title: Emergence from minimally conscious state: insights from evaluation of posttraumatic confusion.
abstract: BACKGROUND
  Guidelines for defining the minimally conscious state (MCS) specify behaviors that characterize emergence, including "reliable and consistent" functional communication (accurate yes/no responding). Guidelines were developed by consensus because of lack of empirical data.
  
  
  OBJECTIVE
  To evaluate the utility of the operational threshold for emergence from posttraumatic MCS, by determining yes/no accuracy to questions of varied difficulty, including simple orientation questions, using all items from the Yes/No Subscale of the Mississippi Aphasia Screening Test.
  
  
  METHODS
  Prospective observational study of a cohort of responsive patients recovering from traumatic brain injury in an acute inpatient brain injury rehabilitation program.
  
  
  RESULTS
  Of the 629 observations from 144 participants, name recognition was the easiest yes/no question, with nonconfused individuals responding with 100% accuracy, whereas only 75% to 78% of confused participants on initial evaluation answered this question correctly. Generalized Estimating Equations analysis revealed that confused participants were more likely to respond inaccurately to all yes/no questions. Nonconfused participants had a reduction in odds of inaccuracy ranging from 45.6% to 99.7% (p = 0.001 to 0.02) depending on the type of yes/no question.
  
  
  CONCLUSIONS
  Accuracy for simple orientation yes/no questions remains challenging for responsive patients in early recovery from traumatic brain injury. Although name recognition questions are relatively easier than other types of yes/no questions, including situational orientation questions, confused patients still may answer these incorrectly. Results suggest the operational threshold for yes/no response accuracy as a diagnostic criterion for emergence from the minimally conscious state should be revisited, with particular consideration of the type of yes/no questions and the requisite accuracy threshold for responses.
authors.affiliation: James A. Haley Veterans Hospital, MH & BS/Polytrauma (116B), 13000 Bruce B. Downs Blvd., Tampa, FL 33612, USA. risa.richardson@va.gov
authors.forename: R
authors.initials: R
authors.lastname: Nakase-Richardson
authors.forename: S A
authors.initials: SA
authors.lastname: Yablon
authors.forename: M
authors.initials: M
authors.lastname: Sherer
authors.forename: T G
authors.initials: TG
authors.lastname: Nick
authors.forename: C C
authors.initials: CC
authors.lastname: Evans
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000150:complications* / Q000523:psychology; D003142:Communication; D003221:Confusion / Q000209:etiology* / Q000523:psychology; D005260:Female; D006801:Humans; D008297:Male; D011939:Mental Recall; D008875:Middle Aged; D009483:Neuropsychological Tests; D018458:Persistent Vegetative State / Q000503:physiopathology / Q000523:psychology; D011446:Prospective Studies; D020127:Recovery of Function; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires