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Evaluating the performance of a binary diagnostic test, including artificial intelligence classification algorithms, involves measuring sensitivity, specificity, positive predictive value, and negative predictive value. Particularly when comparing the performance of two diagnostic tests applied on the same set of patients, these metrics are crucial for identifying the more accurate test. However, comparing predictive values presents statistical challenges because their denominators depend on the test outcomes, unlike the comparison of sensitivities and specificities. This paper reviews existing methods for comparing predictive values and proposes using the permutation test. The permutation test is an intuitive, non-parametric method suitable for datasets with small sample sizes. We demonstrate each method using a dataset from MRI and combined modality of mammography and ultrasound in diagnosing breast cancer.
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Background@#Pulmonary nocardiosis is a rare opportunistic infection with occasional systemic dissemination. This study aimed to investigate the computed tomography (CT) findings and prognosis of pulmonary nocardiosis associated with dissemination. @*Methods@#We conducted a retrospective analysis of patients diagnosed with pulmonary nocardiosis between March 2001 and September 2023. We reviewed the chest CT findings and categorized them based on the dominant CT findings as consolidation, nodules and/ or masses, consolidation with multiple nodules, and nodular bronchiectasis. We compared chest CT findings between localized and disseminated pulmonary nocardiosis and identified significant prognostic factors associated with 12-month mortality using multivariate Cox regression analysis. @*Results@#Pulmonary nocardiosis was diagnosed in 75 patients, of whom 14 (18.7%) had dissemination, including involvement of the brain in 9 (64.3%) cases, soft tissue in 3 (21.4%) cases and positive blood cultures in 3 (21.4%) cases. Disseminated pulmonary nocardiosis showed a higher frequency of cavitation (64.3% vs. 32.8%, P = 0.029) and pleural effusion (64.3% vs. 29.5%, P = 0.014) compared to localized infection. The 12-month mortality rate was 25.3%. The presence of dissemination was not a significant prognostic factor (hazard ratio [HR], 0.80; confidence interval [CI], 0.23–2.75; P = 0.724). Malignancy (HR, 9.73; CI, 2.32–40.72; P = 0.002), use of steroid medication (HR, 3.72; CI, 1.33–10.38; P = 0.012), and a CT pattern of consolidation with multiple nodules (HR, 4.99; CI, 1.41–17.70; P = 0.013) were associated with higher mortality rates. @*Conclusion@#Pulmonary nocardiosis with dissemination showed more frequent cavitation and pleural effusion compared to cases without dissemination, but dissemination alone did not affect the mortality rate of pulmonary nocardiosis.
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Purpose@#We aimed to determine the current application and survival trends of hematopoietic stem cell transplantation (HSCT) among Korean children and adolescents with cancer. @*Materials and Methods@#Data of patients aged < 20 years with KCD-10 (Korean Classifications of Diseases, 10th revision) C codes and specific designation codes were collected from the National Health Insurance Service database. Thirty claim codes for HSCT were included, and data from 2009 to 2019 were analyzed. @*Results@#The operational definition of pediatric cancer yielded an annual average of 2,000, with annual cases decreasing. In 2019, 221 HSCTs were performed, a decrease from the ten-year average of 276. Allografts outnumbered autografts with a ratio of 1.5:1. The source of allograft was bone marrow in 15% of patients in 2009; however, it substantially decreased to 3.3% in 2019. Furthermore, 70.5% of allogeneic HSCT used peripheral blood stem cell (PBSC) grafts, which increased to 89.3% by 2015. Cord blood utilization markedly decreased to 2.7% in 2018. The 5-year overall survival (OS) rate of all patients was 85.1%. Overall mortality decreased among patients who underwent recent HSCT, and they exhibited a higher 5-year OS rate. @*Conclusion@#In Korea, the number of pediatric patients with cancer is declining; however, the ratio of transplants to all patients remains constant. Patients who recently underwent transplantation showed better survival rates, possibly due to HSCT optimization. Korea showed a substantially greater PBSC utilization in pediatric HSCT. An in-depth examination encompassing donor relations and cause of death with a prospective registry is required in future studies.
