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Various electrocardiographic changes occur during sepsis, but data on the clinical importance of a low QRS voltage in sepsis are still limited. We aimed to evaluate the association between low QRS voltage identified early in sepsis and mortality in patients with sepsis. Between September 2019 and December 2020, all consecutive adult patients diagnosed with sepsis in the emergency room or general ward at Samsung Medical Center were enrolled. Patients without a 12-lead electrocardiogram recorded within 48 h of recognition of sepsis were excluded. In 432 eligible patients, 12-lead electrocardiogram was recorded within the median of 24 min from the first recognition of sepsis, and low QRS voltage was identified in 115 (26.6%) patients. The low QRS group showed more severe organ dysfunction and had higher levels of N-terminal pro-brain natriuretic peptide. The hospital mortality was significantly higher in the low QRS voltage group than in the normal QRS voltage group (49.6% vs. 28.1%, p < 0.001). Similarly, among the 160 patients who required intensive care unit admission, significantly more patients in the low QRS group died in the intensive care unit (35.9% vs. 18.2%, p = 0.021). Low QRS voltage was associated with increased hospital mortality in patients with sepsis. [ABSTRACT FROM AUTHOR]

Background Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities. Objective To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols. Design Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023. Setting Cross-sectional online survey including hospitals, rehabilitation and long-term facilities. Methods Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers. Results Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n  = 1110) of wards/units, 18.6% (n  = 310) used personal judgement or no assessment, and 10% (n  = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n  = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [ n  = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289–9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions. Conclusion Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium. [ABSTRACT FROM AUTHOR]

This study determined whether compared to conventional mechanical ventilation (MV), extracorporeal membrane oxygenation (ECMO) is associated with decreased hospital mortality or fibrotic changes in patients with COVID-19 acute respiratory distress syndrome. A cohort of 72 patients treated with ECMO and 390 with conventional MV were analyzed (February 2020–December 2021). A target trial was emulated comparing the treatment strategies of initiating ECMO vs no ECMO within 7 days of MV in patients with a PaO2/FiO2 < 80 or a PaCO2 ≥ 60 mmHg. A total of 222 patients met the eligibility criteria for the emulated trial, among whom 42 initiated ECMO. ECMO was associated with a lower risk of hospital mortality (hazard ratio [HR], 0.56; 95% confidence interval [CI] 0.36–0.96). The risk was lower in patients who were younger (age < 70 years), had less comorbidities (Charlson comorbidity index < 2), underwent prone positioning before ECMO, and had driving pressures ≥ 15 cmH2O at inclusion. Furthermore, ECMO was associated with a lower risk of fibrotic changes (HR, 0.30; 95% CI 0.11–0.70). However, the finding was limited due to relatively small number of patients and differences in observability between the ECMO and conventional MV groups. [ABSTRACT FROM AUTHOR]

Simple Summary: This study aimed to develop a new warning score for cancer patients who are at risk of getting worse in the hospital. Cancer patients can have serious problems due to their treatment or cancer itself. A quick response system is used to find and treat these patients. This study used a deep-learning method to create a warning score based on the changes in vital signs. The warning score, called Can-EWS, was better than the existing score, called MEWS, in predicting and preventing bad outcomes. Can-EWS also had fewer false alarms than MEWS. This study could help improve the safety and care of cancer patients in the hospital. Background: Cancer patients who are admitted to hospitals are at high risk of short-term deterioration due to treatment-related or cancer-specific complications. A rapid response system (RRS) is initiated when patients who are deteriorating or at risk of deteriorating are identified. This study was conducted to develop a deep learning-based early warning score (EWS) for cancer patients (Can-EWS) using delta values in vital signs. Methods: A retrospective cohort study was conducted on all oncology patients who were admitted to the general ward between 2016 and 2020. The data were divided into a training set (January 2016–December 2019) and a held-out test set (January 2020–December 2020). The primary outcome was clinical deterioration, defined as the composite of in-hospital cardiac arrest (IHCA) and unexpected intensive care unit (ICU) transfer. Results: During the study period, 19,739 cancer patients were admitted to the general wards and eligible for this study. Clinical deterioration occurred in 894 cases. IHCA and unexpected ICU transfer prevalence was 1.77 per 1000 admissions and 43.45 per 1000 admissions, respectively. We developed two models: Can-EWS V1, which used input vectors of the original five input variables, and Can-EWS V2, which used input vectors of 10 variables (including an additional five delta variables). The cross-validation performance of the clinical deterioration for Can-EWS V2 (AUROC, 0.946; 95% confidence interval [CI], 0.943–0.948) was higher than that for MEWS of 5 (AUROC, 0.589; 95% CI, 0.587–0.560; p < 0.001) and Can-EWS V1 (AUROC, 0.927; 95% CI, 0.924–0.931). As a virtual prognostic study, additional validation was performed on held-out test data. The AUROC and 95% CI were 0.588 (95% CI, 0.588–0.589), 0.890 (95% CI, 0.888–0.891), and 0.898 (95% CI, 0.897–0.899), for MEWS of 5, Can-EWS V1, and the deployed model Can-EWS V2, respectively. Can-EWS V2 outperformed other approaches for specificities, positive predictive values, negative predictive values, and the number of false alarms per day at the same sensitivity level on the held-out test data. Conclusions: We have developed and validated a deep learning-based EWS for cancer patients using the original values and differences between consecutive measurements of basic vital signs. The Can-EWS has acceptable discriminatory power and sensitivity, with extremely decreased false alarms compared with MEWS. [ABSTRACT FROM AUTHOR]

