VASOPRESSOR REDUCTION EFFECT OF POLYMYXIN B HEMOPERFUSION IN PATIENTS WITH PERITONITIS-INDUCED SEPTIC SHOCK: A PROPENSITY SCORE-MATCHED ANALYSIS.

ABSTRACT: Background : This study aimed to evaluate the effect of polymyxin B hemoperfusion (PMX-HP) in patients with peritonitis-induced septic shock who still required high-dose vasopressors after surgical source control. Methods : This retrospective study included adult patients admitted to the surgical intensive care unit (ICU) at Seoul National University Hospital between July 2014 and February 2021 who underwent major abdominal surgery to control the source of sepsis. Patients were divided into two groups based on whether PMX-HP was applied after surgery or not. The primary and secondary endpoints were the vasopressor reduction effect, and in-ICU mortality, respectively. Propensity score matching was performed to compare the vasopressor reduction effect. Results : A total of 338 patients met the inclusion criteria, of which 23 patients underwent PMX-HP postoperatively, whereas 315 patients did not during the study period. Serum norepinephrine concentration decreased over time regardless of whether PMX-HP was applied. However, it decreased more rapidly in the PMX-HP(+) group than in the PMX-HP(-) group. There were no significant differences in demographics including age, sex, body mass index, and most underlying comorbidities between the two groups. Risk factors for in-ICU mortality were identified by comparing patient characteristics and perioperative factors between the two groups using multivariate analysis. Conclusion : For patients with peritonitis-induced septic shock, PMX-HP rapidly reduces the requirement of vasopressors immediately after surgery but does not reduce in-ICU mortality. This effect could potentially accelerate recovery from shock, reduce sequelae from vasopressors, and ultimately improve quality of life after discharge.

Clinical and Genetic Characteristics Associated With Survival Outcome in Late-Onset Huntington's Disease in South Korea.

BACKGROUND AND PURPOSE: The onset of Huntington's disease (HD) usually occurs before the age of 50 years, and the median survival time from onset is 15 years. We investigated survival in patients with late-onset HD (LoHD) (age at onset ≥60 years) and the associations of the number of mutant CAG repeats and age at onset (AAO) with survival in patients with HD. METHODS: Patients with genetically confirmed HD at six referral centers in South Korea between 2000 and 2020 were analyzed retrospectively. Baseline demographic, clinical, and genetic characteristics and the survival status as at December 2020 were collected. RESULTS: Eighty-seven patients were included, comprising 26 with LoHD (AAO=68.77±5.91 years, mean±standard deviation; 40.54±1.53 mutant CAG repeats) and 61 with common-onset HD (CoHD) (AAO=44.12±8.61 years, 44.72±4.27 mutant CAG repeats). The ages at death were 77.78±7.46 and 53.72±10.86 years in patients with LoHD and CoHD, respectively (p<0.001). The estimated survival time was 15.21±2.49 years for all HD patients, and 10.74±1.95 and 16.15±2.82 years in patients with LoHD and CoHD, respectively. More mutant CAG repeats and higher AAO were associated with shorter survival (hazard ratio [HR]=1.05, 95% confidence interval [CI]=1.01-1.09, p=0.019; and HR=1.17, 95% CI=1.03-1.31, p=0.013; respectively) for all HD patients. The LoHD group showed no significant factors associated with survival after disease onset, whereas the number of mutant CAG repeats had a significant effect (HR=1.12, 95% CI=1.01-1.23, p=0.034) in the CoHD group. CONCLUSIONS: Survival after disease onset was shorter in patients with LoHD than in those with CoHD. More mutant CAG repeats and higher AAO were associated with shorter survival in patients with HD.

Perioperative urinary ketosis and metabolic acidosis in patients fasted for undergoing gynecologic surgery.

