Contexte : Le décès neurologique se caractérise par une perte permanente des fonctions cérébrales essentielles pour la vie, survenant suite à une lésion cérébrale majeure. Le décès isolé du tronc cérébral est une condition dans laquelle tous les critères cliniques du décès neurologique sont rencontrés, bien qu’il existe une circulation sanguine ou une perfusion tissulaire persistante au niveau du cerveau supratentoriel, tel que documenté par des tests paracliniques (communément appelés des « tests ancillaires »). Les trouvailles aux tests ancillaires soulèvent la possibilité de fonction cérébrale supratentorielle résiduelle, bien que leur réelle signification clinique demeure inconnue. Le décès isolé du tronc cérébral n’est pas considéré compatible avec le décès neurologique dans plusieurs jurisdictions à travers le monde, mais il existe peu de données sur sa prévalence, ses caractéristiques et son évolution parmi les patients admis aux soins intensifs suspectés de décès neurologique. De plus, aucun facteur de risque pour le décès isolé du tronc cérébral n’est actuellement connu. Dans le cadre de ce mémoire, deux projets ont été menés afin de caractériser la prévalence, les caractéristiques et l’évolution du décès isolé du tronc cérébral parmi les patients suspectés de décès neurologique, dans un premier temps, et d’estimer l’association entre l’accident vasculaire cérébral infratentoriel et le décès isolé du tronc cérébral dans cette population, dans un deuxième temps. Méthodes : Nous avons effectué une revue systématique et méta-analyse en suivant la méthodologie Cochrane et en interrogeant quatre répertoires d’articles scientifiques et la litérature grise. Nous avons sélectionné des études de cohorte, des études transversales, et des rapports de cas qui incluaient des patients suspectés de décès neurologique et qui rapportaient la prévalence, les caractéristiques ou l’évolution de patients avec une lésion cérébrale infratentorielle et de patients avec un décès isolé du tronc cérébral. Nous avons calculé la prévalence moyenne du décès isolé du tronc cérébral parmi les patients suspectés de décès neurologique avec une méta-analyse bayésienne hiérarchique à effet mixte. Nous avons aussi décrit les caractéristiques et l’évolution des cas de décès isolé du tronc cérébral publiés dans la litérature. Nous avons ensuite effectué une analyse de l’étude INDex, une étude observationnelle transversale, prospective et multicentrique, dans laquelle nous avons enrôlé de façon consécutive les patients adultes admis aux soins intensifs suite à une lésion cérébrale grave et suspectés de décès neurologique sur la base d’un coma profond. Nous avons identifié les patients avec l’exposition d’intérêt, soit un accident vasculaire cérébral infratentoriel, grâce à la base de données INDex et aux tomodensitométries cérébrales sans contraste. Tous les patients ont subi un examen clinique pour le décès neurologique, ainsi qu’un examen radiologique comportant une angiographie cérébrale et un scan de perfusion cérébrale par tomodensitométrie. Les issues primaires étaient le décès isolé du tronc cérébral basé sur la circulation (examen clinique compatible avec le décès neurologique et présence de circulation sanguine supratentorielle en absence de circulation sanguine infratentorielle à l’angiographie par tomodensitométrie) et le décès isolé du tronc cérébral basé sur la perfusion (examen clinique compatible avec le décès neurologique et présence de perfusion supratentorielle en absence de perfusion infratentorielle au scan de perfusion par tomodensitométrie). Nous avons estimé les associations entre l’accident vasculaire cérébral infratentoriel et les deux définitions de décès isolé du tronc cérébral grâce à des modèles de régression linéaire généralisée utilisant une fonction de liaison logit, un effet aléatoire sur l’ordonnée selon le site participant et une pondération basée sur un score de propension incluant les facteurs de confusion potentiels. Résultats : Un total de 21 études ont été incluses dans la revue systématique et méta-analyse. La prévalence moyenne du décès isolé du tronc cérébral parmi les patients suspectés de décès neurologique était de 1,5% (intervalle de densité à 95% : 0,5-3,9%), bien que le degré de confiance de cet estimé était très bas compte tenu des limitations méthodologiques et de l’hétérogénéité des études regroupées. Dans l’étude observationnelle, la prévalence du décès isolé du tronc cérébral parmi les patients suspectés de décès neurologique était de 12,7% (intervalle de confiance à 95% : 9,1-17,3%) lorsque la condition était définie selon la circulation et de 1,8% (intervalle de confiance à 95% : 0,6-4,2%) lorsqu’elle était définie selon la perfusion. Dans cette étude, nous avons observé une association entre l’accident vasculaire cérébral infratentoriel et le décès isolé du tronc cérébral basé sur la circulation (rapport de cotes ajusté : 2,52; intervalle de confiance à 95% : 1,53-4,17) et entre l’accident vasculaire cérébral infratentoriel et le décès isolé du tronc cérébral basé sur la perfusion (rapport de cotes ajusté : 16,81; intervalle de confiance à 95% : 3,95-71,51). Discussion : Ces trouvailles suggèrent que le décès isolé du tronc cérébral est rare parmi les patients suspectés de décès neurologique et que l’accident vasculaire cérébral infratentoriel pourrait être un facteur de risque dans cette population. / Background: Death by neurologic criteria is characterized by the permanent loss of brain functions essential for life following a severe brain injury. Isolated brainstem death is a medical condition in which all clinical criteria of death by neurologic criteria are fulfilled, but there is persistant supratentorial cerebral blood flow or perfusion on paraclinical testing (“ancillary testing”). These paraclinical findings suggest the possibility that there may be residual supratentorial brain function in isolated brainstem death, although the actual clinical implications of these findings are uncertain. Isolated brainstem death is not considered compatible with death by neurologic criteria in many jurisdictions around the world, but there is little data on its prevalence, characteristics and evolution among patients admitted to the intensive care unit and suspected of neurological death. Furthermore, there are no known risk factors for isolated brainstem death. In this thesis, two projects were conducted in order to characterize the prevalence, caracteristics and evolution of isolated brainstem death among patients suspected of death by neurologic criteria, and to