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Aim: Comparison of the Full Outline of UnResponsiveness (FOUR) score with the Glasgow Coma Scale (GCS) score to find the better scoring system for predicting outcomes among altered sensorium patients in the critical care unit. Materials and methods: This is a prospective observational study. It included 100 patients of altered sensorium, whose GCS and FOUR scores were calculated at admission and followed up till death or discharge to note the outcome. Individual demographics and diagnosis were recorded, and the results were analyzed statistically. Results: The correlation between the two scores was excellent, with the Spearman's correlation coefficient of 0.88. Discrimination ability of the two scoring systems, as assessed by the area under the receiver operating characteristic curve, was 0.778 for GCS score and 0.883 for FOUR score (p <0.001). When area under the curve (AUC) was calculated exclusively in stroke cases, it was 0.836 for GCS score and 0.944 for FOUR score. Among nonstroke cases, the AUC was 0.756 and 0.859, respectively. However, the 95% confidence limits were overlapping among the corresponding scores. Conclusion: The above study concludes that there is a good correlation between GCS and FOUR scores in predicting outcomes. Superiority of FOUR score could not be established statistically in view of overlapping confidence limits. However, it performed at par with GCS in prognosticating mortality among patients with altered sensorium. Clinical significance: In critically ill patients with altered sensorium, explaining the prognosis to the attendants is a challenge for the physician. The commonly used GCS score has several shortcomings, especially in intubated patients. Use of the FOUR score can overcome these shortcomings and help in prognostication of these patients. In view of its good correlation with GCS score and equal efficacy in predicting outcomes in varied etiologies, it can be used as a good alternative to the GCS score. How to cite this article: Javvaji PK, Nagatham P, Venkata RR, Puttam H, John SK, Karavalla H, et al. A Comparison of Full Outline of UnResponsiveness Score with Glasgow Coma Scale Score in Predicting Outcomes among Patients with Altered Mental Status Admitted to the Critical Care Unit. Indian J Crit Care Med 2022;26(2):210-215.
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Hígado Artificial/historia , Adsorción , Animales , Perros , Diseño de Equipo , Historia del Siglo XXRESUMEN
BACKGROUND: Liver cell proliferation after partial hepatectomy in rats has been thoroughly investigated. Although DNA synthesis and morphologic restoration have been studied in this rat model, the functional capacity of the remnant liver during regeneration has not been elucidated. METHODS: We measured the indocyanine green disappearance rate (ICG-k) and serum aminopyrine (CLamp) in rats at various intervals after two-thirds hepatectomy. Morphologic restoration of the liver after hepatectomy was evaluated on the basis of remnant liver weight, proliferating cell nuclear antigen labeling index, and the DNA content of the regenerating liver. Serial changes in ICG-k and CLamp after two-thirds hepatectomy were compared with the degree of morphologic restoration. RESULTS: ICG-k and CLamp were reduced by one third in rats after two-thirds hepatectomy. Although the rate of restoration of remnant liver weight was steady after hepatectomy, ICG-k and CLamp were lowest about 36 hours after hepatectomy. The restoration of ICG-k was comparable to that of liver weight, but the restoration of CLamp was delayed. CONCLUSIONS: Functional liver capacity was minimal during parenchymal cell mitosis in the regenerating liver. Functional restoration after two-thirds hepatectomy was delayed in comparison with morphologic restoration in rat.
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Hepatectomía , Regeneración Hepática , Aminopirina/metabolismo , Animales , Antipirina/metabolismo , ADN/biosíntesis , Verde de Indocianina/metabolismo , Masculino , Ratas , Ratas WistarRESUMEN
The pathogenesis of portal hypertensive gastropathy has not yet been thoroughly elucidated. Changes in the gastric surface mucus layer in prehepatic portal hypertensive and cirrhotic rat models were studied by observing frozen sections fixed with formaldehyde vapor and stained with hematoxylin and eosin. We produced prehepatic portal hypertensive rats by partial ligation of the portal vein, and cirrhotic rats by prolonged administration of carbon tetrachloride (CCl4) and phenobarbital sodium. The thickness of the corporal and antral gastric surface mucus was significantly reduced in prehepatic portal hypertensive and cirrhotic rats compared with the values obtained in control rats for portal hypertension (subjected to sham operation) and control rats for cirrhosis (treated with phenobarbital but not CCl4). These results indicate that the hemodynamic changes associated with portal hypertension reduce the thickness of the gastric surface mucus layer and may be one of the causes of the gastropathy associated with portal hypertension.
