Outcomes of Cerebral Venous Thrombosis due to Vaccine-Induced Immune Thrombotic Thrombocytopenia After the Acute Phase

BACKGROUND

Cerebral venous thrombosis (CVT) due to vaccine-induced immune thrombotic thrombocytopenia (VITT) is a severe condition, with high in-hospital mortality rates. Here, we report clinical outcomes of patients with CVT-VITT after SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) vaccination who survived initial hospitalization.

METHODS

We used data from an international registry of patients who developed CVT within 28 days of SARS-CoV-2 vaccination, collected until February 10, 2022. VITT diagnosis was classified based on the Pavord criteria. Outcomes were mortality, functional independence (modified Rankin Scale score 0-2), VITT relapse, new thrombosis, and bleeding events (all after discharge from initial hospitalization).

RESULTS

Of 107 CVT-VITT cases, 43 (40%) died during initial hospitalization. Of the remaining 64 patients, follow-up data were available for 60 (94%) patients (37 definite VITT, 9 probable VITT, and 14 possible VITT). Median age was 40 years and 45/60 (75%) patients were women. Median follow-up time was 150 days (interquartile range, 94-194). Two patients died during follow-up (3% [95% CI, 1%-11%). Functional independence was achieved by 53/60 (88% [95% CI, 78%-94%]) patients. No new venous or arterial thrombotic events were reported. One patient developed a major bleeding during follow-up (fatal intracerebral bleed).

CONCLUSIONS

In contrast to the high mortality of CVT-VITT in the acute phase, mortality among patients who survived the initial hospitalization was low, new thrombotic events did not occur, and bleeding events were rare. Approximately 9 out of 10 CVT-VITT patients who survived the acute phase were functionally independent at follow-up.

Management of Cerebral Venous Thrombosis Due to Adenoviral COVID-19 Vaccination

Objective

Cerebral venous thrombosis (CVT) caused by vaccine‐induced immune thrombotic thrombocytopenia (VITT) is a rare adverse effect of adenovirus‐based severe acute respiratory syndrome‐coronavirus 2 (SARS‐CoV‐2) vaccines. In March 2021, after autoimmune pathogenesis of VITT was discovered, treatment recommendations were developed. These comprised immunomodulation, non‐heparin anticoagulants, and avoidance of platelet transfusion. The aim of this study was to evaluate adherence to these recommendations and its association with mortality.

Methods

We used data from an international prospective registry of patients with CVT after the adenovirus‐based SARS‐CoV‐2 vaccination. We analyzed possible, probable, or definite VITT‐CVT cases included until January 18, 2022. Immunomodulation entailed administration of intravenous immunoglobulins and/or plasmapheresis.

Results

Ninety‐nine patients with VITT‐CVT from 71 hospitals in 17 countries were analyzed. Five of 38 (13%), 11 of 24 (46%), and 28 of 37 (76%) of the patients diagnosed in March, April, and from May onward, respectively, were treated in‐line with VITT recommendations (p < 0.001). Overall, treatment according to recommendations had no statistically significant influence on mortality (14/44 [32%] vs 29/55 [52%], adjusted odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.16–1.19). However, patients who received immunomodulation had lower mortality (19/65 [29%] vs 24/34 [70%], adjusted OR = 0.19, 95% CI = 0.06–0.58). Treatment with non‐heparin anticoagulants instead of heparins was not associated with lower mortality (17/51 [33%] vs 13/35 [37%], adjusted OR = 0.70, 95% CI = 0.24–2.04). Mortality was also not significantly influenced by platelet transfusion (17/27 [63%] vs 26/72 [36%], adjusted OR = 2.19, 95% CI = 0.74–6.54).

Conclusions

In patients with VITT‐CVT, adherence to VITT treatment recommendations improved over time. Immunomodulation seems crucial for reducing mortality of VITT‐CVT. ANN NEUROL 2022;92:562–573

Linear and non-linear relationships among the dimensions representing the cognitive structure of emotion

