Does a regular Wessex Head Injury Matrix assessment identify early signs of infections in people with Prolonged Disorders of Consciousness?


Dhamapurkar, S.Kashinath.; Wilson, B.A.; Rose, A.; Florschutz, G.; Watson, P.; Shiel, A.

Brain Injury 32(9): 1-7

2018


Patients with brain injury are at high risk for infections. Although infection and cognitive deterioration are established for people with dementia, this has not been shown for patients with a prolonged disorder of consciousness (PDOC). This study determines whether regular Wessex Head Injury Matrix (WHIM) assessments can identify early signs of infections in patients with PDOC. Retrospective and prospective approaches were used to assess the WHIM scores of patients with a PDOC (N = 21 in the retrospective study and 22 in the prospective study). The WHIM total scores decreased due to infections in 17 of the 21 cases of infection (p < 0.001) in the retrospective study and 15 (p = 0.001) of the 22 prospective cases of infection. Patients in a minimally conscious state (MCS) showed a bigger proportion of change between their baseline score and the scores taken in the pre-infection stage in both the retrospective and prospective studies when compared to patients in a vegetative state (VS). The findings suggest the importance of serial WHIM assessments throughout the period of recovery, not only to measure cognitive changes but also to highlight underlying physical changes such as infections that will impact the response to rehabilitation and recovery.

BRAIN
INJURY
2018,
VOL.
32,
NO.
9,
1103-1109
https://doi.org/10.1080/02699052.2018.1484165
Taylor
&
Francis
Taylor
&Francis
Group
ARTICLE
lib
Check
for
updates
Does
a
regular
Wessex
Head
Injury
Matrix
assessment
identify
early
signs
of
infections
in
people
with
Prolonged
Disorders
of
Consciousness?
Samira
Kashinath
Dhamapurkar",
Barbara
A
Wilson",
Anita
Rosea,
Gerhard
Florschutza,
Peter
Watson,
and
Agnes
Shield
aOT
Department,
The
Raphael
Hospital,
Kent,
Tonbridge,
UK;
bNeuropsychology
Department,
Oliver
Zangwill
Centre,
Cambridgeshire,
Cambridge,
UK;
cMRC
Cognition
and
Brain
Sciences
Unit,
Cambridgeshire,
Cambridge,
UK;
dOT
Department,
The
National
University
of
Ireland, Ireland,
Galway
ABSTRACT
Background
&
Objective:
Patients
with
brain
injury
are
at
high
risk
for
infections.
Although
infection
and
cognitive
deterioration
are
established
for
people
with
dementia,
this
has
not
been
shown
for
patients
with
a
prolonged
disorder
of
consciousness
(PDOC).
This
study
determines
whether
regular
Wessex
Head
Injury
Matrix
(WHIM)
assessments
can
identify
early
signs
of
infections
in
patients
with
PDOC.
Method:
Retrospective
and
prospective
approaches
were
used
to
assess
the
WHIM
scores
of
patients
with
a
PDOC
(N
=
21
in
the
retrospective
study
and
22
in
the
prospective
study).
Results:
The
WHIM
total
scores
decreased
due
to
infections
in
17
of
the
21
cases
of
infection
(p
<
0.001)
in
the
retrospective
study
and
15
(p
=
0.001)
of
the
22
prospective
cases
of
infection.
Patients
in
a
minimally
conscious
state
(MCS)
showed
a
bigger
proportion
of
change
between
their
baseline
score
and
the
scores
taken
in
the
pre-infection
stage
in
both
the
retrospective
and
prospective
studies
when
compared
to
patients
in
a
vegetative
state
(VS).
Conclusion:
The
findings
suggest
the
importance
of
serial
WHIM
assessments
throughout
the
period
of
recovery,
not
only
to
measure
cognitive
changes
but
also
to
highlight
underlying
physical
changes
such
as
infections
that
will
impact
the
response
to
rehabilitation
and
recovery.
ARTICLE
HISTORY
Received
22
December
2017
Revised
18
April
2018
Accepted
30
May
2018
KEYWORDS
Wessex
Head
Injury
Matrix
(WHIM);
Infection;
Prolonged
Disorders
of
Consciousness
(PDOC)
Introduction
Patients
with
prolonged
disorders
of
consciousness
(PDOC)
are
those
who
remain
in
a
state
of
wakefulness
but
absent
(vegetative
state
(VS))
or
reduced
awareness
(minimally
con-
scious
state
(MCS)
for
more
than
4
weeks
(1).
Following
severe
brain
injury,
many
patients
progress
through
the
stages
of
coma,
VS
and
MCS
as
they
emerge
into
a
state
of
full
awareness.
A
minority
remain
in
VS
or
MCS
for
the
rest
of
their
lives.
The
brain
injury
may
result
from
any
cause,
including
traumatic
brain
injury
(TBI),
hypoxic
damage
or
vascular
accidents
such
as
a
stroke.
Medical
complications
are
common
after
brain
injury
(2).
The
development
of
post-stroke
infection
leads
to
neurological
deterioration
(3),
may
extend
the
hospital
length
of
stay
(4),
lead
to
poor
functional
outcome,
increase
the
cost
of
care
(5)
and
may
result
in
death
(6).
