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Purpose: 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., Methods: 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., Results: 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., Conclusions: 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.Implications for rehabilitationIntensive 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.

Purpose: Intensive care unit (ICU) survivors suffer from physical weakness and challenges returning to daily life. With the importance of rehabilitating patients in the pediatric intensive care unit being increasingly recognized, we evaluated the prevalence of physical and occupational therapy (PT/OT)-provided rehabilitation and factors affecting its use., Methods: We conducted a retrospective cohort analysis of rehabilitation between 2013 and 2019 using the Korean National Health Insurance database. All patients aged 28 days to 18 years who had been admitted to 245 ICUs for more than 2 days were included. Neonatal ICUs were excluded., Results: Of 13,276 patients, 2,447 (18%) received PT/OT-provided rehabilitation during their hospitalization; prevalence was lowest for patients younger than 3 years (11%). Neurologic patients were most likely to receive rehabilitation (adjusted odds ratio [aOR], 6.47; 95% confidence interval [CI], 5.11-8.20). Longer ICU stay (versus ≤ 1 week) was associated with rehabilitation (aOR for 1-2 weeks, 3.50 [95% CI, 3.04-4.03]; 2-3 weeks, 6.60 [95% CI, 5.45-8.00]; >3 weeks, 13.69 [95% CI, 11.46-16.35]). Mechanical ventilation >2 days (aOR, 0.78; 95% CI, 0.67-0.91) and hemodialysis (aOR, 0.50; 95% CI, 0.41-0.52) were negatively affecting factors., Conclusion: Prevalence of rehabilitation for critically ill children was low and concentrated on patients with a prolonged ICU stay. The finding that mechanical ventilation, a risk factor for ICU-acquired weakness, was an obstacle to rehabilitation highlights the need for studies on early preventive rehabilitation based on individual patient needs., Competing Interests: The authors have declared that no competing interests exist.

Background: There is a lack of nationwide studies on critically ill patients' health disparity under the National Health Insurance (NHI) system. We evaluated health disparities in intensive care unit (ICU) admission, outcomes, and readmission in impoverished children., Methods: We conducted a retrospective cohort study using a national database from the Korean NHI and Medical Aid Program (MAP). MAP supports the population whose household income is lower than 40% of the median Korean household income. We defined poverty as being a MAP beneficiary and compared the poverty and non-poverty groups. Patients between 28 days and 18 years old who were admitted to the ICU were included. Hospital mortality and readmission were analyzed with adjustment for patient characteristics, hospital type, and management procedures., Results: Out of 17,893 patients, 1153 (6.4%) patients were in poverty. The age-standardized ICU admission rate was higher in the poverty group (126.9 vs. 80.2 per 100,000 person-years). There was more age-standardized mortality in the poverty group (11.8 vs. 4.3 per 100,000 person-years). Patients in the poverty group did not have a statistically different risk of adjusted in-hospital mortality to those in the non-poverty group (odds ratio: 1.15, confidence interval [CI]: 0.84-1.55) but had a higher readmission rate (hazard ratio 1.25, CI 1.09-1.42)., Conclusion: Under the NHI system, the disparity in pediatric critical care outcomes according to poverty is not definite, but the healthcare disparity in pre- and post-hospital care is a concern. Further studies are required to improve pre- and post-hospital healthcare quality of impoverished children.

