Predictive value of mNUTRIC score for chronic critical illness in elderly patients with sepsis / 中华急诊医学杂志

Objective:To explore the predictive value of the modified NUTrition risk in the critically ill (mNUTRIC) score for chronic critical illness (CCI) in elderly sepsis patients.Methods:A prospective observational study was conducted. Elderly sepsis patients admitted to Medical Intensive Care Unit (MICU) of General Hospital of Southern Theatre Command for more than 24 h from August 2019 to January 2021 were enrolled. Age, sex, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, sequential organ failure assessment (SOFA) score, acute gastrointestinal injury (AGI) score, clinical frailty score and mNUTRIC score at admission, length of ICU stay, usage of mechanical ventilation and renal replacement therapy were recorded. According to the occurrence of CCI, patients were divided into the CCI group and rapid recovery (RAP) group, and the differences between the two groups were compared. The risk factor of CCI after sepsis in elderly patients were analyzed by log-binomial regression analysis. Receiver operating characteristic (ROC) analysis was performed for mNUTRIC score. Differences were considered significant at P<0.05. Results:Of the enrolled 91 sepsis patients, 14 (15%) patients died within the first week, 37 (41%) exhibited RAP and 40 (44%) developed CCI. The CCI patients were significantly older and presented a higher APACHE Ⅱ score, CFS score, mNUTRIC score, and usage of mechanical ventilation and renal replacement therapy compared with the RAP patients ( P<0.05). Multivariate regression analysis revealed that mNUTRIC score was an independent risk factor for the development of CCI in elderly sepsis patients, prevalence ratio was 1.503 (95% CI: 1.007-2.244). The area under the curve (AUC) of mNUTRIC score was 0.706 (95% CI: 0.592-0.805). Conclusions:The mNUTRIC score at the time of admission in the intensive care unit can be used to predict CCI after sepsis in elderly sepsis patients.

Application of emotion-focused therapy on social anxiety disorders / 中华行为医学与脑科学杂志

Social anxiety disorder is a common anxiety disorder in which a key feature is interpersonal avoidance accompanied by generalized problems with emotion identification and emotion regulation. In response to the gap in these therapeutic priorities in other therapies, emotion-focused therapy has emerged to fill the part of the treatment of emotions with an emphasis on the relational process. The paper reviews the recent studies related with the treatment of social anxiety disorder with emotion-focused therapy. The results suggest that the main points of social anxiety onset in an emotion-focused perspective are traumatic emotional experiences and self-criticism, and that the therapeutic focus of emotion-focused therapy is on dealing with the traumatic emotional scenario behind the anxiety and exposing it to adaptive emotions to be transformed. It also works better in combination with other more mainstream therapies. This suggests that emotion-focused therapy is a promising approach for the clinical treatment of social anxiety disorder and looks forward to the development of a more integrated treatment approach in the clinic.

Predictive value of neutrophil to lymphocyte ratio in the progression of sepsis to chronic critical illness in elderly patients / 中华危重病急救医学

Objective:To explore the predictive value of neutrophil to lymphocyte ratio (NLR) in the progression of sepsis to chronic critical illness (CCI) in elderly patients.Methods:Patients with sepsis who were hospitalized more than 24 hours and older than 60 years old admitted to the department of medical intensive care unit (MICU) of General Hospital of Southern Theatre Command from August 2019 to April 2021 were enrolled. The neutrophil count (NEU), lymphocyte count (LYM) and NLR of peripheral blood cells were recorded on the 1st, 4th and 7th day after admission. Patients were divided into the CCI group and the non-CCI group according to whether they progressed to CCI, and differences between the two groups were compared. The CCI was defined as a MICU length of stay (LOS) ≥ 14 days and persistent organ dysfunction [sequential organ failure assessment (SOFA) score ≥ 2]. Logistic regression analysis was performed to evaluate the risk factors for predicting CCI. The receiver operator characteristic curve (ROC curve) was plotted for evaluating the predictive value of NLR in the progression of sepsis to CCI in elderly patients.Results:① Among 103 sepsis patients enrolled, 16 (15.5%) died within 2 weeks of admission to the MICU, 46 (44.7%) developed CCI, and 41 (39.8%) were non-CCI. ② Compared between the two groups, the NEU of CCI group on day 7 was significantly higher than that of non-CCI group [×10 9/L: 9.80 (6.72, 16.80) vs. 6.66 (5.14, 9.29), P < 0.01], LYM was significantly lower than that of non-CCI group [×10 9/L: 0.77 (0.46, 1.20) vs. 1.00 (0.86, 1.48), P < 0.05], and NLR on day 4 and day 7 were significantly higher than those of non-CCI group [12.85 (6.56, 17.56) vs. 8.26 (5.34, 13.17), 13.76 (6.97, 23.66) vs. 6.14 (4.04, 8.84), both P < 0.05]. Compared with different time points in the same group, NEU and NLR decreased gradually and LYM increased gradually in non-CCI group (χ 2 values were 10.216, 28.343, 7.189, respectively, all P < 0.05), which tended to be normal. There were no significant differences in NEU, LYM and NLR of CCI group at each time point (χ 2 values were 0.798, 4.478, 5.783, respectively, all P > 0.05). ③ Multivariate Logistic regression analysis showed that NLR on day 7 was an independent risk factor for sepsis progression to CCI [odds ratio ( OR) = 1.155, P = 0.005]. ④ ROC curve analysis showed that the area under the curve (AUC) of NLR predicting the sepsis progression to CCI on day 7 was 0.775, and the 95% confidence interval (95% CI) was 0.670-0.860, P < 0.01; when the cut-off value was 9.25, the sensitivity was 69.57% and the specificity was 80.56%. Conclusion:Dynamic monitoring of NLR is helpful to determine the progress of sepsis in elderly patients, NLR on day 7 has a certain predictive value for the occurrence of CCI.