Urinary
tract
infection
(UTI)
occurs
fre-
quently
in
dementia
and
after
an
acquired
brain
injury.
It
is
associated
with
poorer
outcomes,
with
increased
odds
of
dedine
in
neurological
status
during
hospitalization
(7),
and
death
or
disability
(8-10).
Patient
safety
has
become
a
cornerstone
of
care,
and
prevent-
ing
healthcare-associated
infections
(HCAIs)
has
become
a
priority.
It
is
estimated
that
300,000
patients
a
year
in
England
acquire
an
HCAI
as
a
result
of
care
within
the
National
Health
Service
(NHS)
(11).
In
2007,
meticillin-resistant
Staphylococcus
aureus
(MRSA)
bloodstream
infections
and
Clostridium
difficile
infections
were
recorded
as
the
underlying
cause
of
approxi-
mately
9000
deaths
in
hospital
and
primary
care
in
England
(12).
HCAIs
are
estimated
to
cost
the
NHS
approximately
£1
billion
a
year,
and
£56
million
of
this
is
estimated
to
be
incurred
after
individuals
are
discharged
from
the
hospital
(12).
In
addition
to
increased
costs,
each
one
of
these
infections
means
additional
use
of
NHS
resources,
greater
patient
discomfort
and
a
decrease
in
patient
safety
(11).
A
no-tolerance
attitude
is
now
in
place
in
relation
to
avoiding
HCAI.
HCAI
can
exacerbate
existing
or
underlying
conditions,
delay
recovery
and
adversely
affect
quality
of
life
(11).
Reducing
all
types
of
HCAI
will
help
organizations
avoid
the
following
costs
related
to
these
infections:
drug
therapy,
hospital
readmissions
and
potentially
repeat
procedures,
decontamination,
laboratory
and
imaging
investigations,
liti-
gation,
ward
closures,
medical,
nursing
and
management
time,
increased
community
nursing/rehabilitation
as
a
result
of
morbidity
following
HCAI,
staff
sickness
and
associated
staff
cover.
In
summary,
infections
can
prolong
hospital
stays,
create
long-term
disability,
increase
resistance
to
antimicro-
bials,
represent
a
massive
additional
financial
burden
for
health
systems,
generate
high
costs
for
patients
and
their
family
and
cause
unnecessary
deaths
(13).
Thus,
reduction
in
the
rates
and
severity
of
infection
are
essential
for
cost
savings
and
ensuring
high-quality-care
provision.
CONTACT
Samira
Kashinath
Dhamapurkar
Samaira_sagi@yahoo.co.in
CI
Occupational
Therapy
Department,
The
Raphael
Hospital,
Coldharbour
Lane,
Tonbridge,
Kent,
TN11
9LE,
UK.
Color
versions
of
one
or
more
of
the
figures
in
the
article
can
be
found
online
at
www.tandfonline.com/ibij.
ei
2018
Taylor
&
Francis
Group,
LLC
1104
0
S.
K.
DHAMAPURKAR
ET
AL.
HCAIs
can
occur
across
a
wide
range
of
clinical
conditions,
can
affect
patients
of
all
ages
and
are
caused
by
a
wide
range
of
microorganisms.
These
are
often
carried
by
the
patients
themselves
and
take
advantage
of
a
route
into
the
body
provided
by
an
invasive
device
or
procedure.
HCAIs
can
occur
in
otherwise
healthy
individuals
especially
if
invasive
procedures
or
devices
are
used,
e.g.
indwelling
urinary
cathe-
ters
are
the
most
common
cause
of
UTIs
and
bloodstream
infections
are
associated
with
vascular
access
devices
(14).
Infection
is
a
common
cause
of
morbidity
in
the
general
medical
population,
but
patients
in
PDOC
are
at
an
even
higher
risk
of
infection
than
other
patient
groups.
This
is
not
only
due
to
the
fact
that
several
devices
may
be
in
place
such
as
a
metallic
plates
(cranioplasty),
urinary
catheters,
tracheostomy
tubes,
percutaneous
endoscopic
gastrostomy
(PEG)
tubes,
indwelling
catheters,
etc.,
but
also
due
to
patient's
inability
to
communi-
cate
effectively
or
to
express
concerns.
In
the
absence
of
func-
tional
interactive
communication
in
patients
with
PDOC,
it
is
difficult
to
identify
early
signs
of
infections
when
compared
to
healthy
individuals.
Hence,
it
requires
timely
assessment
and
careful
observation
of
their
behaviours.
The
Wessex
Head
Injury
Matrix
(WHIM)
(15)
is
a
beha-
vioural
observational
assessment
tool
commonly
used
for
the
assessment
of
patients
in
and
emerging
from
a
coma
and
patients
in
the
PDOC.
Although
recording
vital
signs
such
as
heart
rate
and
temperature
is
a
helpful
method
to
monitor
physiological
changes,
the
question
asked
in
this
study
is
whether
an
otherwise
unexplained
reduction
in
the
WHIM
total
score
is
useful
in
providing
information
that
could
detect
early
signs
of
infection.
