Diagnostic Developments in Differentiating Unresponsive Wakefulness Syndrome and the Minimally Conscious State

When treating patients with a disorder of consciousness (DOC), it is essential to obtain an accurate diagnosis as soon as possible to generate individualized treatment programs. However, accurately diagnosing patients with DOCs is challenging and prone to errors when differentiating patients in a Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) from those in a Minimally Conscious State (MCS). Upwards of ~40% of patients with a DOC can be misdiagnosed when specifically designed behavioral scales are not employed or improperly administered. To improve diagnostic accuracy for these patients, several important neuroimaging and electrophysiological technologies have been proposed. These include Positron Emission Tomography (PET), functional Magnetic Resonance Imaging (fMRI), Electroencephalography (EEG), and Transcranial Magnetic Stimulation (TMS). Here, we review the different ways in which these techniques can improve diagnostic differentiation between VS/UWS and MCS patients. We do so by referring to studies that were conducted within the last 10 years, which were extracted from the PubMed database. In total, 55 studies met our criteria (clinical diagnoses of VS/UWS from MCS as made by PET, fMRI, EEG and TMS- EEG tools) and were included in this review. By summarizing the promising results achieved in understanding and diagnosing these conditions, we aim to emphasize the need for more such tools to be incorporated in standard clinical practice, as well as the importance of data sharing to incentivize the community to meet these goals.

Nociceptive Response Is a Possible Marker of Evolution in the Level of Consciousness in Unresponsive Wakefulness Syndrome Patients

The Nociception Coma Scale (NCS) and its revised version (NCS-R) were used to evaluate behavioral responses to pain in non-communicative patients. We hypothesized that if patients demonstrate changes to their NCS(-R) scores over time, their evolving behavioral abilities could indicate a forthcoming diagnostic improvement with the Coma Recovery Scale-Revised (CRS-R). Forty-three Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) patients were enrolled in the study. The patients were assessed weekly using the CRS-R and NCS(-R) for four consecutive weeks. The first assessment was within 10 days after hospitalization. The assessments were performed between 09:30 and 11:30 AM in a room with constant levels of humidity, light and temperature, as well as an absence of transient noise. Noxious stimuli were administered using a Newton-meter, with pressure applied to the fingernail bed for a maximum of 5 s unless interrupted by a behavioral response from subjects. Seventeen patients demonstrated improvements in their level of consciousness, 13 of whom showed significant behavioral changes through the NCS(-R) before being diagnosed with a Minimally Conscious State (MCS) according to the CRS-R. The behavioral changes observed using the NCS(-R) corresponded to a high probability of observing an improvement from VS/UWS to MCS. To characterize the increased likelihood of this transition, our results present threshold scores of ≥5 for the NCS (accuracy 86%, sensitivity 87%, and specificity 86%) and ≥3 for the NCS-R (accuracy 77%, sensitivity 89%, and specificity 73%). In conclusion, a careful evaluation of responses to nociceptive stimuli in DOC patients could constitute an effective procedure in assessing their evolving conscious state.

Latex Harvesting Technologies Adapted to Hevea brasiliensis Muell Clones GT 1; RRIC 100 and BPM 24 Arg. (Euphorbiaceae) belonging to the Moderate Metabolism Class in the Socio-economic Context of Côte d'Ivoire

Improving the productivity of rubber trees has always been a major concern for rubber farmers. The majority of growers opt for overexploitation of the trees. This disturbs the physiological balance of the rubber trees, which leads to the recrudescence of tapping panel dryness and rather to a drop in production. To solve this problem, the present study proposes to define a latex harvesting technology (or technologies) for the moderate metabolism clone class that will allow the improvement of plantation yield and the increase of the economic life of the trees. To achieve this, the GT 1, RRIC 100 and BPM 24 clones of the moderate metabolism class were used as plant material. The results showed that the reduction in tapping frequency had no negative effect on the vegetative state of the trees. This reduction was compensated by a high number of annual stimulations, which resulted in high dry rubber production. Analysis of dry rubber production, radial rubber growth and tapping panel dryness rate indicates that the moderate metabolic class clones performed better with the latex harvesting technologies S/2 d3 6d/7 ET2.5% Pa1(1) 6/y; S/2 d4 6d/7 ET2.5% Pa1(1) 6/y and S/2 d5 6d/7 ET2.5% Pa1(1) 1.