BACKGROUND: Our bodies have adaptive mechanisms to fasting, in which glycogen stored in the liver and muscle protein are broken down, but also lipid mobilisation is triggered. As a result, glycerol and fatty acids are released into the bloodstream, increasing the production of ketone bodies in liver. However, there are limited studies on the incidence of perioperative urinary ketosis, the intraoperative blood glucose changes and metabolic acidosis after fasting for surgery in non-diabetic adult patients. METHODS: We conducted a retrospective cohort study involving 1831 patients undergoing gynecologic surgery under general anesthesia from January to December 2022. Ketosis was assessed using a postoperative urine test, while blood glucose levels and acid-base status were collected from intraoperative arterial blood gas analyses. RESULTS: Of 1535 patients who underwent postoperative urinalysis, 912 (59.4%) patients had ketonuria. Patients with ketonuria were younger, had lower body mass index, and had fewer comorbidities than those without ketonuria. After adjustments, younger age, higher body mass index and surgery starting late afternoon were significant risk factors for postoperative ketonuria. Of the 929 patients assessed with intraoperative arterial blood gas analyses, 29.0% showed metabolic acidosis. Multivariable logistic regression revealed that perioperative ketonuria and prolonged surgery significantly increased the risk for moderate-to-severe metabolic acidosis. CONCLUSION: Perioperative urinary ketosis and intraoperative metabolic acidosis are common in patients undergoing gynecologic surgery, even with short-term preoperative fasting. The risks are notably higher in younger patients with lower body mass index. Optimization of preoperative fasting strategies including implementation of oral carbohydrate loading should be considered for reducing perioperative metabolic derangement due to ketosis.

Real-time machine learning model to predict short-term mortality in critically ill patients: development and international validation.

BACKGROUND: A real-time model for predicting short-term mortality in critically ill patients is needed to identify patients at imminent risk. However, the performance of the model needs to be validated in various clinical settings and ethnicities before its clinical application. In this study, we aim to develop an ensemble machine learning model using routinely measured clinical variables at a single academic institution in South Korea. METHODS: We developed an ensemble model using deep learning and light gradient boosting machine models. Internal validation was performed using the last two years of the internal cohort dataset, collected from a single academic hospital in South Korea between 2007 and 2021. External validation was performed using the full Medical Information Mart for Intensive Care (MIMIC), eICU-Collaborative Research Database (eICU-CRD), and Amsterdam University Medical Center database (AmsterdamUMCdb) data. The area under the receiver operating characteristic curve (AUROC) was calculated and compared to that for the National Early Warning Score (NEWS). RESULTS: The developed model (iMORS) demonstrated high predictive performance with an internal AUROC of 0.964 (95% confidence interval [CI] 0.963-0.965) and external AUROCs of 0.890 (95% CI 0.889-0.891) for MIMIC, 0.886 (95% CI 0.885-0.887) for eICU-CRD, and 0.870 (95% CI 0.868-0.873) for AmsterdamUMCdb. The model outperformed the NEWS with higher AUROCs in the internal and external validation (0.866 for the internal, 0.746 for MIMIC, 0.798 for eICU-CRD, and 0.819 for AmsterdamUMCdb; p < 0.001). CONCLUSIONS: Our real-time machine learning model to predict short-term mortality in critically ill patients showed excellent performance in both internal and external validations. This model could be a useful decision-support tool in the intensive care units to assist clinicians.

Prevalence and outcomes of chronic comorbid conditions in patients with sepsis in Korea: a nationwide cohort study from 2011 to 2016.

BACKGROUND: Chronic comorbid conditions are common in patients with sepsis and may affect the outcomes. This study aimed to evaluate the prevalence and outcomes of common comorbidities in patients with sepsis. METHODS: We conducted a nationwide retrospective cohort study. Using data from the National Health Insurance Service of Korea. Adult patients (age ≥ 18 years) who were hospitalized in tertiary or general hospitals with a diagnosis of sepsis between 2011 and 2016 were analyzed. After screening of all International Classification of Diseases 10th revision codes for comorbidities, we identified hypertension, diabetes mellitus (DM), liver cirrhosis (LC), chronic kidney disease (CKD), and malignancy as prevalent comorbidities. RESULTS: Overall, 373,539 patients diagnosed with sepsis were hospitalized in Korea between 2011 and 2016. Among them, 46.7% had hypertension, 23.6% had DM, 7.4% had LC, 13.7% had CKD, and 30.7% had malignancy. In-hospital mortality rates for patients with hypertension, DM, LC, CKD, and malignancy were 25.5%, 25.2%, 34.5%, 28.0%, and 33.3%, respectively, showing a decreasing trend over time (P < 0.001). After adjusting for baseline characteristics, male sex, older age, use of mechanical ventilation, and continuous renal replacement therapy, LC, CKD, and malignancy were significantly associated with in-hospital mortality. CONCLUSIONS: Hypertension is the most prevalent comorbidity in patients with sepsis, and it is associated with an increased survival rate. Additionally, liver cirrhosis, chronic kidney disease, and malignancy result in higher mortality rates than hypertension and DM, and are significant risk factors for in-hospital mortality in patients with sepsis.

