Background and objectives Although venous congestion has been linked to renal dysfunction in heart failure, its significance in a broader context has not been investigated.Design, setting, participants, & measurements Using an inception cohort of 12,778 critically ill adult patients admitted to an urban tertiary medical center between 2001 and 2008, we examined whether the presence of peripheral edema on admission physical examination was associated with an increased risk of AKI within the first 7 days of critical illness. In addition, in those with admission central venous pressure (CVP) measurements, we examined the association of CVPs with subsequent AKI. AKI was defined using the Kidney Disease Improving Global Outcomes criteria.Results Of the 18% (n=2338) of patients with peripheral edema on admission, 27% (n=631) developed AKI, compared with 16% (n=1713) of those without peripheral edema. In a model that included adjustment for comorbidities, severity of illness, and the presence of pulmonary edema, peripheral edema was associated with a 30% higher risk of AKI (95% confidence interval [95% CI], 1.15 to 1.46; P,0.001), whereas pulmonary edema was not significantly related to risk. Peripheral edema was also associated with a 13% higher adjusted risk of a higher AKI stage (95% CI, 1.07 to 1.20; P,0.001). Furthermore, levels of trace, 1+, 2+, and 3+ edema were associated with 34% (95% CI, 1.10 to 1.65), 17% (95% CI, 0.96 to 1.14), 47% (95% CI, 1.18 to 1.83), and 57% (95% CI, 1.07 to 2.31) higher adjusted risk of AKI, respectively, compared with edema-free patients. In the 4761 patients with admission CVP measurements, each 1 cm H 2 O higher CVP was associated with a 2% higher adjusted risk of AKI (95% CI, 1.00 to 1.03; P=0.02).Conclusions Venous congestion, as manifested as either peripheral edema or increased CVP, is directly associated with AKI in critically ill patients. Whether treatment of venous congestion with diuretics can modify this risk will require further study.

Background: Childhood pneumonia is a leading cause of mortality worldwide. Growing evidence suggests that lung ultrasound (LUS) may be a reliable diagnostic alternative to chest x-ray for childhood pneumonia. However, it is unclear whether sonographer experience affects the diagnostic accuracy of LUS. We summarize the diagnostic accuracy of LUS for pneumonia and compare the performance between novice and advanced sonographers with a systematic review and meta-analysis. Methods:We searched PubMed and EMBASE from inception to February 2018 for eligible studies that evaluated the utility of LUS in children suspected of having pneumonia against the reference standard of either imaging results alone or a combination of clinical, laboratory, and imaging results. We reported the study using the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies. We used QUADAS-2 to appraise the included studies' methodologic quality. We employed a random-effect bivariate model and a hierarchical summary receiver operating characteristic curve to evaluate LUS's performance characteristics. We conducted subgroup analyses and meta-regression based on level of sonographer training to summarize and compare LUS's diagnostic accuracy for pneumonia between novice (training ≤ 7 days) and advanced sonographers.Results: Twenty-five studies (n = 3,353) were included in the meta-analysis. For diagnosing pneumonia, LUS demonstrated an overall sensitivity of 0.94 (95% confidence interval [CI] = 0.89 to 0.97), specificity of 0.92 (95% CI = 0.78 to 0.98), positive likelihood ratio of 12.40 (95% CI = 4.00 to 38.10), and negative likelihood ratio of 0.07 (95% CI = 0.04 to 0.12), with an area under ROC curve of 0.97 (95% CI = 0.95 to 0.98). Meta-regression revealed a significant difference in the diagnostic accuracy for pneumonia for LUS between novice and advanced sonographers (p < 0.01).Conclusion: LUS can accurately diagnose pneumonia in children. However, this test demonstrates operatordependent variability, with more experienced sonographers having higher diagnostic accuracy. Further work on evidence-based educational methods to train novice sonographers in LUS is required.

BACKGROUND:Indwelling arterial catheters (IACs) are used extensively in the ICU for hemodynamic monitoring and for blood gas analysis. IAC use also poses potentially serious risks, including bloodstream infections and vascular complications. Th e purpose of this study was to assess whether IAC use was associated with mortality in patients who are mechanically ventilated and do not require vasopressor support.

Hypomagnesemia can lead to cardiac arrhythmias. Recently, observational data has linked chronic proton pump inhibitor (PPI) exposure to hypomagnesemia. Whether PPI exposure increases the risk for arrhythmias has not been well studied. Using a large, single center inception cohort of critically ill patients, we examined whether PPI exposure was associated with admission electrocardiogram (ECG) readings of a cardiac arrhythmia in over 8000 patients. There were 24.5% PPI users while 6% were taking a histamine 2 antagonist. 14.3% had a cardiac arrhythmia. PPI use was associated with a 1.18 (95% CI=1.02–1.36, p=0.02) unadjusted and 0.96 (95% CI=0.83–1.12, p=0.62) adjusted risk of arrhythmia. Amongst diuretic users (n=2468), PPI use was similarly not associated with an increased risk of cardiac arrhythmia. In summary, in a large cohort of critically ill patients, PPI exposure is not associated with an increased risk of cardiac arrhythmia.

Attention: Mr, Fred C. Mattmueller Contract AT(ll-l)-926 COO-926-32 Gentlemen: ' Efforts to date thus far have not been successful in adequately describing a model for the flow of two-phase steam-vater mixtures through apertures. Two models are described in the Appendix to this report. Both models pertain to flashing from superheated liquid Jets; one model provides heat transfer by conduction, and the second model describes a turbulent heat transfer. The experimental program has been expanded and four new apertures have been ordered. Unfortunately the machining of the pressure taps proved to be most difficult, and consequently the apertures are now just being finished. Figure 1 illustrates the dimensions and pressure tap locations. Although our contract funds have been completely used and the contract time has been exceeded, the program will be continued until June, 1965* One Ph.D. graduate student will continue work with me. Other work which has been carried out include a reevaluation of the orifice coefficient and this work will be reported later. Critical two-phase flow models have been further studied, including some applications to liquid metals. This work, too, will be reported later. The general study of two-phase flow balances, critiques of other investigations, and further work on burnout models, although not supported by the past contract, are of direct interest to the overall purpose of the containment studies and will be noted in future reports, /-/~xAlso lnclj^d^irT^iis jg>p6rt Is tho^authp^^p a r t i o j patlon iryfcro p r e^r a t i o h o f a paper for the 1964 Geneva meeting.