International medical learners and their adjustment after returning to their countries of origin: a qualitative study.

INTRODUCTION: International medical trainees, including residents and fellows, must cope with many challenges, such as differences in cultural hierarchical systems, languages, and acceptance. Nonetheless, the need for adjustment perpetuates even after training is completed abroad. When some international trainees return to their countries of origin, they continue to face adjustment challenges due to reverse culture shock. Others must make many further readjustments. This study presents an exploration of the adjustment and coping strategies of international medical learners after returning to their countries of origin upon completion of their programs. METHOD: This study employed a qualitative approach grounded in interpretivism and utilised inductive thematic analysis following Braun and Clarke's method. Semi-structured, in-depth individual interviews were employed to explore the participants' coping strategies. Participants included international medical learners who were (1) international medical graduates who had already returned to their countries of origin, (2) non-Canadian citizens or nonpermanent residents by the start of the programs, and (3) previously enrolled in a residency or fellowship training programme at the University of Toronto, Ontario, Canada. RESULTS: Seventeen participants were included. Three main themes and seven subthemes were created from the analysis and are represented by the Ice Skater Landing Model. According to this model, there are three main forces in coping processes upon returning home: driving, stabilising, and situational forces. The sum and interaction of these forces impact the readjustment process. CONCLUSION: International medical learners who have trained abroad and returned to their countries of origin often struggle with readjustment. An equilibrium between the driving and stabilising forces is crucial for a smooth transition. The findings of this study can help stakeholders better understand coping processes. As healthy coping processes are related to job satisfaction and retention, efforts to support and shorten repatriation adjustment are worthwhile.

Association between cardiopulmonary resuscitation audit results with in-situ simulation and in-hospital cardiac arrest outcomes and key performance indicators.

INTRODUCTION: In-situ simulation (ISS) is a method to evaluate the performance of hospital units in performing cardiopulmonary resuscitation (CPR). It is conducted by placing a high-fidelity mannequin at hospital units with simulated scenarios and having each unit's performance evaluated. However, little is known about its impact on actual patient outcomes. Therefore, we aimed to evaluate the association between the ISS results and actual outcomes of patients with in-hospital cardiac arrest (IHCA). METHODS: This retrospective study was conducted by reviewing Siriraj Hospital's CPR ISS results in association with the data of IHCA patients between January 2012 and January 2019. Actual outcomes were determined by patients' outcomes (sustained return of spontaneous circulation (ROSC) and survival to hospital discharge) and arrest performance indicators (time-to-first-epinephrine and time-to-defibrillation). These outcomes were investigated for association with the ISS scores in multilevel regression models with hospital units as clusters. RESULTS: There were 2146 cardiac arrests included with sustained ROSC rate of 65.3% and survival to hospital discharge rate of 12.9%. Higher ISS scores were significantly associated with improved sustained ROSC rate (adjusted odds ratio 1.32 (95%CI 1.04, 1.67); p = 0.01) and a decrease in time-to-defibrillation (-0.42 (95%CI -0.73, -0.11); p = 0.009). Although higher scores were also associated with better survival to hospital discharge and a decrease in time-to-first-epinephrine, most models for these outcomes failed to reach statistical significance. CONCLUSION: CPR ISS results were associated with some important patient outcomes and arrest performance indicators. Therefore, it may be an appropriate performance evaluation method that can guide the direction of improvement.

Clinical factors associated with in-hospital mortality in elderly versus non-elderly pneumonia patients in the emergency department.

BACKGROUND: Pneumonia is a respiratory infection with an increasing incidence with age. However, limited evidence has identified factors associated with its outcome among different age groups, especially in the elderly and in the emergency department (ED) setting. We aimed to identify clinical factors associated with in-hospital mortality in elderly versus non-elderly pneumonia patients in the ED. METHODS: A retrospective observational study was conducted at the ED of Siriraj Hospital, Thailand. Patients aged at least 18 years old diagnosed with non-COVID pneumonia between June 1, 2021, and May 31, 2022, were included. They were categorized into the elderly (age ≥ 65 years) and non-elderly (age < 65 years) groups. The primary outcome was in-hospital mortality. We employed multivariate logistic regression models to identify independent factors associated with the outcome in each age group. RESULTS: We enrolled 735 patients, 515 elderly and 222 non-elderly. There was no difference in in-hospital mortality rate between the two groups (39.0% in the elderly and 32.9% in the non-elderly; p = 0.116). In the elderly cohort, independent factors associated with in-hospital mortality were do-not-resuscitate (DNR) status (adjusted odds ratio (aOR) 12.89; 95% confidence interval (CI) 7.19-23.1; p < 0.001), Glasgow Coma Scale (GCS) score (aOR 0.91; 95%CI 0.85-0.96; p = 0.002), hemoglobin level (aOR 0.9; 95%CI 0.82-0.98; p = 0.012) and the type of initial oxygen support (p = 0.05). Among non-elderly patients, independent factors were DNR status (aOR 6.81; 95%CI 3.18-14.59; p < 0.001), GCS score (aOR 0.89; 95%CI 0.8-0.99; p = 0.025), platelet level (aOR 1; 95%CI 1-1; p = 0.038), Charlson Comorbidity Index (CCI) (aOR 1.12; 95%CI 0.99-1.28; p = 0.078), and the type of initial oxygen support p = 0.079). CONCLUSION: In pneumonia patients presenting to the ED, DNR status, lower GCS score, and more invasive initial oxygen supplementation were independently associated with in-hospital mortality in both elderly and non-elderly groups. However, lower hemoglobin level was only associated with in-hospital mortality in the elderly, while higher CCI and lower platelet count were independent factors only in the non-elderly. These findings emphasize the importance of age-specific considerations for the disease, and these factors are potential prognostic markers that may be used in clinical practice to improve patient outcomes.