While dimensional models play a key role in emotion psychology, no consensus has been reached about their number and nature. The current study sheds a new light on this central issue by examining linear and non-linear relationships among the dimensions in the cognitive emotion structure. The meaning of 80 emotion terms was evaluated on 68 features representing appraisals, action tendencies, bodily reactions, expressions, and subjective experiences by 213 English-speaking US, 156 French-speaking Swiss, and 194 Indonesian-speaking Indonesian students. In a two-dimensional valence and arousal representation, neither linear nor non-linear relationships were observed. In a four-dimensional valence, power, arousal, and novelty representation, both linear (e.g. a positive relationship between valence and power) and non-linear (e.g. a strong positive correlation between valence and power found only for positively valenced emotion terms) relationships were observed. Joy- and sadness-related emotion terms where about as well represented by the two- than by the four-dimensional representation. However, especially anger- and surprise-related terms were only adequately represented by the four-dimensional representation. These findings were generalisable across the three languages. Even though a two-dimensional structure fits the data well in general, four dimensions are needed to sufficiently represent the cognitive structure of the whole gamut of human emotions.

Characteristics and Outcomes of Patients With Cerebral Venous Sinus Thrombosis in SARS-CoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia

Importance

Thrombosis with thrombocytopenia syndrome (TTS) has been reported after vaccination with the SARS-CoV-2 vaccines ChAdOx1 nCov-19 (Oxford-AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & Johnson).

Objective

To describe the clinical characteristics and outcome of patients with cerebral venous sinus thrombosis (CVST) after SARS-CoV-2 vaccination with and without TTS.

Design, Setting, and Participants

This cohort study used data from an international registry of consecutive patients with CVST within 28 days of SARS-CoV-2 vaccination included between March 29 and June 18, 2021, from 81 hospitals in 19 countries. For reference, data from patients with CVST between 2015 and 2018 were derived from an existing international registry. Clinical characteristics and mortality rate were described for adults with (1) CVST in the setting of SARS-CoV-2 vaccine-induced immune thrombotic thrombocytopenia, (2) CVST after SARS-CoV-2 vaccination not fulling criteria for TTS, and (3) CVST unrelated to SARS-CoV-2 vaccination.

Exposures

Patients were classified as having TTS if they had new-onset thrombocytopenia without recent exposure to heparin, in accordance with the Brighton Collaboration interim criteria.

Main Outcomes and Measures

Clinical characteristics and mortality rate.

Results

Of 116 patients with postvaccination CVST, 78 (67.2%) had TTS, of whom 76 had been vaccinated with ChAdOx1 nCov-19; 38 (32.8%) had no indication of TTS. The control group included 207 patients with CVST before the COVID-19 pandemic. A total of 63 of 78 (81%), 30 of 38 (79%), and 145 of 207 (70.0%) patients, respectively, were female, and the mean (SD) age was 45 (14), 55 (20), and 42 (16) years, respectively. Concomitant thromboembolism occurred in 25 of 70 patients (36%) in the TTS group, 2 of 35 (6%) in the no TTS group, and 10 of 206 (4.9%) in the control group, and in-hospital mortality rates were 47% (36 of 76; 95% CI, 37-58), 5% (2 of 37; 95% CI, 1-18), and 3.9% (8 of 207; 95% CI, 2.0-7.4), respectively. The mortality rate was 61% (14 of 23) among patients in the TTS group diagnosed before the condition garnered attention in the scientific community and 42% (22 of 53) among patients diagnosed later.

Conclusions and Relevance

In this cohort study of patients with CVST, a distinct clinical profile and high mortality rate was observed in patients meeting criteria for TTS after SARS-CoV-2 vaccination.

Roles of the multiplex real-time PCR assay and β-D-glucan in a high-risk population for intra-abdominal candidiasis (IAC)

Multiplex quantitative real-time PCR (MRT-PCR) using blood can improve the diagnosis of intra-abdominal candidiasis (IAC). We prospectively studied 39 patients with suspected IAC in the absence of previous antifungal therapy. Blood cultures, MRT-PCR, and β-D-glucan (BDG) in serum were performed in all patients. IAC was defined according to the 2013 European Consensus criteria. For MRT-PCR, the probes targeted the ITS1 or ITS2 regions of ribosomal DNA. Candidaemia was confirmed only in four patients (10%), and IAC criteria were present in 17 patients (43.6%). The sensitivity of MRT-PCR was 25% but increased to 63.6% (P = .06) in plasma obtained prior to volume overload and transfusion; specificity was above 85% in all cases. BDG performance was improved using a cutoff > 260 pg/ml, and improvement was not observed in samples obtained before transfusion. In this cohort of high risk of IAC and low rate of bloodstream infection, the performance of non-culture-based methods (MRT-PCR or BDG) was moderate but may be a complementary tool given the limitations of diagnostic methods available in clinical practice. Volume overload requirements, in combination with other factors, decrease the accuracy of MRT-PCR in patients with IAC.

