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1.  Proceedings of the 14th annual conference of INEBRIA 
Holloway, Aisha S. | Ferguson, Jennifer | Landale, Sarah | Cariola, Laura | Newbury-Birch, Dorothy | Flynn, Amy | Knight, John R. | Sherritt, Lon | Harris, Sion K. | O’Donnell, Amy J. | Kaner, Eileen | Hanratty, Barbara | Loree, Amy M. | Yonkers, Kimberly A. | Ondersma, Steven J. | Gilstead-Hayden, Kate | Martino, Steve | Adam, Angeline | Schwartz, Robert P. | Wu, Li-Tzy | Subramaniam, Geetha | Sharma, Gaurav | McNeely, Jennifer | Berman, Anne H. | Kolaas, Karoline | Petersén, Elisabeth | Bendtsen, Preben | Hedman, Erik | Linderoth, Catharina | Müssener, Ulrika | Sinadinovic, Kristina | Spak, Fredrik | Gremyr, Ida | Thurang, Anna | Mitchell, Ann M. | Finnell, Deborah | Savage, Christine L. | Mahmoud, Khadejah F. | Riordan, Benjamin C. | Conner, Tamlin S. | Flett, Jayde A. M. | Scarf, Damian | McRee, Bonnie | Vendetti, Janice | Gallucci, Karen Steinberg | Robaina, Kate | Clark, Brendan J. | Jones, Jacqueline | Reed, Kathryne D. | Hodapp, Rachel M. | Douglas, Ivor | Burnham, Ellen L. | Aagaard, Laura | Cook, Paul F. | Harris, Brett R. | Yu, Jiang | Wolff, Margaret | Rogers, Meighan | Barbosa, Carolina | Wedehase, Brendan J. | Dunlap, Laura J. | Mitchell, Shannon G. | Dusek, Kristi A. | Gryczynski, Jan | Kirk, Arethusa S. | Oros, Marla T. | Hosler, Colleen | O’Grady, Kevin E. | Brown, Barry S. | Angus, Colin | Sherborne, Sidney | Gillespie, Duncan | Meier, Petra | Brennan, Alan | de Vargas, Divane | Soares, Janaina | Castelblanco, Donna | Doran, Kelly M. | Wittman, Ian | Shelley, Donna | Rotrosen, John | Gelberg, Lillian | Edelman, E. Jennifer | Maisto, Stephen A. | Hansen, Nathan B. | Cutter, Christopher J. | Deng, Yanhong | Dziura, James | Fiellin, Lynn E. | O’Connor, Patrick G. | Bedimo, Roger | Gibert, Cynthia | Marconi, Vincent C. | Rimland, David | Rodriguez-Barradas, Maria C. | Simberkoff, Michael S. | Justice, Amy C. | Bryant, Kendall J. | Fiellin, David A. | Giles, Emma L. | Coulton, Simon | Deluca, Paolo | Drummond, Colin | Howel, Denise | McColl, Elaine | McGovern, Ruth | Scott, Stephanie | Stamp, Elaine | Sumnall, Harry | Vale, Luke | Alabani, Viviana | Atkinson, Amanda | Boniface, Sadie | Frankham, Jo | Gilvarry, Eilish | Hendrie, Nadine | Howe, Nicola | McGeechan, Grant J. | Ramsey, Amy | Stanley, Grant | Clephane, Justine | Gardiner, David | Holmes, John | Martin, Neil | Shevills, Colin | Soutar, Melanie | Chi, Felicia W. | Weisner, Constance | Ross, Thekla B. | Mertens, Jennifer | Sterling, Stacy A. | Shorter, Gillian W. | Heather, Nick | Bray, Jeremy | Cohen, Hildie A. | McPherson, Tracy L. | Adam, Cyrille | López-Pelayo, Hugo | Gual, Antoni | Segura-Garcia, Lidia | Colom, Joan | Ornelas, India J. | Doyle, Suzanne | Donovan, Dennis | Duran, Bonnie | Torres, Vanessa | Gaume, Jacques | Grazioli, Véronique | Fortini, Cristiana | Paroz, Sophie | Bertholet, Nicolas | Daeppen, Jean-Bernard | Satterfield, Jason M. | Gregorich, Steven | Alvarado, Nicholas J. | Muñoz, Ricardo | Kulieva, Gozel | Vijayaraghavan, Maya | Adam, Angéline | Cunningham, John A. | Díaz, Estela | Palacio-Vieira, Jorge | Godinho, Alexandra | Kushir, Vladyslav | O’Brien, Kimberly H. M. | Aguinaldo, Laika D. | Sellers, Christina