MRI findings at neurological onset predict neurological prognosis in hemorrhagic shock and encephalopathy syndrome.

BACKGROUND: Hemorrhagic shock and encephalopathy syndrome (HSES) is a devastating disease and has an uncertain pathogenesis. The aim of this study was to predict neurological outcomes for HSES using magnetic resonance imaging (MRI) findings at neurological onset and elucidate the pathophysiology of HSES in the acute phase from serial MRI changes. MATERIALS AND METHODS: We analyzed the MRI findings of 13 patients who underwent an initial MRI within 24 h of neurological onset. According to neurological prognosis, seven patients were included in the severe group and six in the non-severe group. All patients in the non-severe group had a follow-up MRI. We divided the whole brain into 14 regions and each region was scored according to diffusion-weighted imaging findings. We compared the total scores of each region between the two groups and between onset and follow-up MRI. RESULTS: At neurological onset, symmetrical lesions were found predominantly in the frontal, parietal, and occipital lobes in 12 of 13 patients (92%). In the severe group, the total score for onset MRI was significantly higher than those in the non-severe group (p = 0.003). The total score was significantly higher for follow-up than those of onset MRI (p = 0.036). White matter lesions that showed a bright tree appearance were observed in the follow-up MRIs of all patients. CONCLUSION: Total scores for onset MRIs are useful for predicting neurological prognosis in patients with HSES. In addition to widespread cortical involvement of predominantly watershed areas, white matter lesions may play a role in the progression of brain edema.

Successful Outcome in an Adult Patient with Influenza-associated Hemorrhagic Shock and Encephalopathy Syndrome.

A 50-year-old woman presented with coma and hemorrhagic shock. A rapid influenza antigen test revealed influenza A infection; other laboratory examinations ruled out any other suspected infections. She was diagnosed with hemorrhagic shock and encephalopathy syndrome (HSES) induced by influenza A. She was administered methylprednisolone pulse therapy and peramivir. Subsequently, she was discharged without any sequelae. Only a few cases of influenza-induced HSES have been reported, and the clinical outcomes were very poor. We herein report a successfully treated adult case of influenza-induced HSES and review this rare syndrome.

Characteristic neuroradiologic features in hemorrhagic shock and encephalopathy syndrome.

Hemorrhagic shock and encephalopathy syndrome is a devastating disease, but the pathogenesis remains unclear. The aim of this study was to examine the usefulness of neuroimaging in establishing a diagnosis and elucidating the pathogenesis. We analyzed the neuroradiologic features of 22 patients who fulfilled the Levin criteria. All patients underwent brain computed tomography (CT), and 14 patients underwent brain magnetic resonance imaging (MRI) including diffusion-weighted imaging in 10 patients. Initial CT showed normal findings in 14 of 18 (78%) patients, but subsequently hypodensities appeared in bilateral watershed zones and progressed to whole brain edema. MRI revealed cytotoxic edema, showing hyperintensities in bilateral watershed zones on diffusion-weighted imaging with a low apparent diffusion coefficient. Serial neuroimaging showed characteristic features of a widespread brain ischemic event mainly in watershed zones in hemorrhagic shock and encephalopathy syndrome.

[Hemorrhagic shock and encephalopathy syndrome (HSES)].

Hemorrhagic shock and encephalopathy syndrome (HSES) is characterized by abrupt onset of hyperpyrexia, encephalopathy(seizure and coma), shock, diarrhea, disseminated intravascular coagulation, and renal and hepatic failure. HSES occurs in infants and prognosis is quite poor; early death in 35-82%, severe neurological squeal in 20-30%, and normal in only 10-20%. The underlying pathogenesis is still unknown. Although previous reports revealed that lowered plasma alpha1-antitrypsin level or elevated cytokine levels including IL-6 and TNF-alpha, the results are controversial.

Neural tube defect and folic acid.

PIP: Neural tube defect (NTD) is a group of congenital anomalies, which include anencephaly, encephalocele, iniencephaly, meningocele, myelomeningocele, myeloschisis, lipomeningocele, and rashischisis. Congenital malformations of the central nervous system constitute more than half of all congenital malformations with an incidence of 1-2/1000 births. The condition is thought to arise from multifactorial etiology with a distinct genetic predisposition. This paper discusses the pathogenesis of NTD and explores the use of folic acid for the prevention of this serious congenital malformation. Two studies, which have shown a significant protective effect of folic acid use on NTD prevention in high-risk mothers, are cited. In considering the effectiveness of folic acid supplementation on NTD prevention, obstetricians, pediatricians, neonatologists, and family doctors are called to initiate a collective effort to increase awareness among women in the childbearing age on the need of daily multivitamin intake with folic acid prior to pregnancy.^ieng

Neonatal cholestasis in Kashmiri children.

