Clinical parameters at time of admission as prognostic indicators in cats presented for trauma to an emergency centre in New Zealand: a retrospective analysis

OBJECTIVES

The aims of this study were to describe the clinical features of cats presented for trauma in a first-opinion and referral teaching hospital in New Zealand, and to determine the relationship between those features and outcome.

METHODS

The electronic medical records of cats presented for trauma to the Massey University Pet Emergency Centre between September 2013 and January 2019 were examined, from which the signalment, clinical parameters and patient outcomes were extracted. Cases were assigned an Animal Trauma Triage (ATT) score and Modified Glasgow Coma Scale (MGCS) score. Variables were selected for inclusion in a logistic regression model to predict survival, and backward elimination was used to find the minimal significant model.

RESULTS

In total, 530 cats met the inclusion criteria. The cause of injury was not known in the majority of cases (38.0%). The most common location of injury was the hindlimbs/pelvis/tail (n = 247; 41%), and skin lacerations/abrasions were the most common specific injury. Multivariate analysis revealed altered mentation (odds ratio [OR] 0.31, P = 0.029), hypothermia (rectal temperature <37.8°C [<100.04°F]; OR 0.45, P = 0.015) and an ATT score ⩾5 (OR 0.13, P <0.001) to be statistically significantly associated with mortality.

CONCLUSIONS AND RELEVANCE

Altered mentation and hypothermia are easily measurable perfusion parameter abnormalities associated with mortality in cats presenting with trauma. The ATT score appears to be an accurate prognostic indicator in cats presenting with trauma in New Zealand. These results highlight the importance of incorporating a hands-on triage examination in each cat that presents as an emergency after trauma.

In-Hospital Depressed Level of Consciousness and Long-Term Functional Outcomes in ICU Survivors

OBJECTIVES

Among critically ill patients, acutely depressed level of consciousness is associated with mortality, but its relationship to long-term outcomes such as disability and physical function is unknown. We investigated the relationship of level of consciousness during hospitalization with long-term disability and physical function in ICU survivors.

DESIGN

Multi-center observational cohort study.

SETTING

Medical or surgical ICUs at five U.S. centers.

PATIENTS

Adult survivors of respiratory failure or shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Depressed level of consciousness during hospitalization was defined using the Richmond Agitation Sedation Scale (RASS) score (including all negative scores) by calculating the area under the curve using linear interpolation. Sedative-associated level of consciousness was similarly defined for all hospital days that sedation was received. We measured disability in basic activities of daily living (BADLs), instrumental activities of daily living (IADLs), discharge destination, and self-reported physical function. In separate models, we evaluated associations between these measures of level of consciousness and outcomes using multivariable regression, adjusted for age, sex, race, body mass index, education level, comorbidities, baseline frailty, baseline IADLs and BADLs, hospital type (civilian vs veteran), modified mean daily Sequential Organ Failure Assessment score, duration of severe sepsis, duration of mechanical ventilation, and hospital length of stay. Of the 1,040 patients enrolled in the ICU, 781 survived to hospital discharge. We assessed outcomes in 624 patients at 3 months and 527 patients at 12 months. After adjusting for covariates, there was no association between depressed level of consciousness (total or sedation-associated) with BADLs or IADLs at either 3- or 12-month follow-up. There was also no association with self-reported physical function at 3 or 12 months or with discharge destination.

CONCLUSIONS

Depressed level of consciousness, as defined by the RASS, was not associated with disability or self-reported physical function. Future studies should investigate additional modifiable in-hospital risk factors for disability and poor physical function following critical illness.

Clinimetric study and review of the Reaction Level Scale

OBJECTIVES

Although the Reaction Level Scale (RLS) is still used for the assessment of the level of consciousness in distinct centers, its clinical characteristics and significance have been incompletely researched. In the current study, the clinimetric properties, the prognostic value, and the impact of the raters' background on the application of the RLS, in comparison with the Glasgow Coma Scale (GCS), are investigated.