Comparison of postoperative ascites replacement strategies on time to first flatus after living donor liver transplantation: Albumin vs. lactated Ringer's solution.

INTRODUCTION: There is insufficient evidence regarding the optimal regimen for ascites replacement after living donor liver transplantation (LT) and its effectiveness. The aim of this study is to evaluate the impact of replacing postoperative ascites after LT with albumin on time to first flatus during recovery with early ambulation and incidence of acute kidney injury (AKI). METHODS: Adult patients who underwent elective living donor LT at Seoul National University Hospital from 2019 to 2021 were randomly assigned to either the albumin group or lactated Ringer's group, based on the ascites replacement regimen. Replacement of postoperative ascites was performed for all patients every 4 h after LT until the patient was transferred to the general ward. Seventy percent of ascites drained during the previous 4 h was replaced over the next 4 h with continuous infusion of fluids with a prescribed regimen according to the assigned group. In the albumin group, 30% of a total of 70% of drained ascites was replaced with 5% albumin solution, and remnant 40% was replaced with lactated Ringer's solution. In the lactated Ringer's group, 70% of drained ascites was replaced with only lactated Ringer's solution. The primary outcome was the time to first flatus from the end of the LT and the secondary outcome was the incidence of AKI for up to postoperative day 7. RESULTS: Among the 157 patients who were screened for eligibility, 72 patients were enrolled. The mean age was 63 ± 8.2 years, and 73.0 % (46/63) were male. Time to first flatus was similar between the two groups (66.7 ± 24.1 h vs. 68.5 ± 25.6 h, p = .778). The albumin group showed a higher glomerular filtration rate and lower incidence of AKI until postoperative day 7, compared to the lactated Ringer's group. CONCLUSIONS: Using lactated Ringer's solution alone for replacement of ascites after living donor LT did not reduce the time to first flatus and was associated with an increased risk of AKI. Further research on the optimal ascites replacement regimen and the target serum albumin level which should be corrected after LT is required.

Timing of prophylactic antibiotics administration and suspected systemic infection after percutaneous biliary intervention.

BACKGROUND/PURPOSE: Prophylactic antibiotics administration before percutaneous biliary intervention (PBI) is currently recommended, but the underlying evidence is mostly extrapolated from prophylactic antibiotics before surgery. The aim of this study was to evaluate the impact of prophylactic antibiotics administration timing on the incidence of suspected systemic infection after PBI. METHODS: The incidence of suspected systemic infection after PBI was compared in patients who received prophylactic antibiotics at four different time intervals between antibiotics administration and skin puncture for PBI. Suspected post-intervention systemic infection was assessed according to predetermined clinical criteria. RESULTS: There were 98 (21.6%) suspected systemic infections after 454 PBIs in 404 patients. There were significant differences among the four groups in the incidence of suspected systemic infection after the intervention (p = .020). Fever was the most common sign of suspected systemic infection. Administration of prophylactic antibiotics more than an hour before PBI was identified as an independent risk factor of suspected systemic infection after adjusting for other relevant factors (adjusted odds ratio = 10.54; 95% confidence interval, 1.40-78.86). CONCLUSIONS: The incidence of suspected systemic infection after the PBI was significantly lower when prophylactic antibiotics were administered within an hour before the intervention.

Selective ring expansion and C-H functionalization of azulenes.

