[Guide for the treatment of acute altered mental status. Iberoamerican Academy of Pediatric Neurology]

In pediatric patients, an acute altered mental status refers to a sudden and significant change in a child's brain function and level of consciousness. It may manifest as confusion, disorientation, agitation, lethargy or even a loss of consciousness. This condition is a medical emergency, and requires immediate evaluation and attention. There are several causes of acute altered mental status in children, including infections of the central nervous system such as meningitis or encephalitis, traumatic brain injury, metabolic disorders, seizures and poisoning, among others. The aim of this study was to analyse, prepare and classify the current literature in order to determine the best recommendations for the treatment of cases of acute altered mental status with various causes in pediatric patients. The study was based on opinions from experts in the field in order to classify the recommendations, and was submitted to the scientific committee of the Iberoamerican Academy of Pediatric Neurology for review. Our guide is an aid for the treatment of this non-specific symptom based on a basic and advanced approach, which can be applied by any pediatric neurologist.

Short communication: Utilisation of n-alkanes to estimate feed intake in horses fed known amounts of a labelled concentrate supplement

The assessment of feed intake in stabled horses is a difficult task to accomplish. Faecal markers, namely n-alkanes, have been used successfully for the estimation of this important nutritional parameter. This usually involves the dosing of synthetic n-alkanes via different matrices, a laborious task that may also influence the animal normal foraging behaviour. An experiment was conducted to evaluate a relative simple methodology to quantify feed intake in horses, based on the provision of measured amounts of a concentrate supplement labelled with beeswax and the utilisation of n-alkanes as faecal markers. Four Lusitano horses were used in three consecutive experimental periods. Animals were fed on cereal straw and different proportions of a previously prepared beeswax-labelled concentrate supplement (BLCS; 0.05, 0.10 and 0.20, DM basis). Beeswax labelling was performed to provide a distinct n-alkane profile for the concentrate feed. Prior to feed intake calculations, proportions of labelled concentrate supplement in the diets were estimated using n-alkanes C₂₅ to C₃₃ by least-square optimisation procedures. Results showed that the beeswax labelling resulted in high n-alkane concentrations in the concentrate feed, especially for the odd-chain n-alkanes. Estimates of diet composition did not differ from the measured values, except for the diet with highest BLCS incorporation, with an underestimation of 10%. DM intake was accurately estimated by the "labelled supplement method" in all diets. However, for the lowest BLCS incorporation, DM intake was underestimated by 16% whereas for the higher levels of BLCS in the diet, measured and estimated DM intake values were almost identical with a slight overestimation of only 0.7 and 0.2% (10 and 20% of BLCS, respectively). Results indicate that both diet composition and feed intake can be accurately estimated in horses using the "labelled supplement method", even when very low levels of the labelled concentrate supplement are included in the animals' diet. This method eliminates the need for daily dosing with external synthetic markers, providing advantages in terms of minimising animal management and interference with their normal foraging behaviour.

Epidemiological scenarios for human rabies exposure notified in Colombia during ten years: A challenge to implement surveillance actions with a differential approach on vulnerable populations

Based on notified cases of human rabies exposure and human deaths by rabies to Colombia public health surveillance system between 2007 and 2016, we conducted a spatiotemporal analysis to identify epidemiological scenarios of high human rabies exposure due to dogs, cats, bats, or farm animals (n = 666,411 cases). The incidence rate of human rabies exposures was analyzed by using geographical information system (spatiotemporal distribution and Cluster and Outlier Analysis (Anselin Local Moran's I)) data for all Colombian cities. The incidence rate of human rabies exposures due to dogs and cats showed an increasing trend, while aggression due bats and farm animals fluctuated throughout the analyzed period. Human deaths by rabies transmitted by cat and bat occurred in the Andean and Orinoquia regions, which had urban and rural scenarios. The urban scenario showed the highest exposure to human rabies due to cats and dogs in cities characterized with high human population density and greater economic development. In contrary, the highest human rabies exposure in the rural scenario was observed due to contact of mucosa or injured skin with the infected saliva of farm animals with the rabies virus, principally among workers in the agroforestry area. The inequality scenario showed some outlier cities with high human rabies exposure due to farm animals principally in the Pacific region (characterized by the highest poverty rates in Colombia), being Afro-descendant and indigenous population the most exposed. The highest exposure due to bats bite was observed among indigenous people residing in cities of the Amazon region as a dispersed population (Amazonian scenario). None of the high exposure scenarios were related to human deaths by rabies due to dogs aggression. The identified scenarios can help develop better surveillance systems with a differential approach to the vulnerable population and strengthening them in areas with rabies viral circulation.

