Full Outline Of Unresponsiveness Scale Research Articles

Analysis of the diagnostic informativity of non-contrast computed tomography markers of intracerebral hemorrhage expansion in assessment of the individual risk of early neurological deterioration in patients with hemorrhagic hemispheric stroke

The aim of the study was to evaluate the diagnostic informativity of non-contrast computed tomography (NCCT) markers of intracerebral hemorrhage (ICH) expansion in assessment of the individual risk of early neurological deterioration (END) in patients with hemorrhagic hemispheric stroke (HHS). Materials and methods. A prospective, cohort study was conducted involving 333 patients in the acute period of hypertensive spontaneous supratentorial ICH on the background of conservative therapy. The level of neurological deficit was assessed using the Full Outline of Unresponsiveness (FOUR) coma scale and the National Institute of Health Stroke Scale (NIHSS). The computed tomography of the brain was used to verify the ICH volume, the midline shift (MS), the secondary intraventricular hemorrhage volume (IVHV) and NCCT markers of intracerebral hemorrhage expansion. As a combined clinical endpoint, END was considered (decrease of the FOUR scale score ≥2 or/and increase of the NIHSS score ≥4 or/and lethal outcome within 48 hours of hospitalization). Results. Early neurological deterioration was registered in 112 patients. On the basis of a comparative analysis, it was established that the specific weight of END was significantly higher in subcohorts of patients with individual NCCT markers of intracerebral hemorrhage expansion, than it was in subcohorts of patients without corresponding NCCT signs (p ˂ 0.0001). It was established that the following NCCT markers of ICH expansion are the most sensitive predictors of END: hypodensity, swirl sign and irregular shape (sensitivity >90.0 %). The most specific NCCT markers were island sign, black hole sign, blend sign, satellite sign and heterogeneous density (specificity >87.0 %). In accordance with the multiple logistic regression analysis, hypodensity (OR (95 % CI) = 13.56 (4.54–40.49), p < 0.0001) and island sign (OR (95 % CI) = 5.94 (2.05–17.16), p = 0.0010) are independently associated with the risk of END. A highly sensitive multi-prediction logistic regression model was elaborated in order to predict END in patients with HHS which takes into account the most informative NCCT markers of ICH expansion (hypodensity, island sign) and quantitative neuroimaging indicators (MS, IVHV) (AUC ± SE (95 % CI) = 0.92 ± 0.02 (0.89–0.95), р ˂ 0.0001). Conclusions. Non-contrast computed tomography markers of ICH expansion are associated with increased risk of END in patients with HHS. Hypodensity and island sign are independent predictors of END. The integration of NCCT markers of ICH expansion with quantitative neuroimaging indicators (MS, IVHV) in the structure of the multi-prediction logistic regression model allows to assess the individual risk of END with an accuracy of >85.0 %.

Nutritional Status of Patients with Chronic Critical Illness

Material and methods. We examined 23 patients with chronic critical illness who were in a minimally conscious state (MCS) with 10.9±2.5 scores on the FOUR (Full Outline of Unresponsiveness) Score Coma Scale. Indicators of carbohydrate, lipid, protein and energy exchange metabolism were evaluated using specimens sampled in the morning hours. Nutritional support was provided by isocaloric isonitrogenic mixtures.Results. Blood biochemistry showed decreases in total protein and albumin levels in 86.9% and 91.3% of patients, respectively. The tests also revealed decreased concentrations of several amino acids, including essential amino acids: histidine (38.3±13.07 µmol/l), methionine (12.68±3.81 µmol/l), threonine (61.6 [58.5;87.7] µmol/l), tryptophan (33.06±15.95 µmol/l), and non-essential amino acids: arginine (40.50 [22.2; 46.9] µmol/l), glutamic acid (124.5±39.29 µmol/l), tyrosine (37.97±10.12 µmol/l). Some correlations between the concentrations of individual amino acids and other indicators were revealed, such as histidine and CRP (r=–0.68, P=0.043), tryptophan and CRP (r=–0.86, P=0.002), histidine and leukocyte count (r=–0.76, P=0.015), methionine and lysine (r=0.88, P=0.008), methionine and patient's weight (r=–0.68, P=0.042). A relationship between threonine concentration and the level of consciousness on the FOUR scale (r=–0.73, P=0.037) was also found. All patients demonstrated significant alterations of carbohydrate and lipid metabolism.Conclusion. Alteration of adequate protein metabolism seems to be the most affected constituent in the nutritional status of patients with chronic critical illness. It is manifested by a decrease in the concentration of total protein and a number of essential and non-essential amino acids, which implies the importance of highprotein nutritional support and correction of the amino acid profile.