Are concepts of achievement-related emotions universal across cultures? A semantic profiling approach

Verifying that conceptualisations of emotions are consistent across languages and cultures is a critical precondition for meaningful cross-cultural research on emotional experience. For achievement-related emotions tied to successes or failures, such evidence is virtually non-existent. To address this gap, we compared Canadian, German, Colombian, and Chinese university students' (N _Total = 126) perceptions of affective, cognitive, motivational, physiological, and expressive characteristics of 16 achievement-related emotions using a psycholinguistic tool for profiling emotion concepts (Achievement Emotions CoreGRID). Cross-cultural similarity of emotion concepts quantified through double-entry intraclass correlations was generally high, and highest for their affective, cognitive, and motivational components. However, results also point to cultural variation, particularly for physiological and expressive components. Variation in perceived physiological characteristics was most pronounced for boredom, and for comparisons of Canada, Germany, and Colombia with China. Implications for theoretical propositions of universality of emotion concepts and future research on achievement-related emotions are discussed.

Mobilization of iron from ferritin: new steps and details

Much evidence indicates that iron stored in ferritin is mobilized through protein degradation in lysosomes, but concerns about this process have lingered, and the mechanistic details of its aspects are lacking. In the studies presented here, ⁵⁹Fe-labeled ferritin was induced by preloading hepatic (HepG2) cells with radiolabeled Fe. Placing these cells in a medium containing desferrioxamine resulted in the loss of ferritin-⁵⁹Fe, but adding high concentrations of reducing agents or modulating the internal GSH concentration failed to alter the rates of ferritin-⁵⁹Fe release. Confocal microscopy showed that Fe deprivation increased the movement of ferritin into lysosomes and hyperaccumulation was observed when lysosomal proteolysis was inhibited. It also resulted in the rapid movement of DMT1 to lysosomes, which was inhibited by bafilomycin. Ferrihydrite crystals isolated from purified rat liver/spleen ferritin were solubilized at pH 5 and 7 by GSH, ascorbate, citrate and lysosomal fluids obtained from livers and J774a.1 macrophages. The inhibition of DMT1/Nramp2 and siRNA knockdown of Nramp1 each reduced the transfer of ⁵⁹Fe from lysosomes to the cytosol; and hepatocyte-specific knockout of DMT1 in mice prevented the release of Fe from the liver responding to EPO treatment, but did not inhibit lysosomal ferritin degradation. We conclude that ferritin-Fe mobilization does not occur through changes in cellular concentrations of reducing/chelating agents but by the coordinated movement of ferritin and DMT1 to lysosomes, where the ferrihydrite crystals exposed by ferritin degradation dissolve in the lysosomal fluid, and the reduced iron is transported back to the cytosol via DMT1 in hepatocytes, and by both DMT1 and Nramp1 in macrophages, prior to release into the blood or storage in ferritin.

One-year prognosis of non-traumatic cortical subarachnoid haemorrhage: A prospective series of 34 patients

INTRODUCTION

Cortical subarachnoid haemorrhage (cSAH) has multiple aetiologies. No prospective study has reported the long-term progression of the condition. The objective of this study is to describe the clinical and aetiological characteristics of patients with cSAH and to gain insight into prognosis.

METHODS

We performed a prospective, observational, multi-centre study. Data on clinical and radiological variables were collected; during a one-year follow-up period, we recorded data on mortality, dependence, rebleeding, and the appearance of dementia.

RESULTS

The study included 34 patients (mean age, 68.3 years; range, 27-89). The most frequent symptoms were headache and focal neurological deficits, which were frequently transient and recurrent. CT scans returned pathological findings in 28 patients (85%). Brain MRI scans were performed in 30 patients (88%), revealing acute ischaemia in 10 (29%), old haemorrhage in 7 (21%), and superficial siderosis in 2 (6%). Aetiology was identified in 26 patients (76.5%): causes were cerebral amyloid angiopathy in 8, ischaemic stroke in 5, vasculitis in 4, reversible posterior encephalopathy in 2, venous thrombosis in 2, reversible cerebral vasoconstriction syndrome in 2, carotid occlusion in 1, Marfan syndrome in 1, and meningeal carcinomatosis in 1. Three patients died during follow-up (2 due to causes related to the cause of cSAH). Three patients developed dementia, 3 had lobar haemorrhages, and one had a second cSAH.