estimate the association between infratentorial stroke and isolated brainstem death in this same population. Methods: We conducted a systematic review and meta-analysis following guidance from the Cochrane group, conducting our searches in four databases and the grey literature. We selected cohort and cross-sectional studies, as well as case reports, including patients suspected of death by neurologic criteria and reporting the prevalence, the characteristics or the evolution of patients with an infratentorial brain injury and of patients with isolated brainstem death. We estimated the mean prevalence of isolated brainstem death among patients suspected by death by neurologic criteria with a hierarchial mixed-effects Bayesian meta-analysis. We decribed the characteristics and evolution of patients with isolated brainstem death published in the literature. We also performed an analysis of the INDex trial, which was an observational, cross-sectional, prospective and multicentric study, in which we enrolled consecutive adult patients admitted to the intensive care unit following a severe brain injury and suspected of death by neurologic criteria based on a deep coma. We identified patients with the exposure of interest, infratentorial stroke, using the INDex database and non-contrast brain CT scans. All patients underwent clinical evaluation for death by neurologic criteria as well as radiologic evaluation with cerebral CT-angiography and CT-perfusion scans. Primary outcomes were isolated brainstem death based on flow (clinical examination consistent with death by neurologic criteria and presence of supratentorial blood flow in the absence of infratentorial flow on CT-angiography) and isolated brainstem death based on perfusion (clinical examination consistent with death by neurologic criteria and presence of supratentorial perfusion in the absence of infratentorial perfusion on CT-perfusion). We estimated associations between infratentorial stroke and both definitions of isolated brainstem death using generalized linear regression models with a logit function, random effects in the intercept according to the participating site, and inverse probability weighting based on a propensity score including all potential confounders. Results: In total, 21 studies were included in the systematic review and meta-analysis. The mean prevalence of isolated brainstem death among patients suspected of death by neurologic criteria was 1.5% (95% highest density interval: 0.5-3.9%), although the level of certainty in this estimate was very low due to methodological limitations and heterogeneity in included studies. In the observational study, the prevalence of isolated brainstem death among patients suspected of death by neurologic criteria was 12.7% (95% confidence interval: 9.1-17.3%) when the condition was based on flow and 1.8% (95% confidence interval: 0.6-4.2%) when it was based on perfusion. In this study, we observed an association between infratentorial stroke and isolated brainstem death based on flow (adjusted odds ratio: 2.52; 95% confidence interval: 1.53-4.17) and between infratentorial stroke and isolated brainstem death based on perfusion (adjusted odds ratio: 16.81; 95% confidence interval: 3.95-71.51). Discussion: These findings suggest that isolated brainstem death is rare among patients suspected of death by neurologic criteria and that infratentorial stroke may be a risk factor for this condition in this population.

Domaine de recherche: Bioéthique / Bien que largement accepté dans la communauté médicale, le concept de mort cérébrale est encore mal compris par certains professionnels de la santé et par le public en général. Il est au centre de débats et demeure une source de controverses. Malgré la confusion et les variations de pratiques documentées, les sources d’incertitudes et de confusion entourant le concept n’ont pas encore été étudiées en profondeur. Pourtant, cette confusion est à même d’influencer les débats et les décisions de fin de vie et de don d’organes, et soulève ainsi de sérieuses considérations tant éthiques que médicales. Ce mémoire de maîtrise propose d’abord une revue de la littérature discutant des origines, de l’évolution et des débats en lien avec le concept de mort cérébrale et les enjeux éthiques associés. Les approches méthodologiques utilisées pour la réalisation de cette recherche sont ensuite décrites. Les résultats découlant de l’analyse de contenu qualitative de médias canadiens et américains des différentes représentations de la mort cérébrales qu’on y retrouve suivent. Ces résultats décrivent l’utilisation du terme de « mort cérébrale » dans des contextes de don d’organes, de définitions de la mort cérébrale, de détermination de la mort, d’enjeux de fin de vie, d’enjeux légaux ainsi que des usages familiers du terme. Finalement, une discussion générale quant au rôle de la terminologie utilisée pour parler du concept de mort cérébrale puis celui des professionnels de la santé impliqués dans sa détermination et les pratiques de don d’organes, ainsi que des recommandations pour le futur concluront ce mémoire. / Despite being widely accepted by the medical community, the concept of brain death is still misunderstood by healthcare providers and the general public. It is central to several debates and remains a source of controversy. In spite of documented practice variations and conceptual confusion surrounding brain death, the upstream sources of variability and uncertainty have not been extensively investigated. This confusion is likely to influence debates and decisions about end-of-life and organ donation, and thus raises serious medical and ethical considerations. This thesis first proposes a review of the literature discussing the origins, the evolution and the debates related to the concept of brain death, as well as the ethical issues associated with brain death. The methodological approaches used for the realization of this research are then described. The results obtained from the qualitative content analysis of Canadian and American media about the different depictions of brain death follow. These results describe the use of the term “brain death” in contexts of organ donation, definitions of brain death, determination of death, end-of-life issues, legal issues and also colloquial uses of the term. Finally, a general discussion about the role of the terminology used to discuss the concept and that of healthcare professionals involved in its determination and organ donation practices, as well as recommendations for the future will conclude this thesis.