The Incidence of Diaphragmatic Dysfunction in Patients Presenting With Dyspnea in the Emergency Department.

OBJECTIVES: Diaphragmatic dysfunction has been reported as a cause of dyspnea, and its diagnosis can be made using ultrasound. Diaphragmatic ultrasound is mainly used to predict respiratory failure in chronic conditions. The use of diaphragmatic ultrasound has also risen in acute settings, such as emergency departments (EDs). However, the number of studies on its use still needs to be increased. The present study aimed to find the incidence of diaphragmatic dysfunction in the ED. METHODS: This prospective cohort study was conducted in an ED. We enrolled patients aged greater than 18 years who presented with dyspnea. Diaphragmatic excursion and diaphragmatic thickness techniques were performed. The primary outcome was the incidence of diaphragmatic dysfunction. The secondary outcomes were the associations between diaphragmatic dysfunction and the composition of respiratory therapies within 24 hours, intubation within 24 hours, and 7-day mortality. RESULTS: A total of 237 patients were analyzed. The incidences of diaphragmatic dysfunction assessed by diaphragmatic excursion and diaphragm thickness were 22.4 and 32.1%, respectively. Patients with sepsis and cancer had the highest incidences. Diaphragmatic dysfunction assessed by both techniques was not associated with the composition of respiratory support therapies within 24 hours, intubation within 24 hours, or 7-day mortality. CONCLUSIONS: The incidence of diaphragmatic dysfunction in dyspneic patients in the ED ranged from 22.4 to 32.1%, depending on the ultrasound technique. Diaphragmatic dysfunction was not associated with the composition of respiratory support therapies, intubation, or mortality.

Performance of the European Society of Cardiology 0/1-Hour, 0/2-Hour, and 0/3-Hour Algorithms for Rapid Triage of Acute Myocardial Infarction : An International Collaborative Meta-analysis.

BACKGROUND: The 2020 European Society of Cardiology (ESC) guidelines recommend using the 0/1-hour and 0/2-hour algorithms over the 0/3-hour algorithm as the first and second choices of high-sensitivity cardiac troponin (hs-cTn)-based strategies for triage of patients with suspected acute myocardial infarction (AMI). PURPOSE: To evaluate the diagnostic accuracies of the ESC 0/1-hour, 0/2-hour, and 0/3-hour algorithms. DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus from 1 January 2011 to 31 December 2020. (PROSPERO: CRD42020216479). STUDY SELECTION: Prospective studies that evaluated the ESC 0/1-hour, 0/2-hour, or 0/3-hour algorithms in adult patients presenting with suspected AMI. DATA EXTRACTION: The primary outcome was index AMI. Twenty unique cohorts were identified. Primary data were obtained from investigators of 16 cohorts and aggregate data were extracted from 4 cohorts. Two independent authors assessed each study for methodological quality. DATA SYNTHESIS: A total of 32 studies (20 cohorts) with 30 066 patients were analyzed. The 0/1-hour algorithm had a pooled sensitivity of 99.1% (95% CI, 98.5% to 99.5%) and negative predictive value (NPV) of 99.8% (CI, 99.6% to 99.9%) for ruling out AMI. The 0/2-hour algorithm had a pooled sensitivity of 98.6% (CI, 97.2% to 99.3%) and NPV of 99.6% (CI, 99.4% to 99.8%). The 0/3-hour algorithm had a pooled sensitivity of 93.7% (CI, 87.4% to 97.0%) and NPV of 98.7% (CI, 97.7% to 99.3%). Sensitivity of the 0/3-hour algorithm was attenuated in studies that did not use clinical criteria (GRACE score <140 and pain-free) compared with studies that used clinical criteria (90.2% [CI, 82.9 to 94.6] vs. 98.4% [CI, 88.6 to 99.8]). All 3 algorithms had similar specificities and positive predictive values for ruling in AMI, but heterogeneity across studies was substantial. Diagnostic performance was similar across the hs-cTnT (Elecsys; Roche), hs-cTnI (Architect; Abbott), and hs-cTnI (Centaur/Atellica; Siemens) assays. LIMITATION: Diagnostic accuracy, inclusion and exclusion criteria, and cardiac troponin sampling time varied among studies. CONCLUSION: The ESC 0/1-hour and 0/2-hour algorithms have higher sensitivities and NPVs than the 0/3-hour algorithm for index AMI. PRIMARY FUNDING SOURCE: National Taiwan University Hospital.