If
so,
could
this
improve
PDOC
out-
comes
and
reduce
healthcare
costs
for
this
population?
The
association
between
infection
and
worst
cognitive
outcome
is
well
established
for
patients
with
acquired
brain
injury
(7,10)
and
dementia
(8);
however,
to
date,
no
investigation
has
been
conducted
in
patients
with
PDOC.
Hence,
this
study
aims
to
add
further
knowledge
to
the
existing
body
of
literature.
Aim:
To
determine
whether
a
decline
in
WHIM
score
indicates
the
onset
of
an
infection.
Objectives
To
identify
whether
total
WHIM
scores
decrease
prior
to
a
patient
with
PDOC
acquiring
an
infection
and
to
ascertain
whether
after
infection
patients
return
to
pre-
vious
levels
of
functioning/baseline.
To
establish
whether
there
are
differences
between
VS
and
MCS
and
TBI
and
non-traumatic
brain
injury
(NTBI)
and
UTI
and
other
infections
with
respect
to
changes
in
the
total
WHIM
scores.
Method
Study
Design
Both
a
retrospective
and
a
prospective
approach
were
used
to
examine
whether
the
results
of
regular
WHIM
assessments
provide
an
indicator
to
identify
early
signs
of
infections
in
patients
with
PDOC.
In
the
retrospective
study,
records
of
all
patients
admitted
with
a
diagnosis
of
PDOC
between
April
2015
and
February
2017
were
examined.
In
the
prospective
study,
patients
admitted
from
March
2017
to
October
2017
were
observed.
WHIM
data
were
used
to
identify
cognitive
behaviours.
Documented
infection
was
confirmed
according
to
the
follow-
ing
criteria.
Clinical
symptoms
such
as
increased
and
discoloured
secretions,
raised
temperature
and
pulse
rate,
foul-smel-
ling
urine,
positive
urine
dipstick,
etc.
Blood,
urine
and/
or
sputum
samples
from
the
patients
presenting
with
clinical
symptoms
were
sent
to
the
laboratory
within
24
h.
Positive
culture
of
body
fluids,
tissue
sample
or
indwel-
ling
catheters
by
recognized
pathogenic
microorganisms
Lung
examination
The
following
complications
might
affect
the
WHIM
score:
nutrition
and
hydration,
pharmacological
treatments
such
as
the
side
effects
of
medications,
metabolic
causes,
sleep
dis-
turbances,
fatigue,
overstimulation,
positioning,
environmen-
tal
factors
such
as
too
much
noise
and
pain.
We
avoided
these
complications
as
far
as
possible
by
regular
monitoring
of
intake/output,
weight,
vitals
records,
blood
sugar,
electrolytes
and
liver-function
test,
observing
sleep-wake
cycles,
regular
reviewing
of
medications
and
assessing
patients
at
different
times
of
the
day,
in
different
locations
and
with
different
people
present.
All
patients
were
uniformly
treated
as
per
the
practice
protocol.
Inclusion
and
exclusion
criteria
were
the
same
for
both
retrospective
and
prospective
studies.
Inclusion
criteria
The
inclusion
criteria
were
as
follows.
Patients
with
TBI/NTBI
(18
years
and
older)
who
were
in
VS/MCS
12
weeks
or
more
after
their
acquired
brain
injury
Prior
to
the
baseline
assessment,
patients
had
to
have
been
free
of
infection
for
at
least
1
week.
Exclusion
criteria
PDOC
of
degenerative
aetiology,
past
medical
history
of
intel-
lectual
disability
or
organic
mental
health
condition,
any
patient
outside
of
diagnostic
(PDOC)
criteria
and
patients
who
have
emerged
from
PDOC
or
patients
diagnosed
with
locked-in
syndrome.
Ethical
Approval
The
study
was
approved
by
the
local
ethics
committee
and
the
Research
Ethics
Committee
at
National
University
of
Ireland
Galway.
Each
patient's
next
of
kin
signed
an
informed
consent
form.
Data
were
stored
in
accordance
with
Caldicott
Principles.
BRAIN
INJURY
0
1105
Study
Procedure
Retrospective:
A
longitudinal
observational
study
(serial
assessments
of
WHIM)
A
pro
forma
was
used
to
collect
data
from
the
case
records
of
patients
included
in
the
study.
This
included
demographic
data,
aetiology,
neuroimaging/neurosurgical
records,
baseline
WHIM
score
(an
initial
behavioural
observation
record),
total
WHIM
scores
(pre-,
during
and
post-infection
period),
med-
ication
changes,
infection
details,
any
acute
hospital
admis-
sion
entries,
nursing
records
(vital
signs),
chest
examination
records
and
medication
record
sheet.
The
WHIM
assessments
were
conducted
by
neuropsychologists
and
occupational
therapists.
WHIM
data
were
analysed
on
a
single-subject
basis
initially
using
descriptive
statistics
and
visual
inspection.
Changes
in
WHIM
scores,
i.e.
increased
or
decreased
total
WHIM
scores,
were
further
evaluated
to
identify
a
possible
underlying
precursor,
such
as
an
alteration
in
medication
and
their
side
effects,
dietary
changes,
infection,
sleep
patterns
and
so
forth.
