Association of the Verbal Component of the GCS With Mortality in Patients With Encephalopathy Who Are Not Undergoing Mechanical Ventilation

Background and Objectives:The utility of the Glasgow Coma Scale (GCS) in intubated patients is limited due to reliance on language function evaluation. The Full Outline of UnResponsiveness (FOUR) Score was designed to circumvent this shortcoming, instead adding evaluations of brainstem reflexes (FOUR B) and specific respiratory patterns (FOUR R). We aimed to determine if the verbal component of the GCS (GCS V) among encephalopathic non-intubated patients significantly contributes to mortality prediction and to assess GCS vs. FOUR Score performance.Methods:All prospectively consented patients ≥18 years admitted to the Internal Medicine service at Zambia’s University Teaching Hospital from October 3rd, 2017 to May 21st, 2018 with a GCS of ≤10 have undergone simultaneous GCS and FOUR Score assessments. The patients were not eligible for mechanical ventilatory support per local standards. Patients’ demographics and clinical characteristics were presented as either percentage frequencies or numerical summaries of spread. The predictive power of the GSC without Verbal component vs. total GCS vs. FOUR Score on mortality were estimated using the area under the receiver operating characteristic (AU-ROC).Results:235 patients (50% women; mean age 47.5 years) were enrolled. All patients were Black. Presumed etiology was CNS infection (64; 27%), stroke (63; 27%), systemic infection (39; 16.6%), metabolic encephalopathy (3; 14.5 %), 14.9% unknown. In-hospital mortality was 83%. AU ROC for GCS Eye+Motor (0.662) vs. total GCS (0.641) vs. total FOUR Score (0.657) did not differ. Odds ratio mortality for GCS > 6 vs. < 6 was 0.32, 95% CI 0.14-0.72 (p 0.01); for FOUR Score >10 vs. <10 was 0.41, 95% CI 0.19-0.86 (p 0.02).Conclusion:Absence of a verbal component of GCS had no significant impact on total GCS’s performance and either GCS or FOUR Score are acceptable scoring tools for mortality prediction in the resource-limited setting. These findings need further validation in the countries with readily available mechanical ventilatory support.Classification of Evidence:This study provides Class I evidence that the verbal component of the GCS does not significantly contribute to a total GCS score in mortality prediction among encephalopathic patients who are not intubated.

Assessing the effectiveness of the full outline of unresponsiveness scale and the Glasgow coma scale in patients of traumatic head injury

Background: The Glasgow coma scale (GCS) is the most commonly used scale while the full outline of unresponsiveness (FOUR) score is a new validated coma scale in the evaluation of the level of consciousness in head injury patients. The aim of the study was to compare and assess the effectiveness of the FOUR score and the GCS in patients of traumatic head injury.Methods: This was a prospective observational study conducted in the department of surgery, Gandhi medical college, Bhopal during a 2 year period in which 100 patients of traumatic head injury were evaluated. The FOUR score and GCS score of these patients were assessed on admission and outcome followed for 2 weeks.Results: The mean age group of 100 patients was 25-45 years with 79% male and 21% female patients. The FOUR scale was found to have a marginally higher sensitivity of 65.6% while the GCS had a sensitivity of 64.2%. The FOUR scale however had a higher specificity of 71.5% compared to 66.4% of GCS. The Youden index showed that FOUR scale (46%) has a better prediction for death than GCS (35%). FOUR had a higher accuracy of 75% than GCS with an accuracy of 65%.Conclusions: Both FOUR score and GCS are valuable scales in assessment of traumatic head injury. The FOUR scale however is more accurate than the GCS in predicting outcome of head injury patients.

