Neurologic Associations With Cardiac, Pulmonary, Renal, Hepatobiliary, and Hematologic Disease

The brain has a higher demand for cardiac output than any other organ, and it strictly relies on oxygen and glucose metabolism. Consequently, the brain is exquisitely sensitive to homeostatic disturbances and extraneural organ dysfunction leading to cardiac, pulmonary, renal, hepatobiliary, and hematologic diseases. The primary neurologic manifestation of extraneural organic dysfunction is diffuse bihemispheric dysfunction or encephalopathy, which often lacks lateralizing or localizing signs. Common clinical findings are lethargy, difficulty with attention and orientation, sleep-wake disturbance, and psychomotor slowing. As organic dysfunction progresses, a moderate encephalopathy ensues, with worsening cognitive function, gross disorientation, hypoactive or hyperactive psychomotor state, frontal release signs, asterixis, and myoclonus. If organ failure (eg, hepatic or renal) progresses further, stupor and coma may result unless organ function improves. Patients with underlying organic brain disease from degenerative dementia can decompensate out of proportion to neurologically normal counterparts, resulting in encephalopathy even from minor organ dysfunction or infection.

Clinical Characteristics and Factors Associated with Unfavorable Outcomes of Pediatric Inflammatory Multisystem Syndrome Related to COVID-19 in Lima-Peru

Objective: Describe the clinical-epidemiological profile and determine the factors associated with unfavorable outcomes of pediatrics multisystemic inflammatory syndrome (SIM-P) related to COVID-19 at Edgardo Rebagliati Martins National Hospital (HNERM), Lima-Perú, from April to September 2020. Materials and methods: Retrospective cohort in children under 14 years of age. The current criteria were used for the diagnosis of SIM-P. The effect size was estimated with relative risk (RR) and 95% confidence intervals, using a generalized linear Poisson family model with robust variance. Results: 43 patients were included, 22 (51.2%) Kawasaki Disease (EK), 10 (23.3%) shock, and 11(25.6%) fever with inflammatory markers. The median age was 8 years, most men, without comorbidity, with negative molecular test and positive IgG. Gastrointestinal and mucocutaneous manifestations predominated, with altered inflammatory markers and myocardial injury. Most required intravenous immunoglobulin (IVIG), aspirin (AAS), corticosteroids and antibiotics. More than a third required VMI, ICU and developed organic dysfunction, with a lethality of 4.6% (2/43). Increasing lethality to 20% (2/10) in the shock subgroup. Five were found (14.7%) coronary aneurysm. Having some comorbidity (RR 1.79; IC95%1.02-3.14), C-reactive protein ≥ 10 mg/dL (RR 2.09; IC95%1.15-3.79), and SatO2 ≤92 in emergency (RR 2.84; IC95%1.47-5.50) was morelikely to betransferred to ICU. In addition, those with some comorability (RR 2.23; IC95%1.04-4.79), with lymphopenia <500cel/mL (RR 2.8; IC95%1.24-6.30), and with d≥ 3 mg/L (RR 3.57; IC95%1.23-10.38) were more likely to require VMI. Conclusion: Active monitoringis an eye to make early diagnosis and management in order to improve the prognosis.

SOFAMONIA: Comparison of the original SOFA score with the proposed new score including serum ammonia

Introduction: Hyperammonemia can represent organic dysfunction of the brain, kidney, or liver. Evaluation of serum ammonia concentrations as a parameter for organ dysfunction may be justified. Objective: To evaluate the performance of serum ammonia as an additional or substitute variable for organ systems in the Sequential Organ Failure Assessment (SOFA) score. Methods: A prospective cohort study including 173 patients admitted to the intensive care unit between March 2015 and February 2016. SOFAMONIA scores were defined as follows: SOFAMONIA1 (Glasgow coma scale replaced by serum ammonia), SOFAMONIA2 (serum bilirubin replaced by serum ammonia), SOFAMONIA3 (renal system score replaced by serum ammonia), and SOFAMONIA4 (addition of serum ammonia to the original SOFA as the seventh variable, changing the maximum score from 24 to 28). Results: The original SOFA presented an area under the curve–receiver operating characteristic of 0.697 to predict hospital mortality. There was a positive correlation between SOFA and SOFAMONIA scores. SOFAMONIA1 presented a cut-off point of 5 for area under the curve 0.684 (0.610–0.753, 95% confidence interval), SOFAMONIA2 presented a cut-off point of 9 for area under the curve 0.701 (0.626–0.768, 95% confidence interval), SOFAMONIA3 presented a cut-off point of 8 for area under the curve 0.674 (0.598–0.743, 95% confidence interval), and SOFAMONIA4 presented a cut-off point of 8 for area under the curve 0.702 (0.628–0.769, 95% confidence interval). Conclusions: The addition of ammonia as the seventh parameter of the SOFA score showed the best performance to predict hospital mortality. The addition of ammonia as a representative of metabolic dysfunction may be useful in the follow-up of critically ill patients.

