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Objective:This study aimed to evaluate the rate of transfusion for cardiovascular surgeries between 2010 and 2019 in Republic of Korea and the association between blood transfusion and postoperative mortality. Methods: Data were extracted from the National Health Insurance Service database in Republic of Korea. This study includes adult patients who underwent cardiovascular surgery between 1 January 2010 and 31 December 2019. The endpoints were in-hospital mortality and the 1-year all-cause mortality. Results: The analysis included 62,794 cases, with transfusions used in 88.8% of cases. Multivariable logistic regression revealed that older age, comorbidities, hospital admission through the emergency room, aortic procedures (versus coronary artery bypass grafting), cardiopulmonary bypass, repeat procedures, and supportive therapies during the intensive care (extracorporeal membrane oxygenation and mechanical ventilation) were risk factors for blood transfusion. Female sex was associated with a lower risk of transfusion. Perioperative blood transfusion was associated with a 6.87-fold increased risk of in-hospital mortality (odds ratio [OR]: 6.87, 95% confidence interval [CI]: 3.95, 11.93; p < 0.001) and a 3.20-fold increased risk of 1-year all-cause mortality (OR: 3.35, 95% CI: 2.75, 3.93; p < 0.001). Conclusions: Blood transfusion is used at a high rate in cardiovascular surgeries, and it was associated with increases in the risk of in-hospital and 1-year all-cause mortality. However, these correlations should be viewed with caution as emergent phenomena rather than causative. Understanding factors associated with the need for blood transfusion can assist surgeons in predicting the outcomes of cardiovascular surgery and in tailoring procedures as needed to optimize outcomes. [ABSTRACT FROM AUTHOR]

Background Solid organ transplant recipients (SOTRs) are at higher risk for severe infection. However, the risk for severe COVID-19 and vaccine effectiveness among SOTRs remain unclear. Methods This retrospective study used a nationwide health care claims database and COVID-19 registry from the Republic of Korea (2020 to 2022). Adult SOTRs diagnosed with COVID-19 were matched with up to 4 non-SOTR COVID-19 patients by propensity score. Severe COVID-19 was defined as treatment with high-flow nasal cannulae, mechanical ventilation, or extracorporeal membrane oxygenation. Results Among 6783 SOTRs with COVID-19, severe COVID-19 was reported with the highest rate in lung transplant recipients (13.16%), followed by the heart (6.30%), kidney (3.90%), and liver (2.40%). SOTRs had a higher risk of severe COVID-19 compared to non-SOTRs, and lung transplant recipients showed the highest risk (adjusted odds ratio, 18.14; 95% confidence interval [CI], 8.53–38.58). Vaccine effectiveness against severe disease among SOTRs was 47% (95% CI, 18%–65%), 64% (95% CI, 49%–75%), and 64% (95% CI, 29%–81%) for 2, 3, and 4 doses, respectively. Conclusions SOTRs are at significantly higher risk for severe COVID-19 compared to non-SOTRs. Vaccination is effective in preventing the progression to severe COVID-19. Efforts should be made to improve vaccine uptake among SOTRs, while additional protective measures should be developed. [ABSTRACT FROM AUTHOR]

The pituitary gland is either directly or indirectly impacted by SARS-CoV-2 infection. As a consequence of SARS-CoV-2 infection, hypothalamic–pituitary dysfunction or pituitary apoplexy can occur. This study aimed to investigate severe COVID-19 outcomes and COVID-19-related mortality in patients with underlying pituitary disease in Korea using a nationwide cohort database. The data required for this study were obtained from the Health Insurance Review and Assessment Service of Korea. Patients with SARS-CoV-2 infection between January 2020 and December 2021 were divided into the following three groups and analyzed: Group A, those who were hospitalized for SARS-CoV-2 infection without underlying pituitary disease (n = 725,170); Group B, those who were hospitalized for SARS-CoV-2 infection with underlying pituitary disease without exposure to systemic steroids (n = 1509); and Group C, patients with underlying pituitary disease and exposure to systemic steroids (n = 365). Differences in severe COVID-19, requirement for oxygen therapy, intensive care unit admission, application of invasive ventilation or use of extracorporeal membrane oxygenation, and COVID-19-related deaths between groups were then analyzed. Group C had the highest rates of hospitalization after COVID-19 infection (82.2%) and mortality within 30 days of infection (6.8%). Group B had a 1.3-fold increase in severe COVID-19 outcomes compared to Group A. Group C had 1.8-fold and 1.3-fold increases in severe COVID-19 outcomes compared to Group A and Group B, respectively. Group C also had 2.34 and 3.24 times higher mortality rates within 30 days of COVID-19 infection than Group A and Group B, respectively. In conclusion, patients with pituitary disease who are receiving systemic steroids have poorer outcomes and higher mortality associated with COVID-19. Therefore, thorough COVID-19 infection control is required in these patients. [ABSTRACT FROM AUTHOR]

Background: The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) remains controversial in trauma patients with acute respiratory distress syndrome (ARDS). Here, we aimed to investigate the therapeutic benefits of VV ECMO and the factors affecting patient outcomes. Methods: From 2017 to 2019, 21/1938 trauma patients (median age: 47 years; 18 men) at a level I trauma center received VV ECMO for post-traumatic ARDS. Demographic, injury-specific, ECMO, and outcome data were prospectively collected and retrospectively reviewed to analyze the factors affecting hospital mortality and ECMO results. Results: 19 patients (90.5%) were successfully weaned off ECMO; 16 patients (76.2%) survived to discharge. In univariate analysis, there was a significant difference in survival between the groups with a Trauma and Injury Severity Score (TRISS) ⩾0.5 and TRISS <0.5 (p = 0.05). The area under the receiver operating characteristic curve (AUC) for both TRISS and Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) scores for death was 0.78. In those who failed ECMO weaning, the AUCs of the TRISS and RESP scores were 0.90 and 0.80, respectively. Conclusions: In patients with ARDS caused by severe trauma and supported by VV ECMO, survival is associated with TRISS; TRISS and RESP scores may be predictive of mortality and failure in ECMO weaning. [ABSTRACT FROM AUTHOR]