Background: Frailty is a multidimensional syndrome that leads to an increase in vulnerability. Previous studies have suggested that frailty is associated with poor health-related outcomes. For frailty screening, the Clinical Frailty Scale (CFS) is a simple tool that is widely used in various translated versions. We aimed to translate the CSF into Korean and evaluated its contents and concurrent validity., Methods: Translations and back-translations of the CFS were conducted independently. A multidisciplinary team decided the final CFS-K. Between August 2019 and April 2020, a total of 100 outpatient and inpatient participants aged ≥65 years were enrolled prospectively. The clinical characteristics were evaluated using the CFS-K. The CFS-K scores were compared with those of other frailty screening tools using Pearson's correlation coefficient and Spearman's rank correlation. The area under curve (AUC) for identifying the Eastern Cooperative Oncology Group Performance Status (ECOG PS) grade 3 or more was calculated for the CFS-K and other screening tools., Results: The mean age of the participants was 76.5 years (standard deviation [SD], 7.0), and 63 (63%) participants were male. The mean CFS-K was 4.8 (SD, 2.5). Low body mass index (p = 0.013) and low score on the Korean version of the Mini-Mental State Examination (p < 0.001) were significantly associated with high CFS-K scores, except for those assigned to scale 9 (terminally ill). The CFS-K showed a significant correlation with other frailty screening tools (R = 0.7742-0.9190; p < 0.01), except in the case of those assigned to scale 9 (terminally ill). In comparison with other scales, the CFS-K identified ECOG PS grade 3 or more with the best performance (AUC = 0.99). Patients assigned to scale 9 on the CFS-K (terminally ill) had similar frailty scores to those assigned to scale 4 (vulnerable) or 5 (mildly frail)., Conclusions: In conclusion, the CFS-K is a valid scale for measuring frailty in older Korean patients. The CFS-K scores were significantly correlated with the scores of other scales. To evaluate the predictive and prognostic value of this scale, further larger-scale studies in various clinical settings are warranted.

Background: COVID-19, which is accompanied by acute respiratory distress, multiple organ failure, and death, has spread worldwide much faster than previously thought. However, at present, it has limited treatments., Objective: To overcome this issue, we developed an artificial intelligence (AI) model of COVID-19, named EDRnet (ensemble learning model based on deep neural network and random forest models), to predict in-hospital mortality using a routine blood sample at the time of hospital admission., Methods: We selected 28 blood biomarkers and used the age and gender information of patients as model inputs. To improve the mortality prediction, we adopted an ensemble approach combining deep neural network and random forest models. We trained our model with a database of blood samples from 361 COVID-19 patients in Wuhan, China, and applied it to 106 COVID-19 patients in three Korean medical institutions., Results: In the testing data sets, EDRnet provided high sensitivity (100%), specificity (91%), and accuracy (92%). To extend the number of patient data points, we developed a web application (BeatCOVID19) where anyone can access the model to predict mortality and can register his or her own blood laboratory results., Conclusions: Our new AI model, EDRnet, accurately predicts the mortality rate for COVID-19. It is publicly available and aims to help health care providers fight COVID-19 and improve patients' outcomes., (©Hoon Ko, Heewon Chung, Wu Seong Kang, Chul Park, Do Wan Kim, Seong Eun Kim, Chi Ryang Chung, Ryoung Eun Ko, Hooseok Lee, Jae Ho Seo, Tae-Young Choi, Rafael Jaimes, Kyung Won Kim, Jinseok Lee. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 23.12.2020.)

Background: Despite the increasing importance of rehabilitation for critically ill patients, there is little information regarding how rehabilitation therapy is utilized in clinical practice. Our objectives were to evaluate the implementation rate of rehabilitation therapy in the intensive care unit (ICU) survivors and to investigate the effects of rehabilitation therapy on outcomes., Methods: A retrospective nationwide cohort study with including > 18 years of ages admitted to ICU between January 2008 and May 2015 (n = 1,465,776). The analyzed outcomes were readmission to ICU readmission and emergency room (ER) visit., Results: During the study period, 249,918 (17.1%) patients received rehabilitation therapy. The percentage of patients receiving any rehabilitation therapy increased annually from 14% in 2008 to 20% in 2014, and the percentages for each type of therapy also increased over time. The most common type of rehabilitation was physical therapy (91.9%), followed by neuromuscular electrical stimulation (29.6%), occupational (28.6%), respiratory, (11.6%) and swallowing (10.3%) therapies. After adjusting for confounding variables, the risk of 30-day ICU readmission was lower in patients who received rehabilitation therapy than in those who did not ( P < 0.001; hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.65-0.75). And, the risk of 30-day ER visit was also lower in patients who received rehabilitation therapy ( P < 0.001; HR, 0.83; 95% CI, 0.77-0.88)., Conclusion: In this nationwide cohort study in Korea, only 17% of all ICU patients received rehabilitation therapy. However, rehabilitation is associated with a significant reduction in the risk of 30-day ICU readmission and ER visit., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2020 The Korean Academy of Medical Sciences.)