We report a transition metal-catalyzed ring expansion of azulene that can be contrasted with C-H functionalization. This study represents the first example of the successful ring expansion of azulene using Cu(hfacac)2 (hfacac: hexafluoroacetylacetonate) with a diazo reagent. This result is notable for extending the Buchner reaction, previously limited to benzenoid aromatics, to nonbenzenoid compounds. The chemoselectivity of the reaction can be directed towards C-H functionalization by substituting the Cu catalyst with AgOTf. This approach does not require the addition of phosphine, NHC, or related ligands, and prefunctionalization of azulenes is unnecessary. Furthermore, the method exhibits excellent functional group tolerance, allowing for the synthesis of a wide range of 6,7-bicyclic compounds and C-H functionalized azulenes. We also present a theoretical study that explains the experimental observations, explaining why copper afford the ring expansion product while silver forms the C-H alkylation product.

Real-time machine learning model to predict in-hospital cardiac arrest using heart rate variability in ICU.

Predicting in-hospital cardiac arrest in patients admitted to an intensive care unit (ICU) allows prompt interventions to improve patient outcomes. We developed and validated a machine learning-based real-time model for in-hospital cardiac arrest predictions using electrocardiogram (ECG)-based heart rate variability (HRV) measures. The HRV measures, including time/frequency domains and nonlinear measures, were calculated from 5 min epochs of ECG signals from ICU patients. A light gradient boosting machine (LGBM) algorithm was used to develop the proposed model for predicting in-hospital cardiac arrest within 0.5-24 h. The LGBM model using 33 HRV measures achieved an area under the receiver operating characteristic curve of 0.881 (95% CI: 0.875-0.887) and an area under the precision-recall curve of 0.104 (95% CI: 0.093-0.116). The most important feature was the baseline width of the triangular interpolation of the RR interval histogram. As our model uses only ECG data, it can be easily applied in clinical practice.

Risk factors of hemodialysis catheter dysfunction in patients undergoing continuous renal replacement therapy: a retrospective study.

BACKGROUND: Continuous renal replacement therapy is a relatively common modality applied to critically ill patients with renal impairment. To maintain stable continuous renal replacement therapy, sufficient blood flow through the circuit is crucial, but catheter dysfunction reduces the blood flow by inadequate pressures within the circuit. Therefore, exploring and modifying the possible risk factors related to catheter dysfunction can help to provide continuous renal replacement therapy with minimal interruption. METHODS: Adult patients who received continuous renal replacement therapy at Seoul National University Hospital between January 2019 and December 2021 were retrospectively analyzed. Patients who received continuous renal replacement therapy via a temporary hemodialysis catheter, inserted at the bedside under ultrasound guidance within 12 h of continuous renal replacement therapy initiation were included. RESULTS: A total of 507 continuous renal replacement therapy sessions in 457 patients were analyzed. Dialysis catheter dysfunction occurred in 119 sessions (23.5%). Multivariate analysis showed that less prolonged prothrombin time (adjusted OR 0.49, 95% CI, 0.30-0.82, p = 0.007) and activated partial thromboplastin time (adjusted OR 1.01, 95% CI, 1.00-1.01, p = 0.049) were associated with increased risk of catheter dysfunction. Risk factors of re-catheterization included vascular access to the left jugular and femoral vein. CONCLUSIONS: In critically ill patients undergoing continuous renal replacement therapy, less prolonged prothrombin time was associated with earlier catheter dysfunction. Use of left internal jugular veins and femoral vein were associated with increased risk of re-catheterization compared to the right internal jugular vein.

The effect of audiovisual feedback of monitor/defibrillators on percentage of appropriate compression depth and rate during cardiopulmonary resuscitation.