M. | Spirito, Anthony | Chang, Grace | Blake-Lamb, Tiffany | LaFave, Lea R. Ayers | Thies, Kathleen M. | Pepin, Amy L. | Sprangers, Kara E. | Bradley, Martha | Jorgensen, Shasta | Catano, Nico A. | Murray, Adelaide R. | Schachter, Deborah | Andersen, Ronald M. | Rey, Guillermina Natera | Vahidi, Mani | Rico, Melvin W. | Baumeister, Sebastian E. | Johansson, Magnus | Sinadinovic, Christina | Hermansson, Ulric | Andreasson, Sven | O’Grady, Megan A. | Kapoor, Sandeep | Akkari, Cherine | Bernal, Camila | Pappacena, Kristen | Morley, Jeanne | Auerbach, Mark | Neighbors, Charles J. | Kwon, Nancy | Conigliaro, Joseph | Morgenstern, Jon | Magill, Molly | Apodaca, Timothy R. | Borsari, Brian | Hoadley, Ariel | Scott Tonigan, J. | Moyers, Theresa | Fitzgerald, Niamh M. | Schölin, Lisa | Barticevic, Nicolas | Zuzulich, Soledad | Poblete, Fernando | Norambuena, Pablo | Sacco, Paul | Ting, Laura | Beaulieu, Michele | Wallace, Paul George | Andrews, Matthew | Daley, Kate | Shenker, Don | Gallagher, Louise | Watson, Rod | Weaver, Tim | Bruguera, Pol | Oliveras, Clara | Gavotti, Carolina | Barrio, Pablo | Braddick, Fleur | Miquel, Laia | Suárez, Montse | Bruguera, Carla | Brown, Richard L. | Capell, Julie Whelan | Paul Moberg, D. | Maslowsky, Julie | Saunders, Laura A. | McCormack, Ryan P. | Scheidell, Joy | Gonzalez, Mirelis | Bauroth, Sabrina | Liu, Weiwei | Lindsay, Dawn L. | Lincoln, Piper | Hagle, Holly | Wallhed Finn, Sara | Hammarberg, Anders | Andréasson, Sven | King, Sarah E. | Vargo, Rachael | Kameg, Brayden N. | Acquavita, Shauna P. | Van Loon, Ruth Anne | Smith, Rachel | Brehm, Bonnie J. | Diers, Tiffiny | Kim, Karissa | Barker, Andrea | Jones, Ashley L. | Skinner, Asheley C. | Hinman, Agatha | Svikis, Dace S. | Thacker, Casey L. | Resnicow, Ken | Beatty, Jessica R. | Janisse, James | Puder, Karoline | Bakshi, Ann-Sofie | Milward, Joanna M. | Kimergard, Andreas | Garnett, Claire V. | Crane, David | Brown, Jamie | West, Robert | Michie, Susan | Rosendahl, Ingvar | Andersson, Claes | Gajecki, Mikael | Blankers, Matthijs | Donoghue, Kim | Lynch, Ellen | Maconochie, Ian | Phillips, Ceri | Pockett, Rhys | Phillips, Tom | Patton, R. | Russell, Ian | Strang, John | Stewart, Maureen T. | Quinn, Amity E. | Brolin, Mary | Evans, Brooke | Horgan, Constance M. | Liu, Junqing | McCree, Fern | Kanovsky, Doug | Oberlander, Tyler | Zhang, Huan | Hamlin, Ben | Saunders, Robert | Barton, Mary B. | Scholle, Sarah H. | Santora, Patricia | Bhatt, Chirag | Ahmed, Kazi | Hodgkin, Dominic | Gao, Wenwu | Merrick, Elizabeth L. | Drebing, Charles E. | Larson, Mary Jo | Sharma, Monica | Petry, Nancy M. | Saitz, Richard | Weisner, Constance M. | Young-Wolff, Kelly C. | Lu, Wendy Y. | Blosnich, John R. | Lehavot, Keren | Glass, Joseph E. | Williams, Emily C. | Bensley, Kara M. | Chan, Gary | Dombrowski, Julie | Fortney, John | Rubinsky, Anna D. | Lapham, Gwen T. | Forray, Ariadna | Olmstead, Todd A. | Gilstad-Hayden, Kathryn | Kershaw, Trace | Dillon, Pamela | Weaver, Michael F. | Grekin, Emily R. | Ellis, Jennifer D. | McGoron, Lucy | McGoron, Lucy
doi:10.1186/s13722-017-0087-8
PMCID: PMC5606215
2.  Brief versus Full Alcohol Use Disorders Identification Test in NHLBI ARDS Network Clinical Trials 
Critical care medicine  2015;43(9):e382-e385.
