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Lupine Publishers | The Nutritional Status of the Children with Severe- ECC Comparison with the Nutritional Status of Children without Caries Aged 3-5-Years-Old and with the Caregiver’s Demographics in a Kenyan Hospital

Lupine Publishers | The Nutritional Status of the Children with Severe- ECC Comparison with the Nutritional Status of Children without Caries Aged 3-5-Years-Old and with the Caregiver’s Demographics in a Kenyan Hospital

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Lupine Publishers | Dentistry Open Access Journal

Abstract

Severe early childhood caries (Severe-ECC) is an aggressive, infectious and preventable form of dental caries that affects very young children. The survey purposed to examine any differences in the severity of poor nutrition in children without decay and those children with dental decay in the age group between thirty-six and sixty months. Sampling was purposeful and 196 children aged between 3 to 5 years for this study. The study was hospital-based where eighty-one children with severe dental decay who had attended the Nyanza Provincial General Hospital (NNPGH). Similarly, one hundred and fifteen children who were caries free were chosen from amongst the children attending the maternal child health clinic at NNPGH over a period of three months. Odds Ratio (OR) and 95% Confidence Interval (CI) were used to estimate the strength of association between Severe ECC and nutritional status. The mean dmft for the children with severe Early Childhood Caries (ECC) was 7.5±19. The prevalence of malnutrition was reported among both groups of children with severe ECC and without decay as 28 (14.3%) underweight, wasting 5(2.5%), and stunting 9(4.6%). The malnutrition in children with, Severe-ECC was observed as 27(14%) underweight; 10(4.9%) of the children were wasted, and 5(2.5%) were stunted. However among the children without caries 26 (13.9%) were underweight while 5 (2.6% were wasted, and 12 (6.1%) were stunted. Both children those with severe ECC and those with decay, however, the children who were likely to be underweight at 1.23 times were those affected with severe ECC at 1.23 times compared to the children without decay. Hence other factors may be playing a role in malnutrition of children aged 3-5year old.
Keywords: Severe-ECC; Nutritional status; Caregivers demographics

Introduction

Early childhood caries (ECC) is defined as the presence of one or more decayed (non-cavitated or cavitated lesions), those missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. Severe Early Childhood Caries reported in children below three years of age as smooth surface caries1. One or more cavitated, missing teeth due to caries has been associated with age s 3-5years.The filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing or filled a score ≥ 4 for age 3years, a score of ≥ five is associated with 4years while cavitation, restored tooth and missing due to caries a score of ≥6 is for children in the 5-year-old group. All these scores constitute Severe – ECC [1].
Disadvantaged groups have been found to be vulnerable to ECC in both developed and developing countries and even within a single country disparity by social standing there exist, differences due to diet, fluoride use, and social empowerment. Disparities in social empowerment may persist due to lack of access to dental care and inadequate utilisation of dental care even when available [2]. Untreated caries and associated infections can cause pain, discomfort, reduced intake of foods because eating is painful
[3]. Pain may also because the child refuses the caregiver from maintaining good oral hygiene for the child. There is a paucity of literature on the prevalence of Severe -ECC in Kenya. However, a study conducted in nursery school children in Nairobi on the on dental caries and dietary patterns reported a prevalence of 63.5% among 3-5 years old [4]. A survey conducted in Kiambaa division in Kiambu County, a peri-urban population, reported ECC prevalence in 3 - 5-year-olds of 59.5% [5]. Several studies on nutritional status and dental caries have reported variable results. A retrospective survey on the body mass index was done in the United States of America, and it involved two hundred and ninety-three children aged two to five years with Severe - ECC receiving dental treatment under general anaesthesia. In the study, the weight groups were defined by being assigned the CDC body mass index about on age and gender of the children. Results showed that the distribution of subjects by percentiles and the children who were underweight were 11%; of the study sample. However the children whose weight was normal weight 67%; at risk of overweight 9%; overweight 11%. This study concluded that significantly, more children in the sample were underweight than in the reference population [6]. However comparative research on the nutritional status and dental caries among a large sample of four and five-year-old South African children found no significant association between the prevalence of caries and stunting or wasting. However, a relationship was found between decayed, missing and filled surfaces and wasting [7]. This study, therefore, aimed to compare the nutritional status of children aged 3 – 5 years with Severe-ECC and the nutritional status of those aged 3-5 years without caries.
Severe ECC is also associated with oral Microbiota, and in particular anaerobic bacteria of the species Scardovia Wigggsiae and others have been found in abundance in severe ECC lesions [8]

