"Save the coma movement", save the "vegetable"

*It is only for medical professionals to read for reference.
What is the rescue coma movement? In recent years, with the improvement of critical care medicine, especially neurocritical medicine technology, the chances of survival of neurocritical patients have been significantly improved, and patients with chronic consciousness disorders may also increase accordingly
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The primary consideration for the patient's quality of life is the restoration of consciousness
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Focusing on the content of consciousness recovery, at the 24th National Neurology Conference of the Chinese Medical Association, Professor Pan Suyue from the Nanfang Hospital of Southern Medical University, starting from the implicit cognition of chronic consciousness disorders, further introduced " "Save the Coma Campaign", brought a wonderful report
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Chronic disorders of consciousness may have implicit cognition.
With the advancement of assessment technology in recent years, it has been discovered that some patients who originally thought they were unconscious are actually cognitive motor separation or implicit cognition
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Neuroimaging and electrophysiological evaluation play an important role in this
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Studies have found that some neurotransmitter modulating drugs and related treatments can restore consciousness to some patients
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Please see the following two cases.
Case 1.
A male brain trauma patient from South Africa, in a vegetative state for 3 years (semi-comatose), was given Zolpidem 10mg due to restlessness.
After 15 minutes, the patient was fully awake and remained awake for 3-4 Hours
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After that, Zolpidem was given 10mg qd to maintain consciousness for 3-4 hours a day [1]
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The patient underwent SPECT examination before and after taking Zolpidem.
It was found that the left frontal lobe, parietal lobe and lenticular nucleus were significantly hypometabolized before taking Zolpidem
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After taking Zolpidem, extensive cortex and high metabolism in the above-mentioned low-metabolic areas appeared
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After that, the patient's awake time was gradually prolonged and he was fully awake in 2006, with an IQ score of 70-90
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Case 2 A 23-year-old female with traumatic brain injury was diagnosed in vegetative state (VS) for 5 months.
Functional magnetic resonance imaging (fMRI) showed that the patient had language-specific or heterogeneous brain activity [2]
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The patient is in a state of cognitive motor separation
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Motor cognitive dissociation state refers to coma patients, VS patients, and minimally conscious state (MCS) patients who use electroencephalography (EEG) or fMRI to show brain activity during meditation tasks, and neuroimaging examination shows Respond to instructions
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Which patients have hidden cognition? In 2020, a meta-analysis on implicit cognition was published.
The purpose of this study is to understand the clinical and demographic characteristics of patients with implicit cognition using the active paradigm [3]
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The inclusion criteria for this meta-analysis are: patient age> 18 years; diagnosis of VS or MCS; use of the active paradigm and use of electrophysiology and/or imaging to judge implicit cognition; the study is an observational study between 2006 and 2019
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Finally, a total of 25 studies were included, 16 of which used neuroelectrophysiological methods, 4 studies used imaging methods, and 5 studies used electrophysiological + imaging methods
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The active task paradigm used in the research includes counting and meditation (space/movement)
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The results of the study showed that 54% of those who responded to the active task paradigm were patients with traumatic head injury, and 67% were diagnosed with MCS
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From the perspective of the types of chronic consciousness disorders, 18.
8% of VS patients were responders to the active task paradigm, and 32.
9% of MCS patients were responders to the active task paradigm
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Obviously, not all patients with DoC have hidden cognition
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Not all patients with DoC can regain consciousness
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Therefore, it is necessary to study the assessment methods and treatment of DoC patients; to predict which patients can regain consciousness
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The "Save the Coma Campaign" is such a clinical and scientific research movement
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Introduction to the Coma Rescue Campaign (Curing Coma Campaign, CCC), initiated by the American Society of Critical Neurology
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CCC has formed a scientific advisory committee (SAC) together with a group of coma research experts, neurologists and neurorehabilitation experts from different disciplines
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The following picture shows the CCC promotion picture and organizational structure [4,5]
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Figure 1: Publicity map and organizational structure of the rescue coma campaign [4,5] In October 2019, CCC held its first meeting at the NCS annual meeting in Vancouver
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The initial task was to identify scientific gaps and establish a "road map" for coma scientific research
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The ultimate goal is to establish a long-term framework to study the mechanism of consciousness and develop methods to treat consciousness disorders
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The first meeting focused on recording the three pillars of the research on disorders of consciousness, namely, the clinical research of chronic disorders of consciousness (Disorders of Consciousness, DoC) classification, biomarkers and proof-of-concept
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▌ Pillar 1: DoC classification CCC divides DoC into four major classifications, namely DoC without corresponding structural damage, DoC with structural or functional damage that can be treated by substitution or bypass, and it is not suitable for drugs or DoC, mimics of anatomical replacement or repair therapy
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For each type of classification, there is a corresponding diagnosis and treatment goal
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For example, for DoC without corresponding structural damage, the goal of diagnosis and treatment is to clarify and cure
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The specific definitions, example diseases and targets of the four types are shown in the table below (Table 1)
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Table 1: Types of chronic consciousness disorders▌ Pillar 2: Biomarkers The biomarkers currently used to assess consciousness include brain resting state assessment, passive intervention tasks, and active intervention tasks.
