Full Outline Of Unresponsiveness Research Articles

Absence of Cerebrospinal Fluid Pleocytosis in Encephalitis.

Early diagnosis of encephalitis involves identifying signs of neuroinflammation, including cerebrospinal fluid (CSF) pleocytosis. However, absence of CSF pleocytosis in encephalitis has been described, most notably in autoimmune encephalitis. We examined clinical characteristics and outcomes associated with the absence or presence of CSF white blood cell pleocytosis (≥ 5 cells/µL), to inform timely diagnosis and management of encephalitis. This retrospective study compares initial CSF profiles in 597 adult patients with all-cause encephalitis. Of the 597 patients, 446 (74.7%) had CSF pleocytosis while 151 (25.3%) did not. CSF pleocytosis occurred more commonly in infectious cases (200/446, 44.8%), along with 59 (13.2%) autoimmune cases, comprised chiefly of anti-NMDAR encephalitis (37/59, 62.7%). Notably, the group without pleocytosis was comprised of similar proportions of infectious (47/151, 31.1%) and autoimmune (38/151, 25.92%; p>0.05) encephalitis. Among those with infectious encephalitis, 47/247 (19%) had absent pleocytosis, including 18/76 (23.7%) with HSV-1 encephalitis. The absence of pleocytosis was associated with a decreased rate of acyclovir administration (47.7% in patients without pleocytosis vs. 71.1% in patients with pleocytosis, p<0.001). Despite pleocytosis being associated with some measures of clinical severity at admission such as a Full Outline of UnResponsiveness (FOUR) score ≤14, it was not associated with mortality or prolonged hospitalization. CSF pleocytosis is an important criterion for encephalitis diagnosis, but 25.3% of patients with all-cause encephalitis and 23.7% of those with HSV-1 encephalitis exhibit absence of pleocytosis on initial LP. Acyclovir initiation should not be delayed in the absence of pleocytosis in patients with suspected encephalitis.

The Glasgow Coma Scale and Full Outline of Unresponsiveness score evaluation to predict patient outcomes with neurological illnesses in intensive care units in West Bank: a prospective cross-sectional study.

Determining the clinical neurological state of the patient is essential for making decisions and forecasting results. The Glasgow Coma Scale and the Full Outline of Unresponsiveness (FOUR) Scale are commonly used tools for measuring behavioral consciousness. This study aims to compare scales among patients with neurological disorders in intensive care units (ICUs) in the West Bank. A prospective cross-sectional design was employed. All patients admitted to ICUs who met inclusion criteria were involved in this study. Data were collected from from An-Najah National University, Al-Watani, and Rafedia Hospital. Both tools were used to collect data. A total of 84 patients were assessed, 69.0% of the patients were male, and the average length of stay was 6.4 days. The mean score on the Glasgow Coma scale was 11.2 on admission 11.6 after 48 hours, and 12.2 on discharge. The mean FOUR Scale score was 12.2 on admission, 12.4 after 48 hours, and 12.5 at discharge. This study indicates that both the Glasgow Coma Scale and the FOUR scale are effective in predicting outcomes for neurologically deteriorated critically ill patients. However, the FOUR scale proved to be more reliable when assessing outcomes in ICU patients.

ASSESSMENT OF THE LEVEL OF CONSCIOUSNESS IN REAL CLINICAL PRACTICE USING THE GLASGOW COMA SCALE AND THE FOUR SCALE

Examination of the level of consciousness is one of the basic elements of assessing patients in a life-threatening condition. Depression of the consciousness influence on the patient’s severity, therapy planning. The dynamic assessment is carried out at the prehospital stage, as well as in intensive care units. Domestic and foreign literature sources were studied to determine the optimal tool and algorithm for its use in assessing the level of consciousness of patients delivered by emergency medical services. The analysis of the works from the scientific databases PubMed, eLibrary, Google Scholar, MedRxiv devoted to the diagnosis and treatment of patients with a reduced level of consciousness was carried out. The Full Outline of Unresponsiveness (FOUR) scale and the Glasgow Coma Scale (GCS) have an equally high level of psychometric parameters when assessing patients in general intensive care, however, the assessment of brainstem reflexes included in the FOUR scale makes it optimal for triage and dynamic monitoring of patients during ongoing treatment.

