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Rationale: Degradation of the endothelial glycocalyx, a glycosaminoglycan (GAG)-rich layer lining the vascular lumen, is associated with the onset of kidney injury in animal models of critical illness. It is unclear if similar pathogenic degradation occurs in critically ill patients.Objectives: To determine if urinary indices of GAG fragmentation are associated with outcomes in patients with critical illnesses such as septic shock or acute respiratory distress syndrome (ARDS).Methods: We prospectively collected urine from 30 patients within 24 hours of admission to the Denver Health Medical Intensive Care Unit (ICU) for septic shock. As a nonseptic ICU control, we collected urine from 25 surgical ICU patients admitted for trauma. As a medical ICU validation cohort, we obtained serially collected urine samples from 70 patients with ARDS. We performed mass spectrometry on urine samples to determine GAG (heparan sulfate, chondroitin sulfate, and hyaluronic acid) concentrations as well as patterns of heparan sulfate/chondroitin sulfate disaccharide sulfation. We compared these indices to measurements obtained using dimethylmethylene blue, an inexpensive, colorimetric urinary assay of sulfated GAGs.Measurements and Main Results: In septic shock, indices of GAG fragmentation correlated with both the development of renal dysfunction over the 72 hours after urine collection and with hospital mortality. This association remained after controlling for severity of illness and was similarly observed using the inexpensive dimethylmethylene blue assay. These predictive findings were corroborated using urine samples previously collected at three consecutive time points from patients with ARDS.Conclusions: Early indices of urinary GAG fragmentation predict acute kidney injury and in-hospital mortality in patients with septic shock or ARDS. Clinical trial registered with www.clinicaltrials.gov (NCT01900275). [ABSTRACT FROM AUTHOR]

Background Rehospitalization is an important and costly outcome that occurs commonly in several diseases encountered in the medical intensive care unit ( ICU). Although alcohol use disorders are present in 40% of ICU survivors and alcohol withdrawal is the most common alcohol-related reason for admission to an ICU, rates and predictors of rehospitalization have not been previously reported in this population. Methods We conducted a retrospective cohort study of medical ICU survivors with a primary or secondary discharge diagnosis of alcohol withdrawal using 2 administrative databases. The primary outcome was time to rehospitalization or death. Secondary outcomes included time to first emergency department or urgent care clinic visit in the subset of ICU survivors who were not rehospitalized. Cox proportional hazard models were adjusted for age, gender, race, homelessness, smoking, and payer source. Results Of 1,178 patients discharged from the medical ICU over the study period, 468 (40%) were readmitted to the hospital and 54 (4%) died within 1 year. Schizophrenia (hazard ratio 2.23, 95% CI 1.57, 3.34, p < 0.001), anxiety disorder (hazard ratio 2.04, 95% CI 1.30, 3.32, p < 0.01), depression (hazard ratio 1.62, 95% CI 1.05, 2.40, p = 0.03), and Deyo comorbidity score ≥3 (hazard ratio 1.43, 95% CI 1.09, 1.89, p = 0.01) were significant predictors of time to death or first rehospitalization. Bipolar disorder was associated with time to first emergency department or urgent care clinic visit (hazard ratio 2.03, 95% CI 1.24, 3.62, p < 0.01) in the 656 patients who were alive and not rehospitalized within 1 year. Conclusions The presence of a psychiatric comorbidity is a significant predictor of multiple measures of unplanned healthcare utilization in medical ICU survivors with a primary or secondary discharge diagnosis of alcohol withdrawal. This finding highlights the potential importance of targeting longitudinal multidisciplinary care to patients with a dual diagnosis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Head of bed elevation ≥ 30° reduces ventilator-associated pneumonia in mechanically ventilated patients, but adherence is variable and difficult to monitor continuously. Unlike many clinical variables, head of bed elevation is not electronically displayed or monitored with audible alarms. HYPOTHESIS: Continuous monitoring of head of bed elevation with audible alerts and visual cues when the elevation is < 30° will improve adherence by 15%. METHODS: Head of bed elevation was continuously monitored and recorded on a central monitoring station and displayed on the bedside monitor of 16 of 24 medical intensive care unit beds. Manual bedside checks were performed twice daily at varying times. RESULTS: Continuous head of bed angle was available from 98 of 313 (31%) patient beds over a 7.5 month period, representing 322 of 1,373 mechanical ventilator days (24%). Continuous monitoring was performed for 7,720 hours, 5,542 hours with the data displayed on bedside monitors and 2,178 hours with the data available only from central monitors. Head of bed elevation was ≥ 30° for 76% of the hours when the data were displayed on bedside monitors, and for 61% of hours when it was not (P < .001, odds ratio 2.3, 95% CI 2.0 -2.6). Intermittent bedside checks for head of bed elevation ≥ 30° found 97 ± 2% adherence. CONCLUSIONS: Real-time monitoring of head of bed elevation is feasible, and when combined with audible alarms and visual cues, improves ≥ 30° elevation adherence. Intermittent bedside checks over-estimate actual adherence. [ABSTRACT FROM AUTHOR]

As part of the Water Research Foundation (Denver, CO) project "Post-Treatment Stabilization of Desalinated Water," a questionnaire was developed and distributed to water utilities employing desalination processes to survey post-treatment practices, compile process and water quality data, highlight operating cost and post-treatment operation experiences, and identify distribution system secondary impacts. A total of eighty-three surveys were distributed to water utilities in the United States (USA), Caribbean and Europe, and responses collected over a period of six months duration from the time of initial mailing. Twenty-five questionnaires were returned yielding a thirty percent response rate. Twenty-one of the twenty-five responses were received from the USA, three from Europe and one response was received from the Caribbean. The average-daily permeate flow of the facilities surveyed ranged from 0.39 m³/min (0.15 million gallons per day (MGD)) to 184 m³/min (70 MGD). Results indicated a variety of methods are employed when post-treating desalinated permeate, with a majority of the surveyed facilities reporting the use of chemical addition using caustic soda (sodium hydroxide) or soda ash (sodium carbonate) for pH adjustment. More than one form of post-treatment was implemented with or without the need for by-pass or native source water blending, and was dependent on source water type. Facilities that relied upon process by-pass for post-treatment stabilization reported blending ratios between 10 and 30%, with an average blending flow rate between 5.26 m³/min (2.0 MGD) and 27.6 m³/min (10.5 MGD). Blended water alkalinity averaged 150 mg/l as CaCO3, as compared to post-treatment with alkalinity adjustment that approximated 62 mg/l as CaCO3 at the point-of-entry (POE). Primary disinfection was typically accomplished by chlorine addition, although a number of facilities reported using chloramines for secondary disinfection. The reported pH averaged 8.2 units at the POE. [ABSTRACT FROM AUTHOR]