Background: Respiratory quotient (RQ) may be used as a tissue hypoxia marker in various clinical settings but its prognostic significance in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) is not known. Methods: Medical records of adult patients admitted to the intensive care units after ECPR in whom RQ could be calculated from May 2004 to April 2020 were retrospectively reviewed. Patients were divided into good neurologic outcome and poor neurologic outcome groups. Prognostic significance of RQ was compared to other clinical characteristics and markers of tissue hypoxia. Results: During the study period, 155 patients were eligible for analysis. Of them, 90 (58.1%) had a poor neurologic outcome. The group with poor neurologic outcome had a higher incidence of out-of-hospital cardiac arrest (25.6% vs. 9.2%, P=0.010) and longer cardiopulmonary resuscitation to pump-on time (33.0 vs. 25.2 minutes, P=0.001) than the group with good neurologic outcome. For tissue hypoxia markers, the group with poor neurologic outcome had higher RQ (2.2 vs. 1.7, P=0.021) and lactate levels (8.2 vs. 5.4 mmol/L, P=0.004) than the group with good neurologic outcome. On multivariable analysis, age, cardiopulmonary resuscitation to pump-on time, and lactate levels above 7.1 mmol/L were significant predictors for a poor neurologic outcome but not RQ. Conclusions: In patients who received ECPR, RQ was not independently associated with poor neurologic outcome. [ABSTRACT FROM AUTHOR]

Soluble suppression of tumorigenesis-2 (sST2) is an emerging biomarker for sepsis as well as for heart failure. We investigated the prognostic utility of sST2 for predicting clinical outcomes in hospitalized coronavirus disease 2019 (COVID-19) patients. In a total of 52 hospitalized COVID-19 patients, sST2 levels were measured using the ichroma ST2 assay (Boditech Med Inc., Chuncheon-si, Gang-won-do, Republic of Korea). Clinical outcomes included intensive care unit (ICU) admission, ventilator use, extracorporeal membrane oxygenation (ECMO) use, and 30-day mortality. sST2 was analyzed according to clinical outcomes. sST2, sequential organ failure assessment (SOFA) score, critical disease, and 4C mortality score were compared using the receiver operating characteristic (ROC) curve and Kaplan–Meier methods for clinical outcomes. The sST2 level differed significantly according to ICU admission, ventilator use, ECMO use, and 30-day mortality (all p < 0.05). On ROC curve analysis, sST2 predicted ICU admission, ventilator use, ECMO use, and 30-day mortality comparable to SOFA score but significantly better than critical disease. sST2 predicted ICU admission, ventilator use, and ECMO use significantly better than the 4C mortality score. On Kaplan–Meier survival analysis, hazard ratios (95% confidence interval) were 8.4 (2.7–26.8) for sST2, 14.8 (3.0–71.7) for SOFA score, 1.8 (0.5–6.5) for critical disease, and 11.7 (3.4–40.1) for 4C mortality score. This study demonstrated that sST2 could be a useful biomarker to predict ICU admission, ventilator use, ECMO use, and 30-day mortality in hospitalized COVID-19 patients. sST2 may be implemented as a prognostic COVID-19 biomarker in clinical practice. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to investigate trends in extracorporeal membrane oxygenation (ECMO) treatment during 2005–2018 and examine factors associated with in-hospital mortality. Methods: We conducted a population-based cohort study based on health records obtained from the National Health Insurance Service database in South Korea. All adult patients (⩾18 years old) who received ECMO treatment in the intensive care unit after hospitalization from 2005 to 2018 were enrolled. Results: We analyzed data for 21,129 adult ECMO patients from 128 hospitals. The prevalence of ECMO treatment gradually and continuously increased from 4 per 100,000 individuals (95% confidence interval [CI]: 3–4) in 2005 to 67.4 per 100,000 individuals (95% CI: 65–68) in 2018. There was a significant increase in ECMO treatment for acute respiratory distress syndrome (ARDS) or respiratory failure (from 2.5% during 2005–2008 to 14.5% during 2016–2018). The overall in-hospital and 30-day mortality rates of the patients were 48.4% and 53.5%, respectively. The in-hospital mortality rate was highest among patients with shock (62.1%) and lowest among ECMO patients with liver failure (21.6%). On multivariable logistic regression, a higher hospital case volume was associated with improvement in in-hospital mortality (p < 0.001). Conclusions: In South Korea, the prevalence of ECMO treatment has increased gradually and continuously between 2005 and 2018. There was a significant increase in the prevalence of ECMO treatment for ARDS or respiratory failure. Our results support that ECMO treatment indications have been expanding, and ECMO will become vital for treating critically ill patients in the future. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID-19) during pregnancy is associated with increased disease severity and an increased risk of perinatal complications. However, few studies of pregnant women with COVID-19 have been conducted in Korea. The purpose of this study was to describe the clinical course and pregnancy outcomes of pregnant women admitted to our hospital with COVID-19 according to the severity. Materials and Methods: This retrospective cohort study included women aged 18 years of age or older who were hospitalized in the Gachon University Gil Medical Center with COVID-19 during pregnancy between July 1, 2021 and January 31, 2022. COVID-19 severity was classified according to the “Criteria for severity classification by symptoms of COVID-19” presented by the Korea Disease Control and Prevention Agency. Severe cases were defined as those who required oxygen treatment administered via a high-flow nasal cannula or invasive mechanical ventilation or should be applied extracorporeal membrane oxygenation (ECMO) or continuous renal replacement therapy. Results: A total of 103 pregnant women were hospitalized with COVID-19 during the study period. Their mean age was 33 (± 4.14) years, and 4 (3.9%) had been vaccinated against COVID-19. At the time of diagnosis of COVID-19, 3 (2.9%), 33 (32.0%), and 67 (65.1%) patients were in the first, second, and third trimester, respectively. The most common symptoms were cough (99 patients, 96.1%) and fever (85 patients, 82.5%). There was 1 (1.0%) asymptomatic patient. Forty patients (38.8%) required supplemental oxygen and 19 patients (18.4%) had severe disease. Of the 19 severe cases, 7 were in the 2nd trimester and 12 were in the 3rd trimester. Forty-one (39.8%) patients delivered, including two twin deliveries. Of the 41 cases of delivery, 14 were premature, 4 out of 21 (19.0%) in mild, 4 out of 12 (25.0%) in moderate, and 6 out of 8 (75.0%) in severe. Severe disease was associated with an increased rate of preterm birth (P = 0.012). Four of the 43 neonates (9.1%) received oxygen treatment. Conclusion: Pregnant women with COVID-19 had a high rate of severe disease and a high preterm delivery rate, especially among those with severe disease. [ABSTRACT FROM AUTHOR]

