Thrombocytopenia in the Course of COVID-19 Infection

We report three cases of severe thrombocytopenia during COVID-19 infection associated with either cutaneous purpura or mucosal bleeding. The initial investigations ruled out other causes of thrombocytopenia. Two of the patients were treated with intravenous immunoglobulins and eltrombopag, while the third recovered spontaneously. A good clinical and biological response was achieved in all patients leading to hospital discharge.

History and Outcome of Febrile Neutropenia Outside the Oncology Setting: A Retrospective Study of 76 Cases Related to Non-Chemotherapy Drugs

BACKGROUND

Despite major advances in its prevention and treatment, febrile neutropenia remains a most concerning complication of cancer chemotherapy. Outside the oncology setting, however, only few data are currently available on febrile neutropenia related to non-chemotherapy drugs. We report here data on 76 patients with febrile neutropenia related to non-chemotherapy drugs, followed up in a referral center within a university hospital.

PATIENTS AND METHODS

Data from 76 patients with idiosyncratic drug-induced febrile neutropenia were retrospectively reviewed. All cases were extracted from a cohort study on agranulocytosis conducted at the Strasbourg University Hospital (Strasbourg, France).

RESULTS

Mean patient age was 52.2 years old (range: 18-93) and gender ratio (F/M) 1.6, with several comorbidities present in 86.8% of patients. The most common causative drugs were: antibiotics (37.4%), antithyroid drugs (17.2%), neuroleptic and anti-epileptic agents (13.1%), non-steroidal anti-inflammatory agents and analgesics (8%), and platelet aggregation inhibitors (8%). Main clinical presentations upon hospitalization included isolated fever (30%), sore throat, acute tonsillitis and sinusitis (18.4%), documented pneumonia (18.4%), septicemia (14.5%), and septic shock (6.6%). Mean neutrophil count at nadir was 0.13 × 10(9)/L (range: 0-0.48). While in hospital, 22 patients (28.9%) worsened clinically and required intensive care unit placement. All patients were promptly treated with broad-spectrum antibiotics, and 45 (59.2%) with hematopoietic growth factors. Mean duration of hematological recovery (neutrophil count ≥1.5 × 10(9)/L) was 7.5 days (range: 2-21), which was reduced to 0.7 days (range: 2-16) (p = 0.089) with hematopoietic growth factors. Outcome was favorable in 89.5% of patients, whereas eight died.

CONCLUSIONS

Like in oncology and myelosuppressive chemotherapy settings, idiosyncratic febrile neutropenia is typically serious, about 40% of patients exhibiting severe pneumonia, septicemia, and septic shock, with a mortality rate of 10%. Like in febrile, chemotherapy-related neutropenia, modern and timely management (immediate broad spectrum antibiotherapy, hematopoietic growth factors) may reduce infection-related mortality. All practitioners should be aware of this potential side-effect that may even occur in the event of "daily medication" exposure.

Idiosyncratic drug-induced neutropenia & agranulocytosis

BACKGROUD

Few data is currently available on neutropenia and agranulocytosis related to drug intake. We report here data on 203 patients with established idiosyncratic drug-induced agranulocytosis, followed up in a referral centre within a university hospital.

PATIENTS AND METHODS

Data from 203 patients with idiosyncratic drug-induced agranulocytosis were retrospectively reviewed. All cases were extracted from a cohort study on agranulocytosis in the Strasbourg University Hospital (Strasbourg, France) RESULTS: : The mean age was 61.6 years old (range: 18-95), the gender ratio (F/M) was 1.3. Several comorbidities were present in 63.5%. The most frequent causative drugs were: antibiotics (49.3%), especially ß-lactams and cotrimoxazole; antithyroid drugs (16.7%); neuroleptic and anti-epileptic agents (11.8%); antiviral agents (7.9%); and platelet aggregation inhibitors as ticlopidine and acid acetylsalicylic (6.9%). The main primary clinical manifestations during hospitalization included: isolated fever (26.3%); septicaemia (13.9%); documented pneumonia (13.4%); sore throat and acute tonsillitis (9.3%); and septic shock (6.7%). The mean neutrophil count at nadir was 0.148 x 10⁹/L (range: 0-0.48). All febrile patients were treated with broad-spectrum antibiotics and 107 (52.7%) with hematopoietic growth factors. The mean duration of haematological recovery (neutrophil count ≥1.5 x 10⁹/L) was 7.8 (range: 2-20). This mean duration was reduced to 2.1 days (range: 2-16) (p = 0.057) with hematopoietic growth factors. Outcome was favourable in 91.6% of patients; seventeen died. Thirty-seven patients (18.2%) required intensive care.

