Effect of conventional treatment plus long-term transcranial direct current stimulation on consciousness recovery of minimally conscious patients after traumatic brain injury / 中华创伤杂志

Objective:To investigate the effect of conventional treatment plus long-term transcranial direct current stimulation (tDCS) on consciousness recovery in patients with minimally conscious state (MCS) after traumatic brain injury (TBI).Methods:A retrospective cohort study was conducted to analyze the clinical data of 60 patients with MCS after TBI admitted to Zhejiang Armed Police Corps Hospital from January 2019 to December 2020, including 38 males and 22 females, aged 19-60 years [(45.7±11.4)years]. Course of disease was 3-6 months [(4.6±0.9)months]. Of all, 30 patients received internal medicine, hyperbaric oxygen, rehabilitation and other conventional treatment (conventional treatment group), and 30 patients received tDCS stimulation on the basis of conventional treatment (tDCS treatment group). The tDCS stimulation contained 4 cycles for 28 days with each cycle lasting for 7 days (stimulation for 5 days, rest for 2 days). Coma recovery scale-revised (CRS-R) total score, brainstem auditory evoked potential (BAEP) score and clinical effictive rate (significantly effective+effective) were compared between the two groups before treatment, during 4 cycles of treatment and at 6 months and 12 months after treatment. Complications induced by tDCS were also evaluated.Results:There was no significant difference in CRS-R total score and BAEP score between the two groups before treatment (all P>0.05). CRS-R total score and BAEP score in tDCS treatment group were significantly higher than those in conventional treatment group during 4 cycles of treatment and at 6 months and 12 months after treatment (all P<0.05). CRS-R total score and BAEP score in both groups gradually increased during 4 cycles of treatment and at 6 months and 12 months after treatment (all P<0.05). The clinical effective rate in tDCS treatment group was 73% (22/30) when compared to 57% (17/30) in conventional treatment group ( P<0.05). In tDCS treatment group, 10 patients had local reversible slight redness at the cathodal position, while no other serious adverse effects, such as local burns, ulceration, exudation or epilepsy. Conclusion:Compared with conventional treatment, conventional treatment plus long-term tDCS can be more effective in improving the state of consciousness without serious adverse effects for MCS patients after TBI.

Application of three-fourths prone position drainage in patients with pulmonary infection and consciousness disorders after tracheotomy / 中国实用护理杂志

Objective:To analyze the application effect of three-fourths prone position drainage method in patients with pulmonary infection and consciousness disorders after tracheotomy.Methods:A total of 84 patients with consciousness disorders who were admitted to the First Affiliated Hospital of Wenzhou Medical University from January 2018 to October 2020 with pulmonary infection after tracheotomy were selected. They were divided into the control group and the observation group, there were 42 cases in each group according to random number table method. The control group received routine prone position drainage for pulmonary infection after tracheotomy and the observation group was given three-fourths prone position drainage method. The arterial partial pressure of oxygen(PaO 2), arterial partial pressure of carbon dioxide(PaCO 2) before and after intervention, the drainage effect after the intervention, the absorption of pulmonary infection foci, and the time of antibiotic treatment for pulmonary infection during the patients′ hospitalization were compared between the two groups. Results:After the intervention, PaO 2 and PaCO 2 were (91.87 ± 7.21), (35.34 ± 3.28) mmHg(1 mmHg=0.133 kPa) in the observation group, and (85.23 ± 7.90), (43.41 ± 3.39) mmHg in the control group, the differences between the two groups were statistically significant ( t=-4.02, 11.09, both P<0.05). After the intervention, the apparent rate, effective rate, and ineffective rate were 78.57%(33/42), 19.05% (8/42), 2.38% (1/42) in the observation group,and 33.33% (14/42), 45.24% (19/42), 21.43% (9/42) in the control group. The drainage effect of the observation group was better than that of the control group, and the difference was statistically significant ( Z=-4.28, P<0.05). After the intervention, the complete absorption rate of the pulmonary infection foci and the time taken to treat pulmonary infection with antibiotics during hospitalization were 59.52% (25/42), (10.67 ± 2.70) d in the observation group, and 35.71%(15/42), (13.51 ± 3.46) d in the control group, the differences were statistically significant ( χ2=4.77, t=4.19, both P<0.05). Conclusions:The three-fourths prone position drainage method has significant application effect in patients with pulmonary infection and consciousness disorder after tracheotomy. It can effectively improve the drainage effect, improve oxygenation, promote the absorption of lung infections, and shorten the antibiotic treatment time.

Cross-cultural adaptation and content validity evidence of the Brazilian version of the Nociception Coma Scale-revised / Adaptação transcultural e evidência de validade de conteúdo da versão brasileira da Nociception Coma Scale-revised

ABSTRACT BACKGROUND AND OBJECTIVES: There are communication barriers to assess pain in patients with consciousness and cognitive disorders. This study aimed to make the cross-cultural adaptation of the Nociception Coma Scale-Revised (NCS-R) to the Portuguese language and check the validation evidence of the content of the NCR-R Brazilian version in non-communicative patients with consciousness and cognitive disorders. METHODS: This is a methodological study to check the cross-cultural adaptation of the NCR-R, divided into two stages: cross-cultural adaptation and check of the content validity. The cross-cultural adaptation phase included an initial translation, synthesis of translations, back-translation, expert committee, and cognitive debriefing based on Beaton and Price. A second expert committee evaluated the translated and adapted version to check the content validity index RESULTS: The NCS-R scale was translated and cross-culturally adapted, presenting good evidence of content validity with a Content Validity Index of 0.86. CONCLUSION: The NCS-R is translated and transculturally adapted and has good evidence of content validity.