The Functional Status Score for the Intensive Care Unit (FSS-ICU) evaluates the physical function of ICU patients. The objective of the study was to translate and cross-culturally adapt the FSS-ICU into Korean and assess its reliability and validity. An expert committee supervised the forward and backward translation process and the final translated version. Experienced physiotherapists assessed patients (n= 31) from a medical ICU using the Korean version of FSS-ICU. Intra-class correlation coefficients (ICCs) and Bland–Altman's plots were used to evaluate reliability, and Cronbach's alpha for internal consistency. Construct validity was evaluated using Spearman's correlation coefficients. Two physiotherapists in each of the two university hospitals independently assessed 31 medical ICU patients, with a mean FSS-ICU total score of 23 (range: 4–35). The FSS-ICU Korean version demonstrated excellent internal consistency, with Cronbach's alpha of 0.897 for the total FSS-ICU score, and a range of 0.844–0.892 with deletion of each individual activity within the FSS-ICU. Intra-rater and inter-rater reliability were excellent for all of five FSS-ICU activities and the total score, with an ICC range of 0.930–0.993. Bland–Altman's plots revealed a mean difference in FSS-ICU total score of 0.2 (95% limits of agreement: −1.9 to 2.3) between two physiotherapists. The Korean version of FSS-ICU had good convergent and divergent validity with moderate to strong correlation with mobility and muscle strength measures, and poor correlation with unrelated measures. The Korean version of the FSS-ICU showed excellent intra-rater and inter-rater reliability, internal consistency, and construct validity for medical ICU patients. The results of this study, along with prior publications, support that the FSS-ICU Korean version is a valid and reliable assessment tool for the ICU environment. Intensive care unit patients usually experience decreased muscle strength and physical function. The Korean version of the Functional Status Score for the Intensive Care Unit (FSS-ICU) is suitable for use with Korean speakers and has a valid, reliable measurement tool for physical function of intensive care unit patients. A well-standardized training with videos and written materials is important to ensure correct implementation of the Korean version of the FSS-ICU. [ABSTRACT FROM AUTHOR]

Background: Continuous renal replacement therapy (CRRT) is the standard treatment for severe acute kidney injury in critically ill patients. However, a practical consensus for discontinuing CRRT is lacking. We aimed to develop a prediction model with simple clinical parameters for successful discontinuation of CRRT. Methods: Adult patients who received CRRT at Samsung Medical Center from 2007 to 2017 were included. Patients with preexisting ESRD and patients who progressed to ESRD within 1 year or died within 7 days after CRRT were excluded. Successful discontinuation of CRRT was defined as no requirement for renal replacement therapy for 7 days after discontinuing CRRT. Patients were assigned to either a success group or failure group according to whether discontinuation of CRRT was successful or not. Results: A total of 1,158 patients were included in the final analyses. The success group showed greater urine output on the day before CRRT discontinuation (D-1) and the discontinuation day (D0). Multivariable analysis identified that urine output ≥300 mL on D-1, and mean arterial pressure 50∼78 mm Hg, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 were predictive factors for successful discontinuation of CRRT. A scoring system using the 4 variables above (area under the receiver operating curve: 0.731) was developed. Conclusions: Scoring system composed of urine output ≥300 mL/day on D-1, and adequate blood pressure, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 was developed to predict successful discontinuation of CRRT. [ABSTRACT FROM AUTHOR]