ASSESSMENT OF RADIUM ACTIVITY CONCENTRATION AND RADON EXHALATION RATES IN IBERIAN PENINSULA BUILDING MATERIALS

Radium (226Ra) is a natural radioactive element of the uranium decay series, which could also be present in building materials. Radon (222Rn) is continuously produced by the decay of 226Ra and its presence inside buildings can contribute to the increase of the population exposure to ionizing radiation. In this work, the amount of radium activity concentration and radon exhalation rates in several types of building materials that are commonly used in the Iberian Peninsula have been tested. The radium activity concentration was measured by gamma-ray spectrometry, whereas the radon exhalation rates were carried out using a continuous radon monitor (active measuring technique) and a solid state nuclear track detectors (passive measuring technique). The 226Ra mean values range from 5.0 to 123.4 Bq kg-1. As expected, the results show that the radon exhalation rate is higher in granites samples relatively to others building materials analysed. A positive correlation was found between radium activity concentration and radon exhalation rates in both techniques. The emanation fraction and alpha index were also calculated.

The effect of C content on the mechanical properties of Ti-Zr coatings

In this study, Ti-Zr and Ti-Zr-C coatings were deposited at room temperature via pulsed-DC magnetron sputtering. A 70Ti-30Zr at% target and a 99.99% graphite plate were used to deposit samples. In order to modify C content, coatings were deposited at different target powers such as 50, 75 and 100 W. Changes on the structure, microstructure and mechanical properties due to C addition were studied. Results indicate that the as-deposited coatings were partly crystalline and that an increment on C content stabilized α' phase and inhibited the appearance of ω precipitates. Therefore, Ti-Zr-C alloys with C>1.9 at% showed only α' phase whereas the others alloys exhibited α'+ω structures. Hardness values from 12.94 to 34.31 GPa were obtained, whereas the elastic modulus was found between 181.84 and 298 GPa. Finally, a high elastic recovery ratio (0.69-0.87) was observed as a function of composition. The overall properties of these coatings were improved due to C content increment, martensitic α' phase and nanocrystalline grain size (10-16 nm).

Development of a couple of methods for measuring radon exhalation from building materials commonly used in the Iberian Peninsula

Radon is considered to be the main contributor to the worldwide population exposure to natural sources of radiation and so a lot of efforts have been made in most countries to assess indoor radon concentrations. Radon exhales from the earth's surface and is part of the radioactive decay series of uranium, which is also present in building materials. In this work, measurements of radon exhalation rates in building materials commonly used in the Iberian Peninsula have been carried out by using two different methods: active and passive techniques. In the first technique, the radon exhalation rate was measured following the radon activity growth as a function of time, by using a continuous radon monitor. The second technique is based on integrated measurements by using solid-state nuclear track detectors and a Spark Counter reading equipment. The results obtained by both measuring methods were found to be consistent.

[Treatment of herpes simplex encephalitis in children]

INTRODUCTION

Herpes simplex encephalitis (HSE) is a focal infectious disease of the central nervous system (CNS) acknowledged the world over as being severe.

DEVELOPMENT

The epidemiology is well known in developed countries. It presents in patients over the age of 3 months. The mechanism by which the virus reactivates and penetrates into the CNS is still not fully understood. A timely diagnosis is crucial so that early treatment can be established within the first four days of the infectious process. By so doing, it becomes possible to raise the chances of survival by over 50%. The physician should have a strong suspicion when faced with a patient with symptoms of encephalitis, especially if he or she has focal neurological manifestations, including manifestations in the neuropsychiatric sphere. The non-invasive diagnostic method par excellence is high-sensitivity magnetic resonance imaging studies of the brain within the first 24-48 hours following the onset of the clinical signs and symptoms. Determination of viral DNA in cerebrospinal fluid by the polymerase chain reaction method is the technique with the highest degree of sensitivity and specificity available for carrying out the diagnosis. Effective treatment is intravenous acyclovir: 30 mg/kg/day in three doses.

CONCLUSIONS

Encephalitis produced by the herpes virus is a disease that is dreaded because of the high mortality rate and the devastation it causes in the living conditions of survivors. Our aim is to stimulate the clinical suspicion of HSE so that pharmacological treatment can be established even while diagnostic tests are being carried out. We suggest early neuropsychological evaluation and follow-up of the manifestations of focal sequelae related to the frontotemporal regions.