CONCLUSIONS

The present study demonstrated that idiosyncratic drug-induced agranulocytosis is a relative rare events; that antibiotics, antithyroid, neuroleptic and anti-epileptic agents, and platelet aggregation inhibitors are the main incriminated drug classes; that agranulocytosis typically serious, with at least 50% exhibiting severe sepsis and a mortality rate <10%; and that modern management of such disorder may reduce the infection-related mortality.

Idiosyncratic Drug-Induced Severe Neutropenia and Agranulocytosis in Elderly Patients (≥75 years): A Monocentric Cohort Study of 61 Cases

BACKGROUND

Little data is currently available in the literature on neutropenia and agranulocytosis in the elderly, and, to our knowledge, idiosyncratic drug-induced agranulocytosis is particularly poorly covered, or not at all.

OBJECTIVE

We herein describe the clinical picture and outcome of patients aged ≥75 years with established idiosyncratic drug-induced agranulocytosis.

PATIENTS AND METHODS

Data from 61 patients over 75 years old with idiosyncratic drug-induced agranulocytosis were retrospectively reviewed. All cases were extracted from a cohort study on agranulocytosis (n = 203) in the Strasbourg University Hospitals (Strasbourg, France), a referral center.

RESULTS

The mean age was 84.9 years (range 75-95), the gender ratio (F/M) was 2.4. Underlying diseases were present in 74 %. The most frequent causative drugs were antibiotics (43.8 %), antithyroid drugs (15.8 %), neuroleptic and anti-epileptic agents (12.3 %), and antiaggregant platelet agents (10.5 %). The primary clinical features during hospitalization included isolated fever (27.6 %), septicemia or septic shock (24.1 %), and pneumonia (20.7 %). The mean neutrophil count at nadir was 0.15 × 109/L (range 0-0.4). All febrile patients were treated with broad-spectrum antibiotics and 36 with hematopoietic growth factors. Outcome was favorable in 85.3 % of patients; nine patients died. Two elderly patients (3.3 %) died of uncontrolled septic shock relating to the depth of the neutropenia. Comparison of mortality between <75- and ≥75-year-old patients revealed a statistical difference: 4.2 % versus 14.8 % (p = 0.023).

CONCLUSIONS

Our study demonstrates that 30 % of idiosyncratic drug-induced agranulocytosis concerned elderly patients. Antibiotic, antithyroid, neuroleptic, anti-epileptic, and antiaggregant platelet agents are the primary causative drug classes. Idiosyncratic drug-induced agranulocytosis is typically serious in this frail population of elderly patients, with at least 50 % suffering from severe sepsis and with a mortality rate of approximately 15 %. Modern management of agranulocytosis may reduce the infection-related mortality (3.3 %).

[Experimentation of an e-platform to detect situations at risk of cardiac impairment (platform E-care) in an internal medicine unit]

INTRODUCTION

Monitoring patients with heart failure by telemedicine systems is a potential means susceptible to optimize the management of these patients and avoid life-threatening emergencies. In this context, we experimented in internal medicine unit an e-platform E-care dedicated to automated, intelligent detection of situations at risk of heart failure.

METHODS

The E-care platform based on medical sensors (blood pressure, heart rate, O2, weight), communicating (Bluetooth), to go up, in real time, to an intelligent physiological information and an analysis of the ontology medical, leading ultimately to the generation of alerts. After a development phase (proof of concept), the E-care platform has been deployed and tested by health professionals and patients in an internal medicine unit with 20 beds, opened on emergencies to the Strasbourg University Hospitals.

