Critical review of technologies for the on-site treatment of hospital wastewater: From conventional to combined advanced processes.

This review aims to assess different technologies for the on-site treatment of hospital wastewater (HWW) to remove pharmaceutical compounds (PhCs) as sustances of emerging concern at a bench, pilot, and full scales from 2014 to 2020. Moreover, a rough characterisation of hospital effluents is presented. The main detected PhCs are antibiotics and psychiatric drugs, with concentrations up to 1.1 mg/L. On the one hand, regarding the presented technologies, membrane bioreactors (MBRs) are a good alternative for treating HWW with PhCs removal values higher than 80% in removing analgesics, anti-inflammatories, cardiovascular drugs, and some antibiotics. Moreover, this system has been scaled up to the pilot plant scale. However, some target compounds are still present in the treated effluent, such as psychiatric and contrast media drugs and recalcitrant antibiotics (erythromycin and sulfamethoxazole). On the other hand, ozonation effectively removes antibiotics found in the HWW (>93%), and some studies are carried out at the pilot plant scale. Even though, some families, such as the X-ray contrast media, are recalcitrant to ozone. Other advanced oxidation processes (AOPs), such as Fenton-like or UV treatments, seem very effective for removing pharmaceuticals, Antibiotic Resistance Bacteria (ARBs) and Antibiotic Resistance Genes (ARGs). However, they are not implanted at pilot plant or full scale as they usually consider extra reactants such as ozone, iron, or UV-light, making the scale-up of the processes a challenging task to treat high-loading wastewater. Thus, several examples of biological wastewater treatment methods combined with AOPs have been proposed as the better strategy to treat HWW with high removal of PhCs (generally over 98%) and ARGs/ARBs (below the detection limit) and lower spending on reactants. However, it still requires further development and optimisation of the integrated processes.

Photocatalytic inactivation of dual- and mono-species biofilms by immobilized TiO2.

Biofilms formed by different bacterial species are likely to play key roles in photocatalytic resistance. This study aims to evaluate the efficacy of a photocatalytic immobilized nanotube system (TiO2-NT) (IS) and suspended nanoparticles (TiO2-NP) (SS) against mono- and dual-species biofilms developed by Gram-negative and Gram-positive strains. Two main factors were corroborated to significantly affect the biofilm resistance during photocatalytic inactivation, i.e., the biofilm-growth conditions and biofilm-forming surfaces. Gram-positive bacteria showed great photosensitivity when forming dual-species biofilms in comparison with the Gram-positive bacteria in single communities. When grown onto TiO2-NT (IS) surfaces for immobilized photocatalytic systems, mono- and dual-species biofilms did not exhibit differences in photocatalytic inactivation according to kinetic constant values (p > 0.05) but led to a reduction of ca. 3-4 log10. However, TiO2-NT (IS) surfaces did affect biofilm colonization as the growth of mono-species biofilms of Gram-negative and Gram-positive bacteria is significantly (p ≤ 0.05) favored compared to co-culturing; although, the photocatalytic inactivation rate did not show initial bacterial concentration dependence. The biofilm growth surface (which depends on the photocatalytic configuration) also favored resistance of mono-species biofilms of Gram-positive bacteria compared to that of Gram-negative in immobilized photocatalytic systems, but opposite behavior was confirmed with suspended TiO2 (p ≤ 0.05). Successful efficacy of immobilized TiO2 for inactivation of mono- and dual-species biofilms was accomplished, making it feasible to transfer this technology into real scenarios in water treatment and food processing.

Best Practice Framework of Fracture Liaison Services in Spain and their coordination with Primary Care.