The utility of the Rapid Emergency Medicine Score (REMS) compared with three other early warning scores in predicting in-hospital mortality among COVID-19 patients in the emergency department: a multicenter validation study.

BACKGROUND: Many early warning scores (EWSs) have been validated to prognosticate adverse outcomes of COVID-19 in the Emergency Department (ED), including the quick Sequential Organ Failure Assessment (qSOFA), the Modified Early Warning Score (MEWS), and the National Early Warning Score (NEWS). However, the Rapid Emergency Medicine Score (REMS) has not been widely validated for this purpose. We aimed to assess and compare the prognostic utility of REMS with that of qSOFA, MEWS, and NEWS for predicting mortality in emergency COVID-19 patients. METHODS: We conducted a multi-center retrospective study at five EDs of various levels of care in Thailand. Adult patients visiting the ED who tested positive for COVID-19 prior to ED arrival or within the index hospital visit between January and December 2021 were included. Their EWSs at ED arrival were calculated and analysed. The primary outcome was all-cause in-hospital mortality. The secondary outcome was mechanical ventilation. RESULTS: A total of 978 patients were included in the study; 254 (26%) died at hospital discharge, and 155 (15.8%) were intubated. REMS yielded the highest discrimination capacity for in-hospital mortality (the area under the receiver operator characteristics curves (AUROC) 0.771 (95% confidence interval (CI) 0.738, 0.804)), which was significantly higher than qSOFA (AUROC 0.620 (95%CI 0.589, 0.651); p < 0.001), MEWS (AUROC 0.657 (95%CI 0.619, 0.694); p < 0.001), and NEWS (AUROC 0.732 (95%CI 0.697, 0.767); p = 0.037). REMS was also the best EWS in terms of calibration, overall model performance, and balanced diagnostic accuracy indices at its optimal cutoff. REMS also performed better than other EWSs for mechanical ventilation. CONCLUSION: REMS was the early warning score with the highest prognostic utility as it outperformed qSOFA, MEWS, and NEWS in predicting in-hospital mortality in COVID-19 patients in the ED.

Clinical and radiological outcomes of robotic-assisted versus conventional total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND PURPOSE: Robotic-assisted total knee arthroplasty (RATKA) is an alternative surgical treatment method to conventional total knee arthroplasty (COTKA) that may deliver better surgical accuracy. However, its impact on patient outcomes is uncertain. The aim of this systematic review of randomized controlled trials (RCTs) is to evaluate whether RATKA could improve functional and radiological outcomes compared with COTKA in adult patients with primary osteoarthritis of the knee. METHODS: We searched Ovid MEDLINE, EMBASE, Scopus, and the Cochrane Library to identify published RCTs comparing RATKA with COTKA. 2 reviewers independently screened eligible studies, reviewed the full texts, assessed risk of bias using the Risk of Bias 2.0 tool, and extracted data. Outcomes were patient-reported outcomes, range of motion, and mechanical alignment (MA) deviation and outliers, and complications. RESULTS: We included 12 RCTs involving 2,200 patients. RATKA probably results in little to no effect on patient-reported outcomes (mean difference (MD) in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score of -0.35 (95% confidence interval [CI] -0.78 to 0.07) and range of motion (MD -0.73°; CI -7.5° to 6.0°) compared with COTKA. However, RATKA likely results in a lower degree of MA outliers (risk ratio 0.43; CI 0.27 to 0.67) and less deviation from neutral MA (MD -0.94°; CI -1.1° to -0.73°). There were no differences in revision rate or major adverse effects associated with RATKA. CONCLUSION: Although RATKA likely results in higher radiologic accuracy than COTKA, this may not be clinically meaningful. Also, there is probably no clinically important difference in clinical outcomes between RATKA and COTKA, while it is as yet inconclusive regarding the revision and complication rates due to insufficient evidence.

