Recovery of patients after four months or more in the persistent vegetative state

Cerebral Glucose Metabolism in Patients with Chronic Disorders of Consciousness

OBJECTIVE

To measure regional cerebral metabolic rate of glucose (CMRGlu) in patients with chronic disorders of consciousness (DOCs) using 18F-fluorodeoxyglucose positron emission tomography (FDG-PET).

METHODS

This retrospective cohort study examined 50 patients (mean age: 40.9 ± 20.1 years) with traumatic brain injury (TBI)-induced chronic DOCs [minimally conscious state (MCS)+, n = 20; MCS-, n = 15 and vegetative state (VS), n = 15]. We measured FDG-PET-based CMRGlu values in 12 regions of both brain hemispheres and compared those among MCS+, MCS - and VS patients.

RESULTS

In both hemispheres, the regional CMRGlu reduced with consciousness deterioration in 11 of 12 regions (91.7%). In seven right hemisphere regions, CMRGlu values were markedly higher in MCS+ patients than in MCS- patients. Furthermore, CMRGlu was suggestively higher in the left occipital region in MCS- patients than in VS patients.

CONCLUSION

Functional preservation in the left occipital region in patients with chronic DOCs might reflect an awareness of external environments, whereas extensive functional preservation in the right cerebral hemisphere might reflect communication motivation.

Transcranial Magnetic Stimulation in Disorders of Consciousness: An Update and Perspectives

Disorders of consciousness (DOC) is a state in which consciousness is affected by brain injuries, leading to dysfunction in vigilance, awareness, and behavior. DOC encompasses coma, vegetative state, and minimally conscious state based on neurobehavioral function. Currently, DOC is one of the most common neurological disorders with a rapidly increasing incidence worldwide. Therefore, DOC not only impacts the lives of individuals and their families but is also becoming a serious public health threat. Repetitive transcranial magnetic stimulation (rTMS) can stimulate electrical activity using a pulsed magnetic field in the brain, with great value in the treatment of chronic pain, neurological diseases, and mental illnesses. However, the clinical application of rTMS in patients with DOC is debatable. Herein, we report the recent main findings of the clinical therapeutics of rTMS for DOC, including its efficacy and possible mechanisms. In addition, we discuss the potential key parameters (timing, location, frequency, strength, and secession of rTMS applications) that affect the therapeutic efficiency of rTMS in patients with DOC. This review may help develop clinical guidelines for the therapeutic application of rTMS in DOC.

Medication Adherence in Patients With Glaucoma and Disability

Importance

People with disabilities tend to have lower medication adherence. Glaucoma medication adherence has been scantly studied for people with disability.

Objective

To determine whether disability leads to reduced glaucoma medication adherence and whether this decrease varies by type of disability.

Design, Setting, and Participants

This population-based case-control study enrolled individuals with glaucoma and without disability, who were followed up until they received disability certification. All patients in Taiwan with confirmed glaucoma in 1 or both eyes were identified using National Health Insurance claims data. All patients with glaucoma who required glaucoma medication adherence (confirmed glaucoma, suspected glaucoma, and patients with ocular hypertension) and had newly obtained disability status after December 31, 2013, were identified and matched to counterparts without disability based on age and sex. The study period was January 1, 1997, to December 31, 2017. Data were analyzed from May 2021 to August 2021.

Exposures

All patients were followed up until they obtained confirmed disability status, which was identified using the National Disability Registry in Taiwan.

Main Outcomes and Measures

Secondary adherence was measured using frequencies of glaucoma medication refills and outpatient visits at 1-year and 2-year intervals.

