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Pisano F, Bilotta F. Verbal Glasgow Coma Scale as predictor of persistent disorder of consciousness: Insights for improving accuracy and reliability in clinical practice. Clin Neurol Neurosurg 2024; 240:108274. [PMID: 38583299 DOI: 10.1016/j.clineuro.2024.108274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/20/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
This brief report discusses the relationship between verbal function, disorders of consciousness, and neurological follow-up after acute brain injury. It provides valuable insights for improving the accuracy and reliability of Verbal Glasgow Coma Scale scoring in clinical practice. The report addresses the need for standardized training and underlines the importance of physiological stabilization before assessment. Clarity in communication, recognition of non-verbal cues, and serial assessments are emphasized as critical factors to reduce the Verbal Glasgow Coma Scale inconsistencies. It also promotes interdisciplinary collaboration and cultural sensitivity to refine the Verbal Glasgow Coma Scale evaluation, improving the prediction of long-term neurological outcomes after acute brain injury and optimizing effective rehabilitation programs. Possible strategies to implement in the routine clinical practice the provided tips are discussed.
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Affiliation(s)
- Francesca Pisano
- Department of Cognitive Sciences, Psychology, Education and Cultural Studies, University of Messina, Messina 98121, Italy; Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, Rome 00161, Italy.
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, Rome 00161, Italy
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2
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Altıntop ÇG, Latifoğlu F, Akın AK, Ülgey A. Quantitative Electroencephalography Analysis for Improved Assessment of Consciousness Levels in Deep Coma Patients Using a Proposed Stimulus Stage. Diagnostics (Basel) 2023; 13:diagnostics13081383. [PMID: 37189484 DOI: 10.3390/diagnostics13081383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 05/17/2023] Open
Abstract
"Coma" is defined as an inability to obey commands, to speak, or to open the eyes. So, a coma is a state of unarousable unconsciousness. In a clinical setting, the ability to respond to a command is often used to infer consciousness. Evaluation of the patient's level of consciousness (LeOC) is important for neurological evaluation. The Glasgow Coma Scale (GCS) is the most widely used and popular scoring system for neurological evaluation and is used to assess a patient's level of consciousness. The aim of this study is the evaluation of GCSs with an objective approach based on numerical results. So, EEG signals were recorded from 39 patients in a coma state with a new procedure proposed by us in a deep coma state (GCS: between 3 and 8). The EEG signals were divided into four sub-bands as alpha, beta, delta, and theta, and their power spectral density was calculated. As a result of power spectral analysis, 10 different features were extracted from EEG signals in the time and frequency domains. The features were statistically analyzed to differentiate the different LeOC and to relate with the GCS. Additionally, some machine learning algorithms have been used to measure the performance of the features for distinguishing patients with different GCSs in a deep coma. This study demonstrated that GCS 3 and GCS 8 patients were classified from other levels of consciousness in terms of decreased theta activity. To the best of our knowledge, this is the first study to classify patients in a deep coma (GCS between 3 and 8) with 96.44% classification performance.
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Affiliation(s)
| | - Fatma Latifoğlu
- Department of Biomedical Engineering, Erciyes University, Kayseri 38039, Turkey
| | - Aynur Karayol Akın
- Department of Anesthesiology and Reanimation, Erciyes University, Kayseri 38039, Turkey
| | - Ayşe Ülgey
- Department of Anesthesiology and Reanimation, Erciyes University, Kayseri 38039, Turkey
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3
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De Souza MR, Pipek LZ, Fagundes CF, Solla DJF, da Silva GCL, Godoy DA, Kolias AG, Amorim RLO, Paiva WS. External validation of the Glasgow coma scale-pupils in low- to middle-income country patients with traumatic brain injury: Could “motor score-pupil” have higher prognostic value? Surg Neurol Int 2022; 13:510. [DOI: 10.25259/sni_737_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
Background:
The objective of this study is to validate the admission Glasgow coma scale (GCS) associated with pupil response (GCS-P) to predict traumatic brain injury (TBI) patient’s outcomes in a low- to middle-income country and to compare its performance with that of a simplified model combining the better motor response of the GCS and the pupilar response (MS-P).
Methods:
This is a prospective cohort of patients with TBI in a tertiary trauma reference center in Brazil. Predictive values of the GCS, GCS-P, and MS-P were evaluated and compared for 14 day and in-hospital mortality outcomes and length of hospital stay (LHS).
Results:
The study enrolled 447 patients. MS-P demonstrated better discriminative ability than GCS to predict mortality (AUC 0.736 × 0.658; P < 0.001) and higher AUC than GCS-P (0.736 × 0.704, respectively; P = 0.073). For hospital mortality, MS-P demonstrated better discrimination than GCS (AUC, 0.750 × 0.682; P < 0.001) and higher AUC than GCS-P (0.750 × 0.714; P = 0.027). Both scores were good predictors of LHS (r2 = 0.084 [GCS-P] × 0.079 [GCS] × 0.072 [MS-P]).
Conclusion:
The predictive value of the GCS, GCS-P, and MS-P scales was demonstrated, thus contributing to its external validation in low- to middle-income country.