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., Competing Interests: The authors have declared that no competing interests exist.

Background: This study aimed to develop a risk prediction model for neurologic outcomes in patients who underwent extracorporeal cardiopulmonary resuscitation (ECPR)., Methods: Between May 2004 and April 2016, a total of 274 patients who underwent ECPR were included in this analysis. The primary outcome was neurologic status on discharge from the hospital, as assessed by Cerebral Performance Categories (CPC) scale. To develop a new predictive scoring system, backward stepwise elimination and a z-score-based scoring scheme were used on the basis of logistic regression analyses., Results: A total of 95 patients (34.7%) survived until discharge. Of these, 78 patients (28.5%) had favorable neurologic outcomes (CPC scores of 1 or 2). In the multivariable logistic regression analysis, significant predictors of poor neurologic outcome included age older than 65 years, initial Sequential Organ Failure Assessment score greater than 13 points, first monitored arrest rhythm, low-flow time longer than 30 minutes, initial pulse pressure less than 25 mm Hg, initial mean arterial pressure less than 70 mm Hg, and serum glucose level greater than 300 mg/dL. There was also a significant interaction between age and low-flow time. The newly developed neurologic outcome score after ECPR (nECPR) more effectively predicted poor neurologic outcome (C-statistic, 0.867; 95% confidence interval, 0.823 to 0.912) than the former ECPR score (p = 0.019) and the survival after venoarterial ECMO score (p < 0.001)., Conclusions: The investigators created a risk prediction model for neurologic outcomes using independent predictors and the interaction between age and low-flow time, and this new scoring system could predict early neurologic prognosis more effectively in ECPR-treated patients. It may be help guide decisions in ECPR management for intensivists, cardiovascular surgeons, or cardiologists., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Although several studies have reported outcome data on critically ill children, detailed reports by age are not available. We aimed to evaluate the age-specific estimates of trends in causes of diagnosis, procedures, and outcomes of pediatric admissions to ICUs in a national representative sample., Design: A population-based retrospective cohort study., Setting: Three hundred forty-four hospitals in South Korea., Patients: All pediatric admissions to ICUs in Korea from August 1, 2009, to September 30, 2014, were covered by the Korean National Health Insurance Corporation, with virtually complete coverage of the pediatric population in Korea. Patients less than 18 years with at least one ICUs admission between August 1, 2009, and September 30, 2014. We excluded neonatal admissions (< 28 days), neonatal ICUs, and admissions for health status other than a disease or injury. The final sample size was 38,684 admissions from 32,443 pediatric patients., Intervention: None., Measurements and Main Results: The overall age-standardized admission rate for pediatric patients was 75.9 admissions per 100,000 person-years. The most common primary diagnosis of admissions was congenital malformation (10,897 admissions, 28.2%), with marked differences by age at admission (5,712 admissions [54.8%] in infants, 3,994 admissions [24.6%] in children, and 1,191 admissions [9.9%] in adolescents). Injury was the most common primary diagnosis in adolescents (3,248 admissions, 27.1%). The overall in-hospital mortality was 2,234 (5.8%) with relatively minor variations across age. Neoplasms and circulatory and neurologic diseases had both high frequency of admissions and high in-hospital mortality., Conclusions: Admission patterns, diagnosis, management, and outcomes of pediatric patients admitted to ICUs varied by age groups. Strategies to improve critical care qualities of pediatric patients need to be based on the differences of age and may need to be targeted at specific age groups.