Materials and Methods

One hundred and ninety-six children aged between 3 to 5 years were recruited for this study. Purposive sampling was done to select Eighty-one children with Severe - ECC was chosen from amongst the patients who had sought dental treatment at the dental clinic at the Nyanza Provincial General Hospital (NNPGH). However, 115 children who were caries free were selected from amongst the children attending the maternal child health clinic at NNPGH over a period of three months. Inclusion criteria were: the child was 3 – 5 years of age, was medically healthy, and the parent or caregiver was willing to consent. A semi-structured questionnaire was administered to the caregiver in a face to face interview, and information was collected on the socio-demographic background of the children. There gathered data included education level, age, gender, and the caregiver’s, occupation, and area of residence of the caregivers. The Intraoral examination was carried using dental mirrors and a Michigan O dental probe under natural light as the child sat on an ordinary chair facing the light. Severe ECC was defined as decayed, missing or filled a score of ≥ 4 (age 3), ≥ 5 (age 4), ≥ 6 (age 5). Before dental caries diagnosis, each tooth was dried using a piece of sterile gauze. WHO 1997 caries diagnosis criteria were used, and dental caries was diagnosed when there was a clinically detectable loss of tooth substance and when such damage had been treated with fillings or extraction [9]. Anthropometric measurements were determined to assess the nutritional status of the children and height of the children were obtained by measuring the child standing when standing erect and barefoot, using a measured with a standard height board to the nearest 0.5cm. Weight for age was measured using a Salter scale to the nearest 0.1kg. Each parameter of height and weight had three measurements taken, and an average of each was then recorded. The Cut-offs +2 standard deviations (SD) were used to identify children at significant risk for either delayed (<-2SD) or excessive (>+2SD) growth. The indicators were weight-for-age (WAZ), height-for-weight (HAZ), weight-forheight (WHZ) based on the World Health Organisation(WHO) 2005 recommended reference standard [10]. The collected data collected were coded, cleaned and analysed using SPSS version 17.0 (SPSS Inc, Chicago Illinois, USA) for Windows and Microsoft Office Excel 2007. Nutritional data was analyzed using Epi-Nutri program of Epi-Info version 3.5.1. Descriptive statistics such as proportions were used to summarize categorical variables while measures of central tendency such as mean, standard deviations and ranges were used to summarise continuous variables. The strength of association was established between categorical values using a Pearson’s Chi-square tests. Odds Ratio (OR) and 95% Confidence Interval (CI) were used to estimate the strength of association between independent variables and the dependent variable. The multivariate analysis was done using binary logistic regression at a statistical significance set at p≤0.05. The relevant research and ethics approving institutions approved the study.

