Successful exchange transfusion in extremely preterm infant after symptomatic lipid overdose

BACKGROUND

Complications of intravenous lipid administration are relatively uncommon. However, inadvertent rapid infusion of intravenous fat emulsion (IVFE) is an inherent risk when fats are infused separately from the dextrose-amino acid solution.

CASE REPORT

Extremely preterm infant, born at 25 weeks and 6 days of gestational age weighing 920 g, who inadvertently received a massive overdose of IVFE due to a device failure. He developed lethargy, apnea, metabolic acidosis and hemodynamic instability requiring mechanical ventilation and inotropic support. Despite discontinuation of IVFE and supportive care, clinical course and metabolic acidosis worsened, so a double-volume exchange transfusion was performed. The procedure was well tolerated, without complications. Serum triglyceride concentration as well as other laboratory data normalized immediately after the exchange transfusion. The patient was extubated to continuous positive airway pressure and inotropic support was discontinued 24 hours after the procedure. He was discharged home at 40 weeks of corrected age with normal magnetic resonance imaging and neurological examination.

CONCLUSION

In cases of profound, symptomatic hypertriglyceridemia due to lipid overdose, double-volume exchange transfusion should be considered, even in extremely preterm infants.

[Recurrent parathyroid cyst: a clinical case]

The parathyroid cyst is a very infrequent entity, so much so that only round about 200 cases have been described up to now. It can be functional and non-functional. The studies of image don't clarify to us if procedence becomes of parathyroid or it has another origin, and the diagnosis is made with the analysis come from the liquid obtained in the puncture aspiration, where high PTH's concentrations are seen. Surgery is the treatment for functional cysts and the puncture aspiration for non- functional, the fact that they use to get solved with only one but sometimes is necessary to repeated it, even more than one time, keeping for the surgery when recurrent. We presented a clinical case of recurrent parathyroid cyst and his natural evolution, due to patient rejects surgery, being necessary repeated punctures. It hasn't become malignant after 10 years and his functional status wasn't changed, being necessary to accomplish repeated punctures aspirations each 2-3 months for local bothers.

Involvement of adenovirus in clinical mononucleosis-like syndromes in young children

Although Epstein-Barr virus (EBV) commonly causes infectious mononucleosis (IM) or IM-like syndromes, other agents can be implicated. In this study, viral and parasitic screening was performed to determine the etiological agent of pediatric IM-like syndromes in 38 children. Adenovirus was the agent most frequently detected (47.3%), followed by EBV (31.5%) and cytomegalovirus (2.6%). Although the statistically significant difference between viral detection rates observed in patients who fulfilled clinical and hematological criteria and detection rates in those who presented clinical symptoms only (91.6% vs. 64.3%) indicates that hematological abnormalities are common in viral IM-like syndromes, the existence of syndromes of viral etiology without hematological criteria cannot be discarded. A further analysis showed an absence of lymphocytosis in adenovirus infections as well as a low number (14.3%) of EBV infections associated with increased neutrophils. These data suggest the usefulness of appropriate virological techniques for the detection of adenovirus in pediatric IM-like syndromes.

Hobnail haemangioma associated with the menstrual cycle

We report the third case in the literature of a hobnail haemangioma with cyclic changes throughout the menstrual cycle in a 36-year-old woman, suggesting a hormonal basis for the variations in the tumour. This patient was under oral contraceptive treatment due to ovarian endometriosis, making the clinical diagnosis difficult.

[Low grade collecting duct carcinoma of the kidney. Presentation of one case and literature revision]

Collecting duct renal cell carcinoma is an uncommon variant of renal carcinoma. Typically its behaviour is more aggressive than other forms of renal carcinoma and usually it is diagnosed at advanced stages. A 57-year-old man visited our hospital by right lumbar pain. Abdominal CT showed a enhanced mass on the right kidney. A right partial nephrectomy was done. Histological examination of the surgical specimen showed a low grade collecting duct carcinoma of the kidney. This is a new entity, with unknown behaviour but seems to be less aggressive than classical collecting duct carcinoma of the kidney. The clinical, radiological, pathological and immunohistochemical characteristics of this tumor are reported, and the literature is reviewed.

Influence of highly active anti-retroviral therapy (HAART) on the natural history of extra-pulmonary tuberculosis in HIV patients

OBJECTIVE

To determine factors related to survival in acquired immune-deficiency syndrome (AIDS) patients with extra-pulmonary tuberculosis (EPTB), when this condition is the first AIDS-defining disease.

