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Patients with ischemic stroke have an increased propensity to fall, resulting in significant physical and psychological distress. This study examined the association between falls in the 3 months prior to intensive care unit (ICU) admission and mortality within 28 days among 2950 adult ICU patients diagnosed with ischemic stroke from 2008 to 2019, focusing on the potential mediating role of delirium. The primary outcomes were short-term mortality (28, 60, and 90 days) and the risk of delirium. Each patient was followed for at least 1 year. Delirium was primarily assessed using the Confusion Assessment Method for the ICU and by reviewing nursing notes. Group differences between patients with and without a history of falls were compared using the Wilcoxon rank-sum test or the chi-squared test. Cox proportional risk or logistic regression models were used to explore the association between fall history and outcomes, and causal mediation analysis was performed. Results showed that patients with a recent fall history had a significantly increased risk of 28-day (hazard ratio [HR]: 1.62, 95% confidence interval [CI]: 1.35–1.94), 60-day (HR: 1.67, 95% CI: 1.42–1.98), and 90-day mortality (HR: 1.66, 95% CI: 1.41–1.95), as well as an increased risk of delirium (odds ratio: 2.00, 95% CI: 1.66–2.42). Delirium significantly mediated the association between fall history and 28-day mortality (total effect: HR: 1.77, 95% CI: 1.45–2.16; natural indirect effect: HR: 1.12, 95% CI: 1.05–1.21; proportion mediated: 24.6%). These findings suggest that ischemic stroke patients with a recent fall have an increased risk of short-term mortality, partly mediated by delirium. Strategies aimed at preventing delirium may potentially improve prognosis in this patient population. [ABSTRACT FROM AUTHOR]

Background: We aimed to compare the efficacy of tocilizumab with conventional immunotherapy in refractory patients with acetylcholine receptor antibody‐positive (AChR‐Ab+) generalized myasthenia gravis (gMG). Methods: This single‐center prospective cohort study was based on patients from an MG registry study in China and conducted from February 10, 2021 to March 31, 2022. Adult refractory patients with AChR‐Ab+ gMG were assigned to tocilizumab or conventional immunotherapy groups. The primary efficacy outcome was the mean difference of MG activities of daily living (MG‐ADL) change at weeks 4, 8, 12, 16, 20, 24 corresponding to that at the baseline between the two groups. A generalized estimating equation model was used for the primary outcome analysis. Safety was assessed based on adverse events. Results: Of 34 eligible patients, 20 (mean [standard deviation] age, 53.8 [21.9] years; 12 [60.0%] female) received tocilizumab and 14 received conventional immunotherapy (45.8 [18.0] years; 8 [57.1%] female). The tocilizumab group had greater reduction in MG‐ADL score at week 4 (adjusted mean difference, −3.4; 95% CI, −4.7 to −2.0; p < 0.001) than the conventional immunotherapy group, with significant differences sustained through week 24 (adjusted mean difference, −4.5; 95% CI, −6.4 to −2.6; p < 0.001). At week 24, the proportion of patients achieving higher levels of MG‐ADL (up to 7‐point reduction) and QMG (up to 11‐point reduction) scores improvement was significantly greater with tocilizumab. Tocilizumab had acceptable safety profiles without severe or unexpected safety issues. Conclusion: Tocilizumab is safe and effective in improving the MG‐ADL score and reducing prednisone dose in refractory AChR‐Ab+ gMG, suggesting tocilizumab has the potential to be a valuable therapeutic option for such patients. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the association between frailty and postoperative delirium (POD) in elderly cardiac surgery patients. Methods: A retrospective study was conducted of older patients admitted to the intensive care unit after cardiac surgery at a tertiary academic medical center in Boston from 2008 to 2019. Frailty was measured using the Modified Frailty Index (MFI), which categorized patients into frail (MFI ≥3) and non‐frail (MFI = 0–2) groups. Delirium was identified using the confusion assessment method for the intensive care unit and nursing notes. Logistic regression models were used to examine the association between frailty and POD, and odds ratios (OR) with 95% confidence intervals (CI) were calculated. Results: Of the 2080 patients included (median age approximately 74 years, 30.9% female), 614 were frail and 1466 were non‐frail. The incidence of delirium was significantly higher in the frail group (29.2% vs. 16.4%, p < 0.05). After adjustment for age, sex, race, marital status, Acute Physiology Score III (APSIII), sequential organ failure assessment (SOFA), albumin, creatinine, hemoglobin, white blood cell count, type of surgery, alcohol use, smoking, cerebrovascular disease, use of benzodiazepines, and mechanical ventilation, multivariate logistic regression indicated a significantly increased risk of delirium in frail patients (adjusted OR: 1.61, 95% CI: 1.23–2.10, p < 0.001, E‐value: 1.85). Conclusions: Frailty is an independent risk factor for POD in older patients after cardiac surgery. Further research should focus on frailty assessment and tailored interventions to improve outcomes. [ABSTRACT FROM AUTHOR]

