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Patients with mild-to-moderate coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS) can be treated with a high-flow nasal cannula (HFNC). The use of the respiratory rate-oxygenation (ROX) index, calculated as the ratio of oxygen saturation (SpO 2 )/fractional oxygen (FiO 2 ) to respiratory rate, in the first few hours after HFNC initiation can help identify patients who fail HFNC therapy later. However, few studies have documented the use of the ROX index during the period of HFNC therapy. Therefore, we aimed to demonstrate the diagnostic performance of the ROX index when calculated throughout the HFNC therapy period and to determine the best cut-off point for predicting HFNC failure. We conducted a retrospective study of patients with COVID-19-associated ARDS who commenced HFNC at the Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Thailand, between April 1 and August 30, 2021. We calculated the ROX index every 4 h throughout the HFNC therapy period and defined HFNC failure as a subsequent endotracheal tube intubation. The performance of the ROX index was analyzed using the area under the receiver operating characteristic curve (AUC). We applied the ROX index ≤ 4.88 to predict HFNC failure and obtained a new ROX cut-off point using Youden’s method. In total, 212 patients with COVID-19 treated with HFNC were included in the study. Of these, 81 patients (38.2%) experienced HFNC failure. The ROX index ≤ 4.88 demonstrated a reasonable performance in predicting HFNC failure (AUC, 0.77; 95% confidence interval [CI], 0.72–0.83; p<0.001). However, compared with the original cut-off point of ≤ 4.88, the new ROX index cut-off point of ≤ 5.84 delivered optimal performance (AUC, 0.84; 95% CI, 0.79–0.88; p<0.001), with a significantly better discriminative ability (p = 0.007). In conclusion, a ROX index ≤ 5.84 was found to be optimal for predicting HFNC failure in patients with COVID-19-associated ARDS.

Mortality rates among critically ill pediatric patients remain a persistent challenge. It is imperative to identify patients at higher risk to effectively allocate appropriate resources. Our study aimed to develop a prediction score based on clinical parameters and hemogram to predict pediatric intensive care unit (PICU) mortality. We conducted a retrospective study to develop a clinical prediction score using data from children aged 1 month to 18 years admitted for at least 24 hours to the PICU at Chiang Mai University between January 2018 and December 2022. PICU mortality was defined as death within 28 days of admission. The score was developed using multivariable logistic regression and assessed for calibration and discrimination. There were 29 deaths in 330 children (8.8%). Our model for predicting 28-day ICU mortality uses four key predictors: male gender, use of vasoactive drugs, red blood cell distribution width (RDW) ≥15.9%, and platelet distribution width (PDW), categorized as follows: <10% (0 points), 10-14.9% (2 points), and ≥15% (4 points). Scores range from 0 to 8, with a cutoff value of 5 to differentiate low-risk (<5) from high-risk (≥5) groups. The tool demonstrates excellent performance with an AuROC curve of 0.86 (95% CI: 0.80-0.91, p<0.001) showing excellent discrimination and calibration, 82.8% sensitivity, and 73.1% specificity, respectively. The score, developed from clinical data and hemogram, demonstrated potential in predicting ICU mortality among critically ill children. However, further studies are necessary to externally validate the score before it can be confidentially implemented in clinical practices.

Background The coronavirus disease (COVID-19) pandemic indeed strains healthcare systems worldwide, resulting in a surge of patients with severe conditions. Numerous physiological severity scores have been assigned to assess critical conditions; however, a comprehensive comparison of these scoring systems remains lacking. Therefore, this study aimed to evaluate the performance of the severity scores upon admission in predicting the progression of COVID-19 patients to a severe condition within 14 days after hospitalization. Methods Non-critically ill COVID-19 patients admitted to the Faculty of Medicine, Vajira Hospital, between 1 January 2021 and 30 June 2021, were assessed. We compared the discriminated ability of physiological severity scores in predicting disease progression to critical conditions using the area under the receiver operating characteristic curve (AUC). Results Totally, 348 non-critically ill COVID-19 patients were included. Of these, 60 patients (17.2%) progressed to severe conditions within 14 days after hospitalization. The National Early Warning Score 2 with age and body mass index (NEWS2 Plus) was the most outperformed than the National Early Warning Score (NEWS), the National Early Warning Score 2 (NEWS2), the Hamilton Early Warning Score (HEWS), the Modified Early Warning Score (MEWS), and the quick Sepsis-related Organ Failure Assessment (qSOFA) scores, for predicting deterioration to severe conditions [AUC 0.77 (95% CI; 0.72-0.83)]. The NEWS2 Plus with a cutoff point of five exhibited high sensitivity (83.3%) and high negative predictive value (NPV) of 94.7%. Conclusions NEWS2 Plus score can enhance its utility for triage of COVID-19 patients’ clinical status upon admission and guide appropriate management decisions for resource allocation. Trial registration TCTR20241026001, registered on 26 October 2024.