Changes
in
WHIM
scores
due
to
the
infection
were
further
studied
in
two
groups
(TBI/NTBI)
to
evaluate
any
difference
between
these
two
aetiologies.
Prospective
Study:
Patients'
levels
of
consciousness
and
awareness
were
assessed
using
the
Royal
College
of
Physicians
(RCP)
guidelines
on
PDOC
(2013).
The
WHIM
assessments
were
conducted
by
`blind'
assessors
who
were
working
within
the
occupational
therapy
and
neuropsychology
department
of
the
participating
hospital.
As
part
of
the
assessment,
varied
sensory
stimuli
(visual,
auditory,
olfactory,
tactile,
gustatory)
were
provided
to
elicit
responses
from
the
patients,
and
observed
behaviours
were
documented
on
WHIM
behavioural
observational
sheets.
During
in-patient
rehabilitation,
each
patient
was
screened
for
indications
of
consciousness.
Criteria
for
this
included
(1)
a
behavioural
manifestation
of
the
sense
of
self
or
an
environment,
(2)
functional
use
of
an
object,
(3)
functional
interactive
communication
or
(4)
con-
sistent
choice
making.
During
in-patient
rehabilitation,
each
patient
was
evaluated
on
the
WHIM
at
least
10
times
over
a
3-week
period.
In
addition,
all
patients
were
monitored
daily
by
rehabilitation
assistants
who
documented
vital
signs
to
record
physiological
changes.
Baseline
assessment
was
documented
as
the
mean
of
three
WHIM
assessments
carried
out
over
different
times
of
the
day.
After
baseline
testing,
patients'
cognitive
behaviours
were
assessed
for
a
maximum
of
12
weeks
using
the
WHIM.
Weekly
follow-up
data,
consisting
of
WHIM
scores
(at
least
2-3
per
week),
current
medications
and
medical
complications,
were
noted
during
the
study
period.
If
behavioural
changes
were
observed,
patients
were
further
evaluated
for
any
changes
in
their
sleep-wake
pattern,
medica-
tions
alteration/sedation,
medical
complications,
nutrition,
hydration,
daily
schedules,
positioning,
environment,
oversti-
mulation/fatigue,
etc.
When
negative
change
on
the
WHIM
scores
were
observed,
these
behavioural
changes
were
reported
on
the
same
day
to
the
relevant
professionals,
e.g.
in-house
physician,
nurse
in-charge
to
perform
urine
analysis
and
physio
in-charge
for
chest
auscultation
and
for
further
interventions.
Patients
were
reassessed
on
WHIM
to
evaluate
the
fluctuation
and
recovery
of
their
cognition
over
the
infection
period
and
after
the
completion
of
an
antibiotic
course
(if
relevant).
Each
WHIM
assessment
took
20
-
30
min
to
perform.
Other
Interventions
Neuro-rehabilitation
(multidisciplinary
therapeutic
interven-
tions,
suitable
medications
and
nursing
care)
Outcome
measure
to
assess
cognition
The
WHIM
is
a
62-item
hierarchical
scale,
which
provides
a
sequential
framework
of
observation
covering
an
individual's
level
of
responsiveness
and
interaction
with
their
environment.
Behaviours
may
occur
either
spontaneously
or
in
response
to
stimulation.
The
WHIM
was
designed
to
be
used
by
different
members
of
the
multidisciplinary
team;
it
was
developed
to
monitor
changes
from
coma
through
to
emergence
from
post-
traumatic
amnesia
in
patients
with
TBI.
It
is
shown
to
be
valid
and
reliable
in
this
context
(15,16),
and
it
also
has
applicability
in
other
causes
of
PDOC
(1).
Data
Collection
Retrospective
Retrospective
data
were
collected
from
33
participants
who
were
inpatients
between
April
2015
and
Feb
2017.
Of
these,
12
patients
with
PDOC
were
excluded
from
the
retrospective
study
due
to
degenerative
conditions,
past
history
of
mental
health
illness,
insufficient
WHIM
data
and
reduced
WHIM
scores
due
to
reasons
other
than
infection.
In
total,
retro-
spective
data
were
included
from
21
patients
with
PDOC
(nine
TBI
and
12
NTBI).
Positive
cultures
of
respiratory
secretions
were
present
in
10
patients
(48%
of
the
total
parti-
cipants);
in
nine
patients
(43%
of
the
total
participants),
infection
was
recorded
to
be
UTI
and
in
two
patients
other
infections
were
documented.
Prospective
In
total,
prospective
data
were
collected
from
22
patients
with
PDOC
(11
TBI
and
11
NTBI)
between
March
2017
and
Oct
2017.
A
positive
culture
of
respiratory
secretions
was
present
in
11
patients
(50%
of
the
total
participants),
in
10
patients
(49%
of
the
total
participants)
infection
was
recorded
to
be
a
UTI
and
in
one
patient
another
(C-diff)
infection
was
documented.
Statistical
analysis
Statistics
were
calculated
using
SPSS
software.