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Affiliation(s)
| | | | | | | | | | | | - Angelos G. Kolias
- Cambridge Biomedical Campus, Addenbrooke’s Hospital, Cambridge, United Kingdom,
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4
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Ghauri MS, Ueno A, Mohammed S, Miulli DE, Siddiqi J. Evaluating the Reliability of Neurological Pupillary Index as a Prognostic Measurement of Neurological Function in Critical Care Patients. Cureus 2022; 14:e28901. [PMID: 36237784 PMCID: PMC9544528 DOI: 10.7759/cureus.28901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/07/2022] [Indexed: 11/29/2022] Open
Abstract
Background Neurological pupil index (NPi) is a novel method of assessing pupillary size and reactivity using pupillometry to reduce human subjectivity. This paper aims to evaluate the use of NPi as a potential prognostic tool in a broad population of neurocritical care patients by observing the correlation between NPi, modified Rankin Scale (mRS), and Glasgow Coma Scale (GCS). Methods Our data was collected from 194 patients in the neurosurgical intensive care unit (ICU) at Arrowhead Regional Medical Center (ARMC), as determined by the power calculation. We utilized the Kolmogorov-Smirnova and Shapiro-Wilk normality tests with Lilliefors significance correction. Pearson product-moment correlation was performed between average final NPi and final GCS. Multi-variate linear regression and analysis of variance (ANOVA) were used to evaluate the association and predictive capabilities of NPi on GCS and discharge mRS. Finally, we evaluated whether age, ethnicity, sex, length of stay (LOS), or discharge location were significantly associated with NPi. Results We observed a significant correlation between final GCS and NPi (r=0.609, p<0.001). Our regression analysis revealed that NPi significantly predicted GCS and mRS scores; however, no associations were found between age, ethnicity, sex, LOS, or discharge location. Limitations of our study include a single institutional study with a lack of disease subtyping and the inability to quantify the predictive ability of NPi. Conclusion The analysis revealed a strong correlation between final GCS and average final NPi. NPi was also able to significantly predict GCS and mRS scores. The correlation between NPi and established methods to determine neurological function, such as mRS and GCS, suggests that NPi can be a good prognostication tool for neurological diseases.
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Hunt IE, Wittenberg BE, Kennamer B, Crutcher CL, Tender GC, Hunt JP, DiGiorgio AM. A Retrospective review on the timing of Glasgow Coma Score documentation in a trauma database: implications for patient care, research, and performance metrics. World Neurosurg 2022; 163:e559-e564. [DOI: 10.1016/j.wneu.2022.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 11/16/2022]
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6
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Haines L, Wang W, Harhay M, Martin N, Halpern S, Courtright K. Opportunities to Improve Palliative Care Delivery in Trauma Critical Illness. Am J Hosp Palliat Care 2021; 39:633-640. [PMID: 34467775 DOI: 10.1177/10499091211042303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite recommendations to integrate palliative care (PC) into care for critically ill trauma patients, little is known about current PC practices in trauma care to inform opportunities for improvement. OBJECTIVE Describe patterns of PC delivery among a large, critically ill trauma cohort. SETTING/SUBJECTS Retrospective cohort study of adult (≥18 years) trauma patients admitted to an intensive care unit (ICU) at an urban, level one trauma center in the United States from March 1, 2017 to March 1, 2019. METHODS We linked the electronic medical record with the institutional trauma registry. PC process measures included a PC consult order, advance care planning (ACP) note, and hospice use. Unadjusted results are reported for the total population, decedents, and subgroups at risk for poor outcomes (age ≥55 years, Black race ≥1 pre-existing comorbidity, and severe injury) after trauma. RESULTS Among 1309 eligible admissions, 902 (68.9%) were male, 640 (48.9%) were Black, and 654 (50.0%) were ≥55 years old. Eighty-one (6.2%) patients received a PC consult order, 66 (5.0%) had an ACP note, and 13 (1.1%) were discharged to hospice. Among decedents (N = 91; 7%), 28 (30.8%) received a PC consult order and 36 (39.6%) had an ACP note. For high-risk subgroups, PC consult orders and ACP note rates ranged from 4.5-12.8% and 4.5-11.8%, respectively. CONCLUSION PC delivery was rare among this cohort, including those at high risk for poor outcomes. Urgent efforts are needed to identify barriers to and develop targeted interventions for high quality PC delivery in trauma ICU care.
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Affiliation(s)
- Lindsay Haines
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Wei Wang
- Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Michael Harhay
- Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Niels Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott Halpern
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Katherine Courtright
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
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7
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Altıntop ÇG, Latifoğlu F, Akın AK, İleri R, Yazar MA. Analysis of Consciousness Level Using Galvanic Skin Response during Therapeutic Effect. J Med Syst 2020; 45:1. [PMID: 33236166 DOI: 10.1007/s10916-020-01677-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Abstract
The neurological status of patients in the Intensive Care Units (ICU) is determined by the Glasgow Coma Scale (GCS). Patients in coma are thought to be unaware of what is happening around them. However, many studies show that the family plays an important role in the recovery of the patient and is a great emotional resource. In this study, Galvanic Skin Response (GSR) signals were analyzed from 31 patients with low consciousness levels between GCS 3 and 8 to determine relationship between consciousness level and GSR signals as a new approach. The effect of family and nurse on unconscious patients was investigated by GSR signals recorded with a new proposed protocol. The signals were recorded during conversation and touching of the patient by the nurse and their families. According to numerical results, the level of consciousness can be separated using GSR signals. Also, it was found that family and nurse had statistically significant effects on the patient. Patients with GCS 3,4, and 5 were considered to have low level of consciousness, while patients with GCS 6,7, and 8 were considered to have high level of consciousness. According to our results, it is obtained lower GSR amplitude in low GCS (3, 4, 5) compared to high GCS (7, 8). It was concluded that these patients were aware of therapeutic affect although they were unconscious. During the classification stage of this study, the class imbalance problem, which is common in medical diagnosis, was solved using Synthetic Minority Over-Sampling Technique (SMOTE), Adaptive Synthetic Sampling (ADASYN) and random oversampling methods. In addition, level of consciousness was classified with 92.7% success using various decision tree algorithms. Random Forest was the method which provides higher accuracy compared to all other methods. The obtained results showed that GSR signal analysis recorded in different stages gives very successful GCS score classification performance according to literature studies.
