Malignant Cerebral Ischemia in A COVID-19 Infected Patient: Case Review and Histopathological Findings.

Severe acute respiratory syndrome coronavirus (SARS-CoV-2) is responsible for an unprecedented worldwide pandemic that has severely impacted the United States. As the pandemic continues, a growing body of evidence suggests that infected patients may develop significant coagulopathy with resultant thromboembolic complications including deep vein thrombosis, pulmonary embolism, myocardial infarction, and ischemic stroke. However, this data is limited and comes from recent small case series and observational studies on stroke types, mechanisms, and outcomes.1-14 Furthermore, evidence on the role of therapeutic anticoagulation in SARS-CoV-2 infected patients with elevated inflammatory markers, such as D-dimer, is also limited. We report the case of a middle-aged patient who presented with a large vessel ischemic stroke likely resulting from an underlying inflammatory response in the setting of known novel coronavirus infection (COVID-19). Histopathologic analysis of the patient's ischemic brain tissue revealed hypoxic neurons, significant edema from the underlying ischemic insult, fibrin thrombi in small vessels, and fibroid necrosis of the vascular wall without any signs of vasculature inflammation. Brain biopsy was negative for the presence of SARS-CoV-2 RNA (RT-PCR assay). Along with a growing body of literature, our case suggests that cerebrovascular thromboembolic events in COVID-19 infection may be related to acquired hypercoagulability and coagulation cascade activation due to the release of inflammatory markers and cytokines, rather than virus-induced vasculitis. Further studies to investigate the mechanism of cerebrovascular thromboembolic events and their prevention is warranted.

Análisis de la calidad de los servicios académico-administrativos en una universidad colombiana / Analysis of the quality of academic-administrative services in a Colombian university / Análise da qualidade dos serviços académico-administrativos em uma universidade colombiana

Resumen Introducción. En este artículo se presentan los resultados finales de la investigación Análisis de la calidad de los servicios académico-administrativos en una universidad colombiana. Objetivo. Determinar la percepción de los estudiantes respecto a los servicios ofrecidos. Materiales y Métodos. Se utilizó el instrumento Servqualing aplicándose a una muestra de 832 estudiantes los cuales fueron seleccionados por el método sistemático. Se realizó Análisis de Factores. Resultados. El análisis arrojó tres dimensiones con 61,39 % de la varianza explicada, KMO=0,973 y un determinante de 0,01325. La confiabilidad del instrumento de medición usando Alpha de Cronbach fue de 0,949, indicando una alta fiabilidad de la escala y validez interna y externa obtenida con pruebas estadísticas significativas al 5 %. Conclusiones. Los resultados evidencian que el nivel de calidad global de los servicios académico administrativos, tienen una Buena, percepción con una calificación de 4,08 (80 %), indicando que los mejores resultados se encontraron en los ítems asociados con la dimensión 3 y con oportunidades de mejora principalmente en la dimensión 1. Estos resultados permiten orientaciones precisas para la toma de decisiones y conllevan al mejoramiento continuo de la calidad del servicio.

Abstract Introduction. This article shows the final results of the research "Analysis of the quality of academic-administrative services in a Colombian university". Objective. Determine the perception of students regarding the services offered. Materials and Methods. For the measurement, the Servqualing instrument was applied to a sample of 832 students who were selected by the systematic method. Results. A factor analysis was carried out which showed three dimensions with 61.39% of the variance explained, KMO = 0.973 and a determinant of 0.01325. The reliability of the measuring instrument using Cronbach's Alpha was 0.949, indicating a high reliability of the scale, and internal and external validity was obtained with significant statistical tests at 5%. Conclusions. The results show that the overall quality level of academic administrative services has a good perception with a score of4.08 (80%), indicating that the best results were found in the items associated with dimension 3 and with opportunities for improvement, mainly in dimension 1. These results allow precise guidelines for decision making and lead to continuous improvement of service quality.

Resumo Introdução. Neste artigo apresenta-se os resultados finais da pesquisa Análise da qualidade dos serviços académico-administrativos em uma universidade colombiana. Objetivo. Determinar a percepção dos estudantes respeito aos serviços oferecidos. Materiais e Métodos. Utilizou-se o instrumento Servqualing aplicando-se em uma amostra de 832 estudantes os quais foram selecionados pelo método sistemático. Realizou-se Análise de Fatores. Resultados. O análise mostrou três dimensões com 61,39 % da variância explicada, KMO=0,973 e um determinante de 0,01325. A confiabilidade do instrumento de medição usando Alpha de Cronbach foi de 0,949, indicando uma alta fiabilidade da escala e validez interna e externa obtida com provas estatísticas significativas ao 5 %. Conclusões. Os resultados evidenciam que o nível de qualidade global dos serviços académico-administrativos, tem uma Boa, percepção com uma qualificação de 4,08 (80%), indicando que os melhores resultados se encontraram nos itens associados com a dimensão 3 e com oportunidades de melhora principalmente na dimensão 1. Estes resultados permitem orientações precisas para a toma de decisões e acarreiam ao melhoramento contínuo da qualidade do serviço.