BACKGROUND: High quality cardiopulmonary resuscitation (CPR) is one of the key elements of the survival chain in cardiac arrest. Audiovisual feedback of chest compressions have been suggested to be beneficial by increasing the quality of CPR in the simulated cardiac arrests. METHODS: A prospective before and after study was performed to investigate the effect of a real-time audiovisual feedback system on CPR quality during in-hospital cardiac arrest in intensive care units from November 2018 to February 2022. In the feedback period, CPR was performed with the aid of the real-time audiovisual feedback system. The primary outcome was the percentage of compressions with both adequate depth (5.0-6.0 cm) and rate (100-120/minute). RESULTS: A total of 27,295 compressions in 30 cardiac arrests in the no-feedback period and 27,965 compressions in 30 arrests in the feedback period were analyzed. The percentage of compressions with both adequate depth and rate was 11.8% in the feedback period and 16.8% in the no-feedback period (P < 0.01). The percentage of compressions with adequate rate in the feedback period was lower than that in the no-feedback period (67.3% vs. 75.5%, P < 0.01). The percentage of beyond-target depth with the feedback was significantly higher than that without feedback (64.2% vs. 51.4%, P < 0.01). CONCLUSION: Real-time audiovisual feedback system did not increase CPR quality and was associated with a higher percentage of compression depth deeper than the recommended 5.0-6.0 cm. It is essential to explore more effective ways of implementing feedback in real clinical settings to improve of the quality of CPR. TRIAL REGISTRATION: NCT03902873 (study start: Nov. 2018, initial release April 2019, retrospectively registered).

Ethnicity- and sex-specific genome wide association study on Parkinson's disease.

Most previous genome-wide association studies (GWASs) on Parkinson's disease (PD) focus on the European population. There are several sex-specific clinical differences in PD, but little is known about its genetic background. We aimed to perform an ethnicity-specific and sex-specific GWAS on PD in the Korean population. A total of 1050 PD patients and 5000 controls were included. For primary analysis, we performed a GWAS using a logistic additive model adjusted for age and sex. The same statistical models were applied to sex-specific analyses. Genotyping was performed using a customized microarray chip optimized for the Korean population. Nine single nucleotide polymorphisms (SNPs) including four in the SNCA locus and three from the PARK16 locus were associated with PD in Koreans. The rs34778348 in the LRRK2 locus showed a strong association, though failed to pass cluster quality control. There were no notable genome-wide significant markers near the MAPT or GBA1 loci. In the female-only analysis, rs34778348 in LRRK2 and the four other SNPs in the SNCA showed a strong association with PD. In the male-only analysis, no SNP surpassed the genome-wide significance threshold under Bonferroni correction; however, the most significant signal was rs708726 in the PARK16 locus. This ethnicity- and sex-specific GWAS on PD implicate the pan-ethnic effect of SNCA, the universal but East-Asian inclined effect of PARK16, the East Asian-specific role of LRRK2 G2385R variants, and the possible disproportionate effect of SNCA and PARK16 between sexes for PD susceptibility. These findings suggest the different genetic contributions to sporadic PD in terms of ethnicity and sex.

Bi0-Reduced Graphene Oxide Composites for the Enhanced Capture and Cold Immobilization of Off-Gas Radioactive Iodine.

Radioactive waste management is critical for maintaining the sustainability of nuclear fuel cycles. In this study, we propose a novel bismuth-based reduced graphene oxide (Bi0-rGO) composite for the immobilization of off-gas radioactive iodine. This material synthesized via a solvothermal route exhibited a low surface area (2.96 m2/g) combined with a maximum iodine sorption capacity of 1228 ± 25 mg/g at 200 °C. The iodine sorbent was mixed with Bi2O3 powder and distilled water to fabricate waste matrices, which were cold-sintered at 300 °C under a uniaxial pressure of 500 MPa for 20 min to achieve a relative density of ∼98% and Vickers hardness of 1.3 ± 0.1 GPa. The utilized methodology reduced the iodine leaching rate by approximately 3 orders of magnitude through the formation of a chemically durable iodine-bearing waste form (BiOI). This study demonstrates the high potential of Bi0-rGO as an innovative solution for the immobilization of radioactive waste at relatively low temperatures.

Effects of Cold Sintering on the Performance of Zeolite 13X as a Consolidated Adsorbent for Cesium.