Backgrounds: The management of lung complications, especially fibrosis, after COVID-19 pneumonia, is an important issue in the COVID-19 post-pandemic era. We aimed to investigate risk factors for pulmonary fibrosis development in patients with severe COVID-19 pneumonia., Methods: Clinical and radiological data were prospectively collected from 64 patients who required mechanical ventilation due to COVID-19 pneumonia and were enrolled from eight hospitals in South Korea. Fibrotic changes on chest CT were evaluated by visual assessment, and extent of fibrosis (mixed disease score) was measured using automatic quantification system., Results: 64 patients were enrolled, and their mean age was 58.2 years (64.1% were males). On chest CT (median interval: 60 days [IQR; 41-78 days] from enrolment), 35 (54.7%) patients showed ≥3 fibrotic lesions. The most frequent fibrotic change was traction bronchiectasis (47 patients, 73.4 %). Median extent of fibrosis measured by automatic quantification was 10.6% (IQR, 3.8-40.7%). In a multivariable Cox proportional hazard model, which included nine variables with a p value of <0.10 in an unadjusted analysis as well as age, sex and Body Mass Index, male sex (HR, 3.01; 95% CI, 1.27 to 7.11) and higher initial Sequential Organ Failure Assessment (SOFA) score (HR, 1.18; 95% CI, 1.02 to 1.37) were independently associated with pulmonary fibrosis (≥3 fibrotic lesions)., Conclusion: Our data suggests that male gender and higher SOFA score at intensive care unit admission were associated with pulmonary fibrosis in patients with severe COVID-19 pneumonia requiring mechanical ventilation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Sepsis is a leading global cause of mortality, and predicting its outcomes is vital for improving patient care. This study explored the capabilities of ChatGPT, a state-of-the-art natural language processing model, in predicting in-hospital mortality for sepsis patients., Methods: This study utilized data from the Korean Sepsis Alliance (KSA) database, collected between 2019 and 2021, focusing on adult intensive care unit (ICU) patients and aiming to determine whether ChatGPT could predict all-cause mortality after ICU admission at 7 and 30 days. Structured prompts enabled ChatGPT to engage in in-context learning, with the number of patient examples varying from zero to six. The predictive capabilities of ChatGPT-3.5-turbo and ChatGPT-4 were then compared against a gradient boosting model (GBM) using various performance metrics., Results: From the KSA database, 4,786 patients formed the 7-day mortality prediction dataset, of whom 718 died, and 4,025 patients formed the 30-day dataset, with 1,368 deaths. Age and clinical markers (e.g., Sequential Organ Failure Assessment score and lactic acid levels) showed significant differences between survivors and non-survivors in both datasets. For 7-day mortality predictions, the area under the receiver operating characteristic curve (AUROC) was 0.70-0.83 for GPT-4, 0.51-0.70 for GPT-3.5, and 0.79 for GBM. The AUROC for 30-day mortality was 0.51-0.59 for GPT-4, 0.47-0.57 for GPT-3.5, and 0.76 for GBM. Zero-shot predictions using GPT-4 for mortality from ICU admission to day 30 showed AUROCs from the mid-0.60s to 0.75 for GPT-4 and mainly from 0.47 to 0.63 for GPT-3.5., Conclusions: GPT-4 demonstrated potential in predicting short-term in-hospital mortality, although its performance varied across different evaluation metrics.

Background: Limited data are available on the relationship of disseminated intravascular coagulation (DIC) with mortality in patients receiving extracorporeal membrane oxygenation (ECMO). Thus, we investigated the association of DIC score and antithrombin (AT) III with clinical outcomes in patients undergoing ECMO., Methods: We analyzed 703 patients who underwent ECMO between January 2014 and May 2022 at Samsung Medical Center. The DIC score was calculated using laboratory findings within 24 h of the ECMO initiation, and ≥ 5 was defined as overt DIC. In addition, the AT III level was measured to identify the correlation with the DIC score., Results: Among the study patients, 169 (24.0%) were diagnosed with overt DIC (DIC group) during early maintenance therapy. In-hospital mortality was significantly higher in the DIC group than in the non-DIC group (55.0% vs. 36.5%, p  < 0.001). Bleeding events were significantly higher in the group of patients with a DIC score of 7 or 8 than in the other group (20.8% vs. 8.4%, p  = 0.038). DIC score negatively correlated with AT III level ( r  = -0.417, p  < 0.001). The predictive performance of AT III for overt DIC had statistical significance with a c-static of 0.81 (95% confidence interval (CI), 0.77-0.84, p  < 0.001)., Conclusion: Overt DIC was associated with higher in-hospital mortality and a tendency to bleed in ECMO patients. Furthermore, AT III plasma levels can easily predict overt DIC in patients undergoing ECMO. These findings suggest that monitoring AT III plasma levels may be important in the management of ECMO., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Kim, Ko, Choi, Chung, Cho and Yang.)