of developing an ILC in heavy smokers. There is currently little evidence upon which to base guidelines for screening at-risk patients for MLC, and the risk-reward tradeoffs for screening this patient population are unknown. The goal of this investigation was to estimate the maximum mortality benefit of CT screening for MLC. We developed a computational model to estimate the maximum rates of CT detection of MLC and surgical resection to be expected in a given population as a function of time after resection of an ILC. Applying the model to a hypothetical high-risk population suggests that screening for MLC within 5 years after resection of an ILC may identify only a very small number of treatable cancers. The risk of death from a potentially resectable MLC increases dramatically past this point, however, suggesting that screening after 5 years is imperative. The model also predicts a substantial detection gap for MLC that demonstrates the benefit to be gained as more sensitive screening methods are developed.

Hypermetabolism and malnourishment are common in the intensive care unit. Malnutrition is associated with increased morbidity and mortality, and most intensive care unit patients receive specialized nutrition therapy to attenuate the effects of malnourishment. However, the optimal amount of energy to deliver is unknown, with some studies suggesting that full calorie feeding improves clinical outcomes but other studies concluding that caloric intake may not be important in determining outcome. In this narrative review, we discuss the studies of critically ill patients that examine the relationship between dose of nutrition and clinically important outcomes. Observational studies suggest that achieving targeted caloric intake might not be necessary since provision of approximately 25% to 66% of goal calories may be sufficient. Randomized controlled trials comparing early aggressive use of enteral nutrition compared with delayed, less aggressive use of enteral nutrition suggest that providing increased calories with early, aggressive enteral nutrition is associated with improved clinical outcomes. However, energy provision with parenteral nutrition, either instead of or supplemental to enteral nutrition, does not offer additional benefits. In summary, the optimal amount of calories to provide critically ill patients is unclear given the limitations of the existing data. However, evidence suggests that improving adequacy of enteral nutrition by moving intake closer to goal calories might be associated with a clinical benefit. There is no role for supplemental parenteral nutrition to increase caloric delivery in the early phase of critical illness. Further high-quality evidence from randomized trials investigating the optimal amount of energy intake in intensive care unit patients is needed. [ABSTRACT FROM AUTHOR]

OBJECTIVES:: The quality of family-clinician communication in the intensive care unit is often inadequate, but little is known about specific clinician communication behaviors that might improve family satisfaction. In this exploratory analysis, we hypothesized that clinicians’ communication behaviors providing emotional support to families during intensive care unit conferences would be associated with increased family satisfaction.DESIGN:: We audiotaped 51 intensive care unit family conferences in which withholding or withdrawing life support was discussed or bad news was delivered. Emotional support techniques used by clinicians during each conference were identified and coded using grounded theory.SETTING:: Four Seattle hospitals.SUBJECTS:: Family members of critically ill patients.INTERVENTIONS:: Questionnaires rating satisfaction with communication were completed by 169 family members.MEASUREMENTS AND MAIN RESULTS:: Linear regression with generalized estimating equation methods was used to analyze the association between the frequency of clinicians’ emotionally supportive statements and family satisfaction. Increasing frequency of three types of clinicians’ statements during family conferences was associated with increased family satisfaction: a) assurances that the patient will not be abandoned before death (p = .015); b) assurances that the patient will be comfortable and will not suffer (p = .029); and c) support for family’s decisions about end- of-life care, including support for family’s decision to withdraw or not to withdraw life-support (p = .005).CONCLUSIONS:: Most family members participating in this study were quite satisfied with the communication in the family conferences. Specific clinician communication behaviors are associated with increased family satisfaction during family conferences among family members who are willing to have a family conference recorded. Our results suggest that clinicians in the intensive care unit may improve the experiences of families of critically ill patients by providing explicit support for decisions made by a family with regard to end-of-life care and by assuring families continuity of high-quality care with particular attention to the patient’s comfort. [ABSTRACT FROM AUTHOR]