CONCLUSIONS

The most frequent causes of cSAH in our series were cerebral amyloid angiopathy, ischaemic stroke, and vasculitis. This type of haemorrhage has a worse prognosis than other non-aneurysmal cSAH. There are numerous possible causes, and prognosis depends on the aetiology. In elderly patients, intracranial haemorrhage is frequently associated with cognitive impairment.

Effects of achievement contexts on the meaning structure of emotion words

Little is known about the impact of context on the meaning of emotion words. In the present study, we used a semantic profiling instrument (GRID) to investigate features representing five emotion components (appraisal, bodily reaction, expression, action tendencies, and feeling) of 11 emotion words in situational contexts involving success or failure. We compared these to the data from an earlier study in which participants evaluated the typicality of features out of context. Profile analyses identified features for which typicality changed as a function of context for all emotion words, except contentment, with appraisal features being most frequently affected. Those context effects occurred for both hypothesised basic and non-basic emotion words. Moreover, both data sets revealed a four-dimensional structure. The four dimensions were largely similar (valence, power, arousal, and novelty). The results suggest that context may not change the underlying dimensionality but affects facets of the meaning of emotion words.

Mapping Emotion Terms into Affective Space

Abstract. Recent empirical work on the semantics of emotion terms across many different cultures and languages, using a theoretical componential approach, suggested that four dimensions are needed to parsimoniously describe the semantic space of the emotion domain as reflected in emotion terms ( Fontaine, Scherer, Roesch, & Ellsworth, 2007 ; Fontaine, Scherer, & Soriano, 2013 ). In addition to valence, power, and arousal, a novelty dimension was discovered that mostly differentiated surprise from other emotions. Here, we further explore the existence and nature of the fourth dimension in semantic emotion space using a much larger and much more representative set of emotion terms. A group of 156 participants each rated 10 out of a set of 80 French emotion terms with respect to semantic meaning. The meaning of an emotion term was evaluated with respect to 68 emotion features representing the appraisal, action tendency, bodily reaction, expression, and feeling components of the emotion process. A principal component analysis confirmed the four-dimensional valence, power, arousal, and novelty structure. Moreover, this larger and much more representative set of emotion terms revealed that the novelty dimension not only differentiates surprise terms from other emotion terms, but also identifies substantial variation within the fear and joy emotion families.

Synthetic single and double aza-scorpiand macrocycles acting as inhibitors of the antioxidant enzymes iron superoxide dismutase and trypanothione reductase in Trypanosoma cruzi with promising results in a murine model

Synthetic scorpiand-like azamacrocycles selectively inhibit SOD and TR enzymes of Trypanosoma cruzi in mice causing death of the parasites and increasing the mouse survival rate after infection and treatment.

A comparison of sevoflurane, target-controlled infusion propofol, and propofol/isoflurane anesthesia in patients undergoing carotid surgery: a quality of anesthesia and recovery profile

In a prospective randomized study in patients undergoing carotid endarterectomy, we compared the hemodynamic effects, the quality of induction, and the quality of recovery from a hypnotic drug for the induction of anesthesia with sevoflurane, a target-controlled infusion (TCI) of propofol, or propofol 1.5 microg/kg followed by isoflurane. All patients were premedicated with midazolam and received sufentanil 0.4 microg/kg at induction. The induction of anesthesia was associated with a decrease in arterial blood pressure in all groups, but this was least pronounced in the Sevoflurane group. There were similar a number of episodes of hypotension, hypertension, and tachycardia among groups, but the incidence of bradycardia was less in the TCI group (P < 0.05) compared with the other groups. The duration of episodes of hypotension was shorter (P < 0.05) in the TCI Propofol group (1.9 +/- 2.3 min) compared with the Sevoflurane group (4.7 +/- 3.6 min). The duration of episodes of bradycardia was significantly lower (P < 0.05) in the TCI Propofol group (0.1 +/- 0.5 min) in comparison with the Propofol Bolus group (2.5 +/- 3.9 min). Similar doses of vasoactive drugs were used in all groups. The induction of anesthesia with sevoflurane was associated with inferior conditions for intubation in comparison with both Propofol groups, although the time to intubation was faster in the Sevoflurane group (P < 0.05). The recovery characteristics were similar in the three groups.