DESIGN

A retrospective cohort-study of 549 AIDS patients with EPTB as the first AIDS-defining disease. Potential candidates to predict survival were sex, human immunodeficiency virus (HIV) exposure, the coexistence of pulmonary and EPTB at diagnosis, tuberculin skin test, directly observed therapy for tuberculosis (DOT), and highly active anti-retroviral therapy (HAART). The Kaplan-Meier method and Cox regression models were used to assess factors associated with survival.

RESULTS

Estimated 3-year survival was 47.0% for those diagnosed before 1993, 72.6% for patients with first AIDS diagnosis during 1995-1996 and 84.6% for those diagnosed after 1996. A negative tuberculin test (hazard ratio [HR] = 1.6, 95% CI 1.1-2.3), not being on DOT (HR 2.2; 95% CI 1.3-3.7) and having pulmonary tuberculosis involvement also (HR 1.3; 95% CI 1.1-1.7) were independently associated with poorer survival. The survival of patients significantly improved after the introduction of HAART (HR 0.4; 95% CI 0.2-0.6).

CONCLUSION

The survival of HIV patients with EPTB as their first AIDS-defining disease has substantially improved during the last decade. A negative tuberculin skin test and not receiving DOT are associated with poorer survival among HIV-infected patients whose first AIDS-defining disease is EPTB.

[Pulmonary capillary hemangiomatosis: a rare cause of pulmonary hypertension]

Pulmonary capillary hemangiomatosis (PCH) is a rare cause of pulmonary hypertension characterized by capillary proliferation infiltrating the structures of the pulmonary parenchyma. Although veins are particularly involved, proliferation also affects bronchiolar, interstitial and other structures. We report a case of PCH in a 70-year-old man. Pulmonary artery hypertension was demonstrated by echocardiogram and angiography. Severe emphysema could be seen in a computed tomographic scan of the thorax, even though spirometric values indicated that airflow obstruction was mild. Dyspnea and respiratory insufficiency progressed with marked shunting until death. Tissue inspection at the autopsy revealed capillary proliferation in the alveolar walls with occasional oviform protrusions into air spaces or around small vessels and bronchioles. Endothelial cells in newly formed vessels were not atypical and mitosis was scarce; p53 expression was negative and Ki67 proliferation slight, indicating that PCH is not a neoplastic process as has sometimes been suggested.

The Suzuki coupling reaction in the stereocontrolled synthesis of 9-cis-retinoic acid and its ring-demethylated analogues

The thallium-accelerated Suzuki coupling reaction of tetraenyl iodide 19 and cyclohexenyl boronate 18 afforded ethyl 9-cis-retinoate (12) in high yield. Both coupling partners of the Suzuki reaction are better reacted immediately after generation from their precursors, tetraenylstannane 10 and cyclohexenyl iodide 13. The geometrically homogeneous tetraenylstannane 10, comprising the polyenic side chain of ethyl 9-cis-retinoate and its ring-demethylated analogues, was synthesized by a stereoselective Horner-Wadsworth-Emmons reaction. On the other hand, easily available cyclohexanones are ideal starting materials for preparation of the cyclohexenyl boronates required for the synthesis of the ring-modified 9-cis-retinoic acid analogues. For hindered cyclohexanones, hydrazones were converted to cyclohexenyl iodides. Iodine-lithium exchange and trapping with B(OMe)(3) then afforded the cyclohexenyl boronates. If the precursor cyclohexanone has secondary carbons, the alkenyllithium species was conveniently formed by elimination of the C,N-dilithiated intermediate obtained upon treating the trisylhydrazone with n-BuLi (Shapiro reaction). None of the above procedures allowed the generation of the more substituted organolithium from 2-methylcyclohexanone. However, the alternative Stille cross-coupling of 34 and 10 afforded 9-cis-1,1-bisdemethylretinoic acid 7. Both Suzuki and Stille coupling reactions took place under mild conditions, and the preservation of the retinoid side-chain geometry was therefore secured.

DNA bending by asymmetrically tethered cations: influence of tether flexibility

BACKGROUND

We have been studying the proposal that laterally asymmetric charge neutralization along the DNA double helix can induce collapse toward the neutralized surface. Results of previous experiments implied that such a phenomenon can occur, suggesting a role for local interphosphate repulsive forces in DNA shape and rigidity.