Introdução: A hiperidrose primária consiste em uma sudorese excessiva em regiões limitadas do corpo. A simpatectomia torácica videotoracoscópica é um dos tratamentos propostos para a hiperidrose primária palmar, aliando alto sucesso terapêutico com baixo risco. A fisiopatologia da hiperidrose primária ainda não está totalmente esclarecida. Objetivos: Analisar as características morfométricas dos gânglios simpáticos torácicos (G3), removidos cirurgicamente de pacientes portadores de hiperidrose palmar. Como controle foram utilizados os gânglios simpáticos, removidos no mesmo nível (G3), de pacientes doadores de órgãos por morte encefálica, sabidamente sem hiperidrose. Foram estudadas a estereologia e a apoptose celular e as fibras do sistema colágeno /elastina da matriz extracelular. Métodos: Estudo transversal, no qual foram incluídos 40 gânglios simpáticos torácicos (G3) removidos do hemitórax esquerdo, provenientes de pacientes com hiperidrose palmar (Grupo I), submetidos à simpatectomia videotoracoscópica, e 14 gânglios simpáticos de pacientes controle sabidamente sem hiperidrose (Grupo II), removidos por esternotomia mediana. Resultados: Em relação ao sexo, a proporção de mulheres e homens foi de 30:10, no Grupo I, e 7:7 no Grupo II, com p = 0,103. A idade no Grupo I, variou de 10 a 42 anos, com uma média de 23,73 (+ 7,51) e no Grupo II variou de 17 a 68 anos, com uma média de 37,57 (+ 16,65) , apresentando um p = 0,009. A média das células ganglionares nos pacientes do Grupo I foi de 14,25 (+ 3,81) e no Grupo II foi de 10,65 (+ 4,93) com p = 0,007. A média das células ganglionares coradas pela caspase (apoptose) no Grupo I foi de 2,37 (+ 0,79) e no Grupo II foi de 0,77 (+ 0,28) com p < 0,001. A mediana da área de colágeno corada pelo Picrosírius no Grupo I foi de 0,80 IQ (0,08-1,87) e no Grupo II foi de 2,36 IQ (0,49-5,98) com p = 0,061. Conclusões: Os pacientes portadores de hiperidrose primária palmar apresentam um maior número de células ganglionares no gânglio simpático, em relação aos do grupo controle. Há um número maior de células ganglionares simpáticas em apoptose na hiperidrose. Os pacientes portadores de hiperidrose apresentam menos colágeno no gânglio simpático / Introduction: Primary hyperhidrosis consists of excessive sweating in small areas of the body. The video-assisted thoracic sympathectomy is one of the suggested treatments for primary palmar hyperhidrosis, which combines high therapeutic success with low risk. The pathophysiology of primary hyperhidrosis is not fully understood yet. Objectives: Analyzing the morphometric characteristics of the thoracic sympathetic ganglion (G3) surgically removed from patients with palmar hyperhidrosis. The sympathetic ganglion removed at the same level (G3) from patients who are organ donors after brain death and who did not have hyperhidrosis were used as control. Stereology and cellular apoptosis, as well as the fibers of the collagen/elastin system of the extracellular matrix were subjected to scrutiny. Methods: Cross-sectional study, which included 40 thoracic sympathetic ganglion (G3) removed from the left hemithorax of patients who have palmar hyperhidrosis (Group I) and underwent video-assisted thoracoscopic sympathectomy, and also 14 sympathetic ganglion from control patients who did not have hyperhidrosis (Group II), which were removed with median sternotomy. Results: In regards to gender , the proportion of women to men was 30:10 in Group I and 7:7 in Group II, with p = 0.103. The age Group I ranged from 10 to 42 years, with an average of 23.73 (+ 7.51) years and in Group II, from to 17 to 68 years, with an average of 37.57 (+ 16.65) years, with p = 0.009. The average of ganglion cells in Group I was 14.25 (+ 3.81) and in Group II, 10.65 (+ 4.93) with p = 0.007. The average ganglion cells stained by Caspase (apoptosis) in Group I was 2.37 (+0.79) and in Group II, 0.77 (+ 0.28) with p = 0.001. The median collagen area by Picrosirius in Group I was 0.80 IQ (0.08-1.87) and in Group II, 2.36 IQ (0.49-5.98) with p = 0.061. Conclusions: Patients with primary palmar hyperhidrosis have an increased number of ganglion cells in the sympathetic ganglion in comparison to the control group. There are a higher number of sympathetic ganglion cells in apoptosis in hyperhidrosis. Patients with hyperhidrosis have less collagen in sympathetic ganglion

Made available in DSpace on 2016-04-26T20:29:19Z (GMT). No. of bitstreams: 1 Rosa Maria Neves Abade.pdf: 744784 bytes, checksum: e107327e59a55bd37a1558ba31f36b93 (MD5) Previous issue date: 2009-06-08 / The ongoing transformation of humanity in search of better quality of life caused over the years, several scientific studies. The advances of modern science, especially related to the human body were becoming reality, and for this reason, there was growing concern in the band of fundamental rights. The transplantation of organs, is a fruit of the development of modern science, whose task involves a dichotomy between individual and collective interests, requiring therefore the involvement of the state. The moment of death is subject guarded in law, which is controversial and complex and in need of legal determinants. The theme of this study focuses on the understanding of these aspects in the law of organ transplantation. It was analyzed for both the law itself, the basic concept of transplantation and its historical development and legislation. The principle of human dignity, how to format the new concept of citizenship as well as other fundamental rights guaranteed by the Constitution, were also analyzed. Focusing on the issue of consent, the initial choice of the legislature called by the model of consent "assumed", the amendment introduced by MP No 1718/98, later pacified by Law 10211/01, and the legal, requirements for validity of consent, its free and revocability. Finally, the study concludes with a description of the existing articles of Law No. 9. 