BackgroundAtrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all‐cause mortality may guide interventions.Methods and ResultsIn the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose‐adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all‐cause mortality in the 14 171 participants in the intention‐to‐treat population. The median age was 73 years, and the mean CHADS 2 score was 3.5. Over 1.9 years of median follow‐up, 1214 (8.6%) patients died. Kaplan–Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all‐cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33–1.70, P<0.0001) and age ≥75 years (hazard ratio 1.69, 95% CI 1.51–1.90, P<0.0001) were associated with higher all‐cause mortality. Multiple additional characteristics were independently associated with higher mortality, with decreasing creatinine clearance, chronic obstructive pulmonary disease, male sex, peripheral vascular disease, and diabetes being among the most strongly associated (model C‐index 0.677).ConclusionsIn a large population of patients anticoagulated for nonvalvular atrial fibrillation, ≈7 in 10 deaths were cardiovascular, whereas <1 in 10 deaths were caused by nonhemorrhagic stroke or systemic embolism. Optimal prevention and treatment of heart failure, renal impairment, chronic obstructive pulmonary disease, and diabetes may improve survival.Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00403767.

Genetic variations in genes involved in the glutathione and DNA repair pathways are associated with SCLC survival.

M yasthenia gravis, an autoimmune disorder of the neuromuscular junction, can cause severe skeletal-muscle weakness.1 About 15% to 20% of myasthenia gravis patients experience myasthenic crises, defined as respiratory failures that necessitate mechanical ventilation.2 Myasthenic crisis is typically triggered by an infection; however, it can be precipitated by any stressful event or by drugs. Patients with myasthenia gravis are typically prescribed pyridostigmine and steroids as maintenance to prevent a crisis, and they are given intravenous immunoglobulin (IVIG) and plasmapheresis as rescue therapies. It is crucial to avoid interventions that might exacerbate the disease process.We report the case of a patient with myasthenia gravis and metastatic thymoma who was admitted to our institution's intensive care unit (ICU) for management of a myasthenic crisis. Her condition was worsened by the administration of intravenous magnesium (Mg). In addition, we discuss the relevant medical literature. Case ReportIn 2014, a 62-year-old woman with a history of metastatic thymic carcinoma and myasthenia gravis presented at our emergency center with a 2-day history of difficulty in swallowing, shortness of breath, and progressive weakness. She was taking 30 mg of prednisone every morning, 60 mg of pyridostigmine twice/d, and 180 mg of extended-release pyridostigmine at night. Her symptoms suggested a myasthenic crisis, and she was admitted to the ICU. She was given steroids, IVIG, scheduled pyridostigmine, and broad-spectrum antibiotics for suspected pneumonia. On ICU day 2, her serum Mg level was 2.2 mg/dL, and she was given 16 mEq of magnesium sulfate intravenously. That evening, test results of pulmonary function showed substantial decreases in the patient's vital capacity (from 1.1 to 0.6 L) and negative inspiratory force (from -15 to -10). The patient declined intubation and invasive mechanical ventilation. During the morning of ICU day 3, the patient was granted a trial of noninvasive ventilation and was given steroids, IVIG, and a pyridostigmine drip. When the trial ventilation failed to improve her condition, she agreed to intubation and mechanical ventilation. She underwent 3 plasma exchanges and was successfully extubated on ICU day 4. The next morning, her serum Mg level of 2.2 mg/dL prompted another intravenous dose of 16 mEq of magnesium sulfate. The patient reported worsening weakness in her upper extremities, hoarseness, and

Objectives Improving family-centered outcomes is a priority in oncologic critical care. As part of the Intensive Care Unit (ICU) Patient-Centered Outcomes Research Collaborative, we implemented patient- and family-centered initiatives in a comprehensive cancer center. Methods A multidisciplinary team was created to implement the initiatives. We instituted an open visitation policy (OVP) that revamped the use of the two-way communication boards and enhanced the waiting room experience by hosting ICU family-centered events. To assess the initiatives’ effects, we carried out pre-intervention (PRE) and post-intervention (POST) family/caregiver and ICU practitioner surveys. Results A total of 159 (PRE = 79, POST = 80) family members and 147 (PRE = 95, POST = 52) ICU practitioners participated. Regarding the decision-making process, family members felt more included (40.5% vs. 68.8%, p < 0.001) and more supported (29.1% vs. 48.8%, p = 0.011) after the implementation of the initiatives. The caregivers also felt more control over the decision-making process in the POST survey (34.2% vs. 56.3%, p = 0.005). Although 33% of the ICU staff considered OVP was beneficial for the ICU, 41% disagreed and 26% were neutral. Only half of them responded that OVP was beneficial for patients and 63% agreed that OVP was beneficial for families. Half of the practitioners agreed that OVP resulted in additional work for staff. Significance of results Our project effectively promoted patient- and family-centered care. The families expressed satisfaction with the communication of information and the decision-making process. However, the ICU staff felt that the initiatives increased their work load. Further research is needed to understand whether making this project universal or introducing additional novel practices would significantly benefit patients admitted to the ICU and their family.