Results

A total of 196 children aged 3-5 years were recruited into the study, eighty-one children with S - ECC (41.3%) and 115(58.7%) without caries. The study group had a mean age of 4.1 + 0.6years, and it ranged from 3- 5 years with a high proportion of the children (62.2%) aged four years. There was a statistically significant difference in age distribution among children with Severe ECC and children without caries (χ2=28.36, d.f=2, p<0.001). The majority of the children with caries were aged four years (84.0%) compared to those without caries (47.0%).Gender distribution was comparable with boys slightly more (51.0%) than girls (49.0%).
Sixty-five children (33.2%) lived in the rural community, and 131(66.8%) lived in the urban area. The differences in the area of residence were significant with a Pearson chi square=13.36, df=1, p≤0.001) for the children with severe ECC and those children without decay. It was noted that sixty-six (81.5%) out of 81 children with Severe ECC lived in an urban setting when compared to children who were caries- free who had 65 (56.5%) out of 115 children who were caries free. Some sixty-eight caregivers had had primary school education of whom 24 (29.6% had severe ECC while 44 (38.3%)) were caries free. However, 103 caregivers had secondary school education of whom 43 (53.1% had severe-ECC and60 (52.2%), while 21 (10.7%) their caregivers had tertiary education and 14 (17.3%) and seven 6.1% were caries free. Also, children whose caregivers had a primary level of education had the highest prevalence of severe-ECC followed by those whose caregivers had secondary education. The differences in the severecares prevalence were significant with a Pearson Chi-square =9.41 d.f 3, p≤0.024 Table 1 & 2.
Table 1: Age and gender distribution of children with Severe - ECC and children without caries.
Table 2: Level of education, demographics for the caregivers, place of residence, level of education, and occupation.
The mean dmft of 7; 5±1.9 d was observed among children with Severe – ECC, and it ranged from 5 to 12 scores. Scores. However, the mean dmft for the males was 7.5±1.8 and for females (7.5±2.0), which was statistically insignificant difference found between the two groups (t=0.15, p=0.88). The mean dmft score for children aged three years was 6.9 ± 2.2, four years was 7.6 ± 1.9, and for five-year-olds was 7.2 ±1.2 and all the dmft ranged from 5-12. The dmft progressively increased with age and peaked at age four years. There were no statistically significant differences found between the age groups (t=1.59, p=0.248). Figure 1.
Figure 1: Distribution of decayed, missing, and filled teeth by age and gender.
Overall the decayed component of the dmft contributed 92.3%. The missing and filled component of the dmft contributed 7.4% and 0.3% respectively. The overall prevalence of underweight for acute malnutrition, stunting, and wasting for chronic malnutrition was 14.3%, 4.6%, and 3.6% respectively. There were more females 17(17.7%), 4 (4.2%), and 5 (5.2%) who were underweight, wasted and stunted respectively when compared to males, but this difference was not statistically significant Pearson Chi-square respectively for underweight, stunted and wasted were 1.80,df=1, p=0.180 ; 0.19,d. f=1, p=0.660 and 0.16, d.f=1, p=0.686 Figures 2 & 3.
Figure 2: Prevalence of malnutrition for children aged 3-5 n=196.
Figure 3: Nutritional status by gender distribution.
Table 3: Underweight among children with caregivers place residence, level of education, and occupation.
When the caregiver’s residence, level of education, and occupation were considered the children who lived in the rural areas had higher prevalences of were underweight 10(15.4%), when compared to the children in the urban areas 18(13.7%) resided in urban areas. Sixty-eight children had caregivers whose education was of a primary level, and 11(16.2%) of the children were underweight while 57 (83.8%) had normal weight for age. Children whose parents had a secondary education were 103 of whom 14 (13.6% were underweight, and 89 (86,4%) had normal weight for an age while caregivers who had higher education were eighteen of whom 3(14.3%) were underweight, and 15( 85.7%) had normal weight. There were more underweight children 24(15,7) out of 153 when weight for age was examined about the caregivers who were informally employed, However, the differences in the children who were underweight with the caregiver’s various demographics were not significant Table 3.
According to the educational level, the children who were stunted and whose parents had a primary education were four (9.3%)), secondary 6(8.8%), and higher education were 5(7.7%). The caregivers who had formally employed were from the urban area while those who were informally employed and had primary school education were from the rural areas Table 4. There were statistically insignificant differences in the caregiver’s place of residence, the level of education, and occupation among children who stunted and those who were not stunted.
Table 4: Stunting among children about caregivers place of residence, level of education, and occupation.
For the children who were wasted five 7.4% of the caregivers lived in the Urban area and had a primary level of education; also 6(3.9%) of the caregivers had informal employment, and 2(3.1%) resided in rural areas Table 5. There statistically insignificant differences in the caregiver’s place of residence, the level of education, and occupation among children who wasted and those who were not wasted.
Table 5: Wasting among children about caregivers place of residence, level of education, and occupation.
There was a slightly higher prevalence of underweight 14’8% for the children suffering from severe ECC compared with children without decay 13.9%. Although there were differences in the nutritional status of children with severe- ECC and children without caries the differences were insignificant for stunting with p=0.311; also underweight was insignificant with p=0.859 while wasting had p=0.451). A child identified with Severe- ECC at risk 1.08 more times likely to become underweight when compared to a child who did not have decay odds ratio lower and upper limits of 0.48 and 2.4 at 95% CL Table 6.
Table 6: Comparison of the nutritional status of children with Severe ECC and children without caries.
Multivariate analysis was done to determine the relationship between underweight and Severe- ECC among the participating children. Five factors associated with underweight and Severe- ECC at P≤0.05 during bivariate analysis were considered for multivariable analysis upon fitting the factors using binary logistic regression. Adjusting for child’s age in years, child’s oral hygiene status, child feeding on demand, place of residence and caregiver’s level of education, the occurrence of S-ECC was not significantly associated with underweight (AOR=1.23; 95% CI: 0.45 – 3.35; p=0.689). However, a child with S – ECC was 1.23 times more likely to have low weight for an age when compared to a child who was caries – free. However adjusting for other factors, age three years was found to be statistically significantly associated with underweight with an Adjusted Odds Ratio value =2.83; 95% CI: 1.15 – 6.96; p=0.023 Table 7. A child aged three years was 2.83 times more likely to be underweight when compared to one aged four years.
