External Validation and Calibration of the DecaPreT Prediction Model for Decannulation in Patients with Acquired Brain Injury.

We propose a new set of clinical variables for a more accurate early prediction of safe decannulation in patients with severe acquired brain injury (ABI), during a post-acute rehabilitation course. Starting from the already validated DecaPreT scale, we tested the accuracy of new logistic regression models where the coefficients of the original predictors were reestimated. Patients with tracheostomy were retrospectively selected from the database of the neurorehabilitation unit at the S. Anna Institute of Crotone, Italy. New potential predictors of decannulation were screened from variables collected on admission during clinical examination, including (a) age at injury, (b) coma recovery scale-revised (CRS-r) scores, and c) length of ICU period. Of 273 patients with ABI (mean age 53.01 years; 34% female; median DecaPreT = 0.61), 61.5% were safely decannulated before discharge. In the validation phase, the linear logistic prediction model, created with the new multivariable predictors, obtained an area under the receiver operating characteristics curve of 0.901. Our model improves the reliability of simple clinical variables detected at the admission of the post-acute phase in predicting decannulation of ABI patients, thus helping clinicians to plan better rehabilitation.

The Impact of Medical Complications in Predicting the Rehabilitation Outcome of Patients With Disorders of Consciousness After Severe Traumatic Brain Injury.

In this study, we sought to assess the predictors of outcome in patients with disorders of consciousness (DOC) after severe traumatic brain injury (TBI) during neurorehabilitation stay. In total, 96 patients with DOC (vegetative state, minimally conscious state, or emergence from minimally conscious state) were enrolled (69 males; mean age 43.6 ± 20.8 years) and the improvement of the degree of disability, as assessed by the Disability Rating Scale, was considered the main outcome measure. To define the best predictor, a series of demographical and clinical factors were modeled using a twofold approach: (1) logistic regression to evaluate a possible causal effect among variables; and (2) machine learning algorithms (ML), to define the best predictive model. Univariate analysis demonstrated that disability in DOC patients statistically decreased at the discharge with respect to admission. Genitourinary was the most frequent medical complication (MC) emerging during the neurorehabilitation period. The logistic model revealed that the total amount of MCs is a risk factor for lack of functional improvement. ML discloses that the most important prognostic factors are the respiratory and hepatic complications together with the presence of the upper gastrointestinal comorbidities. Our study provides new evidence on the most adverse short-term factors predicting a functional recovery in DOC patients after severe TBI. The occurrence of medical complications during neurorehabilitation stay should be considered to avoid poor outcomes.

Paroxysmal Sympathetic Hyperactivity Rate in Vegetative or Minimally Conscious State after Acquired Brain Injury Evaluated by Paroxysmal Sympathetic Hyperactivity Assessment Measure.

The rate of paroxysmal sympathetic hyperactivity (PSH) was retrospectively assessed using the Paroxysmal Sympathetic Hyperactivity-Assessment Measure (PSH-AM) scale in patients with disorders of consciousness attributed to traumatic and non-traumatic acquired brain injury during the rehabilitation phase. These results were compared with previous studies carried out in the same clinical scenario, in order to verify the prevalence of PSH signs from 1998 to 2014. The entire sample consisted of 140 patients in vegetative state/unresponsive wakefulness syndrome or minimally conscious state admitted to a neurorehabilitation subacute unit from June 2010 to December 2014. PSH-AM revealed the presence of PSH in 16% of traumatic and 12% of non-traumatic younger patients. In the non-traumatic group, the rate was higher in patients with anoxia-hypoxia (37.5%) etiology than those with vascular brain injury (6.7%). A comparison with previous studies revealed a reduction in the number of PSH cases in traumatic patients. This study provides evidence that PSH-AM can be used prospectively to detect the rate of PSH and stratify severity of signs. Further longitudinal analysis is warranted to confirm the prevalence of PSH signs in non-traumatic brain injured patients.

Decreasing incidence of paroxysmal sympathetic hyperactivity syndrome in the vegetative state.

OBJECTIVE: To update knowledge of the incidence of paroxysmal sympathetic hyperactivity (PSH, also referred to as dysautonomia), an emergency condition tentatively attributed to sympathetic paroxysms or diencephalic-hypothalamic disarrangement associated with severe diffuse brain axonal damage or hypoxia. This condition is reportedly common in the vegetative state, threatens survival and affects outcome. METHODS: The results of a retrospective study on 333 subjects in a vegetative state admitted to a dedicated unit in 1998-2005 are compared with a survey on patients admitted to the same unit in 2006-2010. RESULTS AND COMMENT: In the 1998-2005 period, the incidence of PSH was 32% and 16% in post-traumatic and non-traumatic patients, respectively. It decreased to 18% and 7% in the 2006-2010 period. The PSH duration and the time spent in emergency units before admission and in the dedicated unit for the vegetative state after admission also decreased significantly. Incidence was greater among post-traumatic- patients; its effect on outcome does not appear to have changed.

Neurorehabilitation for severe disorder of consciousness: the S. Anna - RAN operational model.

The operational model and strategies designed for use in the S. Anna - Research in Advanced Neurorehabilitation Institute for the care and neurorehabilitation of subjects in the vegetative or minimally conscious states are described here. A total of 722 patients were admitted, cared for and discharged from the institute in the period 1998-2009. Application of the model approach has progressively shortened the time of hospitalization and rehabilitation and reduced costs.

Visual pursuit in the severe disorder of consciousness.

Visual pursuit is a key descriptor of the minimally conscious state (above 80% of cases). It is also observable in about 20% of subjects in vegetative state. Its reappearance after severe brain damage anticipates a favorable outcome, with recovery of consciousness in 73% of subjects (45% in the absence of it). We considered retrospectively 395 subjects in vegetative state because of traumatic (63%), massive acute vascular (30%), or diffuse anoxic-hypoxic (7%) brain damage consecutively admitted to one dedicated unit during the years 1998-2008. Visual tracking was observed in 290 subjects (73.4%) and was already detectable within 50 days from brain injury in about 60% of post-traumatic or vascular subjects and 21% of anoxic-hypoxic patients. After 230 days of follow-up or more, it was observed in 89% and 88% of post-traumatic and vascular subjects and in 67% of anoxic-hypoxic patients. Rating with the Glasgow Outcome Scale (GOS) was better in those subjects with recovered visual tracking and inversely correlated with the time of reappearance in post-traumatic and vascular subjects; also the subjects with late recovery of eye tracking (230 days or more) had better GOS outcome than those without it. The observation of visual tracking reappearing in subjects in vegetative state would reflect recuperation of the brainstem-cortical interaction and overall brain functional organization that are thought to sustain consciousness and are interfered with by the "functional disconnection," resulting in the vegetative state.