RESUMO JUSTIFICATIVA E OBJETIVOS: Em pacientes com desordens de consciência e distúrbios cognitivos há barreiras de comunicação para a avaliação da dor. O objetivo deste estudo foi realizar a adaptação transcultural da Nociception Coma Scale-revised (NCS-R) para a língua portuguesa e verificar as evidências de validade de conteúdo da versão brasileira da NCS-R em pacientes não comunicativos com desordens de consciência e distúrbios cognitivos. MÉTODOS: Estudo metodológico para adaptação transcultural da NCS-R dividido em duas etapas: adaptação transcultural e verificação da validade de conteúdo. A fase de adaptação transcultural incluiu a tradução inicial, síntese das traduções, retrotradução, comitê de especialista e debriefing cognitivo baseado em Beaton e Price. A versão traduzida e adaptada foi avaliada por um segundo comitê de especialistas para a avaliação do índice de validade de conteúdo. RESULTADOS: A NCS-R foi traduzida, adaptada do ponto de vista transcultural e apresentou boa evidência de validade de conteúdo com Índice de Validade de Conteúdo de 0,86. CONCLUSÃO: A NCS-R encontra-se traduzida e adaptada do ponto de vista transcultural, e possui boa evidência de validade de conteúdo.

Terapia musical em pacientes com distúrbios da consciência: uma revisão integrativa / Music therapy in patients with disorders of consciousness: an integrative review

Resumo Introdução A terapia com música é amplamente utilizada para tratamento e assistência em várias doenças, incluindo distúrbios da consciência, demência, acidente vascular cerebral, distúrbios psiquiátricos, Parkinson, dor de origens diversas, entre outros. Sabe-se que ouvir música influencia o humor e a excitação, o que pode melhorar o desempenho em uma variedade de tarefas cognitivas. Objetivo Analisar as informações disponíveis na literatura sobre as evidências científicas do uso da música como recurso terapêutico. Método Trata-se de uma revisão integrativa com buscas de artigos publicados em periódicos nacionais e internacionais indexados nas bases de dados e banco de revistas: Pubmed, Cinahl, Web of Science e SciELO, entre dezembro/2017 e janeiro/2018. Utilizou-se os descritores "música" e "distúrbios da consciência" de forma associada em português, inglês e espanhol. Resultados Foram selecionados 14 estudos heterogêneos, porém com boa qualidade metodológica, dentre os quais se destacam estudos intervencionais e observacionais com grau de recomendação A. Conclusão O estudo concluiu haver na literatura científica algumas evidências da efetividade e da eficácia da terapia musical no tratamento e avaliação de pessoas em coma, estados minimamente conscientes e estado vegetativo persistente.

Abstract Introduction Music therapy is widely used for treatment and care in various diseases including disorders of consciousness, dementia, stroke, psychiatric disorders, Parkinson's disease, pain of several origins among others. It is known that listening to music influences mood and arousal, which can improve performance on a variety of cognitive tasks. Objective To analyze the information available in the literature about scientific evidences of the use of music as a therapeutic resource. Method This is an integrative review with search of articles published in national and international journals indexed in databases and journal banks: Pubmed, Cinahl, Web of Science and SciELO, between December/2017 and January/2018. We used the descriptors "music" and "disorders of consciousness" in Portuguese, English and Spanish. Results We selected 14 heterogeneous studies with good methodological quality, among which we highlight interventional and observational studies with a degree of recommendation A. Conclusion The study concludes to exist some evidence in the scientific literature about the effectiveness and efficacy of music therapy in the treatment and evaluation of people in coma, minimally conscious states and persistent vegetative state.

Aplicativo para avaliação do nível de consciência em adultos: produção tecnológica em enfermagem / Aplicación para evaluación del nível de consciencia en adultos: producción tecnológica en enfermería / App to evaluate the level of consciousness in adults: technological production in nursing

RESUMO Objetivo: desenvolver um aplicativo para a avaliação do nível de consciência em adultos. Método: produção tecnológica, estruturada a partir do referencial teórico da metodologia da aprendizagem baseada em problemas e desenvolvido considerando os passos do design instrucional contextualizado (análise, design, desenvolvimento, avaliação). Estudo realizado na Universidade Federal de Santa Catarina, de maio de 2014 a abril de 2015. Resultados: o aplicativo apresenta os conteúdos: escalas para avaliação do nível de consciência, avaliação pupilar, reflexos e padrão respiratório, apresentados aos usuários por meio de textos curtos com breves explicações, imagens e vídeos. Conclusão: o aplicativo pode facilitar o estudo sobre a temática em qualquer hora ou local, permitindo inclusive sua aplicação à beira do leito, contribuindo assim para melhorias do ensino, assistência e segurança de pacientes em estado crítico. O resultado da avaliação da tecnologia por docentes e estudantes será objeto de estudos futuros.

RESUMEN Objetivo: desarrollar una aplicación para analizar el nivel de consciencia en adultos. Método: producción tecnológica, estructurada por medio del referencial teórico de la metodología de aprendizaje basada en problemas, la cual se desarrolló considerándo los pasos del diseño educacional contextualizado (análisis, design, desarrollo, evaluación). Estudio que se realizó en la Universidad Federal de Santa Catarina, de mayo de 2014 a abril de 2015. Resultados: la aplicación presenta los contenidos: escalas para evaluación del nivel de consciencia, evaluación pupilar, reflejos y patrón respiratorio, presentados a los usuarios por medio de textos cortos con breves explicaciones, imágenes y videos. Conclusión: la aplicación puede facilitar el estudio acerca de la temática en cualquier hora o local, posibilitando incluso su uso en el lecho, lo que contribuye para mejorías de la enseñanza, asistencia y seguridad de pacientes en condición crítica. El resultado de la evaluación de la tecnología por docentes y estudiantes será objeto de estudios futuros.

ABSTRACT Objective: to develop an app for assessing the level of consciousness in adults. Method: technological production, structured from the theoretical framework of problem-based learning methodology and developed considering the steps of contextualized instructional design (analysis, design, development, evaluation). Study conducted at the Federal University of Santa Catarina, from May 2014 to April 2015. Results: the app presents the contents: scales for evaluation of the level of consciousness, pupillary evaluation, reflexes and breathing pattern, presented to the users through short texts with brief explanations, images and videos. Conclusion: the app can facilitate the study of the theme at any time or place, even allowing its application at the bedside, thus contributing to improvements in teaching, care and safety of critically ill patients. The results of the evaluation of the technology by teachers and students will be the object of future studies.