Mulberry bodies in the urine sediment of a patient with chronic kidney disease

ObjectivesFabry disease is a hereditary disease caused by a mutation in the α-galactosidase A (GLA) gene resulting in the accumulation of glycosphingolipids in different organs. Timely diagnosis is crucial for the early initiation of treatment to avoid organic dysfunction secondary to lipid accumulation. In view of the above, a number of studies have been performed to assess the role of mulberry bodies as a new diagnostic tool. In this study, we report a case demonstrating the utility of this test.Case presentationWe report the case of a woman of advanced age without a history of chronic disease with symptoms consistent with urinary tract infection (dysuria, pelvic pain, and frequent urination). Based on laboratory test results, a diagnosis of anemia with concomitant chronic kidney disease was established. Urine test revealed microhematuria, proteinuria, urine sediment, and the presence of lipid particles consistent with mulberry bodies.ConclusionsThe identification of mulberry bodies and cells in urine sediment is an easy-to-use tool potentially useful in diagnosing Fabry disease, which may contribute to initiate enzyme replacement therapy in a timely manner and reduce systemic deterioration.

Inflammatory cytokines and organ dysfunction associate with the aberrant DNA methylome of monocytes in sepsis

Background Sepsis, a life-threatening organ dysfunction caused by a dysregulated systemic immune response to infection, associates with reduced responsiveness to subsequent infections. How such tolerance is acquired is not well understood but is known to involve epigenetic and transcriptional dysregulation. Methods Bead arrays were used to compare global DNA methylation changes in patients with sepsis, non-infectious systemic inflammatory response syndrome, and healthy controls. Bioinformatic analyses were performed to dissect functional reprogramming and signaling pathways related to the acquisition of these specific DNA methylation alterations. Finally, in vitro experiments using human monocytes were performed to test the induction of similar DNA methylation reprogramming. Results Here, we focused on DNA methylation changes associated with sepsis, given their potential role in stabilizing altered phenotypes. Tolerized monocytes from patients with sepsis display changes in their DNA methylomes with respect to those from healthy controls, affecting critical monocyte-related genes. DNA methylation profiles correlate with IL-10 and IL-6 levels, significantly increased in monocytes in sepsis, as well as with the Sequential Organ Failure Assessment score; the observed changes associate with TFs and pathways downstream to toll-like receptors and inflammatory cytokines. In fact, in vitro stimulation of toll-like receptors in monocytes results in similar gains and losses of methylation together with the acquisition of tolerance. Conclusion We have identified a DNA methylation signature associated with sepsis that is downstream to the response of monocytes to inflammatory signals associated with the acquisition of a tolerized phenotype and organic dysfunction.

Level of acuity, severity and intensity of care of adults and older adults admitted to the Intensive Care Unit

ABSTRACT Objective: To characterize the level of acuity, severity and intensity of care of adults and older adults admitted to Intensive Care Units and to identify the predictors of severity with their respective predictive capacity according to the age group. Method: A retrospective cohort based on the analysis of medical records of individuals admitted to eight adult intensive care units in the city of São Paulo. The clinical characteristics at admission in relation to severity profile and intensity of care were analyzed through association and correlation tests. The predictors were identified by linear regression and the predictive capacity through the ROC curve. Results: Of the 781 cases (41.1% from older adults), 56.2% were males with a mean age of 54.1 ± 17.3 years. The burden of the disease, the organic dysfunction and the number of devices were the predictors associated with greater severity among adults and older adults, in which the organic dysfunction had the highest predictive capacity (80%) in both groups. Conclusion: Adults and older adults presented a similar profile of severity and intensity of care in admission to the Intensive Care Unit. Organic dysfunction was the factor with the best ability to predict severity in adults and older adults.

