Predicting mortality among patients with severe COVID-19 pneumonia based on admission vital sign indices: a retrospective cohort study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pneumonia remains a major public health concern. Vital sign indices-shock index (SI; heart rate [HR]/systolic blood pressure [SBP]), shock index age (SIA, SI × age), MinPulse (MP; maximum HR-HR), Pulse max index (PMI; HR/maximum HR), and blood pressure-age index (BPAI; SBP/age)-are better predictors of mortality in patients with trauma compared to traditional vital signs. We hypothesized that these vital sign indices may serve as predictors of mortality in patients with severe COVID-19 pneumonia. This study aimed to describe the association between vital sign indices at admission and COVID-19 pneumonia mortality and to modify the CURB-65 with the best performing vital sign index to establish a new mortality prediction tool. METHODS: This retrospective study was conducted at a tertiary care center in southern Thailand. Adult patients diagnosed with COVID-19 pneumonia were enrolled in this study between January 2020 and July 2022. Patient demographic and clinical data on admission were collected from an electronic database. The area under the receiver operating characteristic (AUC) curve analysis was used to assess the predictive power of the resultant multivariable logistic regression model after univariate and multivariate analyses of variables with identified associations with in-hospital mortality. RESULTS: In total, 251 patients with COVID-19 pneumonia were enrolled in this study. The in-hospital mortality rate was 27.9%. Non-survivors had significantly higher HR, respiratory rate, SIA, and PMI and lower MP and BPAI than survivors. A cutoff value of 51 for SIA (AUC, 0.663; specificity, 80%) was used to predict mortality. When SIA was introduced as a modifier for the CURB-65 score, the new score (the CURSIA score) showed a higher AUC than the Acute Physiology and Chronic Health Evaluation II and CURB-65 scores (AUCs: 0.785, 0.780, and 0.774, respectively) without statistical significance. CONCLUSIONS: SIA and CURSIA scores were significantly associated with COVID-19 pneumonia mortality. These scores may contribute to better patient triage than traditional vital signs.

Platelet-to-White Blood Cell Ratio as a Predictor of Mortality in Patients with Severe COVID-19 Pneumonia: A Retrospective Cohort Study.

Purpose: Complete blood count (CBC) parameters are widely used as predictors of Coronavirus disease 2019 (COVID-19) severity. However, the clinical significance of these markers in severe COVID-19 pneumonia remains unclear. This study aimed to investigate the role of CBC parameters in predicting mortality in patients with severe COVID-19 pneumonia. Patients and Methods: We conducted a retrospective study at a tertiary care center in southern Thailand. Between January 2020 and December 2021, adult patients who had been diagnosed with severe COVID-19 pneumonia were enrolled. Demographic and clinical data, including CBC data on admission, were analyzed and compared between survivors and non-survivors. Results: A total of 215 patients with severe COVID-19 pneumonia were enrolled. The in-hospital mortality was 29.3%. Non-survivors had a significantly lower platelet-to-white blood cell ratio (PWR) than survivors (15.8 vs 29.0, p < 0.001). PWR had the best accuracy in predicting in-hospital mortality, with an area under the curve (AUC) of the receiver operating characteristic curve of 0.801, followed by the CURB-65 of 0.789. Conclusion: PWR appears to be a simple independent predictor of mortality in patients with severe COVID-19 pneumonia.

Validation of response processes in medical assessment using an explanatory item response model.

BACKGROUND: Response process validation is a crucial source of test validity. The expected cognitive load scale was created based on the reflection of the mental effort by which borderline students solve an item defined by experts. The stem length affects the students' extraneous cognitive load. The purposes of this study were to develop an exam for medical students and corroborate the response process validity by analyzing the correlation between the expected cognitive load, stem length, and the difficulty. METHODS: This was a correlational study. Five medical teachers as the experts and 183 third-year medical students were enrolled from the Faculty of Medicine, Prince of Songkla University, Thailand. The instruments used were a medical physiology exam and a three-level expected cognitive load evaluation form judged by medical teachers. Data were analyzed using an explanatory item response model. RESULTS: The test consists of 20 items and 21 possible scores. The median score was 8, with a quartile deviation of 1.5. Nine items had long stems (more than two lines). Sixteen items were judged as high (level 2 or 3) expected cognitive load. When adding the expected cognitive load in a Rasch model, the expected cognitive load significantly correlated with item difficulty. In the Rasch model that included both the expected cognitive load and stem length, a long stem had a greater effect on item difficulty than low expected cognitive load. However, the Rasch model showed the best fit. CONCLUSIONS: The long stem had a stronger correlation with test difficulty than expected cognitive load, which indirectly implied response process validity. We suggest incorporating stem length and expected cognitive load to create an appropriate distribution of the difficulty of the entire test.