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Purpose@#The female sex is reported to have a higher risk of adverse events (AEs) from cytotoxic chemotherapy. Few studies examined the sex differences in AEs and their impact on the use of medical services during adjuvant chemotherapy. This sub-study aimed to compare the incidence of any grade and grade ≥ 3 AEs, healthcare utilization, chemotherapy completion rate, and dose intensity according to sex. @*Materials and Methods@#This is a sub-study of a multicenter cohort conducted in Korea that evaluated the impact of healthcare reimbursement on AE evaluation in patients who received adjuvant chemotherapy between September 2013 and December 2016 at four hospitals in Korea. @*Results@#A total of 1,170 patients with colorectal, gastric, or non–small cell lung cancer were included in the study. Female patients were younger, had fewer comorbidities, and experienced less postoperative weight loss of > 10%. Females had significantly higher rates of any grade AEs including nausea, abdominal pain, stomatitis, vomiting, and neutropenia, and experienced more grade ≥ 3 neutropenia, nausea, and vomiting. The dose intensity of chemotherapy was significantly lower in females, and they also experienced more frequent dose reduction after the first cycle. Moreover, female patients receiving platinum-containing regimens had significantly higher rates of unscheduled outpatient visits. @*Conclusion@#Our study found that females experienced a higher incidence of multiple any-grade AEs and severe neutropenia, nausea, and vomiting, across various cancer types, leading to more frequent dose reductions. Physicians should be aware of sex differences in AEs for chemotherapy decisions.
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Propensity score matching (PSM) is an increasingly applied method of ensuring comparability between groups of interest. However, PSM is often applied unconditionally, without precise considerations. The purpose of this study is to provide a nonmathematical guide for clinicians at the stage of designing a PSM-based study. We provide a seed of thought for considering whether applying PSM would be appropriate and, if so, the scope of the list of variables. Although PSM may be simple, its results could vary substantially according to how the propensity score is constructed. Misleading results can be avoided through a critical review of the process of PSM.
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Background/Aims@#Data on the immunoprotective status against measles, mumps, rubella, varicella zoster virus (VZV), hepatitis A virus (HAV), and Epstein-Barr virus (EBV) infection in patients with inflammatory bowel disease (IBD) are still lacking. Therefore, we investigated the seropositivity rates for viral infectious diseases and the associated factors in Korean patients with IBD. @*Methods@#In this retrospective cohort study, serum immunoglobulin G antibody positivity rates against measles virus, mumps virus, rubella virus, VZV, HAV, and EBV viral capsid antigen (VCA) were measured in patients with Crohn’s disease or ulcerative colitis (UC) who first visited the IBD clinic. Seropositivity rates and their associated factors were analyzed. @*Results@#Between January 2016 and December 2018, 263 patients were enrolled (male, 167 [67.3%]; UC, 134 [50.9%]). The median age at serological test was 30 years (interquartile range, 22 to 46). The seropositivity rates were 84.0%, 85.2%, 66.5%, 87.4%, 50.0%, and 93.7% for measles, mumps, rubella, VZV, HAV, and EBV, respectively. Younger age at serological test was associated with seronegative status for measles (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.88 to 0.96), VZV (aOR, 0.83; 95% CI, 0.74 to 0.93), and HAV (aOR, 0.93; 95% CI, 0.91 to 0.95). Furthermore, IBD type-UC was associated with seronegative status against VZV (aOR, 0.33; 95% CI, 0.11 to 0.99). @*Conclusions@#Seropositivity rates for common viral infectious diseases in Korean patients with IBD were similar to those of the general population. In the younger age group, protective immunity against measles, VZV, and HAV is required, with proper vaccination, as necessary.
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Purpose@#To evaluate the applicability of Greulich-Pyle (GP) standards to bone age (BA) assessment in healthy Korean children using manual and deep learning-based methods. @*Materials and Methods@#We collected 485 hand radiographs of healthy children aged 2–17 years (262 boys) between 2008 and 2017. Based on GP method, BA was assessed manually by two radiologists and automatically by two deep learning-based BA assessment (DLBAA), which estimated GP-assigned (original model) and optimal (modified model) BAs. Estimated BA was compared to chronological age (CA) using intraclass correlation (ICC), Bland-Altman analysis, linear regression, mean absolute error, and root mean square error. The proportion of children showing a difference >12 months between the estimated BA and CA was calculated. @*Results@#CA and all estimated BA showed excellent agreement (ICC ≥0.978, p12 months in 44.3%, 44.5%, 39.2%, and 36.1% for radiologist 1, radiologist 2, original, and modified DLBAA models, respectively. @*Conclusion@#Contemporary healthy Korean children showed different rates of skeletal development than GP standard-BA, and systemic bias should be considered when determining children’s skeletal maturation.