Automated sample preparation and gas chromatographic-mass spectrometric analysis of urinary androgenic anabolic steroids

This paper presents an automated method for extracting anabolic agents from urine samples for their GC-MS analysis by selected-ion monitoring. The sample preparation was carried out in a Hewlett-Packard 7686 SPE PrepStation system. Each 0.6-ml aliquot was hydrolyzed, extracted, dried and trimethylsilyl (TMS) derivatized in a 2-ml vial without any hands-on labor. When sample preparation was finished 2 microl of the extract was injected into the gas chromatograph by split (1:10) mode. Due to the small amount of free space in the 2-ml vials for handling the sample, parameters like time of hydrolysis, type of shaking, number of extractions and some TMS derivatization parameters had to be adjusted to achieve the best recovery for all of the compounds in the screening. Manual and automated sample preparation schemes were compared in terms of linearity, precision, accuracy, limit of detection and recovery data. When large concentrations were analyzed using the automated method no carry-over effect was observed.

Leucodystrophy and oculocutaneous albinism in a child with an 11q14 deletion

We report a patient with an undetermined leucodystrophy associated with type 1A oculocutaneous albinism (OCA). Type 1 OCA results from recessive mutations in the tyrosinase gene (TYR) located in 11q14.3. The patient was found by FISH to carry a deletion of at least the first exon of the TYR gene on one chromosome and a (TG) deletion at codon 244/245 on the second chromosome. The existence of the microdeletion suggested that a gene responsible for leucodystrophy was located in the vicinity of the TYR gene. A combination of a test of hemizygosity and contig mapping studies allowed us to map the gene within a 0.6 cM region flanked by microsatellite markers D11S1780 and D11S931.

Emission of greenhouse gases from anaerobic digestion processes: comparison with other municipal solid waste treatments

This contribution analyzes the anaerobic digestion process and compares GHG emissions estimated for four different management processes for MSW (Municipal Solid Waste): biogasification, landfilling, composting and incineration. The comparison has been undertaken by considering in the estimation of the emissions the full cycle of MSW treatment, and not only the emissions derived from the fraction of MSW treated by each particular system. For instance, the fraction of MSW not submitted to biological treatment has to be incinerated or deposited in a landfill. The corresponding emissions of these processes have to be considered in the calculations of the final emissions.

Effects of low-dose and high-dose glucagon on glucose production and gluconeogenesis in humans

The analysis of mass isotopomers in blood glucose and lactate can be used to estimate gluconeogenesis (Gneo), glucose production (GP), and, by subtraction, nongluconeogenic glucose release by the liver. At 6 AM, 18 normal subjects received a 7-hour primed constant infusion of [U-13C6] glucose. After a 3-hour baseline period (12 hours of fasting), somatostatin, insulin, hydrocortisone, growth hormone (GH), and glucagon were infused for 4 hours. Glucagon was infused at a low-dose (n = 6) or high-dose (n = 6) concentration for 4 hours and was compared with fasting alone (n = 6). Low-dose glucagon infusion increased plasma glucagon (64 +/- 3 v 44 +/- 7 ng/L, low glucagon v baseline). GP increased above baseline (15.5 +/- 0.5 v 13.8 +/- 0.5 micromol/kg/min, P < .05), which was also greater than fasting alone (11 .5 +/- 0.6 micromol/kg/min, P < .05). The elevation in GP was due to a near doubling of nongluconeogenic glucose release compared with fasting alone (8.3 +/- 0.6 v 4.7 +/- 0.5 micromol/kg/min, P < .01). High-dose glucagon infusion (125 +/- 25 ng/L) increased GP above baseline (15.8 +/- 0.6 v 13.5 +/- 0.5 micromol/kg/min, P < .05), which was also greater than fasting alone (11.5 +/- 0.6 micromol/kg/min, P < .05). The increase in GP was due to an increase in Gneo (8.5 +/- 0.5 v 6.8 +/- 0.7 micromol/kg/min, P < .05) and nongluconeogenic glucose release (7.4 +/- 0.5 v 4.7 +/- 0.4 micromol/kg/min, P < .05) compared with fasting. Low-dose glucagon increases GP only by stimulation of nongluconeogenic glucose release. High-dose glucagon increases GP by an increase in both Gneo and nongluconeogenic glucose release.