Aims and Objectives: To investigate whether a low Braden Skin Score (BSS), reflecting an increased risk of pressure injury, could predict the risk of delirium in older patients in the intensive care unit (ICU). Background: Delirium, a common acute encephalopathy syndrome in older ICU patients, is associated with prolonged hospital stay, long‐term cognitive impairment and increased mortality. However, few studies have explored the relationship between BSS and delirium. Design: Multicenter cohort study. Methods: The study included 24,123 older adults from the Medical Information Mart for Intensive Care IV (MIMIC‐IV) database and 1090 older adults from the eICU Collaborative Research Database (eICU‐CRD), all of whom had a record of BSS on admission to the ICU. We used structured query language to extract relevant data from the electronic health records. Delirium, the primary outcome, was primarily diagnosed by the Confusion Assessment Method for the ICU or the Intensive Care Delirium Screening Checklist. Logistic regression models were used to validate the association between BSS and outcome. A STROBE checklist was the reporting guide for this study. Results: The median age within the MIMIC‐IV and eICU‐CRD databases was approximately 77 and 75 years, respectively, with 11,195 (46.4%) and 524 (48.1%) being female. The median BSS at enrollment in both databases was 15 (interquartile range: 13, 17). Multivariate logistic regression showed a negative association between BSS on ICU admission and the prevalence of delirium. Similar patterns were found in the eICU‐CRD database. Conclusions: This study found a significant negative relationship between ICU admission BSS and the prevalence of delirium in older patients. Relevance to Clinical Practice: The BSS, which is simple and accessible, may reflect the health and frailty of older patients. It is recommended that BSS assessment be included as an essential component of delirium management strategies for older patients in the ICU. No Patient or Public Contribution: This is a retrospective cohort study, and no patients or the public were involved in the design and conduct of the study. [ABSTRACT FROM AUTHOR]