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Affiliation(s)
| | - Fatma Latifoğlu
- Department of Biomedical Engineering, Erciyes University, Kayseri, Turkey.
| | - Aynur Karayol Akın
- Department of Anesthesiology and Reanimation, Erciyes University, Kayseri, Turkey
| | - Ramis İleri
- Department of Biomedical Engineering, Erciyes University, Kayseri, Turkey
| | - Mehmet Akif Yazar
- Department of Anesthesiology and Reanimation, Konya Training and Research Hospital, Konya, Turkey
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8
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In-Suk Bae MD, Hyoung-Joon Chun MD, Hyeong-Joong Yi MD, Kyu-Sun Choi MD. Using components of the Glasgow coma scale and Rotterdam CT scores for mortality risk stratification in adult patients with traumatic brain injury: A preliminary study. Clin Neurol Neurosurg 2019; 188:105599. [PMID: 31760257 DOI: 10.1016/j.clineuro.2019.105599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The Glasgow Coma Scale (GCS) and Rotterdam Computed Tomography Score (RCTS) are widely used to predict outcomes after traumatic brain injury (TBI). The objective of this study was to determine whether the GCS and RCTS components can be used to predict outcomes in patients with traumatic intracranial hemorrhage (IH) after TBI. PATIENTS AND METHODS Between May 2009 and July 2017, 773 patients with IH after TBI were retrospectively reviewed. Data on initial GCS, RCTS according to initial brain CT, and status at hospital discharge and last follow-up were collected. Logistic regression analysis was performed to evaluate the relationship between GCS and RCTS components with outcomes after TBI. RESULTS Among the 773 patients, the overall in-hospital mortality rate was 14.0%. Variables independently associated with outcomes were the verbal (V-GCS) and motor components of GCS (M-GCS), epidural mass lesion (E-RCTS) and intraventricular or subarachnoid hemorrhage components of RCTS (H-RCTS) (p < 0.0001). The new TBI score was obtained with the following calculation: [V-GCS + M-GCS] - [E-RCTS + H-RCTS]. CONCLUSION The new TBI score includes both clinical status and radiologic findings from patients with IH after TBI. The new TBI score is a useful tool for assessing TBI patients with IH in that it combines the GCS and RCTS components that increases area under the curve for predicting in-hospital mortality and unfavorable outcomes and eliminates the paradoxical relationship with outcomes which was observed in GCS score. It allows a practical method to stratify the risk of outcomes after TBI.
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Affiliation(s)
- M D In-Suk Bae
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - M D Hyoung-Joon Chun
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea.
| | - M D Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - M D Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
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9
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Bae IS, Chun HJ, Yi HJ, Bak KH, Choi KS, Kim DW. Modified Glasgow Coma Scale Using Serum Factors as a Prognostic Model in Traumatic Brain Injury. World Neurosurg 2019; 126:e959-e964. [PMID: 30876987 DOI: 10.1016/j.wneu.2019.02.197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of death and disability. This study evaluated a possible relationship between serum factors at admission and the outcome of TBI. We propose a statistically validated scale for patients with TBI that combines serum factors and the Glasgow Coma Scale (GCS). METHODS Between May 2011 and July 2016, 219 patients underwent decompressive craniectomy for TBI. We assessed laboratory data on admission, and correlations with GSC and Glasgow Outcome Scale were investigated. The modified GCS was developed from a multivariable logistic regression model, which was validated with the backward stepwise method. RESULTS Of 219 patients with TBI enrolled in our study, 175 were men (79.9%) and 44 were women (20.1%) with a mean age of 49.1 ± 11.5 years. Initial serum values of hemoglobin, platelets, prothrombin time, and lactate dehydrogenase were associated with in-hospital mortality. The factor score was derived by adding the following points: hemoglobin (≥13.0 g/dL = 0, <13.0 g/dL = 1), platelets (≥150 × 103/mm3 = 0, <150 × 103/mm3 = 1), prothrombin time (<13.2 seconds = 0, ≥13.2 seconds = 1), and lactate dehydrogenase (<271 U/L = 0, ≥271 U/L = 1). The modified GCS score (GCS score [range, 6-15] - FS [range, 0-4]) was calculated. CONCLUSIONS The modified GCS score using serum factors extended the information provided about patient outcomes to be comparable to more complex methods. The modified GCS score may be useful to predict in-hospital mortality in patients with TBI.