Efficacy of Moraceae with chlorhexidine mouthwash on the microbial flora of critically ill intubated patients: a randomized controlled pilot study.

Critically ill intubated patients are routinely provided with chlorhexidine (CHX) for their mouth washing, but CHX mouthwash induces several complications. In this study, we aimed to evaluate the efficacy and safety of Moraceae with CHX mouthwash in the reduction of oral bacterial count in critically ill patients and to compare it with CHX-alone mouthwash. This double-blind, randomized, controlled trial included critically ill patients receiving mechanical ventilation. The patients were randomly divided into two groups based on the Modified Beck oral assessment score. The primary endpoint was a reduction in oral bacterial counts after mouth washing on day 1 and day 4. Thirty patients were included in this study; 15 patients received Moraceae with CHX mouthwash and 15 patients received CHX-alone mouthwash. The oral bacterial counts in the Moraceae with CHX group did not differ from the CHX group after mouth washing on day 1 and day 4 of admission. The patients in the CHX group experienced more intolerable taste than those in the Moraceae group (60% vs. 13.3%, P = 0.008). Moraceae with CHX mouthwash had the same effectiveness as CHX alone on bacterial flora but exhibited less intolerable side effects than CHX alone.Trial registration: TCTR20190530003; 30/05/2019.

Ability of a modified Sequential Organ Failure Assessment score to predict mortality among sepsis patients in a resource-limited setting.

BACKGROUND: Some variables of the Sequential Organ Failure Assessment (SOFA) score are not routinely measured in sepsis patients, especially in countries with limited resources. Therefore, this study was conducted to evaluate the accuracy of the modified SOFA (mSOFA) and compared its ability to predict mortality in sepsis patients to that of the original SOFA score. METHODS: Sepsis patients admitted to the medical intensive care unit of Songklanagarind Hospital between 2011 and 2018 were retrospectively analyzed. The primary outcome was all-cause in-hospital mortality. RESULTS: A total of 1,522 sepsis patients were enrolled. The mean SOFA and mSOFA scores were 9.7±4.3 and 8.8±3.9, respectively. The discrimination of the mSOFA score was significantly higher than that of the SOFA score for all-cause in-hospital mortality (area under the receiver operating characteristic curve, 0.891 [95% confidence interval, 0.875-0.907] vs. 0.879 [0.862-0.896]; P<0.001), all-cause intensive care unit (ICU) mortality (0.880 [0.863-0.898] vs. 0.871 [0.853-0.889], P=0.01) and all-cause 28-day mortality (0.887 [0.871-0.904] vs. 0.874 [0.856-0.892], P<0.001). The ability of mSOFA score to predict all-cause in-hospital and 28-day mortality was higher than that of the SOFA score within the subgroups of sepsis according to age, sepsis severity and serum lactate levels. The mSOFA score was demonstrated to have a performance similar to the original SOFA score regarding the prediction of mortality in sepsis patients with cirrhosis or hepatic dysfunction. CONCLUSIONS: The mSOFA score was a good alternative to the original SOFA core in predicting mortality among sepsis patients admitted to the ICU.

Comparison of Race-Based and Non-Race-Based Equations for Kidney Function Estimation in Critically Ill Thai Patients for Vancomycin Dosing.

Empiric antibiotic dosing frequently relies on an estimate of kidney function based on age, serum creatinine, sex, and race (on occasion). New non-race-based estimated glomerular filtration rate (eGFR) equations have been published, but their role in supporting dosing is not known. Here, we report on a population pharmacokinetic model of vancomycin that serves as a useful probe substrate of eGFR in critically ill Thai patients. Data were obtained from medical records during a 10-year period. A nonlinear mixed-effects modeling approach was conducted to estimate vancomycin parameters. Data from 208 critically ill patients (58.2% men and 36.0% septic shock) with 398 vancomycin concentrations were collected. Twenty-three covariates including 12 kidney function estimates were tested and ranked on the basis of the model performance. The median (min, max) age, weight, and serum creatinine was 69 (18, 97) years, 60.0 (27, 120) kg, and 1.53 (0.18, 7.15) mg/dL, respectively. The best base model was a 1-compartment linear elimination with zero-order input and proportional error model. A Thai-specific eGFR equation not indexed to body surface area model best predicted vancomycin clearance (CL). The typical value for volume of distribution and CL was 67.5 L and 1.22 L/h, respectively. A loading dose of 2000 mg followed by maintenance dose regimens based on eGFR is suggested. The Thai GFR not indexed to BSA model best predicts vancomycin CL and dosing in the critically ill Thai population. A 5% to 10% absolute gain in the vancomycin probability of target attainment is expected with the use of this population-specific eGFR equation.