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Purpose@#Cancer-related fatigue is a common and distressing symptom that occurs during cancer treatment. This study aimed to find factors that are related to cancer-related fatigue, and its effect on patients’ quality of life. @*Materials and Methods@#This study included 159 patients who completed questionnaires and interviews during their initial examination at the sleep clinic for cancer patients, Asan Medical Center, between December 2018 and January 2020. Their medical reports were reviewed retrospectively. Questionnaire data about depression, anxiety, insomnia, fear of disease progression, and dysfunctional beliefs about sleep, pain, and quality of life, were reviewed. Additionally, patient sleep structure data were analyzed. @*Results@#Factors such as depression (p < 0.001), anxiety (p < 0.001), fear of cancer progression (p < 0.001), fatigue (p=0.027), and time in bed during 24 hours (p=0.037) were significant expecting variables for low quality of life from logistic regression analysis. In pathway analysis, depression (p < 0.001), not cancer-related fatigue (p=0.537), act as a direct risk factor on quality of life. And also, depression was an overall risk factor for insomnia, fatigue, and daily activity of cancer patients. @*Conclusion@#Cancer-related fatigue did not show significant effect on patient’s quality of life in this study. However, the result of pathway analysis highlights the importance of assessing depression in the process of cancer treatment and providing appropriate interventions.
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Purpose@#Cancer-related fatigue is a common and distressing symptom that occurs during cancer treatment. This study aimed to find factors that are related to cancer-related fatigue, and its effect on patients’ quality of life. @*Materials and Methods@#This study included 159 patients who completed questionnaires and interviews during their initial examination at the sleep clinic for cancer patients, Asan Medical Center, between December 2018 and January 2020. Their medical reports were reviewed retrospectively. Questionnaire data about depression, anxiety, insomnia, fear of disease progression, and dysfunctional beliefs about sleep, pain, and quality of life, were reviewed. Additionally, patient sleep structure data were analyzed. @*Results@#Factors such as depression (p < 0.001), anxiety (p < 0.001), fear of cancer progression (p < 0.001), fatigue (p=0.027), and time in bed during 24 hours (p=0.037) were significant expecting variables for low quality of life from logistic regression analysis. In pathway analysis, depression (p < 0.001), not cancer-related fatigue (p=0.537), act as a direct risk factor on quality of life. And also, depression was an overall risk factor for insomnia, fatigue, and daily activity of cancer patients. @*Conclusion@#Cancer-related fatigue did not show significant effect on patient’s quality of life in this study. However, the result of pathway analysis highlights the importance of assessing depression in the process of cancer treatment and providing appropriate interventions.
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Purpose@#Six forms relating to decisions on life-sustaining treatment (LST) for patients at the end-of-life (EOL) in hospital are required by the “Act on Decision of LST for Patients at the EOL.” We investigated the preparation and creation status of these documents from the database of the National Agency for Management of LST. @*Materials and Methods@#We analyzed the contents and details of each document necessary for decisions on LST, and the creation status of forms. We defined patients completing form 1 as “self-determined” of LST, and those whose family members had completed form 11/12 as “family decision” of LST. According to the determination subject, we compared the four items of LST on form 13 (the paper of implementation of LST) and the documentation time interval between forms. @*Results@#The six forms require information about the patient, doctor, specialized doctor, family members, institution, decision for LST, and intention to use hospice services. Of 44,381 who had completed at least one document, 36,693 patients had form 13. Among them, 11,531, 10,976, and 12,551 people completed forms 1, 11, and 12, respectively. The documentation time interval from forms 1, 11, or 12 to form 13 was 8.6±13.6 days, 1.0±9.5 days, and 1.5±9.7 days, respectively. @*Conclusion@#The self-determination rate of LST was 31% and the mean time interval from self-determination to implementation of LST was 8.6 days. The creation of these forms still takes place when the patients are close to death.