MATERIALS AND METHODS

A systematic review on the available clinical evidence for the RLS was first carried out. Next, the RLS was translated into Greek, and patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with both RLS and GCS, by four raters (two consultants, one resident, and one nurse) within one hour. Interrater reliability, construct validity, and predictive value (mortality and poor outcome, at discharge and at 6 months) were evaluated.

RESULTS

Literature review retrieved 9 clinimetric studies related to the RLS, most of low quality, indicating that the scale has not been thoroughly studied. Both versions of the RLS (original and modified) showed high interrater reliability (κ_w >0.80 for all pairs of raters), construct validity (Spearman's p > .90 for all raters), and prognostic value (areas under the curve >0.85 for all raters and outcomes). However, except for broader patients' coverage, it failed to show any advantage over the GCS.

CONCLUSIONS

The RLS has not succeeded in showing any advantage over the GCS in terms of reliability and validity. Available evidence cannot justify its use in clinical practice as a substitute to the widely applied GCS.

Classification of Depth of Coma Using Complexity Measures and Nonlinear Features of Electroencephalogram Signals

In recent years, some electrophysiological analysis methods of consciousness have been proposed. Most of these studies are based on visual interpretation or statistical analysis, and there is hardly any work classifying the level of consciousness in a deep coma. In this study, we perform an analysis of electroencephalography complexity measures by quantifying features efficiency in differentiating patients in different consciousness levels. Several measures of complexity have been proposed to quantify the complexity of signals. Our aim is to lay the foundation of a system that will objectively define the level of consciousness by performing a complexity analysis of Electroencephalogram (EEG) signals. Therefore, a nonlinear analysis of EEG signals obtained with a recording scheme proposed by us from 39 patients with Glasgow Coma Scale (GCS) between 3 and 8 was performed. Various entropy values (approximate entropy, permutation entropy, etc.) obtained from different algorithms, Hjorth parameters, Lempel-Ziv complexity and Kolmogorov complexity values were extracted from the signals as features. The features were analyzed statistically and the success of features in classifying different levels of consciousness was measured by various classifiers. Consequently, levels of consciousness in deep coma (GCS between 3 and 8) were classified with an accuracy of 90.3%. To the authors' best knowledge, this is the first demonstration of the discriminative nonlinear features extracted from tactile and auditory stimuli EEG signals in distinguishing different GCSs of comatose patients.

Survival Rates and Factors Related to the Survival of Traffic Accident Patients Transported by Emergency Medical Services

Background

Traffic accident patients place a tremendous burden on health care services because they require substantial, rapid, and effective evaluation, management, and treatment by emergency medical services (EMS) to decrease morbidity and mortality rates. This study investigated the 1-month survival rate and factors related to the survival of traffic accident patients managed by EMS.

Patients and Methods

We retrospectively analyzed data of traffic accident patients serviced by the Surgico Medical Ambulance and Rescue Team (SMART) at Vajira Hospital, Bangkok, from January 1, 2018, to December 31, 2020. The data were collected from EMS patient care reports recorded using the emergency medical triage protocol as well as the criteria-based dispatch response codes in Thailand. Survival data at 1 month were obtained from electronic medical records.

Results

Of the 340 traffic accident patients who fulfilled the study criteria, 314 (92.35%) were alive at 1 month. A multivariable analysis using multiple logistic regression identified prehospital level of consciousness, airway management, and cardiopulmonary resuscitation as factors associated with survival. Unresponsive patients had a lower survival rate than responsive patients (adjusted odds ratio [OR_adj] = 0.16, 95% confidence interval [CI]: 0.05-0.56, p = 0.004). Prehospital airway management and cardiopulmonary resuscitation reduced the survival rate by 0.30 and 0.10 times, respectively (OR_adj = 0.30, 95% CI: 0.09-0.97, p = 0.045 and OR_adj = 0.10, 95% CI: 0.02-0.47, p = 0.004, respectively).