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Mucosa Gástrica/patología , Hipertensión Portal/patología , Animales , Presión Sanguínea , Hipertensión Portal/fisiopatología , Cirrosis Hepática Experimental/patología , Masculino , Tamaño de los Órganos , Ratas , Ratas Wistar , Bazo/patología , Factores de TiempoRESUMEN
A 5-year-old girl underwent laparotomy in 1972 because of hepatomegaly and mottled radiopacities shown by cholangiography. Polycystic segmental dilatation of the intrahepatic bile ducts, typical of Caroli's disease, was found. Thereafter she remained in good health for over 21 years with careful medical management. In 1972 mottled radiopacities of the hepatic parenchyma were also demonstrated by cholangiography in her 9-year-old brother, who, however, remained asymptomatic until hematemesis due to esophageal varices suddenly occurred in 1993. At the time of the pre-operative evaluation for esophageal transection, his condition was definitively diagnosed as Caroli's disease. Their father was in good health, but in 1993 was shown by CT to have the same disease. The mode of inheritance is likely to be autosomal dominant, although Caroli's disease or congenital hepatic fibrosis is generally considered autosomal recessive (McKusick number 263200) (1). If we had not examined the father, this particular family would have been accepted as an example of autosomal recessive inheritance. We suggest that further family studies are needed to exclude the autosomal dominant mode of inheritance, and that at least some of the recessive cases in the literature are, in fact, autosomal dominant. Well-documented cases of "classical" Caroli's disease in the literature were reviewed with special reference to the long-term results. In addition, an international questionnaire aimed at establishing the further clinical course of the patient was sent to authors who reported cases after 1968.(ABSTRACT TRUNCATED AT 250 WORDS)
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Enfermedad de Caroli/genética , Genes Dominantes , Adulto , Enfermedad de Caroli/diagnóstico , Enfermedad de Caroli/terapia , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Masculino , Núcleo Familiar , Linaje , PronósticoRESUMEN
We performed adult hepatocyte transplantation (HCTx) and fetal liver transplantation (FLTx) into the spleens of hyperbilirubinemic Gunn rats in congenic combination and we compared the long-term effects of these procedures for as long as 12 months. Proliferative activity of intrasplenic hepatocytes was evaluated using antiproliferating cell nuclear antigen (PCNA) immunohistochemical staining. The serum total bilirubin levels (T. Bil) significantly decreased from 7.16 +/- 0.25 mg/dl to 4.38 +/- 0.60 mg/dl 2 months after HCTx and gradually decreased thereafter until 12 months after transplantation (3.23 +/- 0.37 mg/dl, P < 0.05 vs preoperative value). The T. Bil change after FLTx was similar to that of HCTx: 7.22 +/- 0.24 mg/dl before FLTx, and 4.92 +/- 0.24 and 3.06 +/- 0.47 mg/dl, 2 and 12 months after FLTx (P < 0.05), respectively. Bilirubin glucuronides, which were not detectable in the bile from untreated Gunn rats, appeared in considerable amounts 4 months after HCTx and FLTx (27.5% and 36.0% of total bile, respectively). PCNA labeling indices of intrasplenic hepatocytes (4.9% +/- 0.9% and 3.7% +/- 0.7%, 6 months after HCTx and FLTx, respectively) were slightly higher than those of normal hepatocytes (1.0% +/- 0.1%) in the host liver. In conclusion, both adult and fetal rat hepatocytes transplanted into the spleen in congenic combination functioned for at least a year in terms of bilirubin glucuronidation. The spleen is considered to be one of the optimal grafting sites for hepatocytes, with nearly lifelong significant function and proliferative activity.
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Trasplante de Células/fisiología , Trasplante de Tejido Fetal/fisiología , Hiperbilirrubinemia/sangre , Trasplante de Hígado/fisiología , Hígado/citología , Bazo/patología , Animales , Bilis/química , Bilirrubina/metabolismo , División Celular , Trasplante de Células/patología , Cerebelo/patología , Trasplante de Tejido Fetal/patología , Glucuronatos/metabolismo , Hígado/embriología , Trasplante de Hígado/patología , Antígeno Nuclear de Célula en Proliferación/metabolismo , Ratas , Ratas Gunn , Ratas Wistar , Bazo/metabolismo , Bazo/cirugíaAsunto(s)
Trasplante de Células , Hiperbilirrubinemia/terapia , Hígado/citología , Bazo , Animales , Bilirrubina/sangre , División Celular , Trasplante de Células/patología , Femenino , Hepatectomía , Hiperbilirrubinemia/sangre , Hiperbilirrubinemia/patología , Inmunohistoquímica , Cinética , Antígeno Nuclear de Célula en Proliferación/análisis , Ratas , Ratas Gunn , Ratas Wistar , Bazo/patología , Factores de Tiempo , Trasplante HomólogoAsunto(s)
Trasplante de Células/fisiología , ADN/biosíntesis , Hepatectomía , Hígado/citología , Animales , Bilirrubina/sangre , Separación Celular , Células Cultivadas , Colagenasas , Hígado/metabolismo , Antígeno Nuclear de Célula en Proliferación/análisis , Ratas , Ratas Gunn , Ratas Wistar , Bazo , Trasplante HeterotópicoAsunto(s)