311 ULTRASTRUCTURAL ANALYSIS OF OVINE PREANTRAL FOLLICLES CULTURED IN THE PRESENCE OF INDOLE ACETIC ACID, EGF, AND FSH

Previous studies from our team demonstrated that ovine primordial follicles are successfully activated in vitro after culturing in medium supplemented with 40 ng/mL indole acetic acid (IAA); besides that, the addition of IAA and epidermal growth factor (EGF) or EGF and follicle stimulating hormone (FSH) to the culture media were the most effective treatments to sustain the health and viability of activated ovine primordial follicles during in vitro culture. In this work, follicular quality was assessed only by histological studies; there is a great need to evaluate ultrastructural changes occurring in primordial follicles during activation in vitro. The aim of this study was to investigate the ultrastructural characteristics of preantral follicles after culturing of cortical slices in media containing IAA, EGF, and FSH, alone and in combination. Ovaries (n = 8) from adult merino ewes were collected at local slaughterhouses. Small pieces of ovarian fragments were removed for transmission electron microscopy (TEM). These pieces of ovarian cortex were cultured in culture dishes containing 1 mL aliquots of culture medium at 39�C with 5% CO2 in air. The media used were: (T1) Minimum essential medium (MEM) supplemented with ITS (insulin 6.25 �g/mL, transferrin 6.25 �g/mL and selenium 6.25 ng/mL), 0.23 mM pyruvate, 2 mM glutamine, 2 mM hypoxantine, 1.25 mg/mL bovine serum albumin (BSA), and antibiotics (100 ��g/mL penicillin and 100 ��g/mL streptomycim) (MEM+, control medium); (T2) MEM+IAA (40 ng/mL); (T3) MEM+IAA + epidermal growth factor (EGF) (100 ng/mL; Sigma, St. Louis, MO, USA); or (T4) MEM+EGF+FSH (100 ng/mL). After 6 days of culture of cortex tissue fragments in media, ultrastructural analysis was performed on preantral follicles (n = 3 in each treatment) included in a small cortical fragments. Preantral follicles were classified according to the stage of development as primordial follicles or as developing follicles. Preantral follicles cultured in supplemented media for 6 days were ultrastructurally normal. Their oocytes had an intact nucleus and cytoplasm that contained heterogeneous-sized lipid droplets, and numerous round or elongated mitochondria with intact parallel cristae were observed. Occasionally these organelles were associated with smooth endoplasmic reticulum (SER). Rough endoplasmic reticulum (RER) was rarely found. The cytoplasm of granulosa cells contained a large number of mitochondria and abundant RER. In contrast, follicles cultured in MEM+ (control) had a large number of vacuoles in the oocyte cytoplasm and excessive clustering of the chromatin material in the nucleus, suggesting an initial process of oocyte degeneration. In conclusion, the presence of IAA, EGF, FSH and their combinations helped to maintain ultrastructural integrity of ovine preantral follicles in cortical slices cultured in vitro.

Learning curve for sonographic examination of the fetal nasal bone at 11-14 weeks

OBJECTIVE

To determine the number of ultrasound examinations necessary for training sonographers to examine accurately the fetal nasal bone at 11-14 weeks' gestation.

METHODS

Fifteen sonographers with experience in measuring nuchal translucency were asked to examine the nasal bone during the routine 11-14-week scan. The supervising doctor recorded if the sonographer succeeded in obtaining the correct image. Each sonographer performed a total of 140 examinations, and the data were analyzed in seven groups of 20 examinations. In a second study, two sonographers with extensive experience in examining the nasal bone examined independently 100 consecutive patients at a median fetal crown-rump length of 65 (45-84) mm and median gestational age of 12 (11-14) weeks and recorded whether the nasal bone was absent or present.

RESULTS

In the first group of 20 examinations, there was failure to obtain the correct image of the fetal profile in 1-5 (median, 4) cases. In the subsequent three groups, there was failure to obtain the correct image in 0-3 (median, 1) cases. In the fifth and sixth groups failure occurred in 0-2 (median, 0) cases and in the seventh group all sonographers obtained successful images of the fetal profile in all cases. One sonographer obtained successful images of all cases after the first 40 scans, four after the first 60 scans, six after the first 80 and two each after the first 100 and 120 scans. In the second study, there was agreement between the two sonographers that the nasal bone was absent in two and present in 98 of the 100 consecutive patients examined.

CONCLUSION

The minimum number of scans required for an experienced sonographer to become competent in examining the fetal nasal bone is on average 80, with a range of 40-120.

Intracavernous injection in the treatment of erectile dysfunction after radical prostatectomy: an observational study

CONTEXT

Despite the recent improvements in performing radical retropubic prostatectomy that have led to a considerable decrease in the complication rate, erectile dysfunction still represents a major problem. Moreover, less invasive treatment options that are emerging for erectile dysfunction have not shown satisfactory results in managing these patients.

OBJECTIVE

To study the efficacy and side effects of self-injection therapy in the treatment of men who had become impotent after undergoing radical prostatectomy due to prostate cancer, over a study period of 96 months.

DESIGN

Observational study.

SETTING

University Referral Center.