OBJECTIVES
Alcohol use disorders (AUDs) are common among patients admitted to an intensive care unit, yet systematic screening is rarely performed. We sought to confirm the construct validity of the full Alcohol Use Disorders Identification Test (AUDIT) and to evaluate the performance of the brief 3 item AUDIT-C using the full AUDIT as a proxy gold standard in a population of patients with a medical critical illness.
DESIGN
Secondary Analysis
SETTING
The Acute Respiratory Distress Syndrome (ARDS) Network, a consortium of 12 university centers (44 hospitals) dedicated to conducting multicenter clinical trials in patients with ARDS.
SUBJECTS
Patients meeting consensus criteria for Acute Respiratory Distress Syndrome
INTERVENTIONS
None
MEASUREMENTS AND MAIN RESULTS
Of 1,133 patients enrolled in one of three ARDS Network studies, 1,037 (92%) had full AUDIT data available. Of the included patients, 236 (23%) scored above the screening threshold for an alcohol use disorder on the full AUDIT. Construct validity analysis of the full AUDIT supported a three factor model. Compared to the full AUDIT, the AUDIT-C had an area under the receiver operating characteristic (AuROC) curve of 0.99 for men and 0.98 for women. The optimal cutoff was 4 for both genders. At this cutoff, the AUDIT-C had a sensitivity of 95% (95% CI 92%, 98%) and specificity of 94% (95% CI 92%, 96%) for men and sensitivity of 89% (95% CI 82%, 96%) and specificity of 99% (95% CI 98%, 100%) for women.
CONCLUSIONS
Though a 3 factor structure for the AUDIT was confirmed in ICU patients with ARDS, the first 3 questions focusing on alcohol consumption provide information that is comparable to the full 10 item AUDIT screening questionnaire. This study is limited by the lack of a true gold standard and the performance of the AUDIT-C is likely overestimated due to this limitation.
doi:10.1097/CCM.0000000000001181
PMCID: PMC4847535  PMID: 26136102
alcohol use disorders identification test; acute lung injury; alcohol use disorder; alcohol misuse; unhealthy alcohol use
3.  Facilitators and Barriers to Initiating Change in Medical Intensive Care Unit Survivors with Alcohol Use Disorders: A qualitative study 
Journal of critical care  2013;28(5):849-856.
Purpose
Alcohol abuse and dependence are collectively referred to as alcohol use disorders (AUD). An AUD is present in up to one third of patients admitted to an intensive care unit (ICU). We sought to understand the barriers and facilitators to change in ICU survivors with an AUD in order to provide a foundation upon which to tailor alcohol-related interventions.
Methods
We utilized a qualitative approach with a broad constructivist framework, conducting semistructured interviews in medical ICU survivors with an AUD. Patients were included if they were admitted to one of two medical ICUs and were excluded if they refused participation, were unable to participate, or did not speak English. Digitally recorded and professionally transcribed interviews were analyzed using a general inductive approach and grouped into themes.
Results
Nineteen patients were included with an average age of 51 [interquartile range (IQR) 36–51] years and an average APACHE II score of 9 [IQR 5–13]; 68% were Caucasian, 74% were male, and the most common reason for admission was alcohol withdrawal (n = 8). We identified five facilitators of change: empathy of the inpatient healthcare environment, recognition of accumulating problems, religion, pressure from others to stop drinking, and trigger events. We identified 3 barriers to change: missed opportunities, psychiatric comorbidity, and cognitive dysfunction. Social networks were identified as either a barrier or facilitator to change depending on the specific context.