Background: Dementia is a significant cause of death in the older population and is becoming an important public health issue as the population ages and the prevalence of dementia increases. The Braden score is one of the most commonly used clinical tools to assess the risk of skin pressure injury in patients, and some studies have reported that it may reflect the state of frailty of patients. The present study attempted to explore the association between Braden score and 90‐day mortality, pressure injury, and aspiration pneumonia in older patients with dementia in the intensive care unit (ICU). Methods: The study involved extracting crucial data from the Medical Information Market for Intensive Care IV (MIMIC‐IV) database using Structured Query Language, with a license certificate obtained after completing the necessary training and examination available on the MIMIC‐IV website. A retrospective analysis was performed on older patients with dementia, aged 65 or older, who were first admitted to the ICU. Ninth and tenth revision International Classification of Diseases codes were used to identify patients with dementia. The primary outcome was 90‐day mortality. Cox proportional hazards models were used to determine the association between Braden score and death, and hazard ratios (HR) and 95% confidence intervals (CI) were calculated. Propensity score matching and E‐value assessments were employed for sensitivity analysis. Results: A total of 2892 patients with a median age of approximately 85 years (interquartile range 78.74–89.59) were included, of whom 1625 were female (56.2%). Patients had a median Braden score of 14 (interquartile range 12–15) at ICU admission. Braden score at ICU admission was inversely associated with 90‐day mortality risk after adjustment for demographics, severity of illness, treatment and medications, delirium, and sepsis (adjusted HR: 0.92, 95% CI: 0.87–0.98, p = 0.006). Patients were divided into two groups with a cut‐off value of 15: high‐risk group and low‐risk group. Compared to the low‐risk group (Braden score >15), the risk of 90‐day mortality was significantly increased in the high‐risk group (Braden score ≤15) (adjusted HR: 1.52, 95% CI: 1.10–2.09, p = 0.011, E‐value: 2.01), the risk of pressure injury (adjusted OR: 2.62, 95% CI: 2.02–3.43, E‐value: 2.62) and aspiration pneumonia (adjusted OR: 2.55, 95% CI: 1.84–3.61, E‐value: 2.57) was also significantly higher. Conclusions: The Braden score may be a quick and simple screening tool to identify the risk of adverse outcomes in critically ill older adults with dementia. Key points: The Braden score, which is commonly used to assess the risk of pressure injury, may reflect frailty in patients.The Braden score at ICU admission was inversely associated with 90‐day mortality risk, suggesting its potential as a mortality predictor.The findings suggest that the Braden score could be a valuable tool for quickly identifying critically ill older adults with dementia who are at risk of adverse outcomes. [ABSTRACT FROM AUTHOR]

Background: Delirium is prevalent in ischemic stroke patients, particularly those in the intensive care unit (ICU), and it poses a significant burden on patients and caregivers, leading to increased mortality rates, prolonged hospital stays, and impaired cognitive function. Dysphagia, a common symptom in critically ill patients with ischemic stroke, further complicates their condition. However, the association between dysphagia and delirium in this context remains unclear. The objective of this study was to investigate the correlation between dysphagia and delirium in ICU patients with ischemic stroke. Methods: A retrospective analysis was conducted on adult patients diagnosed with ischemic stroke at a medical center in Boston. Ischemic stroke cases were identified using the ninth and tenth revisions of the International Classification of Diseases. Dysphagia was defined as a positive bedside swallowing screen performed by medical staff on the day of ICU admission, while delirium was assessed using the ICU Confusion Assessment Method and review of nursing notes. Logistic regression models were used to explore the association between dysphagia and delirium. Causal mediation analysis was employed to identify potential mediating variables. Results: The study comprised 1838 participants, with a median age of approximately 70 years, and 50.5% were female. Among the total study population, the prevalence of delirium was 43.4%, with a higher prevalence observed in the dysphagia group (60.7% vs. 40.8%, p < 0.001) compared to the non-dysphagia group. After adjusting for confounding factors including age, sex, race, dementia, depression, sedative medications, history of falls, visual or hearing deficit, sequential organ failure score, and Glasgow coma score, multifactorial logistic regression analysis demonstrated a significant association between dysphagia and an increased likelihood of delirium (odds ratio [OR]: 1.48; 95% confidence interval [CI]: 1.07–2.05; p = 0.018; E-value = 1.73). Causal mediation analysis revealed that serum albumin levels partially mediated the association between dysphagia and delirium in critically ill patients with ischemic stroke (average causal mediated effect [ACME]: 0.02, 95% CI: 0.01 to 0.03; p < 0.001). Conclusion: ICU admission dysphagia may independently contribute to the risk of delirium in patients with ischemic stroke. Early identification and intervention in ischemic stroke patients with dysphagia may help mitigate the risk of delirium and improve patient prognosis. [ABSTRACT FROM AUTHOR]