Conclusion

Traffic accident patients had a high survival rate at 1 month. We identified three factors regarding EMS treatment which were related to increased survival: a prehospital responsive level of consciousness, no prehospital airway management, and no prehospital cardiopulmonary resuscitation. Therefore, the development of standard guidelines for the management of traffic accident patients by EMS is crucial to increase the survival rate of traffic accident patients.

A relational approach to consciousness: categories of level and contents of consciousness

Characterizing consciousness in and of itself is notoriously difficult. Here, we propose an alternative approach to characterize, and eventually define, consciousness through exhaustive descriptions of consciousness' relationships to all other consciousness. This approach is founded in category theory. Indeed, category theory can prove that two objects A and B in a category can be equivalent if and only if all the relationships that A holds with others in the category are the same as those of B; this proof is called the Yoneda lemma. To introduce the Yoneda lemma, we gradually introduce key concepts of category theory to consciousness researchers. Along the way, we propose several possible definitions of categories of consciousness, both in terms of level and contents, through the usage of simple examples. We propose to use the categorical structure of consciousness as a gold standard to formalize empirical research (e.g. color qualia structure at fovea and periphery) and, especially, the empirical testing of theories of consciousness.

Cross-Cultural Adaptation and Validation of the Italian Version of the Observational Scale of Level of Arousal

OBJECTIVES

Along with deficit of attention, level of arousal is a primary criterion for the diagnosis of delirium. The Observational Scale of Level of Arousal (OSLA) is a quick, simple, and observational instrument used to evaluate the variation of arousal for rapid screening of delirium in clinical practice. The current study aims to perform a cross-cultural adaption of and to validate the Italian version of the OSLA scale to detect delirium in older aged, hospitalized patients.

DESIGN

Longitudinal study.

SETTING AND PARTICIPANTS

In hospital and transitional care setting. Old age patients.

METHODS

A cross-cultural adaptation of the OSLA from English into Italian was conducted, including back-translation. The validation of the OSLA was assessed in 116 older patients (age >65 years) admitted to geriatric, internal medicine, and transitional care wards. The 4 "A"s Test serves as the gold standard for the measurement of delirium.

RESULTS

Incident delirium was assessed longitudinally at different time points during hospitalization. The Italian version of OSLA demonstrated adequate internal consistency, specificity, sensitivity, agreement, test-retest reliability, and sensitivity to change, indicating adequate its clinometric properties in the detection of delirium in a real world hospitalized cohort of older adults.

CONCLUSIONS AND IMPLICATIONS

The current study is among the few studies to assess arousal as a core feature of delirium by virtue of a longitudinal assessment of delirium, moving a step forward in the implementation of a brief and easy to use delirium-screening tool for the measurement of important clinical outcomes in a frail, old aged hospitalized population.

Adaptive Sedation Monitoring From EEG in ICU Patients With Online Learning

Sedative medications are routinely administered to provide comfort and facilitate clinical care in critically ill ICU patients. Prior work shows that brain monitoring using electroencephalography (EEG) to track sedation levels may help medical personnel to optimize drug dosing and avoid the adverse effects of oversedation and undersedation. However, the performance of sedation monitoring methods proposed to date deal poorly with individual variability across patients, leading to inconsistent performance. To address this challenge we develop an online learning approach based on Adaptive Regularization of Weight Vectors (AROW). Our approach adaptively updates a sedation level prediction algorithm under a continuously evolving data distribution. The prediction model is gradually calibrated for individual patients in response to EEG observations and routine clinical assessments over time. The evaluations are performed on a population of 172 sedated ICU patients whose sedation levels were assessed using the Richmond Agitation-Sedation Scale (scores between -5 = comatose and 0 = awake). The proposed adaptive model achieves better performance than the same model without adaptation (average accuracies with tolerance of one level difference: 68.76% vs. 61.10%). Moreover, our approach is shown to be robust to sudden changes caused by label noise. Medication administrations have different effects on model performance. We find that the model performs best in patients receiving only propofol, compared to patients receiving no sedation or multiple simultaneous sedative medications.