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Affiliation(s)
- In-Suk Bae
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Hyoung-Joon Chun
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea.
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Koang-Hum Bak
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Dong-Won Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Seoul, South Korea
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10
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Gao X, Yan S, Wu W, Zhang R, Lu Y, Xiao S. Implications from China patient safety incidents reporting system. Ther Clin Risk Manag 2019; 15:259-267. [PMID: 30799925 PMCID: PMC6371930 DOI: 10.2147/tcrm.s190117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective We aimed to explain the operational mechanism of China National Patient Safety Incidents Reporting System, analyze patterns and trends of incidents reporting, and discuss the implication of the incidents reporting to improve hospital patient safety. Design A nationwide, registry-based, observational study design. Data source The database of China National Patient Safety Incidents Reporting System. Outcome measures Outcome measures of this study included the temporal, regional, and hospital distribution of the reports, as well as the incident type, location, parties, and possible reasons for frequently occurring incidents. Results During 2012–2017, 36,498 patient safety incidents were reported. By analyzing the time trends, we found that there was a significant upward trend on incidents reporting in China. The most common type of incidents was drug-related incidents, followed by nursing-related incidents and surgery-related incidents. The three most frequent locations of incident occurrence were Patient’s Room (65.4%), Ambulatory Care Unit (8.4%), and Intensive Care Unit (7.4%). The majority of the incidents involved nurses (40.7%), followed by physicians (29.5%) and medical technologist (13.6%). About 44.4% of the incidents were attributed to the junior staff (work experience ≤5 years). In addition, incidents triggered by the senior staff (work experience >5 years) were more often associated with severe patient harm. Conclusion To strengthen the incidents reporting system and generate useful evidence through learning from incidents reporting will be important to China’s success in improving the nation’s patient safety status.
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Affiliation(s)
- Xinqiang Gao
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China,
| | - Shipeng Yan
- Department of Cancer Prevention and Control, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan Province, China
| | - Wenqiong Wu
- Department of Cancer Prevention and Control, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan Province, China
| | - Rui Zhang
- Department of Health Policy and Management, School of Public Health, Peiking University, Peiking, China
| | - Yuliang Lu
- Department of the Medical Affairs, Binzhou Medical University Hospital, Binzhou Medical University, Bingzhou, Shandong Province, China
| | - Shuiyuan Xiao
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China,
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DiBrito SR, Cerullo M, Goldstein SD, Ziegfeld S, Stewart D, Nasr IW. Reliability of Glasgow Coma Score in pediatric trauma patients. J Pediatr Surg 2018; 53:1789-1794. [PMID: 29429772 DOI: 10.1016/j.jpedsurg.2017.12.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 11/27/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Discordant assessments of Glasgow Coma Score (GCS) following trauma can result in inappropriate triage. This study sought to determine the reliability of prehospital GCS compared to emergency department (ED) GCS. METHODS We conducted a retrospective review of traumas from 01/2000 to 12/2015 at a Level-1 pediatric trauma center. We evaluated reliability between field and ED GCS using Pearson's correlation. We ascertained the difference between prehospital and ED GCS (delta-GCS). Associations between patient characteristics and delta-GCS were modeled using Poisson and linear regression, adjusting for demographic and clinical covariates. RESULTS We identified 5306 patients. Pearson's correlation for GCS measurements was 0.57 for ages 0-3, and 0.67-0.77 for other age groups. Mean delta-GCS was highest for age<3years (0.95, SD=2.4). Poisson regression demonstrated that compared to children 0-3years, higher age was associated with lower delta-GCS (RR 0.65 95% CI 0.56-0.74). Linear regression showed that in those with a delta-GCS, more severe injury (higher ISS, worse ED disposition) and older age were associated with a negative change, signifying decline in score. CONCLUSIONS GCS is generally unreliable in pediatric trauma patients aged 0-3years, particularly the verbal score component. This may impact accuracy of triage priority for pediatric trauma patients. LEVEL OF EVIDENCE III, Prognostic.