The ability to accurately predict the prognosis and intervention requirements for treating highly infectious diseases, such as COVID-19, can greatly support the effective management of patients, especially in resource-limited settings. The aim of the study is to develop and validate a multimodal artificial intelligence (AI) system using clinical findings, laboratory data and AI-interpreted features of chest X-rays (CXRs), and to predict the prognosis and the required interventions for patients diagnosed with COVID-19, using multi-center data. In total, 2282 real-time reverse transcriptase polymerase chain reaction-confirmed COVID-19 patients' initial clinical findings, laboratory data and CXRs were retrospectively collected from 13 medical centers in South Korea, between January 2020 and June 2021. The prognostic outcomes collected included intensive care unit (ICU) admission and in-hospital mortality. Intervention outcomes included the use of oxygen (O2) supplementation, mechanical ventilation and extracorporeal membrane oxygenation (ECMO). A deep learning algorithm detecting 10 common CXR abnormalities (DLAD-10) was used to infer the initial CXR taken. A random forest model with a quantile classifier was used to predict the prognostic and intervention outcomes, using multimodal data. The area under the receiver operating curve (AUROC) values for the single-modal model, using clinical findings, laboratory data and the outputs from DLAD-10, were 0.742 (95% confidence interval [CI], 0.696–0.788), 0.794 (0.745–0.843) and 0.770 (0.724–0.815), respectively. The AUROC of the combined model, using clinical findings, laboratory data and DLAD-10 outputs, was significantly higher at 0.854 (0.820–0.889) than that of all other models (p < 0.001, using DeLong's test). In the order of importance, age, dyspnea, consolidation and fever were significant clinical variables for prediction. The most predictive DLAD-10 output was consolidation. We have shown that a multimodal AI model can improve the performance of predicting both the prognosis and intervention in COVID-19 patients, and this could assist in effective treatment and subsequent resource management. Further, image feature extraction using an established AI engine with well-defined clinical outputs, and combining them with different modes of clinical data, could be a useful way of creating an understandable multimodal prediction model. [ABSTRACT FROM AUTHOR]

Background: This study aimed to investigate the prevalence of 7‐, 30‐, 60‐, and 365‐day overall and cause‐specific mortality following extracorporeal membrane oxygenation (ECMO) support. Methods: The National Health Insurance claims database in South Korea was the data source for this population‐based cohort study. We enrolled all adult patients aged ≥18 years receiving intensive care unit ECMO support from January 1, 2005 to December 31, 2018. The study population was divided into three groups based on the main diagnoses during ECMO support: (1) cardiovascular, (2) respiratory, and (3) other diagnoses group (all other main diagnoses rather than cardiovascular or respiratory diseases). Results: A total of 18 697 patients were included in the final analysis (64.5%, 10.9%, and 24.6% in the cardiovascular, respiratory, and other groups, respectively). The corresponding 7‐, 30‐, 60‐, and 365‐day mortality rates in these groups were 33.1%, 56.1%, 62.4%, and 67.7%. Kaplan–Meier curves demonstrated that the median survival time was shortest in the cardiovascular group (12.0 days, 95% confidence interval [CI]: 11.3–12.7), with 31.0 (95% CI: 28.5–33.6) and 49.0 (95% CI: 44.4–57.6) day survival in the respiratory and other diagnoses groups (p < 0.001). Conclusions: Approximately one‐third of patients died within 7 days, half of the patients died within 30 days, and two‐thirds died within 365 days of ECMO support. Overall survival time was shortest in the cardiovascular group, followed by that of the respiratory group. [ABSTRACT FROM AUTHOR]

Summary: We investigated the prevalence of insomnia in extracorporeal membrane oxygenation (ECMO)‐treated patients and examined the association between post‐ECMO insomnia disorder and long‐term mortality. In the present population‐based cohort study, we used data from the National Health Insurance Claims database in South Korea. All adult patients who underwent ECMO between 2006 and 2014 were included, and ECMO‐treated patients were defined as those who survived >365 days after ECMO. Insomnia disorder was identified using the International Classification of Diseases 10th Revision codes G47.0 and F51.0. Overall, 3,055 ECMO‐treated patients were included in the final analysis: 431 (14.1%) had pre‐ECMO insomnia disorder, while 148 (4.8%) were newly diagnosed with insomnia disorder up to 1 year after ECMO. In multivariable Cox regression model, patients with post‐ECMO insomnia disorder had higher 5‐year all‐cause mortality (ACM) than controls (hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.21–2.42; p = 0.003); however, those with pre‐ECMO insomnia disorder did not (p = 0.655). In sensitivity analysis, post‐ECMO insomnia disorder with underlying psychiatric illness was associated with a 2.39‐fold higher 5‐year ACM in ECMO‐treated patients (HR 2.39, 95% CI 1.52–3.75; p < 0.001). In conclusion, at 1‐year after ECMO, 4.8% of ECMO‐treated patients were newly diagnosed with insomnia disorder, and post‐ECMO insomnia disorder was associated with higher 5‐year ACM, especially in those with underlying psychiatric illness. Our present results suggest that the development of insomnia disorder might be related to poorer long‐term survival in ECMO‐treated patients, especially in case of underlying psychiatric illness. [ABSTRACT FROM AUTHOR]

We examined and compared the clinical characteristics of acute respiratory distress syndrome (ARDS) patients who received and did not receive extracorporeal membrane oxygenation (ECMO) support. The national health insurance database of South Korea was used to obtain real-world data. All adult patients admitted to intensive care units for ARDS treatment between 1 January 2014 and 31 December 2019 were included in this study. Of the 10,173 patients with ARDS included in the analysis, 740 (7.3%) received ECMO support for a mean duration of 1.6 days (standard deviation [SD]: 2.8 days) and were assigned to the ECMO group. The ECMO group had a significantly lower mean age at 57.0 years (SD: 15.7 years) than the non-ECMO group (71.8 Â years [SD: 15.1 Â years], P < 0.001). In multivariable logistic regression, a 1-year increase in age was associated with a 5% lower prevalence of ECMO support. The annual case volume was classified into four groups by quartile ratio (Q1 [lowest], Q2, Q3, and Q4 [highest]), and Q2, Q3, and Q4 groups showed a higher prevalence of ECMO support than the Q1 group. ECMO support was also performed more frequently in high case volume centers than in low case volume centers for ARDS patients. [ABSTRACT FROM AUTHOR]