WHIM
data
were
analysed
to
identify
any
changes
in
behavioural
assessment
mea-
sures,
to
determine
the
factors
affecting
consciousness
and
the
effects
of
secondary
complications
on
the
level
of
consciousness.
1106
0
S.
K.
DHAMAPURKAR
ET
AL.
Data
were
analysed
on
a
single-subject
basis
initially
using
descriptive
statistics
and
visual
inspection.
Non-parametric
ana-
lysis
was
used
to
examine
data
for
associations
between
reduced
or
absent
behaviours
prior
to
diagnosis
of
infection,
e.g.
a
Mann-
Whitney
test
was
used
to
compare
the
differences
between
two
independent
groups
(TBI
vs.
NTBI;
VS
vs.
MCS)
as
the
dependent
variable
was
not
normally
distributed
for
the
retrospective
study
group.
A
one-sample
t-test
was
used
to
analyse
group
(TBI
vs.
NTBI)
to
determine
infections
and
WHIM
behavioural
representation.
A
one-sample
t-test
was
used
for
prospective
data
as
the
dependent
variable
(TBI:
11
vs.
NTBI:
11)
was
normally
distributed.
A
non-parametric
Kendall's
tau-b
test
was
used
to
analyse
the
co-relationship
with
age
and
gender
due
to
a
relatively
large
Cook's
distance
indicating
an
outlier
and
due
to
skew
in
difference
scores
in
female
groups
and
low
number
of
females
in
the
study.
Fisher's
exact
test
was
used
to
examine
whether
the
changes
in
total
WHIM
score
in
patients
with
PDOC
were
inde-
pendent
of
or
associated
with
an
infection.
Descriptive
statistics
were
used
to
allow
simpler
interpretation
of
the
WHIM
data,
e.g.
graphical
description
(graph
and
table).
Results
Characteristics
of
the
population
Twenty-one
patients
with
PDOC
(16
male
and
5
female)
were
included
in
the
fmal
retrospective
analysis.
The
patients
ranged
in
age
from
20
to
73
years
(TBI:
20-59
years;
NTBI:
35-73
years),
with
a
mean
age
of
47
years.
Nine
patients
had
a
TBI
and
12
had
a
non-traumatic
aetiology.
All
(i.e.
21
patients)
had
a
PEG
for
enteral
nutrition,
eight
had
a
tracheostomy
for
breathing,
three
had
an
indwelling
catheter
and
11
had
a
cranioplasty.
Amongst
the
11
patients
who
had
cranioplasty,
four
patients
had
cranio-
plasty
during
the
current
study
period.
The
mean
length
of
time
since
injury
was
approximately
four
years
(3.95)
for
the
whole
group
(range
2-7
years),
3.6
years
for
the
TBI
group
(range
2-6
years)
and
4.16
years
for
the
NTBI
group
(range
2-7
years).
Seven
patients
had
UTI
and
12
patients
had
a
respiratory
infection.
Two
patients
with
MCS
(one
with
NTBI
and
the
other
with
TBI)
had
infection
at
a
post-operative
site
(ventricular
peritoneal
(VP)
shunt).
In
the
follow-up
(prospective)
study,
22
patients
with
PDOC
(11
TBI
AND
11
NTBI)
were
included.
The
majority
of
patients
with
TBI
were
in
MCS
(n
=
9).
Their
ages
varied
from
21
to
73
years
(TBI:
21-67;
NTBI:
29-73).
Of
a
total
of
11
NTBI,
six
patients
were
in
VS
and
five
in
MCS.
Of
the
11
patients
with
NTBI,
respiratory
infections
were
noted
in
seven,
UTI
in
three
and
one
patient's
medical
record
recorded
c-diff.
Of
the
11
patients
with
TBI,
seven
had
a
UTI
and
the
rest
were
reported
to
have
a
respiratory
infection.
Tables
1
and
2
show
characteristics
of
the
study
population.
Table
1.
Characteristic
of
prospective
data.
Aetiology
Gender
Age
PDOC
Type
of
infection
Total
WHIM
score
Prospective
data
Baseline
Pre-
infection
Post-
infection
TBI
1TBI
M
34
MCS
UTI
19
18
18
2TBI
M
41
MCS
UTI
21
23
21
3TBI
M
21
MCS
Chest
17
15
21
4TBI
F
67
MCS
UTI
10
10
10
5TBI
M
41
MCS
UTI
20
15
18
6TBI
M
41
MCS
UTI
23
16
21
7TBI
M
34
MCS
Chest
15
12
13
8TBI
M
25
MCS
Chest
15
12
17
9TBI
M
25
MCS
Chest
12
10
9
10TBI
F
47
VS
UTI
5 5
5
11TBI
F
47
VS
UTI
4 4 4
NTBI
1NTBI
F
41
MC5
Chest
19
13
19
2NTBI
M
55
MC5
Chest
21
15
22
3NTBI
M
43
MC5
UTI
16
13
18
4NTBI
M
71
MC5
Chest
10
6
9
5NTBI
M
29
MC5
c-diff
13
12
10
6NTBI
M
44
VS
Chest
5
3
4
7NTBI
M
34
VS
UTI
8
6
9
8NTBI
M
73
VS
Chest
6
2
5
9NTBI
F
68
VS
Chest
5 5
5
1ONTBI
F
35
VS
UTI
6 6 6
11NTBI
M
73
VS
Chest
5 5
5
TBI:
traumatic
brain
injury;
NTBI:
non-traumatic
brain
injury;
UTI:
urinary
tract
infection;
PDOC:
prolonged
disorders
of
consciousness;
MCS:
minimally
con-
scious
state;
VS:
vegetative
state
cases
(p
<
0.001).