Acute traumatic coma awakening by right median nerve electrical stimulation: a randomised controlled trial

PurposeSevere traumatic brain injury (TBI) leads to acute coma and may result in prolonged disorder of consciousness (pDOC). We aimed to determine whether right median nerve electrical stimulation is a safe and effective treatment for accelerating emergence from coma after TBI.MethodsThis randomised controlled trial was performed in 22 centres in China. Participants with acute coma at 7–14 days after TBI were randomly assigned (1:1) to either routine therapy and right median nerve electrical stimulation (RMNS group) or routine treatment (control group). The RMNS group received 20 mA, 300 μs, 40 Hz stimulation pulses, lasting 20 s per minutes, 8 h per day, for 2 weeks. The primary outcome was the proportion of patients who regained consciousness 6 months post-injury. The secondary endpoints were Glasgow Coma Scale (GCS), Full Outline of Unresponsiveness scale (FOUR), Coma Recovery Scale-Revised (CRS-R), Disability Rating Scale (DRS) and Glasgow Outcome Scale Extended (GOSE) scores reported as medians on day 28, 3 months and 6 months after injury, and GCS and FOUR scores on day 1 and day 7 during stimulation. Primary analyses were based on the intention-to-treat set.ResultsBetween March 26, 2016, and October 18, 2020, 329 participants were recruited, of whom 167 were randomised to the RMNS group and 162 to the control group. At 6 months post-injury, a higher proportion of patients in the RMNS group regained consciousness compared with the control group (72.5%, n = 121, 95% confidence interval (CI) 65.2–78.7% vs. 56.8%, n = 92, 95% CI 49.1–64.2%, p = 0.004). GOSE at 3 months and 6 months (5 [interquartile range (IQR) 3–7] vs. 4 [IQR 2–6], p = 0.002; 6 [IQR 3–7] vs. 4 [IQR 2–7], p = 0.0005) and FOUR at 28 days (15 [IQR 13–16] vs. 13 [interquartile range (IQR) 11–16], p = 0.002) were significantly increased in the RMNS group compared with the control group. Trajectory analysis showed that significantly more patients in the RMNS group had faster GCS, CRS-R and DRS improvement (p = 0.01, 0.004 and 0.04, respectively). Adverse events were similar in both groups. No serious adverse events were associated with the stimulation device.ConclusionRight median nerve electrical stimulation is a possible effective treatment for patients with acute traumatic coma, that will require validation in a confirmatory trial.

Investigating RTS, TRISS, GCS, and FOUR as measures for predicting the mortality in trauma patients: A prospective study

Background: Some measures have been proposed for the prediction of death after trauma; however, there is a lack of studies on this issue in trauma patients. Therefore, this study was conducted to compare the validity of four scales in predicting the death of trauma patients, and we hypothesized that the accuracies of various scales are different. Methods: This descriptive-analytical study was conducted prospectively on 600 trauma patients admitted at the emergency ward of Imam Khomeini Hospital in Ilam, Ilam province, west of Iran. The subjects were selected by convenience sampling. Data were collected using the checklists developed for trauma patients, including the Full Outline of UnResponsiveness (FOUR) score, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), and Trauma and Injury Severity Score (TRISS), and then the data were analyzed using the chi-square test and the area under the receiver operating characteristic curve (AUC). Results: Among the 600 patients, most of them were male (76.8%), with a mean and standard deviation of the age of 31.16 ± 18.06 years, and road traffic accident was the most common cause of trauma (73%). The FOUR scale was the most valid in predicting the mortality of trauma patients, and its sensitivity, specificity, positive and negative predictive values, and accuracy were equal to 93.2, 94.5, 64.7, 99.2, and 94.3%, respectively. The AUC was equal to 0.938 for the FOUR scale, followed by the RTS (0.787). Conclusion: Results of the study about the predictive value of the scales for mortality prediction of trauma patients showed that the FOUR scale had the highest accuracy compared to other scales. Thus, for applying this scale in trauma and emergency centers, besides our results, further studies are needed to support the study findings.

A Comparative Study to Evaluate Prognostic Value of Glasgow Coma Score and Full Outline of Unresponsiveness Scale to Predict the Outcome of Unconscious Child in the Paediatric Intensive Care Unit