RESULTS

We now show that, whereas six ammonium ions tethered to one DNA face on flexible propyl chains can induce detectable DNA curvature, tethering of ammonium ions on rigid propynyl tethers does not induce DNA curvature. Molecular modeling indicates differing propensities for phosphate salt bridge formation between propyl- and propynyl-tethered ammonium ions.

CONCLUSIONS

Ammonium ion localization is suggested as a key factor in induced bending. Rigidification of the double helix by stacking of propyne groups cannot be excluded.

Torquoselectivity in the cationic cyclopentannelation of (2Z)-hexa-2,4,5-trienal acetals

Inter- and intramolecular trapping experiments and density functional theory ab initio calculations for model systems are consistent with the acid-catalyzed rearrangement of 2-[(1Z)-hexa-1,3,4-trienyl]dioxolanes 1 to tetrahydroalkylidenecyclopenta-1,4-dioxins 4; this involves the electrocyclic ring closure of substituted hydroxypentadienyl carbocations. The reaction, which may be considered a variant of the Nazarov cyclization, occurs much more readily than the standard Nazarov cyclization, proceeding rapidly even at -30 degrees C. B3LYP/6-31G**//HF/6-31G** calculations for models 36, 38 and 40 predict that the two alternative conrotations at the cyclization termini are associated with activation energies differing by 0.55, 0.56 and 1.60 kcalmol(-1), respectively, in favour of the R-outwards rotation. This last value corresponds to an E-41/Z-41 product ratio of >99:1 at -60 degrees C, in consonance with the experimental observation that divinylallene 1a rearranges exclusively to E-4a at temperatures below -30 degrees C. At higher temperatures the torquoselectivity of the reaction 1a-->4a is masked by subsequent isomerization to the Z isomer, the greater stability of which is attributable to steric interaction between the substituent at the exocyclic double bond and the bulky neighbouring tBu group in the E isomer.

[Quality in compliance and prescription of nursing treatment orders for injectable drugs]

OBJECTIVES

To analyse the quality of prescription and compliance with nursing treatment orders (NTOs) in primary care teams (PCTs), in order to identify potential problems and establish interventions.

DESIGN

Observational, crossover study.

SETTING

Three health districts in Santa Coloma de Gramenet.

PATIENTS AND OTHER PARTICIPANTS

NTO forms for injectable medication referred to nursing from PCTs between March 1 and November 30, 1996.

MEASUREMENTS AND MAIN RESULTS

1,088 NTO sheets containing 1,119 prescriptions were evaluated. 64.61% of the NTOs came from PCTs. Compliance with the NTO on the length of treatment (63.33%), on length and guidelines taken together (58.00%) and on allergies to medicine (28.31%) was deficient. The most prescribed therapeutic groups were medicines for the locomotive apparatus (36.10%) and drugs for infections (24.66%). 56.03% of prescriptions had high intrinsic value. It was difficult to justify 72.48% of prescriptions.

CONCLUSIONS

Deficiencies were detected in compliance with NTOs, due to the absence of information which was vital for correct administration. There was low-quality prescription and over-use of parenteral administration.

[Epidemiologic situation of tuberculosis under the influence of HIV in the health area of Ibiza and Formentera (1987-1993)]

OBJECTIVES

To analyse the epidemiology of Tuberculosis and determine the characteristics of patients infected by HIV vs those not infected.

DESIGN

A descriptive-retrospective study.

SETTING

Ibiza and Formentera Health Area.

PATIENTS

268 patients over 16 diagnosed with TB between 7/1/1987 and 12/31/1993.

MEASUREMENTS AND MAIN RESULTS

The highest accumulated annual incidence was detected in 1989 (82.4/100,000 inhabitants), but had decreased considerably by 1993 (42.8/100,000). The proportion of HIV+ cases increased to 37.0% of the total in 1993. 75% of the total were male and 57.5% between 20 and 39 (x = 38.1; SD = 15.4). 63.1% had pulmonary TB, 60.8% producing bacilli, 19.8% were HIV+, of which 47.2% were intravenous drug users and 20.8% homosexuals. There was a 75.4% cure rate, 4.9% who left treatment and 16.1% lost during follow-up.

CONCLUSIONS

During the study period a progressive increase in the proportion of cases with HIV infection was observed. Control and follow-up of Tuberculosis was more difficult in these patients.