Full Outline of UnResponsiveness (FOUR) Scale: a Multicenter Validation Study of the Psychometric Properties of the Approved Russian Version

Assessment of the individual level of consciousness on admission of a patient with brain injury to the intensive care unit (ICU) is a priority task and a mandatory step in the overall assessment of neurological status. The Full Outline of UnResponsiveness (FOUR) scale, developed at the Mayo Clinic (USA) in 2005, is a widely used tool for comprehensive assessment of patients with altered state of consciousness. The lack of a validated Russian-language version of the FOUR scale has hindered its widespread use in clinical practice. Therefore, the official Russian version of the FOUR scale was developed and adapted for use in Russia after the first stage of the validation study (linguistic and cultural adaptation).Aim. To evaluate the psychometric properties of the Russian version of the FOUR scale for comprehensive assessment of patients in altered state of consciousness.Materials and Methods. As part of a prospective multicenter validation study, the psychometric properties of the scale (reliability, validity, and sensitivity) were evaluated in a group of 171 adult patients with altered conscious state of various etiologies, such as ischemic and hemorrhagic stroke, neuroinflammatory conditions, and traumatic brain injury. Patients’ responses were assessed on the first day of ICU stay and 2-3 days later by two ICU neurologists with at least three years of experience.Results. High levels of validity and reliability were obtained for the Russian version of the FOUR scale for comprehensive assessment of unresponsive patients, including Spearman’s rank correlation coefficient r=0.99 (P&lt;0.0001), Cohen’s κ=0.77 (P&lt;0.001), Cronbach’s α=0.87 (P&lt;0.0001). Regarding the sensitivity of the FOUR scale, no significant changes were found after comprehensive assessment of unresponsive patients on day 1 in the ICU and 2-3 days later (Wilcoxon test, P=0.906). There was a good correlation between the FOUR and Glasgow Coma Scale scores used to assess patients with altered state of consciousness, confirming the validity of the test with r=0.91 (P&lt;0.0001).Conclusion. The Russian version of the FOUR scale for comprehensive assessment of unresponsive patients is a valid, reliable, and sensitive clinical tool. Sufficiently verified level of psychometric properties allows its authorized use in Russia and other Russian-speaking countries. The scale is available for download via QR code and at the website of the International Scales and Questionnaires Validation Group at the Scientific Center of Neurology.

Evaluation of Prognostic Scores in Patients with Head Trauma in the Emergency Department

Background: The aim of this study was to investigate the effectiveness of Glasgow coma scale (GCS), GCS-motor component (mGCS), and FOUR (Full Outline of Un-responsiveness) Scores in predicting the prognosis of patients who presented to the emergency department with head trauma. Methods: In this prospective cross-sectional study, was obtained to collected data of patients with head trauma, who presented to the emergency department. Participants’ demographic data, medical history, GCS, FOUR scores, the duration of emergency department stays, as well as 24-hour, 7-day, and 28-day mortality rates were recorded on the case report forms. Results: Data from 302 patients were used to develop a risk score for detecting significant brain pathology via computed tomography (CT) scans. The regression model, incorporating total GCS and sex-based variables, explained 22.5% of variance and accurately classified 91.1% of cases. The model's area under the curve for detecting significant pathology via CT was 0.714. Conclusion: GCS, mGCS, and FOUR scores did not achieve the necessary the diagnostic performance benchmark to be used alone to predict or exclude clinically significant brain injury in patients with head trauma.