434/97 and the amendments of the Law 10211/01, emphasizing the criminal aspects, and the legislature's purpose in punishing criminal conduct planned there. It is concluded that this law needs to change, with the exception of open type, suggesting that types are anticipating the outcome of death for fraud, the creation of intermediate types, and application of extrapenais purposes of sentencing / As permanentes transformações da humanidade, em busca de melhor qualidade de vida desencadearam, ao longo dos anos, vários estudos científicos. Os avanços da ciência moderna, mormente vinculadas ao corpo humano, foram se tornando realidade e, por esta razão, houve crescente preocupação no resguardo dos direitos fundamentais. O transplante de órgãos é um dos frutos da evolução da ciência moderna, cuja realização envolve uma dicotomia entre o interesse individual e coletivo, exigindo, assim, a intervenção do Estado. O momento da morte é assunto resguardado nesta lei, sendo este polêmico e complexo, com necessidade de determinantes legais. O tema deste estudo focaliza a compreensão destes aspectos na lei de transplante de órgãos. Analisou-se para tanto, a lei propriamente dita, o básico conceito de transplante e sua evolução histórica e também legislativa. O princípio da dignidade humana, como formador do novo conceito de cidadania, bem como os demais direitos fundamentais, assegurados pela Constituição Federal, foram também analisados. Enfocou-se o aspecto do consentimento, a opção inicial do legislador pelo modelo de consentimento chamado "presumido", a alteração introduzida pela MP nº 1.718/98, posteriormente pacificada pela Lei 10.211/01, bem como a natureza jurídica, os requisitos para a validade do consentimento, sua gratuidade e revogabilidade. Finalmente, culmina o estudo com a descrição dos artigos da Lei vigente nº 9.434/97, bem como as alterações da lei nº 10.211/01, enfatizando os aspectos penais, bem como o objetivo do legislador em punir as condutas criminosas ali previstas. Conclui-se que referida lei necessita de alterações, com a exclusão de tipos abertos, sugerindo tipos que façam a previsão do resultado morte a título de dolo, a criação de tipos intermediários, bem como aplicação de efeitos extrapenais da condenação

INTRODUÇÂO: A morte encefálica (ME) induz instabilidade hemodinâmica com hipoperfusão microcirculatória, desencadeando inflamação e disfunção de órgãos. OBJETIVO: Este estudo teve como objetivo investigar os efeitos da solução salina hipertônica (SH) 7,5% na evolução da resposta inflamatória no tecido mesentérico de ratos submetidos à ME. MÉTODOS: Ratos Wistar machos foram anestesiados e ventilados mecanicamente. A ME foi induzida pela insuflação rápida de um balão posicionado na cavidade intracraniana (Fogart 4F). Os ratos foram divididos aleatoriamente em: 1) Falso-operado, ratos submetidos aos procedimentos cirúrgicos e trepanação (FO, n=17); 2) Controle, ratos tratados com solução salina isotônica (NaCl 0,9%, 4 mL/kg) imediatamente após ME (CO, n=17); 3) Solução hipertônica 1, ratos tratados com solução hipertônica (NaCl 7,5%, 4 mL/kg) imediatamente após ME (SH1, n=17); 4) Solução hipertônica 60, ratos tratados com solução hipertônica 60 min após ME (SH60, n=17). Três horas após a indução da ME ou o término do procedimento cirúrgico para os animais do grupo FO, foram coletados os seguintes dados: (a) perfusão mesentérica, fluxo sanguíneo e interações leucócito-endotélio no mesentério, pela técnica de microscopia intravital; (b) expressão de proteínas de óxido nítrico sintase endotelial (eNOS), endotelina-1, P-selectina e molécula de adesão intercelular (ICAM)-1, por imunohistoquímica; (c) expressão gênica de eNOS e endotelina-1, por reação em cadeia da polimerase em tempo real (PCR); (d) concentrações séricas de citocinas, quimiocinas e corticosterona por meio de enzimaimunoensaio (ELISA). RESULTADOS: Todos os grupos submetidos a ME apresentaram um comportamento semelhante da pressão arterial, sendo observado um pico hipertensivo, seguido de período de hipotensão, logo após a insuflação do cateter intra-craniano. A proporção de pequenos vasos perfundidos foi diminuída no grupo CO (46%) em comparação com FO (74%, p=0,0039). A SH foi capaz de restaurar a proporção de vasos perfundidos (SH1=71%, p=0,0018). Não houve diferenças no fluxo sanguíneo mesentérico entre os grupos. A expressão proteica de eNOS aumentou significativamente em ratos com SH (SH1 e SH60, p=0,0002) em comparação ao grupo CO. Resultados semelhantes foram observados em relação à endotelina-1 (p < 0,0001). Não houve diferenças na expressão gênica de eNOS e endotelina-1. O aumento no número de leucócitos \"rollers\" (p=0,0015) e migrados (p=0,0063) foi observado no grupo CO em comparação com FO. Ratos com SH demonstraram redução significativa em todos os parâmetros da interação leucócito-endotélio. Com relação às moléculas de adesão, a expressão de ICAM-1 estava elevada no grupo CO em comparação com o FO, enquanto que o