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• W2151970570 abstract "We appreciate the comments and interest of Professor Steen and his colleagues in our article [[1]Torbey M.T. Geocadin R. Bhardwaj A. Brain arrest neurological outcome scale (BrANOS): predicting mortality and severe disability following cardiac arrest.Resuscitation. 2004; 63: 55-63Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar]. Predicting neurological outcome following cardiac arrest (CA) in the early post-resuscitation phase remains a difficult task. Hence, we proposed the Brain Arrest and Neurological Outcome Scale (BrANOS) in an attempt to incorporate radiological and clinical markers of brain injury and provide an accurate prognosticator of poor outcome in patients resuscitated under normothermic conditions. The study was undertaken between 1996 and 2000, a time when hypothermia was still investigational and not yet considered standard of care. The results and conclusions are valid under the conditions that the study was undertaken. Steen and colleagues have raised a question about post-resuscitation care in our study and the use of hypothermia. While this question is of great scientific and practical importance, it is a separate question that needs to be addressed in a separate study. We made no extrapolations on the applicability of our results to hypothermia since this was not within the scope of the study. Modifications to BrANOS may be needed to accommodate for hypothermia and sedation. One such modification may require documenting Glasgow coma scale (GCS) either prior to initiation of hypothermia or after hypothermia has ended. It is important to keep in mind that recommendations [2Nolan J.P. Morley P.T. Hoek T.L. Hickey RW Therapeutic hypothermia after cardiac arrest. An advisory statement by the Advancement Life Support Task Force of the International Liaison committee on Resuscitation.Resuscitation. 2003; 57: 231-235Abstract Full Text Full Text PDF PubMed Scopus (453) Google Scholar, 3Nolan J.P. Morley P.T. Vanden Hoek T.L. et al.Therapeutic hypothermia after cardiac arrest: an advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation.Circulation. 2003; 108: 118-121Crossref PubMed Scopus (625) Google Scholar] supporting the use of hypothermia were made based on two prospective, randomized, controlled clinical trials demonstrating the protective effect of hypothermia in CA due to ventricular fibrillation [4Bernard S.A. Gray T.W. Buist M.D. et al.Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.N Engl J Med. 2002; 346: 557-563Crossref PubMed Scopus (4346) Google Scholar, 5Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549–56.Google Scholar]. Furthermore, the patients studied represent a highly select group of CA patients. In the HACA study [[5]Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549–56.Google Scholar], 3551 subjects were screened and only 305 (9%) were recruited. In the hypothermia group, 10% (14/137) did not complete the hypothermia therapy for various reasons. So a number of issues require further consideration before applying therapeutic hypothermia as standard of care for CA patients. First, it remains uncertain whether hypothermia is effective in out-of-hospital CA due to causes other than ventricular fibrillation. Secondly, the labor intensity associated with surface cooling limits the practical application of rapid induction of hypothermia. The approach of using ice packs and/or refrigerated air blankets [4Bernard S.A. Gray T.W. Buist M.D. et al.Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.N Engl J Med. 2002; 346: 557-563Crossref PubMed Scopus (4346) Google Scholar, 5Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549–56.Google Scholar] is slow and may be logistically difficult in busy emergency departments [[6]Bernard S.A. Therapeutic hypothermia after cardiac arrest. Hypothermia is now standard care for some types of cardiac arrest.Med J Aust. 2004; 181: 468-469PubMed Google Scholar]. All these considerations point to a vast number of patients that will not get hypothermia under current standards and it is in these patients that BrANOS could still be applied. Steen and Colleagues raised some concerns about the cross-validation with jack knife technique and the small sample size of the study. We are in complete agreement that BrANOS should be tested prospectively and cross-validated in an independent sample. We believe that we clearly conveyed this message in our conclusion. As for the sample size, we agree that larger sample size may lead to a stronger conclusion. Our sample size was calculated based on the efficient confidence bounds for ROC curves, described by Schaffer [[7]Schafer H. Efficient confidence bounds for ROC curves.Stat Med. 1994; 13: 1551-1661Crossref PubMed Scopus (26) Google Scholar]. Interestingly, the two clinical trials that brought hypothermia to the forefront [4Bernard S.A. Gray T.W. Buist M.D. et al.Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.N Engl J Med. 2002; 346: 557-563Crossref PubMed Scopus (4346) Google Scholar, 5Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549–56.Google Scholar] did not have a very large sample size as would be expected from a randomized clinical trial. The first trial had 43 hypothermic patients [[4]Bernard S.A. Gray T.W. Buist M.D. et al.Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.N Engl J Med. 2002; 346: 557-563Crossref PubMed Scopus (4346) Google Scholar] and the second had 137 [[5]Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549–56.Google Scholar]. Regarding the high mortality reported in our study, we would emphasize that our cohort included all CA patients and not only those with ventricular fibrillation. Only 25% of our patients had ventricular fibrillation. It is well known that these patients have a better prognosis compared to other causes of CA. Therefore, our results are consistent with other studies showing that less than 5% of patients survive to hospital discharge [8Finn J.C. Jacobs I.G. Holman C.D. Oxer H.F. Outcomes of out-of-hospital cardiac arrest patients in Perth, Western Australia, 1996–1999.Resuscitation. 2001; 51: 247-255Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 9Bernard S.A. Outcome from prehospital cardiac arrest in Melbourne, Australia.Emerg Med. 1998; 10: 25-29Crossref Scopus (51) Google Scholar]. In conclusion, we would like to emphasize that at the present time our findings do not yet justify general limitation of treatment within 48 h of CA. Our results hopefully, once validated in a prospective fashion, will help to identify CA candidates for future clinical trial and help family and health providers to make early decisions regarding withdrawal of life support. None. Predicting outcome after cardiac arrest: Two caveatsResuscitationVol. 66Issue 1PreviewWe have with interest read the recent article by Torbey et al. on predicting mortality and severe disability following cardiac arrest [1]. One of us (PAS) is a topic reviewer on the outcome prediction for the upcoming 2005 CPR guidelines revision and we have particular interest in prediction statistics and also hypothermia. The authors are to be commended for trying to study this difficult clinical and ethically very important topic. Full-Text PDF" @default.
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