PMC:4628351 / 577-3401 JSONTXT

{"project":"TEST0","denotations":[{"id":"26526799-222-227-1545985","span":{"begin":243,"end":244},"obj":"[\"26366291\"]"},{"id":"26526799-183-188-1545986","span":{"begin":1485,"end":1486},"obj":"[\"26212234\"]"},{"id":"26526799-236-241-1545987","span":{"begin":2415,"end":2416},"obj":"[\"26212234\"]"},{"id":"26526799-166-171-1545988","span":{"begin":2585,"end":2586},"obj":"[\"26212234\"]"}],"text":"Letter to the editor\nWe read with great interest the article titled “At what level of unconsciousness is mild therapeutic hypothermia indicated for out-of-hospital cardiac arrest: a retrospective, historical cohort study” by Natsukawa et al. [1]. However, there are some critical issues in this study that should be pointed out.\nFirst, we could not identify the data that directly support the authors’ conclusion that mild therapeutic hypothermia (MTH) may be unnecessary in patients with a Glasgow Coma Scale (GCS) motor response score of 5 or higher. In Table three, the authors suggested that not only a GCS motor response score of 5 or 6 but also MTH were the independent factors predictive of good neurological outcomes in all study populations. Therefore, MTH should be considered in all study patients, including those with GCS motor scores of 5 or 6.\nSecond, the authors combined patients with GCS motor scores of 5 and 6 before analyzing the data and drawing conclusions. However, GCS motor scores of 5 and 6 should not be combined into the same category because we know that, in clinical practice, patients with GCS motor score 6 are clearly different from those with GCS motor scores 1–5.\nThird, because this study is a single-center retrospective study, selection bias should be discussed. We recently published a study on the impact of the GCS motor score at admission on neurological outcomes in out-of-hospital cardiac arrest patients receiving therapeutic hypothermia [2] In our study, 25 % (1/4) of patients with GCS motor score 5 had a poor neurological outcome despite MTH; however, 52 % (130/249) of patients with an initial GCS motor score of 1 who underwent MTH had good neurological outcomes. However, in the study by Natsukawa et al., patients with GCS motor score 1 who underwent MTH had extremely poor outcome [favorable neurological outcome; 7/53 (13.2 %) (Table two)]. This was considered to be due to the existence of patients with cardiopulmonary arrest of non-cardiac origin. Therefore, this study group contained a more heterogeneous population, which makes it more difficult to interpret the study results.\nFourth, we should not rely on a single parameter, i.e., the GCS motor score in this case, to determine the indications for MTH because other physical examination findings, such as the pupil size, are also associated with the neurological outcome in patients who undergo MTH [2]. Based on the current evidence, an initial GCS motor score can provide at least some baseline objective data for prognosis discussions with surrogate decision makers [2].\nIn conclusion, although neurological evaluation using the GCS motor score is mandatory for post-cardiac arrest patients, further study is required to determine if this score can be used as an indicator for mild therapeutic hypothermia."}

{"project":"2_test","denotations":[{"id":"26526799-26366291-61278385","span":{"begin":243,"end":244},"obj":"26366291"},{"id":"26526799-26212234-61278386","span":{"begin":1485,"end":1486},"obj":"26212234"},{"id":"26526799-26212234-61278387","span":{"begin":2415,"end":2416},"obj":"26212234"},{"id":"26526799-26212234-61278388","span":{"begin":2585,"end":2586},"obj":"26212234"}],"text":"Letter to the editor\nWe read with great interest the article titled “At what level of unconsciousness is mild therapeutic hypothermia indicated for out-of-hospital cardiac arrest: a retrospective, historical cohort study” by Natsukawa et al. [1]. However, there are some critical issues in this study that should be pointed out.\nFirst, we could not identify the data that directly support the authors’ conclusion that mild therapeutic hypothermia (MTH) may be unnecessary in patients with a Glasgow Coma Scale (GCS) motor response score of 5 or higher. In Table three, the authors suggested that not only a GCS motor response score of 5 or 6 but also MTH were the independent factors predictive of good neurological outcomes in all study populations. Therefore, MTH should be considered in all study patients, including those with GCS motor scores of 5 or 6.\nSecond, the authors combined patients with GCS motor scores of 5 and 6 before analyzing the data and drawing conclusions. However, GCS motor scores of 5 and 6 should not be combined into the same category because we know that, in clinical practice, patients with GCS motor score 6 are clearly different from those with GCS motor scores 1–5.\nThird, because this study is a single-center retrospective study, selection bias should be discussed. We recently published a study on the impact of the GCS motor score at admission on neurological outcomes in out-of-hospital cardiac arrest patients receiving therapeutic hypothermia [2] In our study, 25 % (1/4) of patients with GCS motor score 5 had a poor neurological outcome despite MTH; however, 52 % (130/249) of patients with an initial GCS motor score of 1 who underwent MTH had good neurological outcomes. However, in the study by Natsukawa et al., patients with GCS motor score 1 who underwent MTH had extremely poor outcome [favorable neurological outcome; 7/53 (13.2 %) (Table two)]. This was considered to be due to the existence of patients with cardiopulmonary arrest of non-cardiac origin. Therefore, this study group contained a more heterogeneous population, which makes it more difficult to interpret the study results.\nFourth, we should not rely on a single parameter, i.e., the GCS motor score in this case, to determine the indications for MTH because other physical examination findings, such as the pupil size, are also associated with the neurological outcome in patients who undergo MTH [2]. Based on the current evidence, an initial GCS motor score can provide at least some baseline objective data for prognosis discussions with surrogate decision makers [2].\nIn conclusion, although neurological evaluation using the GCS motor score is mandatory for post-cardiac arrest patients, further study is required to determine if this score can be used as an indicator for mild therapeutic hypothermia."}