Predicting acute respiratory distress syndrome in influenza pneumonia patients using delta mean platelet volume.

BACKGROUND: Patients with influenza pneumonia are at high risk of rapid progression to acute respiratory distress syndrome (ARDS). Mean platelet volume (MPV), which reflects platelet size, is considered to be a crucial inflammatory marker. The study aim was to investigate the role of delta mean platelet volume (delta MPV) in predicting ARDS in patients with influenza pneumonia. METHODS: This retrospective study was conducted in a tertiary care centre in southern Thailand. Adult patients diagnosed with influenza pneumonia were enrolled from January 2015 to December 2020. Demographic data, laboratory investigations including delta MPV (MPV on day 2 minus MPV on day 1), management records, and clinical outcomes were collected for analysis. The study population was divided into two groups according to the development of ARDS. RESULTS: During the study, 1240 patients with laboratory-confirmed influenza were screened and 212 pneumonia patients were enrolled. Fifty-six patients (26.4%) met the diagnostic criteria for ARDS during hospitalization. Delta MPV was significantly higher in the ARDS group compared to that in the non-ARDS group (1.0 fL vs 0.2 fL, p < 0.001). Multivariable logistic regression revealed that delta MPV is an independent predictor of ARDS (OR 17.37; 95% CI 6.5-46.4; p < 0.001). Receiver operating characteristic curve analysis indicated a cut-off value of 0.7 fL for delta MPV (sensitivity 80.36%, specificity 80.77%) to predict ARDS in patients with influenza pneumonia. CONCLUSIONS: Delta MPV strongly predicts ARDS in influenza pneumonia patients. Implementation of delta MPV may be useful in identifying at-risk patients who will require intensive care and ARDS prevention.

CPR Compression Rotation Every One Minute Versus Two Minutes: A Randomized Cross-Over Manikin Study.

BACKGROUND: The current basic life support guidelines recommend two-minute shifts for providing chest compressions when two rescuers are performing cardiopulmonary resuscitation. However, various studies have found that rescuer fatigue can occur within one minute, coupled with a decay in the quality of chest compressions. Our aim was to compare chest compression quality metrics and rescuer fatigue between alternating rescuers in performing one- and two-minute chest compressions. METHODS: This prospective randomized cross-over study was conducted at Songklanagarind Hospital, Hat Yai, Songkhla, Thailand. We enrolled sixth-year medical students and residents and randomly grouped them into pairs to perform 8 minutes of chest compression, utilizing both the one-minute and two-minute scenarios on a manikin. The primary end points were chest compression depth and rate. The secondary end points included rescuers' fatigue, respiratory rate, and heart rate. RESULTS: One hundred four participants were recruited. Compared with participants in the two-minute group, participants in the one-minute group had significantly higher mean (standard deviation, SD) compression depth (mm) (45.8 (7.2) vs. 44.5 (7.1), P=0.01) but there was no difference in the mean (SD) rate (compressions per min) (116.1 (12.5) vs. 117.8 (12.4), P=0.08), respectively. The rescuers in the one-minute group had significantly less fatigue (P < 0.001) and change in respiratory rate (P < 0.001), but there was no difference in the change of heart rate (P=0.59) between the two groups. CONCLUSION: There were a significantly higher compression depth and lower rescuer fatigue in the 1-minute chest compression group compared with the 2-minute group. This trial is registered with TCTR20170823001.

