PMC:4628351 / 3403-8695 JSONTXT

{"project":"TEST0","denotations":[{"id":"26526799-48-53-1545989","span":{"begin":75,"end":76},"obj":"[\"26366291\"]"},{"id":"26526799-178-183-1545990","span":{"begin":2337,"end":2338},"obj":"[\"26212234\"]"}],"text":"Response\nWe appreciate Dr. Hifumi’s well-advised comments about our paper [1] “At what level of unconsciousness is mild therapeutic hypothermia indicated for out-of-hospital cardiac arrest: a retrospective, historical cohort study.”\nWe will now outline the reasons why we concluded that mild therapeutic hypothermia (MTH) may be unnecessary in patients with a Glasgow Coma Scale (GCS) motor response score of 5 or higher, although MTH was an independent predictive factor for good neurological outcome, and the reason that we combined patients with GCS motor response score of 5 and 6. Firstly, we performed chi-squared automatic interaction detection (CHAID) analysis with GCS motor response score and MTH as independent variables and good recovery at 30 days after admission as the dependent variable. The tree created after applying CHAID is shown in Fig. 1. The terminal branches of the tree represent CHAID-derived homogeneous categories (terminal nodes). We obtained five terminal nodes. Patients classified with a GCS motor response score of 5 or higher had the highest percentage of good recovery. Secondly, the percentage of patients with a good recovery in the GCS M5 and M6 groups was around 100 %, and for the patients with a bad recovery in the GCS M5 and M6 groups, it was difficult to believe that implementing MTH would have improved the CPC at 30 days after hospital admission.\nFig. 1 Chi-squared automatic interaction detection classification tree for good recovery at 30 days after hospital admission. GCS M1: patients classified with a GCS motor response score of 1. GCS M2–4: patients classified with a GCS motor response score from 2 to 4. GCS M5–6: patients classified with a GCS motor response score of 5 or higher. GCS M2–4 and MTH+: patients classified with a GCS motor response score from 2 to 4 and treated with MTH. GCS M2–4 and MTH−: patients classified with a GCS motor response score from 2 to 4 and treated without MTH. GCS M2 and MTH−: patients classified with a GCS motor response score of 1 and treated without MTH. GCS M3–4 and MTH−: patients classified with a GCS motor response score from 3 to 4 and treated without MTH\nThe primary reason that the percentage of good recovery of patients with GCS motor response score 1 in our study (7/53, 13.2%) was lower than that in the study by Hifumi et al. [2] (130/249, 52 %) is that our study population included more severe patients, such as patients who underwent E-CPR and patients with non-cardiac cause for cardiac arrest such as hypoxia and hypovolemia. The study by Hifumi et al. did not include patients who underwent E-CPR or patients with non-cardiac cause for cardiac arrest.\nRegarding why the percentage of bad recovery for patients with GCS motor response score 5 in our study (1/32, 3.2 %) was lower than those in the study by Hifumi et al. (1/4, 25 %), there are three reasons. Firstly, because the number of patients with a GCS motor response score of 5 in the study by Hifumi et al. was only four, a small number, we cannot discuss whether the percentage is high or low, and on the other hand, we also regard the number of patients with bad recovery in the study by Hifumi et al., one, as a small number. In our study, one case with GCS motor response score 5 with Cerebral Performance Category 5 that had not undergone MTH was admitted to the hospital due to malnutrition and died in hospital from an inability to control the primary disease. In this case, it was difficult to believe that MTH would have improved the CPC at 30 days after hospital admission. Secondly, in the study by Hifumi et al., there were multiple different hospital centers each with different inclusion criteria, a different protocol of MTH, and a different capacity of the intensive care unit. These factors resulted in variation in results between sites and a relatively high percentage of bad recovery in patients with GCS motor response score 5. Thirdly, the study by Hifumi et al. included only patients who were treated with MTH. There was no comparison to patients who were treated without MTH, and it is possible that there was no difference in the percentage of good recovery between patients who were treated with MTH and patients who were treated without MTH.\nRegarding the question about relying on a single parameter, the GCS M score, to determine the indication for MTH, we must consider the significant adverse effects of MTH such as cardiac output insufficiency and coagulation disorder. Cardiogenic shock is common in post-cardiac arrest patients, and MTH can potentially worsen the situation. Also, post-cardiac arrest patients sometimes have thoracic trauma from prolonged chest compressions, and coagulation disorders could worsen any hemorrhage. We believe that it is better to treat with MTH only when the benefits of MTH outweigh the risks. We want to emphasize that we must prevent hyperthermia for all post-cardiac arrest patients admitted to ICU, however MTH may be unnecessary for patients with a GCS motor response score of 5 or higher.\nRegarding the requirement for further study, we also wrote in our article that we propose that a prospective study to evaluate the neurological outcome of GCS motor response score 5 with or without MTH in post-cardiac arrest patients would be beneficial."}