Ciclosporina/uso terapéutico , Supervivencia de Injerto/inmunología , Trasplante de Corazón/inmunología , Trasplante de Piel/inmunología , Animales , Circulación Coronaria , Esquema de Medicación , Masculino , Ratas , Ratas Endogámicas Lew , Ratas Endogámicas , Trasplante Heterólogo , Trasplante HomólogoRESUMEN
To examine whether structural changes in hepatocytes and/or sinusoidal areas contribute to the portal hypertensive state in non-alcoholic cirrhosis, a new method of morphometric analysis using a computer-aided color image analyzer was performed in 16 patients with non-alcoholic cirrhosis, which allowed quantitative evaluation of various morphometric parameters of sinusoids and hepatocytes. The sinusoidal pressure gradient was estimated theoretically with these and clearance parameters using Poiseulle's equation and compared with the hepatic venous pressure gradient measure by hepatic vein cannulation. A significant relationship was found between the hepatic venous pressure gradient and sinusoidal volumetric ratio (r = -0.598, p < 0.05), but not between mean hepatocyte volume and sinusoidal volumetric ratio (r = 0.416, NS), or the hepatic venous pressure gradient (r = 0.371, NS). The estimated sinusoidal pressure gradient showed a significant relationship with the hepatic venous pressure gradient (r = 0.637, p < 0.01). However, the absolute values of the former were much lower than those of the latter. Therefore, in non-alcoholic cirrhosis, although sinusoidal stenosis not caused by hepatocyte swelling may lead to increased vascular resistance, other factors must also play a significant role.
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Vasos Sanguíneos/patología , Hipertensión Portal/patología , Cirrosis Hepática/patología , Anciano , Vasos Sanguíneos/fisiología , Femenino , Humanos , Hipertensión Portal/fisiopatología , Procesamiento de Imagen Asistido por Computador , Hígado/irrigación sanguínea , Hígado/patología , Hígado/fisiología , Circulación Hepática , Cirrosis Hepática/fisiopatología , Masculino , Persona de Mediana Edad , Resistencia Vascular/fisiologíaAsunto(s)
Anticuerpos Monoclonales/uso terapéutico , Moléculas de Adhesión Celular/inmunología , Supervivencia de Injerto/inmunología , Terapia de Inmunosupresión/métodos , Trasplante de Hígado/inmunología , Antígeno-1 Asociado a Función de Linfocito/inmunología , Animales , Molécula 1 de Adhesión Intercelular , Trasplante de Hígado/fisiología , Masculino , Ratas , Ratas Endogámicas Lew , Ratas Endogámicas , Factores de Tiempo , Trasplante HomólogoRESUMEN
BACKGROUND: We studied new prognostic factors of esophageal variceal rupture by analyzing electronic video images of esophageal varices in 30 patients with portal hypertension. METHODS: Fifteen of the patients were emergency or elective cases (bleeders), and the remaining 15 were prophylactic cases (nonbleeders). A comparison was made between the bleeders and nonbleeders in terms of endoscopic findings and the image processing data, especially variceal color tone and red color sign. RESULTS: Endoscopic findings based on the general rules prepared by the Japanese Research Society for Portal Hypertension showed no significant difference between the two groups. However, with regard to the image processing data, both the ratio of red signal and the ratio of value were significantly lower in bleeders than in nonbleeders. In addition, the area ratio of red color sign was significantly higher in the former than in the latter. A follow-up study of nonbleeders also indicated that image processing data were more reliable than traditional endoscopic rules. CONCLUSIONS: By adding these image processing data to the traditional general rules for recording endoscopic findings, it is possible to select patients with varices that have a higher risk of rupture.
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Várices Esofágicas y Gástricas/diagnóstico , Esofagoscopía , Hemorragia Gastrointestinal/diagnóstico , Esofagoscopía/métodos , Femenino , Estudios de Seguimiento , Humanos , Hipertensión Portal/complicaciones , Procesamiento de Imagen Asistido por Computador , Masculino , Persona de Mediana Edad , Pronóstico , Rotura Espontánea , Grabación en VideoRESUMEN
During the last three decades the Sugiura procedure and other nonshunting operations have been widely performed as the operations of choice for bleeding esophageal varices in Japan. The Sugiura procedure (University of Tokyo method), a transthoracoabdominal esophageal transection, consists in paraesophageal devascularization, esophageal transection and reanastomosis, splenectomy, and pyloroplasty. The results have been satisfactory with low operative mortality and low rebleeding rate. The prognosis of the patients after this operation depended on the liver function at the time of operation but not on whether operation was done as an emergency, elective, or prophylactic measure. Although the Sugiura procedure has recently been performed in more selected cases with an advance in endoscopic injection sclerotherapy, this procedure remains the ultimate direct operation for portal hypertension in Japan.