[Rotavirus infection associated with adult thrombotic microangiopathy]

BACKGROUND

A preceding viral syndrome is classically cited as a triggering factor for thrombotic microangiopathy although only anecdotal reports of the causal agent have been documented.

CASE REPORT

An 84-year-old woman developed thrombotic microangiopathy secondary to diarrhea. An exhaustive etiological work-up documented the presence of Rotavirus alone in the fecal matter. The clinical course was favorable after 9 plasma exchanges using frozen fresh plasma and was associated with disappearance of the Rotavirus.

DISCUSSION

Enterohemorrhagic Escherichia coli is the most commonly identified infectious agent causing thrombotic microangiopathy. A small number of cases caused by viral agents (particularly retroviruses) have also been documented. To our knowledge, this is the first case attributable to a Rotavirus. In our case, the presence of the Rotavirus in the fecal matter and the favorable clinical course when the virus disappeared would be in favor of its causal role in the pathogenesis of thrombotic micorangiopathy.

Lidar inversion of atmospheric backscatter and extinction-to-backscatter ratios by use of a Kalman filter

A first inversion of the backscatter profile and extinction-to-backscatter ratio from pulsed elastic-backscatter lidar returns is treated by means of an extended Kalman filter (EKF). The EKF approach enables one to overcome the intrinsic limitations of standard straightforward nonmemory procedures such as the slope method, exponential curve fitting, and the backward inversion algorithm. Whereas those procedures are inherently not adaptable because independent inversions are performed for each return signal and neither the statistics of the signals nor a priori uncertainties (e.g., boundary calibrations) are taken into account, in the case of the Kalman filter the filter updates itself because it is weighted by the imbalance between the a priori estimates of the optical parameters (i.e., past inversions) and the new estimates based on a minimum-variance criterion, as long as there are different lidar returns. Calibration errors and initialization uncertainties can be assimilated also. The study begins with the formulation of the inversion problem and an appropriate atmospheric stochastic model. Based on extensive simulation and realistic conditions, it is shown that the EKF approach enables one to retrieve the optical parameters as time-range-dependent functions and hence to track the atmospheric evolution; the performance of this approach is limited only by the quality and availability of the a priori information and the accuracy of the atmospheric model used. The study ends with an encouraging practical inversion of a live scene measured at the Nd:YAG elastic-backscatter lidar station at our premises at the Polytechnic University of Catalonia, Barcelona.

[A possibility of central diffusion during stellate ganglion blockade: "the sheath of the spinal rachidian nerve"]

Stellate ganglion block is a common treatment for neuropathic pain. The technique is not without potentially severe complications when a paratracheal approach is used. A 33-year-old woman complained of atypical facial pain of 15 years' duration with pain intensity of 6 to 8 on a visual analog scale and no pain-free periods upon use of inadequate analgesia. One minute after performing a second stellate ganglion block the patient showed signs of apnea and paralysis of the upper extremities and face, with no involvement of oculomotor muscles or the lower extremities, and no loss of consciousness. Assisted ventilation was started. Signs and symptoms resolved fully after 15 minutes. A few days later, the patient reported having perceived paresthesia in the affected zone during the procedure. Central spread of a portion of local anesthetic by way of the spinal nerve sheath toward the subarachnoid space may cause partial cervical and basal nuclear blockade. Signs would be apnea, involvement of the upper extremities and facial muscles, although paresthesia during the injection is the only evidence supporting this hypothesis. Bone contact and negative aspiration while performing a stellate ganglion block do not guarantee avoidance of complications.

[Intestinal complications of thrombotic microangiopathy in the adult. 4 cases and review of the literature]

We report four cases of adult thrombotic microangiopathy associating diarrhea with severe ischemic colitis. In one case, the intestinal complications was severe and diffuse ischemic colitis, in two cases an inaugural colonic perforation requiring colectomy and in the last case a massive mesenteric infarct. In three cases, histologic examination showed vessel occlusion with microthrombi. Despite treatment with plasma exchange and plasma infusion, death ensued in two cases. Principally described in childhood thrombotic microangiopathy, intestinal complications occur exceptionally in adult thrombotic microangiopathy and are associated with a poor prognosis. Inaugural ischemic colitis revealing an adult thrombotic microangiopathy is also uncommon and thrombotic microangiopathy could be evoked in all patients presenting acute ischemic colitis.