Purpose: ECMO use has increased lately. However, differences between adult ECMO and non-ECMO patients admitted to the ICU remain unstudied. In terms of volume-outcome relationship, the impact of ECMO volume on survival has not been validated in a real world cohort., Materials and Methods: Retrospective analysis of data from the Korean Health Insurance Review and Assessment Service over 5 years, between August 1, 2009 and July 31, 2014. The ECMO group comprised patients who received ≥1 ECMO run. Data on patient demographics, ICU and hospital length of stay, cost, treatments, and in-hospital mortality were collected. Usage trends were analyzed by 5 one-year periods., Results: Among 1, 265, 508 ICU patients, 6078 underwent ECMO during the study period. The number of ECMO patients rose by 2.5 times, and ECMO hospitals from 50 to 86 between periods 1 and 5. Compared to non-ECMO patients, the ECMO group was younger (59 years vs. 64 years, p < .0001) with more comorbidities. Healthcare expenditure and in-hospital mortality in the ECMO group were higher (US $23,600 vs. $5100; 63.4% vs. 12.6%; p < .0001). Using multivariable analysis, age ≥ 50 years, CRRT, and annual hospital ECMO volume < 20 negatively impacted survival to discharge., Conclusion: The prevalence of ECMO among ICU patients was 0.5%. The expenditure and in-hospital mortality of the ECMO group were four and five times higher than non-ECMO group respectively. An annual hospital ECMO volume ≥ 20 may improve survival to hospital discharge., (Copyright © 2018 Elsevier Inc. All rights reserved.)

There is conflicting evidence for the clinical benefit of statin therapy in patients with vasospastic angina (VSA). We investigated the association of statin therapy with clinical outcomes in relatively large populations with clinically suspected VSA from a nationwide population-based database. Data were collected from the Health Insurance Review and Assessment database records of 4,099 patients that were in an intensive care unit with VSA between January 1, 2008 and May 31, 2015. We divided the patients into a statin group (n = 1,795) and a non-statin group (n = 2,304). The primary outcome was a composite of cardiac arrest and acute myocardial infarction (AMI). The median follow-up duration was 3.8 years (interquartile range: 2.2 to 5.8 years). Cardiac arrest or AMI occurred in 120 patients (5.2%) in the statin group, and 97 patients (5.4%) in the non-statin group (P = 0.976). With inverse probability of treatment weighting, there was no significant difference in the rate of cardiac arrest or AMI between the two groups (adjusted hazard ratio [HR], 0.99; 95% confidence interval [CI], 0.76-1.30; P = 0.937), or even between the non-statin group and high-intensity statin group (adjusted HR, 1.08; 95% CI, 0.69-1.70; P = 0.75). The beneficial association of statin use with the primary outcome was consistently lacking across the various comorbidity types. Statin therapy was not associated with reduced cardiac arrest or AMI in patients with VSA, regardless of statin intensity. Prospective, randomized trials will be needed to confirm our findings., Competing Interests: Samsung Medical Center does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Although the utilization of extracorporeal membrane oxygenation (ECMO) is increasing and its technology is evolving, only a few epidemiologic reports have described the uses and outcomes of ECMO. The aim of this study was to investigate the changes in utilization and survival rate in patients supported with ECMO for severe respiratory failure in Korea., Methods: This was a multicenter study on consecutive patients who underwent ECMO across 16 hospitals in Korea. The records of all patients who required ECMO for acute respiratory failure between 2012 and 2015 were retrospectively reviewed, and the utilization of ECMO was analyzed over time., Results: During the study period, 5552 patients received ECMO in Korea as a whole, and a total of 2472 patients received ECMO at the participating 16 hospitals. We analyzed 487 (19.7%) patients who received ECMO for respiratory failure. The number of ECMO procedures provided for respiratory failure increased from 104 to 153 during the study period. The in-hospital survival rate increased from 30.8% to 35.9%. The use of prone positioning increased from 6.8% to 49.0% (p < 0.001), and the use of neuromuscular blockers also increased from 28.2% to 58.2% (p < 0.001). Multiple regression analysis showed that old age (OR 1.038 (95% CI 1.022, 1.054)), use of corticosteroid (OR 2.251 (95% CI 1.153, 4.397)), continuous renal replacement therapy (OR 2.196 (95% CI 1.135, 4.247)), driving pressure (OR 1.072 (95% CI 1.031, 1.114)), and prolonged ECMO duration (OR 1.020 (95% CI 1.003, 1.038)) were associated with increased odds of mortality., Conclusions: Utilization of ECMO and survival rates of patients who received ECMO for respiratory failure increased over time in Korea. The use of pre-ECMO prone positioning and neuromuscular blockers also increased during the same period.