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Purpose@#The main purpose of the Life-Sustaining Treatment Decisions Act recently enacted in Korea is to respect the patient’s self-determination. We aimed to investigate the current status and features of patient self-determination after implementation of the law. @*Materials and Methods@#Between February 2018 and January 2019, 54,635 cancer deaths were identified from the National Health Insurance Service (NHIS) database. We analyzed the characteristics of decedents who complied with the law process by self-determination compared with decedents with family determination and with decedents who did not comply with the law process. @*Results@#In multivariable analysis, patients with self-determination were younger, were less likely to live in rural areas, were less likely to belong to the highest income quintile, were less likely to be treated in general hospitals, and were more likely to show a longer time from cancer diagnosis compared with patients with family determination. Compared with patients who did not comply with the law process, patients with self-determination were younger, lived in Seoul or capital area, were less likely to belong to the highest income quintile, were treated in general hospitals, were less likely to have genitourinary or hematologic malignancies, scored higher on the Charlson comorbidity index, and showed a longer time from cancer diagnosis. Patients with self-determination were more likely to use hospice and less likely to use intensive care units (ICUs) at the end-of-life (EOL). @*Conclusion@#Decedents with self-determination were more likely to be younger, reside in the Seoul or capital area, show a longer time from cancer diagnosis, and were less likely to belong to the highest income quintile. They utilized hospice more frequently, and received less ICU care at the EOL.
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Purpose@#In Korea, the “Act on Hospice and Palliative Care and Decisions on Life-sustaining Treatment for Patients at the End of Life” was enacted on February 4, 2018. This study was conducted to analyze the current state of life-sustaining treatment decisions based on National Health Insurance Service (NHIS) data after the law came into force. @*Materials and Methods@#The data of 173,028 cancer deaths were extracted from NHIS qualification data between November 2015 and January 2019. @*Results@#The number of cancer deaths complied with the law process was 14,438 of 54,635 cases (26.4%). The rate of patient self-determination was 49.0%. The patients complying with the law process have used a hospice center more frequently (28% vs. 14%). However, the rate of intensive care unit (ICU) admission was similar between the patients who complied with and without the law process (ICU admission, 23% vs. 21%). There was no difference in the proportion of patients who had undergone mechanical ventilation and hemodialysis in the comparative analysis before and after the enforcement of the law and the analysis according to the compliance with the law. The patients who complied with the law process received cardiopulmonary resuscitation at a lower rate. @*Conclusion@#The law has positive effects on the rate of life-sustaining treatment decision by patient’s determination. However, there was no sufficient effect on the withholding or withdrawing of life-sustaining treatment, which could protect the patient from unnecessary or harmful interventions.
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Purpose@#The “Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment for Patients at the End-of-Life” was enacted on February 3, 2016 and went into effect on February 4, 2018 in Korea. This study reviewed the first year of determination to life-sustaining treatment (LST) through data analysis of the National Agency for Management of Life-Sustaining Treatment. @*Materials and Methods@#The National Agency for Management of LST provided data between February 4, 2018 and January 31, 2019 anonymously from 33,549 patients. According to the forms patients were defined as either elf-determinants or family-determinants. @*Results@#The median age of the patient was 73 and the majority was male (59.9%). Cancer patients were 59% and self-determinants were 32.1%. Cancer patients had a higher rate of self-determinants than non-cancer (47.3% vs. 10.1%). Plan for hospice service was high in cancer patients among self-determinants (81.0% vs. 37.5%, p < 0.001). In comparison to family-determinants, self-determinants were younger (median age, 67 years vs. 75 years; p < 0.001) and had more cancer diagnosis (87.1% vs. 45.9%, p < 0.001). Decision of withholding or withdrawing of LSTs in cancer patients was higher than non-cancer patients in four items. @*Conclusion@#Cancer patients had a higher rate in self-determination and withholding or withdrawing of LSTs than non-cancer patients. Continued revision of the law and education of the public will be able to promote withdrawing or withholding the futile LSTs in patients at end-of-life. Further study following the revision of the law should be evaluated to change of end-of-life care.