Results

A total of 46 468 patients with glaucoma (23 234 with disability and 23 234 without disability; 24 508 men [52.7%]; 21 960 women [47.3%] mean [SD] age, 72.5 [14.3] years) were included in the study. Overall, the frequency of glaucoma outpatient visits was higher in people with disabilities than those without disabilities both before the index dates (difference, 0.64 [95% CI, 0.57-0.72]; P < .001) and after the index dates (difference, 0.34 [95% CI, 0.27-0.41]; P < .001) when using 1-year intervals. However, when stratified by the type of disability, having limb disability, being in a vegetative state, and having dementia were associated with fewer outpatient visits and lower medication adherence (at a maximum of 17.60 [95% CI, 8.90-26.30] percentage points lower; P < .001) compared with people without disability. Adjusted regression results revealed that people with visual disability had a mean of 2.50 (95% CI, 2.34-2.67) times more glaucoma outpatient visits than their matches who were disability free (P < .001).

Conclusions and Relevance

Certain types of disability can reduce glaucoma medication adherence by up to 17.60%. Policies targeting medication adherence should consider these disability types.

Defining catastrophic brain injury in children leading to coma and disorders of consciousness and the scope of the problem

PURPOSE OF REVIEW

Severe brain injury in children resulting in coma and disorders of consciousness (DOC) is a catastrophic event for the life and function of children and their families. The present article summarizes the recently published pediatric literature on validated diagnostic assessments, potential predictors of recovery, and outcome measures used in children with catastrophic brain injury (CBI). Literature search terms included variants of consciousness, diagnostic tests, predictors of outcome, and outcome measures.

RECENT FINDINGS

Developmentally appropriate diagnostic tools, outcome predictors, and outcome measures are lacking for children with CBI leading to coma and DOC. Individual case prognosis relies on serial clinical examinations and experience. Evidence regarding optimal diagnosis of the highest level of consciousness and management of children with CBI is needed. Global efforts through the ongoing Curing Coma Campaign are aimed at: developing common data elements for information capture; streamlining the classification of coma endotypes; describing trajectories with biomarkers to monitor recovery or disease progression; and devising effective treatments for adults and children.

SUMMARY

Standardized, developmentally appropriate diagnostic and outcome assessments for CBI in children are needed. Future research should use these content standards to update our understanding of children with CBI leading to coma and DOC, and evaluate effective practices using acute adjunctive and rehabilitation therapies.

Temporal Profile of Recovery of Communication in Patients With Disorders of Consciousness After Severe Brain Injury

OBJECTIVE

Characterize the temporal profile of recovery of communication after severe brain injury.

DESIGN

Retrospective cohort study.

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

Patients with severe acquired brain injury and no evidence of communication on the Coma Recovery Scale-Revised (CRS-R) (N=175).

MAIN OUTCOME MEASURES

Time from injury to recovery of intentional communication (IC, inconsistent yes/no responses) and functional communication (FC, consistent and accurate yes/no responses) on the CRS-R Communication subscale.

RESULTS

Patients (N=175) were included in the primary observation period of the first 8 weeks of inpatient rehabilitation (median [interquartile range, IQR]: 48 [27-61] years old, 105 men, 28 [21-38] days postinjury, 100 traumatic etiology). Fifty-four patients (31%) did not recover IC or FC. Thirty patients (17%) recovered IC only (median [IQR] days from injury to IC= 40 [34-54]), 72 patients (41%) recovered IC followed by FC (days from injury to FC=50 [42-61]), and 19 patients (11%) recovered FC without first recovering IC (43 [32-63]). The patients who recovered neither IC nor FC within 8 weeks of admission were admitted to rehabilitation later than those who recovered IC and/or FC (P<.01). Sixteen patients who did not recover communication within 8 weeks of admission to rehabilitation subsequently recovered FC prior to discharge.

CONCLUSIONS

In patients with severe brain injury receiving inpatient rehabilitation, discernible yes-no responses emerged approximately 6 weeks postinjury and became reliable 1 week later. Approximately 1 in 3 patients did not demonstrate IC or FC within 8 weeks of admission to rehabilitation, although 33% of these individuals recovered communication prior to discharge. In total, 61% of patients recovered FC prior to discharge from rehabilitation.