Characteristics and factors associated with mortality in palliative patients visiting the Emergency Department of a large tertiary hospital in Thailand.

BACKGROUND: The characteristics and outcomes of palliative patients who visited the Emergency Department (ED) in Thailand, a country in which no standard palliative care system existed, have not been comprehensively studied. We aimed to report the characteristics of ED palliative patients and investigate factors associated with mortality. METHODS: A prospective observational study was conducted at Siriraj Hospital, Bangkok, Thailand, between March 2019 and February 2021 by means of interviewing palliative patients and/or their caregivers and medical record review. Palliative patients with either incurable cancer or other end-stage chronic diseases were included. RESULTS: A total of 182 patients were enrolled. Their mean age was 73 years, 61.5% were female, and 53.8% had incurable cancer. Of these, 20.3% had previously visited the palliative clinic. Approximately 60% had advanced directives, 4.9% had a living will, and 27.5% had plans on their preferred place of death. The most common chief complaint was dyspnea (43.4%), and the main reason for ED visits was 'cannot control symptoms' (80%). At the ED, 17% of the patients had been seen by the palliative care team, and 23.1% died. Although 51% were admitted, 48.9% could not survive to discharge. Cancer, having received morphine, a palliative performance scale > 30, and ED palliative consultation were independently associated with hospital mortality. CONCLUSION: The recognition and utilization of palliative care were largely inadequate, especially for non-cancer patients. An improvement and promotion in the palliative care system from the ED through home care are mandatory to improve the quality of life of palliative patients.

Number of attempts required by emergency physicians to achieve competency in diaphragmatic ultrasound imaging.

PURPOSE: This research aimed to determine the number of attempts that emergency physicians need to become proficient in undertaking diaphragmatic ultrasound imaging. METHODS: A prospective observational study was conducted at the emergency department (ED) of a tertiary-care university hospital. Sixteen emergency physicians were each required to obtain a set of images of the right hemidiaphragm of five dyspneic patients using both diaphragmatic excursion and thickness techniques. The images were subsequently reviewed by a specialist using American College of Emergency Physician guidelines. If the evaluations of a physician did not reach the expected standard, the physician was to be given feedback and requested to collect images from another five patients. The process was to be repeated until such time as the images obtained by the physician were deemed to be up to standard. RESULTS: Eighty patients, twelve emergency medicine residents, and four attending physicians were enrolled. Following a didactic session on diaphragmatic ultrasound imaging and its interpretation, practicing on five patients proved sufficient to achieve an adequate level of competency in conducting diaphragmatic ultrasound examinations. CONCLUSION: Practicing on five patients is sufficient for emergency physicians to achieve an adequate level of competency in conducting right-sided diaphragmatic ultrasound examinations.

Independent risk factors of mortality in patients with sepsis receiving single-dose etomidate as an induction agent during rapid sequence intubation in a large tertiary emergency department in Thailand.

BACKGROUND: There is limited evidence regarding factors associated with mortality in septic patients receiving etomidate. This study aimed to determine independent pre-intubation factors predicting 28-day mortality in septic patients receiving single-dose etomidate as an induction agent during rapid sequence intubation (RSI). METHODS: This single-center retrospective cohort study included intubated septic patients receiving etomidate as an induction agent during RSI in the emergency department of Siriraj hospital, Bangkok, Thailand, between January 1st, 2016 and June 30th, 2020. Pre-intubation characteristics were compared between survivors and non-survivors. Independent risk factors associated with 28-day mortality were identified using the Cox proportional hazards regression model. Association between etomidate dosage and mortality was also determined. RESULTS: A total of 344 patients, 238 (69%) survivors and 106 (31%) non-survivors, were included in the analyses. The initial Cox hazards model identified a pre-intubation lactate level ≥ 4 mmol/L as an independent factor associated with mortality (adjusted Hazards ratio [aHR] 2.66, 95% confidence interval [CI] 1.55-4.56). After removing lactate level from the model due to limited lactate values in the data, cancer was also predictive of 28-day mortality (aHR 1.83, 95%CI 1.10-3.04), while patients with respiratory infections and underlying chronic lung disease were associated with lower mortality (aHR 0.54, 95%CI 0.37-0.80 and aHR 0.57, 0.33-0.96, respectively). Etomidate dosage was not associated with mortality in our study. CONCLUSION: In septic patients who received a single dose of etomidate, a pre-intubation lactate level ≥ 4 mmol/L and cancer were associated with increased 28-day mortality, while respiratory infection and underlying chronic lung disease were associated with lower mortality. Physicians may take these factors into consideration when selecting induction agents for septic patients.

The COVID-19 pandemic: the effect on airway Management in non-COVID emergency patients.