RESULTS

One hundred and eighty patients were included and 1500 measurements were obtained. The patient profile included in this experiment was an elderly patient, with comorbidity in 90% of cases, with a loss of autonomy in 25%. Health professionals were using E-care platform every day to their great satisfaction. This experiment made it possible to validate the technology choices, to consolidate the system, and to test the robustness of the platform E-care. The collection continuously allowed us to have the critical number of patients for more detailed analysis of the relevance of alerts related to heart impairment. A preliminary analysis showed the relevance of the generated alerts.

CONCLUSION

Preliminary results following the deployment of E-care platform in hospitals appear to show the relevance of technological choices, tools and solutions developed and adopted. This telemedicine system allows automatic, non-intrusive, generate alerts related to the detection of situations at risk for heart failure. Ultimately, E-care was capable of preventing hospitalization. A home deployment is currently underway.

Peripheral neuropathy in Whipples disease: a case report

Whipples disease is a chronic multisystem inflammatory disease with predominantly gastrointestinal manifestations due to Tropheryma whipplei infection. Typical neurological abnormalities include dementia, eye movement abnormalities, hypothalamic dysfunction and oculomasticatory myorhythmias. The literature on peripheral neuropathy in Whipples disease is sparse and the involvement of peripheral nerves in Whipples disease has not been documented convincingly so far. We present a case of Whipples disease presenting by axonal peripheral neuropathy without gastrointestinal involvement. The diagnosis was confirmed by a sural nerve biopsy and consequent PCR of the sample. All clinical signs disappeared progressively during the antibiotic therapy. Two years after the T. whipplei infection, the patient developed dopa-sensitive Parkinson's disease, although these two events seem to be unrelated. This case illustrates the value of peripheral nerve biopsy in cases of axonal neuropathy of unexplained origin and extends the clinical spectrum of Whipples disease to a new modality.

P4-15-01: High Prevalence of Prospective Memory (PM) Impairment in Early Breast Cancer (EBC) Survivors within 1 Year of Adjuvant Chemotherapy Completion: Novel Findings Concerning Post Chemotherapy Cognitive Effects

Background Numerous studies have demonstrated that EBC survivors report more memory problems than healthy controls. However, evidence of impairment on objective tests of memory remains inconclusive. Past research has focussed exclusively on retrospective memory (remembering information from the past when asked to do so), but the complaints of EBC patients appear better described as “prospective memory” failures defined as forgetting to carry out in the future previously formed intentions. The effective performance of many day-to-day activities relies on PM and its impairment has negative consequences in everyday life. Despite its high ecological relevance, no study has evaluated PM functioning in EBC survivors. Consequently, we assessed the prevalence of PM impairment among EBC survivors in the year following completion of chemotherapy. Methods We undertook a cross sectional quantitative case-control study aiming to recruit 80 patients from the Ottawa Hospital Regional Cancer Centre and 80 matched healthy controls from the community. Patients were within 1 year of having completed a first course of chemotherapy. A standardized test of prospective memory (Memory for Intention Screening Test) was administered to both groups. Following the International Cognition and Cancer Task Force recommendation (2008), impairment was defined as a score that fell one standard deviation below the mean performance of the control group. Standardized measures of depression (CESD), anxiety (STAI) and fatigue (Fact-F) were also completed. Results Data are available on 36 patients and 18 controls. Age was well balanced between the groups (case-control mean age 54y vs. 51y, respectively, p=.204). Overall PM impairment was observed in 41% of the participants. More importantly, the rate of PM impairment was significantly higher in the EBC group than controls (53% vs 17%; p &lt; 0.005; odds ratio = 5.588; 95% CI=1.376 to 22.7). Multivariate logistic regression showed that PM performance was unaffected by age (p=0.459), depression (p=0.358), anxiety (p=0.512) or fatigue (p=0.595). Conclusions These preliminary findings provide further support for the hypothesis that breast cancer treatment can impair cognitive processes and yield new and important insights into the type of memory problems experienced by EBC survivors. They suggest that a significant proportion of patients exhibit deficits in PM, an aspect of memory involved in effective daily functioning. Our results also suggest that emotional distress and fatigue do not contribute to PM functioning. Further studies in this area should be directed at understanding the severity and duration of PM impairment. Acknowledging and studying this vexing problem in EBC survivors will aid in developing appropriate rehabilitation strategies.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-15-01.