Hubungan Kadar Laminin Serum dengan Tingkat Kesadaran Menurut Skor FOUR pada Pasien Cedera Otak Akibat Trauma

Traumatic brain injury (TBI) could result in disorders of central nervous system (CNS). Serum laminin level and the FOUR score have both been suggested as predictors for the outcomes after TBI. This study was aimed to evaluate the relationship between serum laminin level and the FOUR score in TBI patients. This was an observational and analytical study with a cross-sectional design. Subjects were 32 patients with TBI and FOUR scores of 0-16 admitted at the Emergency Surgery Installation of Prof. Dr. R. D. Kandou Hospital. Venous blood sample for laminin was taken less than 24 hours after trauma. Assessment of the level of consciousness was determined by using the FOUR score at Emergency Surgery Installation admission <24 hours and observation after >24 hours. Proportional regression model was used to assess changes in FOUR score associated with laminin level. The results obtained 32 patients with TBI, mean laminin level was 818.4 pg/mL with range IQR 597.4-1235.4 pg/mL. In final regression model, each increase of one unit of pre-24 hours FOUR score decreased serum laminin level by 54.4 pg/mL (95% CI -76.3; 32.1 pg/mL, p<0.001). Same as the relationship occurred for the FOUR score after 24 hours, but the decrease was slightly smaller, at 37.2 pg/mL (95% CI -50.2; -24.3 pg/mL, p<0.001). FOUR scores with a high risk of mortality were more likely to be found in relatively high serum laminin levels. In conclusion, there is a relationship between serum laminin level and the FOUR score. Increase in serum laminin level is a potential alternative to lower FOUR score and to predictof poorer outcome in patient with TBI.Keywords: laminin; FOUR score; traumatic brain injury (TBI) Abstrak: Pada cedera otak akibat trauma (COT) sering terjadi gangguan saraf pusat. Laminin serum dan skor FOUR disarankan sebagai prediktor luaran setelah COT. Penelitian ini bertujuan untuk mengevaluasi hubungan antara kadar laminin serum dan skor FOUR pada pasien COT. Jenis penelitian ialah analitik observasional dengan desain potong lintang. Penelitian dilaksanakan pada 32 pasien dengan COT dan skor FOUR 0-16 yang masuk ke Instalasi Rawat Darurat Bedah (IRDB) RSUP Prof. Dr.R. D. Kandou, Manado. Sampel darah vena untuk pemeriksaan serum laminin diambil kurang dari 24 jam setelah trauma. Penilaian tingkat kesadaran ditetapkan dengan skor FOUR saat masuk IRDB <24 jam dan observasi setelah >24 jam. Model regresi proporsional digunakan untuk menilai hubungan kadar laminin serum dengan skor FOUR. Hasil penelitian mendapatkan 32 pasien dengan COT. Rerata kadar laminin serum 818,4 pg/mL dengan range IQR 597,4-1.235,4 pg/mL. Pada model regresi akhir, setiap peningkatan satu unit skor FOUR pra 24 jam rata-rata menurunkan kadar laminin serum sebesar 54,4 pg/mL (95% CI -76,3; 32,1 pg/mL, p<0,001). Hubungan sejenis terjadi untuk skor FOUR pasca 24 jam, tetapi nilai penurunannya sedikit lebih kecil, yakni 37,2 pg/mL (95% CI -50,2; -24,3 pg/mL, p<0,001). Skor FOUR dengan risiko mortalitas tinggi lebih cenderung ditemukan pada kadar laminin serum relatif tinggi. Simpulan penelitian ini ialah terdapat hubungan antara kadar laminin serum dengan skor FOUR. Peningkatan kadar laminin serum merupakan alternatif potensial skor FOUR yang lebih rendah untuk memrediksi luaran yang lebih buruk pada pasien COT.Kata kunci: laminin; skor FOUR; cedera otak akibat trauma (COT)

FOUR Score Versus GCS in Patients with Traumatic Brain Injury in the Prehospital Setting