Introduction and Objectives: This study investigated whether the vasoactive inotropic score (VIS) is independently predictive of mortality in cardiogenic shock (CS)., Methods: This study was retrospective, observational study. Patients who were admitted to the cardiac intensive care unit from January 2012 to December 2015 were screened, and 493 CS patients were finally enrolled. To quantify pharmacologic support, the patients were divided into 5 groups based on a quintile of VIS: 1 to 10, 11 to 20, 21 to 38, 39 to 85, and > 85. The primary outcome was in-hospital mortality., Results: In-hospital mortalities in the 5 VIS groups in increasing order were 8.2%, 14.1%, 21.1%, 32.0%, and 65.7%, respectively (P < .001). Multivariable analysis indicated that VIS ranges of 39 to 85 (aOR, 3.85; 95%CI, 1.60-9.22; P = .003) and over 85 (aOR, 10.83; 95%CI, 4.43-26.43; P < .001) remained significant prognostic predictors for in-hospital mortality. With multiple logistic regression to remove any confounding effects, we found that the localized regression lines regarding the odds of death intersected each other's (medical therapy alone and combined extracorporeal membrane oxygenation group) path at VIS = 130. In contrast to linear correlation between VIS and mortality for patients treated with medical therapy alone, there was little association between a VIS of 130 or more and the probability of in-hospital mortality for patients who were treated with extracorporeal membrane oxygenation., Conclusions: A high level of vasoactive inotropic support during the first 48hours was significantly associated with increased in-hospital mortality in adult CS patients., (Copyright © 2018 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: The long-term prognosis of vasospastic angina (VSA) patients presenting with aborted sudden cardiac death (ASCD) is still unknown. We sought to compare the long-term clinical outcomes between VSA patients presenting with and without ASCD by retrospective analysis of a nationwide population-based database., Methods: A total of 6972 patients in the Health Insurance Review and Assessment database who were hospitalized in the intensive care unit with VSA between July 1, 2007 and May 31, 2015 were enrolled. Primary outcome was the composite of cardiac arrest and acute myocardial infarction after discharge., Results: Five hundred ninety-eight (8.6%) VSA patients presented with ASCD. On inverse probability of treatment weighting, ASCD patients had a significantly increased risk of the composite of cardiac arrest and acute myocardial infarction (adjusted hazard ratio, 2.52; 95% confidence interval, 1.72-3.67; p < 0.001) during the median follow-up duration of 4 years. The association of ASCD presentation with a worse outcome in terms of primary outcome was consistent across various subgroups, including comorbidity type and use of vasodilators (all p-values for interaction: non-significant). ASCD patients treated with an implantable cardioverter defibrillator (ICD) had a lower incidence of the composite of cardiac arrest and acute myocardial infarction during follow-up than those without an ICD (p = 0.009)., Conclusions: VSA patients that present with ASCD are at increased risk of cardiac arrest or myocardial infarction during long-term follow-up despite adequate vasodilator therapy. An ICD is a potential therapeutic option for secondary prevention., (Copyright © 2018. Published by Elsevier B.V.)