Effects of Mannitol 20% on Outcomes in Nontraumatic Intracerebral Hemorrhage

BACKGROUND

A large number of stroke patients are not the perfect candidate for craniotomy and invasive procedures, so providing an alternative and noninvasive method, which is applicable in terms of costs and facilities, is necessary. Thus, the present study aimed to determine the effects of mannitol 20% on outcome of the patients with nontraumatic intracerebral hemorrhage (ICH) in patients admitted to Isfahan's Al-Zahra Hospital during 2012 and 2013.

MATERIALS AND METHODS

This is a clinical trial study which is conducted during 2012-2013 in Isfahan's Al-Zahra Hospital. In this study, 41 patients suffering from ICH received mannitol 20% for 3 days, and volume of hemorrhage and Glasgow Coma Scale (GCS) of patients were controlled every 12 h. The collected data were analyzed via SPSS software.

RESULTS

The mean ICH volume was 22.1 ± 6.3 ml in pre intervention and 38.4 ± 19.3 ml in post intervention, and according to the t-paired test, before and after treatment the difference was significant (P < 0.001). Hemorrhage volume was stable in nine patients (22%), it increased in 25 patients (61%), and decreased in seven patients (17.1%). The mean index of GCS before and after treatment was 11.85 ± 1.6 and 9.37 ± 2.65, respectively. Moreover according to t-paired test, the difference was significant before and after treatment (P < 0.001). During using mannitol, the GCS index was stable in eight patients (19.5%), it increased in eight patients (19.5%) and decreased in 25 patients (61%).

CONCLUSIONS

Mannitol injection was not effective in reducing hemorrhage size, and its use is not recommended, also, further studies in this field have been proposed.

Factors involved in the discontinuation of oral intake in elderly patients with recurrent aspiration pneumonia: a multicenter study

Purpose

To assess the factors involved in oral intake discontinuation in elderly patients with recurrent aspiration pneumonia.

Patients and methods

This study included patients with pneumonia who were treated at Jichi Medical University Hospital between 2007 and 2013, at Toyooka Public Hospital between 2011 and 2013 and at Yuzawa Community Medical Center between 2010 and 2012. We consecutively enrolled patients with aspiration pneumonia. The primary study point was oral intake discontinuation after the initiation of oral intake during hospitalization in cases of recurrent aspiration. Various parameters were recorded at admission, at the initiation of intake, and during hospitalization; these parameters were statistically evaluated.

Results

A total of 390 patients were assigned to either a “no reaspiration of intake” group (n=310) or a “reaspiration of intake” group (n=80), depending on whether intake was discontinued owing to aspiration during hospitalization. At admission, the following items significantly differed between the groups: level of consciousness, respiratory rate, oxygen saturation, CURB-65 score, extent of infiltration/opacity on chest radiography, albumin levels, blood urea nitrogen levels, and application of swallowing function assessment. At the initiation of intake, level of consciousness, pulse rate, and albumin levels significantly differed between the groups. The following items did not significantly differ between groups: systolic blood pressure, pulse rate, C-reactive protein, bacteremia, use of ventilator at admission, oxygen administration, respiratory rate, and systolic blood pressure at initiation of intake. Multivariate analysis revealed that application of swallowing function assessment, level of consciousness at the initiation of intake, and extent of infiltration/opacity on chest radiography were significant predictive variables for discontinuation of intake.

Conclusion

A low level of consciousness at the initiation of intake and a greater extent of infiltration/opacity on chest radiography and the application of a swallowing function are important factors. These factors may be helpful to determine a suitable timing for resumption of oral intake.