BACKGROUND: During the COVID-19 outbreak, healthcare providers might have avoided droplet/aerosol-generating procedures, such as non-invasive ventilation (NIV) and high-flow nasal cannula (HFNC) due to the concern of themselves being infected. We hypothesized that this change of practice could have also occurred to other non-COVID-infected patients in the Emergency Department (ED). METHODS: A retrospective analytic study was conducted in the ED of Siriraj Hospital, Bangkok, Thailand, including adult patients presenting with signs and symptoms of respiratory distress between 1 March and 30 April 2020 (the COVID period). A comparison group using the same inclusion criteria was retrieved from 1 March to 30 April 2019 (the pre-COVID period). The primary outcome was rate of NIV and HFNC use. The secondary outcomes were rate of intubation, failure of NIV and HFNC, complications, and mortality. RESULTS: A total of 360 and 333 patients were included during the pre-COVID and COVID periods, respectively. After adjusting for baseline differences, patients in the COVID period were less likely to receive either NIV or HFNC than the pre-COVID period (adjusted OR 0.52 [95%CI 0.29-0.92]). Overall, intubation rate was similar between the two study periods. However, patients in respiratory distress with pulmonary edema had a relatively higher intubation rate in the COVID period. There were higher failure rates of NIV and HFNC, more infectious complications, and a higher rate of mortality in the pre-COVID period. CONCLUSION: During the COVID-19 pandemic, the overall usage of NIV and HFNC in emergency non-COVID patients decreased. Although not affecting the overall intubation rate, this change of practice could have affected some groups of patients. Therefore, treatment decisions based on a balance between the benefits to the patients and the safety of healthcare providers should be made.

The utility of the rapid emergency medicine score (REMS) compared with SIRS, qSOFA and NEWS for Predicting in-hospital Mortality among Patients with suspicion of Sepsis in an emergency department.

BACKGROUND: Many early warning scores (EWSs) have been validated to prognosticate adverse outcomes secondary to sepsis in the Emergency Department (ED). These EWSs include the Systemic Inflammatory Response Syndrome criteria (SIRS), the quick Sequential Organ Failure Assessment (qSOFA) and the National Early Warning Score (NEWS). However, the Rapid Emergency Medicine Score (REMS) has never been validated for this purpose. We aimed to assess and compare the prognostic utility of REMS with that of SIRS, qSOFA and NEWS for predicting mortality in patients with suspicion of sepsis in the ED. METHODS: We conducted a retrospective study at the ED of Siriraj Hospital Mahidol University, Thailand. Adult patients suspected of having sepsis in the ED between August 2018 and July 2019 were included. Their EWSs were calculated. The primary outcome was all-cause in-hospital mortality. The secondary outcome was 7-day mortality. RESULTS: A total of 1622 patients were included in the study; 457 (28.2%) died at hospital discharge. REMS yielded the highest discrimination capacity for in-hospital mortality (the area under the receiver operator characteristics curves (AUROC) 0.62 (95% confidence interval (CI) 0.59, 0.65)), which was significantly higher than qSOFA (AUROC 0.58 (95%CI 0.55, 0.60); p = 0.005) and SIRS (AUROC 0.52 (95%CI 0.49, 0.55); p < 0.001) but not significantly superior to NEWS (AUROC 0.61 (95%CI 0.58, 0.64); p = 0.27). REMS was the best EWS in terms of calibration and association with the outcome. It could also provide the highest net benefit from the decision curve analysis. Comparison of EWSs plus baseline risk model showed similar results. REMS also performed better than other EWSs for 7-day mortality. CONCLUSION: REMS was an early warning score with higher accuracy than sepsis-related scores (qSOFA and SIRS), similar to NEWS, and had the highest utility in terms of net benefit compared to SIRS, qSOFA and NEWS in predicting in-hospital mortality in patients presenting to the ED with suspected sepsis.

High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Relieving Dyspnea in Emergency Palliative Patients With Do-Not-Intubate Status: A Randomized Crossover Study.