We aimed to investigate the associations of previous influenza/URI with the susceptibility of COVID-19 patients compared to that of non-COVID-19 participants. A nationwide COVID-19 cohort database was collected by the Korea National Health Insurance Corporation. A total of 8,070 COVID-19 patients (1 January 2020 through 4 June 2020) were matched with 32,280 control participants. Severe COVID-19 morbidity was defined based on the treatment histories of the intensive care unit, invasive ventilation, and extracorporeal membrane oxygenation and death. The susceptibility/morbidity/mortality associated with prior histories of 1–14, 1–30, 1–90, 15–45, 15–90, and 31–90 days before COVID-19 onset were analyzed using conditional/unconditional logistic regression. Prior influenza infection was related to increased susceptibility to COVID-19 (adjusted odds ratio [95% confidence interval] = 3.07 [1.61–5.85] for 1–14 days and 1.91 [1.54–2.37] for 1–90 days). Prior URI was also associated with increased susceptibility to COVID-19 (6.95 [6.38–7.58] for 1–14 days, 4.99 [4.64–5.37] for 1–30 days, and 2.70 [2.55–2.86] for 1–90 days). COVID-19 morbidity was positively associated with influenza (3.64 [1.55–9.21] and 3.59 [1.42–9.05]) and URI (1.40 [1.11–1.78] and 1.28 [1.02–1.61]) at 1–14 days and 1–30 days, respectively. Overall, previous influenza/URI did not show an association with COVID-19 mortality. Previous influenza/URI histories were associated with increased COVID-19 susceptibility and morbidity. Our findings indicate why controlling influenza/URI is important during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Objectives: The quality of life after extracorporeal membrane oxygenation therapy has emerged as an important issue for extracorporeal membrane oxygenation survival; however, its association with long-term prognosis has not been identified. We investigated the changes in the quality of life after extracorporeal membrane oxygenation among the survivors and examine the association between a worse quality of life and 3-year all-cause mortality.Design: This was a population-based cohort study.Setting: Data were obtained from the National Health Insurance Service database in South Korea.Patients: Adult individuals (≥ 18 yr old) who received extracorporeal membrane oxygenation therapy from 2006 to 2017 were included. Extracorporeal membrane oxygenation survivors were defined as patients who had survived for 1-year after the initiation of extracorporeal membrane oxygenation therapy.Interventions: None.Measurements and Main Results: The income level, employment status, and registered disability were examined before and 1-year after extracorporeal membrane oxygenation therapy. The decreased income level, job loss, and newly acquired disability were considered as change in the quality of life among extracorporeal membrane oxygenation survivors. A total of 5,821 adult extracorporeal membrane oxygenation survivors were included in the final analysis, and 2,959 patients (50.8%) experienced quality of life change. Specifically, 1,782 patients (30.6%) experienced a decrease in income, 682 (11.7%) lost their jobs, and 1,540 (26.5%) had a new disability within 1-year after extracorporeal membrane oxygenation therapy. In the multivariable Cox regression model, newly acquired disability was associated with 2.31-fold higher 3-year all-cause mortality among extracorporeal membrane oxygenation survivors (hazard ratio, 2.31; 95% CI, 1.79-2.97; p < 0.001), while job loss (p = 0.180) and decreased income (p = 0.993) were not associated with the 3-year all-cause mortality.Conclusions: At 12 months after extracorporeal membrane oxygenation therapy, nearly half survivors experienced quality of life worsening such as unemployment, decreased income, and new disability. Additionally, among the three factors, acquiring a new disability might significantly increase the 3-year mortality. This is the first study to report the association between changes in the quality of life and long-term prognosis in extracorporeal membrane oxygenation survivors. [ABSTRACT FROM AUTHOR]

Background: Quality of life following extracorporeal membrane oxygenation (ECMO) therapy is an important health issue. We aimed to describe the characteristics of patients who developed chronic respiratory disease (CRD) following ECMO therapy, and investigate the association between newly diagnosed post-ECMO CRDs and 5-year all-cause mortality among ECMO survivors.Methods: We analyzed data from the National Health Insurance Service in South Korea. All adult patients who underwent ECMO therapy in the intensive care unit between 2006 and 2014 were included. ECMO survivors were defined as those who survived for 365 days after ECMO therapy. Chronic obstructive pulmonary disease (COPD), asthma, interstitial lung disease, lung cancer, lung disease due to external agents, obstructive sleep apnea, and lung tuberculosis were considered as CRDs.Results: A total of 3055 ECMO survivors were included, and 345 (11.3%) were newly diagnosed with CRDs 365 days after ECMO therapy. The prevalence of asthma was the highest at 6.1% (185). In the multivariate logistic regression, ECMO survivors who underwent ECMO therapy for acute respiratory distress syndrome (ARDS) or respiratory failure had a 2.00-fold increase in post-ECMO CRD (95% confidence interval [CI]: 1.39 to 2.89; P < 0.001). In the multivariate Cox regression, newly diagnosed post-ECMO CRD was associated with a 1.47-fold (95% CI: 1.17 to 1.86; P = 0.001) higher 5-year all-cause mortality.Conclusions: At 12 months after ECMO therapy, 11.3% of ECMO survivors were newly diagnosed with CRDs. Patients who underwent ECMO therapy for ARDS or respiratory failure were associated with a higher incidence of newly diagnosed post-ECMO CRD compared to those who underwent ECMO for other causes. Additionally, post-ECMO CRDs were associated with a higher 5-year all-cause mortality. Our results suggest that ECMO survivors with newly diagnosed post-ECMO CRD might be a high-risk group requiring dedicated interventions. [ABSTRACT FROM AUTHOR]