Comparison of the Prognostic Accuracy of Full Outline of Unresponsiveness (FOUR) Score with Glasgow Coma Scale (GCS) Score among Patients with Traumatic Brain Injury in a Tertiary Care Center

Abstract Objectives The Glasgow Coma Scale (GCS) is widely used and considered the gold standard in assessing the consciousness of patients with traumatic brain injury. However, some significant limitations, like the considerable variations in interobserver reliability and predictive validity, were the reason for developing the Full Outline of Unresponsiveness (FOUR) score. The current study aims to compare the prognostic accuracy of the FOUR score with the GCS score for in-hospital mortality and morbidity among patients with traumatic brain injury. Materials and Methods A prospective cohort study was conducted, where 237 participants were selected by consecutive sampling from a tertiary care center. These patients were assessed with the help of GCS and FOUR scores within 6 hours of admission, and other clinical parameters were also noted. The level of consciousness was checked every day with the help of GCS and FOUR scores until their last hospitalization day. Glasgow Outcome Scale was used to assess their outcome on the last day of hospitalization. The GCS and FOUR scores were compared, and data were analyzed by descriptive and inferential statistics. The chi-square test, independent Student's t-test, and receiver operating characteristic analysis were used for inferential analysis. Results The area under the curve (AUC) for the GCS score at the 6th hour for predicting mortality was 0.865 with a cutoff value of 5.5, and it yields a sensitivity of 87% and a specificity of 64%. The AUC for FOUR scores at the 6th hour for predicting the mortality was 0.893, with a cutoff value of 5.5, and it yields a sensitivity of 87% and a specificity of 73%. Conclusion The current study shows that, as per the AUC of GCS and FOUR scores, their sensitivity was equal, but specificity was higher in the FOUR score. So, the FOUR score has higher accuracy than the GCS score in the prediction of mortality among traumatic brain injury patients.

Full Outline of Unresponsiveness Score versus Glasgow Coma Scale in Predicting Clinical Outcomes in Altered Mental Status.

Full outline of unresponsiveness (FOUR) score has advantages over Glasgow Coma Scale (GCS); as it can be used in intubated patients and provides greater neurological details. It has been studied mainly in the trauma and neuroscience setting. Our primary objective was to compare the FOUR versus GCS score as predictors of mortality at 30 days and poor functional outcome at 3 months among nontrauma patients in the emergency department (ED). This prospective observational study was conducted on adult patients presenting with altered mental status (duration <7 days) in the ED (March 2019-November 2020). Data collection included demographic and clinical features, the GCS and FOUR scores, the feasibility of acquiring and interpreting FOUR on a Likert scale, duration of hospital stay, 30-day mortality, and functional outcome at 3 months on the modified Rankin Scale. Trained emergency medicine residents managing the patient collected the data. The area under receiver's operating characteristics curve (AUROC) was used to compare the accuracy of the GCS and FOUR scores in predicting outcomes. The FOUR score equivalent of GCS cutoffs for categorizing neurological impairment (mild, moderate, and severe) was also investigated. Two hundred and ninety-one patients were included, with a mean age of 50.3 years and 67.4% males. Most patients (40.2%) had altered mental status for 1-3 days and hepatic encephalopathy was the most common ED diagnosis. The mortality at 30 days was 66.7% (194 of 291), and 88% (256 of 291) of patients had poor functional outcomes at 3 months. The AUROCs for predicting 30-day mortality were similar for both the scores (GCS: 0.70, FOUR: 0.71, and the P value for difference: 0.9). Similarly, the AUROCs for predicting 3-month poor functional outcome were 0.683 and 0.669 using GCS and FOUR, respectively, with a nonsignificant difference (P = 0.82). The FOUR score strata of 14-16, 11-13, and 0-10 were found to be equivalent to the GCS scores of 13-15 (mild), 9-12 (moderate), and 3-8 (severe). The feasibility of acquiring and interpreting GCS and FOUR scores on the Likert scale was found to be "easy." The FOUR score is similar to GCS in predicting mortality at 30 days and poor neurological outcomes at 3 months among nontrauma patients of ED. Moreover, it was found that the FOUR score is "easy" to assess and interpret by the emergency residents.