When
data
for
the
patients
with
TBI
and
NTBI
are
examined
separately,
all
patients
with
TBI
(p
=
0.008)
but
only
eight
(p
=
0.034)
of
the
12
patients
with
NTBI
showed
decreased
behaviours.
Interestingly,
the
majority
of
the
patients
who
showed
changes
were
in
MCS
(100%)
and
only
three
patients
were
in
VS
(42%).
Figure
1
shows
a
comparison
of
the
baseline,
pre-infection
and
post-infection
total
WHIM
scores
for
TBI
and
NTBI
retrospective
study
patients.
The
results
of
the
prospective
study
indicated
that
the
WHIM
total
score
decreased
due
to
the
infections
in
15
(68%;
p
=
0.001)
of
the
22
infection
cases.
When
data
for
the
patients
with
TBI
and
NTBI
are
examined
separately,
seven
of
the
11
patients
with
TBI
(64%)
and
eight
of
the
11
patients
with
NTBI
(73%)
showed
higher
baseline
scores
when
compared
to
pre-infection.
That
is,
there
were
no
differences
in
the
proportions
of
people
showing
increased/no
change/decreased
total
WHIM
scores
from
base-
line
to
pre-infection
noted
between
TBI
and
NTBI
(Fisher's
p
=
1.00).
However,
86%
of
MCS
and
only
38%
of
the
patients
with
VS
showed
a
decrease
in
the
total
WHIM
score
in
the
pre-
infection
level
(Fisher's
exact
p
=
0.011).
Figure
2
shows
a
comparison
of
the
baseline,
pre-infection
and
post-infection
total
WHIM
scores
for
TBI
and
NTBI
prospective
study
patients.
This
emphasizes
that
similar
results
were
obtained
for
both
retrospective
and
prospective
studies,
i.e.
patients
with
MCS
showed
a
bigger
proportion
of
change
in
the
total
WHIM
scores
at
baseline
to
pre-infection
level
when
compared
to
those
with
VS.
Association
between
baseline
total
WHIM
score
and
total
WHIM
score
prior
to
a
patient
acquiring
an
infection
Cognitive
changes
were
recorded
using
the
WHIM.
The
results
of
the
retrospective
study
indicated
that
the
WHIM
total
score
decreased
due
to
the
infections
in
17
(80%)
of
the
21
infection
Association
between
baseline
and
post-infection
total
WHIM
score
Eleven
of
the
21
patients
from
the
retrospective
study
returned
to
previous
levels
of
functioning
after
an
infection
episode.
Of
these,
six
had
TBI
and
five
had
NTBI.
The
total
I
25
§
20
~~
Illliill
l
iii
2
E
15
Ts
10
O
5
0
BRAIN
INJURY
0
1107
Table
2.
Characteristic
of
retrospective
data.
Patients
Gender
Age
PDOC
Type
of
infection
Total
WHIM
score
Retrospective
data
Pre-
Post-
Baseline
infection infection
TBI
1TBI
M
25
MCS
Respiratory
12
8
14
2TBI
M
41
MCS
Respiratory
21
16
23
3TBI
M
20
MCS
UTI
20
16
21
4TBI
M
34
MCS
Respiratory
22
13
21
5TBI
M
20
MCS
Respiratory
16
13
12
6TBI
M
20
MCS
UTI
20
15
21
7TBI
M
54
MCS
UTI
19
11
17
8TBI
M
52
MCS
VP
shunt
and
20
4 4
CN5
infection
Ventriculitis
after
cranioplasty
9TBI
M
59
MCS
Respiratory
13
5
6
Admission
to
A
&
E
NTBI
1-NTBI
M
41
MCS
Respiratory
14
9
15
2-NTBI
F
41
MCS
VP
shunt
and
cranioplasty
infection
25
5
14
3-NTBI
M
55
MCS
Respiratory
19
10
22
4-NTBI
M
70
MCS
Respiratory
15
'11
14
5-NTBI
M
71
MCS
UTI
10
6
10
6-NTBI
M
61
VS
UTI
8 8 8
7-NTBI
M
43
VS
UTI
6 6 6
8-NTBI
F
68
VS
Respiratory
8
6
7
9-NTBI
F
68
VS
Respiratory
6 6 6
10-NTBI
F
46
VS
Respiratory
6
5
5
11-NTBI
F
35
VS
UTI
7
6 6
12-NTBI
M
73
VS
Respiratory
6 6 6
TBI:
traumatic
brain
injury;
NTBI:
non-traumatic
brain
injury;
UTI:
urinary
tract
infection
PDOC:
prolonged
disorders
of
consciousness;
MCS:
minimally
conscious
state;
VS:
vegetative
state
WHIM
scores
remained
below
the
baseline
level
after
recov-
ery
from
the
infection
amongst
three
patients
with
TBI
and
one
patient
with
NTBI.
In
case
of
two
patients
with
TBI,
cognitive
levels
dropped
from
MCS
to
VS,
where
they
showed
reflexive
behaviour
only.
The
infection
(one
TBI
and
one
NTBI)
was
recorded
at
the
post-operative
site
(VP
shunt
infection
and
infected
cranioplasty).
The
patient
with
TBI
and
VP
shunt
infection
died,
whereas
the
patient
with
NTBI
and
infection
at
cranioplasty
started
to
slowly
regain
some
of
the
previous
level
of
functioning.
Twelve
of
the
22
patients
from
the
prospective
study
con-
tinued
to
show
cognitive
improvement
after
recovery
from
infections.
Around
23%
of
the
total
population
showed
a
higher
total
WHIM
score
at
post-infection
when
compared
to
the
baseline,
whereas
36%
of
the
total
population
showed
no
change
and
in
41%
patients,
the
total
WHIM
score
remained
low
at
post-infection
(TBI
vs.
NTBI,
p
=
1.00;
MCS
vs.
VS,
p
=
0.27).
This
highlights
that
similar
results
were
obtained
from
both
retrospective
and
prospective
studies,
i.e.
no
differences
were
noticed
in
proportions
of
people
showing
increased/no
change/decreased
total
WHIM
scores
between
baseline
and
post-infection
for
TBI
and
NTBI.
Association
between
pre-
and
post-infection
total
WHIM
score
Post-infection
total
WHIM
scores
were
higher
than
the
pre-infec-
tion
scores
in
the
retrospective
sample
(p
=
0.001).
The
largest
difference
was
between
the
pre-
and
post-infection
scores
for
patients
with
MCS
(p
=
0.004);
however,
there
were
no
differences
between
TBI
and
NTBI,
with
both
showing
higher
post-infection
scores
(TBI
p
=
0.020
and
NTBI
p
=
0.028).
Similarly,
no
differ-
ences
were
recorded
between
groups
for
different
types
of
infec-
tion
or
between
males
and
females.
From
the
prospective
study,
55%
of
the
patients
continued
to
show
cognitive
improvement
after
recovery
from
infections.
Similar
to
the
results
in
the
retro-
spective
study,
the
largest
differences
were
noticed
between
pre-
and
post-infection
scores
for patients
with
MCS
(64%);
however,
no
such
differences
were
noticed
amongst
TBI
vs.
NTBI
(p
=
0.73).
However,
compared
to
males
(69%
who
tended
to
show
higher
post-infection
scores),
female
patients
(83%)
tended
to
show
no
change
(Fisher's
exact
p
=
0.013).
Discussion
This
study
set
out
to
examine
whether
a
decline
in
WHIM
scores
indicates
the
presence
of
an
infection
in
patients
with
PDOC.
The
authors
found
a
general
relationship
between
a
drop
in
total
WHIM
scores
and
infection.
The
patients
with
MCS
showed
a
greater
proportion
of
change
compared
to
the
patients
with
VS
between
their
baseline
score
and
the
scores
Retrospective Study
30
TBI
and
NTBI
patients
for
Retrospective
study
E2sdine
Pre-infs.coon
Figure
1.
A
comparison
of
baseline,
pre-infection
and
post-infection
total
WHIM
scores
for
TBI
and
NTBI
retrospective
study
patients.
1108
0
S.
K.
DHAMAPURKAR
ET
AL.
Prospective
Study
I
I
I
11
1
1 II
11
,9:)
,
4
1
/4
4
.0
,
`
.
,S
i
eS
t
e
c
e
,o
e
,os
te
c
eSS
TBI
and
NTBI
patients
for
prospective
study
EB3eline
Paat•infE
25
20
S
Y
O
2
15
10
O
0
I
I
II
II
Figure
2.
A
comparison
of
baseline,
pre-infection
and
post-infection
total
WHIM
scores
for
TBI
and
NTBI
retrospective
study
patients.
taken
in
the
pre-infection
stage
in
both
the
retrospective
(100%)
and
prospective
(85%)
studies.
The
association
between
infection
and
worse
cognitive
outcome
is
well
estab-
lished
both
for
patients
with
acquired
brain
injury
[7/10]
and
for
patients
with
dementia
(8);
however,
to
date
no
investiga-
tion
has
been
conducted
in
patients
with
PDOC.
Hence,
this
study
adds
further
knowledge
to
the
existing
body
of
literature.
Infection
is
a
common
cause
of
morbidity
in
the
general
medical
population,
but
patients
in
PDOC
are
particularly
vulnerable.
In
the
absence
of
functional
interactive
communi-
cation
in
patients
with
PDOC,
it
is
important
to
identify
early
signs
of
infections.
The
WHIM
was
chosen
for
this
study
as
it
measures
subtle
changes
in
patient's
cognitive
behaviour
over
time
(1).
Wilson
et
al.,
(16)
in
their
study,
showed
that
a
serial
record
of
WHIM
scores
can
be
used
to
monitor
the
consistency
of
responses,
as
well
as
trends
towards
change
over
time.