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Affiliation(s)
- Sandra R DiBrito
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
| | - Marcelo Cerullo
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
| | - Seth D Goldstein
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
| | - Susan Ziegfeld
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
| | - Dylan Stewart
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
| | - Isam W Nasr
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
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Sanello A, Gausche-Hill M, Mulkerin W, Sporer KA, Brown JF, Koenig KL, Rudnick EM, Salvucci AA, Gilbert GH. Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2018; 19:527-541. [PMID: 29760852 PMCID: PMC5942021 DOI: 10.5811/westjem.2018.1.36559] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/15/2017] [Accepted: 01/04/2018] [Indexed: 12/11/2022] Open
Abstract
Introduction In the United States emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with an acute change in mental status and to compare these recommendations against the current protocols used by the 33 EMS agencies in the State of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with altered mental status (AMS) and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the AMS protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were patient assessment, point-of-care tests, supplemental oxygen, use of standardized scoring, evaluating for causes of AMS, blood glucose evaluation, toxicological treatment, and pediatric evaluation and management. Results Protocols across 33 EMS agencies in California varied widely. All protocols call for a blood glucose check, 21 (64%) suggest treating adults at <60mg/dL, and half allow for the use of dextrose 10%. All the protocols recommend naloxone for signs of opioid overdose, but only 13 (39%) give specific parameters. Half the agencies (52%) recommend considering other toxicological causes of AMS, often by using the mnemonic AEIOU TIPS. Eight (24%) recommend a 12-lead electrocardiogram; others simply suggest cardiac monitoring. Fourteen (42%) advise supplemental oxygen as needed; only seven (21%) give specific parameters. In terms of considering various etiologies of AMS, 25 (76%) give instructions to consider trauma, 20 (61%) to consider stroke, and 18 (55%) to consider seizure. Twenty-three (70%) of the agencies have separate pediatric AMS protocols; others include pediatric considerations within the adult protocol. Conclusion Protocols for patients with AMS vary widely across the State of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Ashley Sanello
- Los Angeles County Emergency Medical Services (EMS) Agency, Santa Fe Springs, California.,David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services (EMS) Agency, Santa Fe Springs, California.,Harbor UCLA, Department of Emergency Medicine, Torrance, California.,David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California.,EMS Medical Directors Association of California
| | - William Mulkerin
- Stanford University, Department of Emergency Medicine, Stanford, California
| | - Karl A Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,EMS Medical Directors Association of California
| | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,EMS Medical Directors Association of California
| | - Kristi L Koenig
- EMS Medical Directors Association of California.,County of San Diego, Health & Human Services Agency, Emergency Medical Services, San Diego, California.,University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Eric M Rudnick
- EMS Medical Directors Association of California.,NorCal EMS Agency, Redding, California
| | - Angelo A Salvucci
- EMS Medical Directors Association of California.,Ventura County EMS Agency, Oxnard, California
| | - Gregory H Gilbert
- EMS Medical Directors Association of California.,Stanford University, Department of Emergency Medicine, Stanford, California
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Reith FC, Synnot A, van den Brande R, Gruen RL, Maas AI. Factors Influencing the Reliability of the Glasgow Coma Scale: A Systematic Review. Neurosurgery 2018; 80:829-839. [PMID: 28327922 DOI: 10.1093/neuros/nyw178] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 12/23/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Glasgow Coma Scale (GCS) characterizes patients with diminished consciousness. In a recent systematic review, we found overall adequate reliability across different clinical settings, but reliability estimates varied considerably between studies, and methodological quality of studies was overall poor. Identifying and understanding factors that can affect its reliability is important, in order to promote high standards for clinical use of the GCS. OBJECTIVE The aim of this systematic review was to identify factors that influence reliability and to provide an evidence base for promoting consistent and reliable application of the GCS. METHODS A comprehensive literature search was undertaken in MEDLINE, EMBASE, and CINAHL from 1974 to July 2016. Studies assessing the reliability of the GCS in adults or describing any factor that influences reliability were included. Two reviewers independently screened citations, selected full texts, and undertook data extraction and critical appraisal. Methodological quality of studies was evaluated with the consensus-based standards for the selection of health measurement instruments checklist. Data were synthesized narratively and presented in tables. RESULTS Forty-one studies were included for analysis. Factors identified that may influence reliability are education and training, the level of consciousness, and type of stimuli used. Conflicting results were found for experience of the observer, the pathology causing the reduced consciousness, and intubation/sedation. No clear influence was found for the professional background of observers. CONCLUSION Reliability of the GCS is influenced by multiple factors and as such is context dependent. This review points to the potential for improvement from training and education and standardization of assessment methods, for which recommendations are presented.
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Affiliation(s)
- Florence Cm Reith
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Anneliese Synnot
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Preventive Medicine and Public Health, Monash University, Melbourne, Australia.,Cochrane Consumers and Communication Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.,National Trauma Institute, Melbourne, Australia
| | - Ruben van den Brande
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Russell L Gruen
- Lee Kong Chian School of Medicine, Nanyang Institute of Technology in Health and Medicine (NITHM), Nanyang Technological University, 637553, Singapore
| | - Andrew Ir Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Braine ME, Cook N. The Glasgow Coma Scale and evidence-informed practice: a critical review of where we are and where we need to be. J Clin Nurs 2017; 26:280-293. [PMID: 27218835 DOI: 10.1111/jocn.13390] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2016] [Indexed: 12/16/2022]
Abstract
AIMS AND OBJECTIVES This paper aims to critically consider the evidence since the Glasgow Coma Scale was first launched, reflecting on how that evidence has shaped practice. It illustrates the lack of clarity and consensus about the use of the tool in practice and draws upon existing evidence to determine the route to clarity for an evidence-informed approach to practice. BACKGROUND The Glasgow Coma Scale has permeated and influenced practice for over 40 years, being well-established worldwide as the key tool for assessing level of consciousness. During this time, the tool has been scrutinised, evaluated, challenged and re-launched in a plethora of publications. This has led to an insight into the challenges, and to some extent the opportunities, in using the Glasgow Coma Scale in practice but has also resulted in a lack of clarity. DESIGN This is a discursive paper that invites readers to explore and arrive at a more comprehensive understanding of the Glasgow Coma Scale in practice and is based on searches of Scopus, Web of Knowledge, PubMed, Science Direct and CINAHL databases. RESULTS While the Glasgow Coma Scale has been rivalled by other tools in an attempt to improve upon it, a shift in practice to those tools has not occurred. The tool has withstood the test of time in this respect, indicating the need for further research into its use and a clear education strategy to standardise implementation in practice. CONCLUSION Further exploration is needed into the application of painful stimuli in using the Glasgow Coma Scale to assess level of consciousness. In addition, a robust educational strategy is necessary to maximise consistency in its use in practice. RELEVANCE TO CLINICAL PRACTICE The evidence illustrates inconsistency and confusion in the use of the Glasgow Coma Scale in practice; this has the potential to compromise care and clarity around the issues is therefore necessary.