Utility of the Full Outline of UnResponsiveness score in children with altered sensorium: A single-center prospective observational study

Background: Recent studies on the Full Outline of UnResponsiveness (FOUR) score suggest that it can overcome the limitations of the Glasgow Coma Scale (GCS). Hence, this study was planned to predict the outcome of children with altered sensorium using the FOUR score and to compare it with the GCS score. Subjects and Methods: This was a single-center prospective observational study conducted in children in the age group of ≥2 months–12 years with altered sensorium included in this study. Admission GCS and FOUR scores were collected. Data were analyzed to compare the FOUR score to GCS in relation to outcome (survivors/nonsurvivors). Results: Out of 90 cases with altered sensorium, 12 expired (13.3%). The mean (standard deviation [SD]) of age (years) was 4.69 (3.72) and the maximum in the age group of 1–5 years (n = 42). The mean (SD), median (interquartile range), and range for GCS at admission for survivors versus nonsurvivors were 11.58 (1.62) versus 6.08 (1.08), 12 (11–13) versus 6 (5.75–7), and 7–17 versus 4–8, and for FOUR score, 13.51 (1.46) versus 8.67 (1.50), 13 (13–15) versus 8 (7.75–10), and 9–16 versus 7–11 were observed, P &lt; 0.001. Admission GCS score of ≤8 (12 out of 15) and FOUR score &lt;11 (10 out of 12) died, P &lt; 0.001. ROC curve analysis for mortality prediction, the area under the curve for GCS (cutoff of 8) was 0.992, and for the FOUR score (cutoff of 11), 0.989 was observed, P &lt; 0.001. Conclusions: Admission FOUR and GCS scores are comparable for the prediction of mortality in children with altered sensorium. The FOUR score of ≤11 strongly correlated with mortality.

Evaluating GCS and FOUR Score in Predicting Mortality of Traumatic Brain Injury Patients (TBI): A Prospective Study in a Tertiary Hospital of South Malabar

ABSTRACT Objective: This study evaluated the full outline of Unresponsiveness (FOUR) score and Glasgow Coma Scale (GCS) to predict traumatic brain injury (TBI) outcomes. Methods: Among 107 patients, FOUR and GCS grading systems analyzed emergency department patients within 24 hours. FOUR and GCS were assessed simultaneously. Patients were followed for 15 days/discharge/death to evaluate the results. Modified Rankin scores measured in-hospital mortality, morbidity, and stay. Results: 65.42% of patients were 25–65. 10% were under 25, and 25% were over 65. Patients were 81% male. Road traffic accidents (RTAs) (90%), falls (7.48%), and assaults (1.47%) caused TBI. 19.62% died. 85.7% of 21 non-survivors had GCS &lt;5 and FOUR &lt;4. GCS mortality sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 85.71%, 93.02%, 75, and 96.4 (P &lt; 0.0001). FOUR score mortality sensitivity, specificity, PPV, and NPV were 85.71%, 96.51%, 85.7, and 96.5 (P &lt; 0.0001). GCS and FOUR AUCs matched (P = 0.52). The unadjusted model reduced in-hospital mortality by 14% for every one point increase in GCS. Every 1-point FOUR score increase reduced in-hospital mortality by 40% in the unadjusted model. GCS and FOUR scored 0.9 Spearman. Conclusion: The FOUR score was comparable in the prediction of mortality in these patients.

Improving Pediatric Critical Care Nurses' Practice in Implementing the Full Outline of Unresponsiveness Coma Scale.

