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Driessen DMF, Utens CMA, Ribbers PGM, van Erp WS, Heijenbrok-Kal MH. Short-term outcomes of early intensive neurorehabilitation for prolonged disorders of consciousness: A prospective cohort study. Ann Phys Rehabil Med 2024; 67:101838. [PMID: 38830314 DOI: 10.1016/j.rehab.2024.101838] [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: 05/24/2023] [Revised: 02/23/2024] [Accepted: 03/02/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Advances in medical care have increased survival in people with severe brain injuries and with that the number of survivors with prolonged disorders of consciousness (PDOC) has increased. In the literature, early intensive neurorehabilitation (EIN) for people with PDOC is recommended to achieve the best possible outcomes. OBJECTIVES To evaluate the frequency and extent of recovery of consciousness, mortality, complications, pain and discomfort, and medication during a nationwide EIN programme in people with PDOC after acquired brain injury. We hypothesized that level of consciousness would improve in half of people with PDOC. METHODS Prospective cohort study. People with PDOC aged 16 years and older admitted to the EIN department centralized in a single rehabilitation centre in the Netherlands (Libra Rehabilitation & Audiology) were included. The EIN delivers a subacute medical level of care and rehabilitation for a maximum duration of 14 weeks. The outcome measures were level of consciousness (CRS-R), mortality, number of complications, medication and pain/discomfort (NCS-R). RESULTS Of the 104 people included, 68 % emerged to a minimal conscious state with command-following or higher during EIN and 44 % regained consciousness. Mortality during EIN was 6 %, and 50 % of deaths followed a non-treatment decision or withdrawal of life-sustaining treatment. Almost all participants had at least 1 medical complication, leading to hospital readmission for 30 %. 73 % showed no pain or discomfort. During EIN, cardiovascular medication and analgesics were reduced by 15 %. CONCLUSIONS During the EIN programme, a large percentage of people with PDOC regained at least a minimal conscious state or even consciousness. These outcomes and the frequent medical complications in these people suggest that intensive specialized care should be offered to all people with PDOC. The outcomes of this study might help health professionals to better inform the families of people with PDOC about the short-term prognosis of PDOC. PROTOCOL REGISTRATION NUMBER The Dutch Trial Register, NL 8138.
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Affiliation(s)
- Danielle M F Driessen
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands; Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands.
| | - Cecile M A Utens
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands; Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands
| | - Prof Gerard M Ribbers
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands; Rijndam Rehabilitation, PO Box 23181, 3001 KD, Rotterdam, the Netherlands
| | - Willemijn S van Erp
- Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands; Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, the Netherlands; Accolade Zorg, the Netherlands
| | - Majanka H Heijenbrok-Kal
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands; Rijndam Rehabilitation, PO Box 23181, 3001 KD, Rotterdam, the Netherlands
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Lehrer H, Dayan I, Elkayam K, Kfir A, Bierman U, Front L, Catz A, Aidinoff E. Responses to stimuli in the 'snoezelen' room in unresponsive wakefulness or in minimally responsive state. Brain Inj 2022; 36:1167-1175. [PMID: 35978560 DOI: 10.1080/02699052.2022.2110286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Sensory stimulation in Snoezelen room increased responsiveness after brain injury and dementia. OBJECTIVE To explore the physiological and clinical effects of Snoezelen stimulation in persons with unresponsive wakefulness syndrome or minimally conscious state (UWS or MCS). DESIGN A comparative prospective observational cohort study. METHODS Ten patients with UWS and 25 in MCS were exposed to consecutive stimuli involving the 5 senses in a Snoezelen room. Heart rate (HR) and cerebral blood flow velocity (CBFV), and scores of the Loewenstein communication scale (LCS) were obtained before and during or after the stimuli. RESULTS The stimuli increased HR values and decreased left hemisphere CBFV values in patients with MCS (p < 0.05). Stimulation increased LCS scores (from 28.48 ± 6.55 to 31.13 ± 7.14; p < 0.001) in patients with MCS, but not in the UWS group. LCS gain correlated with HR and right hemisphere CBFV gains in patients with MCS (r = 0.439 and 0.636 respectively, p < 0.05). CONCLUSIONS Snoezelen stimulation induced immediate improvement in communication and physiological changes in patients with MSC, and had a minor physiological effect in patients with UWS. If additional studies support these findings, it will be possible to suggest that Snoezelen stimulation can affect arousal, and possibly improve functioning.