tratamento com SH diminuiu a expressão de ICAM-1 (SH1 e SH60, p=0,0002). CONCLUSÕES: O emprego da solução salina hipertônica melhorou a perfusão mesentérica, influenciou positivamente o metabolismo do óxido nítrico e reduziu a inflamação no mesentério, com diminuição da adesão e migração leucocitária, em ratos submetidos a ME / BACKGROUND: Brain death (BD) induces hemodynamic instability with microcirculatory hypoperfusion leading to increased organ inflammation and dysfunction. OBJETIVE: To investigate the effects of 7.5% hypertonic saline solution (HS) on the course of the inflammatory response in rats submitted to BD. METHODS: Male Wistar rats were anesthetized and mechanically ventilated. BD was induced by rapid inflation of intracranial balloon catheter (Fogart 4F). Rats were randomly divided in: 1) Sham-operated, rats submitted only to trepanation (SH, n=17); 2) Control, rats treated with normal saline solution (NaCl 0.9%, 4 mL/kg) immediately after BD (CO, n=17); 3) Hypertonic solution 1, rats treated with hypertonic solution (NaCl 7.5%, 4 mL/kg) immediately after BD (HS1, n=17); 4) Hypertonic solution 60, rats treated with hypertonic solution 60 min after BD (HS60, n=17). Hundred eighty minutes thereafter the following experiments were performed: (a) mesenteric perfusion, blood flow, and leukocyte-endothelial interactions, by intravital microscopy; (b) protein expression of endothelial nitric oxide synthase (eNOS), endothelin-1, P-selectin, and intercellular cell adhesion molecule (ICAM)-1, by immunohistochemistry; (c) gene expression of eNOS, and endothelin-1, by real-time polymerase chain reaction (PCR); (d) serum concentrations of cytokines, chemokines and corticosterone by enzyme-linked immunosorbent assay (ELISA). RESULTS: All BD groups presented similar hypertensive peak followed by hypotension. The proportion of perfused small vessels was decreased in CO group (46%) compared to SH (74%, p=0.0039). HS was able to restore the proportion of perfused vessels (HS1=71%, p=0.0018). There were no differences in mesenteric blood flow between groups. eNOS protein expression significantly increased in rats given HS (HS1, and HS60, p=0.0002). Similar results were observed regarding endothelin-1 (p < 0.0001). There were no differences in eNOS and endothelin-1 gene expression. Increased numbers of rolling (p=0.0015) and migrated (p=0.0063) leukocytes were observed in CO group compared to SH. Rats given HS demonstrated an overall reduction in leukocyte-endothelial interactions. Levels of ICAM-1 increased in CO group compared to SH, and decreased in HS-treated groups (p=0.0002). CONCLUSIONS: Hypertonic saline improves mesenteric perfusion, increased eNOS and endothelin-1 protein expression, and reduced inflammation by decreasing leukocyte adhesion and migration in BD rats

INTRODUÇÃO: Estudos experimentais suportam a evidência de leucopenia persistente desencadeada pela morte encefálica (ME). OBJETIVO: Esse estudo teve como objetivo investigar o comportamento leucocitário na medula óssea e no sangue após a morte encefálica em ratos. MÉTODOS: A morte encefálica foi induzida através da inserção e insuflação rápida de um cateter no espaço intracraniano. Ratos falso-operados (FO) foram apenas trepanados. Decorridas seis horas, as células da medula óssea, coletadas da cavidade femural, foram utilizadas para as contagens total e diferencial e analisadas por citometria de fluxo para a caracterização das subpopulações linfocitárias, a expressão de moléculas de adesão granulocíticas e apoptose/necrose (método de Anexina V/Iodeto de Propídio (PI)). RESULTADOS: Ratos com ME apresentaram uma redução de 30% no número de células da medula óssea devido à redução de linfócitos (40%) e células segmentadas (45%). As subpopulações de linfócitos na medula óssea foram semelhantes nos animais ME e FO (CD3, p=0,1; CD4, p=0,4; CD3/CD4, p=0,4; CD5, p=0,4, CD3/CD5, p=0,2; CD8, p=0,8). A expressão de L-selectina e beta2-Integrinas nos granulócitos também não diferiram entre os grupos (CD11a, p=0,9; CD11b/c, p=0,7; CD62L, p=0,1). Não existem diferenças nas porcentagens de apoptose e de necrose (Anexina V, p=0,73; PI, p=0,21; Anexina V/PI, p=0,29). CONCLUSÃO: Os dados sugerem que a redução na mobilização de células da medula óssea para o sangue, desencadeada pela morte encefálica, não se relaciona a alterações de subpopulações de linfócitos, expressão de moléculas de adesão granulocíticas, ou apoptose e necrose / INTRODUCTION: Experimental findings support the evidence of a persistent leucopenia triggered by brain death (BD). AIMS: This study aimed to investigate leukocyte behavior in bone marrow and blood after BD in rats. METHODS: BD was induced by quickly inflation of an intracranial balloon catheter. Sham operated (SH) rats were trepanned only. Six hours thereafter bone marrow cells harvested from the femoral cavity were used for total and differential counts, and analyzed by flow cytometry to characterize lymphocyte subsets, granulocyte adhesion molecules expression, and apoptosis/necrosis (annexin V/propidium iodide (PI) protocol). RESULTS: BD rats exhibited a 30% reduction in bone marrow cells due to a reduction in lymphocytes (40%) and segmented cells (45%). Bone marrow lymphocyte subsets were similar in BD and SH rats (CD3, p=0.1; CD4, p=0.4; CD3/CD4, p=0.4; CD5, p=0.4, CD3/CD5, p=0.2; CD8, p=0.8). Expression of L-selectin and ?2-integrins on granulocytes did not differ (CD11a, p=0.9; CD11b/c, p=0.7; CD62L, p=0.1). There were no differences in the percentage of apoptosis and necrosis (Annexin V, p=0.73; PI, p=0.21; Annexin V/PI, p=0.29). CONCLUSIONS: Data presented suggest that the down-regulation of the bone marrow triggered by BD is not related to changes in lymphocyte subsets, granulocyte adhesion molecules expression, or apoptosis and necrosis