Introduction: Pump-controlled retrograde trial off has recently been introduced as an effective method for weaning from veno-arterial extracorporeal membrane oxygenation in pediatric patients. However, studies on pump-controlled retrograde trial off in adults are still lacking. Thus, this study aimed to examine the outcomes of pump-controlled retrograde trial off for weaning from veno-arterial extracorporeal membrane oxygenation in adult patients. Methods: Between January 2018 and July 2019, 87 consecutive adult patients underwent veno-arterial extracorporeal membrane oxygenation support, of whom 47 (54.0%) underwent pump-controlled retrograde trial off for weaning from extracorporeal membrane oxygenation and were enrolled in this study. The pump-controlled retrograde trial off results, extracorporeal membrane oxygenation reapplication rate, and clinical outcomes were analyzed. Results: Of the 47 patients, 38 (80.9%) were weaned from veno-arterial extracorporeal membrane oxygenation on the first attempt of pump-controlled retrograde trial off, 5 (10.6%) on the second attempt, and 4 (8.5%) on the third attempt. Three patients were converted to venovenous extracorporeal membrane oxygenation by desaturation but had stable blood pressure during pump-controlled retrograde trial off. No extracorporeal membrane oxygenation reapplication was performed within 3 days after removal, and two patients underwent veno-arterial extracorporeal membrane oxygenation during follow-up. No complications associated with pump-controlled retrograde trial off occurred during the weaning process, including thromboembolic events. Five in-hospital deaths (10.6%) occurred after weaning from extracorporeal membrane oxygenation. Conclusion: Pump-controlled retrograde trial off is an effective method to safely wean from veno-arterial extracorporeal membrane oxygenation in adult patients. It is simple and can be easily implemented without additional invasive procedures and may help prevent deterioration of the cardiovascular system after weaning from veno-arterial extracorporeal membrane oxygenation. [ABSTRACT FROM AUTHOR]

Objectives: To identify whether the prognostic implications of Vasoactive Inotropic Score according to use of mechanical circulatory support differ in the treatment of acute myocardial infarction complicated by cardiogenic shock.Design: A multicenter retrospective and prospective observational cohort study.Setting/patient: The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy registry includes 1,247 patients with cardiogenic shock from 12 centers in Korea. A total of 836 patients with acute myocardial infarction complicated by cardiogenic shock were finally selected, and the study population was stratified by quartiles of Vasoactive Inotropic Score (< 10, 10-30, 30-90, and > 90) for the present study.Interventions: None.Measurements and Main Results: Primary endpoint was in-hospital mortality and secondary endpoint was follow-up mortality. Among the study population, 326 patients (39.0%) received medical treatment alone, 218 (26.1%) received intra-aortic balloon pump, and 292 (34.9%) received extracorporeal membrane oxygenation. In-hospital mortality occurred in 305 patients (36.5%) and was significantly higher in patients with higher Vasoactive Inotropic Score (15.6%, 20.8%, 40.2%, and 67.3%, for < 10, 10-30, 30-90, and > 90; p < 0.001). Vasoactive Inotropic Score showed better ability to predict in-hospital mortality in acute myocardial infarction patients with cardiogenic shock who received medical treatment alone (area under the curve: 0.797; 95% CI, 0.728-0.865) than in those who received intra-aortic balloon pump (area under the curve, 0.704; 95% CI, 0.625-0.783) or extracorporeal membrane oxygenation (area under the curve, 0.644; 95% CI, 0.580-0.709). The best cutoff value of Vasoactive Inotropic Score for the prediction of in-hospital mortality also differed according to the use of mechanical circulatory support (16.5, 40.1, and 84.0 for medical treatment alone, intra-aortic balloon pump, and extracorporeal membrane oxygenation, respectively). There was a significant interaction between Vasoactive Inotropic Score as a continuous value and the use of mechanical circulatory support including intra-aortic balloon pump (interaction-p = 0.006) and extracorporeal membrane oxygenation (interaction-p < 0.001) for all-cause mortality during follow-up.Conclusions: High Vasoactive Inotropic Score was associated with significantly higher in-hospital and follow-up mortality in patients with acute myocardial infarction complicated by cardiogenic shock. The predictive value of Vasoactive Inotropic Score for mortality was significantly higher in acute myocardial infarction patients with cardiogenic shock treated by medical treatment alone than in those treated by mechanical circulatory support such as intra-aortic balloon pump or extracorporeal membrane oxygenation. [ABSTRACT FROM AUTHOR]

Background: Unavailability or saturation of the intensive care unit may be associated with the fatality of COVID-19. Prioritizing the patients for hospitalization and intensive care may be critical for reducing the fatality of COVID-19. This study aimed to develop and validate a new integer-based scoring system for predicting patients with COVID-19 requiring intensive care, using only the predictors available upon triage. Methods: This is a retrospective study using cohort data from the Korean Centers for Disease Control and Prevention that included all admitted patients with COVID-19 between January 19 and June 3, 2020, in South Korea. The primary outcome was patients requiring intensive care defined as actual admission to the intensive care unit; at any time use of an extracorporeal life support device, mechanical ventilation, or vasopressors; and death. Patients admitted until March 20 were included for the training dataset to develop the prediction models and externally validated for the patients admitted afterward. Two logistic regression models were developed with different predictors and the predictive performance was compared: one with patient-provided variables and the other with added radiologic and laboratory variables. An integer-based scoring system was developed based on the developed logistic regression model. Results: A total of 5193 patients were considered, with 4663 patients included after excluding patients with age under 18 or insufficient data. For the training dataset, 3238 patients were included. Of the included patients, 444 (9.5%) patients required intensive care. The model developed with only the clinical variables showed an area under the curve of 0.884 for the validation set. The performance did not differ when radiologic and laboratory variables were added. Seven variables were selected for developing an integer-based scoring system: age, sex, initial body temperature, dyspnea, hemoptysis, history of chronic kidney disease, and activities of daily living. The area under the curve of the scoring system was 0.880. Conclusions: An integer-based scoring system was developed for predicting patients with COVID-19 requiring intensive care, with high performance. This system may aid decision support for prioritizing the patient for hospitalization and intensive care, particularly in a situation with limited medical resources. [ABSTRACT FROM AUTHOR]