Cold sintering, a novel low-temperature consolidation technique, has shown promising results in various inorganic materials. However, the application of this technique to nanoporous materials for energy and environmental fields is not yet fully understood. This study investigates the effects of cold sintering on the relative densities, compressive strengths, chemical durabilities, crystal structures, specific surface areas, and adsorption capacities of zeolites. Cold sintering at 200 °C achieved 10 to 20% greater densification than conventional high temperature (700 °C) sintering; however, the original nanoporous structure of dry cold sintered zeolite was not maintained. Introducing liquid agents during the cold sintering process resulted in reduced degradation of the SSA and increased densification. Using NaOH as the liquid agent increased the solubility of elements in zeolite, which promoted chemical mobility and achieved the highest relative density (96.7 ± 2.8%). However, soluble layers between the particles led to fragmentation, making it unsuitable for aqueous applications. Using H2O as the liquid agent resulted in a relative density of 90.4 ± 4.1% while maintaining the nanoporous properties and structural integrity of zeolite under water. The cesium adsorption capacity (19.0 ± 0.1 mg·g-1) was similar to that of conventional zeolite ion exchangers, indicating that cold sintering with H2O was an efficient, economical, and safer alternative to conventional high-temperature consolidation method. Our findings suggest that this cold sintering can be applied to other nanoporous materials, such as metal-organic frameworks and covalent organic frameworks, in separation, catalysis, and adsorption applications.

The Association Between Institutional Case Volume of Hematopoietic Stem Cell Transplantation and Mortality.

BACKGROUND: Hematopoietic stem cell transplantation (HSCT) is a complex, high-risk procedure with significant morbidity and mortality. The positive impact of higher institutional case volume on survival has been reported in various high-risk procedures. The association between annual institutional HSCT case volume and mortality was analyzed using the National Health Insurance Service database. METHODS: Data on 16,213 HSCTs performed in 46 Korean centers between 2007 and 2018 were extracted. Centers were divided into low- or high-volume centers using an average of 25 annual cases as the cut-off. Adjusted odds ratios (OR) for 1-year mortality after allogeneic and autologous HSCT were estimated using multivariable logistic regression. RESULTS: For allogeneic HSCT, low-volume centers (≤25 cases/y) were associated with higher 1-year mortality (adjusted OR 1.17, 95% CI 1.04-1.31, P = .008). However, low-volume centers did not show higher 1-year mortality (adjusted OR 1.03, 95% CI 0.89-1.19, P = .709) for autologous HSCT. Long-term mortality after HSCT was significantly worse in low-volume centers (adjusted hazard ratio [HR] 1.17, 95% CI, 1.09-1.25, P < .001 and adjusted HR 1.09, 95% CI, 1.01-1.17, P = .024, allogeneic and autologous HSCT, respectively) compared with high-volume centers. CONCLUSION: Our data suggest that higher institutional HSCT case volume seems to be associated with better short- and long-term survival.

Early Postoperative Fever and Atelectasis in Patients Undergoing Upper Abdominal Surgery.

BACKGROUND: Atelectasis is a common complication after upper abdominal surgery and considered as a cause of early postoperative fever (EPF) within 48 hours after surgery. However, the pathophysiologic mechanism of how atelectasis causes fever remains unclear. STUDY DESIGN: Data for adult patients who underwent elective major upper abdominal surgery under general anesthesia at Seoul National University Hospital between January and December of 2021 were retrospectively analyzed. The primary outcome was the association between fever and atelectasis within 2 days after surgery. RESULTS: Of 1,624 patients, 810 patients (49.9%) developed EPF. The incidence of atelectasis was similar between the fever group and the no-fever group (51.6% vs 53.9%, p = 0.348). Multivariate analysis showed no significant association between atelectasis and EPF. Culture tests (21.7% vs 8.8%, p < 0.001) and prolonged use of antibiotics (25.9% vs 13.9%, p < 0.001) were more frequent in the fever group compared to the no-fever group. However, the frequency of bacterial growth on culture tests and postoperative pulmonary complications within 7 days were similar between the two groups. CONCLUSIONS: EPF after major upper abdominal surgery was not associated with radiologically detected atelectasis. EPF also was not associated with the increased risk of postoperative pulmonary complications, bacterial growth on culture studies, or prolonged length of hospital stay.