A
review
by
the
US
Task Force
(17)
identified
13
cognitive
assessments
for
PDOC
with
minor/moderate
reservations,
including
WHIM,
Sensory
Modality
assessment
and
Rehabilitation
Techniques
(18)(SMART)
and
the
JFK
Coma
Recovery
Scale-Revised
(19)(JFK
CRS-R).
A
UK
survey
demonstrated
that
the
WHIM
is
the
most
commonly
used
tool
in
the
UK,
followed
by
the
SMART
and
then
the
CRS-R
(1).
The
WHIM
covers
a
different
range
of
responses
from
the
SMART
and
CRS-R.
Its
ceiling
extends
beyond
that
of
the
CRS-
R
or
SMART
to
track
patients
until
they
emerge
from
post-
traumatic
amnesia.
The
WHIM
is
relatively
easy
to
employ
in
neurorehabilitation
settings,
requires
minimal
staff
training
and
is
less
time-consuming
to
administer,
thereby
facilitating
regular
or
routine
serial
assessments
(1)
when
compared
to
SMART
(18).
Although
SMART
undoubtedly
provides
a
more
robust
assessment
of
patients
who
are
in
VS,
it
also
requires
extensive
specialist
training
and
is
not
widely
available.
Similar
to
SMART,
the
JFK
CRS-R
(19)
covers
a
broadly
similar
range
of
responses;
however,
use
of
the
JFK
CRS-R
has
not
been
widely
documented
in
UK
settings
(16).
The
authors
examined
the
patterns
of
change
in
the
total
WHIM
scores
recorded
serially
over
time
to
determine
whether
the
baseline
data
would
change
prior
to
patient
obtaining
an
infection.
Fifteen
patients
with
PDOC
from
the
prospective
study
showed
a
drop
in
WHIM
scores
prior
to
developing
an
infection.
On
further
analysis,
the
rates
of
change
in
the
total
WHIM
scores
increased
progressively
across
12
patients
with
PDOC
in
the
post-infection
stage.
This
emphasizes
that
the
serial
application
of
WHIM
is
an
important
indicator
to
identify
early
signs
of
infection.
The
results
of
the
retrospective
study
indicated
that
the
total
WHIM
scores
decreased
due
to
infections
in
80%
of
the
patients
with
infection;
similarly,
the
prospective
study
showed
that
the
WHIM
total
score
decreased
due
to
the
infections
in
68%
of
the
patients
with
infections.
The
results
of
the
study
confirm
that
in
the
pre-infection
stage,
some
patients
demonstrated
decreased
wakefulness,
lethargy
and
decreased
alertness.
Others
presented
with
increased
agitation
and
vocalization.
All
patients
presented
with
raised
tempera-
ture
and
with
an
increased
pulse
rate
compared
to
their
base-
line.
Patients
with
respiratory
infection
showed
increased
respiratory
rates
but
decreased
oxygen
saturation.
With
regard
to
alertness,
patients
with
respiratory
infections
were
observed
and
documented
to
be
sleepier,
whereas
patients
with
urinary
infection
were
more
restless
(WHIM
no.
11).
This
increased
restlessness
and
agitation
prior
to
urination
could
be
due
to
pain
as
a
consequence
of
the
UTI.
The
RCP
guidelines
(1)
suggest
that
the
cause
of
injury
is
an
important
factor
for
outcome
of
patients
in
PDOC
and
that
patients
with
NTBI
have
a
shorter
window
of
recovery
com-
pared
to
patients
with
TBI.
In
four
of
the
reported
infections
(out
of
21
from
the
retrospective
study),
there
was
no
change
in
the
total
WHIM
scores.
All
these
patients
had
a
non-traumatic
aetiology.
An
explanation
for
this
may
be
that
these
patients
were
in
VS
and
their
total
WHIM
score
was
already
too
low
to
show
any
meaningful
changes
in
their
WHIM
behaviour.
Similar
results
were
noticed
for
the
prospective
study,
where
no
changes
were
noticed
in
the
total
WHIM
scores
for
six
patients.
Of
those
six
patients,
five
were
in
VS.
Conclusion
An
unexplained
reduced
WHIM
score
appears
to
be
a
pre-
dictor
of
underlying
infections.
The
patients
with
MCS
showed
a
greater
proportion
of
change
between
their
baseline
BRAIN
INJURY
0
1109
score
and
the
scores
taken
in
the
pre-infection
stage
in
both
the
retrospective
and
prospective
studies
compared
to
the
patients
with
VS.
Thus,
the
findings
of
the
study
suggest
the
importance
of
serial/regular
WHIM
assessments
throughout
the
period
of
recovery
not
only
to
measure
cognitive
changes
but
also
to
highlight
underlying
physical
changes
such
as
infections
that
will
impact
rehabilitation
and
recovery.
Timely
understanding
of
the
risk
of
infection
among
patients
with
brain
injury
could
minimize
infection-related
longer
hospital
stays
and
adverse
outcomes.
Conflicting
Interests
The
authors
report
no
conflicts
of
interest.
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