Background: The use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation has greatly increased. However, data regarding the clinical outcomes of this approach are lacking. The objective of this multicenter prospective observational cohort study was to evaluate lung transplantation outcomes in Korean Organ Transplantation Registry (KOTRY) patients for whom ECMO was used as a bridge to transplantation.Methods: Between March 2015 and December 2017, a total of 112 patients received lung transplantation and were registered in the KOTRY, which is a prospective, multicenter cohort registry. The entire cohort was divided into two groups: the control group (n = 85, 75.9%) and bridge-ECMO group (n = 27, 24.1%).Results: There were no significant differences in pre-transplant and intraoperative characteristics except for poorer oxygenation, more ventilator use, and longer operation time in the bridge-ECMO group. The prevalence of primary graft dysfunction at 0, 24, 48, and 72 h after transplantation did not differ between the two groups. Although postoperative hospital stays were longer in the bridge-ECMO group than in the control group, hospital mortality did not differ between the two groups (25.9% vs. 13.3%, P = 0.212). The majority of patients (70.4% of the bridge-ECMO group and 77.6% of the control group) were discharged directly to their homes. Finally, the use of ECMO as a bridge to lung transplantation did not significantly affect overall survival and graft function.Conclusions: Short- and long-term post-transplant outcomes of bridge-ECMO patients were comparable to recipients who did not receive ECMO. [ABSTRACT FROM AUTHOR]

There was a pandemic of influenza A (H1N1) in 2009; in Korea, there was also an H1N1 epidemic in 2016. We aim to investigate whether survival had improved in the setting of recent advances in intensive care unit (ICU) management. We conducted a retrospective analysis of acute respiratory failure patients with H1N1 influenza pneumonia in 2016 and 2009 respectively at two tertiary referral hospitals in Korea. A total of 28 patients were treated in 2016, and 34 in 2009. There was no significant difference in SOFA scores on ICU admission day. In-hospital mortality was significantly lower in patients of 2016 compared to those of 2009 (18% vs. 44% P = 0.028). By multivariable analyses, the treatment year 2016 was associated with a greater likelihood of survival. Compared to the patients treated in 2009, those treated in 2016 were one seventh as likely to die after adjusting for other clinical variables (hazard ratio for mortality, 0.15; 95% confidence interval. 0.03–0.63, P = 0.010). Improved survival in patients who underwent extracorporeal membrane oxygenation treatment (in-hospital mortality, 17% vs. 60%, P = 0.242) and decreased tidal volumes during mechanical ventilation (median 5.4 mL/kg vs. median 9.2 mL/kg, P = 0.018) were observed in 2016 compared to 2009. Treatment outcomes for patients with H1N1 acute respiratory failure improved from 2009 to 2016 in two tertiary referral centers in South Korea. [ABSTRACT FROM AUTHOR]

BACKGROUND: Better outcomes have been observed in patients with acute unprovoked than provoked pulmonary embolism (PE). Prognostic biomarkers were studied in heterogeneous patient population and were not verified in patients with unprovoked PE. METHODS: Patients diagnosed with unprovoked acute PE from 2010 to 2017 at Asan Medical Center, South Korea, were analyzed retrospectively. Adverse composite outcomes were defined as thrombolysis, thrombectomy, extracorporeal membrane oxygenation, or death. Venous blood samples were collected at the first visit before anticoagulant treatment. Biomarkers associated with composite outcomes were analyzed and compared with preexisting risk models. RESULTS: This study included 265 patients (48.7% male) with a median age of 66.0 (interquartile range 52.0, 75.0) years. Composite outcomes occurred in 20 (7.5%) patients. Hemoglobin, uric acid, and glucose were significantly and independently associated with adverse composite outcomes. This biomarker model showed the highest prognostic accuracy for adverse composite outcomes, with an area under the curve of 0.806 (95% confidence interval: 0.702–0.911,P < 0.001), which was significantly better than that of PE severity index (PESI) or simplified PESI, and comparable to that of the European Society of Cardiology (ESC) risk classification. CONCLUSIONS: The biomarker model including hemoglobin, uric acid, and glucose has good prognostic performance comparable to the ESC risk classification while PESI or simplified PESI score was not useful in unprovoked PE. [ABSTRACT FROM AUTHOR]

Managing acute respiratory distress syndrome (ARDS) after severe blunt traumatic lung injury can be challenging. In cases where patients are refractory to conventional therapy, extracorporeal membrane oxygenation (ECMO) should be considered. In addition, the heparin-coated circuit can reduce hemorrhagic complications in patients with multiple traumas. Although prolonged ECMO may be necessary, excellent outcomes are frequently associated. In this study, we report long-term support with venovenous-ECMO applied in a child with severe blunt trauma in Korea. This 10-year-old and 30-kg male with severe blunt thoracic trauma after a car accident developed severe ARDS a few days later, and ECMO was administered for 33 days. Because of pulmonary hemorrhage during ECMO support, heparin was stopped for 3 days and then restarted. He was weaned from ECMO successfully and has been able to run without difficulty for the 2 years since discharge. [ABSTRACT FROM AUTHOR]

Background: Dedicated intensive care unit (ICU) physician staffing is associated with a reduction in ICU mortality rates in general medical and surgical ICUs. However, limited data are available on the role of a cardiac intensivist in the cardiac intensive care unit (CICU).Objectives: This study investigated the association of cardiac intensivist-directed care with clinical outcomes in adult patients admitted to the CICU.Methods: This study analyzed 2,431 patients admitted to the CICU at Samsung Medical Center in Seoul, South Korea, from January 2012 to December 2015. In January 2013 the CICU was changed from a low-intensity staffing model to a high-intensity staffing model managed by a dedicated cardiac intensivist. Eligible patients were divided into either a low-intensity management group (n = 616) or a high-intensity management group (n = 1,815). One-to-many (1:N) propensity score matching with variable matching ratios was also performed. The primary outcome was death in the CICU.Results: Death in the CICU occurred in 55 patients (8.9%) in the low-intensity group versus 74 patients (4.1%) in the high-intensity group (p < 0.001). Of 135 patients who underwent extracorporeal membrane oxygenation, the CICU mortality rate in the high-intensity group was also lower than that in the low-intensity group (54.5% vs. 22.5%; p = 0.001). On propensity score matching, high-intensity staffing was found associated with a lower CICU mortality rate in the matched cohort of patients (7.5% vs. 3.7%; adjusted odds ratio: 0.53; 95% confidence interval: 0.32 to 0.86; p = 0.010). In overall and propensity-matched patients, there were no substantive differences in either median length of CICU stay or readmission rates between the 2 groups.Conclusions: The presence of a dedicated cardiac intensivist was associated with a reduction in CICU mortality rates in patients with cardiovascular disease who required critical care. [ABSTRACT FROM AUTHOR]