Background: The current issue of improving mortality and care in paediatric patient is very challenging. Early anticipation and intervention will be helpful in improving the outcome in emergency and paediatric intensive care unit (PICU) by the use of Glasgow Coma Scale (GCS) and Full Outline of Unresponsiveness (FOUR) score. Decreasing in GCS and FOUR score is associated with worsening level of consciousness. Aim: The Aim of the study was to compare the prognostic value of FOUR and GCS score in unconscious children to predict the survival in unconscious children to predict the morbidity pattern. Materials and Methods: The present observational study was done from June 2019 to June 2020 at PICU of Department of Paediatrics, BRD Medical College, Gorakhpur, following Ethical Clearance from the Institutional Ethics Committee of BRD Medical College. All the admitted unconscious children in PICU were included in our study. Data entry and analysis were done using SPSS. Data were analysed using appropriate statistical test. Results: In our study, 65 (50.0%) patients were 9–12 years old and male was predominant. Seventy-eight (60%) patients had symptoms of <3 days. GCS score of E, V, M response at the time of admission was assessed in which maximum patients seen in E2 i.e., 60 (46.2%), V2 50 (38.5%) patients and M5 47 (36.1%) patients, while after 12 h patients, maximum GCS were seen in E3 54 (41.5%) patients, V2 54 (41.5%) patients and M5 (42.3%) patients and after 72 h patients maximum GCS was seen in E4 80 (61.5%) patients, V 54 (41.5%) patients and M51 (39.2%) patients. FOUR score baseline eye response was maximum in E2 39 (30%), motor response in M2 76 (58.5%), brain stem function response in B4 118 (90.8%) and respiration response in R4 44 (33.8%). Similarly, after 12 h score was E3 44 (33.8%), M3 48 (36.9%), B4 74 (56.9%), R4 56 (44.4%) while after 72 h score was E3 75 (57.7%), M4 75 (57.7%), B4 88 (67.7%) and R4 88 (67.7%). On final diagnosis, maximum was of AES 40 (30.7%). Thirty-two patients expired during the study period. Conclusion: FOUR and GCS score both is the good predictor of severity of disease and of mortality and may help in prioritising the treatment of sick as well as the counselling of parents about disease severity.

Communicating With Unconscious Patients: An Overview.

Nurses are told to speak to their unconscious patients because hearing is said to be the last sense to depart. There was little reliable evidence before the 1990s that patients in an unconscious state could hear and understand what was being said. That led to reluctance on the part of health professionals to communicate with these unresponsive patients. This historical overview aims to present researched evidence from the 1990s to the present detailing awareness that occurs in unconscious patients, when that awareness increases, and how to detect that awareness. It also includes research about the benefits of communicating with unconscious patients and descriptions of how registered nurses and other health care professionals, from a postsurvey after a continuing education course on experiences of unconscious patients, plan to communicate with unconscious patients. A literature search was conducted, which included more than 150 articles and books about experiences of unconscious patients in several electronic databases, including PubMed, CINAHL, and the British Nursing Index. In addition, an analysis of 105 postcourse responses by registered nurses (89%) and other health professionals (11%), licensed practical nurses, emergency medical technicians, and cardiac technicians after taking a continuing education course on experiences of previously unconscious patients were analyzed. The Glasgow Coma Scale and the Full Outline of Unresponsiveness scale are helpful behavioral tools to identify levels of coma but miss detecting awareness in patients who can hear and understand but cannot move. The estimates are that 25% to 40% (J Trauma. 1975;15:94-98; J Neurosci Nurs. 1988;20:223-228; J Neurosci Nurs. 1990;22(1):52-53; Am J Crit Care. 1995;3:227-232) of patients diagnosed with a disorder of consciousness can hear and understand what is being said in their environment. Substantial evidence supports that isolation and loneliness, such as experienced by some patients perceived to be unaware, can be physically and psychologically harmful. Strong evidence shows that some patients diagnosed as being in a vegetative state can hear and understand what is being said in their environment. Interviews with previously unconscious patients and electrophysiological methods show that awareness can be detected in patients perceived to be unconscious. There is documented evidence that patients experience awareness when going into unconsciousness, even when they appear unaware and when moved. To our knowledge, these times have not been researched using electrophysiological devices but established from interviews.

Comparison of Glasgow Coma Scale with Full Outline of Unresponsiveness Scale for predicting mortality among patients admitted in a Medical Intensive Care Unit