Nutrition support in the chronic critically ill patients / 中华危重病急救医学

Over the last decade, chronic critically ill (CCI) has emerged as an epidemic in intensive care unit (ICU) survivors worldwide. Advances in ICU technology and implementation of care bundles has significantly decreased early deaths of critically ill patients, and have allowed them to survive previously lethal multiple organ failure (MOF). However, more and more survivors leave persistent low grade organ dysfunctions, depend on continues organ support, need to stay in ICU, and become CCI patients. These patients experience a persistent immune dysregulation with persistent inflammation, immunosuppression, and catabolic syndrome. Therefore, malnutrition is an important feature of patients with CCI, and nutritional support is a crucial part of their treatment. The main strategies of nutritional support are as follows: providing sufficient calories and proteins with appropriate anabolic agents to promote anabolic metabolism, using immunomodulators to improve immune suppression and inflammatory responses, and supplementing micronutrients to enhance metabolic support. In this review, the nutritional assessment, calorie assessment, protein assessment and other nutrient supplementation (such as β blocker, testosterone and oxandrolone, immunonutrition, vitamins) of CCI patients were reviewed, so as to provide reference for the treatment of CCI.

A 180-day mortality predictive score based on frailty syndrome in elderly patients with sepsis: a Logistic regression analysis model / 中华危重病急救医学