See Table 2 for details
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The next steps in biomarker research include the study of anatomical and biochemical pathways related to consciousness and the establishment of a shared database
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It is necessary to carry out prospective studies of clinically closely related and highly specific typing
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It is necessary to conduct continuous assessments during the acute phase and over several years
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And promote large-scale research based on the preliminary findings of these studies
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Table 2: Biomarkers currently used to assess awareness ▌ Pillar 3: Proof-of-concept trial design and completion of rigorous, proof-of-concept clinical trials for ICU patients.
The ultimate goal is to provide effective wake-up therapy for DoC patients in the acute phase
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The main obstacle to conducting a proof-of-concept trial is that (1) the patient did not have strict internal factor classification before entering the clinical trial; (2) the early clinical trial did not use appropriate brain function testing methods to reflect the therapeutic effect
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Therefore, it is necessary to study new tools to identify whether DoC patients preserve consciousness-related structures/functions; to study new treatment methods for targets related to consciousness restoration
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Pharmacological and electrophysiological stimulation therapy can reactivate the brain network of specific patients, but there is an urgent need for tools and body fluid biomarkers that can map individual brain networks to determine which patients may benefit
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The second meeting of CCC discussed six aspects, as follows: (1) A new classification method needs to be developed based on the DoC biological model.
This classification method can directly guide treatment and improve prognosis
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(2) Accurate, reliable, and reproducible biomarkers are needed to accurately judge the prognosis and serve as the end point of RCT
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(3) Clinical research: For patients with well-defined DoC, biomarkers, endpoints, and feasible treatment methods can be defined through research.
Once the treatment methods are effective, they can be transformed into routine clinical treatments as soon as possible
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(4) Prognosis: develop accurate, reliable and reproducible predictive tools; promote high-quality prognostic communication between clinicians and decision makers
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(5) Long-term recovery: Based on the long-term natural history of DoC, research on biomarkers and clinical factors that can accurately predict good or poor prognosis, and understand the effectiveness of specific interventions
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(6) Database: Establish a large and simple international database based on common data components
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In short, with the improvement of ICU treatment technology, the number of patients with impaired consciousness will increase year by year, and the clinical need for such patients to wake up increases
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With the improvement of brain structure and function assessment methods, the in-depth research of brain networks and brain-computer interfaces, some patients can benefit from treatment, restore consciousness, and even restore the ability to live independently
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The "Saving Coma Campaign" initiated by the American Society of Critical Care Medicine has certain significance and deserves everyone's attention and participation
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The content of this article is compiled from the lecture of Professor Pan Suyue at the 24th National Neurology Conference of the Chinese Medical Association-"Introduction to the Movement to Save the Coma"
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 Expert profile Professor Pan Suyue, chief physician, doctoral tutor, and a leading medical talent in Guangdong Province
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Director of Department of Neurology, Nanfang Hospital, and Dean of Baiyun Cerebrovascular Hospital, Nanfang Hospital
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Chairman of the Committee of Critical Cerebrovascular Diseases of the Brain Prevention Committee of the National Health and Family Planning Commission, Leader of the Neurosurgery Collaboration Group of the Neurology Branch of the Chinese Medical Association, Leader of the Neurological Diseases Group of the Enteral and Parenteral Nutrition Branch of the Chinese Medical Association, and Neurology of the Chinese Medical Association Member of the branch, chairman of the Ninth Guangdong Medical Association Neurology Branch, deputy chairman of the Critical Cerebrovascular Disease Branch of the Chinese Stroke Association, deputy director of the Neurological Critical Care Professional Committee of the Neurologist Branch of the Chinese Medical Doctor Association, and vice president of the International Journal of Cerebrovascular Disease Edit
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He has published 109 SCI papers in journals such as Critical Care Medicine, Storke, Neuropharmacology and JCBFM, and presided over more than 10 projects from the National Natural Science Foundation of China
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 References: [1] Clauss RP, Güldenpfennig WM, Nel HW, Sathekge MM, Venkannagari RR.
Extraordinary arousal from semi-comatose state on zolpidem.
A case report.
S Afr Med J.
2000;90(1):68-72 .
[2]Owen AM,Coleman MR,Boly M,Davis MH,Laureys S,Pickard JD.
Detecting awareness in the vegetative state.
Science.
2006;313(5792):1402.
[3]Schnakers C,Hirsch M,NoéE ,et al.
Covert Cognition in Disorders of Consciousness:A Meta-Analysis.
Brain Sci.
2020;10(12):930.
[4]https:// ]Olson DM, Hemphill JC 3rd;Curing Coma Campaign and its Executive Committe.
The Curing Coma Campaign:Challenging the Paradigm for Disorders of Consciousness.
Neurocrit Care.
2021;35(Suppl 1):1-3.