Global and local complexity of intracranial EEG decreases during NREM sleep

Key to understanding the neuronal basis of consciousness is the characterization of the neural signatures of changes in level of consciousness during sleep. Here we analysed three measures of dynamical complexity on spontaneous depth electrode recordings from 10 epilepsy patients during wakeful rest (WR) and different stages of sleep: (i) Lempel-Ziv complexity, which is derived from how compressible the data are; (ii) amplitude coalition entropy, which measures the variability over time of the set of channels active above a threshold; (iii) synchrony coalition entropy, which measures the variability over time of the set of synchronous channels. When computed across sets of channels that are broadly distributed across multiple brain regions, all three measures decreased substantially in all participants during early-night non-rapid eye movement (NREM) sleep. This decrease was partially reversed during late-night NREM sleep, while the measures scored similar to WR during rapid eye movement (REM) sleep. This global pattern was in almost all cases mirrored at the local level by groups of channels located in a single region. In testing for differences between regions, we found elevated signal complexity in the frontal lobe. These differences could not be attributed solely to changes in spectral power between conditions. Our results provide further evidence that the level of consciousness correlates with neural dynamical complexity.

Neurostimulation to improve level of consciousness in patients with epilepsy

When drug-resistant epilepsy is poorly localized or surgical resection is contraindicated, current neurostimulation strategies such as deep brain stimulation and vagal nerve stimulation can palliate the frequency or severity of seizures. However, despite medical and neuromodulatory therapy, a significant proportion of patients continue to experience disabling seizures that impair awareness, causing disability and risking injury or sudden unexplained death. We propose a novel strategy in which neuromodulation is used not only to reduce seizures but also to ameliorate impaired consciousness when the patient is in the ictal and postictal states. Improving or preventing alterations in level of consciousness may have an effect on morbidity (e.g., accidents, drownings, falls), risk for death, and quality of life. Recent studies may have elucidated underlying networks and mechanisms of impaired consciousness and yield potential novel targets for neuromodulation. The feasibility, benefits, and pitfalls of potential deep brain stimulation targets are illustrated in human and animal studies involving minimally conscious/vegetative states, movement disorders, depth of anesthesia, sleep-wake regulation, and epilepsy. We review evidence that viable therapeutic targets for impaired consciousness associated with seizures may be provided by key nodes of the consciousness system in the brainstem reticular activating system, hypothalamus, basal ganglia, thalamus, and basal forebrain.

The state of UK pediatric anesthesia: a survey of National Health Service activity

This secondary analysis of the 2013 United Kingdom National Health Service (NHS) Anaesthesia Activity Survey of the Fifth National Audit Project (of the Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland) shows pediatric anesthesia activity in detail. A local coordinator (LC) in every NHS hospital collected data on patients undergoing any procedure managed by an anesthetist. Questionnaires had 30 question categories. Each LC was randomized to a 2-day period. The pediatric age groups were infants, (<1 year), preschool age (1-5 year), and school age children (6-15 year). The median questionnaire return rate was 98%. The annual caseload was estimated to be 486 900 children: 36 500 infants, 184 700 preschool age, and 265 800 school age children. Almost 90% of children (1-15 year) were ASA 1 or 2 and the substantial majority underwent routine nonurgent ear nose and throat, dental, orthopaedics, or general surgery procedures; 65% were 'day cases'. One in six children were managed outside operating theater sites compared with one in 12 adults. Forty one per cent was in district general hospitals. Almost all ASA 4 and 5 children (89%) and infants (92%) were managed in specialist hospitals. 'Awake' cases and sedation accounted for only 2% of cases. There were notable differences in demography and anesthetic care compared with adults and between different age groups of children. These data enable analysis of the current state of UK pediatric anesthetic practice and highlight differences between pediatric and adult services.

Effects of pain management program on the length of stay of patients with decreased level of consciousness: A clinical trial

Background:

Critical care patients are at higher risk for untreated pain. Pain has persistent and untreated effects on most of the body systems and results in development of complications, chronic pain, and increased length of stay. The aim of this study was to determine the effects of the implementation of a pain management program on the length of stay in patients with decreased level of consciousness, admitted in Al-Zahra hospital intensive care units (ICUs) in 2013.