Possible role for vascular cell proliferation in cerebral vasospasm after subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: During vasospasm after subarachnoid hemorrhage (SAH), cerebral blood vessels show structural changes consistent with the actions of vascular mitogens. We measured platelet-derived vascular growth factors (PDGFs) in the cerebrospinal fluid (CSF) of patients after SAH and tested the effect of these factors on cerebral arteries in vivo and in vitro. METHODS: CSF was sampled from 14 patients after SAH, 6 patients not suffering SAH, and 8 normal controls. ELISA was performed for PDGF-AB, transforming growth factor-beta1, and vascular endothelial growth factor. A mouse model was used to compare cerebral vascular cell proliferation and PDGF staining in SAH compared with sham-operated controls. Normal human pial arteries were incubated for 7 days in vitro, 2 groups with human blood clot and 1 with and 1 without PDGF antibodies. RESULTS: PDGF-AB concentrations in CSF from SAH patients were significantly higher than those from non-SAH patients and normal controls, both during the first week after SAH and for all time points measured. Smooth muscle and fibroblast proliferation was observed after SAH in the mouse model, and this cellular replication was observed in conjunction with PDGF protein at the sites of thrombus. In human pial arteries, localized thrombus stimulated vessel wall proliferation, and proliferation was blocked by neutralizing antibodies directed against PDGFs. CONCLUSIONS: Vascular mitogens are increased in the CSF of patients after SAH. Proliferation of cells in the vascular wall is associated with perivascular thrombus. Cellular proliferation and subsequent vessel wall thickening may contribute to the syndrome of delayed cerebral vasospasm.

Simvastatin increases endothelial nitric oxide synthase and ameliorates cerebral vasospasm resulting from subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Endothelial nitric oxide synthase (eNOS) activity is decreased after subarachnoid hemorrhage (SAH). Simvastatin increases eNOS activity. We hypothesized that simvastatin would increase eNOS protein and ameliorate SAH-induced cerebral vasospasm. METHODS: Mice were treated with subcutaneous simvastatin or vehicle for 14 days and then subjected to endovascular perforation of the right anterior cerebral artery or sham surgery. Three days later, neurological deficits were scored (5 to 27; 27=normal), and middle cerebral artery diameter and eNOS protein were measured. The study was repeated, but simvastatin treatment was started after SAH or sham surgery. RESULTS: In SAH mice, simvastatin pretreatment increased middle cerebral artery diameter (SAH-simvastatin=74+/-22 micro m, SAH-vehicle=52+/-18 micro m, P=0.03; sham-simvastatin=102+/-8 micro m, sham-vehicle=105+/-6 micro m). Pretreatment reduced neurological deficits (SAH-simvastatin=25+/-2, SAH-vehicle=20+/-2, P=0.005; sham-simvastatin and sham-vehicle=27+/-0). Simvastatin pretreatment also increased eNOS protein. Simvastatin posttreatment caused a modest increase in middle cerebral artery diameter in SAH mice (SAH-simvastatin=56+/-12 micro m, SAH-vehicle=45+/-4 micro m, P=0.03; sham-simvastatin=92+/-13 micro m, sham-vehicle=99+/-10 micro m) and reduced neurological deficits (SAH-simvastatin=21+/-1, SAH-vehicle=19+/-2, P=0.009). Simvastatin posttreatment did not significantly increase eNOS protein. CONCLUSIONS: Simvastatin treatment before or after SAH attenuated cerebral vasospasm and neurological deficits in mice. The mechanism may be attributable in part to eNOS upregulation.

Attenuation of cerebral vasospasm after subarachnoid hemorrhage in mice overexpressing extracellular superoxide dismutase.

BACKGROUND AND PURPOSE: Subarachnoid hemorrhage (SAH) increases production of vascular extracellular superoxide anion (*O2-). We examined whether overexpression of murine extracellular superoxide dismutase (EC-SOD) alters SAH-induced cerebral vasospasm, oxidative stress, and neurological outcome. METHODS: Mice exhibiting a 2-fold increase in vascular EC-SOD and wild-type (WT) littermates were subjected to sham surgery or SAH by perforation of the right anterior cerebral artery. Neurological deficits were scored 72 hours later. Middle cerebral artery (MCA) diameter was measured or immunohistochemically stained for nitrotyrosine. RESULTS: MCA diameter (mean+/-SD) was greater in EC-SOD versus WT mice after SAH but not sham surgery (EC-SOD SAH=56+/-10 microm; WT SAH=38+/-13 microm [P<0.01]; EC-SOD sham=99+/-16 microm; WT sham=100+/-15 microm). SAH decreased median (range) neurological score (scoring scale, 9 to 39; no deficit=39) versus shams, but there was no difference between EC-SOD and WT groups (EC-SOD SAH=26 [23 to 30]; WT SAH=23 [19 to 29] [P=0.27]; EC-SOD sham=39 [39]; WT sham=39 [39]). Sensory-motor deficits correlated with MCA diameter (P<0.001) but worsened primarily between 60 and 50 micro m, plateauing below this threshold. The percentage of mice with MCA nitrotyrosine staining increased after SAH in WT (sham=29%; SAH=100% [P<0.05]) but not EC-SOD (sham=33%; SAH=44% [P=0.80]) mice. CONCLUSIONS: Endogenous overexpression of EC-SOD attenuated vasospasm and oxidative stress but failed to reduce neurological deficits after SAH. Extracellular *O2- likely plays a direct role in the etiology of vasospasm.