Adaptação transcultural e evidências de validade da escala Nociception Coma Scale-Revised: versão BR / Cross-cultural adaptation and validity evidence of Nociception Coma Scale - Revised: version BR

Introdução: O autorrelato é considerado padrão ouro para avaliação do paciente com dor. Em pacientes de Unidades de Terapia Intensiva existem barreiras de comunicação para avaliação da dor pelas disfunções neurológicas, alteração do nível de consciência secundária ao uso de sedativos, presença de cânula orotraqueal e outras condições impeditivas do autorrelato. Objetivo: Realizar a adaptação transcultural da NCS-R para a língua portuguesa e avaliar as evidências de validade brasileira da NCS-R em pacientes não comunicativos com desordens de consciência e distúrbios cognitivos. Método: Trata-se de um estudo metodológico para avaliação das evidências de validade da escala Nociception Coma Scale-Revised, dividido em duas etapas: adaptação transcultural e avaliação das evidências de validade do instrumento. O instrumento foi testado em 24 pacientes com desordens de consciência e distúrbios cognitivos das Unidades de Terapia Intensiva Geral e Cardiológica, Unidade Avançada de Insuficiência Cardíaca, Unidades Semicríticas e Unidades Clínicas do Hospital Sírio-Libanês em São Paulo. A fase de adaptação transcultural incluiu tradução inicial, síntese das traduções, retrotradução e comitê de especialistas. Na segunda fase foram avaliadas as evidências de validade quanto à validade de conteúdo e critério. A validade de critério foi verificada pelo teste de correlação da NCS- R entre a escala PAINAD; a NCS-R e o Questionário de Percepção do Profissional de Saúde sobre Indicadores Comportamentais de Dor. Para verificação da confiabilidade, foram avaliadas consistência interna, pelo alfa de Cronbach, e estabilidade, utilizando-se teste e reteste. Resultados: A escala NCS-R foi traduzida e adaptada do ponto de vista transcultural, apresentou evidências de validade de conteúdo (IVC 0,86) e validade de critério convergente moderada (r=0,65) com a escala PAINAD. A NCS-R apresentou resultados aceitáveis de confiabilidade, com alfa de Cronbach de 0,75, no teste-reteste, somente no item resposta motora, apresentou valor acima do aceitável (Kappa 0,61). A percepção dos profissionais sobre a presença de dor durante o estímulo apresentou diferença estatística significante. Conclusões: A NCS-R encontrase traduzida e adaptada, possui evidências de validade de conteúdo, critério e confiabilidade.

Introduction: Self-report is the gold standard for assessing patient pain. In intensive care unit patients, there are communication barriers for pain assessment due to neurological dysfunctions, altered level of consciousness secondary to sedative use, presence of orotracheal cannula and other conditions that impede self-report. Objective: To make the cross-cultural adaptation of NCS-R to the Portuguese language and to evaluate the evidences validity of the Brazilian version of NCS-R in non-communicative patients with consciousness disorders and cognitive disorders. Method: This is a methodological study to check the validity of the Nociception Coma Scale-Revised scale, divided into two stages: cross-cultural adaptation and evaluation of the evidence of instrument validity. The instrument was tested in 24 patients with consciousness and cognitive disorders of the General Intensive Care Units, Cardiac ICU, Advanced Heart Failure Unit, Stepdown Units and Clinical Units of the Hospital Sírio-Libanês in São Paulo. The cross-cultural adaptation phase included initial translation, synthesis of translations, back-translation and expert committee. In the second phase, evidences of validity regarding content validity and criterion validity were evaluated. Criterion validity was verified by the NCS-R correlation test between the PAINAD scale, the NCS-R and the Health Professional Perception Questionnaire on Behavioral Indicators of Pain. Reliability was checked by evaluating the internal consistency by Cronbachs alpha and stability by test and retest. Results: The NCS- R scale was translated and cross-culturally adapted, with evidence of content validity (CVI 0.86) and a moderate convergent criterion validity (r = 0.65) with the PAINAD scale. NCS-R presented acceptable reliability results, with Cronbachs alpha of 0.75; in the test-retest, only in the motor response item, it presented a result above the acceptable value (Kappa 0.61). The professionals perception of the presence of pain during the stimulus presented a statistically significant difference. Conclusions: NCS- R is translated and adapted, has good evidences of content, criterion validity moderate evidence of reliability.

Value of multidisciplinary collaboration in treatment of consciousness disorder after severe traumatic brain injury / 中华创伤杂志

Consciousness disorders are common in patients with severe traumatic brain injury ( sTBI) . There are some differences in the definitions of consciousness disorders in neurophysiology, neuropathology, neuroendocrinology, psychology and philosophy, which makes the evaluation and treatment of patients with consciousness disorders more complicated. The clinical multidisciplinary collaboration can make the assessment more accurate, so as to discover the residual consciousness of patients with consciousness disorder. In terms of treatment, sTBI patients are in critical condition and develop rapidly, accompanied by different systemic injuries and dysfunction of multiple systems, leading to long duration of consciousness disturbance and many complications. Neurosurgery, critical care medicine and rehabilitation medicine have their own advantages and disadvantages, and they have different clinical treatment decisions in handling patients with consciousness disorders. Therefore, multidisciplinary participation is needed in clinical treatment. Multidisciplinary collaboration can reduce the mortality, shorten hospitalization time, reduce hospitalization costs and improve the quality of life of patients with consciousness disorder after sTBI. The author discusses the value of multidisciplinary collaboration in the treatment of patients with post-sTBI consciousness disorder, in order to provide reference for improving clinical efficacy.

Acute necrotizing encephalopathy with onset of youth: a case report / 中华神经科杂志

A young female patient with acute necrotizing encephalopathy (ANE) is reported,who aged 15 years,with a history of upper respiratory tract infection,main clinical manifestations of seizures and consciousness disorders,and brain MRI examination showing characteristic symmetrical bilateral abnormal signals at both thalamic area,pons,and cerebellar hemisphere.Imaging changes corresponded to pathophysiological changes.The initial manifestations were found to be brain swelling and edema.In the acute phase,hemorrhage and necrosis of the affected brain tissues were observed.The recovery period was characterized by hemosiderin deposition and cystic space formation,which was consistent with ANE diagnosis.By early use of high-dose gammaglobulin and methylprednisolone,the prognosis of the patient was good,proving that immunosuppressive therapy by corticosteroids and gammaglobulin is effective for ANE.