Table 7: Logistic Regression Predicting underweight using caries status, Child’s age in years, Child’s oral hygiene status, Child feeding on demand, Place of residence and Caregivers level of education.
Discussion
In the current study found that children with severe ECC were mainly from urban areas in comparison to children who were caries free. The finding of a high prevalence of severe –ECC in the urban children is similar to other studies in Kenya and elsewhere that have shown that children residing in urban areas have a higher caries experience than their rural counterparts [4,5,11,12]. The mean dmft of children with severe ECC in the present study was 7.5+1.9 which is comparable to a study carried out among preschool children of low socioeconomic status in India which reported a mean dmft of 8.9 [13]. Studies in the USA, and Canada among preschool children found mean dmft scores of 9.6±3.6 and 10.5 respectively [13-15]. The differences in the mean dmft may be due to variations in dietary practices among different populations. Also, decayed component accounted for 92.3% of the dmft, and this finding was similar to a study in South Africa [14]. Untreated tooth decay reflects a low utilisation of oral health services or lack and inaccessibility of preventive and curative dental services to the caregivers, or if the facilities are available, they are too costly.
Higher caries experience was observed in the children from the urban areas when compared to their rural counterparts [11]. The mean dmft of children with severe ECC in the present study was 7.5+1.9. The caries experience for severe-ECC in the present study is comparable to a study carried out in a low social, economic status in India among preschooler and reported a mean dmft of 8.9[112]. Studies in the USA, and Canada among preschool children have reported mean dmft scores of 9.6±3.6 and 10.5 respectively [13,14]. The differences in the dmft could be due to variations in dietary practices among different populations. The decayed component in the current study accounted for 92.3% of the dmft, which similar to other studies elsewhere [14]. Untreated tooth decay reflects a low availability and accessibility of preventive and curative dental services.
In this study, there were more females were underweight, stunted, and wasted when compared to males when referenced on the WHO reference standard. However, the differences were insignificant. The WHO child growth standards reference was used to evaluate nutritional status. The WHO growth reference provides a scientifically reliable yardstick of children’s growth achieved under desirable health and nutritional conditions and establishes the breastfed infant has been used as a reference against whom other alternative feeding practices are measured to and compare to regarding growth, health, and development of in children [9]. The children with severe-ECC who were underweight were 4.9%, stunted 2.5%, and those who were wasted were 14.8%. The presence of underweight, stunting, and wasting may be associated with the inability of the children with severe-ECC to chew the available food and absorb enough nutrients resulting in faltering nutritional status. In comparison a study carried out in Italy among 2- 6 years old found that 11% were e underweight, 11.11% overweight and 22.2% to be at risk of overweight [15]. A study in the USA reporting on the BMI of children with severe ECC noted those who were underweight as 11.%, overweight 11%, and those who were at risk of overweight were nine %6. These findings were insignificant may be due to differences in cultural, dietary practices and the primary determinants of nutritional status among the different populations. In Kenya, the primary determinants of nutritional status among children under five years of age include poverty, hunger, and drought [16]. The low weight for age observed with urban children is similar to previous research from other countries where children with high prevalence with severe-ECC had low weight for age [17].
Children who were malnourished were also noted to have severe ECC compared to children who were caries free. There are high levels of malnutrition in Nyanza as reported in the Kenya Demographic and Health Survey 2008-2009 where 19%, 2%, and 14%of the children under five years were underweight, wasted and stunted respectively [18]. Considering the caregiver’s demographic factors children who had low weight for age, wasting and stunted, resided in rural areas. Also, their caregivers had informal employment and had a primary level of education.The finding may be related to the low socioeconomic status and affect access to health care, food security and hence changing overall nutritional status [16,17].
The differences in the nutritional status of the children with ECC and those without ECC was insignificant. South African children aged between four and five years reported similar findings as what has been observed in this study. Njoroge et al. reported 60% in a study population of 338 children aged five years and below[4]. The most affected dentition were the upper central incisors however the severity of decay increased with age and the first and the second deciduous molars had the highest prevalence ranging between 57% -66%. In this study, the caregivers knew the importance of good oral hygiene and significance of snacks about caries formation. However, the infant feeding habits and the weaning practices were not reported on in this study [19,20].
The South African Study found no relationship between the prevalence stunting or wasting with dental caries. However, they reported an association between Wasting with the decayed, missing and filled tooth surfaces [7]. Children with severe ECC were 1.23 times more likely to be underweight when compared to children without caries. Severe ECC may affect general health and development because a toothache associated with caries may affect food intake and sleep [1]. Poor oral health associated with pain may interfere with the intake, mastication digestion of food and nutrients which may lead to decrease in good nutritional health and reduced quality of life for a child [1].
In summary, the difference in the nutritional status of children with severe ECC and children without caries and stunting was insignificant p=0.311, Underweight p=0.859 and wasting p=0.451. However, children with Severe ECC were 1.23 .times more likely to be underweight than children without caries.For more Lupine Publishers Open Access Journal please click: http://lupinepublishers.us/For more Dentistry Open Access Journal articles please click here: https://lupinepublishers.com/dental-and-oral-health-journal/index.phpTo know more about Open Access Publishers please click on Lupine Publishers
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Weaning Pattern Characteristics, Based on Simplified Acute Physiology Score 3, of Critically Ill Patients Requiring Ventilator Care-Juniper Publishers

