Maternal brain death during pregnancy

BACKGROUND: An association between smoking and impaired wound healing has been reported in retrospective studies. The smoking status of a surgical patient may be confounded by social and medical parameters. We have evaluated the effect of smoking in a test wound in volunteers, with special reference to a reliable scientific match between smokers and nonsmokers. METHODS: In a prospective open study with blinded assessment, 19 smoking (20 cigarettes/day) and 18 nonsmoking healthy volunteers were matched with respect to baseline characteristics. The deposition of total protein and mature collagen (expressed as hydroxyproline) was assessed in an expanded polytetrafluoroethylene wound healing model implanted subcutaneously for 10 days. RESULTS: The nonsmokers had a 1.8 times higher median amount of hydroxyproline than the smokers (p < 0.01). The deposition of hydroxyproline was negatively correlated with the consumption of tobacco both before (r = -0.44; p < 0.01) and during the study (r = -0.48; p < 0.005). The impairment was specific for the production of collagenous proteins and not other proteins. CONCLUSIONS: The synthesis of subcutaneous collagen in smokers is specifically impeded, indicating an impaired wound-healing process. Because mature collagen is the main determinator of strength of an operative wound, the results support the view that patients should be advised to stop smoking before an operation.     

Unexpected death due to gestational choriocarcinoma: a report of two cases

The clinical and pathological manifestations of severe intestinal involvement in Wegener's granulomatosis were studied by a review of the literature and reports of two patients. Altogether, six cases, two females and four males, were studied. One patient developed two episodes of bowel manifestations necessitating immediate surgical interventions. The average age at onset of intestinal symptoms was 43.3 yr (26-55 yr) and, in all cases, the first signs of such manifestations developed within the first 2 yr of disease. Prior to the onset of intestinal symptoms, immunosuppressive therapy was administered in six of seven instances. Acute abdominal pain with signs of peritonitis or distention only constituted the main clinical picture in six of the seven events. The last episode was manifested clinically with profuse diarrhoea with blood and mucus. Of the seven instances of severe intestinal manifestations, the small bowel was involved in two, the large bowel in three, and both the small and large bowel were affected in two episodes. Histological evidence of vasculitis in the bowel was demonstrated in three of the seven biopsy specimens, while in four, ischaemia, inflammation and ulceration were the pathological findings. Intestinal perforation was seen four times and surgery was performed in six of seven episodes. Severe intestinal involvement is rare in Wegener's granulomatosis. The initial bowel manifestations occur within the first 2 yr of disease, and affect both the large and small bowel. Histologically, vasculitis, ischaemia, inflammation and ulceration are the prevailing findings. Death due to intestinal catastrophy occurred in one of the six patients reported. Most likely, the manifestations are associated with the disease process rather than related to the use of immunosuppressive agents.     

Tc-99m HMPAO cerebral scintigraphy. A reliable, noninvasive method for determination of brain death

To investigate the relationships between the mammographic aspects (according to Broberg), proliferative activity and hormone receptor status, we studied 165 patients subjected to radical mastectomy for operable breast cancer. The highest percentage of estrogen receptor-positive cases was observed in mammograph class I (p < 0.02) while classes III and V were highest in progesterone receptor-positive cases. Proliferative activity (111 cases) was significantly lower in class I and IV with respect to all other classes (p < 0.03 and p < 0.01, respectively). This study suggests that certain mammographic signs can be related to the biological characteristics of breast cancer.     

Unexpected cardiac arrest during epidural anaesthesia

We reported the case of sudden asystole requiring close chest cardiac massage in a 56-yrs-old health man receiving epidural anaesthesia for elective transurethral resection of bladder tumour (TURBT). The anaesthetic procedure was performed in a regional-block-room. Cardiac arrest developed few minutes after local anaesthetic injection, before the patient has been transferred to the operating room. The importance of patient monitoring during regional anaesthesia must be further on pointed out, especially when the anaesthetic procedure is performed out of the operating room (e.g. in the recovery room or in a "regional-block-room").     

From death concepts to brain death diagnostic criteria

The authors present considerations about death and brain death concepts, as well the legal aspects for its diagnosis in Brazil. They also present the UNICAMP Protocol for the Diagnosis of Brain Death, revised and according with the current law, with standard techniques for the diagnostic exam. They emphasize the importance of a mature ethical position for this frequent and challenging situation.     

Magnetic resonance imaging of brain death

The db/db mutant mouse is a rodent model of genetic diabetes that develops renal glomerular lesions with striking mesangial matrix accumulation by the age of 16 weeks, after 8-10 weeks of sustained hyperglycemia. However, abnormalities in renal function that antedate or accompany the appearance of these pathologic changes, which resemble those found in human diabetes, have not been delineated. We therefore examined renal function in young db/ db mice and their nondiabetic db/m littermates from the age of 8 through 15 weeks. Serum creatinine and blood urea nitrogen concentrations at the onset of diabetes in db/db mice did not differ significantly from mean concentrations in db/m controls. An elevated creatinine clearance, due in large part to increased body weight, and increased urinary albumin excretion were observed in db/db compared with db/m mice soon after establishment of sustained hyperglycemia. A relative reduction in creatinine clearance was demonstrable in db/db mice at the age of 15 weeks, coincident with the appearance of overt compromise in renal function manifested by frank increases in the serum creatinine and blood urea nitrogen. The findings indicate that the well-documented glomerular pathology in db/db mice is accompanied by definable alterations in renal function, which are similar in chronology and nature to those found in human diabetes.     