Exposición no intencional a cannabis en niños en el marco de la regulación del mercado en Uruguay. Reporte de casos asistidos en el Departamento de Emergencia del Centro Hospitalario Pereira Rossell entre marzo y junio de 2017 / Children unintentionally exposed to cannabis within the framework of the Uruguayan Cannabis Sale Regulation. Cases assisted at the Emergency Department of the Pereira Rossell Hospital between March and June 2017 / Exposição não intencional à cânabis em crianças no âmbito do regulamento das vendas do cânabis no Uruguai. Relatório de casos atendidos no Serviço de Emergência do Hospital Pereira Rossell entre março e junho de 2017

Resumen: Introducción: la marihuana es la sustancia de abuso más consumida en América y Europa después del alcohol. En Uruguay la prevalencia es cercana a 23%. El principio activo delta 9-tetrahidrocannabinol es responsable de los efectos psicoactivos. La principal fuente en un niño es una parte de la planta, cigarrillo o comestible con cannabis proveniente de un familiar o vecino. La intoxicación puede ser más severa en niños que en adultos. En Uruguay, en 2013, se aprobó la ley 19.172 que regula el mercado de cannabis, generando un nuevo escenario con potencial riesgo para la población pediátrica. Objetivo: comunicar casos clínicos de intoxicación aguda no intencional por cannabis asistidos entre marzo y junio de 2017, analizar circunstancias de exposición, manifestaciones clínicas, severidad y evolución. Observación clínica: cuatro niños (9 meses, 1, 2 y 8 años) fueron asistidos. En todos ellos la vía de ingreso fue oral en ambiente doméstico. Presentaron síntomas neurológicos agudos: depresión de conciencia, convulsiones, distonías, ataxia, irritabilidad. Requirieron medidas de sostén, descontaminación digestiva y exámenes de laboratorio ampliado. El screening en orina fue positivo en cuatro casos. En dos se realizó la técnica confirmatoria. Aplicando el Poisoning Severity Score, todos sufrieron intoxicación moderada. Se asistieron en conjunto con toxicólogo clínico. Conclusiones: los niños que presentan síntomas predominantemente neurológicos de instalación aguda sin una causa evidente, pueden presentar intoxicación aguda por cannabis, sobre todo cuando en el entorno doméstico hay consumo, cultivo o ambos. Debemos mantener una vigilancia activa. Seguramente futuras investigaciones contribuirán a definir la necesidad de establecer estrategias de prevención destinadas a la población infantil con el objetivo de disminuir el potencial efecto no deseado de este nuevo escenario.

Summary: Introduction: marijuana is most highly consumed abuse substance in America and Europe after alcohol. In Uruguay, the prevalence is close to 23%. The active ingredient, delta 9-tetrahydrocannabinol, is responsible for its psychoactive effects. The main source of access for a child involves a relative and/or neighbor. Intoxication may be more severe in children, In 2013,.cannabis-sale regulating Act 19.172 was approved in Uruguay, and it generated a new potentially risky scenario for children. Objective: report clinical cases of severe unintentional intoxication from cannabis between March and June 2017, and analyze circumstances that led to exposure, clinical manifestations, severity and evolution. Clinical observation: 4 children (9 months, 1, 2 and 8 years of age) were assisted. In all cases, they had ingested cannabis in their home environment. They presented severe neurological symptoms: depressed level of consciousness, convulsive seizures, dystonia, ataxia, irritability. They required supportive measures, digestive decontamination and additional laboratory tests. Urine screening was positive in 4 cases. In 2, we performed confirmatory technique. As per the Poisoning Severity Score, all children suffered moderate intoxication. They were assisted jointly by a clinical toxicologist. Conclusions: children showing predominantly acute neurological symptoms with no apparent cause can be the subject of severe cannabis intoxication, especially when cannabis consumption takes place in their household environments. Surveillance is needed and future research will certainly contribute to the creation of prevention strategies with the purpose of reducing the potential unwanted consequences of this new scenario for children.

Resumo: Introdução: a maconha é a substância do abuso mais consumida na América e na Europa depois do álcool. No Uruguai, a prevalência é próxima de 23%. O ingrediente ativo delta 9-tetrahydrocannabinol é responsável pelos efeitos psicoativos. A principal fonte de acesso à marijuana por parte duma criança é ingerir uma parte da planta, cigarro ou comestível com cânabis de um parente e / ou vizinho. A intoxicação pode ser mais grave em crianças do que em adultos. No Uruguai, em 2013, a Lei 19.172 foi aprovada e regulou a venda de cânabis, gerando um novo cenário com risco potencial para as crianças. Objetivo: relatar casos clínicos de intoxicação aguda não intencional por cânabis atendidos entre março e junho de 2017, analisar as circunstâncias de exposição, manifestações clínicas, gravidade e evolução. Observação clínica: 4 crianças (9 meses, 1, 2 e 8 anos de idade) foram atendidas. Todos eles ingeriram cânabis num ambiente doméstico. Apresentaram sintomas neurológicos agudos: depressão da consciência, convulsões, distonia, ataxia, irritabilidade. Eles precisaram de medidas de suporte, descontaminação digestiva e testes de laboratório adicionais. O screening de urina foi positivo em 4 casos. Em 2, a técnica confirmatória foi realizada. Utilizando o Poisoning Severity Score, todos sofreram intoxicação moderada. Eles foram assistidos conjuntamente pelo toxicologista clínico. Conclusões: é possível que crianças que apresentam sintomas neurológicos predominantemente de instalação aguda sem causa evidente, apresentem intoxicação aguda por cânabis, especialmente quando existe consumo no ambiente ou na cultura domésticos. Nós devemos manter uma vigilância ativa. Com certeza, futuras pesquisas contribuirão para definir estratégias de prevenção para crianças, com o objetivo de reduzir o potencial efeito indesejado desse novo cenário.