Materials and Methods:

In this clinical trial, 50 subjects with decreased level of consciousness were selected by convenient sampling from the ICU wards of Al-Zahra hospital, Isfahan, Iran and were randomly assigned to two groups of study and control. Pain management program was applied on the study group and routine care was implemented in the control group. Data including demographic data and length of stay of patients in the ICUs were collected and analyzed using descriptive statistics and Chi-square test, independent t-test, and paired t-test.

Results:

Results showed that out of 50 subjects attending the study, there were 40% female and 60% male subjects in study, and 52% female and 48% male subjects in control group. (P = 0.395). Overall mean length of stay of the patients in the ICUs was significantly lower in the case group [3.2 (1.4)] days compared to the control group [7.4 (4.8) days] (P < 0.001).

Conclusions:

This study showed that overall mean length of stay of patients in the ICUs was significantly lower in the study group compared to the control group. It is suggested to use this program for patients in ICUs with decreased level of consciousness after a general surgery.

Effect of family members' voice on level of consciousness of comatose patients admitted to the intensive care unit: A single-blind randomized controlled trial

Background:

Coma is one of the most important complications of brain injury. Comatose patients in the intensive care units are exposed to sensory deprivation. This study aims to survey the effect of family members’ voice on level of consciousness of comatose patients hospitalized in the intensive care units.

Materials and Methods:

In this single-blind randomized controlled trial, 40 comatose patients with brain injury with acute subdural hematoma in intensive care units were randomly assigned into two groups. The intervention group was stimulated twice a day each time 5-15 min with a recorded MP3 from family members’ voice for 10 days. The patients’ level of consciousness was measured with Glasgow Coma Scale before and after auditory stimulations. In the control group, GCS was measured without auditory stimulation with the same time duration like intervention group. Data analysis in software SPSS version 15 and using Chi-square test, independent t-test, paired t- test and analysis of variance with repeated measures was done.

Results:

On the first day before the intervention, there was no a statistically significant difference between the mean of GCS in both groups (P = 0.89), but on the tenth day after the intervention, there was a significant difference (P = 0.0001) between the mean GCS in both control and intervention groups. Also, there was a significant difference between the mean daily GCS scores in two groups (P = 0.003). The findings during ten days showed the changes in the level of consciousness in the intervention group from the 4^rd day of the study were more in the mean daily GCS scores than control group.

Conclusion:

This study indicated that family members’ voice can increase level of consciousness of comatose patients with acute subdural hematoma.

General and specific consciousness: a first-order representationalist approach

It is widely acknowledged that a complete theory of consciousness should explain general consciousness (what makes a state conscious at all) and specific consciousness (what gives a conscious state its particular phenomenal quality). We defend first-order representationalism, which argues that consciousness consists of sensory representations directly available to the subject for action selection, belief formation, planning, etc. We provide a neuroscientific framework for this primarily philosophical theory, according to which neural correlates of general consciousness include prefrontal cortex, posterior parietal cortex, and non-specific thalamic nuclei, while neural correlates of specific consciousness include sensory cortex and specific thalamic nuclei. We suggest that recent data support first-order representationalism over biological theory, higher-order representationalism, recurrent processing theory, information integration theory, and global workspace theory.

SNAP II index: an alternative to the COMFORT scale in assessing the level of sedation in mechanically ventilated pediatric patients

Sedation monitoring is essential in pediatric patients on ventilatory support to achieve comfort and safety. The COMFORT scale was designed and validated to assess the level of sedation in intubated pediatric patients. However, it remains unreliable in pharmacologically paralyzed patients. The SNAP II index is calculated using an algorithm that incorporates high-frequency (80-420 Hz) electroencephalogram (EEG) components, known to be useful in discriminating between awake and unconscious states, unlike other measurements that only include low-frequency EEG segments such as the bispectral index score. Previous studies suggested that the SNAP II index is a reliable and sensitive indicator of the level of consciousness in adult patients. Despite its potential, no data are currently available in the pediatric critically ill population on ventilatory support. This is the first pilot study assessing the potential application of the SNAP II index in critically ill pediatric patients by comparing it to the commonly used COMFORT scale.