Longitudinal assessments highlight long-term behavioural recovery in disorders of consciousness

Accurate diagnosis and prognosis of disorders of consciousness is complicated by the variability amongst patients' trajectories. However, the majority of research and scientific knowledge in this field is based on cross-sectional studies. The translational gap in applying this knowledge to inform clinical management can only be bridged by research that systematically examines follow-up. In this study, we present findings from a novel longitudinal study of the long-term recovery trajectory of 39 patients, repeatedly assessed using the Coma Recovery Scale-Revised once every 3 months for 2 years, generating 185 assessments. Despite the expected inter-patient variability, there was a statistically significant improvement in behaviour over time. Further, improvements began approximately 22 months after injury. Individual variation in the trajectory of recovery was influenced by initial diagnosis. Patients with an initial diagnosis of unresponsive wakefulness state, who progressed to the minimally conscious state, did so at a median of 485 days following onset-later than 12-month period after which current guidelines propose permanence. Although current guidelines are based on the expectation that patients with traumatic brain injury show potential for recovery over longer periods than those with non-traumatic injury, we did not observe any differences between trajectories in these two subgroups. However, age was a significant predictor, with younger patients showing more promising recovery. Also, progressive increases in arousal contributed exponentially to improvements in behavioural awareness, especially in minimally conscious patients. These findings highlight the importance of indexing arousal when measuring awareness, and the potential for interventions to regulate arousal to aid long-term behavioural recovery in disorders of consciousness.

Recovery from vegetative state of patients with a severe brain injury: a 4-year real-practice prospective cohort study

Patients who have suffered severe traumatic or nontraumatic brain injuries can show a progressive recovery, transitioning through a range of clinical conditions. They may progress from coma to a vegetative state (VS) and/or a minimally conscious state (MCS). A longer duration of the VS is known to be related to a lower probability of emergence from it; furthermore, the literature seems to lack evidence of late improvements in these patients. This real-practice prospective cohort study was conducted in inpatients in a VS following a severe brain injury, consecutively admitted to a vegetative state unit (VSU). The aim of the study was to assess their recovery in order to identify variables that might increase the probability of a VS patient transitioning to MCS. Rehabilitation treatment included passive joint mobilisation and helping/placing patients into an upright sitting position on a tilt table. All the patients underwent a specific assessment protocol every month to identify any emergence, however late, from the VS. Over a 4-year period, 194 patients suffering sequelae of a severe brain injury, consecutively seen, had an initial Glasgow Coma Scale score ≤ 8. Of these, 63 (32.5%) were in a VS, 84 (43.3%) in a MCS, and 47 (24.2%) in a coma; of the 63 patients admitted in a VS, 49 (57.1% males and 42.9% females, mean age 25.34 ± 19.12 years) were transferred to a specialist VSU and put on a slow-to-recover brain injury programme. Ten of these 49 patients were still in a VS after 36 months; of these 10, 3 recovered consciousness, transitioning to a MCS, 2 died, and 5 remained in a VS during the last 12 months of the observation. Univariate analysis identified male sex, youth, a shorter time from onset of the VS, diffuse brain injury, and the presence of status epilepticus as variables increasing the likelihood of transition to a MCS. Long-term monitoring of patients with chronic disorders of consciousness should be adequately implemented in order to optimise their access to rehabilitation services.

Pressure to Progress: Severe Traumatic Brain Injury and Slow Recovery in the Current Health Care Environment

This paper discusses issues arising from a study of referral from acute care following traumatic brain injury (TBI) in Queensland, in which aged care facilities were relied upon for the discharge of those with slow recovery after severe TBI. The discussion considers: (1) recovery following severe TBI; (2) the current policy context; (3) approaches to care beyond acute care; and (4) implications for policy and practice. In the current health care environment, with increasing pressure on scarce resources, it is critical that practitioners advocate for the dignity and care of people who sustain severe TBI and who are slow to recover.