Background: The triglyceride-glucose index (TyG), an established indicator of insulin resistance, is closely correlated with the prognosis of several metabolic disorders. This study aims to investigate the association between the TyG index and the incidence of critical delirium in patients aged 65 years and older. Methods: We focused on evaluating patients aged 65 years and older diagnosed with critical delirium. Data were obtained from the Medical Information Database for Intensive Care (MIMIC-IV) and the eICU Collaborative Research Database (eICU-CRD). Multivariate logistic regression and restricted cubic spline (RCS) regression were used to determine the relationship between the TyG index and the risk of delirium. Results: Participants aged 65 years and older were identified from the MIMIC-IV (n = 4,649) and eICU-CRD (n = 1,844) databases. Based on optimal thresholds derived from RCS regression, participants were divided into two cohorts: Q1 (< 8.912), Q2 (≥ 8.912). The logistic regression analysis showed a direct correlation between the TyG index and an increased risk of critical delirium among ICU patients aged 65 and older. These findings were validated in the eICU-CRD dataset, and sensitivity analysis further strengthened our conclusions. In addition, the subgroup analysis revealed certain differences. Conclusion: This study highlights a clear, independent relationship between the TyG index and the risk of critical delirium in individuals aged 65 years and older, suggesting the importance of the TyG index as a reliable cardio-cerebrovascular metabolic marker for risk assessment and intervention. [ABSTRACT FROM AUTHOR]

Background: Dysphagia is common in elderly patients with dementia and is one of the common clinical geriatric syndromes. It imposes a heavy burden on patients and their caregivers and is becoming an important public health problem. This study examined the association between dysphagia in older dementia patients in the ICU and the subsequent adverse health outcomes they experience.Patients and Methods: A retrospective analysis of adults (≥ 65 years) with dementia in ICUs of a Boston tertiary academic medical center was conducted. Using the International Classification of Diseases' Ninth and Tenth Revisions, dementia patients were identified. The study cohort comprised 1009 patients, median age 84.82 years, 56.6% female, predominantly White (72.9%). Patients were grouped based on swallowing function: dysphagia (n=282) and no-dysphagia (n=727). Dysphagia was identified via positive bedside swallowing screening. Primary outcomes were 90- and 180-day mortality, secondary outcomes included aspiration pneumonia, pressure injury, and delirium. Cohort characteristics were compared using the Wilcoxon rank-sum and chi-square tests. Dysphagia and outcomes correlations were examined via Kaplan-Meier survival analysis, Cox proportional-hazards regression models, logistic regression models, and subgroup analysis.Results: After adjusting for covariates, the results from multivariate Cox proportional-hazards regression indicated that dysphagia was significantly associated with increased 90-day (HR=1.36, 95% CI=1.07– 1.73, E-value=1.78) and 180-day (HR=1.47, 95% CI=1.18– 1.82, E-value=1.94) mortality; the multifactorial logistic regression results indicated that dysphagia was associated with significant increases in pressure injury (OR=1.58, 95% CI=1.11– 2.23, E-value=1.83) and aspiration pneumonia occurrence (OR=4.04, 95% CI=2.72– 6.01, E-value=7.54), but was not significantly associated with delirium prevalence (OR=1.27, 95% CI=0.93– 1.74).Conclusion: Dysphagia is likely to increase the risk of adverse health outcomes in older adults with dementia in ICU, and these adverse outcomes mostly include 90- and 180-day mortality, aspiration pneumonia, and pressure injury. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to develop and validate internally a clinical predictive model, for predicting myasthenic crisis within 30 days after thymectomy in patients with myasthenia gravis. Methods: Eligible patients were enrolled between January 2015 and May 2019. The primary outcome measure was postoperative myasthenic crisis (POMC). A predictive model was constructed using logistic regression and presented in a nomogram. The area under the receiver operating characteristic curve (AUC) was calculated to examine the performance. The study population was divided into high‐ and low‐risk groups according to Youden index. Calibration curves with 1000 replications bootstrap resampling were plotted to visualize the calibration of the nomogram. Decision curve analyses (DCA) with 1000 replications bootstrap resampling were performed to evaluate the clinical usefulness of the model. Results: A total of 445 patients were enrolled. Five variables were screened including thymus imaging, onset age, MGFA classification, preoperative treatment regimen, and surgical approach. The model exhibited moderate discriminative ability with AUC value 0.771. The threshold probability was 0.113, which was used to differentiate between high‐ and low‐risk groups. The sensitivity and specificity were 72.1% and 77.1%, respectively. The high‐risk group had an 8.70‐fold higher risk of POMC. The calibration plot showed that when the probability was between 0 and 0.5, the deviation calibration curve of the model was consistent with the ideal curve. Interpretation: This nomogram could assist in identifying patients at higher risk of POMC and determining the optimal surgical time for these patients. [ABSTRACT FROM AUTHOR]