Use of ion trap gas chromatography-tandem mass spectrometry for detection and confirmation of anabolic substances at trace levels in doping analysis

A procedure for detecting and confirming 23 anabolic substances and/or metabolites has been developed using a GC-MS-MS ion trap system in full-scan mode. The process used to select the precursor ion, and the optimization of the system parameters used to obtain the daughter ion spectra, are explained. Urine samples were prepared using solid-phase extraction and enzymatic hydrolysis, and after TMS derivatives had been formed, they were injected into the mass spectrometer. This method permits confirmation of the presence of anabolic substances at low ng ml(-1) levels without the need of further purification procedures on the samples. This procedure has been used on more than 2000 urine samples collected from sporting competitions and has made it possible to confirm more than 45 true positive cases which could not have been confirmed using routine GC-MS methods.

Automated analysis of drugs in urine

A totally automated procedure has been developed for the preparation and analysis of 34 basic and neutral drugs in urine samples using an integrated HP 7686 PrepStation-HP 6890 gas chromatographic system. The automated preparation of the sample consisted of a liquid-liquid extraction of 250 microliters urine at alkaline pH with 100 microliters of methyl tert.-butyl ether. After phase separation the organic solvent was automatically placed in the injector of the gas chromatograph and analysed. High recoveries of extraction were obtained. The limits of detection of most of the drugs were less than 0.5 microgram/ml. The method, which allows the preparation and analysis of the samples to be completely synchronised, showed good accuracy and precision.

[Paramedian thalamo-mesencephalic infarct con triphasic waves]

Triphasic waves are usually associated with metabolic encephalopathies but have been reported in patients with other etiologies. The pathophysiology of this EEG pattern remains poorly understood, although they have been attributed to lesion in the connections between the thalamus and cortex. We report a case of top-of-the-basilar artery occlusion with selective paramedian thalamic-mesencephalic infarct in which triphasic waves were evident on the EEG during clinical hypersomnia. To our knowledge this is the first reported case of triphasic waves with selective paramedian thalamomesencephalic infarct. We conclude that triphasic waves are a nonspecific manifestation of diencephalic dysfunction, probably of the paramedian thalamomesencephalic reticular system.

Methotrexate treatment in the management of giant cell arteritis

Eleven newly-diagnosed GCA patients were included in a prospective open study and treated with high initial prednisone doses, a quick-tapering CS schedule and weekly oral MTX for two years. It took a mean of 14 weeks to reach a 10 mg/day dose of prednisone and 29.8 weeks until steroid withdrawal. The mean cumulative dose of prednisone was 3.4 g. Two patients relapsed and five developed CS side effects. No serious MTX side effects were observed. Our results suggest that MTX is safe and could be useful in the therapy of GCA.

[Surgical wound infection: the risk factors and a predictive model]

BACKGROUND

The identification of the factors associated with infection of the surgical wound and the groups of patients with greatest risk of developing the same may aid in the elaboration of prevention strategies.

METHODS

A prospective follow up study of a group of 1,143 patients admitted to general and digestive surgical departments in the Ramón y Cajal Hospital over a period of 7 months was carried out to determine the accumulated incidence of infection of the surgical wound and quantify the associated risk factors. A mathematical model was developed by logistic multiple regression analysis allowing the identification of groups of patients with high risk of infection which were internally evaluated posteriorly.

RESULTS

Surgically intervened patients (70% of those admitted) developed a mean of 11 wound infections out of 100 patients. Five independent factors (age, surgical classification, length of intervention, presurgical stay, and presence of a central route) were associated to increased risk of infection.

CONCLUSIONS

The factors associated with surgical wound infection identified in this study are related to the degree of wound contamination, the intrinsic risk of the patients and quality of health care. The model obtained is more efficient than the traditional surgical classification for the identification of groups of patients with high risk of infection.

Undetected apnea and bradycardia in infants

Despite routine monitoring, a number of prolonged apneic and bradycardic episodes were undetected in a group of infants in the neonatal intensive care unit (NICU). Sixty-one infants were evaluated by 12-hour pneumocardiograms at a post-conceptional age of 35 +/- 3 (SD) weeks. Nursing documentation failed to detect 11 infants with prolonged apnea and bradycardia. Three of these infants were not detected in spite of increased awareness following in-service education. Such a lack of documentation may lead to improper medical management of infants at risk for pathologic apnea and suggests the need for more accurate documentation at the time of discharge.