Pharmacokinetics and Monte Carlo Dosing Simulations of Imipenem in Critically Ill Patients with Life-Threatening Severe Infections During Support with Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO), a cardiopulmonary bypass device, has been found to increase the profound pathophysiological changes associated with life-threatening severe infections in patients with multiple comorbidities, which results in alterations of pharmacokinetic patterns for antibiotics. OBJECTIVES: The aims of this study were (1) to determine the pharmacokinetics of imipenem and (2) to assess the probability of target attainment (PTA) for imipenem in critically ill patients with life-threatening severe infections during support with ECMO. METHODS: The pharmacokinetic studies were carried out following administration of 0.5 g of imipenem every 6 h on the 4th dose of drug administration in 10 patients and a Monte Carlo simulation was performed to determine the PTA of achieving 40% exposure time during which the plasma drug concentrations remained above minimum inhibitory concentration (T > MIC) and 80% T > MIC. RESULTS: The median values of volume of distribution and total clearance (CL) of imipenem in these patients were 13.98 L and 9.78 L/h, respectively. A high PTA (≥ 90%) for a target of 80% with a MIC of 4 µg/mL in patients with CLCR 60-120 mL/min and flow rate of ECMO circuit 3-5.5 L/min was observed when imipenem was administered by a 4-h infusion of 1 g every 6 h. CONCLUSIONS: A high dosage regimen such as 1 g every 6 h of imipenem may be required to achieve pharmacodynamic targets against less susceptible pathogens in this patient population. CLINICALTRIAL. GOV IDENTIFIER: NCT03776305, date of registration: 11 December 2018.

Presenting Symptoms in Sepsis: Is the Mnemonic "SEPSIS" Useful?

BACKGROUND: The mnemonic "SEPSIS" (S = Slurred speech or confusion, E = Extreme shivering or muscle pain, fever, P = Passing no urine all day, S = Severe breathlessness, I = It feels like you are going to die, S = Skin mottled or discolored) has been developed by the World Sepsis Day committee, so as to raise public awareness of the symptomatic presentation of sepsis. However, this mnemonic has not been validated. METHODS: A retrospective, observational, single-center study was performed. All adult septic patients presenting at the emergency department of Songklanagarind Hospital from 2016 to 2019 were included and followed up until either hospital discharge or death. RESULTS: The study included 437 patients, comprising patients with sepsis (n = 250) and those with septic shock (n = 187). Patients presented with symptoms according to the mnemonic as follows: S = 97 (22.2%), E = 240 (54.9%), P = 18 (4.1%), S =181 (41.4%), I = 5 (1.1%), and S = 5 (1.1%). Sixty-five patients (14.9%) did not present with any sepsis-specific symptoms according to the mnemonic. Compared with patients who had at least one mnemonic symptom, a higher proportion of patients without mnemonic symptoms had underlying immunosuppression (24.6% vs 8.3%, P < 0.01) and were diagnosed with intraabdominal infection (38.5% vs 12.1%, P < 0.01). In a multivariable adjusted logistic regression model, vague-presenting symptoms were independently associated with in-hospital mortality (adjusted odds ratio 2.17, 95% confidence interval 1.30-3.61, P = 0.03). CONCLUSION: Two components of the mnemonic "SEPSIS" were rarely reported: it feels like you are going to die and skin mottled or discolored. Using the mnemonic might lead to missed diagnoses, especially in immunosuppression and intraabdominal infection. This mnemonic should be revised for the local context.

Efficacy of Thiamine in the Treatment of Postcardiac Arrest Patients: A Randomized Controlled Study.

BACKGROUND: Thiamine administration has been shown to improve survival in a postcardiac arrest animal study. We aimed to evaluate the efficacy of thiamine in comatose out-of-hospital cardiac arrest (OHCA) patients following return of spontaneous circulation. METHODS: A randomized, double-blinded, placebo-controlled study was conducted. Thirty-seven OHCA patients were randomly assigned to receive either thiamine 100 mg every 8 hours or a placebo. The primary outcome was 28-day all-cause mortality. RESULTS: Over the course of 2 years, 37 patients were randomized to either receive thiamine (n = 20) or a placebo (n = 17). The primary outcome was not different between the groups: 10/20 (50%) in the thiamine group vs. 8/17 (47.1%) in the placebo group (P=0.93 by the log-rank test). There were no significant differences in secondary outcomes between the groups (good neurological outcome, lactate level, and S100B level). CONCLUSIONS: In this study, there were no significant differences in survival outcome. Further studies with a larger population are necessary to confirm these results.

Comparison of knowledge and confidence between medical students as leaders and followers in simulated resuscitation.

