When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Functional Independence

[EN] Accurate estimation of the functional independence of patients with unresponsive wakefulness syndrome (UWS) is essential to adjust family and clinical expectations and plan long-term necessary resources. Although different studies have described the clinical course of these patients, they have methodological limitations that could restrict generalization of the results. This study investigates the neurobehavioral progress of 100 patients with UWS consecutively admitted to a neurorehabilitation center using systematic weekly assessments based on standardized measures, and the functional independence staging of those patients who emerged from a minimally conscious state (MCS) during the first year post-emergence. Our results showed that one year after emergence, most patients were severely dependent, although some of them showed extreme or moderate severity. Clinically meaningful functional improvement was less likely to occur in cognitively-demanding activities, such as activities of daily living and executive function. Consequently, the use of specific and staging functional independence measures, with domain-specific evaluations, are recommended to detect the functional changes that might be expected in these patients. The information provided by these instruments, together with that obtained from repeated assessments of the preserved consciousness with standardized instruments, could help clinicians to adjust expectations and plan necessary resources for this population.This research was funded by the program RISE-Marie-Slodowska-Curie of the European Commission (Grant agreement 778234), by Conselleria de Educacion, Investigacion, Cultura y Deporte of Generalitat Valenciana (SEJI/2019/017), and by Vicerrectorado de Investigacion, Innovacion y transferencia of Universitat Politecnica de Valencia (PAID-06-18).Olaya, J.; Noé, E.; Navarro, MD.; O'valle, M.; Colomer, C.; Moliner, B.; Ippoliti, C.... (2020). When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Functional Independence. Brain Sciences. 10(12):1-14. https://doi.org/10.3390/brainsci10120990S1141012Jennett, B., & Plum, F. (1972). PERSISTENT VEGETATIVE STATE AFTER BRAIN DAMAGE. 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When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Neurobehavioral Progress

[EN] Accurate estimation of the neurobehavioral progress of patients with unresponsive wakefulness syndrome (UWS) is essential to anticipate their most likely clinical course and guide clinical decision making. Although different studies have described this progress and possible predictors of neurobehavioral improvement in these patients, they have methodological limitations that could restrict the validity and generalization of the results. This study investigates the neurobehavioral progress of 100 patients with UWS consecutively admitted to a neurorehabilitation center using systematic weekly assessments based on standardized measures, and the prognostic factors of changes in their neurobehavioral condition. Our results showed that, during the analyzed period, 34% of the patients were able to progress from UWS to minimally conscious state (MCS), 12% of the total sample (near one third from those who progressed to MCS) were able to emerge from MCS, and 10% of the patients died. Transition to MCS was mostly denoted by visual signs, which appeared either alone or in combination with motor signs, and was predicted by etiology and the score on the Coma Recovery Scale-Revised at admission with an accuracy of 75%. Emergence from MCS was denoted in the same proportion by functional communication and object use. Predictive models of emergence from MCS and mortality were not valid and the identified predictors could not be accounted forThis research was funded by the program RISE-Marie-Slodowska-Curie of the European Commission (Grant agreement 778234), by Conselleria de Educacion, Investigacion, Cultura y Deporte of Generalitat Valenciana (SEJI/2019/017), and by Vicerrectorado de Investigacion, Innovacion y transferencia of Universitat Politecnica de Valencia (PAID-06-18)Noé Sebastián, E.; Ferri, J.; Olaya, J.; Navarro, MD.; O'valle, M.; Colomer Font, C.; Moliner, B.... (2021). When, How, and to What Extent Are Individuals with Unresponsive Wakefulness Syndrome Able to Progress? Neurobehavioral Progress. Brain Sciences. 11(1):1-16. https://doi.org/10.3390/brainsci11010126S11611

La spasticité est-elle un facteur de prédictif de l'état nutritionnel des patients en état de conscience altérée ?

Introduction et objectif de l’étude La littérature scientifique concernant l’état nutritionnel des patients en état de conscience altérée (ECA) est à l’heure actuelle très pauvre. Le but de cette étude prospective observationnelle transversale est d’investiguer la relation entre le profil nutritionnel de ces patients et leur état de conscience. Matériel et Méthodes Nous avons collecté et analysé les données cliniques (état de conscience, spasticité) et nutritionnelles (indice de masse corporelle (IMC), apports nutritionnels, biologie) de 80 patients en état d’éveil non répondant (ENR), en état de conscience minimale (ECM) ou en état de conscience minimale émergeant (EECM). Les patients ont été classés selon le résultat de l’analyse nutritionnelle : bien nourri, à risque de dénutrition et dénutri. Résultats De nos 80 patients (43 ± 15 ans), 19 étaient en ENR (24%), 47 en ECM (59%) et 14 en EECM (17%). Parmi eux, 7 (9%) étaient à risque de dénutrition et les 73 autres (91%) étaient bien nourris. L’IMC de ces sujets n’est pas lié à leur niveau d’ECA (p = 0,093), au délai après l’accident (p = 0,12) ou à l’étiologie de leur état neurologique (p = 0,51). Une différence entre l’apport énergétique réellement administré à ces patients et celui qu’ils devraient théoriquement recevoir sur base des recommandations nutritionnelles (30 kcal/kg de poids de calcul) est observée. Les sujets obèses (≥ 30 kg/m²) recevaient 631 ± 328 kcal en moins/jour par rapport aux recommandations et ceux en surpoids (25-29,9 kg/m²), 415 ± 390 kcal/j en moins également. En revanche, les patients avec un IMC faible (< 18,5 kg/m²) recevaient 106 kcal ± 299 kcal/j en plus. La comparaison du niveau de spasticité en fonction de l’IMC révèle une corrélation significative (r = - 0,30, p = 0,009) et montre que les patients les moins spastiques au niveau des membres inférieurs sont plus à risque d’avoir un surpoids (IMC = 27,7 ± 7,5 kg/m²). Au contraire les plus spastiques à ce niveau sont plus à risque d’avoir un IMC plus faible (22,1 ±3,8 kg/m²). Parmi les 9 sujets avec un IMC < 18,5 kg/m², 7 présentent une spasticité sévère, et les 2 autres une spasticité modérée, au niveau des membres inférieurs. L’étude de la différence d’apport énergétique par rapport à la spasticité montre que les patients non spastiques recevaient 297 ± 318 kcal/j en moins par rapport aux recommandations, contre 222 ± 430 kcal/j pour une spasticité moyenne et 41 ± 406 kcal/j pour des niveaux de spasticité plus élevés. Conclusion Nos résultats indiquent que la majorité des patients ECA ont un état nutritionnel satisfaisant. Cet état nutritionnel ne semble pas lié au niveau de conscience, ni au délai ou à la cause de leur accident. Les patients les moins spastiques présentent des critères de surpoids malgré un apport énergétique considérablement réduit par rapport aux recommandations nutritionnelles. En revanche, un niveau élevé de spasticité est associé à un niveau de sous poids (IMC < 18,5 kg/m²) en dépit d’un apport énergétique supérieur à l’objectif préconisé par ces recommandations. Des analyses complémentaires sont en cours (calorimétrie indirecte, impédancemétrie, étude de la spasticité et imagerie métabolique) afin de mieux comprendre les mécanismes sous-jacents