Conclusions
Alcohol-related interventions to motivate and sustain behavior change could be tailored to ICU survivors by accounting for unique barriers and facilitators.
doi:10.1016/j.jcrc.2013.06.011
PMCID: PMC4117201  PMID: 23876701
Intensive care unit; critical illness; alcohol use disorder; brief intervention; motivational interviewing
4.  Healthcare Utilization in Medical Intensive Care Unit Survivors with Alcohol Withdrawal 
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 two 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 (HR 2.23, 95% CI 1.57, 3.34, p < 0.001), anxiety disorder (HR 2.04, 95% CI 1.30, 3.32, p < 0.01), depression (HR 1.62, 95% CI 1.05, 2.40, p = 0.03), and Deyo comorbidity score ≥ 3 (HR 1.43, 95% CI 1.09, 1.1.89, 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 (HR 2.03, 95% CI 1.24, 3.62, p < 0.01) in the 656 patients who were alive and not rehospitalized within one year.
Conclusion
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.
doi:10.1111/acer.12124
PMCID: PMC4045620  PMID: 23647435
alcohol withdrawal; alcohol use disorder; intensive care unit; rehospitalization; dual diagnosis
5.  Alcohol Screening Scores and 90 Day Outcomes in Patients with Acute Lung Injury 
Critical care medicine  2013;41(6):1518-1525.
Objective
The effects of excess alcohol consumption (alcohol misuse) on outcomes in patients with acute lung injury (ALI) have been inconsistent, and there are no studies examining this association in the era of low tidal volume ventilation and a fluid conservative strategy. We sought to determine whether validated scores on the Alcohol Use Disorders Identification Test (AUDIT) that correspond to past year abstinence (zone 1), low-risk drinking (zone 2), mild to moderate alcohol misuse (zone 3), and severe alcohol misuse (zone 4) are associated with poor outcomes in patients with ALI.
Design
Secondary analysis.
Setting
The Acute Respiratory Distress Syndrome (ARDS) network, a consortium of 12 university centers (44 hospitals) dedicated to the conduct of multi-center clinical trials in patients with acute lung injury.
Subjects
Patients meeting consensus criteria for ALI enrolled in one of three recent ARDS network clinical trials.
Interventions
None
Measurements and Main Results
Of 1,133 patients enrolled in one of three ARDS network studies, 1,037 patients had an AUDIT score available for analysis. Alcohol misuse was common with 70 (7%) of patients having AUDIT scores in zone 3 and 129 (12%) patients in zone 4. There was a u-shaped association between validated AUDIT zones and death or persistent hospitalization at 90 days (34% in zone 1, 26% in zone 2, 27% in zone 3, 36% in zone 4; p < 0.05 for comparison of zone 1 to zone 2 and zone 4 to zone 2). In a multiple logistic regression model, there was a significantly higher odds of death or persistent hospitalization in patients in AUDIT zone 4 when compared to those in zone 2 (adjusted OR 1.70; 95% CI 1.00, 2.87; p = 0.048).
Conclusions
Severe, but not mild to moderate alcohol misuse is independently associated with an increased risk of death or persistent hospitalization at 90 days in ALI patients.
doi:10.1097/CCM.0b013e318287f1bb
PMCID: PMC4048714  PMID: 23538449
alcohol use disorders identification test; acute lung injury; alcohol use disorder; alcohol misuse; unhealthy alcohol use
6.  Unhealthy alcohol use in older adults: Association with readmissions and emergency department use in the 30 days after hospital discharge☆ 
Drug and alcohol dependence  2015;158:94-101.
Background
Unhealthy alcohol use could impair recovery of older patients after medical or surgical hospitalizations. However, no prior research has evaluated whether older patients who screen positive for unhealthy alcohol use are at increased risk of readmissions or emergency department (ED) visits within 30 days after discharge. This study examined the association between AUDIT-C alcohol screening results and 30-day readmissions or ED visits.