Relationship between ALS and the degree of cognitive impairment, markers of neurodegeneration and predictors for poor outcome. A prospective study

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) is a common neurodegenerative disease affecting motor neurons and may be associated with impaired cognition. Reliable prognostic factors for ALS patients are still missing.

METHODS

We prospectively included 67 patients, 42 women and 25 men, with clinically defined ALS. The disease severity was assessed and the patients underwent SPECT, lumbar puncture with determination of tau, hyperphosporylated tau (p-tau) and beta-amyloid and a detailed neuropsychological assessment using a standardized test battery. In patients who died, a detailed neuropathologic evaluation was performed.

RESULTS

The mean survival duration was 26.8 months. The delay between the first signs and confirmation of the diagnosis was 12.75 months. Cognitive impairment did not have an impact on the evolution of the disease. There was no correlation between neuropsychological and SPECT findings. Higher age at onset, more pronounced handicap and elevated beta-amyloid in the CSF were associated with shorter survival times. In brain tissue from nine of the deceased patients with ALS and dementia, all showed signs of comorbidity, six had hallmarks of frontotemporal lobar degeneration (FTLD) and three showed Alzheimer disease pathology. Brain tissues form 11 deceased ALS patients who did not show signs of dementia, had only changes compatible with a diagnosis of motor neuron disease.

CONCLUSION

In our prospective study, age, disease severity and CSF beta-amyloid levels taken together were a risk factor suggesting shorter survival times. Dementia is relatively frequent in ALS and may be a consequence of either FTLD or result from co-existing Alzheimer disease.

[Recommendations for the treatment of tobacco dependence]

This first Czech version of guidelines formulated by the working group of mentioned medical associations is based on current literature and international guidelines. They are aimed mainly on clinical medicine and on incorporation of this treatment into the health care system according to WHO recommendations. They should serve to the treatment of tobacco dependence at any level: during any contact with the smoking patient (short intervention), in specialised centres or for the health care providers or health system itself.

Hearing loss as the first feature of late-onset axonal CMT disease due to a novel P0 mutation

A Czech family with three individuals carrying a novel mutation, 290 A-->T (Glu97Val), in the myelin protein zero gene (P0) is reported. The two eldest carriers developed progressive sensorineural hearing loss and abnormal pupillary reaction at age 18. These preceded the onset of the classic signs of Charcot-Marie-Tooth disease (CMT) by more than a decade. Sural nerve biopsy and nerve conduction studies were compatible with the axonal type of CMT. The authors show that progressive hearing loss can be the first symptom in P0 mutation carriers.

Electrodynamic interaction between two atoms in near-field contact

A theoretical study of elements of the quantum electrodynamic interaction between two single-electron atoms in near-field contact is presented. The framework of the study is an electromagnetic propagator formalism that allows one to describe the near-field space-time interaction in such a manner that the Einstein causality and lack of photon localizability are manifest. First we set up the atom-field Hamiltonian in the so-called G-gauge, starting from the Coulomb Hamiltonian, and thereafter we show that this leads to a correct propagator description for the retarded part of the transverse electromagnetic field (operator). In the G-gauge approach, renormalization of the two-particle energy level structure stemming from the transverse self-field occurs. The intraparticle renormalization is calculated for a three-level atom (it is trivial for a two-level atom), and the interparticle renormalization, which depends on the atomic separation, is determined for two two-level atoms. The magnitude of the energy renormalization is always finite in our theory because we do not consider the atoms to be point-like objects from an electromagnetic point of view. Throughout, we relate our G-gauge formalism to the multipole theory often used in studies of interatomic electrodynamics.

