Comorbidities: A Key Issue in Patients with Disorders of Consciousness Francesca Pistoia, 1 Simona Sacco, 1 Marco Franceschini, 2 Marco Sara `, 3 Caterina Pistarini, 4 Benedetta Cazzulani, 4 Ilaria Simonelli, 5,6 Patrizio Pasqualetti, 5,6 and Antonio Carolei 1 Abstract The aim of this study was to identify the impact of comorbidities on outcomes of patients with vegetative state (VS) or minimally conscious state ( MCS). All patients in VS or MCS consecutively admitted to two postacute care units within a 1- year period were evaluated at baseline and at 6 months through the Coma Recovery Scale–Revised Version and the Disability Rating Scale (DRS). Comorbidities were also recorded for each patient along the same period. Six-month outcomes included death, full recovery of consciousness, and functional improvement. One hundred and thirty-nine patients (88 male and 51 female; median age, 59 years) were included. Ninety-seven patients were in VS (70%) and 42 in MCS (30%). At 6 months, 33 patients were dead (24%), 39 had a full recovery of consciousness (28%), and 67 remained in VS or MCS (48%). According to DRS scores, 40% of patients (n = 55) showed a functional improvement in the level of disability. One hundred and thirty patients (94%) showed at least one comorbidity. Severity of comorbidities (hazard ratio [HR] = 2.8; 95% confidence interval [CI], 1.71–4.68; p < 0.001) and the presence of ischemic or organic heart diseases (HR = 2.6; 95% CI, 1.21–5.43; p = 0.014) were the strongest predictors of death, together with increasing age (HR = 1.0; 95% CI, 1.0–1.06; p = 0.033). Respiratory diseases and arrhythmias without organic heart diseases were negative predictors of full recovery of consciousness (odds ratio [OR] = 0.3; 95% CI, 0.12–0.7; p = 0.006; OR = 0.2; 95% CI, 0.07–0.43; p < 0.001) and functional improvement (OR = 0.4; 95% CI, 0.15–0.85, p = 0.020; OR = 0.2; 95% CI, 0.08–0.45; p < 0.001). Our data show that comorbidities are common in these patients and some of them influence recovery of consciousness and outcomes. Key words: brain injury; comorbidities; minimally conscious state; outcome; vegetative state Introduction P atients with disorders of consciousness (DOCs) are im- mediately admitted to intensive care units (ICUs) because of in- stability of vital functions and, after stabilization, they are transferred to postacute care (PAC) units for rehabilitation. 1 However, some patients with DOCs develop medical comorbidities, which may interfere with recovery. To date, there is scant information on the prognostic impact of comorbidities on survival and functional improvement. The aim of this study was to identify the impact of comorbidities on the outcome of severely brain-injured patients with DOCs. Methods Baseline evaluation All patients consecutively admitted to the PAC units of the San Raffaele Cassino Hospital (Rome, Italy) and of the Maugeri Foundation Pavia Hospital (Pavia, Italy) from January 1, 2012 to December 31, 2012 were investigated. All patients were assessed for possible inclusion in the study within 1 week from admission. Inclusion criteria were a diagnosis of vegetative state (VS) or minimally conscious state (MCS) after traumatic brain injury (TBI), stroke, or anoxic encephalopathy (AE), age ‡ 18 years, and informed consent by the proxy or surrogate to participate in this observational study. 2,3 Patients not having any DOC, with a DOC as a result of a rapidly progressive brain tumor, with a chronic DOC at admission (1-year duration from onset), or presenting acute complications requiring readmission to the ICU within 1 week from admission were excluded. Diagnosis of VS or MCS was made through repeated observations along a 1-week period according to clinical criteria and by the use of the Coma Recovery Scale– Revised (CRS-R), Italian version. 4,5 The CRS-R has high sensi- tivity in capturing key behaviors associated with the transition from VS to MCS (such as consistent or reproducible command-follow- ing, object recognition or localization, visual pursuit, and intelli- gible verbalization) or with the emergence from MCS (functional object use and communication). 6 At baseline evaluation, all 1 Neurological Institute, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy. 2 Department of Neurorehabilitation, IRCCS San Raffaele Pisana, Rome, Italy. 3 Post-Coma and Rehabilitation Care Unit, Hospital San Raffaele, Cassino, Italy. 4 Post-Coma and Rehabilitation Care Unit, IRCCS Maugeri Foundation, Pavia, Italy. 5 Medical Statistics and Information Technology, Fatebenefratelli Foundation for Health Research and Education, AFaR Division, Rome, Italy. 6 Unit of Clinical and Molecular Epidemiology, IRCCS San Raffaele Pisana, Rome, Italy. JOURNAL OF NEUROTRAUMA 32:682–688 (May 15, 2015) ª Mary Ann Liebert, Inc. DOI: 10.1089/neu.2014.3659 682