Clinical estimation of consciousness is the most fundamental and crucial component of neurological examinations for pediatric patients in the pediatric intensive care unit (PICU). The full outline of unresponsiveness (FOUR) Coma Scale assesses four variables: eye response, motor response, brainstem reflexes, and respiratory pattern. A score of 0 represents non-function in each category, whereas a score of 4 indicates normal functioning. The FOUR Coma Scale is easy to apply and is currently the most widely used scale for assessing consciousness, particularly in intubated children. This study aimed to improve pediatric critical care nurses' practice in implementing the FOUR Coma Scale. A quasi-experimental research design (pre/post-test design) was employed on a convenience sample composed of 45 male and female nurses who participated in the study and provided direct care for critically ill children at the Medical Pediatric Intensive Care Unit affiliated with the Mansoura University Children's Hospital, Mansoura University, Egypt. All the participants completed the FOUR Coma Scale knowledge and practice assessment questionnaire. Majority of the nurses were females and had bachelors' degrees in nursing (94.6% and 71.1%, respectively). Moray Coma Scale was used to assess level of consciousness (LOC) by more than half the number of nurses (55.6%) in the PICU. All PICU nurses had poor knowledge and practice scores in the pre-intervention phase, and this percentage statistically significantly improved in the post-intervention phase (P = .001). The mean score of nurses' knowledge and practice on the FOUR Coma Scale significantly improved after the implementation of instructional intervention.

The efficacy and safety of bilateral synchronous transcutaneous auricular vagus nerve stimulation for prolonged disorders of consciousness: a multicenter, double-blind, stratified, randomized controlled trial protocol.

Treatment of disorders of consciousness (DOC) poses a huge challenge for clinical medicine. Transcutaneous auricular vagus nerve stimulation (taVNS) is a non-invasive neuromodulation method, which shows potential in improving recovery of DOC. However, the evidence came from single-center, small-sample randomized controlled trial, which is insufficient to form a conclusion. Thereby, we propose a prospective, multicenter, double-blind, stratified, two-arm randomized controlled trial protocol to investigate the efficacy and safety of bilateral synchronous taVNS for treatment of DOC. We aim to recruit 382 patients with prolonged DOC, and divide them into an active stimulation group and a sham stimulation group. The patients in the active stimulation group will receive bilateral synchronous taVNS with a 200 μs pulse width, 20 Hz frequency, and personal adjusted intensity. The sham stimulation group will wear the same stimulator but without current output. Both groups will receive treatment for 30 min per session, twice per day, 6 days per week lasting for 4 weeks. The clinical assessment including Coma Recovery Scale-Revised (CRS-R), Full Outline of Unresponsiveness (FOUR), Glasgow Coma Scale (GCS), and Extended Glasgow Outcome Scale (GOS-E) will be conducted to evaluate its efficacy. Heart rate variability (HRV), blood pressure, and adverse events will be recorded to evaluate its safety. These results will enable us to investigate the efficacy and safety of taVNS for DOC. This protocol will provide multicenter, large-sample, high-quality Class II evidence to support bilateral synchronous taVNS for DOC, and will advance the field of treatment options for DOC.Clinical trial registration:https://www.chictr.org.cn/showproj.html?proj=221851, ChiCTR2400081978.

A comparison of Full Outline of UnResponsiveness (FOUR) score with Glasgow Coma Scale (GCS) in predicting outcomes among patients with acute stroke patients in neurointensive care unit

A comparison of Full Outline of UnResponsiveness (FOUR) score with Glasgow Coma Scale (GCS) in predicting outcomes among patients with acute stroke patients in neurointensive care unit

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 &gt;90.0 %). The most specific NCCT markers were island sign, black hole sign, blend sign, satellite sign and heterogeneous density (specificity &gt;87.0 %). In accordance with the multiple logistic regression analysis, hypodensity (OR (95 % CI) = 13.56 (4.54–40.49), p &lt; 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 &gt;85.0 %.