Background: For assessment of unconscious state in Medical Intensive Care Unit, physician mostly rely on Glasgow Coma Scale (GCS). But its verbal component has limitations in aphasic and intubated patient. More over its predilection ability to mortality is hardly challenged. The FOUR (Full outline of unresponsiveness) score, a new coma scale, evaluates 4 components: Eye, motor responses, brain stem reflexes and respiration. Aim of this study was to compare Full Outline of Unresponsiveness (FOUR) scale for prediction of mortality among patients admitted in Medical Intensive Care Unit (MICU) of a tertiary care hospital of Bangladesh with Glasgow Coma Scale (GCS). Objectives: To compare prediction of mortality between Glasgow Coma Scale (GCS) and Full Outline of Unresponsiveness (FOUR) scale. Methods: This is a prospective observational study was carried out in the Department of Critical Care Medicine, BIRDEM General Hospital to compare the mortality predilection in between FOUR score and GCS score. All consecutive adult unconscious patients over the age of 18 years were included in this study. Sedated patients were examined while they were not getting sedation or during routine sedation window period. Altered conscious level was examined by both GCS and FOUR scales. Data were collected using a check list containing demographic information, preexisting chronic illness, biochemical markers, imaging findings etc. Later patients were followed up and data regarding ICU stay, mortality and time of discharged from ICU were recorded. Both GCS and FOUR score were compared between survivor and non-survivor group and compared both score in between non-survivor group. Ultimately data were analyzed by using Statistical Package for Social Sciences (SPSS) software (version 20). Results: Total 105 unconscious patients were enrolled within the study after fulfilling inclusion & exclusion criteria. Among them 34 patients were survivor and 71 patient were non-survivor. The mean and SD of age in this study were 64 .55 ±14.65 years. The peak age distribution was (61-70) 39%. Among them 54.3 % (n=57) were male and 45.7 % (n=48) were female. DM (82.85%) was the most common comorbidity and the predominant diagnosis was Septic shock 33% followed by Ischemic stroke 29%, Meningo encephalitis 19.04 %, and Electrolytes imbalance 17.14%, Cardiogenic shock 12.38% etc. In both GCS and FOUR score their value significantly differ in case of both survival ([7.15± 1.56]; P<.0001 and [7.74± 2.26]; P<.0001) and non-survival group ([5.38± 1.96]; P <0.0001) and ([5.35± 2.83]; P <0.0001). But comparison of FOUR score (5.35± 2.83) with GCS (5.38± 1.96) in terms of predicting mortality their value not significantly differ (P <0.93). So both GCS and FOUR score is equally effective predicting mortality among unconscious patients. Conclusion: Both GCS and FOUR score significantly vary among survivor and non-survivor groups of unconscious patients but while comparing them regarding predicting mortality there is no significant differences in both score. Finally we conclude that both GCS and FOUR score equally good at predicting in hospital mortality among unconscious patients admitted in MICU. Bangladesh Crit Care J September 2022; 10(2): 76-81

Sarcopenia in Patients After Severe Brain Injury

Introduction This article deals with the problem of sarcopenia in patients after severe brain injury. It presents the results of the comparative analysis of a group of patients and a group of volunteers with performed muscle fiber ultrasound. Relevance Sarcopenia is a serious complication in a critically ill patient. It appears early and progresses rather quickly during the patient’s critical condition. In order to diagnose sarcopenia, both radiation and ultrasound methods can be used. The use of ultrasound methods is less labor-intensive, energy-consuming, and economically costly and does not involve an increase in radiation exposure to the patient. The paper highlights the use and comparison of these methods in patients after severe brain injuries. Aim of study To assess the severity of sarcopenia in patients after severe brain injuries. Materials and methods 25 patients were included in this study with an average age of 56.75±19.84 years, ranging from 22 to 82 years, after severe brain injury in a minimally conscious state according to the FOUR (Full Outline of Unresponsiveness) scale, median 12 (12; 15) points. The assessment was carried out in the first 3 days from the moment of admission to the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology. For comparison purposes, the study included 19 volunteers aged 35.63±7.02 years, ranging from 21 to 47 years. Results The data obtained indicate that patients after severe brain injuries had pronounced muscle fiber disorders affecting its thickness and echogenicity. The thickness of the biceps on the side of the brain injury was 0.93±0.27 cm (min 0.5; max 1.58) and the thickness of the biceps on the side opposite to the brain injury was 0.62±0.2 cm (min 0.27; max 0.93) with p=0.0007, statistically significant. In terms of echogenicity, the differences were not statistically significant (p=0.1). The thickness of the triceps on the side of the brain injury was 0.5±0.17 cm (min 0.25; max 0.82) and the thickness of the triceps on the opposite side to the brain injury was 0.38±0.14 cm (min 0.2; max 0.8) with p=0.028, statistically significant, while the degree of echogenicity according to the Modified Heckmatt scale on the side of the brain injury was 2.5 [2.0; 3.0] (min 2.0; max 4.0), and on the opposite side — 3.0 [3.0; 4.0] (min 2.0; max 4.0), p=0.01, statistically significant. The thickness of the brachioradialis on the side of the brain injury was 0.59±0.15 cm (min 0.39; max 0.92), on the opposite side — 0.50±0.17 cm (min 0.25; max 0.86), p=0.06, statistically significant; while the degree of echogenicity was 2.0 [2.0; 3.0] (min 1.0; max 4.0) on the side of the brain injury and on the opposite side to the brain injury — 2.5 [2.0; 4.0] (min 2.0; max 4.0), p=0.03, statistically significant. Pronounced statistically significant differences were also obtained in the thickness of the rectus femoris muscle (p=0.06) and its echogenicity (p=0.017). In comparing these indicators with the muscles of healthy volunteers for all indicated parameters p<0.05, in most cases p=0.000001, statistically significant. Using computed tomography of the lumbar spine, a decrease in the cross-sectional area of the psoas muscle was revealed. The following values were obtained from the patients: psoas muscle cross-sectional area on the right side: 7.66±2.72 cm 2 (min 3.84; max 12.95), psoas muscle cross-sectional area on the left side: 7.85±2.64 cm 2 (min 3.7; max 12.6), Skeletal Muscle Index: 53.33±15.34 (min 28; max 81). Conclusion Diagnostic ultrasound methods to assess sarcopenia in patients after severe brain injuries have confirmed their effectiveness. In the present study, this method received a pronounced correlation with radiological techniques to identify patients affected by sarcopenia. We obtained statistically significant differences in the group of volunteers and patients, and some parameters differed by more than 2 times, which indicates the presence of severe sarcopenia in this group of patients.