Are Subacute Care Patients Living Longer?

In order to provide prognostic information for gerontologists who regularly counsel families, we determined to measure the longevity of subacute patients who have feeding tubes and tracheostomies. This study compares two cohorts of patients: 2002-2006 and 2015-2019. T-tests were performed to compare the total days in acute care, the total survival days, and the number of hospital admissions between the two groups. Results revealed (2002-2006, 2015-2019), some variance in the acute care days between the two groups (M= 15.4186, 21.49438) and p= .66. There is a wide difference in the total survival days between the two groups with individuals from 2015-2019 living longer than 2002-2006 (M= 229.8198, 644.0449), p< .001. However, there is no statistically significant difference in the number of hospital admissions between the two groups (M= 0.994186, 0.7752809), p= .09754. We hypothesize that advances in technology, medicine, and care over the span of 17 years contribute to increased longevity. On average, patients in the 2015-2019 group survived 414 days longer than the first group. Yet, even with such advances, more days were spent in acute care in the second group (2015-2019). Our data show subacute longevity has nearly tripled in the last decade. Although patients are living longer, they are often in a vegetative state; in most instances, there is no apparent improvement in quality of life. This study provides current data which will help gerontologists improve prognostication and allow them to form a more realistic long view of care.

Understanding Disorders of Consciousness: Opportunities for Critical Care Nurses

Background Disorders of consciousness are powerful predictors of outcomes including mortality among critically ill patients. Encephalopathy, delirium, and coma are disorders of consciousness frequently encountered by critical care nurses but often classified incorrectly. Objective To provide a greater understanding of disorders of consciousness and to provide standardized assessments and nursing interventions for these disorders. Methods A literature search was conducted by using the terms consciousness, mental status, awareness, arousal, wakefulness, assessment, disorders of consciousness, delirium, encephalopathy, coma, vegetative state, and minimal consciousness. Articles were published in the past 10 years in CINAHL and PubMed. Articles were excluded if they were not in English or directly related to caring for patients with a disorder of consciousness. The remaining 142 articles were evaluated for inclusion; 81 articles received full review. Results A disorder of consciousness signifies that the threshold for compensation has been surpassed with potentially irreversible damage. Altered thalamocortical interactions and reduced cortical activity impair communication networks across the various parts of the brain, causing a disturbance in consciousness. Discussion The cue-response theory is a model that describes the process and impact of nursing care on recovery from acute brain injury. Appropriate standardized assessments and interventions must be used to manage altered levels of consciousness in critically ill patients. Conclusions Paying close attention to neurological changes and monitoring them with standardized assessments are critical to implementing early measures to prevent complications.

CIRCADIAN RHYTHM AND CHRONIC DISORDERS OF CONSCIOUSNESS

Among the possible points of therapeutic action and predicting the outcome in patients in a vegetative state and minimally conscious state, the analysis of circadian rhythms, such as the sleep-wake cycle, melatonin secretion, temperature trends, heart rate, and blood pressure, attracts more and more attention. In this review, we analyzed studies on circadian rhythms in patients with chronic disorders of consciousness, assessed the possible limitations of standard methods, proposed a concept for the development of an assessment of the sleep-wake cycle, and assessed the role of exogenous factors that are likely to be involved in the disturbance of circadian rhythms in intensive care units. Based on the results of the study, we came to the conclusion that for the full realization of the rehabilitation potential, it is necessary to develop methods for assessing circadian rhythms based on a multicomponent approach, including 24-hour monitoring using actigraphy for more accurate identification of the rest -activity cycle, video monitoring of the orofascial area to increase the reliability of oculographic assessment and revealing hidden patterns, analysis of the temperature curve, the level of melatonin, TSH, cortisol, as well as exogenous factors. It is necessary to use the information obtained for therapeutic, prognostic, diagnostic and rehabilitation purposes