Bien que largement accepté dans la communauté médicale, le concept de mort cérébrale est encore mal compris par certains professionnels de la santé et par le public en général. Il est au centre de débats et demeure une source de controverses. Malgré la confusion et les variations de pratiques documentées, les sources d’incertitudes et de confusion entourant le concept n’ont pas encore été étudiées en profondeur. Pourtant, cette confusion est à même d’influencer les débats et les décisions de fin de vie et de don d’organes, et soulève ainsi de sérieuses considérations tant éthiques que médicales. Ce mémoire de maîtrise propose d’abord une revue de la littérature discutant des origines, de l’évolution et des débats en lien avec le concept de mort cérébrale et les enjeux éthiques associés. Les approches méthodologiques utilisées pour la réalisation de cette recherche sont ensuite décrites. Les résultats découlant de l’analyse de contenu qualitative de médias canadiens et américains des différentes représentations de la mort cérébrales qu’on y retrouve suivent. Ces résultats décrivent l’utilisation du terme de « mort cérébrale » dans des contextes de don d’organes, de définitions de la mort cérébrale, de détermination de la mort, d’enjeux de fin de vie, d’enjeux légaux ainsi que des usages familiers du terme. Finalement, une discussion générale quant au rôle de la terminologie utilisée pour parler du concept de mort cérébrale puis celui des professionnels de la santé impliqués dans sa détermination et les pratiques de don d’organes, ainsi que des recommandations pour le futur concluront ce mémoire. / Despite being widely accepted by the medical community, the concept of brain death is still misunderstood by healthcare providers and the general public. It is central to several debates and remains a source of controversy. In spite of documented practice variations and conceptual confusion surrounding brain death, the upstream sources of variability and uncertainty have not been extensively investigated. This confusion is likely to influence debates and decisions about end-of-life and organ donation, and thus raises serious medical and ethical considerations. This thesis first proposes a review of the literature discussing the origins, the evolution and the debates related to the concept of brain death, as well as the ethical issues associated with brain death. The methodological approaches used for the realization of this research are then described. The results obtained from the qualitative content analysis of Canadian and American media about the different depictions of brain death follow. These results describe the use of the term “brain death” in contexts of organ donation, definitions of brain death, determination of death, end-of-life issues, legal issues and also colloquial uses of the term. Finally, a general discussion about the role of the terminology used to discuss the concept and that of healthcare professionals involved in its determination and organ donation practices, as well as recommendations for the future will conclude this thesis. / Domaine de recherche: Bioéthique

INTRODUÇÃO: Estudos experimentais suportam a evidência de leucopenia persistente desencadeada pela morte encefálica (ME). OBJETIVO: Esse estudo teve como objetivo investigar o comportamento leucocitário na medula óssea e no sangue após a morte encefálica em ratos. MÉTODOS: A morte encefálica foi induzida através da inserção e insuflação rápida de um cateter no espaço intracraniano. Ratos falso-operados (FO) foram apenas trepanados. Decorridas seis horas, as células da medula óssea, coletadas da cavidade femural, foram utilizadas para as contagens total e diferencial e analisadas por citometria de fluxo para a caracterização das subpopulações linfocitárias, a expressão de moléculas de adesão granulocíticas e apoptose/necrose (método de Anexina V/Iodeto de Propídio (PI)). RESULTADOS: Ratos com ME apresentaram uma redução de 30% no número de células da medula óssea devido à redução de linfócitos (40%) e células segmentadas (45%). As subpopulações de linfócitos na medula óssea foram semelhantes nos animais ME e FO (CD3, p=0,1; CD4, p=0,4; CD3/CD4, p=0,4; CD5, p=0,4, CD3/CD5, p=0,2; CD8, p=0,8). A expressão de L-selectina e beta2-Integrinas nos granulócitos também não diferiram entre os grupos (CD11a, p=0,9; CD11b/c, p=0,7; CD62L, p=0,1). Não existem diferenças nas porcentagens de apoptose e de necrose (Anexina V, p=0,73; PI, p=0,21; Anexina V/PI, p=0,29). CONCLUSÃO: Os dados sugerem que a redução na mobilização de células da medula óssea para o sangue, desencadeada pela morte encefálica, não se relaciona a alterações de subpopulações de linfócitos, expressão de moléculas de adesão granulocíticas, ou apoptose e necrose / INTRODUCTION: Experimental findings support the evidence of a persistent leucopenia triggered by brain death (BD). AIMS: This study aimed to investigate leukocyte behavior in bone marrow and blood after BD in rats. METHODS: BD was induced by quickly inflation of an intracranial balloon catheter. Sham operated (SH) rats were trepanned only. Six