Objectives: We compared the ischemia and rescue rates according to the strategy of distal cannulation.Background: Limb ischemia developing during percutaneous venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is a potentially severe complication. Although appropriate use of a distal perfusion cannula can avoid ischemia, evidences about distal cannulation is still lacking.Methods: Patients who underwent peripheral VA ECMO between January 2010 and August 2015 were reviewed. We classified patients into 2 groups in terms of insertion timing with respect to the onset of ischemia. The preemptive strategy group underwent early insertion of a distal perfusion cannula at commencement of ECMO support. The rescue strategy group underwent delayed cannula insertion after onset of limb ischemia.Results: A total of 151 patients were included in the analysis. Forty-four patients formed the preemptive strategy group and 107 patients formed the rescue strategy group. In total, 10 of 151 (6.7%) patients developed significant limb ischemia, they all were the rescue strategy group (10/107, 9.3%). Of the 10 patients, 2 patients were rescued from limb ischemia after distal cannulation. Otherwise, ischemia was not rescued in the remaining eight patients. Of the latter 8, 3 patient required surgical interventions (2 fasciotomy and 1 below-the-knee amputation) and the other five died from disease aggravation prior to surgical intervention.Conclusions: Preemptive distal perfusion cannulation is safe and effective when used to prevent lower limb ischemia in patients undergoing femoral cannulation to treat ECMO. However, delayed distal cannulation increases the extent of cannulation site bleeding, without improving the ischemia. [ABSTRACT FROM AUTHOR]

Background: The benefit of extracorporeal life support (ECLS) in highly selective patients with out-of-hospital cardiac arrest (OHCA) is supported by previous studies; however, it is unclear whether the effects of ECLS are observed at a population level. This study aimed to determine whether ECLS is associated with improved survival outcomes compared to conventional CPR (cardiopulmonary resuscitation) at a national level.Methods: We used a Korean national OHCA cohort database from 2009 to 2013. The inclusion criteria were OHCA adults with presumed cardiac aetiology and resuscitation by emergency medical services (EMS). Patients were excluded if their information on prehospital time intervals or clinical outcomes at hospital discharge was incomplete or not captured. The primary outcome was neurologically favourable survival to discharge. We compared the primary outcomes between the ECLS and non-ECLS groups using a multivariable logistic regression and a propensity score matching analysis.Results: Of the 119,077 patients with OHCA, 36,547 were included in the analysis. There were 320 patients who received ECLS. There was no significant difference in neurologically favourable survival to discharge between the ECLS group and the non-ECLS group after adjusting for covariates (adjusted OR, 0.65; 95% CI, 0.41-1.04). In the propensity score-matched cohort, there was also no significant difference between the two groups (adjusted OR, 0.94; 95% CI, 0.41-2.14).Conclusions: In this propensity score-matched cohort using a nationwide OHCA database, OHCA victims who received ECLS did not show better survival outcomes than those who did not receive ECLS. [ABSTRACT FROM AUTHOR]

Renal dysfunction after heart transplantation (HT) is associated with poor survival. We investigated the predictive factors of renal outcomes after HT using nationwide cohort data. In this retrospective cohort study using the Health Insurance Review and Assessment database of Korea, 654 patients who received HT between 2008 and 2016 and survived until discharge after HT were analyzed. The median (interquartile range) age was 52 (40–60) years, and 68.1% were male. Perioperative renal replacement therapy (RRT) was performed in 27.8% of patients. During 2.8 years of median followup, end-stage kidney disease (ESKD) developed in 12 patients (1.8%). In a fully adjusted model, RRT > 3 weeks, the use of inotropes/vasopressors and non-use of ACEi/ARB were associated with ESKD. Preexisting renal disease tended to be associated with ESKD. Among the 561 patients without preexisting CKD, 104 (18.5%) developed chronic kidney disease (CKD). Age, extracorporeal membrane oxygenation, and RRT were associated with the development of CKD after HT. Our nationwide cohort study demonstrated that perioperative RRT was a predictor of poor renal outcomes after HT. These results suggest that an active renoprotective strategy is required during the perioperative period. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the association between sex and clinical outcomes in patients with coronavirus disease (COVID-19) using a population-based dataset. Methods: In this retrospective study, insurance claims data from the Korea database were used. Patients who tested positive for COVID-19 were included in the study. All diseases were defined according to the International Classification of Diseases 10th revision. During follow-up, the clinical outcomes, except mortality, were assessed using the electrical codes from the dataset. The clinical outcomes noted were: hospitalization, the use of inotropics, high flow nasal cannula, conventional oxygen therapy, mechanical ventilation, extracorporeal membrane oxygenation, development of acute kidney injury, cardiac arrest, myocardial infarction, acute heart failure, pulmonary embolism, and disseminated intravascular coagulation after the diagnosis of COVID-19. Results: A total of 7327 patients were included; of these, 2964 patients (40.5%) were men and 4363 patients (59.5%) were women. There were no significant differences in the Charlson comorbidity index score between men and women in the same age group. The incidence of mortality and clinical outcomes was higher among men than among women. The mortality rate was the highest for the populations aged 50–64 or ≥65 years. The subgroup analyses for age, diabetes mellitus, or hypertension showed favorable results for patient survival or clinical outcomes for women compared to men. Conclusion: Our population-based study showed that female patients with COVID-19 were associated with favorable outcomes. Furthermore, the impact of sex was more evident in patients aged 50–64 or ≥65 years. [ABSTRACT FROM AUTHOR]