STUDY OBJECTIVE: Palliative patients often visit the emergency department (ED) with respiratory distress during their end-of-life period. The goal of management is alleviating dyspnea and providing comfort. High-flow nasal cannula may be an alternative oxygen-delivering method for palliative patients with do-not-intubate status. We therefore aim to compare the efficacy of high-flow nasal cannula with conventional oxygen therapy in improving dyspnea of palliative patients with do-not-intubate status who have hypoxemic respiratory failure in the ED. METHODS: This randomized, nonblinded, crossover study was conducted with 48 palliative patients aged 18 years or older with do-not-intubate status who presented with hypoxemic respiratory failure to the ED of Siriraj Hospital, Bangkok, Thailand. The participants were randomly allocated to conventional oxygen therapy for 60 minutes, followed by high-flow nasal cannula for 60 minutes (n=24) or vice versa (n=24). The primary outcome was modified Borg scale score. The secondary outcomes were numeric rating scale score of dyspnea and vital signs. RESULTS: Intention-to-treat analysis included 44 patients, 22 in each group. Baseline mean modified Borg scale score was 7.6 (SD 2.2) (conventional oxygen therapy first) and 8.2 (SD 1.8) (high-flow nasal cannula first). At 60 minutes, mean modified Borg scale score in patients receiving conventional oxygen therapy and high-flow nasal cannula was 4.9 (standard of mean 0.3) and 2.9 (standard of mean 0.3), respectively (mean difference 2.0; 95% confidence interval 1.4 to 2.6). Results for the numeric rating scale score of dyspnea were similar to those for the modified Borg scale score. Respiratory rates were lower with high-flow nasal cannula (mean difference 5.9; 95% confidence interval 3.5 to 8.3), and high-flow nasal cannula was associated with a significantly lower first-hour morphine dose. CONCLUSION: High-flow nasal cannula was superior to conventional oxygen therapy in reducing the severity of dyspnea in the first hour of treatment in patients with do-not-intubate status and hypoxemic respiratory failure.

Clinical, functional, and radiological outcomes of robotic assisted versus conventional total hip arthroplasty: a systematic review and meta-analysis of randomized controlled trials.

This systematic review of randomized controlled trials (RCTs) aims to compare important clinical, functional, and radiological outcomes between robotic-assisted total hip arthroplasty (RATHA) and conventional total hip arthroplasty (COTHA) in patients with hip osteoarthritis. We identified published RCTs comparing RATHA with COTHA in Ovid MEDLINE, EMBASE, Scopus, and Cochrane Library. Two reviewers independently performed study screening, risk of bias assessment and data extraction. Main outcomes were major complications, revision, patient-reported outcome measures (PROMs), and radiological outcomes. We included 8 RCTs involving 1014 patients and 977 hips. There was no difference in major complication rate (Relative Risk (RR) 0.78; 95% Confidence Interval (CI) 0.22 to 2.74), revision rate (RR 1.33; 95%CI 0.08 to 22.74), and PROMs (standardized mean difference 0.01; 95%CI - 0.27 to 0.30) between RATHA and COTHA. RATHA resulted in little to no effects on femoral stem alignment (mean difference (MD) - 0.57 degree; 95%CI - 1.16 to 0.03) but yielded overall lower leg length discrepancy (MD - 4.04 mm; 95%CI - 7.08 to - 1.0) compared to COTHA. Most combined estimates had low certainty of evidence mainly due to risk of bias, inconsistency, and imprecision. Based on the current evidence, there is no important difference in clinical and functional outcomes between RATHA and COTHA. The trivial higher radiological accuracy was also unlikely to be clinically meaningful. Regardless, more robust evidence is needed to improve the quality and strength of the current evidence.PROSPERO registration: the protocol was registered in the PROSPERO database (CRD42023453294). All methods were carried out in accordance with relevant guidelines and regulations.

ROX index versus HACOR scale in predicting success and failure of high-flow nasal cannula in the emergency department for patients with acute hypoxemic respiratory failure: a prospective observational study.

BACKGROUND: High-flow nasal cannula has been a promising initial respiratory support measure for patients with acute hypoxemic respiratory failure (AHRF) in the emergency department (ED). However, delayed detection of HFNC failure is associated with increased mortality. The ROX index is a tool that can help predict HFNC success. Nonetheless, its utility in ED patients is limited, and no studies have compared it with the HACOR scale, another tool that may be as accurate in predicting HFNC failure. Therefore, we aimed to compare the prognostic utility of the ROX index and the HACOR scale in emergency AHRF patients. METHODS: This prospective observational study was conducted at the ED of Siriraj Hospital, Thailand, between August 2018 and February 2020. Adult patients with AHRF requiring HFNC in the ED were included. The ROX index and the HACOR scale were measured at 1, 2, and 6 h after HFNC initiation. The primary outcome was HFNC success, defined as no intolerance or escalation towards mechanical ventilation or non-invasive ventilation within 48 h. RESULTS: A total of 75 patients were enrolled; 52 (69.3%) had a successful treatment. The ROX index was higher in the success group, while the HACOR scale was lower at all timepoints. The ROX index yielded generally higher discrimination capacity based on the area under the receiver operating characteristic curve (AUROC) than the HACOR scale [AUROC at 1, 2, and 6 h = 0.815, 0.784, 0.853 for ROX in predicting HFNC success and 0.733, 0.690, and 0.764 for HACOR in predicting HFNC failure]. The ROX index measured at 6 h at the cut-point of 4.88 had 92.98% sensitivity, 61.11% specificity, 88.33% positive predictive value, and 73.33% negative predictive value with a diagnostic accuracy of 85.33%. CONCLUSION: The ROX index had superior prognostic utility in predicting HFNC outcome (success/failure) compared to the HACOR scale in patients with AHRF in the ED setting. Moreover, it is less complex and more efficient to be employed at bedside. Therefore, the ROX index is a more appropriate tool to guide further management and potential escalation therapy for AHRF patients with HFNC therapy initiated in the ED.