Intracranial hemorrhage

Intracranial hemorrhage is a life-threatening condition, the outcome of which can be improved by intensive care. Intracranial hemorrhage may be spontaneous, precipitated by an underlying vascular malformation, induced by trauma, or related to therapeutic anticoagulation. The goals of critical care are to assess the proximate cause, minimize the risks of hemorrhage expansion through blood pressure control and correction of coagulopathy, and obliterate vascular lesions with a high risk of acute rebleeding. Simple bedside scales and interpretation of computed tomography scans assess the severity of neurological injury. Myocardial stunning and pulmonary edema related to neurological injury should be anticipated, and can usually be managed. Fever (often not from infection) is common and can be effectively treated, although therapeutic cooling has not been shown to improve outcomes after intracranial hemorrhage. Most functional and cognitive recovery takes place weeks to months after discharge; expected levels of functional independence (no disability, disability but independence with a device, dependence) may guide conversations with patient representatives. Goals of care impact mortality, with do-not-resuscitate status increasing the predicted mortality for any level of severity of intraparenchymal hemorrhage. Future directions include refining the use of bedside neuro-monitoring (electroencephalogram, invasive monitors), novel approaches to reduce intracranial hemorrhage expansion, minimizing vasospasm, and refining the assessment of quality of life to guide rehabilitation and therapy.

The Vegetative State: Life, Death and Consciousness

The three conditions that are traditionally defined as disorders of consciousness are the comatose state, the minimally conscious state and the vegetative state. Thirty years after the phrase was coined, the definition and management of patients in vegetative states continue to provoke debate. Recent advances in neuroimaging have cast doubt on the assertion that these patients are completely unaware of their environment. This article presents a case report and review of disorders of consciousness, their definition, prognosis and ethical issues in the management of patients.

Predicting outcome in children with hypoxic ischemic encephalopathy

OBJECTIVE

Hypoxic ischemic encephalopathy (HIE) is common in children, and providing accurate and timely prognostic information is important in determining the appropriate level of care. While practice parameters are available for prognostication in adults, similar reviews are not available for children. This article reviews the current evidence in domains used to provide prognostic information in children with coma due to HIE. These include historical features of the event; physical exam signs; neurophysiologic studies, such as electroencephalogram and evoked potentials; and neuroimaging.

DATA SOURCE

A literature search of MEDLINE was performed using the search terms HIE and prognosis cross-referenced in series with specific domains used to provide prognostic information, including physical examination, electroencephalogram, evoked potentials, neuroimaging, and magnetic resonance imaging. The results of these searches were scanned by the authors to identify articles pertaining to children (nonneonates). Further literature was identified from the reference lists of the literature identified by MEDLINE search. Clinical, preclinical, and review articles were identified that were related to the current understanding of prognosis in pediatric HIE. Only literature in English was reviewed.

RESULTS

When performed at least 24 hrs after the inciting event, abnormal exam signs (pupil reactivity and motor response), absent N20 waves bilaterally on somatosensory evoked potentials, electrocerebral silence or burst suppression patterns on electroencephalogram (not due to metabolic or medication etiology), and abnormal magnetic resonance imaging with diffusion restriction in the cortex and basal ganglia are each highly predictive of poor outcome. Combining these modalities improves the overall predictive value.

CONCLUSIONS

All testing provides the best prognostic information several days after hypoxic-ischemic injury, and often multiple tests are required to improve prognostic ability and rule out potentially confounding conditions. Thus, when decisions can be postponed several days, neurologic consultation and testing can provide the best prognostic information to families.

Cerebellar Vermis Relative Hypermetabolism: An Almost Constant PET Finding in an Injured Brain

Cortical alterations of brain metabolism, as seen in PET, obviously depend on the nature of the damage (either mechanical, toxic, anoxic, or other). However, some subcortical abnormalities seem to occur rather frequently regardless of the extension, position and cause of the damage. In particular, relative cerebellar vermis activation seems to be frequently encountered. The aim of this work was to determine the incidence of this pattern in a heterogeneous population of brain trauma, and to compare it on a quantitative basis with a group of age-sex matched controls. The case records of this study consist of 58 consecutive patients, 44 males, 14 females, age 14-69 (median 34) 44 traumatic, 8 anoxic, 4 vascular and 2 toxic injuries. In the trauma group, the visualization of the cerebellar vermis was readily appreciable as a consistent majority of cases. In particular, the mean vermis/cerebellum ratio (calculated by appropriate ROI positioning) was 1.26 +/- 0.17 SD (range 0.92-1.82); in the control group the same parameters showed much less dispersion: average 0.92 +/- 0.06, range 0.80-1.10 (P < 0.005). If, on the basis of the normal group data, a cut-off value of 1 is accepted for the v/c ratio, it is noted that 54/57 trauma patients (95%) showed a ratio above this value. In conclusion, a hypermetabolic cerebellar vermis is a common finding in a damaged brain, regardless of the nature of the trauma (probably due to the relative preservation compared with other structures of alternative metabolic pathways), and seems to be the hallmark of the injured brain.

