Often, the physician is faced with the need to assess what will happen to the patient in the future (the prognosis), based on a quick assessment of the current state. It is based on this assessment that most treatments are chosen. In many cases this assessment is simple, just ask a few questions and a quick exam. But in other cases, the patient’s current state is complex and the prognosis difficult without careful investigation, with many examinations and tests.
But the urgency requires a quick decision, which depends on the possible prognosis. A typical case is a person who has suffered a head injury and is in a coma. Coma is a complex condition, with varying degrees and multiple causes, and the decision about what to do has to be made quickly. It is for moments like this that doctors developed so-called scales. And most scales are named after the cities where they were developed. A useful scale is one that allows for a small number of tests, or for a simple examination, to assess the seriousness of the case and take appropriate measures. A good example is the Glascow scale (Glascow Coma Scale), used to assess patients in a coma.
On this scale, the doctor examines only three aspects. First, the eye response (which goes from “does not open” to “opens in response to pain”, “opens in response to voice” and “opens spontaneously”). Then it examines the verbal response (“does not make sounds”, “makes sounds”, “speaks words” and “confused speech”) and finally examines motor capacity (goes from “does not move”, “extends the limbs in response to pain “,” Retracts limbs abnormally in response to pain “to” responds to verbal commands “).
Each reaction, in each of these three evaluations, receives a score (from 1 to 6). Then just add the points, get the note and, looking at a table, an approximate prognosis can be obtained. It takes no more than 15 minutes, which in emergency is essential. These scales, exactly because they are simple, are difficult to build because it is necessary to choose and relate simple signals to the final result. For this, it is necessary to analyze a large number of patients to be sure that the scale correctly predicts and is simple and fast enough.
The novelty now is that scientists have created a scale, called Dublin-Boston, to assess the prognosis of covid-19 in patients who are having difficulty breathing. It was already known that what happens in these patients is what doctors call a cytokine storm, that is, the amount of these molecules in the blood varies a lot. Scientists knew that two cytokines, which have the opposite effect, increase at this stage of the disease. One is interleukin-6 (IL-6) and the other is interleukin-10 (IL-10). IL-6 causes an increase in the levels of inflammation, which makes it difficult for the lung to function. On the other hand, it also increases IL-10, which has anti-inflammatory activity, an action opposite to that of IL-6. Many other molecules related to cytokines also vary during this stage of the disease. What the scientists did was to measure the amount of various inflammation-related molecules daily in 80 inpatients with breathing difficulties.
In addition, they followed the patients for a few more weeks to see what happened to them. Did they get better, worse, needed to be intubated, or did they die?
What they found is that if you divide the amount of IL-6 in the blood of these patients by the amount of IL-10 you will get an index that very accurately predicts the future of those patients. This index is called the Dublin-Boston scale. On this scale, each increase of one point corresponds to a 5.6 times greater chance of the patient getting worse. In addition, when used on day 4 of shortness of breath, its value accurately predicts how the patient will be on day 7. Another great advantage of this scale, and this influenced the choice of these two interleukins to compose the index, is that both they are easily measured by clinical analysis laboratories and, therefore, can be incorporated into the routine of hospitals.
If this scale is adopted, in a while we will hear in the conversations between friends phrases like: “My uncle is hospitalized with covid-19, he is fine and we are not concerned because on the Dublin-Boston scale he has a score of 1, it will hardly get worse ”. Of course, if the score is 3, the conversation will be different. And this scale is likely to help doctors choose the best treatment for each case.
My guess is that we will still hear a lot about this scale. These are small advances like this that are gradually reducing the deaths caused by covid-19. Good news.
MAIS INFORMAÇÕES: A LINEAR PROGNOSTIC SCORE BASED ON THE RATIO OF INTERLEUKIN-6 TO INTERLEUKIN-10 PREDICTS OUTCOMES IN COVID-19. LANCET https://doi.org/10.1016/j.ebiom.2020.10302 (2020)
HE IS A BIOLOGIST, PHD IN CELL AND MOLECULAR BIOLOGY BY CORNELL UNIVERSITY AND AUTHOR OF THE ARRIVAL OF THE NEW CORONAVIRUS IN BRAZIL; LOTUS SHEET, MOSQUITO SLIPPER; AND THE LONG MARCH OF CANNIBAL CRICKETS