Purpose: To investigate whether the obesity survival paradox, where obesity is associated with improved survival, exists for pneumonia supported with extracorporeal membrane oxygenation (ECMO)., Materials and Methods: Between January 2014 and December 2015, 223 patients with acute respiratory failure who underwent ECMO in 11 hospitals in South Korea were enrolled retrospectively, and data relating to pneumonia cases were analyzed. Patients were divided into groups according to their pre-treatment body mass index (BMI): obese (BMI ≥ 25 kg/m 2 ) and non-obese (BMI < 25 kg/m 2 ). The BMI cut-off was adopted from the World Health Organization for Asian populations., Results: In total, 84 patients had pneumonia: obese group, 26; non-obese group, 58 (mean BMI, 27.8 vs. 21.4, p < 0.001). Pre-ECMO parameters and rescue therapy did not differ between the groups. The rate of successful weaning from ECMO was not different between the groups (76.9% vs. 72.4%, p = 0.753), but survival-to-discharge (73.1% vs. 36.2%, p = 0.002) and 6-month survival (69.2% vs. 36.2%, p = 0.005) rates were higher in the obese group. After adjusting for age and the pre-treatment PaO 2 /FiO 2 ratio, low BMI was significantly associated with 6-month mortality (odds ratio 3.28, 95% confidence interval: 1.06-11.03, p = 0.044)., Conclusions: An obesity survival paradox exists in pneumonia supported with ECMO., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Unfractionated heparin (UFH) is currently the standard anticoagulant used in extracorporeal life support (ECLS). However, severe thrombocytopenia occurs frequently during ECLS use and it may be difficult to determine whether this represents heparin-induced thrombocytopenia (HIT) or not. In this case, UFH cannot be continued. Because a confirmatory laboratory test requires time, argatroban is empirically used if HIT is suspected. However, many patients are not found to have HIT. In non-HIT patients, the effectiveness and safety of argatroban are unclear. Thus, we investigated whether argatroban was safe and useful in patients who were suspected of having HIT and were started on argatroban, but were ultimately found to have non-HIT.We retrospectively reviewed all patients on ECLS who received the anticoagulant argatroban as an alternative to UFH between January 2014 and July 2015. The pretest clinical score (4Ts) was calculated, and a score greater than 4 was considered an indication for argatroban. The target-activated clotting time or activated partial thromboplastin time was 1.5 times the patient's upper normal value. Of 191 patients on ECLS during the study period, 10 (5.2%) were treated with argatroban infusion.No patients were found to have antiplatelet factor 4/heparin antibodies. The average maintenance dose of argatroban was 0.1 μg/kg/min. Platelet counts increased significantly following argatroban administration (P = .02). There were no anticoagulation-related complications such as bleeding or thrombosis.Our results suggest that argatroban is a safe alternative to UFH for patients with non-HIT on ECLS. Argatroban may have a more significant platelet-preserving effect than UFH, regardless of whether HIT is present.

Background: Necroptosis is a form of programmed necrotic cell death that is rapidly emerging as an important pathophysiological pathway in numerous disease states. Necroptosis is dependent on receptor-interacting protein kinase 3 (RIPK3), a protein shown to play an important role in experimental models of critical illness. However, there is limited clinical evidence regarding the role of extracellular RIPK3 in human critical illness., Methods: Plasma RIPK3 levels were measured in 953 patients prospectively enrolled in 5 ongoing intensive care unit (ICU) cohorts in both the USA and Korea. RIPK3 concentrations among groups were compared using prospectively collected phenotypic and outcomes data., Results: In all 5 cohorts, extracellular RIPK3 levels in the plasma were higher in patients who died in the hospital compared with those who survived to discharge. In a combined analysis, increasing RIPK3 levels were associated with elevated odds of in-hospital mortality (odds ratio [OR] 1.7 for each log10-unit increase in RIPK3 level, P < 0.0001). When adjusted for baseline severity of illness, the OR for in-hospital mortality remained statistically significant (OR 1.33, P = 0.007). Higher RIPK3 levels were also associated with more severe organ failure., Conclusions: Our findings suggest that elevated levels of RIPK3 in the plasma of patients admitted to the ICU are associated with in-hospital mortality and organ failure., Funding: Supported by NIH grants P01 HL108801, R01 HL079904, R01 HL055330, R01 HL060234, K99 HL125899, and KL2TR000458-10. Supported by Samsung Medical Center grant SMX1161431.