PARTICIPANTS

168 patients with erectile dysfunction, aged 43 to 78 years old, who underwent radical retropubic prostatectomy due to localized prostate cancer.

PROCEDURES

The patients were treated with self-injection therapy using papaverine, phentolamine and prostaglandin E1, at home.

RESULTS

This study showed an acceptable 94.6% success rate, with no life-threatening complications. In addition to this, our series presented a 13.1% cure rate with this therapy.

CONCLUSION

Self-injection therapy with papaverine, phentolamine and prostaglandin E1 is effective and safe in the treatment of erectile dysfunction after radical prostatectomy.

From external to internal measurement: a form theory approach to evolution

The point of view of external observers has led to an explanation of life based on digitally encoded information. In contrast, the existence of natural internal observers, or agents that belong to the same scale of the observed objects, explains the appearance of form centered approaches. The main controversies in thermodynamics and evolution are due to the changes of perspective, so as to speak, if measurement is considered to be external or internal. Equilibrium theories developed for closed systems under ideal conditions are analogous to external measurements. On the other hand, morphogenetic perspectives as far from equilibrium thermodynamics applicable to open systems allow to imagine self-organizing agents that perform local measurements. Chaitin's algorithmic approach would help to elucidate the relation between digitally encoded information and active forms, because forms and shapes are responsible for specific pattern recognition and play a major role in the process of finding the proper measuring standard. The predominance of form over digital records is illustrated by studying the mapping between genetic descriptions and functional shapes, originally suggested for RNA, by Schuster. Therefore, interactions between living entities are seen as reciprocal measurement processes that bring about couplings (shortened descriptions and local decreases of entropy) that are paid by partial record erasure (increase of entropy). To conclude, this approach centered on the inner dynamics or form is appropriate for understanding how Lamarckism and the modern neutral theory of evolution can be integrated for expanding the neoDarwinian perspective.

Characterization and comparison of Escherichia coli transfer RNAs by graph theory based on secondary structure

We have developed a model to characterize the tRNA structures of Escherichia coli using graph theory. First of all, tRNAs were represented as graphs, whose vertices correspond to nucleotides and the edges to phosphodiester and hydrogen bond linkages. Vertices and edges were weighted using the results of a preliminary quantum study of the nucleotides and the possible coupling between pair bases using the semiempirical method AM1. For each vertex, we defined a nucleotide valence that measures the capability of forming hydrogen bonds. Edges were differentiated by using bond orders. We have proposed weighted structural descriptors-closely related to molecular Randic connectivity and Balaban distance indices-as a distinctive characteristic of each structure. Molecules were characterized by a set of weighted structural descriptors and classified by a clustering method and discriminant function analysis. Two main groups of tRNAs that correspond to the biosynthetic amino acid pathways, in agreement with Wong's coevolution theory of the genetic code, were obtained.

Mirizzi's syndrome. Diagnostic and therapeutic controversies in the laparoscopic era

BACKGROUND

Mirizzi's syndrome (MS) is an unusual cause of obstructive jaundice. It can mimic bile duct cancer, and the role of laparoscopic surgery is not well defined. The aim of this paper is to report five cases and describe the pitfalls encountered in its diagnosis and treatment with a laparoscopic approach.

METHODS

From January 1992 to January 1996, five cases of MS out of 560 patients with gallstones prospectively treated and recorded were found (0.9%).

RESULTS

There were two men and three women, (mean age: 54 years [30-93]). In one case diagnosis of bile duct carcinoma was established but surgery revealed MS. Four cases were approached by laparoscopy, but all of them were converted: in two, due to a distorted anatomy, in a third due in the difficulty of visualizing the distal end of the bile duct, and in the last case due to the impossibility of retrieving the stones. All were treated with a cholecochorrhaphy over a T tube, except one, in which a hepaticojejunostomy was performed. Morbidity and mortality were nil, and they remain asymptomatic after a mean follow-up of 19 months (3-36).

CONCLUSIONS

MS constitutes an important laparoscopic challenge, both to clearance of duct stones and to the proper reconstruction of the biliary duct. A prudent policy is to perform a dissection trial and convert if local conditions are not clear for an experienced laparoscopic surgeon.

Laparoscopic cholecystectomy in cirrhotic patients. Indication or contradiction?

Liver cirrhosis is considered a contraindication to laparoscopic cholecystectomy for the moment. Here we are reporting on results in the surgical treatment of gallstone disease in cirrhotic patients by laparoscopic means. We reviewed the experience over the final period of time in 11 patients since the introduction of laparoscopic procedures in our unit. The index of conversion rate was 9.1% (1/11). The morbidity was nil. The average length of hospital stay was 1.8 days (1-6 days). We propose the use of laparoscopic cholecystectomy in gallstone disease in patients with liver cirrhosis as first-line surgical treatment.