Background: N6-methyladenosine (m6A) modification has been recognized to play fundamental roles in the development of autoimmune diseases. However, the implication of m6A modification in myasthenia gravis (MG) remains largely unknown. Thus, we aimed to systematically explore the potential functions and related immune characteristics of m6A regulators in MG. Methods: The GSE85452 dataset with MG and healthy samples was downloaded from Gene Expression Omnibus (GEO) database. m6A modification regulators were manually curated. The targets of m6A regulators were obtained from m6A2Target database. The differential expressed m6A regulators in GSE85452 dataset were identified by "limma" package and were validated by RT-PCR. Function enrichment analysis of dysregulated m6A regulators was performed using "clusterProfiler" package. Correlation analysis was applied for analyzing the relationships between m6A regulators and immune characteristics. Unsupervised clustering analysis was used to identify distinct m6A modification subtypes. The differences between subtypes were analyzed, including the expression level of all genes and the enrichment degree of immune characteristics. Weighted gene co-expression network analysis (WGCNA) was conducted to obtain modules associated with m6A modification subtypes. Results: We found that CBLL1, RBM15 and YTHDF1 were upregulated in MG samples of GSE85452 dataset, and the results were verified by RT-PCR in blood samples from19 MG patients and 19 controls. The targeted genes common modified by CBLL1, RBM15, and YTHDF1 were mainly enriched in histone modification and Wnt signaling pathway. Correlation analysis showed that three dysregulated m6A regulators were closely associated with immune characteristics. Among them, RBM15 possessed the strongest correlation with immune characteristics, including CD56dim natural killer cell (r = 0.77, P = 0.0023), T follicular helper cell (r = − 0.86, P = 0.0002), Interferon Receptor (r = 0.78, P = 0.0017), and HLA-DOA (r = 0.64, P = 0.0200). Further two distinct m6A modification patterns mediated by three dysregulated m6A regulators was identified. Bioinformatics analysis found that there were 3029 differentially expressed genes and different immune characteristics between two m6A modification patterns. Finally, WGCNA analysis obtained a total of 12 modules and yellow module was the most positively correlated to subtype-2. Conclusion: Our findings suggested that m6A RNA modification had an important effect on immunity molecular mechanism of MG and provided a new perspective into understanding the pathogenesis of MG. [ABSTRACT FROM AUTHOR]

The relationship between sub-daily precipitation and urbanization is widely concerned because short-term precipitation is sensitive to urbanization and difficult to predict. Using the data of summer hourly precipitation and urban development during 2007–2019 at four urban stations and an atmospheric background monitoring station in central China, this study investigates the characteristics of hourly precipitation and hourly extreme precipitation (HEP) under different urbanization background. It is found that high urbanization level may benefit precipitation intensity but not for accumulated precipitation amount and precipitation frequency, and it is also conducive to the occurrence of hourly precipitation within [20, 50) mm. Precipitation amount and frequency for hourly precipitation within [5, 50) mm have similar diurnal variation at fixed station, yet the diurnal variation of precipitation intensity is insignificant. The differences in temporal variation of precipitation are related to urbanization and terrain. Both high urbanization level and speed are conducive to summer HEP; especially summer HEP intensity may increase gradually under sustainable urbanization development. Although growth-type HEP occurs frequently with main contribution to total HEP precipitation amount in central China regardless of urbanization level, the frequency and contribution of continuous-type HEP tends to increase under high urbanization level and speed. [ABSTRACT FROM AUTHOR]

