IntroductionThe Glasgow Coma Scale (GCS) is the most widely used scoring system for comatose patients in intensive care. Limitations of the GCS include the impossibility to assess the verbal score in intubated or aphasic patients, and an inconsistent inter-rater reliability. The FOUR (Full Outline of UnResponsiveness) score, a new coma scale not reliant on verbal response, was recently proposed. The aim of the present study was to compare the inter-rater reliability of the GCS and the FOUR score among unselected patients in general critical care. A further aim was to compare the inter-rater reliability of neurologists with that of intensive care unit (ICU) staff.MethodsIn this prospective observational study, scoring of GCS and FOUR score was performed by neurologists and ICU staff on 267 consecutive patients admitted to intensive care.ResultsIn a total of 437 pair wise ratings the exact inter-rater agreement for the GCS was 71%, and for the FOUR score 82% (P = 0.0016); the inter-rater agreement within a range of ± 1 score point for the GCS was 90%, and for the FOUR score 92% (P = ns.). The exact inter-rater agreement among neurologists was superior to that among ICU staff for the FOUR score (87% vs. 79%, P = 0.04) but not for the GCS (73% vs. 73%). Neurologists and ICU staff did not significantly differ in the inter-rater agreement within a range of ± 1 score point for both GCS (88% vs. 93%) and the FOUR score (91% vs. 88%).ConclusionsThe FOUR score performed better than the GCS for exact inter-rater agreement, but not for the clinically more relevant agreement within the range of ± 1 score point. Though neurologists outperformed ICU staff with regard to exact inter-rater agreement, the inter-rater agreement of ICU staff within the clinically more relevant range of ± 1 score point equalled that of the neurologists. The small advantage in inter-rater reliability of the FOUR score is most likely insufficient to replace the GCS, a score with a long tradition in intensive care.
Long-term treatment of critically ill patients is admittedly burdened with high in-hospital and follow-up mortality. However, the excellent physical and psychological recovery of survivors unequivocally supports the employment of all technical and personnel resources within modern intensive care medicine.
The maturation of bacterial molybdoenzymes is a complex process leading to the insertion of the bulky bis-molybdopterin guanine dinucleotide (bis-MGD) cofactor into the apo-enzyme. Most molybdoenzymes were shown to contain a specific chaperone for the insertion of the bis-MGD cofactor. Formate dehydrogenases (FDH) together with their molecular chaperone partner seem to display an exception to this specificity rule, since the chaperone FdhD has been proven to be involved in the maturation of all three FDH enzymes present in Escherichia coli. Multiple roles have been suggested for FdhD-like chaperones in the past, including the involvement in a sulfur transfer reaction from the l-cysteine desulfurase IscS to bis-MGD by the action of two cysteine residues present in a conserved CXXC motif of the chaperones. However, in this study we show by phylogenetic analyses that the CXXC motif is not conserved among FdhD-like chaperones. We compared in detail the FdhD-like homologues from Rhodobacter capsulatus and E. coli and show that their roles in the maturation of FDH enzymes from different subgroups can be exchanged. We reveal that bis-MGD-binding is a common characteristic of FdhD-like proteins and that the cofactor is bound with a sulfido-ligand at the molybdenum atom to the chaperone. Generally, we reveal that the cysteine residues in the motif CXXC of the chaperone are not essential for the production of active FDH enzymes.
In intensive care units, patients are sedated to reduce the stress caused by illness and/or treatments such as artificial respiration. Regular assessment of the degree of sedation as part of the goal-directed therapy has been recommended as a standard of care. The Swiss Society of Intensive Care Medicine requires all accredited Swiss intensive care units to periodically document the degree of sedation by means of a sedation scale as part of the minimal data set (MDSi). The ten-level Richmond Agitation-Sedation Scale (RASS) is one of two proposed scales for the assessment of the degree of sedation. Because validated versions of the recommended sedation scales exist in English only, the RASS was translated by a systematic iterative procedure in six steps. The iterative translation of the RASS for use in Swiss intensive care units described in this article is an example of interdisciplinary teamwork. Translation of clinical assessment tools for clinical use should be carried out as carefully and stringently as the development of research tools. Based on the experience gained in the described project we recommend the following points to consider when translating clinical assessment tools: a) referring to literature not only on the subject of translation but also on the process of translation itself, b) involving professional translators as language experts, and c) consulting the author(s) of the original version.
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