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Affiliation(s)
- Mary E Braine
- School of Nursing, Midwifery, Social Work & Social Sciences, University of Salford, Salford, UK
| | - Neal Cook
- School of Nursing, Ulster University, Londonderry, UK
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Kupas DF, Melnychuk EM, Young AJ. Glasgow Coma Scale Motor Component (“Patient Does Not Follow Commands”) Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury in Trauma Patients. Ann Emerg Med 2016; 68:744-750.e3. [DOI: 10.1016/j.annemergmed.2016.06.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 06/03/2016] [Accepted: 06/13/2016] [Indexed: 11/28/2022]
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Schumacher M, Denier C, Oudinet JP, Adams D, Guennoun R. Progesterone neuroprotection: The background of clinical trial failure. J Steroid Biochem Mol Biol 2016; 160:53-66. [PMID: 26598278 DOI: 10.1016/j.jsbmb.2015.11.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/08/2015] [Accepted: 11/12/2015] [Indexed: 12/12/2022]
Abstract
Since the first pioneering studies in the 1990s, a large number of experimental animal studies have demonstrated the neuroprotective efficacy of progesterone for brain disorders, including traumatic brain injury (TBI). In addition, this steroid has major assets: it easily crosses the blood-brain-barrier, rapidly diffuses throughout the brain and exerts multiple beneficial effects by acting on many molecular and cellular targets. Moreover, progesterone therapies are well tolerated. Notably, increased brain levels of progesterone are part of endogenous neuroprotective responses to injury. The hormone thus emerged as a particularly promising protective candidate for TBI and stroke patients. The positive outcomes of small Phase 2 trials aimed at testing the safety and potential protective efficacy of progesterone in TBI patients then provided support and guidance for two large, multicenter, randomized and placebo-controlled Phase 3 trials, with more than 2000 TBI patients enrolled. The negative outcomes of both trials, named ProTECT III and SyNAPSE, came as a big disappointment. If these trials were successful, progesterone would have become the first efficient neuroprotective drug for brain-injured patients. Thus, progesterone has joined the numerous neuroprotective candidates that have failed in clinical trials. The aim of this review is a reappraisal of the preclinical animal studies, which provided the proof of concept for the clinical trials, and we critically examine the design of the clinical studies. We made efforts to present a balanced view of the strengths and limitations of the translational studies and of some serious issues with the clinical trials. We place particular emphasis on the translational value of animal studies and the relevance of TBI biomarkers. The probability of failure of ProTECT III and SyNAPSE was very high, and we present them within the broader context of other unsuccessful trials.
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Affiliation(s)
- Michael Schumacher
- U1195 Inserm and University Paris-Sud and University Paris-Saclay, 80 rue du Général Leclerc, 94276 Kremlin-Bicêtre, France.
| | - Christian Denier
- U1195 Inserm and University Paris-Sud and University Paris-Saclay, 80 rue du Général Leclerc, 94276 Kremlin-Bicêtre, France; Department of Neurology, CHU Bicêtre, 78 rue du Général Leclerc, 94275 Kremlin-Bicêtre, France
| | - Jean-Paul Oudinet
- U1195 Inserm and University Paris-Sud and University Paris-Saclay, 80 rue du Général Leclerc, 94276 Kremlin-Bicêtre, France
| | - David Adams
- U1195 Inserm and University Paris-Sud and University Paris-Saclay, 80 rue du Général Leclerc, 94276 Kremlin-Bicêtre, France; Department of Neurology, CHU Bicêtre, 78 rue du Général Leclerc, 94275 Kremlin-Bicêtre, France
| | - Rachida Guennoun
- U1195 Inserm and University Paris-Sud and University Paris-Saclay, 80 rue du Général Leclerc, 94276 Kremlin-Bicêtre, France
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Schneiderman H. Glasgow Coma Creep: Problems of Recognition and Communication. Am J Med 2015; 128:1270-1. [PMID: 26144104 DOI: 10.1016/j.amjmed.2015.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 06/05/2015] [Accepted: 06/08/2015] [Indexed: 11/16/2022]
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Reith FCM, Van den Brande R, Synnot A, Gruen R, Maas AIR. The reliability of the Glasgow Coma Scale: a systematic review. Intensive Care Med 2015; 42:3-15. [PMID: 26564211 DOI: 10.1007/s00134-015-4124-3] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/26/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The Glasgow Coma Scale (GCS) provides a structured method for assessment of the level of consciousness. Its derived sum score is applied in research and adopted in intensive care unit scoring systems. Controversy exists on the reliability of the GCS. The aim of this systematic review was to summarize evidence on the reliability of the GCS. METHODS A literature search was undertaken in MEDLINE, EMBASE and CINAHL. Observational studies that assessed the reliability of the GCS, expressed by a statistical measure, were included. Methodological quality was evaluated with the consensus-based standards for the selection of health measurement instruments checklist and its influence on results considered. Reliability estimates were synthesized narratively. RESULTS We identified 52 relevant studies that showed significant heterogeneity in the type of reliability estimates used, patients studied, setting and characteristics of observers. Methodological quality was good (n = 7), fair (n = 18) or poor (n = 27). In good quality studies, kappa values were ≥0.6 in 85%, and all intraclass correlation coefficients indicated excellent reliability. Poor quality studies showed lower reliability estimates. Reliability for the GCS components was higher than for the sum score. Factors that may influence reliability include education and training, the level of consciousness and type of stimuli used. CONCLUSIONS Only 13% of studies were of good quality and inconsistency in reported reliability estimates was found. Although the reliability was adequate in good quality studies, further improvement is desirable. From a methodological perspective, the quality of reliability studies needs to be improved. From a clinical perspective, a renewed focus on training/education and standardization of assessment is required.