The coordination of Fracture Liaison Services (FLS) with Primary Care (PC) is necessary for the continuity of care of patients with fragility fractures. This study proposes a Best Practice Framework (BPF) and performance indicators for the implementation and follow-up of FLS-PC coordination in clinical practice in Spain. PURPOSE: To develop a BPF for the coordination of FLS with PC in Spain and to improve the continuity of care for patients with fragility fractures. METHODS: A Steering Committee selected experts from seven Spanish FLS and related PC doctors and nurses to participate in a best practice workshop. Selection criteria were an active FLS with an identified champion and prior contact with PC centres linked to the hospital. The main aim of the workshop was to review current FLS practices in Spain and their integration with PC. A BPF document with processes, tools, roles, and metrics was then generated. RESULTS: Spanish FLS consists of a multidisciplinary team of physicians/nurses but with low participation of other professionals and PC staff. Evaluation and treatment strategies are widely variable. Four desired standards were agreed upon: (1) Effective channels for FLS-PC communication; (2) minimum contents of an FLS clinical report and its delivery to PC; (3) adherence monitoring 3 months after FLS baseline visit; and (4) follow-up by PC. Proposed key performance indicators are (a) number of FLS-PC communications, including consensus protocols; (b) confirmation FLS report received by PC; (c) medical/nursing PC appointment after FLS report received; and (d) number of training sessions in PC. CONCLUSIONS: The BPF provides a comprehensive approach for FLS-PC coordination in Spain, to promote the continuity of care in patients with fragility fractures and improve secondary prevention. The implementation of BPF recommendations and performance indicator tracking will benchmark best FLS practices in the future.

Photoelectrocatalytic study and scaling up of titanium dioxide electrodes for wastewater treatment.

Different TiO2 photoelectrodes have been characterized and tested for the photoelectrocatalytic oxidation of methanol. Particulate electrodes (TiO2/Ti and TiO2/ITO) have been shown to notably favour charge-carrier transfer at the electrolyte interface while a thermal electrode (Ti) has been shown to favour charge-carrier separation when applying an electric potential bias according to cyclic voltammetry technique, as a consequence of differences in TiO2 surface between particulate and thermal electrodes. Particulate electrodes lead to a higher photoelectrocatalytic activity for methanol oxidation compared to that of the thermal electrode, probably due to the pure-rutile TiO2 phase composition of the latter and its lower surface area. TiO2/Ti electrode has been shown to be the most effective photoelectrode tested for methanol oxidation since its activity was improved by the combination of the particulate TiO2 layer and the high electrical conductivity of the support. Generally, photocurrent density measured in the photoelectrochemical cell seems to correlate with activity, whereas this correlation is not observed when using a larger photoelectrocatalytic reactor. In contrast, the activity obtained for the scaled-up electrode is found to be similar in terms of surface kinetic constant to that obtained at laboratory scale.

Cluster-tic syndrome as the initial manifestation of multiple sclerosis.

We report the case of a patient diagnosed as having cluster-tic syndrome as the initial manifestation of multiple sclerosis (MS). The patient's headache bouts improved after treatment with antiepileptic drugs, steroids, and beta-interferon. Magnetic resonance imaging (MRI) scans showed a pontine demyelinating lesion involving the area of the trigeminal root inlet and main sensory nucleus. Neurophysiological studies correlated well with MRI lesions. The association between cluster-tic syndrome and MS is an exception, and the mechanism of the pain is still unknown; therefore, this case might suggest a pathophysiological relationship between the trigeminal main sensory nucleus and cluster-tic syndrome.

[Impact of clinical practice guides on the cost of caring for community acquired pneumonia]. / Impacto de las guías de práctica clínica sobre el coste del control de la neumonía extrahospitalaria.