Comparative Study between Glasgow Coma Scale and Full Outline of Unresponsiveness Scale in Clinical Outcomes Prediction of Neurological Disorders Patients

Comparative Study between Glasgow Coma Scale and Full Outline of Unresponsiveness Scale in Clinical Outcomes Prediction of Neurological Disorders Patients

TRADUÇÃO, ADAPTAÇÃO E VALIDAÇÃO DA ESCALA FULL OUTLINE OF UNRESPONSIVENESS PARA O PORTUGUÊS DO BRASIL

ABSTRACT Objective: to translate, culturally adapt and validate the Full Outline of UnResponsiveness scale into Brazilian Portuguese. Method: a methodological study carried out at the Clinical Hospital of Universidade Federal do Triângulo Mineiro, Uberaba, Brazil, through the following stages: translation, synthesis, evaluation by the experts' committee, back-translation, consensus, semantic evaluation and pre-test. A sample of 188 adult patients was reached. Data collection took place between August and December 2020. Concurrent criterion validity was analyzed by comparing the Full Outline of UnResponsiveness scale with the Glasgow Coma Scale by means of Spearman's and Pearson's correlation coefficients; and predictive validity analysis was performed with Cox Regression, Sensitivity and Specificity and Area Under the Receiver Operating Characteristic Curve. The Cronbach's alpha, weighted Kappa and Intraclass Correlation coefficients were also adopted for interobserver reliability. Results: Spearman’s test for the motor and eye response items, respectively, resulted in 0.81 and 0.96, and Pearson's test for the total score was 0.97. A relative risk of 0.80, 95.5% specificity, 51.6% sensitivity and accuracy of 0.80 (95% CI: 0.688-0,905, p<0.001) were obtained. Cronbach's alpha was 0.94, weighted Kappa varied from 0.89 to 1.0, and ICC resulted in 0.99. Conclusion: the Full Outline of UnResponsiveness scale (Brazilian version), maintained four domains and the 20 items from the original scale, making it appropriate for use in Brazil and contributing to the assessment of the level of consciousness and prognosis of adult patients in severe conditions.

Assessing the effectiveness of the full outline of unresponsiveness scale and the Glasgow coma scale in patients of traumatic head injury

Background: The Glasgow coma scale (GCS) is the most commonly used scale while the full outline of unresponsiveness (FOUR) score is a new validated coma scale in the evaluation of the level of consciousness in head injury patients. The aim of the study was to compare and assess the effectiveness of the FOUR score and the GCS in patients of traumatic head injury.Methods: This was a prospective observational study conducted in the department of surgery, Gandhi medical college, Bhopal during a 2 year period in which 100 patients of traumatic head injury were evaluated. The FOUR score and GCS score of these patients were assessed on admission and outcome followed for 2 weeks.Results: The mean age group of 100 patients was 25-45 years with 79% male and 21% female patients. The FOUR scale was found to have a marginally higher sensitivity of 65.6% while the GCS had a sensitivity of 64.2%. The FOUR scale however had a higher specificity of 71.5% compared to 66.4% of GCS. The Youden index showed that FOUR scale (46%) has a better prediction for death than GCS (35%). FOUR had a higher accuracy of 75% than GCS with an accuracy of 65%.Conclusions: Both FOUR score and GCS are valuable scales in assessment of traumatic head injury. The FOUR scale however is more accurate than the GCS in predicting outcome of head injury patients.

Prognostic value of serum S100B concentration in patients with acute spontaneous supratentorial intracerebral hemorrhage