Bloodstream infection (BSI) occurred in 21 of 121 patients (17%) receiving venovenous extracorporeal membrane oxygenation within the median time of 6 days after initiation (interquartile range, 4-19 days). Longer duration of arterial catheterization and more blood transfusions were independently associated with BSI, which is associated with poor clinical outcomes.Infect Control Hosp Epidemiol 2018;1-4.

Purpose: To evaluate unbiased information on the characteristics, procedures, and outcomes of intensive care unit (ICU) admissions in a long-term nationwide study., Materials and Methods: Cohort study of all ICU admissions in patients >18years of age in Korea between August 1, 2009 and September 30, 2014 (1,553,673 ICU admissions in 1,265,509 patients)., Results: From August 2009 to September 2014, the age-standardized ICU admission rate was 744.6 per 100,000 person-years (869.5 per 100,000 person-years in men and 622.0 per 100,000 person-years in women). The overall in-hospital mortality was 13.8% (14.1% in men and 13.5% in women). Among all Koreans, the ICU mortality rate was 102.9 per 100,000 person-years (122.5 per 100,000 person years in men and 83.8 per 100,000 person years in women). The median ICU and hospital length of stay were 4 and 13days, respectively. The median cost per ICU admission was $5051, which increased steadily over the study period. There were marked differences by gender in ICU admission rates, aggressive support, and outcomes., Conclusions: Our study identified increasing trends in ICU admissions and utilization of advance life support systems that add to the burden of care in a developed society., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The effects of convalescent plasma (CP) infusion, one of the treatment options for severe Middle East respiratory syndrome coronavirus (MERS-CoV) infections, have not yet been evaluated., Methods: Serological responses of CP-infused MERS patients during the 2015 Korean MERS outbreak at a tertiary care centre were evaluated. Serological activity was evaluated with anti-MERS-CoV enzyme-linked immunosorbent assay (ELISA) immunoglobulin (Ig)G, ELISA IgA, immunofluorescence assay IgM and plaque reduction neutralization test (PRNT). Donor plasma and one or two recipient's serum samples per week of illness including one taken the day after each CP infusion were evaluated. For sensitivity and specificity analysis of ELISA IgG in predicting neutralization activity, a data set of 138 previously evaluated MERS-CoV-infected patients was used., Results: Three of thirteen MERS patients with respiratory failure received four CP infusions from convalesced MERS-CoV-infected patients, and only two of them showed neutralizing activity. Donor plasma with a PRNT titre 1:80 demonstrated meaningful serological response after CP infusion, while that with a PRNT titre 1:40 did not. ELISA IgG predicted neutralization activity of a PRNT titre ≥1:80 with more than 95% specificity at a cutoff optical density (OD) ratio of 1.6, and with 100% specificity at an OD ratio of 1.9., Conclusions: For effective CP infusion in MERS, donor plasma with a neutralization activity of a PRNT titre ≥1:80 should be used. ELISA IgG could substitute for the neutralization test in resource-limited situations.