Near-field optics and quantum optics: an assignation arranged by four kinds of photons

In the process of emergence a photon emitted from an atom (or a molecule) is usually no better localized in space than to the near-field zone of the source. Near-field optics therefore is of central importance for understanding fundamental statistical aspects related to single-photon tunnelling, the space-time description of photon dynamics, and the photon position-operator problem. In the present work an attempt is made to study the microscopic near-field optical interaction from a quantum statistical point of view. In near-field quantum electrodynamics (QED) scalar and longitudinal photons always are involved and this makes the covariant formulation of QED attractive also in the low-energy regime. We show that the Lorenz gauge condition on the global state vector relates to the near-field electrodynamics of the d-photons. The gauge photon is shown to be of no importance in near-field interactions. To understand the role of the lack of photon localizability we finally study near-field quantum optical correlations in a new so-called propagator gauge.

On the quantum physical relation between photon tunnelling and near-field optics

The standard theory of optical tunnelling based on a mathematical analogy between the time-independent one-particle Schrödinger equation describing electron tunnelling and the Helmholtz equation for the macroscopic electric field is criticized. In a classical perspective photons are related to the dynamics of the transverse part of the electromagnetic field, and with the assumption that the electrons in a coupled photon-atom system are driven in a linear fashion by the field, a rigorous integro-differential equation for the transverse field is established. In the near-field zone of matter a transverse self-field exists and this may cause the appearance of superluminality in optical tunnelling. In the wake of a brief review of the space-time dynamics of free photons, a first-quantized description of the birth process of a single polychromatic photon in the near-field region of an active atom (molecule, mesoscopic particle) is presented, and afterwards the link between photon localizability, Einstein causality and near-field photon tunnelling is discussed. On the basis of a new one-photon quantum theory of near-field scattering from a microscopic (or mesoscopic) object, it is shown that photon tunnelling always appears in photon-atom scattering. A first-order Born approximation cannot capture the phenomenon, however. The emergence of the energy wave function of the scattered photon is followed in space and time.

Superluminal interactions in near-field optics

The fact that photons emitted from an electric-dipole active atom cannot be spatially localized better than to the near-field zone of the atom is seen as the origin of genuine superluminality. By means of a simple model dipole current density the general theory is used to demonstrate numerically how superluminality enters the near-field dynamics, and how from a measurement one could be tempted to believe that superluminal propagation effects occur. Furthermore, it is shown how for source-detector distances larger than a pulse length one should be able to divide the pulse into two separate parts: one purely superluminal part arising solely in the non-local generation process of the field, and another part seemingly propagating with superluminal speed. We comment on different velocity analyses, and we argue that the only fundamental velocity entering the problem is the vacuum velocity of light, which in a measurement would appear as the velocity of the trailing edge of the pulse.

[Diagnostic costs for ambulatory care patients]

Few analyses of the costs of diagnostic plans have been published. We have determined and analyzed the diagnostic costs of 1000 consecutively evaluated patients at the medical outpatient clinic. A data base was developed for this purpose. Based on the itemized tarif the total costs amounted to 622,553.25 SFR. Medical services (consultations) required 20 per cent of this sum, laboratory services and technical investigations 40 per cent each. The average number of consultations per patient was 2.83 +/- 1.85. As expected the first consultation was the most expensive. It amounted on the average to 350.-SFR, 54% of which were used for laboratory and 27% for technical procedures. Chest X-ray, ECG, abdominal ultrasound and upper gastrointestinal endoscopy caused about 20% of the total diagnostic costs. Cost reduction could probably be achieved by using more stringent indications for laboratory and technical services.

[Reduced visual capacity increases the risk of accidents in street traffic]

BACKGROUND

This study was carried out to investigate the relationship between the frequency of traffic accidents and impaired vision.

MATERIALS AND METHODS

Seven hundred and fifty-four drivers involved in accidents were recruited, in addition to 250 accident-free drivers similar in age and driving experience as an control group. The age distribution of the persons involved in traffic accidents (mean 56.3 years) was similar to that of the control group (mean 57.7 years), the difference was not statistically significant. Both groups underwent a complete ophthalmological examination.

