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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]

Frailty and sepsis have a significant impact on patient prognosis. However, research into the relationship between frailty and sepsis in the general adult population remains inadequate. This paper aims to investigate the association between frailty and adverse outcomes in this population. This retrospective analysis investigated sepsis patients who were initially admitted to the intensive care unit (ICU). The Modified Frailty Index (MFI) was derived by tracking patients' International Classification of Diseases (ICD) codes during their hospitalization. Patients were classified into two groups based on their MFI scores: a frail group (MFI ≥ 3) and a non-frail group (MFI = 0–2). The key outcomes were mortality rates at 90 and 180 days, with secondary outcomes including the incidence of delirium and pressure injury. Of the 21,338 patients who were recruited for this study (median age about 68 years, 41.8 % female), 5,507 were classified as frail and 15,831 were classified as non-frail. Frail patients were significantly more likely to have delirium (48.9 % vs. 36.1 %, p < 0.001) and pressure injury (60.5 % vs. 51.4 %, p < 0.001). After controlling for confounding variables, the multifactorial Cox proportional hazard regression analyses revealed a significantly elevated mortality rate at 90 days (adjusted HR: 1.58, 95 % CI: 1.24–2.02, p < 0.001) and 180 days (adjusted HR: 1.47, 95 % CI: 1.18, 1.83, p < 0.001) in the frail group compared to their non-frail counterparts. Frailty independently predisposes adult sepsis patients in the ICU to adverse outcomes. Future investigations should concentrate on evaluating frailty and developing targeted interventions to improve patient prognosis. The MFI provides a simple clinical assessment tool that can be integrated into electronic medical records for immediate calculation. This simplifies the assessment process and plays a key role in predicting patient outcomes. [ABSTRACT FROM AUTHOR]

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: Ischaemic stroke remains a significant global health challenge, associated with high mortality rates. While the Braden Scale is traditionally employed to assess pressure ulcer risk, its potential to predict mortality among the intensive care unit (ICU) patients with ischaemic stroke has not been thoroughly investigated., Aim/s: This study evaluates the predictive value of the Braden Scale for 30-day mortality among patients with ischaemic stroke admitted to ICU., Study Design: We conducted a retrospective analysis of 4710 adult patients with ischaemic stroke from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The association between the Braden Scale scores and 30-day mortality was assessed using receiver operating characteristic (ROC) curve analysis, Cox regression models and Kaplan-Meier survival estimates., Results: Patients with Braden Scale scores ≤ 15.5 showed significantly higher 30-day mortality rates (p-value < 0.001; hazard ratio (HR): 2.08, 95% confidence interval (CI): 1.71-2.53). The area under the ROC curve (AUC) was 0.71, demonstrating good predictive performance. Multivariate analysis confirmed the Braden Scale as an independent predictor of mortality, after adjusting for age, gender and comorbidities., Conclusions: The Braden Scale effectively identifies high-risk ischaemic stroke patients in ICU settings, endorsing its integration into routine assessments to facilitate early intervention strategies., Relevance to Clinical Practice: Integrating the Braden Scale into routine ICU evaluations can enhance mortality risk stratification and improve patient care tailoring., (© 2024 British Association of Critical Care Nurses.)

Background: Atrial fibrillation (AF) and frailty are significant global public health problems associated with advancing age. However, the relationship between frailty and older patients with AF in the intensive care unit (ICU) has not been thoroughly investigated. This study aimed to investigate whether the hospital frailty risk score (HFRS) is associated with adverse outcomes in older patients with AF in the ICU., Methods: This was the first retrospective analysis of older patients with AF admitted to the ICU between 2008 and 2019 at a tertiary academic medical center in Boston. The HFRS was used to measure frailty severity. The outcomes of interest were in-hospital and 30-day mortality and the incidence of sepsis and ischemic stroke., Results: There were 7,792 participants aged approximately 80 years, almost half (44.9%) of whom were female. Among this group, 2,876 individuals were identified as non-frail, while 4,916 were classified as frail. The analysis revealed a significantly greater incidence of in-hospital (18.8% compared to 7.6%) and 30-day mortality (24.5% versus 12.3%) in the frail group. After accounting for potential confounding factors, a multivariate Cox proportional hazards regression analysis revealed that frail participants had a 1.56-fold greater risk of mortality within 30 days (95% CI = 1.38-1.76, p < 0.001)., Conclusions: Frailty is an independent risk factor for adverse outcomes in older patients with AF admitted to the ICU. Therefore, prioritizing frailty assessment and implementing specific intervention strategies to improve prognostic outcomes are recommended., Competing Interests: Competing interests The authors declare that they have no competing interests.

Background: Thymectomy is an efficient and standard treatment strategy for patients with myasthenia gravis (MG), postoperative myasthenic crisis (POMC) is the major complication related to thymectomy and has a strongly life-threatening effect. As a biomarker, whether the bilirubin level is a risk factor for MG progression remains unclear. This study aimed to investigate the association between the preoperative bilirubin level and postoperative myasthenic crisis (POMC)., Methods: We analyzed 375 patients with MG who underwent thymectomy at Tangdu Hospital between January 2012 and September 2021. The primary outcome measurement was POMC. The association between POMC and bilirubin level was analyzed by restricted cubic spline (RCS). Indirect bilirubin (IBIL) was divided into two subgroups based on the normal upper limit of IBIL, 14 μmol/L., Results: Compared with non-POMC group, IBIL levels were significantly higher in patients with POMC. Elevated IBIL levels were closely associated with an increased risk of POMC ( p for trend = 0.002). There was a dose-response curve relationship between IBIL levels and POMC incidence ( p for non-linearity = 0.93). However, DBIL levels showed a U-shaped association with POMC incidence. High IBIL level (≥14 μmol/L) was an independent predictive factor for POMC [odds ratio = 3.47, 95% confidence interval (CI): 1.56-7.8, p = 0.002]. The addition of high IBIL levels improved the prediction model performance (net reclassification index = 0.186, 95% CI: 0.039-0.334; integrated discrimination improvement = 0.0345, 95% CI: 0.005-0.065)., Conclusion: High preoperative IBIL levels, especially those exceeding the normal upper limit, could independently predict the incidence of POMC., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Sun, Ruan, Zhang, Guo, Li, Wang, Gao, Tang, Song, Hao, Huang, Li, Ning, Su, Lu, Wang, Cao, Li and Chang.)