A clinico-neuropathological study on brain death

A clinico-neuropathological study was conducted on 60 cases of brain death, 36 males and 24 females, ranging in age from 11 to 81 years, the average being 49.4 years. Of these, 29 patients died of cerebrovascular disease. The average duration of brain death was 99 hours. The mean weight of the brain was 1466 g. Neuropathological findings were brain edema, congestion, herniation and various subarachnoid hemorrhages. Histologically, the cytoplasm of neurons was pale and ghost-like. In the white matter, myelin staining was pale, and nuclei of the glial cells were shrunken and piknotic. Autolysis of the cerebellar granular layer and the pituitary gland was evident in all cases. No reactive astrocytosis or infiltration of the cells in or around necrotic tissue could be seen. In eight cases, there was laminar infiltration of neutrophils in the superficial area of the cerebrum and brain stem, possibly due to temporary or partial recirculation. Correlation between the degree of autolysis and duration of brain death was observed, but no relationship between the degree of autolysis and the difference of underlying disease could be found. Autolysis in the cerebral cortex, thalamus, tegmentum of the brain stem, cerebellar granular layer and pituitary gland was most prominent. However, neuropathological diagnosis of underlying diseases could be made even in brain death. Histologically, the cases of brain death differed from those of cardiac arrest-induced encephalopathy and from those of long postmortem autopsy.     

Increased apnea threshold in a pediatric patient with suspected brain death

OBJECTIVE: To evaluate the current standards for apnea testing in the evaluation of brain death in children. DESIGN: Case report. SETTING: A tertiary pediatric intensive care unit (ICU). PATIENTS: A single patient admitted to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A formal brain death examination was performed on a 4-yr-old male with a diagnosis of acute pilocytic astrocytoma and global cerebral hypoxic ischemic damage secondary to a cardiorespiratory arrest. The patient fulfilled all criteria for brain death, except the apnea test. An apnea test was performed for 9 mins 23 secs, at which time, spontaneous respiratory effort was noted. The respiratory efforts were initiated with a pH of 7.08 and a PaCO2 of 91 torr (12.1 kPa). CONCLUSION: This case report suggests that current guidelines for apnea testing may lead to erroneous evaluation of medullary-respiratory drive.     

Miller Fisher syndrome, a brainstem encephalitis, mimics brain death

Miller Fisher syndrome is a rare focal encephalitis of the brainstem characterized by cranial nerve palsy, ataxia, and areflexia. While this condition usually is mild and self-limiting, as this case documents, findings may fulfill many of the criteria in the clinical examination for brain death. Unlike brain death, however, it is not associated with irreparable structural damage of the brain or, as is mandatory, does it fulfill a very important prerequisite of brain death, the exclusion of potentially reversible causes of coma. Treatment of Miller Fisher syndrome is supportive.     

Oscillatory brain activity during a motor task

Changes in spectral power in neuromagnetic fields associated with a manual task requiring a high level of sensorimotor integration (SMI) were investigated by analysing spontaneous, non-invasively recorded activity during motor preparation (WAIT), task performance (SMI), and control (REST) conditions in four healthy, right-handed human subjects. Neuromagnetic fields were recorded over the left sensorimotor cortex using a 37-channel instrument. In all subjects, a prominent narrow-band motor preparation rhythm centered near 19 Hz was consistently observed during the WAIT state. During SMI, mean relative increases in 26-30 Hz activity appeared in two of the subjects, paralleling gamma band enhancement recently observed during SMI in monkeys.     

Irrecoverable brain damage after resuscitation: brain death and other syndromes

The diagnosis of diabetes mellitus depends primarily on the doctor being continually aware of this common, important and treatable disease. The previous two articles in this series have described the prevalence of the disease, and the warning signals suggesting that the disease may be present.     

Unexpected death of psychiatric patients: suicide, misadventure, accident or unsolved mystery?

BACKGROUND: Because of the wide range of recommended threshold values for carotid stenosis graduation we performed a prospective study to determine interobserver and interequipment variability of quantitative blood flow velocity measurements. PATIENTS AND METHODS: We recorded absolute blood flow velocities and velocity ratios in 21 patients with carotid artery stenosis using two colour coded duplex ultrasound systems an ATL Ultramark 9 HDI, and a Hewlett Packard SONOS 2500 system. The ATL system was used for the interobserver variation study, where each patient was examined twice on the same day. The Doppler angle was recorded together with blood flow velocities (peak systolic velocity and mean maximum velocity from the velocity-time-integral both in the stenosis jet and 4-5 cm distally in the cranial portion of the internal carotid artery off poststenotic turbulences). RESULTS: The ATL system generated significantly higher blood flow velocity values as compared with the HP system (218 +/- 156 cm/s vs. 169 +/- 114 cm/s; p < 0.001). The Mean Velocity Ratio (the ratio of intrastenotic Vmean and poststenotic Vmean) was constant with both duplex systems. The HP system yielded 10% (Cl, 7-13%) lower predicted stenosis estimates than the ATL system with Vmax as the stenosis criterion. The stenosis estimates calculated from Mean Velocity Ratio values did not differ significantly. The 95% Cl for predicted diameter reduction between two observer was 13.6% (Vmax) and 15.4% (Mean Velocity Ratio). CONCLUSION: Because of significant interequipment differences of colour coded duplex ultrasound systems we recommend calculation of the Mean Velocity Ratio to avoid interpatient and interequipment variation of absolute flow velocities. According to our interobserver variability study, a change of more than 15% diameter reduction on follow-up examinations indicates disease progression or regression.