Aim of the work – to evaluate the informativeness of serum protein S100B levels in detection of short-term prognosis in patients with acute period of spontaneous supratentorial intracerebral hemorrhage (SSICH) on the background of concervative therapy. Materials and methods. Prospective cohort study of 90 patients with acute SSICH on the background of conservative therapy was done. Level of neurological deficit was evaluated using Full Outline of Unresponsiveness Scale, Glasgow Coma Scale and National Institute of Health Stroke Scale. Computed tomography was done to detect the intracerebral hemorrhage volume (ICHV), secondary intraventricular hemorrhage volume (SIVHV) and total volume of intracranial hemorrhage (TVICH). Laboratory blood samples were taken within 24 hours of hospitalization. Levels of S100B protein in serum were measured using immunoassay analysis. Unfavorable variants of course (early neurological deterioration (END) during 48 hours from hospitalization) and disease acute period outcome of ICH (modified Rankin score 4–6 on the 21st day of the disease) were considered as endpoints. Statistical processing of the obtained results included correlation analysis, logistic regression analysis and ROC-analysis. Results. Neurological deterioration during 48 hours after hospitalization was detected in 18 (20.0 %) patients, unfavorable SSICH acute period outcome was revealed in 49 (54.4 %) patients. It was detected that serum S100B protein correlates with ICHV (R = 0.34, P ˂ 0.01), SIVHV (R = 0.39, P ˂ 0.01) and TVICH (R = 0.45, P ˂ 0.01). Thus, the patients with unfavorable SSICH acute period course and outcome are characterized with the higher S100B protein levels (P ˂ 0.0001). High sensitive multipredicive logistic regression model that integrates prognostic value of serum of S100B protein concentration with informativeness of clinical, neurological parameters (National Institute of Health Stroke Scale score, SIVHV) was elaborated. It helps to detect the individual risk of unfavorable acute SSICH period outcome on the ground of conservative therapy with the accuracy 90.0 % (AUC ± SE (95 % CІ) = 0.95 ± 0.02 (0.89–0.99), P ˂ 0.0001). Conclusions. Serum S100B protein levels in patients with SSICH on the 1st day after hospitalization is the informative additional parameter in verification of short-term prognosis on the background of conservative therapy.

Diagnostic and prognostic value of serum hepcidin concentration in patients with acute spontaneous supratentorial intracerebral hemorrhage

The aim of the study was to evaluate the diagnostic and prognostic value of serum hepcidin concentration in patients with acute spontaneous supratentorial intracerebral hemorrhage (SSICH). Materials and methods. Prospective cohort study of 88 patients with acute SSICH receiving the conservative therapy was conducted. Level of neurological deficit was evaluated using the Full Outline of UnResponsiveness Scale, the Glasgow Coma Scale and the National Institute of Health Stroke Scale. Computed tomography was performed to detect an intracerebral hemorrhage volume (ICHV), secondary intraventricular hemorrhage volume (SIVHV) and total volume of intracranial hemorrhage (TVICH). Laboratory blood samples were taken within 24 hours of hospitalization. Hepcidin levels, serum iron concentrations and total iron-binding capacity were determined, followed by calculations of transferrin saturation coefficient. Early neurological deterioration (END) and unfavorable variants of the acute period of SSICH (lethal outcome, modified Rankin score 4-5 on the 21st day of the disease) were considered as endpoints. Statistical processing of the obtained results included a correlation analysis, logistic regression analysis and ROC-analysis. Results. It was identified, that serum hepcidin level in the patients with SSICH was correlated with ICHV (R = 0.44, P ˂ 0.01), SIVHV (R = 0.45, P ˂ 0.01) and TVICH (R = 0.57, P ˂ 0.01). Hepcidin serum concentrations in the patients with ICHV >30 ml exceeded the value of those in cases of ICHV ≤30 ml by 69.0 % (P ˂ 0.0001). Serum levels of hepcidin were significantly higher in the patients with an unfavorable course and outcome of the disease in the acute period on the 1st day of admission (P ˂ 0.0001). Informative multipredictor models were developed via multiple logistic regression analysis, which include hepcidin values coupled with clinical and neurovisualization findings and are predictive of lethal and unfavorable acute period functional outcomes (AUC = 0,93, P ˂ 0.0001). Conclusions. The level of serum hepcidin in patients with acute SSICH is associated with the severity of cerebral lesions. The integration of serum hepcidin concentration with clinical and neuroimaging findings in the structure of multipredictor logistic regression models allows to determine the vital and functional prognosis of the acute period of SSICH with an accuracy of >85 %

Effect of training sessions about Full Outline of Un-Responsiveness scale compared to Glasgow Coma Scale on nurses’ performance, perception and its reliability

Background: Assessing patients’ level of consciousness in intensive care units (ICUs) through Full Outline of Un-Responsiveness (FOUR) scale versus the Glasgow Coma Scale (GCS) requires critical care nurses’ (CCNs) knowledge and skills to detect deterioration of patients’ level of consciousness. Objectives: To evaluate the effect of implementing training sessions on critical care nurses’ performance and perception regarding FOUR scale compared to GCS and reliability of each one. Research hypotheses: Nurses who attend training sessions will show a significant improvement in performance of FOUR scale compared to GCS. Study design: A pretest posttest study design was used in this study. Method: The study was conducted at seven ICUs at Alexandria Main University Hospital including; Unit I, Unit II, Unit III, Medical, Respiratory, Neurosurgery, and Emergency anesthesia ICUs. Subject: A convenient sampling technique of all CCNs (100) and a purposive sample of adult critically ill patients equivalent to the number of nurses’ sample was used to recruit the participants from previously mentioned CCUs. Results: The implemented training sessions were significantly effective in increasing CCNs’ performance and positive perception of FOUR scale compared to GCS. There was overall higher inter-rater reliability regarding FOUR score than that of GCS score Cohen’s kappa (0.92 versus 0.81) and 83% of nurses agreed that FOUR scale is a preferred scale to assess the depth of coma. Conclusion: training sessions were significantly effective in increasing CCNs’ performance and positive perception regarding FOUR scale compared to GCS. Recommendation: Nursing administrators should provide continuous training sessions. Manual for procedures is advised to be distributed to all CCNs including all methods for assessing patients’ level of consciousness (LOC).