Tracking the recovery of consciousness from coma

Predicting the chances of recovery of consciousness and communication in patients who survive their coma but transit in a vegetative state or minimally conscious state (MCS) remains a major challenge for their medical caregivers. Very few studies have examined the slow neuronal changes underlying functional recovery of consciousness from severe chronic brain damage. A case study in this issue of the JCI reports an extraordinary recovery of functional verbal communication and motor function in a patient who remained in MCS for 19 years (see the related article beginning on page 2005). Diffusion tensor MRI showed increased fractional anisotropy (assumed to reflect myelinated fiber density) in posteromedial cortices, encompassing cuneus and precuneus. These same areas showed increased glucose metabolism as studied by PET scanning, likely reflecting the neuronal regrowth paralleling the patient's clinical recovery. This case shows that old dogmas need to be oppugned, as recovery with meaningful reduction in disability continued in this case for nearly 2 decades after extremely severe traumatic brain injury.

Chronic disorders of consciousness

The vegetative state and the minimally conscious state are disorders of consciousness that can be acute and reversible or chronic and irreversible. Diffuse lesions of the thalami, cortical neurons, or the white-matter tracts that connect them cause the vegetative state, which is wakefulness without awareness. Functional imaging with PET and functional MRI shows activation of primary cortical areas with stimulation, but not of secondary areas or distributed neural networks that would indicate awareness. Vegetative state has a poor prognosis for recovery of awareness when present for more than a year in traumatic cases and for 3 months in non-traumatic cases. Patients in minimally conscious state are poorly responsive to stimuli, but show intermittent awareness behaviours. Indeed, findings of preliminary functional imaging studies suggest that some patients could have substantially intact awareness. The outcomes of minimally conscious state are variable. Stimulation treatments have been disappointing in vegetative state but occasionally improve minimally conscious state. Treatment decisions for patients in vegetative state or minimally conscious state should follow established ethical and legal principles and accepted practice guidelines of professional medical specialty societies.

Misdiagnosing the vegetative state after severe brain injury: the influence of medication

Patients who suffer severe brain damage may be left unaware of self and of the environment and in a permanent vegetative state (PVS). The difficulties in correctly ascertaining unawareness after brain injury have been emphasized by a number of authors. It is well recognized that toxic-metabolic and drug-induced cerebral depression occurs acutely after brain injury. However, less attention has been drawn to the effects of medication months after brain injury and the way in which medication may confound assessment of awareness and, thus, the reliable assessment of long-term prognosis. This paper describes two patients who sustained a severe and well-documented structural brain injury, one hypoxic and one traumatic. Both were unaware when first seen at 3 months post-injury, but both have made useful functional recovery. The paper discusses their progress and how the early prescription of large doses of anti-epileptic drugs, sedatives and anti-spastic agents in these circumstances may result in an initial misdiagnosis of the vegetative state.

Human organs from prisoners: kidneys for life

A proposal to allow prisoners to save their lives or to be eligible for commutation of sentence by donating kidneys for transplantation has been a subject of controversy in the Philippines. Notwithstanding the vulnerabilities associated with imprisonment, there are good reasons for allowing organ donations by prisoners. Under certain conditions, such donations can be very beneficial not only to the recipients but to the prisoners themselves. While protection needs to be given to avoid coercion and exploitation, overprotection has to be avoided. The prohibition on the involvement of prisoners in organ transplantation constitutes unjustified overprotection. Under certain conditions, prisoners can make genuinely independent decisions. When it can be reasonably ascertained that they are able to decide freely, society should recognise an obligation to help them implement their decisions, such as when they intend to donate an organ as a way of asserting their religious faith and performing a sacrifice in atonement for their sins.