ObjectiveTo evaluate the association of 25-hydroxyvitamin D (25(OH)D) level on sepsis severity and risk of hospitalisation in emergency department (ED) septic patients when categorised as vitamin D insufficiency according to the level of 25(OH)D<30 ng/mL.DesignCross-sectional observational study.SettingA 900-bed academic tertiary hospital with an ED residency training programme in Bangkok, Thailand.ParticipantsAn observational study of 101 ED septic patients aged ≥18 years was conducted between March 2015 and September 2015.Outcome measuresThe level of 25(OH)D was analysed and correlated with sepsis severity assessed by Acute Physiology Age Chronic Health Evaluation-II (APACHE-II) and Mortality in ED Sepsis (MEDS) scores, and the risk of hospitalisation.ResultsOne hundred and one patients were enrolled, with an average age of 68±18 years, 56% female, APACHE-II score of 14±6, MEDS score of 8±5 and 25(OH)D level was 19±11 ng/mL. The prevalence of vitamin D insufficiency in our ED septic patients was 87% and the admission rate was 88%. A significant association between 25(OH)D level and sepsis severity scores was found, which was measured by APACHE-II and MEDS scores (−0.29; 95% CI −0.41 to −0.17, p<0.001 and −0.15; 95% CI −0.25 to −0.06, p=0.002, respectively). However, vitamin D insufficiency could not determine hospitalisation (OR=1.42; 95% CI 0.27 to 7.34; p=0.68 and OR=1.65; 95% CI 0.07 to 41.7; p=0.76 when adjusted by baseline covariates).ConclusionsThe vitamin D insufficiency of septic patients in our ED was high and had a significant negative association with sepsis severity. However, vitamin D insufficiency status cannot predict the hospitalisation of septic patients who were admitted to the ED. Further research is needed to investigate the role of vitamin D supplementation in the ED in affecting sepsis severity.Trial registration numberTCTR20151127001.

ObjectiveThe utilisation of pH level measurements from gastric contents may indicate the preferred tip position of a nasogastric tube or monitor the efficacy of stress ulcer prophylaxis in critically ill patients. We aimed to determine the accuracy of pH strip (pHS) tests and pH liquid (pHL) tests compared with the standard pH meter (pHM).DesignDiagnostic accuracy study.SettingGastric contents from medically critically ill patients.ParticipantsIn total, 113 gastric samples were collected from 27 critically ill patients.Outcome measureThe level of pH measured by pHM, pHS and pHL.ResultsThe pH values measured by pHM, pHS and pHL were 5.83 (IQR 5.12–6.61), 5.50 (IQR 5.00–6.00) and 5.75 (IQR 5.25–6.25), respectively. The pHS test showed greater accuracy, exhibiting a more positive correlation with the standard pHM measurement than the pHL test, with Y=0.95*X+0.56; rho=0.91, p<0.001, and Y=1.09*X - 0.72; rho=0.75, p<0.001, respectively. However, the pHS test demonstrated less agreement with the pHM than the pHL test, with biases of –0.27 versus 0.18, respectively. Noticeably, a slight variation in pHL from the standard pH values was found when we measured gastric contents with a pH lower than 5.ConclusionBoth the pHS and pHL methods were good options for measuring gastric pH in critically ill patients. However, it was advisable to find alternative approaches to the pHL testing method when anticipated gastric acidity levels fall below 5.Trial registration numberTCTR20220530004.