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Affiliation(s)
- Hiela Lehrer
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Ilil Dayan
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Keren Elkayam
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Adi Kfir
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Uri Bierman
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Lilach Front
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Amiram Catz
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel.,Sackler Faculty of Medicine, Rehabilitation Department, Tel Aviv University, Tel Aviv, Israel
| | - Elena Aidinoff
- Departments of Intensive Care for Consciousness Rehabilitation and Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel.,Sackler Faculty of Medicine, Rehabilitation Department, Tel Aviv University, Tel Aviv, Israel
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Nekrasova J, Kanarskii M, Borisov I, Pradhan P, Shunenkov D, Vorobiev A, Smirnova M, Pasko V, Petrova MV, Luginina E, Pryanikov I. One-Year Demographical and Clinical Indices of Patients with Chronic Disorders of Consciousness. Brain Sci 2021; 11:brainsci11050651. [PMID: 34065687 PMCID: PMC8156613 DOI: 10.3390/brainsci11050651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 12/27/2022] Open
Abstract
This work aims to evaluate the prognostic value of the demographical and clinical data on long-term outcomes (up to 12 months) in patients with severe acquired brain injury with vegetative state/unresponsive wakefulness syndrome (VS/UWS/UWS) or a minimally conscious state (MCS). Patients (n = 211) with VS/UWS/UWS (n = 123) and MCS (n = 88) were admitted to the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology after anoxic brain injury (n = 53), vascular lesions (n = 59), traumatic brain injury (n = 93), and other causes (n = 6). At the beginning of the 12-month study, younger age and a higher score by the Coma Recovery Scale-Revised (CRS-R) predicted a survival. However, no reliable markers of significant positive dynamics of consciousness were found. Based on the etiology, anoxic brain injury has the most unfavorable prognosis. For patients with vascular lesions, the first three months after injury have the most important prognostic value. No correlations were found between survival, increased consciousness, and gender. The demographic and clinical characteristics of patients with chronic DOC can be used to predict long-term mortality in patients with chronic disorders of consciousness. Further research should be devoted to finding reliable predictors of recovery of consciousness.
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Affiliation(s)
- Julia Nekrasova
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Mikhail Kanarskii
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Ilya Borisov
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Pranil Pradhan
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
- Correspondence: ; Tel.: +7-(977)-709-4468
| | - Denis Shunenkov
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Alexey Vorobiev
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Maria Smirnova
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Vera Pasko
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Marina V. Petrova
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
- Department of Anestesiology-Reanimatology, People’s Friendship University of Russia, 117198 Moscow, Russia
| | - Elena Luginina
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
| | - Igor Pryanikov
- Department for the Study of Chronic Disorder of Consciousness, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (J.N.); (M.K.); (I.B.); (D.S.); (A.V.); (I.P.); (M.S.); (V.P.); (M.V.P.); (E.L.)
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Driessen DMF, Utens CMA, Ribbers GM, van Erp WS, Heijenbrok-Kal MH. Outcome registry of early intensive neurorehabilitation in patients with disorders of consciousness: study protocol of a prospective cohort study. BMC Neurol 2021; 21:69. [PMID: 33579219 PMCID: PMC7879405 DOI: 10.1186/s12883-021-02099-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/05/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Prolonged disorders of consciousness (PDOC) may occur after severe brain injury. Two diagnostic entities are distinguished within PDOC: unresponsive wakefulness syndrome (UWS, previously known as vegetative state) and minimally conscious state (MCS). Patients with PDOC may benefit from early intensive neurorehabilitation (EIN). In the Netherlands, the EIN programme is provided by one designated expert rehabilitation centre and forms the starting point of a dedicated chain of specialised rehabilitation and care for this group. This study project, called DOCTOR: Disorders of Consciousness; Treatment and Outcomes Registry, sets up a registry and systematically investigates multiple short- and long-term outcomes of patients with PDOC who receive EIN. METHODS Single-centre prospective cohort study with a 2-year follow-up period. Patients with PDOC due to acute brain injury who receive EIN, aged 16 years and older are included. Measurements will take place at start EIN, in week 5, 10, and at discharge from the EIN programme (duration = max 14 weeks) and at week 28, 40, 52, and 104 after admission to the EIN programme, following patients through the health-care chain. Outcome measures are the changes over time in level of consciousness, using the Coma Recovery Scale-Revised; the frequency and type of medical complications; the mortality rate; level of disability, including the level of motor, cognitive, behavioural and emotional functioning; participation; and quality of life. Secondary outcomes include self-efficacy of caregivers, caregivers' strain and cost-effectiveness of the programme. DISCUSSION The DOCTOR study will provide insight in the recovery patterns and predictors of recovery for multiple outcomes in PDOC patients after following EIN. The results of the study will enable us to benchmark and improve EIN and the organisation of the health-care chain, both for patients with PDOC and for their families. TRIAL REGISTRATION Netherlands Trial Register, NL 8138 . Retrospectively registered 6 November 2019.