Telerehabilitation support for families at home caring for individuals in prolonged states of reduced consciousness

OBJECTIVE

To investigate the use of telerehabilitation to support families caring at home for individuals with prolonged states of reduced consciousness.

DESIGN

A comparison group approach.

PARTICIPANTS

Participants were recruited from a special program that is part of a Model Systems brain injury program located in the Southeast. Five patients, ranging from Rancho 1 to Rancho 3 were discharged home with family members as the primary caregivers.

PROCEDURES

Participant families were followed for 4 to 8 weeks via videophone. Follow-up telephone surveys were conducted with a family member 6 to 9 months after discharge and compared with a similar group that had not received the videophone follow-up.

MAIN OUTCOME MEASURES

Present living status, number of emergency room visits, number of hospitalizations, the caregivers' perceptions of functional status and care needs, readmission for rehabilitation and perceived family needs as measured by the Family Needs Questionnaire (FNQ).

RESULTS

More patients in the videoconferencing group were still living at home and had returned for rehabilitation. On the FNQ, families in the videophone group reported more of their needs met than families in the comparison group.

CONCLUSIONS

The use of videoconferencing to bridge the transition to home for families caring for a family member at the Rancho 1 to Rancho 3 level may assist families in successfully caring for the individual in the home and reducing the number of perceived family needs.

Early indication of emergence from vegetative state derived from assessments with the SMART--a preliminary report

An explanatory analysis of data from serial assessments of 30 patients with a diagnosis of vegetative state (persistent vegetative state) was carried out. The data were gathered using the Sensory Modality Assessment and Rehabilitation Technique (SMART) and the Western Neuro Sensory Stimulation Profile (WNSSP) on the same day in the week post-admission and, thereafter, at 2 monthly intervals. Seven patients emerged from vegetative state during the study, a further six emerged later (by time of the analysis) and the rest remained in vegetative state. Recovery scores were calculated for each measure by subtracting the total score at any one assessment from the total score for the subsequent assessment; the largest recovery scores, shown by each patient, were noted. It was found that those who emerged later could be differentiated mathematically from those who did not emerge, using largest recovery score data from the SMART. This research supports previous

Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit

OBJECTIVE

To identify the number of patients who were misdiagnosed as being in the vegetative state and their characteristics.

DESIGN

Retrospective study of the clinical records of the medical, occupational therapy, and clinical psychology departments.

SETTING

20 bed unit specialising in the rehabilitation of patients with profound brain damage, including the vegetative state.

SUBJECTS

40 patients admitted between 1992 and 1995 with a referral diagnosis of vegetative state.

OUTCOME MEASURES

Patients who showed an ability to communicate consistently using eye pointing or a touch sensitive single switch buzzer.

RESULTS

Of the 40 patients referred as being in the vegetative state, 17 (43%) were considered as having been misdiagnosed; seven of these had been presumed to be vegetative for longer than one year, including three for over four years. Most of the misdiagnosed patients were blind or severely visually impaired. All patients remained severely physically disabled, but nearly all were able to communicate their preference in quality of life issues-some to a high level.

CONCLUSIONS

The vegetative state needs considerable skill to diagnose, requiring assessment over a period of time; diagnosis cannot be made, even by the most experienced clinician, from a bedside assessment. Accurate diagnosis is possible but requires the skills of a multidisciplinary team experienced in the management of people with complex disabilities. Recognition of awareness is essential if an optimal quality of life is to be achieved and to avoid inappropriate approaches to the courts for a declaration for withdrawal of tube feeding.