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Várices Esofágicas y Gástricas/cirugía , Esófago/cirugía , Hemorragia Gastrointestinal/cirugía , Hipertensión Portal/cirugía , Adolescente , Adulto , Anciano , Anastomosis Quirúrgica , Arterias/cirugía , Niño , Preescolar , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/mortalidad , Esófago/irrigación sanguínea , Femenino , Estudios de Seguimiento , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/mortalidad , Humanos , Hipertensión Portal/etiología , Hipertensión Portal/mortalidad , Lactante , Japón , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Tasa de Supervivencia , Venas/cirugíaRESUMEN
The present report describes a rare of a 77-year-old woman who developed encephalopathy and metabolic acidosis associated with hyperammonemia, at the introduction of hemodialysis by chronic renal failure. With the intravenous infusion of HCO3-, levels of acidosis and hyperammonemia decreased rapidly. Concomitantly the disturbance of consciousness was improved. Results of plasma amino acid patterns of pre and post infusion of HCO3- showed improvement of the metabolism of the urea cycle, increased urea synthesis and decreased plasma ammonium levels. The role of the hepatic urea cycle has been considered to be exclusively the elimination of potentially toxic ammonia. In the conventional view, the acid base balance of the body obtains stabilized homeostasis by the function of the principal organs, lungs and kidneys. But, it has been recently shown that urea cycle is an important factor in the maintenance of pH homeostasis, due to regulated metabolism of HCO3-. Both HCO3- and NH4+ are converted to urea indicating the urea cycle's involvement in acid base homeostasis. 2HCO3- + 2NH4+-->urea+CO2+3H2O In this case, with the infusion of HCO3, the metabolism of the urea-cycle was improved and plasma ammonium levels were decreased. This indicates that HCO3- is an important factor for the metabolism of ammonia.
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Amoníaco/sangre , Fallo Renal Crónico/complicaciones , Bicarbonato de Sodio/uso terapéutico , Equilibrio Ácido-Base , Acidosis/tratamiento farmacológico , Acidosis/etiología , Anciano , Femenino , Encefalopatía Hepática/tratamiento farmacológico , Encefalopatía Hepática/etiología , Encefalopatía Hepática/metabolismo , Humanos , Infusiones Intravenosas , Fallo Renal Crónico/terapia , Diálisis Renal/efectos adversos , Urea/metabolismoRESUMEN
To examine whether the biopsy method could affect histological evaluation, the volumetric ratio of human liver parenchyma was estimated in specimens from subcapsular and intralobar areas, and also in specimens obtained by needle biopsy (Tru-Cut needle). A new method of morphometric analysis was performed using a computer-aided color image analyzer. Eighteen cirrhotic, 7 fibrotic, and 4 normal liver biopsies were taken during hepatic resection and analyzed. The parenchymal cell volume ratio in the intralobar area was significantly correlated with that in the subcapsular area, and less significantly with needle biopsy samples (r = 0.844, p < 0.001; r = 0.577, p < 0.01, respectively). Both showed one-to-one correspondence. These results suggest that both wedged and needle biopsy samples are appropriate for assessing the degree of fibrosis or cirrhosis, although the sampling variability of the latter is greater than the former.
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Biopsia con Aguja , Biopsia/métodos , Cirrosis Hepática/patología , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los ResultadosAsunto(s)
Ciclosporina/toxicidad , Isquemia/patología , Circulación Hepática/efectos de los fármacos , Trasplante de Hígado/patología , Hígado/efectos de los fármacos , Animales , Bilirrubina/sangre , Frío , Ciclosporina/sangre , Hígado/patología , Masculino , Ratas , Ratas Endogámicas Lew , Trasplante IsogénicoRESUMEN
It is not clear which theory should be used in patients with bleeding esophageal varices that are not controlled by emergency endoscopic sclerotherapy. Definitive hemostasis is the key to successful therapy of variceal bleeding. Recurrence of haemorrhage in patients with portal hypertension is the most feared life threatening complication. Based on our management of 658 patients with esophageal varices and the availability of treatment options at our institution, the strategy of management of uncontrollable variceal haemorrhage by endoscopic sclerotherapy has evolved. Bleeding was controlled in 64 liver cirrhosis (100%) by devascularization and transection procedures and 50 patients (78%) survived to leave the hospital including 43 of 64 patients (67%) with Child grade C liver cirrhosis. Cumulative rebleeding rate at 10 years following emergency surgery was 3% (2/64). It is associated with a lower morbidity and mortality as well as a lower incidence of subsequent encephalopathy. We suggest that emergency transection and devascularization is an effective salvage treatment for the endoscopic sclerotherapy failed group.