Abstract
Background: The Simplified Acute Physiology Score 3 (SAPS 3) scoring system was developed through a worldwide prospective study to predict hospital mortality in critically ill patients. The present study focuses on how outcomes, according to SAPS 3 score, differ in patients receiving or not receiving mechanical ventilation.
Methods: We retrospectively reviewed electronic medical records of patients admitted to the surgical or medical ICU from October to December 2014. The SAPS 3 model scores were evaluated for all patients, and for subgroups of patients receiving mechanical ventilation (MV group) or not (Non-MV group). The MV group was further subdivided into two groups, based on the ventilator weaning (simple [MV-SW] and others [MV-Others]), to compare patient characteristics and mortality, based on SAPS 3 scores.
Results: The SAPS 3 score and mortality were significantly higher, and the length of ICU stay was significantly longer in the mechanical ventilation group (p = 0.004, p < 0.001, and p = 0.007, respectively) compared to the non-mechanical ventilation group. The MV-SW group included patients requiring significantly more postoperative care, while the MV-Others group had more patients intubated due to hypoxemia (p < 0.001). The AUC value, indicating discrimination, was 0.871.
Conclusion: The present study, conducted using the SAPS 3 score, showed good discrimination. It is believed that this method will be useful in predicting weaning difficulties and mortalities of patients requiring mechanical ventilation.
Keywords: Intensive care unit; Mechanical ventilation; Mortality; SAPS 3; Ventilator weaning

Introduction

Severity scoring systems are used to predict and compare outcomes, to help guide the allocation of limited resources and to evaluate the process of care in intensive care units (ICU). In critically ill patients, several scoring systems have been developed over the last three decades [1,2]. The Acute Physiology and Chronic Health Evaluation (APACHE) and the Simplified Acute Physiology Score (SAPS) are the most widely used scoring systems in ICUs. Recently, the SAPS 3 was developed through a worldwide prospective study to predict hospital mortality in critically ill patients. It is based on 20 different variables, that are easily measured at patient admission, and dissociating patient status from the quality of care in the ICU [3-7]. There has, however, been no investigation into how outcomes differ in patients receiving or not receiving mechanical ventilation.
The aim of this study was to evaluate the epidemiology and prognostic performance of the SAPS 3 in a retrospective electric chart review, and to describe the weaning pattern characteristics of patients receiving mechanical ventilation.