hours thereafter bone marrow cells harvested from the femoral cavity were used for total and differential counts, and analyzed by flow cytometry to characterize lymphocyte subsets, granulocyte adhesion molecules expression, and apoptosis/necrosis (annexin V/propidium iodide (PI) protocol). RESULTS: BD rats exhibited a 30% reduction in bone marrow cells due to a reduction in lymphocytes (40%) and segmented cells (45%). Bone marrow lymphocyte subsets were similar in BD and SH rats (CD3, p=0.1; CD4, p=0.4; CD3/CD4, p=0.4; CD5, p=0.4, CD3/CD5, p=0.2; CD8, p=0.8). Expression of L-selectin and ?2-integrins on granulocytes did not differ (CD11a, p=0.9; CD11b/c, p=0.7; CD62L, p=0.1). There were no differences in the percentage of apoptosis and necrosis (Annexin V, p=0.73; PI, p=0.21; Annexin V/PI, p=0.29). CONCLUSIONS: Data presented suggest that the down-regulation of the bone marrow triggered by BD is not related to changes in lymphocyte subsets, granulocyte adhesion molecules expression, or apoptosis and necrosis

INTRODUÇÂO: A morte encefálica (ME) induz instabilidade hemodinâmica com hipoperfusão microcirculatória, desencadeando inflamação e disfunção de órgãos. OBJETIVO: Este estudo teve como objetivo investigar os efeitos da solução salina hipertônica (SH) 7,5% na evolução da resposta inflamatória no tecido mesentérico de ratos submetidos à ME. MÉTODOS: Ratos Wistar machos foram anestesiados e ventilados mecanicamente. A ME foi induzida pela insuflação rápida de um balão posicionado na cavidade intracraniana (Fogart 4F). Os ratos foram divididos aleatoriamente em: 1) Falso-operado, ratos submetidos aos procedimentos cirúrgicos e trepanação (FO, n=17); 2) Controle, ratos tratados com solução salina isotônica (NaCl 0,9%, 4 mL/kg) imediatamente após ME (CO, n=17); 3) Solução hipertônica 1, ratos tratados com solução hipertônica (NaCl 7,5%, 4 mL/kg) imediatamente após ME (SH1, n=17); 4) Solução hipertônica 60, ratos tratados com solução hipertônica 60 min após ME (SH60, n=17). Três horas após a indução da ME ou o término do procedimento cirúrgico para os animais do grupo FO, foram coletados os seguintes dados: (a) perfusão mesentérica, fluxo sanguíneo e interações leucócito-endotélio no mesentério, pela técnica de microscopia intravital; (b) expressão de proteínas de óxido nítrico sintase endotelial (eNOS), endotelina-1, P-selectina e molécula de adesão intercelular (ICAM)-1, por imunohistoquímica; (c) expressão gênica de eNOS e endotelina-1, por reação em cadeia da polimerase em tempo real (PCR); (d) concentrações séricas de citocinas, quimiocinas e corticosterona por meio de enzimaimunoensaio (ELISA). RESULTADOS: Todos os grupos submetidos a ME apresentaram um comportamento semelhante da pressão arterial, sendo observado um pico hipertensivo, seguido de período de hipotensão, logo após a insuflação do cateter intra-craniano. A proporção de pequenos vasos perfundidos foi diminuída no grupo CO (46%) em comparação com FO (74%, p=0,0039). A SH foi capaz de restaurar a proporção de vasos perfundidos (SH1=71%, p=0,0018). Não houve diferenças no fluxo sanguíneo mesentérico entre os grupos. A expressão proteica de eNOS aumentou significativamente em ratos com SH (SH1 e SH60, p=0,0002) em comparação ao grupo CO. Resultados semelhantes foram observados em relação à endotelina-1 (p < 0,0001). Não houve diferenças na expressão gênica de eNOS e endotelina-1. O aumento no número de leucócitos \"rollers\" (p=0,0015) e migrados (p=0,0063) foi observado no grupo CO em comparação com FO. Ratos com SH demonstraram redução significativa em todos os parâmetros da interação leucócito-endotélio. Com relação às moléculas de adesão, a expressão de ICAM-1 estava elevada no grupo CO em comparação com o FO, enquanto que o tratamento com SH diminuiu a expressão de ICAM-1 (SH1 e SH60, p=0,0002). CONCLUSÕES: O emprego da solução salina hipertônica melhorou a perfusão mesentérica, influenciou positivamente o metabolismo do óxido nítrico e reduziu a inflamação no mesentério, com diminuição da adesão e migração leucocitária, em ratos submetidos a ME / BACKGROUND: Brain death (BD) induces hemodynamic instability with microcirculatory hypoperfusion leading to increased organ inflammation and dysfunction. OBJETIVE: To investigate the effects of 7.5% hypertonic saline solution (HS) on the course of the inflammatory response in rats submitted to BD. METHODS: Male Wistar rats were anesthetized and mechanically ventilated. BD was induced by rapid inflation of intracranial balloon catheter (Fogart 4F). Rats were randomly divided in: 1) Sham-operated, rats submitted only to trepanation (SH, n=17); 2) Control, rats treated with normal saline solution (NaCl 0.9%, 4 mL/kg) immediately after BD (CO, n=17); 3) Hypertonic solution 1, rats treated with hypertonic solution (NaCl 7.5%, 4 mL/kg) immediately after BD (HS1, n=17); 4) Hypertonic solution 60, rats treated with hypertonic solution 60 min after BD (HS60, n=17). Hundred eighty minutes thereafter the following experiments were performed: (a) mesenteric perfusion, blood flow, and leukocyte-endothelial interactions, by intravital microscopy; (b) protein expression of endothelial nitric oxide synthase (eNOS), endothelin-1, P-selectin, and intercellular cell adhesion molecule (ICAM)-1, by immunohistochemistry; (c) gene expression of eNOS, and endothelin-1, by real-time polymerase chain reaction (PCR); (d) serum concentrations of cytokines, chemokines and corticosterone by enzyme-linked