Non-Functional Jaw Muscular Activity in Patients with Disorders of Consciousness Revealed by A Long-Lasting Polygraphy

The presence of involuntary, non-functional jaw muscle activity (NFJMA) has not yet been assessed in patients with disorders of consciousness (DOC), although the presence of bruxism and other forms of movement disorders involving facial muscles is probably more frequent than believed. In this work, we evaluated twenty-two prolonged or chronic DOC patients with a long-lasting polygraphic recording to verify NFJMA occurrence and assess its neurophysiological patterns in this group of patients. A total of 5 out of 22 patients showed the presence of significant NFJMA with electromyographic patterns similar to what can be observed in non-DOC patients with bruxism, thus suggesting a disinhibition of masticatory motor nuclei from the cortical control. On the other hand, in two DOC patients, electromyographic patterns advised for the presence of myorhythmia, thus suggesting a brainstem/diencephalic involvement. Functional, non-invasive tools such as long-lasting polygraphic recordings should be extended to a larger sample of patients, since they are increasingly important in revealing disorders potentially severe and impacting the quality of life of DOC patients

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p &lt; 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

What is the nutritional status of patients with prolonged disorders of consciousness? A retrospective cross-sectional study.

peer reviewed("[en] BACKGROUND: Nutritional status of patients with disorders of consciousness (DoC) is poorly studied. OBJECTIVES: To evaluate the relationship between nutritional status (body mass index, daily calories intake) and clinical variables (level of consciousness, time since injury, diagnosis, etiology and spastic muscle overactivity; SMO,) in patients with prolonged DoCor emerging. Our main hypotheses are i) patients with lower level of consciousness (UWS) have worse nutritional status compared to patients in minimally conscious state (MCS) and ii) SMO could influence nutritional status. METHODS AND RESULTS: Among the 80 patients included in the study (19 UWS, 47 MCS, 14 emerging MCS; 43 ± 15 yo; 3 ± 4 years post-injury, 35 traumatic etiology, 34 females), 9% were at risk to be undernourished, with no differences between UWS and MCS. Patients without SMO had a higher BMI compared to patients with severe SMO. Compared to the recommended daily calories intake, patients with the highest BMI received less calories and patients with the lowest BMI received more calories. We observed a negative correlation between SMO (in lower limbs) and BMI. CONCLUSION: Our study shows that most patients are well nourished, independently from the level of consciousness. SMO may require additional calories in patients' daily needs; however, longitudinal studies are needed to explore the causal relationship between these variables.","[en] ",""

Greater preserved baseline functional MRI connectivity in zolpidem responders compared to non-responders in patients with disorders of consciousness.

Introduction Zolpidem is commonly used as sleep inducer but is one of the few available pharmacological treatments for patients with disorders of consciousness (DOC). Some DOC patients have exhibited paradoxical improvements with zolpidem treatment but the neurological profile of responders remains unclear. No fMRI study has ever been conducted in a group of DOC patients. We investigated the baseline functional brain connectivity in DOC patients responding to zolpidem compared to non-responding patients. Methods Eleven patients in minimally conscious state and 5 who emerged received a 10 mg single dose of zolpidem. Patients were considered responders if a new behaviour was observed using the Coma Recovery Scale-Revised after zolpidem administration. All patients underwent resting-state fMRI (without zolpidem). Hypothesis-free and seed-based region (thalamus) analyses were conducted with age and gender covariates regressed out, comparing patients with 36 healthy volunteers. Results Seven patients qualified as responders (5 sedated, 2 non-sedated) and 9 as non-responders (6 sedated, 3 non-sedated). Hypothesis-free analyses in the sedated group revealed significantly increased intrinsic connectivity among responders in the occipital, occipito-temporal and parieto-occipital areas compared to non-responders. Seed-based analyses showed significantly more preserved positive connectivity of the fronto-insular network in responders compared to non-responders. No significant differences were found between responders and non-responders in the non-sedated condition, possibly due to smaller sample size. Conclusion Our findings suggest a greater preservation of global and local connectivity in zolpidem responders at baseline. Targeting more accurately potential responders to zolpidem can improve the clinical management of DOC patients