We aimed to evaluate the impact of citrate on hemodynamic responses and secondary outcomes, including the filter life span, metabolic complications, and levels of inflammatory cytokines, in critically ill patients who required CRRT compared with those who underwent the heparin-free method. This prospective, multicenter, open-label randomized trial compared regional citrate anticoagulation (RCA) with a heparin-free protocol in severe acute kidney injury (AKI) patients who received continuous venovenous hemodiafiltration (CVVHDF) in the postdilution mode. We measured hemodynamic changes using the FloTrac Sensor/EV1000™ Clinical Platform at certain time points after starting CRRT (0, 6, 12, 24, 48, and 72 h.). The levels of inflammatory cytokines (IL-1β, IL-6, IL-8, IL-10 and TNF-ɑ) were measured on days 1 and 3. Forty-one patients were recruited and randomized into the heparin ( n  = 20) and citrate groups ( n  = 21). The cardiac performances were not significantly different between the 2 groups at any time point. The inflammatory cytokines declined similarly in both treatment arms. The maximum filter survival time was insignificantly longer in the RCA group than in the heparin-free group (44.64 ± 26.56 h. vs p  = 0.693 in citrate and heparin free group). No serious side effects were observed for either treatment arm, even in the group of liver dysfunction patients. RCA did not affect hemodynamic changes during CRRT. Inflammatory cytokines decreased similarly in both treatment arms.The filter life span was longer in the citrate group. RCA is a valid alternative to traditional anticoagulation and results in stable hemodynamic parameters.

Emerging evidence suggests that air pollution, particularly fine particulate matter (PM2.5), may exacerbate migraine. Northern Thailand experiences severe seasonal air pollution, offering a unique context to investigate this association. This study aimed to evaluate the impact of seasonal PM2.5 exposure on migraine frequency, severity, emergency room (ER) visits, and medication use. This retrospective observational study included 42 adult migraine patients attending a university hospital's headache clinic from 2021 to 2023 who completed monthly headache diaries. PM2.5 data were obtained from national monitoring networks. \"Polluted months\" (January-May) were compared with \"non-polluted months\" (June-December). Study outcomes included headache frequency (days/month), pain severity (mild/moderate/severe), ER visits, and medication use. Among 42 patients (mean age: 39.2 years; 57.1% female), headache frequency was higher during polluted months (6.4 vs 4.3 days/month, P < 0.001). All pain severity levels increased significantly during polluted periods. ER visits rose markedly (3.37 vs 0.65 visits/patient, P < 0.001). Use of both migraine-specific and non-specific medications per patient was significantly greater in polluted months. PM2.5 exposure is associated with increased migraine burden. Seasonal air pollution may worsen headache frequency, severity, and healthcare utilization. Air quality should be considered in migraine management and environmental policy planning.

Background There has been a global increase in the incidence of acute kidney injury (AKI), including among critically-ill surgical patients. AKI prediction score provides an opportunity for early detection of patients who are at risk of AKI; however, most of the AKI prediction scores were derived from cardiothoracic surgery. Therefore, we aimed to develop an AKI prediction score for major non-cardiothoracic surgery patients who were admitted to the intensive care unit (ICU). Methods The data of critically-ill patients from non-cardiothoracic operations in the Thai Surgical Intensive Care Unit (THAI-SICU) study were used to develop an AKI prediction score. Independent prognostic factors from regression analysis were included as predictors in the model. The outcome of interest was AKI within 7 days after the ICU admission. The AKI diagnosis was made according to the Kidney Disease Improving Global Outcomes (KDIGO)-2012 serum creatinine criteria. Diagnostic function of the model was determined by area under the Receiver Operating Curve (AuROC). Risk scores were categorized into four risk probability levels: low (0–2.5), moderate (3.0–8.5), high (9.0–11.5), and very high (12.0–16.5) risk. Risk of AKI was presented as likelihood ratios of positive (LH+). Results A total of 3474 critically-ill surgical patients were included in the model; 333 (9.6%) developed AKI. Using multivariable logistic regression analysis, older age, high Sequential Organ Failure Assessment (SOFA) non-renal score, emergency surgery, large volume of perioperative blood loss, less urine output, and sepsis were identified as independent predictors for AKI. Then AKI prediction score was created from these predictors. The summation of the score was 16.5 and had a discriminative ability for predicting AKI at AuROC = 0.839 (95% CI 0.825–0.852). LH+ for AKI were: low risk = 0.117 (0.063–0.200); moderate risk = 0.927 (0.745–1.148); high risk = 5.190 (3.881–6.910); and very high risk = 9.892 (6.230–15.695), respectively. Conclusions The function of AKI prediction score to predict AKI among critically ill patients who underwent non-cardiothoracic surgery was good. It can aid in early recognition of critically-ill surgical patients who are at risk from ICU admission. The scores could guide decision making for aggressive strategies to prevent AKI during the perioperative period or at ICU admission. Trial registration TCTR20190408004 , registered on April 4, 2019.