Clinical value of PET /CT imaging of cerebral blood flow and metabolism in patients with chronic disorders of consciousness / 中华核医学与分子影像杂志

Objective To investigate the value of PET/CT imaging of cerebral glucose metabolism (CGM)and cerebral blood flow (CBF)in evaluating chronic disorders of consciousness (CDC).Methods A total of 10 CDC patients (5 males,5 females,age (50.9 ±17.2)years)and 10 healthy controls (5 males,5 females,age (52.0±10.3)years)from January 2016 to March 2017 were recruited to perform brain PET/CT of CGMand CBF.The brain PET imaging using 13 N-Ammonia was performed and followed by 18 F-fluorodeoxyglucose (FDG)PET.The mean standardized uptake values (SUVmean )of frontal,parietal, temporal and occipital lobes as well as basal ganglia,thalamus were obtained.The SUVmean of cerebral re-gions/SUVmean of cerebellum ratios (SUVr )were acquired.The SUVr were compared between the patients and controls.The imaging characteristics of CGM and CBF were investigated,and their relationships with clinical scores were further analyzed.Two-sample t test and Pearson correlation analysis were used to analyze the data.Results The radioactive distribution in the brain of healthy controls was symmetrical.SUVr of cer-ebral regions in the affected side of patients were significantly lower than those of the controls both in CGM imaging and CBF imaging (t values:2.90-5.19,all P<0.05).In 10 CDC patients,there were 9 with hypo-metabolism in basal ganglia and thalamus,8 with hypometabolism in frontal and parietal lobes,and 7 with hypometabolism in temporal and occipital lobes.At the same time,there were 7 with parietal hypoperfusion and 6 with hypoperfusion in other cerebral regions in the CDC patients.In the frontal,parietal lobes and basal ganglia,the CGMand CBF were both correlated with the clinical scores (r values:0.473-0.606,all P<0.05).Abnormal metabolism-perfusion patterns were divided into 3 types.Type Ⅰ included 2 patients and their hypometabolism and hypoperfusion were mismatched completely.Type Ⅱ included 3 patients and their hypometabolism and hypoperfusion were matched in frontal,parietal,occipital and temporal lobes,while mismatched in basal ganglia and thalamus.Type Ⅲ included 5 patients and their hypometabolism and hypoperfusion were matched completely.The clinical scores of typeⅠ,Ⅱand Ⅲ were 10.5,8.3 and 5.6, respectively.Conclusion The PET/CT imaging of cerebral blood flow and metabolism is useful in evalua-ting the disorders of consciousness.

Assessment of the brain function with 18F-FDG PET/CT in patients with disorders of consciousness / 中华核医学与分子影像杂志

Objective To evaluate the changes of brain metabolism with 18F-fluorodeoxyglucose (FDG) PET/CT in patients with disorders of consciousness (DOC).Methods This retrospective study,from January 2007 to October 2016,included 40 patients (26 males,14 females,age range:17-73 years)in the vegetative state (VS),12 patients (11 males,1 female,age range:25-53 years) in the minimally conscious state (MCS),and 11 patients (10 males,1 female,age range:12-68 years) in the state of recovering from DOC.All patients underwent 18F-FDG PET/CT imaging.The standardized uptake value (SUV) of multiple brain areas among 3 groups of patients was calculated and compared.One-way analysis of variance was used for data analysis.Results The SUV in different encephalic regions among 3 groups were significantly different (F values:6.214-13.642,all P＜0.01) except for mesencephalon.Compared with MCS group,the SUV of cerebral cortex of VS group was lower (t values:2.263-3.548,all P＜0.05).Compared with the recovered group,the SUV of cerebral cortex and cerebellum of VS group was lower (t values:1.299-5.136,all P＜0.05).Compared with the recovered group,the SUV of parietal lobe,temporal lobe,occipital lobe,thalamus and cerebellum of MCS group was lower (t values:1.962-2.841,all P＜0.05).Conclusion 18F-FDG PET/CT may be significant in evaluating brain function of DOC patients.

Study of Simplified Coma Scales: Acute Stroke Patients with Tracheal Intubation / 中华医学杂志(英文版)

<p><b>Background</b>Whether the Glasgow Coma Scale (GCS) can assess intubated patients is still a topic of controversy. We compared the test performance of the GCS motor component (GCS-M)/Simplified Motor Score (SMS) to the total of the GCS in predicting the outcomes of intubated acute severe cerebral vascular disease patients.</p><p><b>Methods</b>A retrospective analysis of prospectively collected observational data was performed. Between January 2012 and October 2015, 106 consecutive acute severe cerebral vascular disease patients with intubation were included in the study. GCS, GCS-M, GCS eye-opening component, and SMS were documented on admission and at 24, 48, and 72 h after admission to Neurointensive Care Unit (NCU). Outcomes were death and unfavorable prognosis (modified Rankin Scale: 5-6) at NCU discharge. The receiver operating characteristic (ROC) curve was obtained to determine the prognostic performance and best cutoff value for each scoring system. Comparison of the area under the ROC curves (AUCs) was performed using the Z- test.</p><p><b>Results</b>Of 106 patients included in the study, 41 (38.7%) patients died, and 69 (65.1%) patients had poor prognosis when discharged from NCU. The four time points within 72 h of admission to the NCU were equivalent for each scale's predictive power, except that 0 h was the best for each scale in predicting outcomes of patients with right-hemisphere lesions. Nonsignificant difference was found between GCS-M AUCs and GCS AUCs in predicting death at 0 h (0.721 vs. 0.717, Z = 0.135, P = 0.893) and 72 h (0.730 vs. 0.765, Z = 1.887, P = 0.060), in predicting poor prognosis at 0 h (0.827 vs. 0.819, Z = 0.395, P = 0.693), 24 h (0.771 vs. 0.760, Z = 0.944, P = 0.345), 48 h (0.732 vs. 0.741, Z = 0.593, P = 0.590), and 72 h (0.775 vs. 0.780, Z = 0.302, P = 0.763). AUCs in predicting death for patients with left-hemisphere lesions ranged from 0.700 to 0.804 for GCS-M and from 0.700 to 0.824 for GCS, in predicting poor prognosis ranged from 0.841 to 0.969 for GCS-M and from 0.875 to 0.969 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h (P > 0.05). No significant difference between GCS-M AUCs and GCS AUCs was found in predicting death (0.964 vs. 0.964, P = 1.000) and poor prognosis (1.000 vs. 1.000, P = 1.000) for patients with right-hemisphere lesions at 0 h. AUCs in predicting death for patients with brainstem or cerebella were poor for GCS-M (<0.700), in predicting poor prognosis ranged from 0.727 to 0.801 for GCS-M and from 0.704 to 0.820 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h (P > 0.05). The SMS AUCs (<0.700) in predicting outcomes were poor.</p><p><b>Conclusions</b>The GCS-M approaches the same test performance as the GCS in assessing the prognosis of intubated acute severe cerebral vascular disease patients. The GCS-M could be accurately and reliably applied in patients with hemisphere lesions, but caution must be taken for patients with brainstem or cerebella lesions.</p>