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Affiliation(s)
- Florence C M Reith
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium. .,University of Antwerp, Edegem, Belgium.
| | - Ruben Van den Brande
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.,University of Antwerp, Edegem, Belgium
| | - Anneliese Synnot
- Australian & New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.,ANZIC-RC, Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Hospital, Level 6, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Russell Gruen
- Central Clinical School, Monash University, Melbourne, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Central Clinical School, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.,University of Antwerp, Edegem, Belgium
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[Mild head injury in children and adults: Diagnostic challenges in the emergency department]. Med Klin Intensivmed Notfmed 2015; 110:379-94; quiz 395-6. [PMID: 26063147 DOI: 10.1007/s00063-015-0047-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.
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Sculthorpe-Petley L, Liu C, Hajra SG, Parvar H, Satel J, Trappenberg TP, Boshra R, D'Arcy RCN. A rapid event-related potential (ERP) method for point-of-care evaluation of brain function: development of the Halifax Consciousness Scanner. J Neurosci Methods 2015; 245:64-72. [PMID: 25701685 DOI: 10.1016/j.jneumeth.2015.02.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 02/10/2015] [Accepted: 02/11/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Event-related potentials (ERPs) may provide a non-invasive index of brain function for a range of clinical applications. However, as a lab-based technique, ERPs are limited by technical challenges that prevent full integration into clinical settings. NEW METHOD To translate ERP capabilities from the lab to clinical applications, we have developed methods like the Halifax Consciousness Scanner (HCS). HCS is essentially a rapid, automated ERP evaluation of brain functional status. The present study describes the ERP components evoked from auditory tones and speech stimuli. ERP results were obtained using a 5-min test in 100 healthy individuals. The HCS sequence was designed to evoke the N100, the mismatch negativity (MMN), P300, the early negative enhancement (ENE), and the N400. These components reflected sensation, perception, attention, memory, and language perception, respectively. Component detection was examined at group and individual levels, and evaluated across both statistical and classification approaches. RESULTS All ERP components were robustly detected at the group level. At the individual level, nonparametric statistical analyses showed reduced accuracy relative to support vector (SVM) machine classification, particularly for speech-based ERPs. Optimized SVM results were MMN: 95.6%; P300: 99.0%; ENE: 91.8%; and N400: 92.3%. CONCLUSIONS A spectrum of individual-level ERPs can be obtained in a very short time. Machine learning classification improved detection accuracy across a large healthy control sample. Translating ERPs into clinical applications is increasingly possible at the individual level.
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Affiliation(s)
- Lauren Sculthorpe-Petley
- Biomedical Translational Imaging Centre (BIOTIC), IWK Health Centre, Suite 3900-1796 Summer St., Halifax, Nova Scotia B3H 3A7, Canada
| | - Careesa Liu
- Faculty of Applied Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia V5A 1S6, Canada
| | - Sujoy Ghosh Hajra
- Faculty of Applied Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia V5A 1S6, Canada
| | - Hossein Parvar
- Faculty of Computer Science, Dalhousie University, 6050 University Ave., P.O. Box 15000, Halifax, Nova Scotia B3H 4R2, Canada
| | - Jason Satel
- School of Psychology, University of Nottingham Malaysia Campus, Jalan Broga, 43500 Semenyih, Selangor Darul Ehsan, Malaysia
| | - Thomas P Trappenberg
- Faculty of Computer Science, Dalhousie University, 6050 University Ave., P.O. Box 15000, Halifax, Nova Scotia B3H 4R2, Canada
| | - Rober Boshra
- Faculty of Computer Science, Dalhousie University, 6050 University Ave., P.O. Box 15000, Halifax, Nova Scotia B3H 4R2, Canada
| | - Ryan C N D'Arcy
- Faculty of Applied Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia V5A 1S6, Canada.
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Leidel B, Lindner T, Wolf S, Bogner V, Steinbeck A, Börner N, Preiser C, Audebert H, Biberthaler P, Kanz KG. Leichtes Schädel-Hirn-Trauma bei Kindern und Erwachsenen. Notf Rett Med 2015. [DOI: 10.1007/s10049-014-1974-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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[Mild head injury in children and adults. Diagnostic challenges in the emergency department]. Unfallchirurg 2015; 118:53-68; quiz 69-70. [PMID: 25630884 DOI: 10.1007/s00113-014-2704-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.
