Lesión cerebral post paro cardiaco: aspectos médicos, éticos y legales / Brain injury after cardiac arrest: Medical, ethical and legal issues disorder

RESUMEN Los sobrevivientes de la reanimación cardiopulmonar posterior a un paro cardiaco pueden tener un amplio rango de desenlaces y van desde recuperación neurológica completa, estado de vigilia sin respuesta, compromiso cognoscitivo diverso o la muerte. La lesión del tejido cerebral se presenta inmediatamente después del paro cardíaco, durante la reanimación y al retornar la circulación espontánea. La severidad y duración de la noxa isquémica determinarán el devenir neurológico. El examen clínico es el punto de partida en el abordaje multimodal del neuropronóstico. Se debe complementar con electroencefalograma, potenciales evocados somatosensoriales, neuroimágenes y biomar-cadores séricos. Entre un 10 a 15% de los pacientes con lesión cerebral posterior al paro cardiaco evolucionan hacia muerte por criterios neurológicos y son potenciales candidatos a la donación de órganos. Un retiro temprano de las terapias de sostenimiento de vida puede malograr la posibilidad de un potencial donante de órganos. Se puede estimar de manera temprana qué pacientes tienen mayor riesgo de evolucionar a muerte por criterios neurológicos. El neurólogo tiene un papel protagónico en el manejo de pacientes con lesión cerebral post paro cardiaco y sus decisiones tienen implicaciones éticas y legales.

ABSTRACT People who survive cardiopulmonary resuscitation (CPR) after cardiac arrest, have a wide range of outcomes including complete neurological recovery, coma, compromised cognitive function and death. Injury of the brain parenchyma starts immediately after a cardiac arrest, during CPR and return of spontaneous circulation. The severity of the ischemic injury will define the neurological outcome. The first step needed to determine a neurological prognosis is the clinical exam, with the help of electroencephalography, somatosensory evoked potentials, neuroimaging, and serum biomarkers. Between 10 and 15% of patients with brain injury after a cardiac arrest, develop brain death and become potential candidates for organ donation. A premature withdrawal of vital support can hamper the possibility of organ donation. The patients with higher risk of developing brain death can be identified early based on neurological criteria. The neurologist has a major role in the approach of patients with brain injury after cardiac arrest and the decision making with legal and ethical consequences.

STAT3 as a candidate transcriptomic prognosticator of sepsis severity levels

Background@#Sepsis is a life-threatening multiple-organ dysfunction caused by a dysregulated host response to infection and is the leading cause of death in non-cardiac intensive care facilities. Early reliable prediction of sepsis outcomes leads to cost-efficient resource allocation and therapeutic strategies. However, there are still no reliable markers to predict the outcome of patients at the initial stage of sepsis. Analyzing transcription profiles enables researchers to predict early outcomes using transcripts and their expression patterns. Transcriptomic profiling of septic patients has been done recently; however, analysis of prognostic outcomes is still scarce.@*Objective@#This study aimed to determine transcriptional indicators that may be useful in the prognosis of the severity of sepsis.@*Methods@#This is a prospective cohort study of Filipino patients admitted for sepsis at the national tertiary referral hospital in Manila, Philippines. We conducted differentially expressed gene analysis, network analyses, and area under the curve study of publicly available datasets of surviving vs. non-surviving sepsis patients to identify candidate prognosticator markers. Quantitative PCR was used to characterize the expression of each marker. A model using ordinal logistic regression analysis was done to determine which among the markers can best predict the outcome of sepsis severity.@*Results@#We identified ACTB, RAC1, STAT3, and UBQLN1 as candidate mRNA prognosticators. The expression of STAT3, a gene involved in immunosuppression, is inversely correlated with the severity of sepsis.@*Conclusion@#Transcriptomic markers such as STAT3 can predict the severity of patients with sepsis. Early detection of its inverse expression may prompt early and more aggressive management of patients.

Diagnostics and Prognostication of Myelodysplastic Syndromes

MDS are a heterogeneous and complex group of clonal hematological neoplasms arising from a hematopoietic stem cell, and characterized by ineffective hematopoiesis, resulting in increased apoptosis in the bone marrow and peripheral cytopenia, which involves one or more lineages. Epigenetic changes are reported as ‘founder’ mutations in the case of MDS. Its incidence in the general population has been reported as five new MDS diagnoses per 100,000 people. It affects men more frequently than it does women, and its incidence increases with age. The diagnostic classification, now in use, is the one of the World Health Organization, revised in August 2016. It recognizes six distinct entities in addition to a provisional entity of childhood. In most of the cases, diagnosis is based on the morphologic quantitative and qualitative evaluation of the peripheral blood and bone marrow using basic hematological techniques. Bone marrow biopsy and flow cytometric immunophenotyping also offer support for further diagnostic elucidation, while cytogenetics and molecular genetics are presently fully integrated into prognostication, treatment processes, and decision-making.

Advance in the study of prognostication of neurological outcome in comatose survivors from cardiac arrest / 中华急诊医学杂志

Early prognostication of neurological outcome in comatose survives after cardiopulmonary resuscitation,an essential component of post-cardiac arrest care is significantly meaningful in both clinical and economic fields.From the perspectives of predictors based on neurological examination,electroencephalogram,evoked potentials,neuroimaging and blood biomarkers and taking advantage of therapeutic hypothermia into consideration,this article reviews the development in evaluation of neurological outcome in comatose survives after cardiac arrest.