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Background@#The coronavirus disease 2019, or COVID-19, has had a major psychological impact on healthcare workers. However, very few scales are available to specifically assess work-related stress and anxiety in healthcare workers responding to a viral epidemic. This study developed a new assessment tool, the Stress and Anxiety to Viral Epidemics-9 (SAVE-9) and aimed to validate it among healthcare workers directly affected by COVID-19 in Korea. @*Methods@#A total of 1,019 healthcare workers responded through anonymous questionnaires during April 20–30, 2020. Exploratory factor analysis (EFA) was conducted to explore the construct validity, and the reliability was assessed using internal consistency measures of Cronbach's alpha coefficients. Receiver operating characteristic analysis was conducted to define the most appropriate cut-off point of SAVE-9 using the Generalized Anxiety Disorder-7 scale (GAD-7; ≥ 5). Second, Spearman's rank correlation coefficient was used to establish convergent validity for the SAVE-9 questionnaire with GAD-7 and the Patient Health Questionnaire-9. @*Results@#The nine-item scale had satisfactory internal consistency (Cronbach's α = 0.795). It adopted a two-factor structure: 1) anxiety regarding viral epidemics and 2) work-related stress associated with viral epidemics. A cut-off score of 22 for the SAVE-9 ascertained levels of stress and anxiety in response to a viral epidemic in healthcare workers that warranted clinical attention. Correlations between the SAVE-9 and the other scales were statistically significant (P < 0.05). @*Conclusion@#The results suggest that the SAVE-9 is a useful, reliable, and valid tool to evaluate stress and anxiety responses in healthcare workers during viral epidemics.
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Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb), remains one of the most important infectious diseases worldwide. Mtb and its culture filtrates or sonic extracts induce apoptosis in macrophages. However, there is a little known about Mtb components that modulate apoptosis and their regulating mechanism. We identified Rv0753c protein with apoptotic potential through searching the biologic active proteins from the multidimensional fractions of Mtb culture filtrate. Here, we investigated the apoptotic effects of Rv0753c on RAW264.7 cells. The recombinant Rv0753c induced RAW264.7 cells apoptosis in a caspase-9-dependent manner. Dissipation of the mitochondrial transmembrane potential (ΔΨ m ), mitochondrial translocation of Bax, and release of cytochrome c from mitochondria were observed in macrophages treated with Rv0753c. Enhanced reactive oxygen species (ROS) production was required for Rv0753c-mediated apoptosis. Furthermore, ROS-mediated JNK activation was major signaling pathway for Rv0753c-induced apoptosis. Moreover, Rv0753c-mediated apoptosis is dependent on TLR4. Altogether, these results suggest that Rv0753c induce apoptosis through ROS-JNK signaling pathway in RAW264.7 cells.
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Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb), remains one of the most important infectious diseases worldwide. Mtb and its culture filtrates or sonic extracts induce apoptosis in macrophages. However, there is a little known about Mtb components that modulate apoptosis and their regulating mechanism. We identified Rv0753c protein with apoptotic potential through searching the biologic active proteins from the multidimensional fractions of Mtb culture filtrate. Here, we investigated the apoptotic effects of Rv0753c on RAW264.7 cells. The recombinant Rv0753c induced RAW264.7 cells apoptosis in a caspase-9-dependent manner. Dissipation of the mitochondrial transmembrane potential (ΔΨ m ), mitochondrial translocation of Bax, and release of cytochrome c from mitochondria were observed in macrophages treated with Rv0753c. Enhanced reactive oxygen species (ROS) production was required for Rv0753c-mediated apoptosis. Furthermore, ROS-mediated JNK activation was major signaling pathway for Rv0753c-induced apoptosis. Moreover, Rv0753c-mediated apoptosis is dependent on TLR4. Altogether, these results suggest that Rv0753c induce apoptosis through ROS-JNK signaling pathway in RAW264.7 cells.
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Background/Aims@#Scoring systems play an important role in predicting intensive care unit (ICU) admission or estimating the risk of death in critically ill patients with hematological malignancies. We evaluated the modified early warning score (MEWS) for predicting ICU admissions and in-hospital mortality among at-risk patients with hematological malignancies and developed an optimized MEWS. @*Methods@#We retrospectively analyzed derivation cohort patients with hematological malignancies who were managed by a medical emergency team (MET) in the general ward and prospectively validated the data. We compared the traditional MEWS with the MEWS plus SpO2/FiO2 (MEWS_SF) score, which were calculated at the time of MET contact. @*Results@#In the derivation cohort, the areas under the receiver-operating characteristic (AUROC) curves were 0.81 for the MEWS (95% confidence interval [CI], 0.76 to 0.87) and 0.87 for the MEWS_SF score (95% CI, 0.87 to 0.92) for predicting ICU admission. The AUROC curves were 0.70 for the MEWS (95% CI, 0.63 to 0.77) and 0.76 for the MEWS_SF score (95% CI, 0.70 to 0.83) for predicting in-hospital mortality. In the validation cohort, the AUROC curves were 0.71 for the MEWS (95% CI, 0.66 to 0.77) and 0.83 for the MEWS_SF score (95% CI, 0.78 to 0.87) for predicting ICU admission. The AUROC curves were 0.64 for the MEWS (95% CI, 0.57 to 0.70) and 0.74 for the MEWS_SF score (95% CI, 0.69 to 0.80) for predicting in-hospital mortality. @*Conclusions@#Compared to the traditional MEWS, the MEWS_SF score may be a useful tool that can be used in the general ward to identify deteriorating patients with hematological malignancies.