Comparative study of the diagnostic power of full outline of unresponsiveness score and Glasgow coma scale in patients with traumatic brain injury in an emergency department

Background: The Glasgow coma scale (GCS) is the most commonly used scale, and the full outline of unresponsiveness (FOUR) score is new validated coma scale as an alternative to GCS to measure the level of consciousness and evaluate the severity of the injury in traumatic brain injury (TBI) patients. Aims and Objectives: The present study compared the performance of FOUR scores and GCS in outcome predictions of TBI cases. Materials and Methods: This prospective and cross-sectional study was conducted over a year by the Emergency Department of a tertiary care hospital, Kovai Medical Center and Hospital, Coimbatore, India. Of 159, 123 patients were recruited from intensive care unit (ICU), and 36 from the ward were included in this study. Data were collected using an observation checklist to determine the similarities and differences in predicting outcomes using the two assessment scales (GCS and FOUR). Results: Most patients were 51–60 years (38%), with a mean age of 41.57. About 82% were male, 18% were female, and 31% had comorbidity of hypertension. Data analysis showed a significant statistical difference in mean FOUR and GCS scores between ICU and ward admission. A multivariate logistic regression study revealed that the probability of ICU admission in trauma patients from the emergency department was associated with a decline in GCS and FOUR scores. The range of predicted ICU admission was similar in both GCS and FOUR score models. Conclusion: Although both scores are good predictors of TBI patients, we concluded that the FOUR score is a recommended predictive model for patients admitted to the medical ICU.

Development of a Novel Neurological Score Combining GCS and FOUR Scales for Assessment of Neurosurgical Patients with Traumatic Brain Injury: GCS-FOUR Scale

Consciousness assessment is crucial for patients with traumatic brain injury. In this study, we developed a novel scoring system combining the Glasgow coma scale (GCS) and the full outline of unresponsiveness (FOUR) and evaluated its association with the intensive care unit (ICU) length of stay, mortality, and functional outcome. We retrospectively analyzed the data from patients with traumatic brain injury admitted to the neurosurgical ICU of our institution during a 2-year period. The eye and motor components of the GCS and the brainstem reflex component of the FOUR were used to compute the GCS-FOUR. We performed statistical analysis to demonstrate the association between the GCS, FOUR, and GCS-FOUR and the ICU length of stay, mortality, the development of a persistent vegetative state, and desirable recovery. A total of 140 patients were included. The mean age was 30.6 years, and 89.3% were male. All 3 scores were associated with the ICU length of stay, mortality, a persistent vegetative state, and good recovery. In terms of predicting mortality, the GCS score exhibited a slight superiority compared with the other indexes, and the GCS-FOUR score showed a slight superiority over the other indexes in predicting for good recovery. The GCS-FOUR is a novel scoring system comparable to the GCS and FOUR regarding its association with functional status after injury, ICU length of stay, and mortality. The GCS-FOUR score provides greater neurological detail than the GCS due to the inclusion of brainstem reflexes, in addition to using the experience of healthcare providers with the GCS score compared with the FOUR in most settings.

Glasgow coma scale and full outline of unresponsiveness. Multicenter validation study in Russia

Glasgow coma scale and full outline of unresponsiveness. Multicenter validation study in Russia

Correlation between bispectral index and FOUR score in critically ill patients with traumatic brain injury: A cross-sectional study