OBJECTIVES: To compare both the knowledge and self-reported confidence levels between medical students as the team leaders and followers in shock resuscitation simulation training. METHODS: A cross-sectional study was conducted with all fifth-year medical students participating in a shock resuscitation simulation-based training between May 2017 and March 2018. The simulation class was a 3-hour session that consisted of 4 shock type scenarios as well as a post-training debriefing. Medical students were assigned into groups of 4-5 members, in which they freely selected a leader, and the rest filled the roles of followers. Of 139 medical students, 32 students were leaders. A 10-question pre-test and post-test determined knowledge assessment. At the end of the class, the students completed a 5-point Likert scale confidence level evaluation questionnaire. A t-test was applied to compare knowledge scores and confidence levels between the leaders and followers. RESULTS: At the end of the class, the knowledge scores between the leaders (M=6.72, SD=1.51) and followers (M=6.93, SD=1.26) were not different (t(137)= -0.81, p=0.42). In addition, the student confidence levels were also similar between the leaders (M=3.63, SD=0.55) and followers (M=3.41, SD=0.64) after training (t(137)=1.70, p=0.09). CONCLUSIONS: The knowledge and confidence levels were not different between either the leaders or followers in simulated resuscitation. With time-limit simulation training, we suggested every student may not need to fulfil the leadership role, but a well-designed course and constructive debriefing are recommended. Future studies should evaluate skills and longitudinal effects of the leader role.

Pharmacokinetics of Imipenem in Critically Ill Patients with Life-threatening Severe Infections During Support with Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has become increasingly used for lifesaving respiratory and/or cardiac failure support in critically ill patients, including those with life-threatening severe infections. This cardiopulmonary bypass device has been shown to enhance the profound pathophysiological changes in this patient population, resulting in an alteration of the pharmacokinetics of antimicrobial agents. OBJECTIVE: The aim of this study was to determine the effect of ECMO on the pharmacokinetics of imipenem in critically ill patients supported by this cardiopulmonary bypass device. METHODS: The study was conducted in critically ill patients with respiratory and/or cardiac failure and severe infections who were supported by ECMO. All patients received a 1-h infusion of 0.5 g of imipenem every 6 h and imipenem pharmacokinetics studies were carried out on the fourth dose of drug administration. RESULTS: Ten patients were enrolled in this study. The pharmacokinetics parameters of imipenem were found to be highly variable. The volume of distribution, total clearance, elimination half-life and the area under the concentration-time curve between 0 and 6 h were 33.38 ± 13.89 L, 9.99 ± 10.47 L/h, 12.01 ± 29.63 h and 88.93 ± 54.07 mg∙h/L, respectively. CONCLUSIONS: Pathophysiological changes in critically ill patients with severe infections during support with ECMO had a greater impact on altered pharmacokinetic patterns of imipenem than those that occur in critically ill patients without ECMO support. Therefore, the largest licensed dose, 1 g every 6 h, of imipenem, may be required to maintain adequate drug concentrations to achieve the pharmacokinetic/pharmacodynamic targets for effective antimicrobial therapy in this patient population.

Green fabrication of anti-bacterial biofilm layer on endotracheal tubing using silver nanoparticles embedded in polyelectrolyte multilayered film.

Endotracheal tubes (ETTs) are a common source of bacterial colonization, leading to ventilator-associated pneumonia (VAP). This research developed a biofilm-resistant ETT, following the principles of green chemistry. Using an aqueous layer-by-layer (LbL) technique, a thick polyelectrolyte multilayered film was deposited on a ventilation tube. The polyelectrolyte multilayered film accommodated silver nanoparticles (AgNPs) formed in situ by reducing Ag+ ions with Eucalyptus citriodora leaf extract. The multilayered film coating conformed to the curved surfaces of the ETT. Film thickness and silver content increased exponentially with the number of polyelectrolyte bilayer pairs, and a sufficiently high AgNPs content of 10-30%w/w was obtained at 75 to 125 bilayer films. Adhesion of the Gram-positive Staphylococcus aureus and Gram-negative Pseudomonas aeruginosa was prevented by 99.9 and 99.99%, respectively, without cytotoxic effects against human lung epithelial cells (p < 0.05).

Comparison of the accuracy of three early warning scores with SOFA score for predicting mortality in adult sepsis and septic shock patients admitted to intensive care unit.

