Background: The Full Outline of Unresponsiveness (FOUR) score is a clinical instrument for the assessment of consciousness which is gradually gaining ground in clinical practice, as it incorporates more complete neurological information than the Glasgow Coma Scale (GCS). The main objectives of the current study were the following: (1) translate and cross-culturally adapt the FOUR score into Greek; (2) evaluate its clinimetric properties, including interrater reliability, internal consistency, and construct validity; and (3) evaluate the reliability of assessments among health care professionals with different levels of experience and training. Methods:The FOUR score was initially translated into Greek. Next, patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with the GCS and FOUR score within one hour by four raters who had different levels of experience and training (two board-certified neurosurgeons, a neurosurgery resident, and a registered nurse). Interrater reliability, internal consistency, and construct validity were evaluated for the scales using weighted Cohen's κ (κ w ) and intraclass correlation coefficients (ICC), Cronbach's α and Spearman's ρ values, respectively. Results: A total of 408 assessments were performed for 99 patients. The interrater reliability was excellent for both the FOUR score (ICC = 0.941) and GCS (ICC = 0.936). The values of κ w exceeded 0.90 for all pairs, suggesting that the FOUR score can be reliably applied by raters with varying experience. Among the scales' components, FOUR score's brainstem and respiratory items showed the lowest, yet high enough (κ w > 0.60), level of agreement. The interrater reliability remained excellent (κ w > 0.85, ICC > 0.90) for all diagnosis and age groups, with a trend toward higher FOUR score values in the most severe cases (ICC = 0.813 vs. 0.723). Both the FOUR score and GCS showed high internal consistency (Cronbach's α > 0.70 for all occasions). The FOUR score correlated strongly with GCS (Spearman's ρ > 0.90 for all raters), suggesting high construct validity.

ABSTRACT

<b><i>Introduction:</i></b> Central nervous system atypical teratoid rhabdoid tumors (ATRTs) are aggressive lesions usually presenting during the first 3 years of life. These tumors have a dismal prognosis with most patients dying within 1 year from presentation. Primary spinal location in infants is very rare. <b><i>Case Presentation:</i></b> We report a case of a 4-month-old boy who presented with a history of hypotonia, poor head control, and gradually reduced level of consciousness, over the past week. Computed tomography (CT) showed acute hydrocephalus with no underlying intracranial pathology. A ventriculoperitoneal shunt was inserted acutely. Postoperatively, ventilator weaning was unsuccessful. MRI of the brain and whole spine revealed an intraspinal extradural contrast-enhancing heterogenous mass in the subaxial cervical spine extending to the thoracic cavity. A biopsy was taken through a transthoracic approach, and histopathology confirmed the diagnosis of ATRT. Several cycles of radiation therapy and chemotherapy were given but the tumor progressed both locally and intracranially. Eventually, pupils became dilated and fixed. Brain CT scan showed widespread ischemic lesions and an extensive intracranial tumor extension with massive bleeding. The child eventually died 110 days after admission. <b><i>Conclusions:</i></b> In infants presenting with acute hydrocephalus where an obvious intracranial cause is not detected, the whole neuraxis should be screened. However, despite aggressive measures and advances in multimodality treatment, prognosis of ATRT remains dismal.

Background Various tools simpler than the Glasgow Coma Scale (GCS) have been proposed for the assessment of consciousness. In this study, the validity of three coma scales [Simplified Motor Scale, Modified GCS Motor Response, and AVPU (alert, verbal, painful, unresponsive)] is evaluated for the recognition of coma and the prediction of short- and long-term mortality and poor outcome. The predictive validity of these scales is also compared to the GCS. Methods Patients treated in the Department of Neurosurgery and the Intensive Care Unit in need of consciousness monitoring were assessed by four raters (two consultants, a resident and a nurse) using the GCS. The corresponding values of the simplified scales were estimated. Outcome was recorded at discharge and at 6 months. Areas Under the Receiver Operating Characteristic Curve (AUCs) were calculated for the prediction of mortality and poor outcome, and the identification of coma. Results Eighty-six patients were included. The simplified scales showed good overall validity (AUCs > 0.720 for all outcomes of interest), but lower than the GCS. For the identification of coma and the prediction of long-term poor outcome, the difference was significant (p < 0.050) for all the ratings of the most experienced rater. The validity of these scales was comparable to the GCS only in predicting in-hospital mortality, but without this being consistent for all raters. Conclusion The simplified scales showed inferior validity than the GCS. Their potential role in clinical practice needs further investigation. Thus, the replacement of the GCS as the main scale for consciousness assessment cannot be currently supported.

Η συγκρότηση της ηθικής υποδομής στην διακυβέρνηση, ως προϊόν μελέτης των δικαιικών και πολιτικών θεμελίων της κρατικής εξουσίας, κατοχυρώνει την αναβάπτιση της ουσιαστικής νομιμοποίησής της βάσει ενός νέου πλαισίου αρχών και αξιών, το οποίο την αυτοδεσμεύει ενώπιον των πολιτών. Η επανανομιμοποίηση της κρατικής εξουσίας όμως δεν μπορεί να γίνει εκτός του πλαισίου μιας επαναδιαρθρωμένης δημόσιας σφαίρας, την οποία θα εγγυάται και θα εξασφαλίζει η ηθική υποδομή. Βασικό διακύβευμα αποτελεί η παραδοχή ότι η μελέτη του εξουσιαστικού φαινομένου δεν μπορεί να είναι μονόπλευρη και αυτοαναφορική. Επειδή η κρατική εξουσία ενέχει δικαιικές, πολιτικές και ηθικές προεκτάσεις, η επαναθεμελίωση της εξουσίας, ως αναγκαίο προαπαιτούμενο της αναβαπτισμένης νομιμοποίησης, δεν μπορεί να γίνει εκτός του εξουσιαστικού φαινομένου και των αρμών δόμησής του. Η διεπιστημονική πραγμάτευση του εξουσιαστικού φαινομένου οφείλει να εντάξει και την πτυχή του ατόμου και να λάβει υπόψη τη διασύνδεση της ατομικής επιλογής με την συγκρότηση της πολιτειακής συλλογικότητας, μιας και το άτομο, ως πολίτης, συνιστά όχι μόνο αποδέκτης της εξουσιαστικής πράξης, αλλά και υποκείμενο της.