Validation of the Italian version of a new coma scale: the FOUR score

Abstract

The Glasgow Coma Scale (GCS) is the most widely accepted tool for the evaluation of consciousness, despite several reported shortcomings. A new coma scale, named Full Outline of UnResponsiveness (FOUR) score, is now available. The aim of the present study is to provide and validate the Italian version of the FOUR score. The Italian version of the FOUR score was developed according to a standardized protocol, and thereafter validated in a series of patients with acute neurological illness. For each patient, the FOUR and the GCS scores were recorded by two physicians randomly selected. The inter-rater agreement for the FOUR and the GCS scores was evaluated using the weighted kappa (κ(w)). The receiving operating characteristic curve was also calculated to determine the ability of the scales to predict outcome. Eighty-seven consecutive patients with an acute brain injury were enrolled. The inter-rater agreement was excellent both for the FOUR (κ(w) = 0.953; P < 0.0001) and the GCS (κ(w) = 0.943; P < 0.01). The area under the curve for mortality was 0.935 for the FOUR and 0.953 for the GCS. The FOUR score provides greater neurological details than the GCS. Our data indicate that the Italian version of the FOUR score is a valid predictor of outcome, yielding reproducible findings across raters independent of their expertise.

The FOUR score: is it just another new coma scale?

“…A new coma scale, the Full Outline Of Unresponsiveness (FOUR) score, is gradually gaining acceptance because of an excellent inter-rater agreement, greater neurologic information, and a high predictive value [3,5,9,[12][13][14][15]. It quantifies consciousness by examining eye and motor responses, brainstem reflexes, and breathing pattern (each with a maximal value of 4).…”

“…], and among examiners with different medical backgrounds and levels of experience [7][8][9][10][11][12][13][14][15]. In this issue, Marcati et al properly evaluate the Italian version of the FOUR score in 87 patients with acute brain injuries.…”

“…In this issue, Marcati et al properly evaluate the Italian version of the FOUR score in 87 patients with acute brain injuries. The FOUR score would be an ideal scale for evaluating comatose patients, since according to Marcati et al, it has proved to be reliable (measuring what it is supposed to measure), valid (giving similar results with repetition), practical (easy to use after minimum training), and highly accurate as a prognostic indicator (test of accuracy yield even higher positive likelihood ratio values for the FOUR score compared to the GCS) [9]. Recent inter-rater reliability studies demonstrate a better agreement with the use of the FOUR score compared to the GCS among medical examiners (especially neurologists) and a lesser, but still good to excellent agreement among examiners with non-neurological backgrounds (including nurses) [7][8][9][10][11].…”

“…This may raise uncertainties whether experience may play a significant role in the use of this scale. However, Marcati et al [9] demonstrate that the clinical experience is not a problematic issue in their validation, and the examiners with different levels of experience are able to evaluate the patients reliability.…”

“…Therefore, it seems that for doctors involved in acute care (ED, ICU, stroke Unit, etc.) the FOUR score may be a preferred option for its higher predictive value, reliability, and greater neurological detail [3,[7][8][9][10][11][12][13][14][15]. Likewise, Marcati et al [9] point out that, among patients with the most severe brain injuries (GCS 3-5), the FOUR score provides more neurological data than the GCS.…”