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Affiliation(s)
- Danielle M F Driessen
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands. .,Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands.
| | - Cecile M A Utens
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.,Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands
| | - Gerard M Ribbers
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.,Rijndam Rehabilitation, PO Box 23181, 3001 KD, Rotterdam, the Netherlands
| | - Willemijn S van Erp
- Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands.,Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, the Netherlands.,Accolade Zorg, Zeist, the Netherlands
| | - Majanka H Heijenbrok-Kal
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.,Rijndam Rehabilitation, PO Box 23181, 3001 KD, Rotterdam, the Netherlands
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5
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Gonzalez-Lara LE, Munce S, Christian J, Owen AM, Weijer C, Webster F. The multiplicity of caregiving burden: a qualitative analysis of families with prolonged disorders of consciousness. Brain Inj 2021; 35:200-208. [PMID: 33385307 DOI: 10.1080/02699052.2020.1865565] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: To understand the multiple and sometimes conflicting roles substitute decision makers (SDMs) of individuals in a vegetative state (VS), minimally conscious state (MCS), or with locked-in syndrome (LIS) perform while caring for a loved one and the competing priorities derived from these roles.Methods: We conducted semi-structured qualitative interviews using a constructive-grounded theory design. Twelve SDMs, who were also family members for 11 patients, were interviewed at two time points (except one) for a total of 21 in-depth interviews.Results: Participants described that caregiving is often the central role which they identify as their top priority and around which they coordinate and to some extent subordinate their other roles. In addition to caregiving, they participated in a wide variety of roles, which were sometimes in conflict, as they became caregivers for a loved one with chronic and complex needs. SDMs described the caregiver role as complex and intense that lead to physical, emotional, social, and economic burdens.Conclusion: SDMs report high levels of burdens in caring for a person with a prolonged disorder of consciousness. Lack of health system support that recognized the broader context of SDMs lives, including their multiple competing priorities, was a major contributing factor.
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Affiliation(s)
| | - Sarah Munce
- Toronto Rehabilitation Institute - University Health Network
| | | | - Adrian M Owen
- The Brain and Mind Institute, Western University, London, Ontario, Canada
| | | | - Fiona Webster
- Labatt Family School of Nursing, Western University, London, Ontario, Canada
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6
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Song M, Yang Y, Yang Z, Cui Y, Yu S, He J, Jiang T. Prognostic models for prolonged disorders of consciousness: an integrative review. Cell Mol Life Sci 2020; 77:3945-3961. [PMID: 32306061 PMCID: PMC11104990 DOI: 10.1007/s00018-020-03512-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 12/21/2022]
Abstract
Disorders of consciousness (DoC) are acquired conditions of severe altered consciousness. During the past decades, some prognostic models for DoC have been explored on the basis of a variety of predictors, including demographics, neurological examinations, clinical diagnosis, neurophysiology and brain images. In this article, a systematic review of pertinent literature was conducted. We identified and evaluated 21 prognostic models involving a total of 1201 DoC patients. In terms of the reported accuracies of predicting the prognosis of DoC, these 21 models vary widely, ranging from 60 to 90%. Using improvement of consciousness level as favorable outcome criteria, we performed a quantitative meta-analysis, and found that the pooled sensitivity and specificity of the hybrid model that combined more than one technique were both superior to those of any single technique, including EEG and fMRI at the tasks and resting state. These results support the view that any single technique has its own advantages and limitations; and the integrations of multiple techniques, including diverse brain images and different paradigms, have the potential to improve predictive accuracy for DoC. Then, we provide methodological points of view and some prospects about future research. Totally, in comparison to a great many diagnostic methods for the DoC, the research of prognostic models is sparse and preliminary, still largely in its infancy with many challenges and opportunities.