The evolution of tuberculosis infection among schoolchildren in Barcelona and the HIV epidemic

SETTING

First grade students in primary schools in the city of Barcelona, Spain.

OBJECTIVE

To estimate the prevalence of tuberculin reaction and sources of infection; to analyse trends in comparison with previous data.

DESIGN

Tuberculin screening of first grade schoolchildren (1985 birth cohort) was undertaken in 1991-92 using 2 TU of PPD RT23.

RESULTS

The prevalence of reactors among the 12,007 children tested from the 1985 cohort was 0.87%, varying among districts between 0.13% and 3.03%. Follow-up of positive tests was completed for 75 children, which led to the identification of 6 cases of previously unknown clinical tuberculosis among these children, while for 14 infected children index cases were found, one of whom was a confirmed HIV-infected IVDU.

CONCLUSION

The comparison of results with data from previous studies suggests that tuberculosis infection among schoolchildren in Barcelona may not be declining as in previous years, especially in areas such as the inner city, where poverty combines with HIV infection and with increasing migration from countries with a higher tuberculosis prevalence.

[Epidemiology of AIDS in Barcelona (1981-1991) (II). A study of mortality and survival]

BACKGROUND

To analyze the evolution of the mortality and survival of AIDS patients in Barcelona.

METHODS

In the mortality study patients living in the city and who were detected from 1981-1991 by an active surveillance system were included. The survival analysis was restricted to patients from 1988-1990 (same definition of AIDS and longer patient follow up). The Kaplan-Meier and Cox methods were used.

RESULTS

In 1991 the rate of mortality was 14.1/100,000, similar to 1990 (14.0/100,000) and greater or much higher than the preceding years. Lethality increased in agreement with the semester of case diagnosis, with values between 100% (first years of the epidemic) and 23% (last semester) being registered. The accumulated probability of survival at 365 days was of 65.2% (CI 95%, 62.2-68.0) and 32.2% (CI 28.8-35.7) at 1.095 days. Median survival of the whole population was 669 days. Statistically significant differences were observed according to the year of diagnosis, prison history, antiretroviral treatment, disease diagnosis, transmission group, district of residence and age group but not according to sex. Multivariate analysis only discarded the influence of prison history.

CONCLUSIONS

Mortality by AIDS has enormously increased. Survival analysis demonstrated better prognosis in the youngest cases, those residing in more favorable socioeconomic districts, diagnoses from diseases added to the old definition of AIDS, the IVDA and homosexual risk groups and the most recently diagnosed cases.

[The epidemiology of the acquired immunodeficiency syndrome in Barcelona (1981-1991) (I). A descriptive study and time trends]

BACKGROUND

To analyze the epidemiologic situation of AIDS in Barcelona with a descriptive study and a temporal trends analysis.

METHODS

Patients detected between 1981 and 1991 were included through a system of active surveillance. Relative risks (RR), odds ratios (OR) with 95% confidence intervals and Student's t-test were calculated. The monthly time distribution of cases was analyzed by different adjustments.

RESULTS

2,321 cases were detected, 70.8% of whom were Barcelona residents. The cumulative incidence rate was 94.7/100,000, and the annual rate for 1991 was 23.4/100,000. The active surveillance system detected 35.0% of cases in 1991. Males showed a higher rate than females (RR = 5.9; CI: 5.2-6.6). Cumulative rates varied between 63.1/100,000 and 263.8/100,000 according to district of residence. 50.9% were intravenous drug users (IVDU) and 33.2% homosexuals, with 15% of the women being attributed to heterosexual transmission. Cases among IVDU were younger than among homosexual cases (p < 0.001). The predominant indicator diseases were Pneumocystis carinii pneumonia (20.6%) and extrapulmonary tuberculosis (19.4%). 41.2% of the cases had a previous history of tuberculosis, a disease more common among IVDU than homosexuals (OR = 4.3; CI: 3.4-5.6). The same occurred among those with a prison record (OR = 46.6; CI: 23.8-103.8). With regard to temporal trends, IVDU showed a greater tendency to increase than homosexuals, but heterosexuals showed a greater percentage increase than both.

CONCLUSIONS

Active epidemiologic surveillance allowed more exhaustive and precise knowledge of AIDS epidemiology. Important differences were seen in incidence and in risk groups according to city districts. The heterosexual route is that which has undergone the greatest increase in the last few months.