immunosorbent assay (ELISA). RESULTS: All BD groups presented similar hypertensive peak followed by hypotension. The proportion of perfused small vessels was decreased in CO group (46%) compared to SH (74%, p=0.0039). HS was able to restore the proportion of perfused vessels (HS1=71%, p=0.0018). There were no differences in mesenteric blood flow between groups. eNOS protein expression significantly increased in rats given HS (HS1, and HS60, p=0.0002). Similar results were observed regarding endothelin-1 (p < 0.0001). There were no differences in eNOS and endothelin-1 gene expression. Increased numbers of rolling (p=0.0015) and migrated (p=0.0063) leukocytes were observed in CO group compared to SH. Rats given HS demonstrated an overall reduction in leukocyte-endothelial interactions. Levels of ICAM-1 increased in CO group compared to SH, and decreased in HS-treated groups (p=0.0002). CONCLUSIONS: Hypertonic saline improves mesenteric perfusion, increased eNOS and endothelin-1 protein expression, and reduced inflammation by decreasing leukocyte adhesion and migration in BD rats

Introdução: A hiperidrose primária consiste em uma sudorese excessiva em regiões limitadas do corpo. A simpatectomia torácica videotoracoscópica é um dos tratamentos propostos para a hiperidrose primária palmar, aliando alto sucesso terapêutico com baixo risco. A fisiopatologia da hiperidrose primária ainda não está totalmente esclarecida. Objetivos: Analisar as características morfométricas dos gânglios simpáticos torácicos (G3), removidos cirurgicamente de pacientes portadores de hiperidrose palmar. Como controle foram utilizados os gânglios simpáticos, removidos no mesmo nível (G3), de pacientes doadores de órgãos por morte encefálica, sabidamente sem hiperidrose. Foram estudadas a estereologia e a apoptose celular e as fibras do sistema colágeno /elastina da matriz extracelular. Métodos: Estudo transversal, no qual foram incluídos 40 gânglios simpáticos torácicos (G3) removidos do hemitórax esquerdo, provenientes de pacientes com hiperidrose palmar (Grupo I), submetidos à simpatectomia videotoracoscópica, e 14 gânglios simpáticos de pacientes controle sabidamente sem hiperidrose (Grupo II), removidos por esternotomia mediana. Resultados: Em relação ao sexo, a proporção de mulheres e homens foi de 30:10, no Grupo I, e 7:7 no Grupo II, com p = 0,103. A idade no Grupo I, variou de 10 a 42 anos, com uma média de 23,73 (+ 7,51) e no Grupo II variou de 17 a 68 anos, com uma média de 37,57 (+ 16,65) , apresentando um p = 0,009. A média das células ganglionares nos pacientes do Grupo I foi de 14,25 (+ 3,81) e no Grupo II foi de 10,65 (+ 4,93) com p = 0,007. A média das células ganglionares coradas pela caspase (apoptose) no Grupo I foi de 2,37 (+ 0,79) e no Grupo II foi de 0,77 (+ 0,28) com p < 0,001. A mediana da área de colágeno corada pelo Picrosírius no Grupo I foi de 0,80 IQ (0,08-1,87) e no Grupo II foi de 2,36 IQ (0,49-5,98) com p = 0,061. Conclusões: Os pacientes portadores de hiperidrose primária palmar apresentam um maior número de células ganglionares no gânglio simpático, em relação aos do grupo controle. Há um número maior de células ganglionares simpáticas em apoptose na hiperidrose. Os pacientes portadores de hiperidrose apresentam menos colágeno no gânglio simpático / Introduction: Primary hyperhidrosis consists of excessive sweating in small areas of the body. The video-assisted thoracic sympathectomy is one of the suggested treatments for primary palmar hyperhidrosis, which combines high therapeutic success with low risk. The pathophysiology of primary hyperhidrosis is not fully understood yet. Objectives: Analyzing the morphometric characteristics of the thoracic sympathetic ganglion (G3) surgically removed from patients with palmar hyperhidrosis. The sympathetic ganglion removed at the same level (G3) from patients who are organ donors after brain death and who did not have hyperhidrosis were used as control. Stereology and cellular apoptosis, as well as the fibers of the collagen/elastin system of the extracellular matrix were subjected to scrutiny. Methods: Cross-sectional study, which included 40 thoracic sympathetic ganglion (G3) removed from the left hemithorax of patients who have palmar hyperhidrosis (Group I) and underwent video-assisted thoracoscopic sympathectomy, and also 14 sympathetic ganglion from control patients who did not have hyperhidrosis (Group II), which were removed with median sternotomy. Results: In regards to gender , the proportion of women to men was 30:10 in Group I and 7:7 in Group II, with p = 0.103. The age Group I ranged from 10 to 42 years, with an average of 23.73 (+ 7.51) years and in Group II, from to 17 to 68 years, with an average of 37.57 (+ 16.65) years, with p = 0.009. The average of ganglion cells in Group I was 14.25 (+ 3.81) and in Group II, 10.65 (+ 4.93) with p = 0.007. The average ganglion cells stained by Caspase (apoptosis) in Group I was 2.37 (+0.79) and in Group II, 0.77 (+ 0.28) with p = 0.001. The median collagen area by Picrosirius in Group I was 0.80 IQ (0.08-1.87) and in Group II, 2.36 IQ (0.49-5.98) with p = 0.061. Conclusions: Patients with primary palmar hyperhidrosis have an increased number of ganglion cells in the sympathetic ganglion in comparison to the control group. There are a higher number of sympathetic ganglion cells in apoptosis in hyperhidrosis. Patients with hyperhidrosis have less collagen in sympathetic ganglion