RESULTS

All three types of accidents (night-time accidents, violations of right of way, accidents during an overtaking manoeuvre) had a statistically significantly higher incidence of reduced photopic visual acuity, mesopic vision and an increased sensitivity to glare. Some other visual functions were also abnormal, with differences according to the type of accident. In particular, there were noticeable differences between the control group and those who were involved in night-time accidents regarding mesopic vision and sensitivity to glare. Concerning mesopic vision, 15% of the 261 persons involved in night-time accidents did not reach the contrast limit of 1:5; with glare, 20.7% failed. In comparison 4% of the control group reached this critical limit without glare and 7.6% with glare. These differences are highly statistically significant. In contrast to these findings, many of the drivers involved in accidents assessed their own visual capability as "excellent".

CONCLUSIONS

The results of this study show that reduced mesopic vision and increased sensitivity to glare are accompanied by an increased risk of night-time accidents (for example, collisions with a non-illuminated obstacle). This emphasizes the importance of regular ophthalmological check-ups including visual functions such as mesopic vision and sensitivity to glare, which currently are not required by the traffic laws in Germany.

[Colorectal carcinoma. Which factors are decisive for development of postoperative complications?]

This retrospective study analyses the prognostic effect of different factors on morbidity and lethality based on selected, primarily resecting colon carcinoma operations (n = 222). In all, 12.2% of our operations were performed under emergency conditions. The total complication rate was 31.5%, the lethality rate 7.7%. The left hemicolectomy cases showed the highest morbidity (48.4%), the rectum amputation the highest lethality (11.8%). Tumour staging tumour differentiation and the sex of the patient showed no significant influence on the postoperative morbidity and lethality. However, a correlation was proved between the age of the patient, tumour localisation, co-morbidity, duration of operation and the conditions under which the operation was performed (emergency or elective), on the one hand, and morbidity and lethality on the other.

Correlation between optical and topographical images from an external reflection near-field microscope with shear force feedback

An external reflection scanning near-field optical microscope with shear force regulation of the tip-surface distance is described. Near-field optical and shear force topographical images are compared for various samples. It is shown that the most important correlative relationships between these images can be deduced from symmetry considerations. The possibility of extracting additional information from the optical images is demonstrated on images of human blood cells.

Recovery from rhabdomyolysis after allogeneic BMT: report of a case with speculation on causation

A case of fulminant rhabdomyolysis occurring 4 months after allogeneic BMT for CML is reported. The patient developed rhabdomyolysis following the empiric institution of antibacterial and anti-tuberculous medication. His inpatient course was complicated by the development of acute anuric renal failure and a severe myopathy. With aggressive supportive care, both of these complications resolved, making this patient the only reported survivor of rhabdomyolysis occurring after BMT.

Phase conjugation of an optical near field

Using degenerate four-wave mixing in an Fe:LiNbO(3) 0.04-wt. % crystal and an external-reflection near-field optical microscope, we have achieved phase conjugation of light emitted by a fiber tip. We observe that the phase-conjugated light at a wavelength of 633 nm can reach a power of ~0.1 nW and produce a 180-nm-wide spot image in the near-field microscope. This is the first direct demonstration, to our knowledge, of the phase conjugation of near-field components of optical fields.

External-reflection near-field optical microscope with cross-polarized detection

An external-reflection scanning near-field optical microscope with the detected light polarized perpendicular to the polarization of the light coupled into the fiber is presented. When various metallic gratings are scanned, it is shown that the lateral and the depth resolutions of this microscope are better than 100 and 10 nm, respectively.

Control of the tip-surface distance in near-field optical microscopy

An experimental technique that makes use of the intensity of the interference pattern formed by light that propagates directly from the single-mode fiber tip and light that is reflected by the surface under anoblique angle of incidence is developed to control the tip-surface distance in near-field opticalmicroscopy. It is shown that by using another fiber as a detector with a polished edge placed at the surface near the fiber tip one can determine the tip-surface separation with an accuracy better than 15 nm at distances less than 1 µm. The technique proposed is used to investigate the influence of the shape of the tip in near-field measurements.