Background/Objectives: Red blood cell distribution width (RDW) and mean platelet volume (MPV) are well-established prognostic biomarkers across various medical conditions. However, their role in predicting mortality among critically ill pediatric patients remains unclear. This study investigates the association between RDW, MPV, and 28-day mortality in pediatric intensive care unit (PICU) patients. Methods: This retrospective cohort study analyzed data from children aged 1 month to 18 years who were admitted to the PICUs at Chiang Mai University Hospital for ≥24 h between January 2018 and December 2022. The primary outcome was 28-day PICU mortality. A log-binomial regression analysis was conducted to assess the association of RDW and MPV with 28-day PICU mortality, adjusting for age, sex, mechanical ventilation, vasoactive drug use, continuous renal replacement therapy, and multiorgan failure. Results: A total of 580 PICU patients were included, 55.3% male, with a median age of 5.9 (IQR: 4.7–10.4) months. The 28-day PICU mortality rate was 9.8% (57/580). Respiratory failure and acute respiratory distress syndrome were the most common admission diagnoses (72.1%). Elevated RDW (≥15%) and MPV (≥10 fL) were independently associated with increased 28-day PICU mortality (adjusted RR: 2.73, 95% CI: 1.45–5.13 and 2.38, and 95% CI: 1.43–3.93, respectively). Both markers demonstrated high negative predictive values (RDW: 96.0% and MPV: 94.6%). Conclusions: Elevated RDW (≥15%) and MPV (≥10 fL) were independently associated with increased 28-day PICU mortality. These findings highlight their potential utility as accessible and cost-effective biomarkers for early risk stratification in critically ill pediatric patients.

Vitamin D is a steroid prohormone that regulates body calcium and phosphate metabolism. Recent studies have shown an association between low vitamin D status and high mortality in patients admitted to intensive care units. To date, there are limited data available specifically about severely septic patients in medical units. To determine the prevalence of vitamin D deficiency in severely septic patients and its clinical outcomes, including mortality rate. A prospective observational study was conducted to investigate the prevalence of vitamin D deficiency and its association with 30-day mortality in patients with severe sepsis. Patients admitted to medical wards at our hospital between November 2014 and March 2015 were included in the study. A 25-hydroxyvitamin D level <20 ng/mL was defined as vitamin D deficiency, and <12 ng/mL as severe deficiency. For an association analysis, the patients were grouped into deficient versus not deficient and severely deficient versus not severely deficient. One hundred and ten eligible patients were enrolled. A total of 83 patients (75%) had vitamin D deficiency and 42 (38%) had severe deficiency. Despite an insignificant higher 30-day hospital mortality rate in vitamin D deficient versus non-deficient groups (16% vs 4%, =0.18), the differences were significant between the severely deficient versus non-severe groups (23% vs 4%, =0.02). The odds ratio of the 30-day mortality rate was 4.83 (95% confidence interval [CI], 0.60-38.77, =0.14) for vitamin D deficiency and 7.69 (95% CI, 2.00-29.55, =0.003) for severe deficiency. The prevalence of vitamin D deficiency was very high in three-quarters of patients with severe sepsis. A significant higher mortality rate was observed, particularly in patients with severe vitamin D deficiency.