Methods
Veterans Affairs (VA) patients age 65 years or older, were eligible if they were hospitalized for a medical or surgical condition (2/1/2009–10/1/2011) and had an AUDIT-C score documented in their VA electronic medical record in the year before they were hospitalized. VA and Medicare data identified VA or non-VA index hospitalizations, readmissions, and ED visits. Primary analyses adjusted for demographics, comorbid conditions, and past-year health care utilization.
Results
Among 579,330 hospitalized patients, 13.7% were readmitted and 12.0% visited an ED within 30 days of discharge. In primary analyses, high-risk drinking (n = 7167) and nondrinking (n =357,086) were associated with increased probability of readmission (13.8%, 95% CI 13.0–14.6%; and 14.2%, 95% CI 14.1–14.3%, respectively), relative to low-risk drinking (12.9%; 95% CI 12.7–13.0%). Only nondrinkers had increased risk for ED visits.
Conclusions
Alcohol screening results indicating high-risk drinking that were available in medical records were modestly associated with risk for 30-day readmissions and were not associated with risk for ED visits.
doi:10.1016/j.drugalcdep.2015.11.008
PMCID: PMC4749399  PMID: 26644137
Alcohol screening; Quality; Unhealthy alcohol use; Emergency department; Readmissions; Post-discharge care
7.  Secondary Prevention in the Intensive Care Unit: Does ICU Admission Represent a “Teachable Moment?” 
Critical care medicine  2011;39(6):1500-1506.
Objective
Cigarette smoking and unhealthy alcohol use are common causes of preventable morbidity and mortality that frequently result in admission to an intensive care unit. Understanding how to identify and intervene in these conditions is important because critical illness may provide a “teachable moment.” Furthermore, the Joint Commission recently proposed screening and receipt of an intervention for tobacco use and unhealthy alcohol use as candidate performance measures for all hospitalized patients. Understanding the efficacy of these interventions may help drive evidence-based institution of programs, if deemed appropriate.
Data Sources
A summary of the published medical literature on interventions for unhealthy alcohol use and smoking obtained through a PubMed search.
Summary
Interventions focusing on behavioral counseling for cigarette smoking in hospitalized patients have been extensively studied. Several studies include or focus on critically ill patients. The evidence demonstrates that behavioral counseling leads to increased rates of smoking cessation but the effect depends on the intensity of the intervention. The identification of unhealthy alcohol use can lead to brief interventions. These interventions are particularly effective in trauma patients with unhealthy alcohol use. However, the current literature would not support routine delivery of brief interventions for unhealthy alcohol use in the medical ICU population.
Conclusion
ICU admission represents a “teachable moment” for smokers and some patients with unhealthy alcohol use. Future studies should assess the efficacy of brief interventions for unhealthy alcohol use in medical ICU patients. In addition, identification of the timing and optimal individual to conduct the intervention will be necessary.
doi:10.1097/CCM.0b013e31821858bb
PMCID: PMC3180919  PMID: 21494113
8.  Diagnosis and treatment of post-extubation dysphagia: Results from a National Survey 
Journal of critical care  2012;27(6):578-586.
Purpose
This study sought to determine the utilization of speech-language pathologist (SLPs) for the diagnosis and treatment of post-extubation dysphagia in survivors of mechanical ventilation.
Methods
We designed, validated, and mailed a survey to 1,966 inpatient SLPs who routinely evaluate patients for post-extubation dysphagia.
Results
The majority of SLP diagnostic evaluations (60%; 95% CI = 59–62%) were performed using clinical techniques with uncertain accuracy. Instrumental diagnostic tests (such as fluoroscopy and endoscopy) are more likely to be available at university than community hospitals. After adjusting for hospital size and academic affiliation, instrumental test use varied significantly by geographical region. Treatments for post-extubation dysphagia usually involved dietary adjustment (76%; 95% CI = 73–79%) and postural changes/compensatory maneuvers (86%; 95% CI = 84–88%), rather than on interventions aimed to improve swallowing function (24%; 95% CI = 21–27%).
