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‘Landmark’ Study Pushed Detection of Covert Consciousness in TBI

Compelling advances in the ability to detect signs of consciousness in unconscious patients who have experienced traumatic brain injury (TBI) are leading to unprecedented changes in the field. There is now hope of improving outcomes and even sparing lives of patients who may otherwise have been mistakenly assessed as having no chance of recovery.

A recent key study represents a tipping point in the mounting evidence of the ability to detect¬†“covert consciousness” in patients with TBI who are in an unconscious state. That research, published in The New England Journal of Medicine (NEJM) in June 2019, linked the promising signals of consciousness in comatose patients, detected only on imaging, with remarkable outcomes a year later.

“This was a landmark study,” said Brian L. Edlow, MD, in a presentation on the issue of covert consciousness during the American Neurological Association’s 2020 virtual annual meeting.

“Importantly, it is the first compelling evidence that early detection of covert consciousness also predicts 1-year outcomes in the Glasgow Outcome Scale Extended (GOSE), showing that covert consciousness in the ICU appears to be relevant for predicting long-term outcomes,” said Edlow, who is associate director of the Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, in Boston.

The researchers showed that 15% of unconscious patients with acute brain injury in the study exhibited significant brain activity on EEG in response to stimuli that included verbal commands such as envisioning that they are playing tennis.

Although other studies have shown similar effects with task-based stimuli, the NEJM study further showed that a year later, the patients who had shown signs of covert consciousness, also called “cognitive motor dissociation” (CMD), were significantly more likely to have a good functional outcome, said the study’s senior author, Jan Claassen, MD, director of critical care neurology at Columbia University, in New York City, who also presented during the ANA session.

“Importantly, a year later after injury, we found that 44% of patients with CMD and only 14% of non-CMD patients had a good functional outcome, defined as a GOSE score indicating a state where they can at least take care of themselves for 8 hours in a day,” he said.

“[Whether] these patients in a CMD state represent a parallel state or a transitory state on the road to recovery remains to be shown,” he said.

Jennifer Frontera, MD, a professor in the Department of Neurology at NYU Langone in New York City and co-moderator of the session, agreed that the research is “remarkable.”

“Also, it is practical, since many could potentially apply and validate his algorithms, since EEG technology is portable and widely available,” she told Medscape Medical News.

Research Has Ushered in a “Sea Change” in Neuro-Critical Care

The research has helped push forward recommendations on the treatment of unconscious patients, Edlow said.

“This has led to a sea change in our field just over the last 2 years, with multiple guidelines published suggesting that it may be time for us to consider incorporating task-based fMRI and EEG

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medicine

New Landmark Study at UM School of Medicine Finds Aspirin Use Reduces Risk of Death in Hospitalized COVID-19 Patients

BALTIMORE, Oct. 26, 2020 /PRNewswire/ —¬†Hospitalized COVID-19 patients who were taking a daily low-dose aspirin to protect against cardiovascular disease had a significantly lower risk of complications and death compared to those who were not taking aspirin, according to a new study led by researchers at the University of Maryland School of Medicine (UMSOM). Aspirin takers were less likely to be placed in the intensive care unit (ICU) or hooked up to a mechanical ventilator, and they were more likely to survive the infection compared to hospitalized patients who were not taking aspirin, The study, published today in the journal Anesthesia and Analgesia, provides “cautious optimism,” the researchers say, for an inexpensive, accessible medication with a well-known safety profile that could help prevent severe complications.

“This is a critical finding that needs to be confirmed through a randomized clinical trial,” said study leader Jonathan Chow, MD, Assistant Professor of Anesthesiology at UMSOM. “If our finding is confirmed, it would make aspirin the first widely available, over-the-counter medication to reduce mortality in COVID-19 patients.”

To conduct the study, Dr. Chow and his colleagues culled through the medical records of 412 COVID-19 patients, age of 55 on average, who were hospitalized over the past few months due to complications of their infection. They were treated at the University of Maryland Medical Center in Baltimore and three other hospitals along the East Coast. About a quarter of the patients were taking a daily low-dose aspirin (usually 81 milligrams) before they were admitted or right after admission to manage their cardiovascular disease.

The researchers found aspirin use was associated with a 44 percent reduction in the risk of being put on a mechanical ventilator, a 43 percent decrease in the risk of ICU admission and – most importantly – a 47 percent decrease in the risk of dying in the hospital compared to those who were not taking aspirin. The patients in the aspirin group did not experience a significant increase in adverse events such as major bleeding while hospitalized.

The researchers controlled for several factors that may have played a role in a patient’s prognosis including age, gender, body mass index, race, hypertension and diabetes. They also accounted for heart disease, kidney disease, liver disease and the use of beta blockers to control blood pressure.

COVID-19 infections increase the risk of dangerous blood clots that can form in the heart, lungs, blood vessels and other organs. Complications from blood clots can, in rare cases, cause heart attacks, strokes and multiple organ failure as well as death.

Doctors often recommend a daily low-dose aspirin for patients who have previously had a heart attack or stroke caused by a blood clot to prevent future blood clots. Daily use, however, can increase the risk of major bleeding or peptic ulcer disease.

“We believe that the blood thinning effects of aspirin provides benefits for COVID-19 patients by preventing microclot formation,” said study co-author Michael A. Mazzeffi, MD, Associate Professor of Anesthesiology at

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