This study aims to investigate the association between thymectomy and the risk of generalization in patients with ocular myasthenia gravis (MG). Data on patients with ocular MG from seven neurological centers in China were retrospectively reviewed. Ocular MG naïve to immunotherapy was categorized according to whether thymectomy was performed (thymectomized group vs. nonsurgical group). Patients in the thymectomized group all underwent surgery within 2 years since ocular symptom onset. The main outcome measure was the generalization. The follow-up period was defined from the date of ocular symptom onset to the date of generalization confirmation, immunotherapy initiation, or last follow-up (defined as 60 months). Of 519 eligible patients (mean [SD] age, 48.7 [15.2] years, 46.6% women), 31 (23.7%) of 131 generalized in the thymectomized group and 122 (31.4%) of 388 did in the nonsurgical group during a median follow-up of 19 months (IQR 8.0–50.0). Thymectomy was independently associated with reduced generalization risk (adjusted HR 0.41, 95% CI 0.25–0.66, P < 0.001). Multivariable stratified analysis also verified this association across the subgroups. Kaplan–Meier curves showed that the 5-year cumulative rate was significantly lower in the thymectomized group than in the nonsurgical group. To conclude, thymectomy may be considered effective in modifying the progression from ocular to generalized MG irrespective of thymoma. [ABSTRACT FROM AUTHOR]

In this study, we report the safety of coronavirus disease 2019 (COVID-19) vaccine in patients with myasthenia gravis (MG). Patients who were vaccinated against COVID-19 were included. Demographics, clinical characteristics, medications, and vaccination information were collected. The main observation outcome is the worsening of MG symptoms within 4 weeks following COVID-19 vaccination. A total of 22 patients with MG vaccinated for COVID-19 were included. Ten (45.5%) patients had ocular MG (OMG), and 12 (55.5%) patients had generalized MG (GMG). Six (27.3%) patients were female, and the mean (SD) onset age was 45.4 (11.8) years. Nineteen (86.4%) patients were seropositive for acetylcholine receptors (AChR) antibody. Seven (31.8%) patients underwent thymectomy, and four of them confirmed thymoma pathologically. Twenty-one patients were administrated with inactivated vaccines, and the remaining one was administrated with recombinant subunit vaccine. Twenty (90.9%) patients did not present MG symptom worsening within 4 weeks of COVID-19 vaccination, and two (9.1%) patients reported slight symptom worsening but resolved quickly within a few days. Our findings suggest inactivated COVID-19 vaccines might be safe in MG patients with Myasthenia Gravis Foundation of America (MGFA) classification I to II, supporting the recommendation to promote vaccination for MG patients during the still expanding COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

It is an important to study atmospheric thermal and dynamic vertical structures over the Tibetan Plateau (TP) and their impact on precipitation by using long-term observation at representative stations. This study exhibits the observational facts of summer precipitation variation on subdiurnal scale and its atmospheric thermal and dynamic vertical structures over the TP with hourly precipitation and intensive soundings in Jiulong during 2013–2020. It is found that precipitation amount and frequency are low in the daytime and high in the nighttime, and hourly precipitation greater than 1 mm mostly occurs at nighttime. Weak precipitation during the daytime may be caused by air advection, and strong precipitation at nighttime may be closely related with air convection. Both humidity and wind speed profiles show obvious fluctuation when precipitation occurs, and the greater the precipitation intensity, the larger the fluctuation. Moreover, the fluctuation of wind speed is small in the morning, large at noon and largest at night, presenting a similar diurnal cycle to that of convective activity over the TP, which is conductive to nighttime precipitation. Additionally, the inverse layer is accompanied by the inverse humidity layer, and wind speed presents multi-peaks distribution in its vertical structure. Both of these are closely related with the underlying surface and topography of Jiulong. More studies on physical mechanism and numerical simulation are necessary for better understanding the atmospheric phenomenon over the TP. [ABSTRACT FROM AUTHOR]