Neuro-visual miscalculations in acute mTBI

ObjectiveTo describe oculomotor abnormalities following acute mild traumatic brain injury (mTBI) as a possible target for Rehabilitation.BackgroundMore than 361,092 service members have sustained mTBI between 2000 and 2016.82.4 percent being mTBI. The vast majority improve within a few weeks. However, small percentages continue to have symptoms of Chronic TBI, including those with objective findings on oculomotor exam. The neuropathology of these finding are well documented and are possible targets of acute mTBI rehabilitation. This case series explores the typical finding of symptomatic patients after mTBI. Neuro-optometry is a subspecialty which evaluates the visual system for dysfunction following neurologic insult. Binocular dysfunction is prevalent following mTBI. Recent literature supports the hypothesis that the visual system can be utilized to evaluate the extent of brain injury. The NSUCO oculomotor test allows for quantification of saccadic and pursuit inaccuracies.MethodsThe case series reported here from the Intrepid Spirit Center (ISC), Fort Hood focuses on the treatment of acute mTBI patients referred by primary care providers or emergency departments. Three military service members with acute mTBI underwent a complete neurologic examination with a neurologist, including an oculomotor function assessment with a Neuro-optometrist utilizing the NSUCO oculomotor test (video attached).ResultsWe have video documentation demonstrates typical oculomotor dysfunction seen in acute mTBI patients, including poor initiation of saccades, inaccurate spatial planning and execution of saccades, and fixation losses on pursuits on binocular assessment.ConclusionOculomotor dysfunction is a verifiable, reproducible documentation of organic dysfunction in acute mTBI amenable to therapeutic approaches including neuro-optometric visual rehabilitation. Neuro-optometric vision rehab is a novel treatment modality for acute mTBI.

Exploring Epidemiological Aspects, Distribution of WHO Maternal Near Miss Criteria, and Organ Dysfunction Defined by SOFA in Cases of Severe Maternal Outcome Admitted to Obstetric ICU: A Cross-Sectional Study

Objective. To explore the epidemiological aspects, to describe the frequency and distribution of WHO maternal near miss (MNM) criteria and the presence of organ dysfunction and failure measured by the maximum SOFA (Sequential Organ Failure Assessment) score (SOFA max) in cases of severe maternal outcome (SMO). Methods. In an observational cross-sectional study performed between January 2013 and December 2015, 279 pregnant or postpartum women were admitted to an obstetric ICU (intensive care unit) in Brazil. MNM, maternal death (grouped as SMO), and potentially life-threatening conditions (PLTC) were defined according to WHO criteria. For categorical variables, a descriptive analysis was carried out. Frequency and distribution of WHO criteria, organ dysfunction, or failure defined by SOFA max were performed. Results. WHO criteria identified 65 SMO and 214 PLTC. Management criteria were present in 58/65 (89.2%) while 61/65 (93.8%) of SMO cases had dysfunction or failure by SOFA. Conclusions. The systematic evaluation of the organic function by SOFA max score identified the presence of organic dysfunction or failure in almost all SMO cases. Management criteria were present in all MD cases. Our results indicate the need for new studies evaluating the parameterization of the WHO laboratory criteria for values compatible with the definition of organic dysfunction by the SOFA to identify MNM.

Extreme Psychospiritual States Versus Organic Brain Disease: Bringing Together Science and the Human Factor

Extreme states can be psychospiritual and “functional” in origin or they can be “organic” and driven by biological dysfunction. Contemporary psychiatry largely rejects this distinction, preferring to insist that everything “extreme” is biological in origin; but the distinction is important for understanding and helping people. Psychospiritual crises, including those labeled bipolar or schizophrenic, are “functional” and express meaning. As “bizarre” as the language or the symbols may seem, meanings that often reflect childhood abuse can be explored in a trusting, kind, and caring therapeutic relationship. The more that a real biological or organic dysfunction, such as traumatic head injury or neurotoxic exposure, is the root cause of the extreme state, the less sense its manifestations will make. Nonetheless, drug-induced extreme states, even when caused by hallucinogens or by psychiatric “medicines,” often leave sufficient brain function operational to reveal important meanings about the person’s experience, along with the otherwise senseless intoxication. With so many people prescribed psychiatric drugs, these neurotoxic chemicals are now the most common cause of extreme states in clinical practice, and withdrawal from these offending agents is critical to recovery (Breggin, 2013). However, even when the extreme state is driven by neurological dysfunction, a safe space and skilled therapists can help relieve the individual’s otherwise overwhelming feelings of anxiety or terror.