PREDICTORS OF EARLY NEUROLOGICAL DETERIORATION IN PATIENTS WITH ACUTE SPONTANEOUS SUPRATENTORIAL INTRACEREBRAL HAEMORHAGE

This study was designed in order to improve diagnostic approaches in acute period of spontaneous intracerebral haemorrhage based on the elaboration of prognostic criteria for detecting early neurological deterioration under the conservative treatment. This prospective study included 339 patients having the first intracerebral haemorrhage. Clinical neurological examinations were carried out over the course of acute period of the disease by using Full Outline of UnResponsiveness scale and National Institute of Health Stroke Scale. The volume of intracerebral and secondary intraventricular haemorrhage, presence and severity of midline shift were detected by neurovisualizing techniques. Early neurological deterioration was chosen as a cumulative endpoint. We considered the signs of deterioration under the therapy during the first 24 – 48 hours following the admission to the hospital: decrease in Full Outline of UnResponsiveness scale score ≥2; increase in the National Institute of Health Stroke Scale score ≥4; lethal outcome. Logistic regressive analysis and ROC-analysis were used for elaboration of the prognostic criteria. Results. Neurological deterioration under the conservative therapy for 24 – 48 hours since the hospitalization was detected in 29,2-33,6% of cases. Multiple logistic regression analysis showed that initial degree of midline shift and volume of secondary intraventricular haemorrhage are the most informative parameters for evaluating risk of early neurological deterioration in patients with hemorrhagic stroke, who received the conservative therapy.
 The volume of secondary intraventricular hemorrhage >13,5 ml (sensitivity 70,5-72,7%, specificity 80,8-82,8%) and mean value of septum pellucidum and pineal gland shift >4,5 mm (sensitivity 60,6-60,7%, specificity 85,8-89,2%) were the predictors for early neurological deterioration. The above-mentioned predictors were integrated into the mathematical models for early neurological deterioration prognosis during 24 hours (AUC (95% CІ) = 0,85 (0,81-0,89), р˂0,0001) and 48 hours since the hospital admission (AUC (95% CІ) = 0,87 (0,83-0,90), р˂0,0001). Conclusions. The informative neurovisualization criteria for early neurological deterioration in patients with spontaneous supratentorial intracerebral haemorrhage were elaborated. They include the integrated degree of midline shift and the volume of secondary intraventricular hemorrhage. These criteria enable to determine the individual cumulative risk of unfavorable outcomes of acute period of the disease under the conservative therapy following 24 – 48 hours since the hospitalization with the accuracy of 81,7-82,9%.

Standardization of Full Outline of Unresponsiveness Scale to Assess the Level of Consciousness of the Patients Hospitalized in the Intensive Care Unit in Iran

Standardization of Full Outline of Unresponsiveness Scale to Assess the Level of Consciousness of the Patients Hospitalized in the Intensive Care Unit in Iran

The first experience of application of “full outline of unresponsiveness” (FOUR SCALE) in patients with acute cerebral insufficiency. Two-center research “FOUR-Rus”. Two-center trial

Background. Analysis of distribution of Full Outline of UnResponsiveness (FOUR) Scale provided by F. M. Wijdicks at the Mayo Clinic in 2005 served as the basis for the initiation of the Federation of anesthesiologists of Russia study “FOUR-Rus” (NCT04018989 ClinicalTrails.gov). Objectives. To assess reproducibility and consistency when using the Russian-language version of the FOUR scale. Materials and methods. 260 patients were selected, aged 37 to 90 years with acute head injury, including: I60 — 39 (15 %), I61 — 86 (33 %), I63 — 130 (51 %), I67 — 4 (0,15 %) patients. Center № 1/2 — 159/101 patients. Age — sex composition, level of sedation and pain in the groups did not differ. For examinations in the centers, 2 ICU physicians and 1 neurologist were selected. Reproducibility and interdisciplinary consistency were assessed in pairs with Cronbach’s alpha (α) internal consistency. Statistical analysis was performed using IBM SPSS Statistics Subscription. Conclusions. There are no differences in consistency and reproducibility between FOUR and GSC in stroke patients when used by resuscitators and neurologists in non-specialized ICU. The FOUR scale has maximum reproducibility and wider possibilities for assessing the level of consciousness.