Clinical factors associated with adverse clinical outcomes in elderly versus non-elderly COVID-19 emergency patients: a multi-center observational study.

BACKGROUND: The COVID-19 pandemic has caused over 6 million deaths worldwide. The elderly accounted for a large proportion of patients with their mortality rate largely higher than the non-elderly. However, limited studies have explored clinical factors associated with poor clinical outcomes in this important population. Therefore, this study aimed to determine factors independently associated with adverse clinical outcomes among COVID-19 elderly patients. METHODS: We conducted a multicenter observational study at five emergency departments (EDs) in Thailand. Patients over 18 years old diagnosed with COVID-19 between January and December 2021 were included. We classified patients into elderly (age ≥ 65 years) and non-elderly (age < 65 years). The primary clinical outcome was in-hospital mortality. The secondary outcomes were endotracheal intubation and intensive care unit admission. We identified independent factors associating with these outcomes both in the whole population and separately by age group using multivariate logistic regression models. RESULTS: A total of 978 patients were included, 519 (53.1%) were elderly and 459 (46.9%) were non-elderly, and 254 (26%) died at hospital discharge. The mortality rate was significantly higher in the elderly group (39.1% versus 14.3%, p<0.001)). In the elderly, age (adjusted odds ratio (aOR) 1.13; 95% confidence interval (CI) 1.1-1.2; p<0.001), male sex (aOR 3.64; 95%CI 1.5-8.8; p=0.004), do-not-resuscitate (DNR) status (aOR 12.46; 95%CI 3.8-40.7; p<0.001), diastolic blood pressure (aOR 0.96; 95%CI 0.9-1.0; p=0.002), body temperature (aOR 1.74; 95%CI 1.0-2.9; p=0.036), and Glasgow Coma Scale (GCS) score (aOR 0.71; 95%CI 0.5-1.0; p=0.026) were independent baseline and physiologic factors associated with in-hospital mortality. Only DNR status and GCS score were associated with in-hospital mortality in both the elderly and non-elderly, as well as the overall population. Lower total bilirubin was independently associated with in-hospital mortality in the elderly (aOR 0.34; 95%CI 0.1-0.9; p=0.035), while a higher level was associated with the outcome in the non-elderly. C-reactive protein (CRP) was the only laboratory factor independently associated with all three study outcomes in the elderly (aOR for in-hospital mortality 1.01; 95%CI 1.0-1.0; p=0.006). CONCLUSION: Important clinical factors associated with in-hospital mortality in elderly COVID-19 patients were age, sex, DNR status, diastolic blood pressure, body temperature, GCS score, total bilirubin, and CRP. These parameters may aid in triage and ED disposition decision-making in this very important patient population during times of limited resources during the COVID-19 pandemic.

Ratio of Oxygen Saturation to Inspired Oxygen, ROX Index, Modified ROX Index to Predict High Flow Cannula Success in COVID-19 Patients: Multicenter Validation Study.

INTRODUCTION: High-flow nasal cannula (HFNC) is a respiratory support measure for coronavirus 2019 (COVID-19) patients that has been increasingly used in the emergency department (ED). Although the respiratory rate oxygenation (ROX) index can predict HFNC success, its utility in emergency COVID-19 patients has not been well-established. Also, no studies have compared it to its simpler component, the oxygen saturation to fraction of inspired oxygen (SpO2/FiO2 [SF]) ratio, or its modified version incorporating heart rate. Therefore, we aimed to compare the utility of the SF ratio, the ROX index (SF ratio/respiratory rate), and the modified ROX index (ROX index/heart rate) in predicting HFNC success in emergency COVID-19 patients. METHODS: We conducted this multicenter retrospective study at five EDs in Thailand between January-December 2021. Adult patients with COVID-19 treated with HFNC in the ED were included. The three study parameters were recorded at 0 and 2 hours. The primary outcome was HFNC success, defined as no requirement of mechanical ventilation at HFNC termination. RESULTS: A total of 173 patients were recruited; 55 (31.8%) had successful treatment. The two-hour SF ratio yielded the highest discrimination capacity (AUROC 0.651, 95% CI 0.558-0.744), followed by two-hour ROX and modified ROX indices (AUROC 0.612 and 0.606, respectively). The two-hour SF ratio also had the best calibration and overall model performance. At its optimal cut-point of 128.19, it gave a balanced sensitivity (65.3%) and specificity (61.8%). The two-hour SF≥128.19 was also significantly and independently associated with HFNC failure (adjusted odds ratio 0.29, 95% CI 0.13-0.65; P=0.003). CONCLUSION: The SF ratio predicted HFNC success better than the ROX and modified ROX indices in ED patients with COVID-19. With its simplicity and efficiency, it may be the appropriate tool to guide management and ED disposition for COVID-19 patients receiving HFNC in the ED.