Spontaneous eye blinking as a diagnostic marker in prolonged disorders of consciousness

Clinical diagnosis of patients with prolonged disorders of consciousness is very challenging. As spontaneous eye blink rate (EBR) is reliably correlated with cognitive activity in healthy individuals, we investigated whether EBR could serve as a marker of patients’ level of consciousness. We assessed ten patients in prolonged Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS; three females; mean age = 50.3 ± 17.8 years) and fourteen patients in Minimally Conscious State (MCS; three females; mean age = 52.9 ± 17.5 years) at their admission to a rehabilitation unit after the acute phase. During two separate 3-min rest conditions, we recorded patients’ EBR by integrating on-line visual and off-line electro-oculographic count. We also assessed EBR during two auditory oddball tasks, i.e. passive listening and active counting of target tones in a sub-group of patients. EBR was significantly higher in MCS than in VS/UWS; moreover, EBR positively correlated with a validated index of responsiveness derived from the Coma Recovery Scale-Revised. Patients’ mean EBR showed no significant differences within sessions and across experimental conditions of the oddball task, in both VS/UWS and MCS. Our findings suggest that, at least in the post-acute phase, observing patients’ EBR for 3 min at rest could help to discriminate between VS/UWS and MCS, improving accuracy of clinical diagnosis.

PGPR, PEMUPUKAN AN ORGANIK DAN VERMIKOMPOST TERHADAP PANJANG BATANG & DIAMETER TEBU (Saccharum officinarum L.) DI SCREENHOUSE

Combine between fertilizer vermicompos, inorganic fertilizer and PGPR is a breakthrough in the development of agricultural technology to increase the growth of persistent vegetative state and the results of production plant cane. This researsh aims to determine the effect of a combination of organic fertilizers (vermicompost), inorganic and PGPR on the growth of the length and diameter of plant cane. Vegetative growth studycondukted in screenhouse Brawijaya university poor starts in August 2019 until january 2020. Treatment such as 1). PGPR 5 ml per liter or 10 ml per liter combined with fertilizer inorganic 100% (7 kw ZA + 3 kw SP 36 + 3 kw kcl 2). PGPR 5ml per liter or 10 ml per liter combined with vermikompos 10 ton/ha mixed with 50% inorganic fertilizer the research was compiled using random design comlplete factorial. Repeated three times result showing that the PGPR 10 ml per liter proved to be able to increase long stalks of, the provision of a mixture of fertilizer and inorganic vermikompos 50% able to ancrease growth of plant in the trunk dameter, sugar cane, a combination pgpr and vermikompos mixed inorganic fertilizers able to enlarge the diameter of a plant stem sugar cane.

A case of bacterial keratitis caused by multi-drug-resistant Shewanella algae without marine exposure

ABSTRACT Shewanella are Gram-negative rods and marine pathogens. Here, we report a case of bacterial keratitis caused by Shewanella algae without marine exposure. A 66-year-old man with suspected pneumonia was sent to the emergency department from a nursing hospital. He had been in there for 2 years in a vegetative state and could not close his eyes voluntarily. Neither the patient nor his family had experienced any marine exposure. Keratitis was suspected in his right eye. Gram-negative rods grew from swab culture and identified as S. algae by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and 16S rRNA sequencing. The patient was treated with topical tobramycin, moxifloxacin and ofloxacin as well as steroids for 14 days, and the keratitis improved. S. algae is a rare human pathogen, and most human infections involve marine exposure. This is the second report of bacterial keratitis caused by S. algae worldwide and the first in Asia.