BACKGROUND: The purpose of this study was to compare the accuracy of the Modified Early Warning Score (MEWS), National Early Warning Score (NEWS) and Search Out Severity (SOS), with the quick Sequential Organ Failure Assessment (qSOFA) and SOFA scores, to predict outcomes in sepsis patients. METHODS: A retrospective study was conducted in intensive care unit of university teaching hospital. RESULTS: A total of 1,589 sepsis patients were enrolled. The SOFA score had the best accuracy to predict hospital mortality, with an area under the receiver operating characteristic curve (AUC) of 0.880 followed by SOS (0.878), MEWS (0.858), qSOFA (0.847) and NEWS (0.833). The SOS score provided a similar performance with SOFA score in predicting mortality. CONCLUSION: The SOS presents nearly as good as the SOFA score, to predict mortality among sepsis patients admitted to the ICU. The early warning score is another, alternative tool to use for risk stratification and sepsis screening for ICU sepsis patients.

Timing of antibiotic administration and lactate measurement in septic shock patients: a comparison between hospital wards and the emergency department.

BACKGROUND: The timing of intravenous antibiotic administration and lactate measurement is associated with survival of septic shock patients. Septic shock patients were admitted to the medical intensive care unit (MICU) from 2 major sources: hospital ward and emergency department (ED). This study aimed to compare the timing of antibiotic administration and lactate measurement between hospital wards and the ED. PATIENTS AND METHODS: Medical data were collected from adult patients admitted to the MICU with septic shock from January 2015 to December 2016. "Time Zero" was defined as the time of diagnosis of sepsis. The associations between the times and risk-adjusted 28-day mortality were assessed. RESULTS: In total, 150 septic shock patients were admitted to the MICU. The median time interval (hour [h] interquartile range [IQR]) from time zero to antibiotic administration was higher in patients from the hospital wards compared to those from the ED (4.84 [3.5-8.11] vs 2.04 [1.37-3.54], P<0.01), but the lactate level measurement time interval (h [IQR]) from time zero was not different between the hospital wards and the ED (1.6 [0.2-2.7] vs 1.6 [0.9-3.0], P=0.85). In multivariate analysis, higher risk-adjusted 28-day mortality was associated with antibiotic monotherapy (odds ratio [OR]: 19.3, 95% confidence interval [CI]: 2.4-153.1, P<0.01) and admission during the weekends (OR: 24.4, 95% CI: 2.9-199.8, P<0.01). CONCLUSION: Antibiotic administration in septic shock patients from the hospital wards took longer, and there was also less appropriate antibiotic prescriptions seen in this group compared with those admitted from the ED. However, neither the timing of antibiotic administration nor lactate measurement was associated with mortality.

Can base excess and anion gap predict lactate level in diagnosis of septic shock?

BACKGROUND: Lactate measurement is the key component in septic shock identification and resuscitation. However, point-of-care lactate testing is not widely used due to the lack of access to nearby test equipment. Biomarkers such as serum lactate, anion gap (AG), and base excess (BE) are used in determining shock in patients with seemingly normal vital signs. PURPOSE: We aimed to determine if these biomarkers can be used interchangeably in patients with septic shock in the emergency setting. PATIENTS AND METHODS: A prospective observational cohort study was undertaken at a tertiary hospital in southern Thailand. Baseline point-of-care BE, AG, and serum lactate were recorded in all patients presenting with septic shock at the emergency department. Overall correlations including area under the receiver operating characteristic curve (AUROC) for both BE and AG to predict serum lactate level were calculated. RESULTS: One hundred and fifteen patients were enrolled. Pearson correlation of serum lactate to BE was -0.59 (r2 = 0.35; 95% confidence interval [CI], -0.69 to -0.44; P < 0.001) and BE to AG was -0.67 (r2 = 0.49; 95% CI, -0.76 to -0.55; P < 0.001), and serum lactate to AG was 0.64 (r2 = 0.41; 95% CI, 0.52 to 0.74; P < 0.001). A cut-off point of 15.8 for AG identified a lactate level ≥2 mmol/L (sensitivity, 71.4%; specificity, 80.7%; and AUROC, 0.76), and the best cut-off value to predict a lactate level ≥4 mmol/L was 18.5 (sensitivity, 64.2%; specificity, 85.5%; and AUROC 0.78). CONCLUSION: In patients with septic shock, lactate and AG showed a strong correlation with each other, whereas lactate and BE showed a moderate correlation with each other. Thus, these biomarkers can be used interchangeably to help determine septic shock earlier in patients.