Effect of transcranial direct current combined with mirror neuronal rehabilitation training / 中国医师进修杂志

Objective To observe the effect of transcranial direct current stimulation (tDCS) with mirror neuronal rehabilitation training system (MNST-V1.0) in post-traumatic unconscious patients after severe craniocerebral injury. Methods A prospective, self controlled and open-label method was used. Thirty-six post-traumatic unconscious patients with severe craniocerebral injury from January 2016 to July 2017 were selected. Four cases of the patients did not complete the treatment and the last 32 cases completed the study. All patients were given routine wake-up therapy, and tDCS combined with MNST-V1.0 (20 min/time, 1 time/d, 6 times/week, a total of 8 weeks) was given at the same time. The Glasgow coma scale (GCS), JFK coma recovery scale and Four coma rating scale before treatment and 2, 4, 8 weeks after treatment were recorded. Results The scores of open reaction, language and motor response score of GCS 2, 4, 8 weeks after treatment were significantly higher than those before treatment:(1.56 ± 0.82), (2.06 ± 1.01) and (3.11 ± 1.45) scores vs. (1.00 ± 0.45) scores, (2.23 ± 1.06), (2.56 ± 1.08) and (3.02 ± 1.04) scores vs. (1.00 ± 0.61) scores, (2.79 ± 1.12), (3.22 ± 1.33) and (4.44 ± 1.07) scores vs. (1.00 ± 0.54) scores, and there were statistical differences (P ＜ 0.01 or ＜0.05). The scores of hearing, vision, movement, speech response, communication and arousal of JFK coma recovery scale 2, 4, 8 weeks after treatment were significantly higher than those before treatment, and there were statistical differences (P＜0.01). The scores of open reaction, sport reaction, brainstem response of Four coma rating scale 2, 4, 8 weeks after treatment were significantly higher than those before treatment, and there were statistical differences (P＜0.05); there was no statistical difference in respiratory score of Four coma rating scale before and after treatment (P＞0.05). Conclusions The tDCS combined with MNST-V1.0 can improve the consciousness level in post-traumatic unconscious patients with severe craniocerebral injury, and have the effect of promoting awakening.

Analysis of the level of consciousness related to the oxygen therapy in patients in anesthesia recovery period / Análise do estado de consciência relacionado à oxigenoterapia em pacientes em recuperação anestésica

Analyze the level of consciousness by means of the Aldrete-Kroulik scale associated with the use of oxygen therapy at the Post-Anesthesia Care Unit (PACU). It is a prospective and comparative study, with quantitative analysis. It was conducted in a big Federal Public Hospital, located in Belo Horizonte city. The sample was consisted of 60 subjects, separated between groups using and do not using oxygen therapy, aged between 18 and 64 years old, submitted to elective surgery, surgical site in upper torso, under general anesthesia, and with the American Society Anesthesiologists (ASA) status I or II. The most part of the patients were female, with 50 years old or older, classified as ASA II, under total intravenous anesthesia, and length of time of anesthesia over 240 minutes. In the analysis of the level of consciousness related to the use of oxygen therapy, it is noteworthy that the p-value (0.069) is significant at the 15 minutes of permanence in the PACU. A large number of patients from the group that received supplemental oxygen therapy showed improvement in the level of consciousness at the 15 minutes of permanence in the PACU. Team work is necessary to prevent patient's complications in anesthetic recovery period.

Analyze the level of consciousness by means of the Aldrete-Kroulik scale associated with the use of oxygen therapy at the Post-Anesthesia Care Unit (PACU). It is a prospective and comparative study, with quantitative analysis. It was conducted in a big Federal Public Hospital, located in Belo Horizonte city. The sample was consisted of 60 subjects, separated between groups using and do not using oxygen therapy, aged between 18 and 64 years old, submitted to elective surgery, surgical site in upper torso, under general anesthesia, and with the American Society Anesthesiologists (ASA) status I or II. The most part of the patients were female, with 50 years old or older, classified as ASA II, under total intravenous anesthesia, and length of time of anesthesia over 240 minutes. In the analysis of the level of consciousness related to the use of oxygen therapy, it is noteworthy that the p-value (0.069) is significant at the 15 minutes of permanence in the PACU. A large number of patients from the group that received supplemental oxygen therapy showed improvement in the level of consciousness at the 15 minutes of permanence in the PACU. Team work is necessary to prevent patient's complications in anesthetic recovery period.

Assessment of nurse's knowledge about Glasgow coma scale at a university hospital / Avaliação do conhecimento de enfermeiros sobre a escala de coma de Glasgow em um hospital universitário

ABSTRACT Objective To assess knowledge of nurses of emergency services and intensive care units about Glasgow Coma Scale. Methods This cross-sectional analytical study included 127 nurses of critical units of an university hospital. We used structured interview with 12 questions to evaluate their knowledge about the scale. Association of Knowledge with professionals’ sociodemographic variables were verified by the Fisher-test, χ2 and likelihood ratio. Results Most of participants were women mean aged 31.1 years, they had graduated more than 5 years previously, and had 1 to 3 years of work experience. In the assessment of best score possible for Glasgow scale (question 3) nurses who had graduate more than 5 years ago presented a lower percentage success rate (p=0.0476). However, in the question 7, which evaluated what interval of the scale indicated moderate severity of brain trauma injury, those with more years of experience had higher percentage of correct answers (p=0.0251). In addition, nurses from emergency service had more correct answers than nurses from intensive care unit (p=0.0143) in the same question. Nurses graduated for more than 5 years ago had a lower percentage of correct answers in question 7 (p=0.0161). Nurses with more work experience had a better score (p=0.0119) to identify how assessment of motor response should be started. Conclusion Number of year since graduation, experience, and work at critical care units interfered in nurses’ knowledge about the scale, which indicates the need of training.