Mouse model of subarachnoid hemorrhage associated cerebral vasospasm: methodological analysis.

The transgenic mouse has been used to study subarachnoid hemorrhage (SAH) induced delayed cerebral vasospasm (DCV). Methodological parameters have not been analyzed to validate this model and associated neurological deficits have not been described. We introduce a technique to quantify DCV and associated neurological deficits. C57BL/6J mice were subjected to SAH or sham surgery. Seventy-two hours later, the vasculature was cast in situ with India ink/gelatin at perfusion pressures of 40-60, 60-80, or 100-120 mmHg. Mice were perfused with and without microfiltration. Additional mice underwent grading of SAH size, measurement of vascular diameters, and neurological examination (score range 5-27; 27= normal). When cast at 60-80 mmHg, SAH was associated with an intraluminal cross-sectional diameter reduction in 3 of 7 ipsilateral vascular segments. At 40-60 mmHg, the diameter of only one segment was reduced. No changes were observed at 100-120 mmHg. Emboli prevented adequate perfusion of vascular segments in the absence of microfiltration. Median (interquartile range) neurologic score was reduced after SAH (sham, 27(27); SAH 11(7-17)). Deficits correlated with middle cerebral artery (MCA) diameter and SAH grade. MCA diameter also correlated with SAH grade. Only when utilizing microfiltration, controlling for hemorrhage size, and casting at perfusion pressures of 60-80 mmHg does India ink/gelatin vascular casting demonstrate consistent DCV that correspnds to neurological deficits. This allows measurement of both anatomical and clinical DCV in the mouse.

Delirium asociado a hospitalizacion prolongada: en pacientes de medicina interna en la Clinica Universitaria Bolivariana / Delirium associated with prolonged hospitalization: in patients of internal medicine at the Clinica Universitaria Bolivariana

Objetivo: Determinar si el delirium se asocia a una mayor duración de la hospitalización y a mayor mortalidad en pacientes ingresados por medicina interna en la Clínica Universitaria Bolivariana. Métodos: durante un mes se entrevistó en dos ocasiones (al ingreso y durante las siguientes 12 horas) a los pacientes que se hospitalizaron por medicina interna con el fin de observar si tenían criterios DSMIV para delirium; además, se entrevistó a los acompañantes y adicionalmente se aplicó el Mini Examen Cognoscitivo. Se registró el diagnóstico de medicina interna, la duración de la hospitalización y la mortalidad. La información se introdujo en una base de datos de Excel2000 para Windows y el análisis estadístico se llevó a cabo con el programa Statistica. Resultados: Se evaluaron 56 pacientes, 31 de los cuales (55,4%) no presentaban delirium y 25 (44,6%) sí. El promedio de la duración de la hospitalización fue 6,06 días para pacientes sin delirium y 8,22 días para pacientes con delirium. Se encontró asociación con significación estadística entre la duración de la hospitalización y delirium (p = 0.0206). Conclusiones: en vista de que se trata de un diagnóstico que genera sobre-costos en los sistemas de salud, además de ser marcador de calidad de atención hospitalaria y dado que se encontró asociación estadística entre éste y mayor duración de la hospitalización, se plantea la necesidad de realizar estudios de costos así como de diagnóstico y de intervención precoz para saber qué repercusiones tiene el incidir sobre esta patología en los aspectos de morbilidad y económico.

Objective: To determine ifdelirium has association with longer hospitalization time and mortality in patients admitted to Clinica Universitaria Bolivariana. Methods: In one month period all patients admitted to de clinic were interviewed twice (in the admission and one more time within the next 12 hours) searching for DSM IV diagnostic entena for delirium, besides the visitors were interviewed and the Mini Mental State Test was applied to the patients. The diagnosis made by internal medicine, hospital stay, and mortality rate were registered. The information was placed in an Excel 2,000 database and the statistical analysis was performed in the Statistica programo Results: 56 patients were evaluated. 31(55.4%) did not have delirium, 25 (44.6%) had it. Hospitalization mean value for nondelirium patients was 6.06 days and 8.32 days for patients with delirium. There was a statistical association between the duration ofhospitalization and delirium (p = 0.0206). Conclusions: Due to the fact that delirium is a diagnosis that increase healing costs and because it 's a quality hospital care marker and taking into account thatwe found a statisticalassociation between delirium and longer hospitalizationwe suggest cost studies, diagnostic and early intervention studies to investigate the impact in the economy and morbidity by interviewing this pathology.