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24
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Masaoka T, Suzuki H. Does the AIMS65, a new risk score for upper gastrointestinal bleeding, work in Japan? Dig Endosc 2014; 26:331-2. [PMID: 24754239 DOI: 10.1111/den.12224] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Tatsuhiro Masaoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Tevlin R, Doherty E, Traynor O. Improving disclosure and management of medical error – An opportunity to transform the surgeons of tomorrow. Surgeon 2013; 11:338-43. [DOI: 10.1016/j.surge.2013.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 07/25/2013] [Accepted: 07/29/2013] [Indexed: 10/26/2022]
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Abstract
BACKGROUND Early diagnosis of traumatic brain injury (TBI) and reliable prediction of outcome are essential for determining treatment strategies and allocating resources. This study introduces the Eppendorf-Cologne Scale (ECS) and evaluated its predictive accuracy for outcome and TBI presence compared with those of the Glasgow Coma Scale (GCS). METHODS A retrospective cohort analysis of severely injured trauma patients registered in the Trauma Registry of the German Society for Trauma Surgery from 1993 to 2010 was conducted. Only directly admitted patients alive on admission and with complete data on GCS, pupil reactivity, and size were included. The ECS was modeled using pupil reactivity, size, and a modified GCS motor component. The unadjusted predictive role of each component was evaluated using multivariable regression analysis. The predictive power regarding the presence of TBI and outcome of the ECS and the GCS was modeled using area under the receiver operating characteristic (AUROC) curve analyses. RESULTS A total of 28,305 patients fulfilled the study inclusion criteria. The ECS outmatched the predictive accuracy of the GCS for outcome (AUROC, 0.824; 95% confidence interval [95% CI], 0.817-0.831; and AUROC, 0.811; 95% CI, 0.804-0.818, respectively; rs = 0.887, p < 0.001) and TBI presence (AUROC, 0.813; 95% CI, 0.805-0.822; and AUROC, 0.777; 95% CI, 0.768-0.786, respectively; rs = 0.889, p < 0.001). Patients with TBI were five times more often unconscious at the scene and showed a 3.5-fold increased in-hospital mortality. An ECS score of 8 was associated with a 20-fold higher mortality compared with an ECS score of 0. The ECS differentiates patients with a fourfold higher mortality within the GCS 3 collective. CONCLUSION The ECS shows a significantly higher accuracy for prediction of outcome and TBI presence compared with the GCS and provides a simple, yet reliable, stratification tool for early decision making. LEVEL OF EVIDENCE Prognostic study, level III.
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Stahel PF. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality (Br J Surg 2012; 99(Suppl 1): 122-130). Br J Surg 2012; 99 Suppl 1:131. [PMID: 22441867 DOI: 10.1002/bjs.7709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- P F Stahel
- Departments of Orthopaedic Surgery and Neurosurgery, University of Colorado, School of Medicine, Denver Health Medical Center, 777 Bannock Street, Denver, Colorado 80204, USA.
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Hoffmann M, Lefering R, Rueger JM, Kolb JP, Izbicki JR, Ruecker AH, Rupprecht M, Lehmann W. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. Br J Surg 2011; 99 Suppl 1:122-30. [PMID: 22441866 DOI: 10.1002/bjs.7707] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Background
Early diagnosis and prediction of traumatic brain injury (TBI) is essential for determining treatment strategies and allocating resources. This study evaluated the predictive accuracy of Glasgow Coma Scale (GCS) verbal, motor and eye components alone, or in addition to pupil size and reactivity, for TBI.
Methods
A retrospective cohort analysis of data from 51 425 severely injured patients registered in the Trauma Registry of the German Society for Trauma Surgery from 1993 to 2009 was undertaken. Only directly admitted patients alive on admission and with complete data on GCS, pupil size and pupil reactivity were included. The unadjusted predictive roles of GCS components and pupil parameters, alone or in combination, were modelled using area under the receiver operating characteristic (AUROC) curve analyses and multivariable logistic regression regarding presence of TBI and death.
Results
Some 24 115 patients fulfilled the study inclusion criteria. Best accuracy for outcome prediction was found for pupil reactivity (AUROC 0·770, 95 per cent confidence interval 0·761 to 0·779) and GCS motor component (AUROC 0·797, 0·788 to 0·805), with less accuracy for GCS eye and verbal components. The combination of pupil reactivity and GCS motor component (AUROC 0·822, 0·814 to 0·830) outmatched the predictive accuracy of GCS alone (AUROC 0·808, 0·800 to 0·815). Pupil reactivity and size were significantly correlated (rs = 0·56, P < 0·001). Patients displaying both unequal pupils and fixed pupils were most likely to have TBI (95·1 per cent of 283 patients). Good outcome (Glasgow Outcome Scale score 4 or more) was documented for only 1929 patients (8·0 per cent) showing fixed and bilateral dilated pupils.
Conclusion
The best predictive accuracy for presence of TBI was obtained using the GCS components. Pupil reactivity together with the GCS motor component performed best in predicting death.
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Affiliation(s)
- M Hoffmann
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - R Lefering
- Institute for Research in Operative Medicine, University of Witten/Herdecke, Cologne-Merheim Medical Centre, Cologne, Germany
| | - J M Rueger
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - J P Kolb
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - J R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - A H Ruecker
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - M Rupprecht
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - W Lehmann
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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