RESUMO Objetivo Avaliar o conhecimento de enfermeiros de unidades críticas, serviços de emergência e unidades de terapia intensiva em relação à escala de coma de Glasgow. Métodos Estudo transversal e analítico com 127 enfermeiros de unidades críticas de um hospital universitário. Utilizou-se entrevista estruturada com 12 questões que avaliaram conhecimento sobre a escala. Associação do conhecimento com variáveis sociodemográficas dos profissionais foi verificada pelo teste de Fisher, teste χ2 e razão de verossimilhança. Resultados Houve predominância de mulheres, média de idade de 31,1 anos, especialistas, mais de 5 anos de formado e experiência profissional de 1 a 3 anos. Na avaliação do melhor escore possível para pontuação na escala (questão 3), enfermeiros com tempo de formação maior que 5 anos apresentaram menor porcentual de acertos (p=0,0476). Em relação à questão 7, que avaliou qual intervalo da escala indicava gravidade moderada do trauma craniencefálico, observou-se que quanto maior o tempo de experiência, maior o porcentual de acertos (p=0,0251), sendo que enfermeiros do serviço de emergência tiveram mais acertos nessa questão em relação aos das unidades de terapia intensiva (p=0,0143). Além disso, enfermeiros formados há mais de 5 anos apresentaram menor porcentual de acertos nessa questão (p=0,0161). Quando se identificou como deve ser iniciada a avaliação da resposta motora, enfermeiros com maior tempo de trabalho na unidade apresentaram mais acertos (p=0,0119). Conclusão Tempo de formação, experiência e trabalho na unidade interferiu no conhecimento de enfermeiros sobre a escala, evidenciando necessidade de capacitação.

Pacientes com desordem de consciência: respostas vitais, faciais e musculares frente música ou mensagem / Pacientes con trastornos de la conciencia: respuestas vitales, faciales y musculares frente música o mensaje / Patients with disorders of consciousness: vital, facial and muscular responses to music or messages

Objetivos: comparar sinais vitais, expressão facial e sinais eletroneurográfi cos basais com medidas durante os estímulos música, mensagem ou “silêncio” em pacientes em coma, estado vegetativo ou sedado e relacionar a pontuação da Escala de Resultado de Glasgow com a intervenção realizada. Método: ensaio Clínico Controlado Transversal Unicego para o pesquisador. A alocação foi aleatória nos três grupos (experimental música, experimental mensagem ou controle). Foram realizadas duas avaliações (sessões) com intervalo de 40 minutos no mesmo dia. Resultados: a maioria dos 76 pacientes eram homens, entre 18 e 36 anos e internados por trauma. Encontraram-se alterações estatisticamente signifi cantes nas variáveis temperatura, expressão facial, eletroneurografi a e Escala de Resultado de Glasgow; alterações mais frequentes na sessão 2, nos pacientes em coma e estado vegetativo, no músculo frontal e no grupo experimental. Conclusões: a expressão facial e a eletroneurografi a parecem ser variáveis mais confi áveis do que os sinais vitais para mensurar consciência. .

Objetivos: comparar señales vitales, expresión facial y señales electroneurográfi cos basales con medidas tomadas durante de estímulos música, mensaje o “silencio” en pacientes en coma, estado vegetativo o sedados; y relacionar la pontuacion de la Escala de Resultados de Glasgow con la intervención. Método: ensayo Clínico Controlado Transversal Uniciego para lo pesquisador. La distribución fue aleatoria en tres grupos (experimental de música, experimental de mensaje o de control). Dos evaluaciones (sesiones) se realizaron con intervalo de 40 minutos en el mismo día. Resultados: la mayoría de los 76 pacientes eram hombres, edades entre 18 y 36 años, y internados por trauma. Se encontraron alteraciones estadísticamente signifi cativas en las variables temperatura, expresión facial, electroneurografía y Escala de Resultados de Glasgow; alteraciones más frecuentes en segunda sesión, en pacientes en coma y estado vegetativo, en músculos frontales y en grupo experimental. Conclusiones: la expresión facial y la electroneurografía parecen ser variables más confi ables que os señales vitales para avaliar consciência. .

Purposes: to compare vital signs, facial expression and basal electroneurographic signs with measures during stimuli music, message or “silence” in coma patients, vegetative status or sedated; and relating the score of Glasgow Results Scale with the intervention realized. Method: a Monoblind Transversal Controlled Clinical Trial to researcher. The distribution, among the three groups, was randomized (experiment with music, experiment with message or control). Two assessments (sessions) were performed with interval of 40 minutes on the same day. Results: most of the 76 patients were male, between 18 to 36 years old and hospitalized due to trauma. Statistically signifi cant changes were found in the variables referred to temperature, facial expression, electroneurography and Glasgow Results Scale; more frequent alterations in second session, in coma and vegetative patients, in frontal muscles and in experiment group. Conclusions: the facial expression and the electroneurography seem to be more trustworthy variables than vital signs to evaluate consciousness. .

Clinical characteristics in four pediatric patients with mild encephalitis/encephalopathy with a reversible splenial lesion of corpus callosum / 中华神经科杂志

Objective To investigate the clinical and imaging features of mild encephalitis/encephalopathy with a reversible splenial lesion of corpus callosum (MERS) in children.Methods Four patients of MERS, who were diagnosed and treated in the First Hospital of Jilin University during 2013-2014, were collected retrospectively.Their clinical, laboratory, radiologic data and the related literatures were reviewed.Results Four patients onsetted as gastrointestinal symptom (3 cases) or respiratory (1 case) symptom, in accompany with disturbance of consciousness (3 cases of drowsiness, 1 case of lethargy), convulsions (4 cases), headache (1 case) as the main symptoms.Abnormal neurological signs included positive cervical resistance (3 cases), positive bilateral Babinski sign (3 cases), bilateral chemosis (2 cases).Laboratory test showed the average blood sodium was 131.6 mmol/L, while the cerebrospinal fluid test only showed abnormality in 1 case.In etiology examination, 2 cases showed human rotavirus antigen positive, and Mycoplasma pneumoniae antibody was found positive in 2 cases.Cranial MRI showed reversible lesion in the splenium of corpus callosum (patchy iso-or hypo-intensity on T1 WI and apparent diffusion coefficient, hyper-intensity on T2WI, FLAIR and DWI, clear boundary).After active treatment, clinical symptoms disappeared within 1 week, and cranial MRI lesions disappeared within 2 weeks.Conclusion The clinical presentations of MERS, which is a clinical-radiological syndrome, are sudden onset and mild, with characteristic changes in brain MRI and good prognosis.