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Affiliation(s)
- Ming Song
- National Laboratory of Pattern Recognition, Institute of Automation, The Chinese Academy of Sciences, Beijing, 100190, China
- Brainnetome Center, Institute of Automation, The Chinese Academy of Sciences, Beijing, 100190, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Zhengyi Yang
- National Laboratory of Pattern Recognition, Institute of Automation, The Chinese Academy of Sciences, Beijing, 100190, China
- Brainnetome Center, Institute of Automation, The Chinese Academy of Sciences, Beijing, 100190, China
| | - Yue Cui
- National Laboratory of Pattern Recognition, Institute of Automation, The Chinese Academy of Sciences, Beijing, 100190, China
- Brainnetome Center, Institute of Automation, The Chinese Academy of Sciences, Beijing, 100190, China
| | - Shan Yu
- National Laboratory of Pattern Recognition, Institute of Automation, The Chinese Academy of Sciences, Beijing, 100190, China
- Brainnetome Center, Institute of Automation, The Chinese Academy of Sciences, Beijing, 100190, China
| | - Jianghong He
- Department of Neurosurgery, The 7th Medical Center of the PLA General Hospital, Beijing, 100070, China.
| | - Tianzi Jiang
- National Laboratory of Pattern Recognition, Institute of Automation, The Chinese Academy of Sciences, Beijing, 100190, China.
- Brainnetome Center, Institute of Automation, The Chinese Academy of Sciences, Beijing, 100190, China.
- CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Beijing, 100190, China.
- Key Laboratory for Neuroinformation of the Ministry of Education, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 625014, China.
- The Queensland Brain Institute, University of Queensland, Brisbane, QLD, 4072, Australia.
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7
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Aidinoff E, Elkayam K, Oximitny A, Groswasser Z, Gelernter I, Catz A. Consciousness recovery after various periods in vegetative state. Brain Inj 2020; 34:1253-1256. [PMID: 32757790 DOI: 10.1080/02699052.2020.1800093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recent studies suggest that late recovery from vegetative state (VS) is more prevalent today than previously thought. This study examined the decline in the rate of recovery from VS with time after admission to rehabilitation, and established a new time frame, in which the odds of recovery from VS remain substantial. METHODS Data of 206 patients with VS after traumatic and non-traumatic brain injuries (TBI and NTBI), who were treated at the Loewenstein Rehabilitation Hospital (LRH), in Raanana, Israel, between 2003 and 2015, and described in a previous publication, were further analysed. Rate of recovery from VS was monitored at several time points after admission to intensive care and consciousness rehabilitation (ICCR). RESULTS The odds of consciousness recovery were at least 54% at admission to ICCR, and 48%, 33%, 19%, and 7% at 3, 6, 9, and 12 months after admission, respectively. CONCLUSIONS The rate of recovery from VS decreases significantly with time, but contrary to previous consensus, 6-12 months after admission to ICCR, the odds of recovery from VS after TBI and NTBI remain substantial.