Glasgow Coma Scale versus Full Outline of Unresponsiveness Scale in Predicting Discharge Outcomes of Traumatic Brain Injury

Context: Neurological assessment is an essential element of early warning scores used to recognize and early save the lives of critically ill patients.Aim: This study aimed to compare the full outline of Unresponsiveness Scale and the Glasgow Coma Scale in predicting discharge outcomes in patients with traumatic brain injuryMethod: A comparative research design conducted at Neurosurgery Intensive Care Unit in El Fayoum University Hospital. The Study recruited a purposive sample of 100 adult patients with TBI. They assessed using three tools (Patients Profile Data Form, Level of Consciousness Assessment," and Tool Discharge Data Assessment Record).Results: GCS is superior to FOUR score in prediction of length of stay and full recovery without any squeal while they are the same in the prediction of motor disability and sensory impairment (physical impairment). FOUR score is superior to GCS in the prediction of mortalityConclusion: the FOUR score provides more neurologic details than the GCS and is a valid predictor of outcome in patients with TBI; thus, it could be considered as a future prognostic model. It recommended for using FOUR score for predicting outcomes in patients with traumatic brain injuries as a valid predictor of discharge outcomes after traumatic brain injury.

P13-S Brainstem auditory and median somatosensory evoked potentials evaluation of clinical outcome in hemorrhagic stroke patients

Introduction Aim of this study was to assess evoked potentials in the prediction of clinical outcome in hemorrhagic stroke patients. Methods In 46 patients (23 men, mean age 65.17 ± 12.58) with hemorrhagic stroke (33 intracerebral and 13 subarachnoid hemorrhage) within the 48 h after admission to neurointensive care unit (NICU), brainstem auditory evoked potentials (BAEP) and median nerve somatosensory evoked potentials (mSSEP) were performed. Among clinical parameters, the Glasgow Coma Score (GCS) and the Full Outline of Unresponsiveness (FOUR) were assessed on the admission and discharge day, while Modified Rankin scale (mRS) was assessed on the discharge day. Results At the admission, there was statistically significant negative correlation between BAEP latencies and FOUR score and GCS. Regarding discharge data, there was significant negative correlation between discharge GCS and right wave V latency and significant positive correlation of mRS with latency of right wave V. Among mSSEP results, significant negative correlation was found between right P14-N20 interlatency and admission date FOUR score and GCS. Also, significant positive correlation was found between both FOUR score and GCS on the admission date with mSSEP P15-N20 amplitudes. Significant positive correlation was found between mSSEP P15-N20 amplitudes and discharge day GCS and FOUR scale values. mRS significantly positively correlated with N20 latencies, while significant negative correlation was found between mRS and mSSEP P15-N20 amplitudes. Conclusion BAEP and mSSEP correlate with different clinical outcomes at admission and discharge in patients with hemorrhagic stroke.

Analysis of diagnostic informative value of the Full Outline of UnResponsiveness Scale in patients with spontaneous supratentorial intracerebral hemorrhage

The main purpose of the study was to verify the diagnostic informative value of the Full Outline of UnResponsiveness Scale in patients with SSICH based on the comparison with neuroimaging criteria of midline shift severity. Material and methods. Prospective cohort study of 138 patients in acute period of SSICH was conducted, which included clinical assessment (using the Full Outline of UnResponsiveness (FOUR) Scale and the Glasgow Coma Scale (GCS) scores) and neuroimaging estimation of cerebral injury severity. A comparative analysis of Spearman’s rank correlation coefficients (R) and different areas under the receiver operating characteristic curves (derived from the same cases) was conducted with the help of Z statistic. Results. The Full Outline of UnResponsiveness Scale was verified as a highly informative tool for the presence and severity of midline shift clinical detection (AUC > 0.80, P < 0.0001) in patients with SSICH, whereas the diagnostic informative value of the FOUR scale within the assessment of severe midline shift clinical signs was higher than that for mild midline shift detection (AUC = 0.97 ± 0.02 versus AUC = 0.84 ± 0.05 for septum pellucidum displacement, P = 0.0158; AUC = 0.99 ± 0.01 versus AUC = 0.92 ± 0.03 for pineal gland displacement, P = 0.0269). The Full Outline of UnResponsiveness Scale had a higher diagnostic informative value than the GCS as for the presence of midline shift clinical signs detection (AUC = 0.81 ± 0.03 versus AUC = 0.67 ± 0.04, P = 0.0002; accuracy 77.5 % versus 63.0 %, P = 0.0085), as well as for the clinical assessment of septum pellucidum displacement severity (AUC = 0.80 ± 0.04 versus AUC = 0.73 ± 0.05, P = 0.0286) and pineal gland displacement (AUC = 0.80 ± 0.05 versus AUC = 0.74 ± 0.05, P = 0.0306) in patients with midline shift <4 mm due to SSICH. Conclusions. The Full Outline of UnResponsiveness Scale is characterized by the higher diagnostic informative value in clinical detecting midline shift severity in patients with SSICH.