Risk factors and prognostic analysis of cranial nerve impairment in 121 patients with tuberculous meningitis / 中华传染病杂志

Objective To investigate the risk factors associated with cranial nerve impairment in patients with tuberculous meningitis.Methods A total of 121 patients with tuberculous meningitis who were admitted to Huashan Hospital from 2000 to 2011 were reviewed retrospectively.Demographic data (gender,age),course of disease,initial results of cerebral spinal fluid (CSF) tests,occurrence of cranial nerve impairment and prognosis of these patients were collected.All the patients were followed up for at least 3 months,and for those with cranial nerve impairment,the minimum follow-up period was 1 year in order to judge the recovery of cranial nerve impairment.Multivariate analysis was performed to study the associated risk factors.Results Out of 121 patients,22 (18.2 ％)developed cranial nerve impairment.Nerves involved were abducens nerve,oculomotor nerve,optic nerve and auditory nerve,and impairment of single nerve occurred in 9 (40.9 ％),8 (36.4 ％),7(31.8％) and 1(4.5％) patient,respectively.Three cases had more than one group of cranial nerves involved,accounting for 13.6％ of the 22 patients with cranial nerve impairment.The incidence of conscious disturbance was significantly higher in patients with cranial nerve impairment than those without impairment (77 ％ vs 45 ％,P=0.020).Delay in diagnosis (OR =1.017,95 ％ CI:1.001-1.033,P=0.040) and occurrence of conscious disturbance (OR =3.242,95 ％ CI:1.142-9.205,P=0.027) were independent predictive factors of cranial nerve injury.During one-year follow-up,90.9％ of patients were fully recovered from cranial nerve impairment,with a median duration of 1 month (range 0.5-6.0 months).Conclusions Cranial nerve impairment is a common complication in patients with tuberculous meningitis.Delay in diagnosis and occurrence of conscious disturbance were independent predictive factors.Most cranial nerve impairment were reversible,and timely diagnosis and treatment are important ways to reduce complications.

Síndrome confusional agudo como forma de presentación de un absceso espinal / Acute confusional syndrome as way of presentation of a spinal abscess

La alteración del nivel de conciencia puede ser producida por múltiples causas, es un síndrome que requiere de una actuación ordenada, rápida y eficaz; ya que se trata de una urgencia médica en la que el tiempo siempre va en contra del paciente. La aproximación al paciente geriátrico con alteración del nivel de conciencia debe ir encaminada al tratamiento de su causa y prevención de sus complicaciones. Objetivo: presentar un caso poco frecuente con un absceso espinal que debutó con un síndrome confusional agudo. Caso Clínico: paciente de 62 años de edad que inicia de forma aguda con cambio en su comportamiento, insomnio, abandono de hábitos cotidianos, se le olvida donde deja las cosas y está muy irritable. Al examen físico se encuentra: trastornos en la perceptividad y esfera cognitiva, dolor a la percusión, movilización de las apófisis espinosas dorsales I y II. Se practicó una resonancia magnética nuclear de región dorsal, la cual demostró la presencia de una lesión en el espacio epidural que se extendía desde el segundo al sexto segmento dorsal .Se llevó de forma urgente al salón de operaciones, se realizó abordaje posterior al raquis dorsal, a través del cual se evacuó un absceso epidural. En un período de 12 días las manifestaciones neuropsiquiatras desaparecieron. Conclusiones: el síndrome confusional agudo es una enfermedad que se puede ver entre el 10-15 por ciento de los pacientes con una enfermedad médico-quirúrgico, incidencia que se eleva hasta el 30 por ciento en los ancianos, y puede ser la forma de presentación poco frecuente de una infección intrarraquídea. El diagnóstico oportuno y tratamiento eficaz impidieron la progresión de las manifestaciones neurológicas y revirtieron la sintomatología.

The alteration of the level of consciousness may be produced by multiple causes; it is a syndrome that requires an orderly, quick and effective performance; since it is a medical urgency in which time always goes against the patient. The approach to the geriatric patient with alteration of the level of consciousness should be guided to the treatment of its cause and to the prevention of their complications. Objective: to present an infrequent case with a spinal abscess that started with an acute confusional syndrome. Clinical case: a 62 years old patient begins with an acute change in his behavior, insomnia, abandonment of daily habits, forgot things and also very irritable. To the physical examination were found: perceptivity disorders and cognitive sphere, pain at percussion, mobilization of I and II dorsal spines (DI-DII). A nuclear magnetic resonance of dorsal region was practiced, which showed up a lesion in the epidural space that extended from the second to the sixth segment (DII to DVI). He was taken urgently to the surgical room; he was carried out a posterior approach to the dorsal rachis, through which an epidural abscess was evacuated. In twelve days, neuropsychiatry manifestations disappeared. Conclusions: acute confusional syndrome is a disease that may be found between 10-15 percent of patients with a medical-surgical disease, incidence that rises until 30 percent in the old men, and may be an infrequent form of presentation of an intrarrhachidian infection. The opportune diagnosis and effective treatment impeded the progression of neurological manifestations and the symptomatology was reverted.

Relationship of somatosensory evoked potential grading with prognosis in long-term unconscious patients after severe traumatic brain injury / 中华创伤杂志

Objective To study prognosis and grading of somatosensory evoked potential(SEP)in long-term unconscious patients after severe traumatic brain injury(TBI).Methods Five prognostic factors including age,sex,injury mechanism,history of temporal craniotomy and SEP grading were selected and analyzed in 47 patients after severe TBI with a duration of unconsciousness longer than two weeks.The prognosis was judged by Glasgow Outcome Scale.Results Prognosis was closely associated with SEP grading(P=0.024).The accuracy of SEP in assessing the prognosis was 91.5%.About 95%-100% of patients with SEP at grade Ⅲ-Ⅲ ended up with severe disability,persistent vegetative state or death.However,43.75% of patients with SEP at grade Ⅰ had good prognoses.Conclusions The SEP grading can objectively and accurately evaluate patients' prognosis and demonstrate the brain function.