Patients with advanced chronic kidney disease (CKD) or who are on hemodialysis (HD) could have increased susceptibility to the 2019 coronavirus disease (COVID-19) given their pre-existing comorbidities, older age, compromised immune system, and regular visits to populated outpatient dialysis centers. This study included 14 consecutive patients on HD or with advanced CKD who initiated HD after being diagnosed with laboratory-confirmed COVID-19 from February to April 2020 in hospitals throughout Daegu, South Korea. The included patients, 42.9% of whom were men, had a mean age of 63.5 years. Four patients had a history of contact with a patient suffering from COVID-19. The most common symptom was cough (50.0%), followed by dyspnea (35.7%). The mean time from symptom onset to diagnosis and admission was 2.6 and 3.5 days, respectively. Patients exhibited lymphopenia and elevated inflammatory markers, including C-reactive protein and ferritin. Chest radiography findings showed pulmonary infiltration in 10 patients. All patients underwent regular HD in a negative pressure room and received antiviral agents. Four patients received mechanical ventilation and continuous renal replacement therapy at a median duration of 14.0 and 8.5 days, respectively. One patient underwent extracorporeal membrane oxygenation for three days. Among the 14 patients included, two died due to acute respiratory distress syndrome, nine were discharged from the hospital, and three remained hospitalized. Despite the high-risk conditions associated with worse outcomes, patients on HD did not exhibit extremely poor overall COVID-19 outcomes perhaps due to early diagnosis, prompt hospitalization, and antiviral therapy. [ABSTRACT FROM AUTHOR]

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been widely applied in various cardiogenic shock (CS). However, there is a lack of consensus on the timing of weaning. Proposed algorithm is, if the patient is tolerable to minimum flow of 1-1.5/min, some echocardiographic and hemodynamic parameters are reasonable, de-cannulation could be considered. The aim of this study was to investigate the outcome of back flow shunt test our team has been done for years, which gives the transient loading condition to right ventricle before final decision of de-cannulation of VA ECMO. We retrospectively reviewed all adult VA-ECMO patients treated at a single tertiary hospital in South Korea between January 2018 to July 2019. Demographic data, diagnosis, echocardiography findings, ECMO configuration, mortality and morbidity data were collected. Backflow shunt test was done by simply reverse the Rota flow with dial to achieve negative flow from artery to vein. The test was stopped by simply dialing back to previous ECMO flow in case of unstable vital signs (Figure) Total of 47 patients underwent back-flow shunt test; 38 were de-cannulated on the 1st trial, 5 were on 2nd, 4 were on 3rd. The mean age was 58±16, 29 (63%) were male and 18 (37%) were female. The etiology of CS was ischemia 32 (70%), myocarditis 6 (13%), non-ischemic heart failure 5 (11%), refractory arrhythmia 2 (4%). All patients were successfully de-cannulated without hemodynamic deterioration. There was no thromboembolic event or oxygenator membrane thrombosis during shunt test. None of the patients needed re-insertion of VA ECMO within 3 days after weaning. In-hospital death after weaning were 4 (8.5%). Our study suggests that back-flow shunt test is a simple, and reversible weaning method applied in CS from various etiology without stopping the VA ECMO and concern of thromboembolism. This test could be effectively applied to the patients with marginal heart function. [ABSTRACT FROM AUTHOR]

Continuous renal replacement therapy (CRRT) has been used as an important intervention in critically ill children. Our center has the only specialized CRRT team (SCT) for children in Korea, which consists of pediatric intensivists, a pediatric nephrologist and CRRT-specialized-nurses. This study was a retrospective single-center analysis, including all pediatric patients admitted to the intensive care unit (ICU) of Severance hospital in Korea and received CRRT between 2003 and 2016, grouped as before SCT (group A, n = 51) and after SCT (group B, n = 212). We obtained the data for sex, age, weight, diagnosis, blood flow rate or type of CRRT machine used, administration of inotropic agents or anticoagulants, and ICU duration before CRRT (hours). A total of 263 patients were included. The age was significantly younger (p < 0.001) and blood flow rate was lower (p = 0.001) in group B than group A. Vasopressors (p < 0.001), continuous veno-venous hemodiafiltration (CVVHDF) (p < 0.001), nafamostat mesilate (p < 0.001), and extracorporeal membrane oxygenation (ECMO)-CRRT (p = 0.004) were more frequently used in group B. Based on our 14-year experience, we conclude that SCT operation could have played an important role in increasing the amount of CRRT utilization. [ABSTRACT FROM AUTHOR]

Introduction: Mortality is very high in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) or cardiac arrest despite intensive use of percutaneous coronary intervention (PCI). Although current guidelines still recommend rapid revascularization in these high-risk patients, several studies showed the benefit of extracorporeal membrane oxygenation (ECMO)-assisted PCI. Hypothesis: ECMO support before revascularization might be beneficial in patients with AMI complicated by profound CS after resuscitated cardiac arrest. Methods: Among 116,374 patients experiencing out-of-hospital cardiac arrest in all emergency medical service of South Korea between 2013 and 2016, a total of 147 resuscitated patients with AMI complicated by profound CS who were treated with both PCI and ECMO were enrolled. Exclusion criteria were as follows: non-cardiac arrest, duration of cardiopulmonary resuscitation < 20 minutes, patients without restoration of spontaneous circulation, patients treated with thrombolysis, patients who did not receive PCI, patients did not receive ECMO treatment, and cases of failed PCI. Enrolled patients were divided into two groups according to timing of ECMO; pre-PCI ECMO group (n = 82) vs. post-PCI ECMO group (n = 65). We compared 30-day mortality between two groups. Results: Age and proportion of male gender were similar between 2 groups. The rate of bystander CPR (29.3% vs. 29.2%, p = 0.996) and shockable rhythm at emergency room (26.8% vs. 26.2%, p = 0.927) were also comparable in 2 groups. Although total duration of CPR was similar between 2 groups (57.4±27.6 vs. 52.0±28.8 minutes, p = 0.313), door to revascularization time was significantly longer in pre-PCI ECMO group than post-PCI ECMO group (123.7±57.6 vs. 105.5±39.1 minutes, p = 0.030). At 30-days, overall mortality was 80.3% (118 patients) in study population, and it was significantly lowered in pre-PCI ECMO group (72.0% vs. 90.8%, p = 0.004). In multivariate Cox-regression analysis, pre-PCI ECMO reduced 30-day mortality compared to post-PCI ECMO (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.47-0.98, p = 0.041). Bystander CPR , shockable rhythm at emergency room and successful therapeutic hypothermia were also associated with reduced 30-day mortality. Conclusions: ECMO treatment before PCI was associated with reduced 30-day mortality compared to ECMO after revascularization in patients with AMI complicated by profound CS after resuscitated cardiac arrest. [ABSTRACT FROM AUTHOR]