Braden score can independently predict 90-day mortality in critically ill patients with dementia.

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.

Does ICU admission dysphagia independently contribute to delirium risk in ischemic stroke patients? Results from a cohort study.

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.

Assessing the Risk of Delirium and Death in Sepsis Using the Braden Score: A Retrospective Study.

AIMS AND OBJECTIVES: To provide a viable tool for the early clinical identification of high-risk populations in patients with sepsis. BACKGROUND: Sepsis-associated delirium (SAD) has the potential to significantly impact the short- and long-term prognosis of patients. However, accurately predicting and effectively managing SAD remains a significant challenge. METHODS: This study employed a retrospective analysis of adult sepsis patients admitted to the intensive care unit (ICU) for the first time. Patients were divided into two groups based on their initial Braden score upon admission to the ICU: a high-risk group (≤ 15 points) and a low-risk group (> 15 points). The relationship between Braden score and delirium was assessed using logistic regression and restricted cubic splines, while restricted mean survival time was employed to analyse the relationship between Braden scores and patients' 90- and 180-day mortality. RESULTS: Of the 28,312 patients included in the study, those in the high-risk group exhibited a significantly elevated risk of delirium (44.8% vs. 29.7%) and higher 90-day (28.7% vs. 19.4%) and 180-day (33.2% vs. 24.1%) mortality rates (all p < 0.001). After adjusting for confounding variables, logistic regression demonstrated that the risk of delirium was 1.54 times higher in the high-risk group (95% CI = 1.45-1.64, p < 0.001). Following propensity score matching, the difference in survival was statistically significant at both time points, with the high-risk group having a reduced survival rate of 7.50 days (95% CI = -8.24, -6.75; p < 0.001) and 15.74 days (95% CI = -17.40, -14.08; p < 0.001) at 90 days and 180 days, respectively. CONCLUSIONS: The Braden score is a simple and effective tool for the early identification of patients at increased risk of adverse outcomes in sepsis. DESIGN: Retrospective study. RELEVANCE TO CLINICAL PRACTICE: The Braden score can be employed by clinical nurses for the purpose of early identification of poor prognostic risk in patients with sepsis. REPORTING METHOD: This study was conducted according to the Strengthening Research in Observational Studies in Epidemiology (STROBE) guidelines. PATIENT OR PUBLIC CONTRIBUTION: Patients were involved in the sample of the study.

Braden score predicts 30-day mortality risk in patients with ischaemic stroke in the ICU: A retrospective analysis based on the MIMIC-IV database.

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.

Landscape analysis of m6A modification regulators related biological functions and immune characteristics in myasthenia gravis.

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.

Triglyceride-glucose index as a valuable predictor for aged 65-years and above in critical delirium patients: evidence from a multi-center study.

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.

Can admission Braden skin score predict delirium in older adults in the intensive care unit? Results from a multicenter study.

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.

Factors associated with the disease family burden of caregivers of myasthenia gravis patients in northwestern China: A cross-sectional study.

BACKGROUND: Patients with myasthenia gravis (MG) lose part of their working or living ability due to illness, and bring burden to caregivers. The purpose of this study was to explore the factors related to caregivers' disease family burden for MG patients in Northwest China. METHODS: The study utilized our Myasthenia Gravis database and distributed online questionnaires to both MG patients and their caregivers. The questionnaires included a general data collection form, the Patient Health Questionnaire-9 (PHQ-9) scale, and the Caregivers' Family Burden Scale of Disease (FBSD). Univariate analysis and multivariate linear regression analysis were run, with FBSD as the outcome variable for separate analyses. RESULTS: 178 MG patients were eligible for inclusion in the analysis, of whom 80 patients' caregivers had a positive family burden of MG. The daily activity burden of the family and the economic burden of the family were the heaviest among the six dimensions of the caregivers' family disease burdens. The factors independently associated with FBSD were depression symptom level, MG severity classification and family's monthly per capita income (p < 0.05). CONCLUSIONS: Depression symptom level, MG severity classification and family's monthly per capita income are independent factors related to the caregivers' disease family burden for MG patients.

Efficacy and safety of tocilizumab in patients with refractory generalized myasthenia gravis.

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.

Association between modified frailty index and postoperative delirium in patients after cardiac surgery: A cohort study of 2080 older adults.

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.

Delirium Mediated the Association Between a History of Falls and Short-Term Mortality Risk in Critically Ill Ischemic Stroke Patients.

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.

Modified frailty index effectively predicts adverse outcomes in sepsis patients in the intensive care unit.

BACKGROUND: 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. METHOD: 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. RESULT: 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. CONCLUSIONS: 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. IMPLICATION FOR CLINICAL PRACTICE: 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.

ICU admission Braden score independently predicts delirium in critically ill patients with ischemic stroke.