Conclusions
SLPs frequently evaluate acute respiratory failure survivors. However, diagnostic evaluations rely mainly upon bedside techniques with uncertain accuracy. The use of instrumental tests varies by geographic location and university affiliation. Current diagnostic practices and feeding decisions for critically ill patients should be viewed with caution until further studies determine the accuracy of bedside detection methods.
doi:10.1016/j.jcrc.2012.07.016
PMCID: PMC3518658  PMID: 23084136
Mechanical Ventilation; Intratracheal Intubation; Respiratory Aspiration; Dysphagia; Swallowing Disorders
9.  Post-extubation dysphagia is associated with longer hospitalization in survivors of critical illness with neurologic impairment 
Critical Care  2013;17(3):R119.
Introduction
Critically ill patients can develop acute respiratory failure requiring endotracheal intubation. Swallowing dysfunction after liberation from mechanical ventilation, also known as post-extubation dysphagia, is common and deleterious among patients without neurologic disease. However, the risk factors associated with the development of post-extubation dysphagia and its effect on hospital lengthofstay in critically ill patients with neurologic disorders remains relatively unexplored.
Methods
We conducted a retrospective, observational cohort study from 2008 to 2010 of patients with neurologic impairment who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech-language pathologist.
Results
A BSE was performed after mechanical ventilation in 25% (630/2,484) of all patients. In the 184 patients with neurologic impairment, post-extubation dysphagia was present in 93% (171/184), and was classified as mild, moderate, or severe in 34% (62/184), 26% (48/184), and 33% (61/184), respectively. In univariate analyses, statistically significant risk factors for moderate/severe dysphagia included longer durations of mechanical ventilation and the presence of a tracheostomy. In multivariate analysis, adjusting for age, tracheostomy, cerebrovascular disease, and severity of illness, mechanical ventilation for >7 days remained independently associated with moderate/severe dysphagia (adjusted odds ratio = 4.48 (95%confidence interval = 2.14 to 9.81), P<0.01). The presence of moderate/severe dysphagia was also significantly associated with prolonged hospital lengthofstay, discharge status, and surgical placement of feeding tubes. When adjusting for age, severity of illness, and tracheostomy, patients with moderate/severe dysphagia stayed in the hospital 4.32 days longer after their initial BSE than patients with none/mild dysphagia (95% confidence interval = 3.04 to 5.60 days, P <0.01).
Conclusion
In a cohort of critically ill patients with neurologic impairment, longer duration of mechanical ventilation is independently associated with post-extubation dysphagia, and the development of post-extubation dysphagia is independently associated with a longer hospital length of stay after the initial BSE.
doi:10.1186/cc12791
PMCID: PMC4057203  PMID: 23786755
mechanical ventilation; intubation; intratracheal; swallowing disorders; dysphagia; aspiration; respiratory
10.  Growth differentiation factor-15 and prognosis in acute respiratory distress syndrome: a retrospective cohort study 
Critical Care  2013;17(3):R92.
Introduction
We sought to determine whether higher levels of the novel biomarker growth differentiation factor-15 (GDF-15) are associated with poor outcomes and the presence of pulmonary vascular dysfunction (PVD) in patients with acute respiratory distress syndrome (ARDS).
Methods
We conducted a retrospective cohort study in patients enrolled in the Acute Respiratory Distress Syndrome Network Fluid and Catheter Treatment (FACT) Trial. Patients enrolled in the FACT Trial who received a pulmonary artery catheter (PAC), had plasma available from the same study day and sufficient hemodynamic data to determine the presence of PVD were included. Logistic regression was used to determine the association between GDF-15 level and 60-day mortality.
Results
Of the 513 patients enrolled in the FACT Trial assigned to receive a PAC, 400 were included in this analysis. Mortality at 60 days was significantly higher in patients whose GDF-15 levels were in the third (28%) or fourth (49%) quartile when compared to patients with GDF-15 levels in the first quartile (12%) (P <0.001). Adjusting for severity of illness measured by APACHE III score, the odds of death for patients with GDF-15 levels in the fourth quartile when compared to the first quartile was 4.26 (95% CI 2.18, 10.92, P <0.001). When added to APACHE III alone for prediction of 60-day mortality, GDF-15 levels increased the area under the receiver operating characteristic curve from 0.72 to 0.77. At an optimal cutoff of 8,103 pg/mL, the sensitivity and specificity of GDF-15 for predicting 60-day mortality were 62% (95% CI 53%, 71%) and 76% (95% CI 71%, 81%), respectively. Levels of GDF-15 were not useful in identifying the presence of PVD, as defined by hemodynamic measurements obtained by a PAC.