Parallel-group, randomised, controlled, non-inferiority trial of high-flow nasal cannula versus non-invasive ventilation for emergency patients with acute cardiogenic pulmonary oedema: study protocol.

INTRODUCTION: High-flow nasal cannula (HFNC) is an innovative oxygen-delivering technique, which has been shown to effectively decrease the intubation risk in patients with hypoxaemic respiratory failure of various aetiologies compared with conventional oxygen therapy. Also, it has proved to be non-inferior to non-invasive positive pressure ventilation (NIPPV) in patients with hypoxaemic respiratory failure primarily due to pneumonia. Evidence on its benefits compared with NIPPV, which is the standard of care for patients with acute cardiogenic pulmonary oedema (ACPE) with hypoxaemic respiratory distress, is limited. Therefore, we planned this study to investigate the effects of HFNC compared with NIPPV for emergency patients with ACPE. METHODS AND ANALYSIS: In this single-centred, non-blinded, parallel-group, randomised, controlled, non-inferiority trial, we will randomly allocate 240 patients visiting the emergency department with ACPE in a 1:1 ratio to receive either HFNC or NIPPV for at least 4 hours using computer-generated mixed-block randomisation concealed by sealed opaque envelopes. The primary outcome is the intubation rate in 72 hours after randomisation. The main secondary outcomes are intolerance rate, mortality rate and treatment failure rate (a composite of intolerance, intubation and mortality). The outcome assessors and data analysts will be blinded to the intervention. These categorical outcomes will be analysed by calculating the risk ratio. Interim analyses evaluating the primary outcome will be performed after half of the expected sample size are recruited. ETHICS AND DISSEMINATION: This study protocol has been approved by the Siriraj Institutional Review Board (study ID: Si 271/2021). It has been granted the Siriraj Research and Development Fund. All participants or their authorised third parties will provide written informed consent prior to trial inclusion. The study results will be published in a peer-reviewed international journal and presented at national and international scientific conferences. TRIAL REGISTRATION NUMBER: TCTR20210413001.

Nasal High-flow Oxygen Versus Conventional Oxygen Therapy for Acute Severe Asthma Patients: A Pilot Randomized Controlled Trial.

BACKGROUND: Nasal high flow (NHF) has demonstrated efficacy in relieving dyspnea in various patients with hypoxemic and hypercapnic respiratory failure. It may also reduce dyspnea in patients with acute severe asthma in the emergency department (ED). The aim of the study was to compare the efficacy of NHF with conventional oxygen therapy (COT) in improving dyspnea in acute severe asthma patients with hypoxemia in the ED. METHODS: This pilot nonblinded randomized controlled trial was conducted involving 37 patients aged ≥ 18 years with acute severe asthma and hypoxemia in the ED of Siriraj Hospital, Bangkok, Thailand (TCTR20180926003). The participants were randomly allocated to receive either COT (n = 18) or NHF (n = 19) for 120 minutes. The primary outcome was comparing the intervention effects on the patients' degree of dyspnea measured using the modified Borg scale (MBS). The secondary outcomes were comparing the interventions based on the numeric rating scale (NRS) of dyspnea, the dyspnea scale assessing accessory muscle use, vital signs, and blood gas results. RESULTS: The intention-to-treat analysis included 37 patients (COT group n = 18 and NHF group n = 19). The baseline mean MBS was 7.8 in both groups. At 120 minutes, the mean (±SD) MBSs in patients receiving COT and NHF were 3.3 (±2.5) and 1.4 (±2.5), respectively (mean difference = 1.9 [95% CI = 0.2 to 3.8], p = 0.043). The trends in NRS and dyspnea score results were similar to those of MBS. Respiratory rates were lower with NHF (mean difference = 4.7 [95% CI = 1.5 to 7.8], p = 0.001). No between- or within-group differences in blood gas results were found. CONCLUSION: Nasal high flow reduced the severity of dyspnea and respiratory rate in hypoxemic patients with acute severe asthma in the ED.