Cheng Katarina, Bassil Ribal, Carandang Raphael, Hall Wiley, Muehlschlegel Susanne
1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts.
2 Department of Surgery, University of Massachusetts Medical School , Worcester, Massachusetts.
J Neurotrauma. 2017 Apr 15;34(8):1603-1609. doi: 10.1089/neu.2016.4657. Epub 2016 Dec 2.
The Glasgow Coma Scale (GCS) has limited utility in intubated patients due to the inability to assign verbal subscores. The verbal subscore can be derived from the eye and motor subscores using a mathematical model, but the advantage of this method and its use in outcome prognostication in traumatic brain injury (TBI) patients remains unknown. We compared the validated "Core+CT"-IMPACT-model performance in 251 intubated TBI patients prospectively enrolled in the longitudinal OPTIMISM study between November 2009 and May 2015 when substituting the original motor GCS (mGCS) with the total estimated GCS (teGCS; with estimated verbal subscore). We hypothesized that model performance would improve with teGCS. Glasgow Outcome Scale (GOS) scores were assessed at 3 and 12 months by trained interviewers. In the complete case analysis, there was no statistically or clinically significant difference in the discrimination (C-statistic) at either time-point using the mGCS versus the teGCS (3 months: 0.893 vs. 0.871;12 months: 0.926 vs. 0.92). At 3 months, IMPACT-model calibration was excellent with mGCS and teGCS (Hosmer-Lemeshow "goodness-of-fit" chi square p value 0.9293 and 0.9934, respectively); it was adequate at 12 months with teGCS (0.5893) but low with mGCS (0.0158), possibly related to diminished power at 12 months. At both time-points, motor GCS contributed more to the variability of outcome (Nagelkerke ΔR) than teGCS (3 months: 5.8% vs. 0.4%; 12 months: 5% vs. 2.6%). The sensitivity analysis with imputed missing outcomes yielded similar results, with improved calibration for both GCS variants. In our cohort of intubated TBI patients, there was no statistically or clinically meaningful improvement in the IMPACT-model performance by substituting the original mGCS with teGCS.
由于无法给出言语分项评分，格拉斯哥昏迷量表（GCS）在插管患者中的应用有限。言语分项评分可通过数学模型从眼睛和运动分项评分中得出，但这种方法的优势及其在创伤性脑损伤（TBI）患者预后评估中的应用尚不清楚。我们比较了在2009年11月至2015年5月期间前瞻性纳入纵向OPTIMISM研究的251例插管TBI患者中，用总估计GCS（teGCS；包括估计的言语分项评分）替代原始运动GCS（mGCS）时，经过验证的“Core+CT”-IMPACT模型的性能。我们假设使用teGCS时模型性能会有所改善。由训练有素的访谈者在3个月和12个月时评估格拉斯哥预后量表（GOS）评分。在完整病例分析中，使用mGCS与teGCS在任何一个时间点的辨别力（C统计量）均无统计学或临床显著差异（3个月：0.893对0.871；12个月：0.926对0.92）。在3个月时，mGCS和teGCS的IMPACT模型校准都很好（Hosmer-Lemeshow“拟合优度”卡方p值分别为0.9293和0.9934）；在12个月时，teGCS的校准足够（0.5893），但mGCS的校准较低（0.0158），这可能与12个月时的检验效能降低有关。在两个时间点，运动GCS对预后变异性（NagelkerkeΔR）的贡献均大于teGCS（3个月：5.8%对0.4%；12个月：5%对2.6%）。对缺失结果进行插补的敏感性分析产生了类似的结果，两种GCS变体的校准均有所改善。在我们的插管TBI患者队列中，用teGCS替代原始mGCS并未使IMPACT模型性能在统计学或临床上有有意义的改善。