Behavioural differences between patients who emerged from vegetative state and those who did not

This paper reports on a meta-analysis of behavioural data gathered using single case research methodology, while evaluating the immediate effects of a treatment (sensory stimulation) on 24 individuals diagnosed as being in vegetative state following trauma. The data derived from time sampling have been used to compile measures of behavioural change in response to environmental events, which are referred to as arousal profiles. In addition to this, interviews were conducted regularly to elicit structured observations from the nursing staff concerning behavioural changes that they had observed. The subjects were divided into two groups according to whether they had emerged from vegetative state or not at the time the meta-analysis commenced. Statistically significant differences were found between the outcome groups in terms of modal arousal profile characteristics; one profile type was characteristic only of those that emerged. The two groups could also be differentiated by the mean recovery curves derived from the interview data. Behavioural differences between the outcome groups have been found which are detectable while the patients are in vegetative state. These findings have prognostic potential.

Persistent vegetative state: what decides the cut-off point?

Advances in medicine and technology have allowed us early and effective diagnosis and treatment of many disease processes, with new and developing interventions ensuring this progression. However, in some illnesses and conditions, despite appropriate treatment, deterioration in the person's condition ensues. This may occur following a cardiopulmonary arrest, where resuscitation may have been 'successful' at the time, but the brain has suffered irreversible anoxic damage. It has been seen that only 10-25% of patients survive to discharge following a cardiac arrest (Broadway 1993), and the consequences of cardiopulmonary resuscitation can not only be costly but can leave the patient in a persistent vegetative state (PVS). PVS, however, does not confine itself to these patients alone, and can present following other cerebral traumas, including head injuries. This is therefore especially pertinent to intensive care nurses, who may find themselves caring for such patients in a critical care setting. Growing public awareness of this altered health state due, for instance, to the Tony Bland case in the UK in 1993, has highlighted a need for greater knowledge of the consequences of the condition and the proposed management of patients in PVS. This paper attempts to describe the course of this syndrome, and considers some of the ethical and moral issues surrounding the care and treatment of patients with PVS. The issues surrounding euthanasia are briefly explored together with the attitudes of those caring for these patients.

Level of care options for the low-functioning brain injury survivor

During the early stages of recovery from severe brain injury many patients are comatose or minimally responsive. Rehabilitation for these low-functioning survivors traditionally includes acute medical care and transfer to a skilled nursing facility or acute rehabilitation. Concerns have been expressed that customary treatment options are ineffective, costly, or both. In response, 'intermediate'-level programmes designed to provide effective, cost-efficient rehabilitation have emerged. The purpose of this paper is to provide information regarding outcome of severe brain injury and the early rehabilitation needs of survivors. Common characteristics, advantages, and disadvantages of various intermediate programmes, including 'subacute' and 'transitional' rehabilitation, are discussed and contrasted.

Assessment of neurological prognosis in comatose survivors of cardiac arrest. BRCT I Study Group

When a patient resuscitated from cardiac arrest remains unconscious the clinician would like to have a reliable early method for predicting the outcome. The objective of our study was to predict cerebral outcome after cardiac arrest by clinical neurological examination. The data were drawn from an international multicentre controlled clinical trial of thiopentone. Twelve hospitals in nine countries took part. 262 comatose cardiac arrest survivors were followed up for one year. These patients were given advanced life support (American Heart Association guidelines) followed by intensive care to a standardised protocol. Glasgow and Glasgow-Pittsburgh coma scores and their constituent signs were recorded at fixed times. Outcome was taken to be the best cerebral performance at any time during follow-up, and for that purpose we used cerebral performance categories (CPC 1-5) of the Glasgow outcome categories. A poor outcome (CPC 3-5) could be predicted immediately after reperfusion (at entry into the study) with an accuracy ranging from 52% to 84% for various signs and scores. On the third day it was possible to identify severely disabled or permanently comatose survivors without false predictions using both coma scores and several of their constituent variables. The best predictor was absence of motor response to pain. This modelling exercise now needs to be repeated on a new series of patients but the results do suggest that, after 3 days, stringent ethical criteria can be met and used in decision-making about termination of care in comatose cardiac arrest survivors.