Comparison of the performance of SOFA, qSOFA and SIRS for predicting mortality and organ failure among sepsis patients admitted to the intensive care unit in a middle-income country.

INTRODUCTION: The Sepsis-3 definition provides a change of two or more scores from zero or a known baseline of the Sequential Organ Failure Assessment (SOFA) as criteria of sepsis. The aim of this study was to compare the SOFA score and the quick SOFA (qSOFA) to Systemic Inflammatory Response Syndrome (SIRS) criteria in predictive ability of mortality and organ failure. METHODS: A-10year retrospective cohort study was conducted in a teaching hospital in Thailand. RESULTS: A total of 2350 of mixed sepsis patients by Sepsis-2 definition were included. The all-cause hospital mortality rate was 44.5%. Of the total sample, 95.6% (n=2247) of patients met criteria for sepsis under the Sepsis-3 definition. The SOFA score presented the best discrimination with an area under the receiver operating characteristic curve (AUC) of 0.839. The AUC of SOFA score for hospital mortality was significantly higher than qSOFA (AUC 0.814, P=0.003) and SIRS (AUC 0.587, P<0.0001). Also, the SOFA score had superior performance than other scores for predicting intensive care unit (ICU) mortality and organ failure. CONCLUSIONS: The SOFA is a superior prognostic tool for predicting mortality and organ failure than qSOFA and SIRS criteria among sepsis patients admitted to the ICU.

Quality of Dying in the Medical Intensive Care Unit: Comparison between Thai Buddhists and Thai Muslims.

BACKGROUND AND AIMS: Religious belief is an important aspect that influences the life of a patient, especially in Asia. We aim to compare the quality of death in an Intensive Care Unit (ICU) between Buddhists and Muslims from the perspectives of the relatives of the patients and the nurses and physicians. SUBJECTS AND METHODS: This was a cohort study of critically ill patients who died after admission to a medical ICU in Songklanagarind Hospital in Thailand between 2015 and 2016. We interviewed by telephone the relatives of patients. The nurses and physicians who cared for the patients responded to a self-questionnaire. RESULTS: A total of 112 patients were enrolled in the study. The quality of death and dying-1 scores in Thai Buddhists and Muslim patients rated by the relatives (8 vs. 8, P = 0.55), nurses (8 vs. 8, P = 0.28), and physicians (7 vs. 7, P = 0.74) were not different. The ratings by the nurses correlated with the relatives (rs = 0.41, P < 0.001) but did not correlate with the physicians (rs = 0.15, P = 0.12). Compared with Buddhist patients, Muslim patients were more likely to have documentation in place at the time of the death of do not resuscitate (100% vs. 80.2%, P = 0.02) and withholding and withdrawing life support (100% vs. 80.2%, P = 0.02). CONCLUSION: There was no difference in the quality of dying and death between Thai Buddhists and Muslims. However, some elements of palliative care were not similar.

High-fidelity medical simulation training improves medical students' knowledge and confidence levels in septic shock resuscitation.

BACKGROUND: Septic shock resuscitation bundles have poor compliance worldwide partly due to a lack of knowledge and clinical skills. High-fidelity simulation-based training is a new teaching technology in our faculty which may improve the performance of medical students in the resuscitation process. However, since the efficacy of this training method in our institute is limited, we organized an extra class for this evaluation. PURPOSE: The aim was to evaluate the effect on medical students' knowledge and confidence levels after the high-fidelity medical simulation training in septic shock management. METHODS: A retrospective study was performed in sixth year medical students during an internal medicine rotation between November 2015 and March 2016. The simulation class was a 2-hour session of a septic shock management scenario and post-training debriefing. Knowledge assessment was determined by a five-question pre-test and post-test examination. At the end of the class, the students completed their confidence evaluation questionnaire. RESULTS: Of the 79 medical students, the mean percentage score ± standard deviation (SD) of the post-test examination was statistically significantly higher than the pre-test (66.83%±19.7% vs 47.59%±19.7%, p<0.001). In addition, the student mean percentage confidence level ± SD in management of septic shock was significantly better after the simulation class (68.10%±12.2% vs 51.64%±13.1%, p<0.001). They also strongly suggested applying this simulation class to the current curriculum. CONCLUSION: High-fidelity medical simulation improved the students' knowledge and confidence in septic shock resuscitation. This simulation class should be included in the curriculum of the sixth year medical students in our institute.