{"project":"2_test","denotations":[{"id":"26526799-26366291-61278389","span":{"begin":75,"end":76},"obj":"26366291"},{"id":"26526799-26212234-61278390","span":{"begin":2337,"end":2338},"obj":"26212234"}],"text":"Response\nWe appreciate Dr. Hifumi’s well-advised comments about our paper [1] “At what level of unconsciousness is mild therapeutic hypothermia indicated for out-of-hospital cardiac arrest: a retrospective, historical cohort study.”\nWe will now outline the reasons why we concluded that mild therapeutic hypothermia (MTH) may be unnecessary in patients with a Glasgow Coma Scale (GCS) motor response score of 5 or higher, although MTH was an independent predictive factor for good neurological outcome, and the reason that we combined patients with GCS motor response score of 5 and 6. Firstly, we performed chi-squared automatic interaction detection (CHAID) analysis with GCS motor response score and MTH as independent variables and good recovery at 30 days after admission as the dependent variable. The tree created after applying CHAID is shown in Fig. 1. The terminal branches of the tree represent CHAID-derived homogeneous categories (terminal nodes). We obtained five terminal nodes. Patients classified with a GCS motor response score of 5 or higher had the highest percentage of good recovery. Secondly, the percentage of patients with a good recovery in the GCS M5 and M6 groups was around 100 %, and for the patients with a bad recovery in the GCS M5 and M6 groups, it was difficult to believe that implementing MTH would have improved the CPC at 30 days after hospital admission.\nFig. 1 Chi-squared automatic interaction detection classification tree for good recovery at 30 days after hospital admission. GCS M1: patients classified with a GCS motor response score of 1. GCS M2–4: patients classified with a GCS motor response score from 2 to 4. GCS M5–6: patients classified with a GCS motor response score of 5 or higher. GCS M2–4 and MTH+: patients classified with a GCS motor response score from 2 to 4 and treated with MTH. GCS M2–4 and MTH−: patients classified with a GCS motor response score from 2 to 4 and treated without MTH. GCS M2 and MTH−: patients classified with a GCS motor response score of 1 and treated without MTH. GCS M3–4 and MTH−: patients classified with a GCS motor response score from 3 to 4 and treated without MTH\nThe primary reason that the percentage of good recovery of patients with GCS motor response score 1 in our study (7/53, 13.2%) was lower than that in the study by Hifumi et al. [2] (130/249, 52 %) is that our study population included more severe patients, such as patients who underwent E-CPR and patients with non-cardiac cause for cardiac arrest such as hypoxia and hypovolemia. The study by Hifumi et al. did not include patients who underwent E-CPR or patients with non-cardiac cause for cardiac arrest.\nRegarding why the percentage of bad recovery for patients with GCS motor response score 5 in our study (1/32, 3.2 %) was lower than those in the study by Hifumi et al. (1/4, 25 %), there are three reasons. Firstly, because the number of patients with a GCS motor response score of 5 in the study by Hifumi et al. was only four, a small number, we cannot discuss whether the percentage is high or low, and on the other hand, we also regard the number of patients with bad recovery in the study by Hifumi et al., one, as a small number. In our study, one case with GCS motor response score 5 with Cerebral Performance Category 5 that had not undergone MTH was admitted to the hospital due to malnutrition and died in hospital from an inability to control the primary disease. In this case, it was difficult to believe that MTH would have improved the CPC at 30 days after hospital admission. Secondly, in the study by Hifumi et al., there were multiple different hospital centers each with different inclusion criteria, a different protocol of MTH, and a different capacity of the intensive care unit. These factors resulted in variation in results between sites and a relatively high percentage of bad recovery in patients with GCS motor response score 5. Thirdly, the study by Hifumi et al. included only patients who were treated with MTH. There was no comparison to patients who were treated without MTH, and it is possible that there was no difference in the percentage of good recovery between patients who were treated with MTH and patients who were treated without MTH.\nRegarding the question about relying on a single parameter, the GCS M score, to determine the indication for MTH, we must consider the significant adverse effects of MTH such as cardiac output insufficiency and coagulation disorder. Cardiogenic shock is common in post-cardiac arrest patients, and MTH can potentially worsen the situation. Also, post-cardiac arrest patients sometimes have thoracic trauma from prolonged chest compressions, and coagulation disorders could worsen any hemorrhage. We believe that it is better to treat with MTH only when the benefits of MTH outweigh the risks. We want to emphasize that we must prevent hyperthermia for all post-cardiac arrest patients admitted to ICU, however MTH may be unnecessary for patients with a GCS motor response score of 5 or higher.\nRegarding the requirement for further study, we also wrote in our article that we propose that a prospective study to evaluate the neurological outcome of GCS motor response score 5 with or without MTH in post-cardiac arrest patients would be beneficial."}