Background: In the last few decades, different coma scoring scales have been proposed. The purpose of this study is to compare two coma scales, the GCS (Glasgow Coma Scale) and the FOUR score (Full Outline of UnResponsiveness score), aiming to examine which scale is better for predicting outcome in traumatic brain injury (TBI) patients in the prehospital setting.Methods: We evaluated the GCS and FOUR scores in the prehospital setting at three different prehospital timepoints, and we reassessed the scores in surviving patients 24 hours, one month and three months after the injury. Then, we compared the outcomes.We used the χ² method, and based on the analysis with the best cut-off point for each model, we calculated the sensitivity, specificity and correct prediction of outcomes with four severity scores. The Youden index, Z score, McNemar's test and ROC curve were also assessed. P < 0.05 was considered statistically significant. Both scales were ranked with gain ratios.Results: We included 200 TBI patients who were treated in a prehospital setting by a prehospital specialized medical unit. In terms of the predictions of positive outcomes, our study showed the following:1. Twenty-four hours after the injury, the best cut-off points obtained were from the FOUR 1 and GCS 1 models.2. One month after the injury, the best cut-off points obtained were from the following models: FOUR 2 and GCS 3 as well as FOUR 3 and GCS 3.3. Three months after the injury, the best cut-off points obtained were from the following models: FOUR 2 and GCS 1, FOUR 3 and GCS 1, and GCS 1 and GCS 2.Conclusions: In our study, the results of our research confirm that there are no practical or clinical differences between the GCS and FOUR scores in terms of predicting morality outcomes 24 hours, one month, and three months after injury. No statistically significant differences were found in the Youden index or the area under the ROC curve 24 hours, one month or three months after the injury.

Debris Removal Using a Hydroxyapatite Nanoparticle-Containing Solution (Vector Polish) with Sonic or Ultrasonic Agitation

Chemomechanical preparation of the root canal system is considered to be the most important part of root canal treatment, including both mechanical removal of tissue remnants and dentine chips, and chemical elimination of biofilm and microorganisms. A number of different solutions and agitation techniques have been proposed for that purpose. It was the aim of the present study to investigate whether root canal cleanliness can be improved by using a hydroxyapatite nanoparticle-containing solution with and without sonic or ultrasonic agitation. Seventy-four single-rooted teeth were divided into four experimental groups (n = 15) and two control groups (n = 7). All teeth were split longitudinally and a groove and three holes were cut into the root canal wall and filled with dentinal debris. Final irrigation was performed using sodium hypochlorite or a hydroxyapatite nanoparticle-containing solution (Vector polish) activated with a sonically or an ultrasonically driven endodontic file. Two calibrated investigators rated the remaining debris using a four-score scale. The results were analyzed using a non-parametric test with α < 0.05. Sonic and ultrasonic irrigation with sodium hypochlorite cleaned the grooves and holes well from debris. The hydroxyapatite nanoparticles activated by a sonic file cleaned grooves and holes equally well. Ultrasonically activated nanoparticles performance was clearly inferior. The syringe control-group left large amounts of debris in grooves and holes. The use of the hydroxyapatite nanoparticles used in this study did not improve removal of debris.

Traumatic Brain Injury: Prognostic Value of Various Coma Scales, CT Scores & Their Comparison Based on Clinical Outcome

Background: Traumatic brain injury (TBI) is common, carries a high morbidity and mortality and has no specific treatment. The Glasgow coma scale (GCS) is considered the gold standard for assessment of unconsciousness in patients with traumatic brain injury against which other scale are compared to overcome the disadvantages of GCS. Materials & Methods: This is Prospective Observational comparative study was conducted in total 128 who admitted with traumatic brain injury (TBI) in Department of General Surgery, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar during the period from November 2016 to November 2018. Results: A total of 128 (112 males) patients were included in the study. Among SMS, 0 is highly sensitive (72.22%), 2 is highly specific (80.43%). In GCS score < 8 was highly sensitive (97.22%) & GCS score 9 - 12 was highly specific (82.61%). In this study Marshall CT score of 4 - 6 (group II) has mortality 43.55% & CT score 1 - 3 (group I) was 13.64%. Where as in Rotterdam CT score was significant mortality with score 4 - 6 (group II) was 56.25% & CT score of 1 - 3 (group I) was 24.11%. In FOUR score with GCS, on 1 day with FOUR score 13 - 16 (group IV) has 5.56%, day 3, 13 - 16 (group IV) has 3.45%, day 7, 13 - 16 (group IV) has 3.13% & day 21, 13 - 16 (group IV) only 3.45% has mortality rate. Conclusion: if SMS is high there is more chance of survival, this helps in patients immediate segregation of patients in casualty. Also conclude that FOUR score has a high degree of internal consistency & is an accurate predictor of Mortality and neurologic outcome in TBI patients. Keywords: Simplified Motor Score, Glasgow Coma Scale, Marshall CT, Rotterdam CT, FOUR scale.