Impact of institutional case volume on intensive care unit mortality.

The primary aim of this review is to explore current knowledge on the relationship between institutional intensive care unit (ICU) patient volume and patient outcomes. Studies indicate that a higher institutional ICU patient volume is positively correlated with patient survival. Although the exact mechanism underlying this association remains unclear, several studies have proposed that the cumulative experience of physicians and selective referral between institutions may play a role. The overall ICU mortality rate in Korea is relatively high compared to other developed countries. A distinctive aspect of critical care in Korea is the existence of significant disparities in the quality of care and services provided across regions and hospitals. Addressing these disparities and optimizing the management of critically ill patients necessitates thoroughly trained intensivists who are well-versed in the latest clinical practice guidelines. A fully functioning unit with adequate patient throughput is also essential for maintaining consistent and reliable quality of patient care. However, the positive impact of ICU volume on mortality outcomes is also linked to complex organizational factors, such as multidisciplinary rounds, nurse staffing and education, the presence of a clinical pharmacist, care protocols for weaning and sedation, and a culture of teamwork and communication. Despite some inconsistencies in the association between ICU patient volume and patient outcomes, which are thought to arise from differences in healthcare systems, ICU case volume significantly affects patient outcomes and should be taken into account when formulating related healthcare policies.

The Profile of Early Sedation Depth and Clinical Outcomes of Mechanically Ventilated Patients in Korea.

BACKGROUND: Current international guidelines recommend against deep sedation as it is associated with worse outcomes in the intensive care unit (ICU). However, in Korea the prevalence of deep sedation and its impact on patients in the ICU are not well known. METHODS: From April 2020 to July 2021, a multicenter, prospective, longitudinal, noninterventional cohort study was performed in 20 Korean ICUs. Sedation depth extent was divided into light and deep using a mean Richmond Agitation-Sedation Scale value within the first 48 hours. Propensity score matching was used to balance covariables; the outcomes were compared between the two groups. RESULTS: Overall, 631 patients (418 [66.2%] and 213 [33.8%] in the deep and light sedation groups, respectively) were included. Mortality rates were 14.1% and 8.4% in the deep and light sedation groups (P = 0.039), respectively. Kaplan-Meier estimates showed that time to extubation (P < 0.001), ICU length of stay (P = 0.005), and death (P = 0.041) differed between the groups. After adjusting for confounders, early deep sedation was only associated with delayed time to extubation (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.55-0.80; P < 0.001). In the matched cohort, deep sedation remained significantly associated with delayed time to extubation (HR, 0.68; 95% CI, 0.56-0.83; P < 0.001) but was not associated with ICU length of stay (HR, 0.94; 95% CI, 0.79-1.13; P = 0.500) and in-hospital mortality (HR, 1.19; 95% CI, 0.65-2.17; P = 0.582). CONCLUSION: In many Korean ICUs, early deep sedation was highly prevalent in mechanically ventilated patients and was associated with delayed extubation, but not prolonged ICU stay or in-hospital death.

Impact of institutional case volume of solid organ transplantation on patient outcomes and implications for healthcare policy in Korea.

Solid organ transplantation is distinguished from other high-risk surgical procedures by the fact that it utilizes an extremely limited and precious resource and requires a multidisciplinary team approach. For several decades, institutional experience, as quantified by center volume, has been shown to be strongly associated with patient outcomes and graft survival after solid organ transplantation. The United States has implemented a minimum case volume requirement and performance standards for accreditation as a validated transplantation center. Solid organ transplantation in Europe is also governed by the European Union, which monitors patient outcomes and organ allocation. The number of solid organ transplantation cases in Korea is increasing, with patient outcomes comparable to international standards. However, Korea has outdated regulations regarding hospital facilities, and performance indicators including patient outcomes after transplantation are not monitored. Therefore, centers perform solid organ transplantation with no meaningful oversight. In this review, data regarding the impact of institutional case volume of kidney, liver, lung, and heart transplantation are summarized, followed by a description of current transplantation center regulations in the United States and Europe. The basis for the necessity of adequate transplantation center regulations in Korea is presented.