Neonatal cholestasis is prolonged elevation of conjugated serum bilirubin (more than 20% of total bilirubin) beyond first 14 days of life. After extensive evaluation a diagnosis of either biliary atresia or neonatal hepatitis is made in 70-80% of cases. Neonatal hepatitis and biliary atresia form a pathophysiologic process directed at various levels of the hepatobiliary tract. Inflammation in the bile duct epithelium may result in the sclerosis and obliteration of the bile ducts and manifest as biliary atresia. Primary hepatocellular inflammation is more likely to result in neonatal hepatitis. Half of the cases of neonatal hepatitis resolve without sequelae, while most of the biliary atresia cases require surgical intervention for repair or, ultimately, liver transplant.

Third trimester abortion for fetal abnormality.

Developments in medical technology have increased the possibility of diagnosing severe structural abnormalties in the fetus. If these occur, a woman may request termination of her pregnancy. This raises serious ethical and legal questions, in particular if the anomalies are discovered in the third trimester when the fetus is considered viable. Should doctors be allowed to act upon a request for abortion in such a situation, and, if so, which safeguards should be in place? These questions are discussed with special reference to the Netherlands where a commission established by the government recently published a report on this matter.

Birth defects: prevention of neural tube defects by periconceptional use of folic acid and screening.

Folate deficiency is one of today's most common vitamin deficiencies in women. Women who consume a low level of folate during pregnancy are at risk for poor pregnancy outcomes including birth defects. Birth defects are the leading cause of fetal and infant deaths throughout the world. Neural tube defects comprise a major portion of the birth tube defects. Neural tube defects are common and serious malformations that originate early in pregnancy. Each year in the US, about 4000 babies are born with these two most common neural tube defects, spina bifida and anencephaly. Spina bifida is the leading cause of childhood paralysis. Several studies showed that about 70% of the neural tube defects could be prevented if all women capable of becoming pregnant consumed 0.4 mg of folic acid daily before and during early pregnancy. This paper reports results from various human and animal studies.

The meaning of the act: reflections on the expressive force of reproductive decision making and policies.

Prenatal and preconceptual testing and screening programs provide information on the basis of which people can choose to avoid the birth of children likely to face disabilities. Some disabilities advocates have objected to such programs and to the decisions made within them, on the grounds that measures taken to avoid the birth of children with disabilities have an "expressive force" that conveys messages disrespectful to people with disabilities. Assessing such a claim requires careful attention to general considerations relating meaning, intention, and social practices; it has only begun to receive such attention. Building on work by Allen Buchanan, who has challenged this claim, I further consider the disabilities advocates' objection, ultimately concluding that it is misplaced; neither individual actions nor general practices of this type necessarily express disrespectful messages.

Value, obligation and the asymmetry question.

Is there a prima facie obligation to produce additional individuals whose lives would be worth living? In his paper 'Is it good to make happy people?', Stuart Rachels argues not only that there is, but, also, that precisely as much weight should be assigned to the quality of life that would be enjoyed by such potential persons, if they were to be actualized, as to the quality of life enjoyed by actually existing persons. In response, I shall argue, first, that Rachels' view is exposed to very serious objections, and secondly, that his arguments in support of his position involve a crucial assumption, which cannot be sustained, concerning the relation between, on the one hand, propositions about good-making and bad-making properties, and, on the other, propositions about right-making and wrong-making ones. I shall then argue that there is a very plausible position concerning the conditions under which an action can be morally wrong which entails the following asymmetry: there is a prima facie obligation not to bring into existence individuals whose lives are not worth living, but there is no corresponding obligation to create additional individuals whose lives would be worth living.

Is it good to make happy people?

Would it be good, other things being equal, for additional people to exist whose lives would be worth living? I examine and reject several arguments for the answer that it would not be good; then I offer opposing arguments that I believe are more successful. Thus, I agree with utilitarians who say that it is better for there to be more happy people. Next I argue for the stronger claim that the happiness of potential people is as important as that of adults. Potential quality of life, then, matters in a host of bioethical issues: abortion, commercial surrogacy, the treatment of defective newborns, and so on. What is the practical upshot of all this? I reject the idea that we must do whatever is necessary to prolong life worth living. But I also reject the view that the side-effects of overpopulation always outweigh the value of realizing potential happiness. So I advocate a middle position, which I do not identify precisely. Even from this middle position, however, potential happiness is more important that is commonly assumed in bioethics.

Compulsory sterilisation in Sweden.

In the Fall of 1997 the leading Swedish newspaper, Dagens Nyheter, created a media hype over the Swedish policy of compulsory sterilisation that had been in operation between 1935 and 1975. In the discussion that followed, the moral condemnation of our medical past was unanimous. However, the reasons for rejecting what had gone on were varied and mutually inconsistent. Three strands of criticism were common: the argument from autonomy, the argument from caution, and the argument from biological scepticism. In the paper it is argued that what point of departure you choose in your criticism of the past should be of consequence also for your ideas about present and future medical practice. In particular, if you rely on the argument from autonomy, you should be prepared to accept a liberal (present and future) use of reproductive techniques.