Background: Acute respiratory distress syndrome (ARDS) is potentially underrecognized by clinicians. Early recognition and subsequent optimal treatment of patients with ARDS may be facilitated by usage of biomarkers. Surfactant protein D (SP-D), a marker of alveolar epithelial injury, has been proposed as a potentially useful biomarker for diagnosis of ARDS in a few studies. We tried to validate the performance of plasma SP-D levels for diagnosis of ARDS., Methods: We conducted a retrospective analysis using data from three (two in USA and one in Korea) prospective biobank cohorts involving 407 critically ill patients admitted to medical intensive care unit (ICU). A propensity score matched analysis (patients with versus without ARDS, matched 1:1) was carried out using significant variables from multiple logistic regression. The diagnostic accuracy of plasma SP-D as a diagnostic marker of ARDS was assessed by receiver operating characteristic curve analysis., Results: Out of the 407 subjects included in this study, 39 (10%) patients fulfilled ARDS criteria. Patients with ARDS had higher SP-D levels in plasma (p < 0.01) and higher hospital-mortality (p < 0.001) than those without ARDS. Thirty eight subjects with ARDS (cases) were successfully matched for propensity for ARDS with 38 subjects without ARDS (controls). Plasma levels of SP-D were higher in cases with ARDS compared to their matched controls without ARDS [median 20.8 ng/mL (interquartile range, 12.7-38.4) versus 7.9 (4.1-17.0); p = 0.001]. The area under the receiver operating characteristic curve for SP-D for the diagnosis of ARDS was 0.71 (95% confidence intervals, 0.60-0.83). A cut-off point of 12.7 ng/mL for SP-D yielded sensitivity of 74% and specificity of 63%., Conclusions: High levels of SP-D within 48 h after ICU admission might serve as a diagnostic marker for ARDS in patients hospitalized in medical ICU. Further prospective trials are required to validate the diagnostic role of SP-D in ARDS, and if its usefulness is greater in direct than in indirect ARDS, as well as across different strata of severity of ARDS.

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) requires urgent decision-making and high-quality skills, which may not be uniformly available throughout the week. Few data exist on the outcomes of patients with cardiac arrest who receive in-hospital ECPR on the weekday versus weekend. Therefore, we investigated whether the outcome differed when patients with in-hospital cardiac arrest received ECPR during the weekend compared with a weekday., Methods: Two hundred patients underwent extracorporeal membrane oxygenation after in-hospital cardiac arrest between January 2004 and December 2013. Patients treated between 0800 on Monday to 1759 on Friday were considered to receive weekday care and patients treated between 1800 on Friday through 0759 on Monday were considered to receive weekend care., Results: A total of 135 cases of ECPR for in-hospital cardiac arrest occurred during the weekday (64 during daytime hours and 71 during nighttime hours), and 65 cases occurred during the weekend (39 during daytime/evening hours and 26 during nighttime hours). Rates of survival to discharge were higher with weekday care than with weekend care (35.8% versus 21.5%, p = 0.041). Cannulation failure was more frequent in the weekend group (1.5% versus 7.7%, p = 0.038). Complication rates were higher on the weekend than on the weekday, including cannulation site bleeding (3.0% versus 10.8%, p = 0.041), limb ischemia (5.9% versus 15.6%, p = 0.026), and procedure-related infections (0.7% versus 9.2%, p = 0.005)., Conclusions: ECPR on the weekend was associated with a lower survival rate and lower resuscitation quality, including higher cannulation failure and higher complication rate., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

This study was performed to estimate the direct medical costs and epidemiology of pneumonia in adults of Korea. We conducted a multi-center, retrospective, observational study and collected data targeting for community-acquired pneumonia patients ( ≥ 50 yr) from 11 hospitals. Costs attributable to the treatment of pneumonia were estimated by reviewing resource utilization and epidemiology data (distribution of pathogen, hospital length of stay, overall outcome) were also collected. A total 693 patients were included; average 70.1 ( ± 10.5) aged, 57.3% male and average 1.16 CURB-65 (confusion, blood urea nitrogen, respiratory rate, blood pressure, age > 65 yr) scored. The pathogen was identified in the 32.9% (228 patients); Streptococcus pneumoniae accounted for 22.4% (51 patients) of identified pathogens. The hospital mortality was 3.2% (especially, for S. pneumoniae was 5.9%) and average length of stay was 9 days. The mean total cost for the treatment of pneumonia was US dollar (USD) 1,782 (SD: USD 1,501). Compared to the cost of all caused pneumonia, that of pneumococcal pneumonia was higher, USD 2,049 ( ± USD 1,919), but not statistically significant. Charge of hospitalization accounted the greatest part of total medical costs. The economic burden of pneumonia was high in Korea, and the prevention of pneumonia should be considered as effective strategy.