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Affiliation(s)
- Elena Aidinoff
- Intensive Care and Consciousness Rehabilitation Department, Loewenstein Rehabilitation Hospital , Raanana, Israel.,Intensive Care and Consciousness Rehabilitation Department, Tel Aviv University , Tel Aviv, Israel
| | - Keren Elkayam
- Intensive Care and Consciousness Rehabilitation Department, Loewenstein Rehabilitation Hospital , Raanana, Israel
| | - Ana Oximitny
- Intensive Care and Consciousness Rehabilitation Department, Loewenstein Rehabilitation Hospital , Raanana, Israel
| | - Zeev Groswasser
- Intensive Care and Consciousness Rehabilitation Department, Loewenstein Rehabilitation Hospital , Raanana, Israel.,Intensive Care and Consciousness Rehabilitation Department, Tel Aviv University , Tel Aviv, Israel
| | - Ilana Gelernter
- Intensive Care and Consciousness Rehabilitation Department, Tel Aviv University , Tel Aviv, Israel
| | - Amiram Catz
- Intensive Care and Consciousness Rehabilitation Department, Loewenstein Rehabilitation Hospital , Raanana, Israel.,Intensive Care and Consciousness Rehabilitation Department, Tel Aviv University , Tel Aviv, Israel
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Arzi A, Rozenkrantz L, Gorodisky L, Rozenkrantz D, Holtzman Y, Ravia A, Bekinschtein TA, Galperin T, Krimchansky BZ, Cohen G, Oksamitni A, Aidinoff E, Sacher Y, Sobel N. Olfactory sniffing signals consciousness in unresponsive patients with brain injuries. Nature 2020; 581:428-433. [PMID: 32461641 DOI: 10.1038/s41586-020-2245-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/26/2020] [Indexed: 11/09/2022]
Abstract
After severe brain injury, it can be difficult to determine the state of consciousness of a patient, to determine whether the patient is unresponsive or perhaps minimally conscious1, and to predict whether they will recover. These diagnoses and prognoses are crucial, as they determine therapeutic strategies such as pain management, and can underlie end-of-life decisions2,3. Nevertheless, there is an error rate of up to 40% in determining the state of consciousness in patients with brain injuries4,5. Olfaction relies on brain structures that are involved in the basic mechanisms of arousal6, and we therefore hypothesized that it may serve as a biomarker for consciousness7. Here we use a non-verbal non-task-dependent measure known as the sniff response8-11 to determine consciousness in patients with brain injuries. By measuring odorant-dependent sniffing, we gain a sensitive measure of olfactory function10-15. We measured the sniff response repeatedly over time in patients with severe brain injuries and found that sniff responses significantly discriminated between unresponsive and minimally conscious states at the group level. Notably, at the single-patient level, if an unresponsive patient had a sniff response, this assured future regaining of consciousness. In addition, olfactory sniff responses were associated with long-term survival rates. These results highlight the importance of olfaction in human brain function, and provide an accessible tool that signals consciousness and recovery in patients with brain injuries.
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Affiliation(s)
- Anat Arzi
- Department of Psychology, University of Cambridge, Cambridge, UK. .,Azrieli Center for Human Brain Imaging and Research, Weizmann Institute of Science, Rehovot, Israel. .,Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel.
| | - Liron Rozenkrantz
- Azrieli Center for Human Brain Imaging and Research, Weizmann Institute of Science, Rehovot, Israel.,Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Lior Gorodisky
- Azrieli Center for Human Brain Imaging and Research, Weizmann Institute of Science, Rehovot, Israel.,Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | | | - Yael Holtzman
- Azrieli Center for Human Brain Imaging and Research, Weizmann Institute of Science, Rehovot, Israel.,Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Aharon Ravia
- Azrieli Center for Human Brain Imaging and Research, Weizmann Institute of Science, Rehovot, Israel.,Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | | | | | | | - Gal Cohen
- Loewenstein Hospital Rehabilitation Center, Raanana, Israel
| | - Anna Oksamitni
- Loewenstein Hospital Rehabilitation Center, Raanana, Israel
| | - Elena Aidinoff
- Loewenstein Hospital Rehabilitation Center, Raanana, Israel
| | - Yaron Sacher
- Loewenstein Hospital Rehabilitation Center, Raanana, Israel.,Sackler Medical Faculty, Tel-Aviv University, Tel Aviv, Israel
| | - Noam Sobel
- Azrieli Center for Human Brain Imaging and Research, Weizmann Institute of Science, Rehovot, Israel. .,Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel.
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The patient with severe traumatic brain injury: clinical decision-making: the first 60 min and beyond. Curr Opin Crit Care 2020; 25:622-629. [PMID: 31574013 DOI: 10.1097/mcc.0000000000000671] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies. RECENT FINDINGS Clinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome. SUMMARY Recent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable.
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