BACKGROUND: Delirium is a common and severe complication in intensive care unit (ICU) patients with acute ischemic stroke, exacerbating cognitive and physical impairments. It prolongs hospitalization, increases healthcare costs, and raises mortality risk. Early prediction is crucial because it facilitates prompt interventions that could possibly reverse or alleviate the detrimental consequences of delirium. Braden scores, traditionally used to assess pressure injury risk, could also signal frailty, providing an early warning of delirium and aiding in prompt and effective patient management. OBJECTIVE: To examine the association between the Braden score and delirium. METHODS: A retrospective analysis of adult ischemic stroke patients in the ICU of a tertiary academic medical center in Boston from 2008 to 2019 was performed. Braden scores were obtained on admission for each patient. Delirium, the primary study outcome, was assessed using the Confusion Assessment Method for Intensive Care Unit and a review of nursing notes. The association between Braden score and delirium was determined using Cox proportional hazards modeling, with hazard ratios (HR) and 95% confidence intervals (CI) calculated. RESULTS: The study included 3,680 patients with a median age of 72 years, of whom 1,798 were women (48.9 %). The median Braden score at ICU admission was 15 (interquartile range 13-17). After adjustment for demographics, laboratory tests, severity of illness, and comorbidities, the Braden score was inversely associated with the risk of delirium (adjusted HR: 0.94, 95 % CI: 0.92-0.96, P < 0.001). CONCLUSIONS: The Braden score may serve as a convenient and simple screening tool to identify the risk of delirium in ICU patients with ischemic stroke. IMPLICATION FOR CLINICAL PRACTICE: The use of the Braden score as a predictor of delirium in ischemic stroke patients in the ICU allows early identification of high-risk patients. This facilitates timely intervention, thereby improving patient outcomes and potentially reducing healthcare costs.

The hospital frailty risk score effectively predicts adverse outcomes in patients with atrial fibrillation in the intensive care unit.

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.

Exploring the Roles of m6A-Modified circRNAs in Myasthenia Gravis Based on Multi-Omics Analysis.

Myasthenia gravis (MG) is an autoimmune disease mediated by autoantibodies. The important roles of circRNAs modified by m6A methylation have been reported in the pathogenesis of other autoimmune diseases, but remain unclear in MG. To address this point, we collected peripheral blood mononuclear cells from six MG patients and six healthy controls and performed m6A­circRNA epitranscriptomic microarray and RNA sequencing. Differentially m6A-modified circRNAs and differentially expressed genes (DEGs) were analyzed. A network was constructed containing 17 circRNAs, 30 miRNAs, and 34 DEGs. The GSE85452 dataset was downloaded. DEGs that were differentially expressed in the GSE85452 dataset were selected as seed genes. Finally, four candidate m6A-modified circRNAs (hsa_circ_0084735, hsa_circ_0018652, hsa_circ_0025731, and hsa_circ_0030997) were identified through a random walk with restart. We found that they had different degree correlations with different immune cells. The results of MeRIP-qPCR showed that the m6A methylated levels of hsa_circ_0084735 and hsa_circ_0025731 were downregulated in MG patients, while the other two circRNAs were not significantly different between MG and control group. For the first time, we explored the pathogenesis of MG at the epigenetic transcriptome level. Our results will open new perspectives for MG research and identify potential biomarkers and therapeutic targets for MG.

Clinical characteristics and prognosis of very late-onset myasthenia gravis in China.

Alteration in onset-age distribution in myasthenia gravis (MG) and its increasing prevalence among the elderly underscores the need for a better understanding of the clinical course of MG and the establishment of personalized treatment. In this study we reviewed the demographics, clinical profile, and treatment of MG. Based on onset age, eligible patients were classified as early-onset MG (onset age ≥18 and <50 years), late-onset MG (onset age ≥50 and <65 years), and very late-onset MG (onset age ≥65 years). Overall, 1160 eligible patients were enrolled. Patients with late- and very late-onset MG showed a male predominance (P=0.02), ocular MG subtype (P=0.001), and seropositivity for acetylcholine receptors and titin antibodies (P<0.001). In very late-onset MG, a lower proportion of patients retained minimal manifestations status or better, a higher proportion of patients had MG-related deaths (P<0.001), and a shorter maintenance time of minimal manifestation status or better was seen at the last follow-up (P=0.007) than that in patients with early- and late-onset MG. Non-immunotherapy may associated with a poor prognosis in patients in the very late-onset group. Further studies on very late-onset MG patients should be performed to evaluate the relationship between immunotherapy and prognosis.

Associations Between Dysphagia and Adverse Health Outcomes in Older Adults with Dementia in Intensive Care Units: A Retrospective Cohort Study.

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.

Nomogram for predicting the risk of postoperative myasthenic crisis in patients with thymectomy.

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.

Safety of COVID-19 vaccine in patients with myasthenia gravis: a self-controlled case series study.

Background: The safety of COVID-19 vaccines has been clarified in clinical trials; however, some immunocompromised patients, such as myasthenia gravis (MG) patients, are still hesitant to receive vaccines. Whether COVID-19 vaccination increases the risk of disease worsening in these patients remains unknown. This study aims to evaluate the risk of disease exacerbation in COVID-19-vaccinated MG patients. Methods: The data in this study were collected from the MG database at Tangdu Hospital, the Fourth Military Medical University, and the Tertiary Referral Diagnostic Center at Huashan Hospital, Fudan University, from 1 April 2022 to 31 October 2022. A self-controlled case series method was applied, and the incidence rate ratios were calculated in the prespecified risk period using conditional Poisson regression. Results: Inactivated COVID-19 vaccines did not increase the risk of disease exacerbation in MG patients with stable disease status. A few patients experienced transient disease worsening, but the symptoms were mild. It is noted that more attention should be paid to thymoma-related MG, especially within 1 week after COVID-19 vaccination. Conclusion: COVID-19 vaccination has no long-term impact on MG relapse.

High indirect bilirubin levels as an independent predictor of postoperative myasthenic crisis: a single-center, retrospective study.

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.