ABSTRACT Introduction For neurological testing and monitoring of traumatic brain injury (TBI) patients whose verbal component of the Glasgow Coma Scale (GCS) cannot be assessed, the Full Outline of Unresponsiveness (FOUR) score has been established. In order to determine the degree of awareness in patients with traumatic brain injury, this study will correlate the FOUR score with the bispectral index (BIS) and global consciousness score (GCS). Methods Twenty TBI patients with traumatic brain injury who were hospitalised to the surgical ICU at Cairo University Hospital participated in our prospective observational research. An observer who was blind to the BIS values assessed each of the FOUR scores and GCS (Covidien BIS complete monitoring system, Mansfield, MA, USA). Each patient provided four sets of readings. Spearman’s correlation coefficient was used to perform a correlation between the FOUR score, GCS, and BIS (r). Results There was a significant correlation between BIS and FOUR score (r = 0.854, 95% confidence interval: 0.780–0.904) (P < 0.001). There was also a significant correlation between BIS and GCS (r = 0.864, 95% confidence interval: 0.795–0.911) (P < 0.001). Conclusion There is a strong correlation between FOUR score, GCS, and BIS values in patients with traumatic brain injury. FOUR score seems a reliable alternative for GCS and BIS in the assessment of degree of consciousness, especially in intubated patients.

Development and validation of a novel score to predict brain death after out-of-hospital cardiac arrest

Background and objectivesBrain death (BD) occurs in 9–24% of successfully resuscitated out-of-hospital cardiac arrests (OHCA). To predict BD after OHCA, we developed a novel brain death risk (BDR) score. MethodsWe identified independent predictors of BD after OHCA in a retrospective, single academic center cohort between 2011 and 2021. The BDR score ranges from 0 to 7 points and includes: non-shockable rhythm (1 point), drug overdose as etiology of arrest (1 point), evidence of grey-white differentiation loss or sulcal effacement on head computed tomography (CT) radiology report within 24 hours of arrest (2 points), Full-Outline-Of-UnResponsiveness (FOUR) score of 0 (2 points), FOUR score 1–5 (1 point), and age <45 years (1 point). We internally validated the BDR score using k-fold cross validation (k = 8) and externally validated the score at an independent academic center. The main outcome was BD. ResultsThe development cohort included 362OHCA patients, of whom 18% (N = 58) experienced BD. Internal validation provided an area under the receiving operator characteristic curve (AUC) (95% CI) of 0.931 (0.905–0.957). In the validation cohort, 19.8% (N = 17) experienced BD. The AUC (95% CI) was 0.849 (0.765–0.933). In both cohorts, a BDR score >4 was the optimal cut off (sensitivity 0.903 and 0.882, specificity 0.830 and 0.652, in the development and validation cohorts respectively). DiscussionThe BDR score identifies those at highest risk for BD after OHCA. Our data suggest that a BDR score >4 is the optimal cut off.

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.

Comparison of Full Outline of Unresponsiveness (FOUR) and Glasgow Coma Scale (GCS) in Determining Outcome among Patients in Critical Care Units – A Prospective Study

Accurate assessment and monitoring of level of consciousness is fundamental for prompt management and recognising warning signs of deterioration in the patient. The Glasgow coma scale (GCS), a widely used tool was compared with full outline of unresponsiveness (FOUR) score as an alternate tool for assessment and prognostication of the outcome. The purpose of this study aimed to compare and evaluate the accuracy between GCS and FOUR score (FS) tool in the neurological assessment and predicting the functional outcome. Materials and Methods: For this observational study, 131 patients were recruited from two major teaching hospitals in Middle Eastern countries. Data was collected on admission from emergency department and reassessed on day two &amp; four. Patient was followed on discharge and outcome evaluated using the Glasgow outcome scale (GOS). Results: The mean age was 56.39±17.29 (18- 87years) with 83(63.4%) male patients. 93 (71%) patients admitted with neurological problems. In terms of predicting the outcome using the GOS, the area under the ROC curve was 92% (CI- 95%, 0.870-0.975) for FS and 74.73 % (CI-95%, 0.825-0.951) for GCS. The sensitivity and specificity for FS on admission (0.976 &amp; 0.543), day two (0.971 &amp; 0.495) &amp; day four (0.971 &amp; 0.340) and for GCS is (0.918 &amp; 0.370) (0.941 &amp; 0.433) (0.971 &amp; 0.330). Conclusions: The FS tool is precise in predicting power of mortality and is an ideal complementary or substitute tool for GCS.