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Purpose@#The purpose of this study was to compare ramosetron (RAM), aprepitant (APR), and dexamethasone (DEX) [RAD] with palonosetron (PAL), APR, and DEX [PAD] in controlling highly-emetogenic chemotherapy (HEC)–induced nausea and vomiting. @*Materials and Methods@#Patients were randomly assigned (1:1) to receive RAD or PAD:RAM (0.3 mg intravenously) or PAL (0.25 mg intravenously) D1, combined with APR (125 mg orally, D1 and 80 mg orally, D2-3) and DEX (12 mg orally or intravenously, D1 and 8 mg orally, D2-4). Patients were stratified by gender, cisplatin-based chemotherapy, and administration schedule. The primary endpoint was overall complete response (CR), defined as no emesis and no rescue regimen during 5 days of HEC. Secondary endpoints were overall complete protection (CP; CR+nausea score < 25 mm) and total control (TC; CR+nausea score < 5 mm). Quality of life was assessed by Functional Living Index Emesis (FLIE) questionnaire on D0 and D6. @*Results@#A total of 279 patients receiving RAD (n=137) or PAD (n=142) were evaluated. Overall CR rates in RAD and PAD recipients were 81.8% and 79.6% (risk difference [RD], 2.2%; 95% confidence interval [CI], −7.1 to 11.4), respectively. Overall CP and TC rates for RAD and PAD were 56.2% and 58.5% (RD, −2.3%; 95% CI, −13.9 to 9.4) and 47.5% vs. 43.7% (RD, 3.8%; 95% CI, −7.9 to 15.5), respectively. FLIE total score ≥ 108 (no impact on daily life) was comparable between RAD and PAD (73.9% vs. 73.4%, respectively). Adverse events were similar between the two groups. @*Conclusion@#In all aspects of efficacy, safety and QOL, RAD is non-inferior to PAD for the control of CINV in cancer patients receiving HEC.
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Radiomics, which involves the use of high-dimensional quantitative imaging features for predictive purposes, is a powerful tool for developing and testing medical hypotheses. Radiologic and statistical challenges in radiomics include those related to the reproducibility of imaging data, control of overfitting due to high dimensionality, and the generalizability of modeling. The aims of this review article are to clarify the distinctions between radiomics features and other omics and imaging data, to describe the challenges and potential strategies in reproducibility and feature selection, and to reveal the epidemiological background of modeling, thereby facilitating and promoting more reproducible and generalizable radiomics research.
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BACKGROUND: Beyond its current function as a rescue therapy in acute respiratory distress syndrome (ARDS), extracorporeal membrane oxygenation (ECMO) may be applied in ARDS patients with less severe hypoxemia to facilitate lung protective ventilation. The purpose of this study was to evaluate the efficacy of extended ECMO use in ARDS patients. METHODS: This study reviewed 223 adult patients who had been admitted to the intensive care units of 11 hospitals in Korea and subsequently treated using ECMO. Among them, the 62 who required ECMO for ARDS were analyzed. The patients were divided into two groups according to pre-ECMO arterial blood gas: an extended group (n=14) and a conventional group (n=48). RESULTS: Baseline characteristics were not different between the groups. The median arterial carbon dioxide tension/fraction of inspired oxygen (FiO2) ratio was higher (97 vs. 61, p<0.001) while the median FiO2 was lower (0.8 vs. 1.0, p<0.001) in the extended compared to the conventional group. The 60-day mortality was 21% in the extended group and 54% in the conventional group (p=0.03). Multivariate analysis indicated that the extended use of ECMO was independently associated with reduced 60-day mortality (odds ratio, 0.10; 95% confidence interval, 0.02–0.64; p=0.02). Lower median peak inspiratory pressure and median dynamic driving pressure were observed in the extended group 24 hours after ECMO support. CONCLUSION: Extended indications of ECMO implementation coupled with protective ventilator settings may improve the clinical outcome of patients with ARDS.