Conclusions
In patients with ARDS, higher levels of GDF-15 are significantly associated with poor outcome but not PVD.
doi:10.1186/cc12737
PMCID: PMC3706804  PMID: 23706007
Acute respiratory distress syndrome; pulmonary vascular dysfunction; risk prediction; growth differentiation factor-15
11.  Severity of Acute Illness is Associated with Baseline Readiness to Change in Medical Intensive Care Unit Patients with Unhealthy Alcohol Use 
Introduction
Unhealthy alcohol use predisposes to multiple conditions that frequently result in critical illness and is present in up to one-third of patients admitted to a medical intensive care unit (ICU). We sought to determine the baseline readiness to change in medical ICU patients with unhealthy alcohol use and hypothesized that the severity of acute illness would be independently associated with higher scores on readiness to change scales. We further sought to determine whether this effect is modified by the severity of unhealthy alcohol use.
Materials and Methods
We performed a cross-sectional observational study of current regular drinkers in three medical ICUs. The Alcohol Use Disorders Identification Test was used to differentiate low risk and unhealthy alcohol use and further categorize patients into risky alcohol use or an alcohol use disorder. The severity of a patient’s acute illness was assessed by calculating the Acute Physiology and Chronic Healthy Evaluation II score at the time of admission to the medical ICU. Readiness to change was assessed using standardized questionnaires.
Results
Of 101 medical ICU patients who were enrolled, 65 met the criteria for unhealthy alcohol use. The association between the severity of acute illness and readiness to change depended on the instrument used. A higher severity of illness measured by APACHEII score was an independent predictor of readiness to change as assessed by the Stages of Change Readiness and Treatment Eagerness Scale (Taking Action scale) (p< 0.01). When a visual analog scale was used to assess readiness to change, there was a significant association with severity of acute illness (p < 0.01) that was modified by the severity of unhealthy alcohol use (p = 0.04 for interaction term).
Conclusion
Medical ICU patients represent a population where brief interventions require further study. Studies of brief intervention should account for the severity of acute illness and the severity of unhealthy alcohol use as potential effect modifiers.
doi:10.1111/j.1530-0277.2011.01648.x
PMCID: PMC3251713  PMID: 21950704
12.  Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness 
Critical Care  2011;15(5):R231.
Introduction
Dysphagia is common among survivors of critical illness who required mechanical ventilation during treatment. The risk factors associated with the development of postextubation dysphagia, and the effects of dysphagia on patient outcomes, have been relatively unexplored.
Methods
We conducted a retrospective, observational cohort study from 2008 to 2010 of all patients over 17 years of age admitted to a university hospital ICU who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist.
Results
A BSE was performed after mechanical ventilation in 25% (630 of 2,484) of all patients. After we excluded patients with stroke and/or neuromuscular disease, our study sample size was 446 patients. We found that dysphagia was present in 84% of patients (n = 374) and classified dysphagia as absent, mild, moderate or severe in 16% (n = 72), 44% (n = 195), 23% (n = 103) and 17% (n = 76), respectively. In univariate analyses, we found that statistically significant risk factors for severe dysphagia included long duration of mechanical ventilation and reintubation. In multivariate analysis, after adjusting for age, gender and severity of illness, we found that mechanical ventilation for more than seven days remained independently associated with moderate or severe dysphagia (adjusted odds ratio (AOR) = 2.84 [interquartile range (IQR) = 1.78 to 4.56]; P < 0.01). The presence of severe postextubation dysphagia was significantly associated with poor patient outcomes, including pneumonia, reintubation, in-hospital mortality, hospital length of stay, discharge status and surgical placement of feeding tubes. In multivariate analysis, we found that the presence of moderate or severe dysphagia was independently associated with the composite outcome of pneumonia, reintubation and death (AOR = 3.31 [IQR = 1.89 to 5.90]; P < 0.01).
Conclusions
In a large cohort of critically ill patients, long duration of mechanical ventilation was independently associated with postextubation dysphagia, and the development of postextubation dysphagia was independently associated with poor patient outcomes.
doi:10.1186/cc10472
PMCID: PMC3334778  PMID: 21958475

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