Material and Methods

The study protocol was approved by the institutional review board.

Patient population

All patients admitted to the surgical or medical ICU from October to December 2014 were included in the present study. In addition, patients who were admitted to the ICU with serious medical or surgical postoperative complications were also included. Pediatric patients (<18 years of age), patients with an ICU stay < 24 h, and patients who were readmitted after an initial ICU discharge were excluded.

Data Collection

One individual retrospectively reviewed the electronic medical records. These records provided all of the data required to predict the mortality rate using the SAPS 3 model. The SAPS 3 score was obtained from the most severe laboratory findings 1 h before or after ICU admission. Predicted hospital mortality rate (PMR) was calculated using the following equation; where score means SAPS 3 admission score [6].
The performance of the model was evaluated in all patients, as well as, in two subgroups of patients who had received mechanical ventilation (MV group) or not (Non-MV group). Based on the ventilator weaning pattern, the MV group was further subdivided into two groups to compare the characteristics and prolonged, or chronic mechanical ventilation weaning.

Statistical Analysis

Statistical analyses were performed using IBM SPSS Statistics 21 for Windows. Data were reported as means ± standard deviation (SD) or medians with 25th and 75th quartiles for continuous variables, and percentages for quantitative variables. Student's t-test, chi-squared test, or Fisher's exact test were used depending on whether the variables were continuous or categorical. P-values less than 0.05 were used to indicate statistical significance. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve was used to measure discrimination for hospital mortality.

Results

MV: patients who received mechanical ventilation; Non-MV: patients who did not received mechanical ventilation; OR: operating room; PACU: postanesthetic unit; eR: emergency room; ICU: intensive care unit; IM: internal medicine; GS: general surgery; NS: neurosurgery; TS: Thoracic surgery; OS: orthopedic surgery; PS: plastic surgery; UR: urosurgery; NR: neurology; SAPS: Simplified Acute Physiology Score; IQR: Interquartile range.
Of the 154 patients admitted to the ICU between October and December 2014, 2 pediatric patients, 4 readmissions, and 7 patients with missing data, mostly due to ICU length of stay < 24 h, were excluded. The study group, therefore, comprised 141 patients: 76 males (53.9%) and mean age 67.7 yr. The characteristics of the study group are shown in (Table 1). There were no significant differences in demographic characteristics between patients in the MV group and the Non-MV group. The SAPS 3 score and ICU mortality were significantly higher in the MV group (p = 0.004 and p < 0.001, respectively). In addition, length of ICU stay was significantly longer (p = 0.007) for the MV group.
MV-SW: patients who received mechanical ventilation and simple weaning; MV-Others: patients who received mechanical ventilation and all other weaning groups; SAPS: Simplified Acute Physiology Score; IQR: inter-quartile range.
The MV group (n = 43; excluding 2 patients with missing weaning protocol data) was subdivided based on weaning pattern. When the reason for the intubation was compared between subgroups, the MV-SW group included patients requiring significantly more postoperative care, while the MV-Other group had significantly more intubations due to hypoxemia (p = 0.001). Observed mortality, SAPS 3 score, and predicted mortality were significantly higher in the MV-Other group (Table 2), and observed mortality (60.0%) was higher than the predicted mortality (39.4%).
Hospital mortality was considerably greater in patients with higher SAPS 3 scores. The highest hospital mortality rate was observed in patients with a SAPS 3 score greater than 90 (Figure 1). Discrimination, as measured by the AUC, was good (AUCs = 0.871), (Figure 2).