Objective:To establish a 180-day mortality predictive score based on frailty syndrome in elderly sepsis patients [elderly sepsis score (ESS)].Methods:A prospective study for sepsis patients aged 60 years and above who were admitted to a medical intensive care unit of the General Hospital of Southern Theatre Command from January 1st, 2018 to December 31st, 2018 was conducted. Univariate analysis was performed on 19 independent variables including gender, age, body mass index (BMI), tumor, charlson comorbidity index (CCI), activity of daily living (ADL), instrumental activity of daily living (IADL), mini-mental state examination (MMSE), geriatric depression scale (GDS), clinical frail scale (CFS), sequential organ failure assessment (SOFA), Glasgow coma scale (GCS), acute physiology and chronic health evaluation (APACHEⅡ, APACHEⅣ), modified NUTRIC score (MNS), multiple drug resistance (MDR), mechanical ventilation (MV), continuous renal replacement therapy (CRRT) and palliative care. Continuous independent variables were converted into classified variables. Multivariate binary regression analysis of risk factors was conducted to screen independent risk factors which affecting 180-day mortality in elderly sepsis patients. Then a 180-day mortality predictive score was established, and the discrimination of the mortality of patients using CFS, SOFA, GCS, APACHEⅡ, APACHEⅣ, MNS scores were compared.Results:A total of 257 patients were enrolled, with a 180-day mortality of 60.7%. Univariate analysis showed that age, tumor, CCI, ADL, IADL, MMSE, CFS, SOFA, GCS, APACHEⅡ, APACHEⅣ, MNS, MDR, MV, CRRT, palliative care were risk factors of 180-day mortality in elderly sepsis patients [age: odds ratio ( OR) = 1.027, 95% confidence interval (95% CI) was 1.005-1.050, P = 0.018; tumor: OR =2.001, 95% CI was 1.022-3.920, P = 0.043; CCI: OR = 1.193, 95% CI was 1.064-1.339, P = 0.003; ADL: OR = 0.851, 95% CI was 0.772-0.940, P = 0.001; IADL: OR = 0.894, 95% CI was 0.826-0.967, P = 0.005; MMSE: OR = 0.962, 95% CI was 0.937-0.988, P = 0.004; CFS: OR = 1.303, 95% CI was 1.089-1.558, P = 0.004; SOFA: OR = 1.112, 95% CI was 1.038-1.191, P = 0.003; GCS: OR = 0.918, 95% CI was 0.863-0.977, P = 0.007; APACHEⅡ: OR = 1.098, 95% CI was 1.053-1.145, P < 0.001; APACHEⅣ: OR = 1.032, 95% CI was 1.020-1.044, P < 0.001; MNS: OR = 1.315, 95% CI was 1.159-1.493, P < 0.001; MDR: OR = 2.029, 95% CI was 1.197-3.437, P = 0.009; MV: OR = 6.408, 95% CI was 3.480-11.798, P < 0.001, CRRT: OR = 2.744, 95% CI was 1.529-4.923, P = 0.001, palliative care: OR = 5.760, 95% CI was 2.177-15.245, P < 0.001]. By binary regression analysis, CFS stratification ( OR = 1.934, 95% CI was 1.267-2.953, P = 0.002), MV ( OR = 4.531, 95% CI was 2.376-8.644, P < 0.001), CRRT ( OR = 2.471, 95% CI was 1.285-4.752, P = 0.007), palliative care ( OR = 6.169, 95% CI was 2.173-17.515, P = 0.001) were independent risk factors of 180-day mortality in elderly patients with sepsis. The model of "ESS = 0.660×CFS stratification+1.511×MV+0.905×CRRT+1.820×palliative care" was established. Receiver operating characteristic curve (ROC curve) analysis showed that the area under the ROC curve (AUC) for predicting 180-day mortality by ESS was 0.785 (95% CI was 0.730-0.834, P < 0.001). When the best cut-off value was 2.2 points, its sensitivity was 78.9%, specificity was 70.3%, the positive predictive value was 80.4%, and the negative predictive value was 68.3%. Simplified ESS was defined as "0.5×CFS stratification+1.5×MV+1×CRRT+2×palliative care". ROC curve analysis showed that AUC for predicting 180-day mortality by simplified ESS was 0.784 (95% CI was 0.729-0.833, P < 0.001). When the best cut-off value was 2.0 points, sensitivity was 76.9%, specificity was 70.3%, the positive predictive value was 80.0%, and the negative predictive value was 66.4%. Compared with CFS, SOFA, GCS, APACHEⅡ, APACHEⅣ and MNS, ESS had a significant difference in discriminating 180-day mortality in elderly patients with sepsis (AUC was 0.785 vs. 0.607, 0.607, 0.600, 0.664, 0.702, 0.657, 95% CI: 0.730-0.734 vs. 0.537-0.678, 0.537-0.677, 0.529-0.671, 0.598-0.730, 0.638-0.766, 0.590-0.725, all P < 0.05). Conclusions:CFS, MV, CRRT, and palliative care are independent risk factors of 180-day mortality in elderly patients with sepsis. We established ESS based on these risk factors. The ESS model has good discrimination and can be used as a reference and assessment tool for prediction and treatment guidance in elderly patients with sepsis.

Research progress of frailty syndrome in critically ill elderly patients / 中华危重病急救医学

Frailty syndrome is the core of the comprehensive geriatric assessment of the elderly, which affects the prognosis of elderly critical illness patients and becomes the hotspot of the current geriatric medical research of elderly patients. In critically ill elderly patients, the incidence rate of frailty syndrome is 21％-59％. Frailty syndrome is an independent risk factor in elderly patients with complications, short-term and long-term mortality. Moreover frailty is always accompanied by poor state and affects the health quality of these patients. In the field of critical care medicine in our country, the study of the frailty syndrome is still in its infancy. This article focuses on the research progress of frailty syndrome, and the assessment of the frailty critical illness elderly patients is helpful for the clinical doctors to determine the prognosis and treatment decision.

Research progress of frailty syndrome in critically ill elderly patients / 中华危重病急救医学

Frailty syndrome is the core of the comprehensive geriatric assessment of the elderly, which affects the prognosis of elderly critical illness patients and becomes the hotspot of the current geriatric medical research of elderly patients. In critically ill elderly patients, the incidence rate of frailty syndrome is 21％-59％. Frailty syndrome is an independent risk factor in elderly patients with complications, short-term and long-term mortality. Moreover frailty is always accompanied by poor state and affects the health quality of these patients. In the field of critical care medicine in our country, the study of the frailty syndrome is still in its infancy. This article focuses on the research progress of frailty syndrome, and the assessment of the frailty critical illness elderly patients is helpful for the clinical doctors to determine the prognosis and treatment decision.