Discussion

In the present study, the mean SAPS 3 score of all patients was 46.1; the score was 10 points higher for the group requiring mechanical ventilation compared to the group without. Although there were no significant differences in gender, age, route of admission, and department between the groups, the group requiring mechanical ventilation exhibited longer ICU stays and higher mortality. Among members of the MV group, those capable of simple weaning showed lower severity scores and mortality.
Many previous studies have shown that SAPS 3 is a scoring system model with good discrimination but poor calibration [5,8-10]. In the present study, the AUC value, which indicates discrimination, was 0.871; this is similar to previous studies (0.8-0.89) and indicates favorable discrimination [5,11]. While there were no in-hospital mortalities in patients with SAPS 3 scores of <40 points, patients with scores of 41-90 points had a mortality rate under 50%, and the mortality rate increased rapidly for patients with scores >90.
Unlike previous SAPS 3 studies that compared discrimination or calibration to outcomes from other scoring models or investigated regional variations [10,12-14], the present study focused on how outcomes differed in patients receiving or not receiving mechanical ventilation. This is because, among various factors affecting SAPS 3, the effect of applying mechanical ventilation on the score is minimal; however, a significant number of patients in the ICU receive ventilator care and applying mechanical ventilation has a clinically significant impact on the clinical course of critically ill patients.
The patient group requiring mechanical ventilation was divided into two subgroups based on the weaning pattern. The simple weaning (MV-SW) group included patients with successful 1st extubation after the 1st SBT. The other (MV-Other) group included all other weaning groups: Difficult weaning (failed 1st SBT trial, but succeeded within the 3rd SBT trials or successful weaning within 7 days after the 1st SBT); prolonged weaning (failed weaning on the 3rd SBT trial or required more than 7 days on the 1st SBT); and chronic mechanical ventilation weaning (the same as tracheostomy) [15,16].
The majority of patients from our hospital had chronic mechanical ventilation weaning when simple weaning failed; for this reason, we consolidated the three groups into one. Since most of the patients who had simple weaning were those who underwent extubation after maintaining mechanical ventilation for postoperative care due to old age, prolonged operation time, or underlying diseases (19 subjects, 82.6%), they not only showed lower SAPS 3 scores, but also lower mortality rates compared to the MV-Other group. Conversely, most ofthe patients within the MV-Other group were intubated for mechanical ventilation because of hypoxemia caused by impairment of normal ventilation function (17 subjects, 85%), which may have manifested as an increase in the severity of weaning.
The mean length of hospital stay for the MV-Other group, whose conditions were more severe, was not significantly different from the MV-SW group; this may be attributed to a shortened overall length of hospital stay due to the larger number of "do not resuscitates" (DNRs) and patients who passed away in this group. Moreover, it can be surmised that the observed mortality rate (60.0%) in this group was higher than the predicted mortality (39.4%) because of the influence limited proactive management for patients who were expected to have unfavorable prognosis and had effectuated DNRs in advance.
The limitations of this study include having a small number of participants, which resulted in a low number of patients in the ventilated group and corresponding subgroups. In addition, at the time of data collection, the hospital did not have a standard weaning protocol; weaning was carried out either by applying a T-piece or a pressure support ventilation (PSV) mode after the SBT and the protocol used was determined by the doctor in charge of the department. Consequently, the reason for a patient not having been placed into a weaning subgroup may not have been due to the patient's condition.
Furthermore, while all charts were reviewed by a single person responsible for the ICU, the SAPS 3 scores were inputted by different doctors who were in charge of the department at the time of admission; for this reason, individual evaluator errors cannot be eliminated. We plan to perform future studies with a larger number of patients; furthermore, the hospital plans to implement a standard SBT protocol, therefore data obtained after the protocol is applied may be compared to the results presented to allow the mechanical ventilation subgroups to be more clearly defined to determine any differences.

Conclusion

In conclusion, in the present study, conducted on patients who were hospitalized in the surgical or internal medicine ICU, SAPS 3 score assisted-evaluations showed good discrimination. It is believed that this will be a useful method for predicting weaning difficulties and mortalities in patients requiring mechanical ventilation.

Acknowledgement

This work was supported by a research grant from Jeju National University Hospital in 2015.
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