PURPOSE: to compare the economic cost of the diagnostic and therapeutic process of the community-acquired pneumonia (CAP) in primary care in two periods (1999 and 2004-05). During the second period they were adapted to the recommendations of three clinical practice guidelines (CPG) on diagnosis and treatment of the pneumonia. PATIENTS AND METHODS: There were 57 episodes of CAP in 1999 and 95 in 2004-05. The cost per episode in each period is estimated. RESULTS: The total cost of the diagnostic and therapeutic process in dropped in 2004-05 compared to 1999: 46.59 euros compared to 71.66 euros (p < 0.05). Six children were referred to the hospital in 1999 compared to 13 in 2004-05, there were no significant differences. CONCLUSIONS: Adherence to the recommendations of the GPC produced a decrease in the cost of the diagnostic and therapeutic process of CAP without involving a decrease in rate of resolution of the disease.

[The contribution made by neurophysiological and ultrasound imaging studies to the diagnosis of carpal tunnel syndrome. Surgical correlation]. / Aportación de los estudios neurofisiológico y ecográfico al diagnóstico del síndrome del túnel carpiano. Correlación quirúrgica.

INTRODUCTION: Electrophysiological study has been for long time the elected approach for the diagnosis and clinical evaluation of carpal tunnel syndrome (CTS). More recently, echography and other imaging techniques have been introduced in current medicine for their potential in the anatomical evaluation of the neural compression. To asses the usefulness of both diagnostic procedures we have compared the findings obtained by electrophysiological and echographic approaches in a group of 60 CTS patients with different degrees of the disease. PATIENTS AND METHODS: In all patients the conduction velocity was evaluated in the median and cubital nerves using surface electrodes. For echography lineal transductors of 5-10 Hz and 5-12.5 MHz were employed. RESULTS: The patients were distributed for each test on a scale depending of the severity of the alterations detected by the corresponding technique and both files were subsequently compared by regression analysis, Pearson test and paired-test. No correlation was detected in any of the statistical test. CONCLUSIONS: The lack of correlation between the results of both proofs emphasizes the usefulness of the two diagnostic approaches in CTS. While electrophysiological study provides information about nerve function, ecography unravels the morphological alterations accounting for the syndrome, therefore being non-excluding complementary approaches.

Trigeminal somatosensory evoked potentials in multiple sclerosis: a case report.

Somatosensory evoked potentials elicited by trigeminal nerve stimulation (TSEPs) allow the study of the trigeminal system, its peripheral to its central portion. As a routine clinical testing procedure, however, this method has not yet received greater attention and still has to wait to become a part of the diagnostic workup in multiple sclerosis (MS). A patient diagnosed as MS was presented with selective involvement of the left trigeminal nerve. Neurophysiologically, the most prominent and persistent abnormalities were found in the TSEPs. The presumed diagnosis of MS was subsequently confirmed by MRI showing evidence of demyelinating disease. There has been a scarcity of references on TSEP. Our study emphasizes its usefulness and a plea is being made for the inclusion of TSEP in protocols for the diagnostic workup in patients with MS.

[Recurrent community acquired pneumonia in young children: risk factor for the development of childhood asthma?]. / Neumonía recurrente adquirida en la comunidad en la edad pediátrica. Factor de riesgo para el desarrollo de asma infantil?

OBJECTIVE: To determine if recurrent community acquired pneumonia (RP) is a risk factor for developing childhood asthma (CA), compared with those children who only suffer one episode of pneumonia or non-recurrent pneumonia (NRP). To determine if patients with CA are more disposed to suffer RP. DESIGN: Historical cohort study. SETTING: Primary care. PARTICIPANTS: A total of 80 episodes of pneumonia identified in 65 infants between the 1st of February 1996 and 30th June 1999. PRINCIPAL MEASUREMENTS: The relative risk (RR) and confidence interval (95% CI) of childhood asthma in the presence of recurrent pneumonia as compared to non-recurrent pneumonia, and the RR of recurrent pneumonia in the presence of childhood asthma. RESULTS: Of the 65 children included, 18 had RP (27.7%; 95% CI, 16.8-38.6). The prevalence of CA was 49.2% (32 children) (95% CI, 37.1-61.4). The diagnosis of CA at any time was higher in children with RP (RR=4.1; 95% CI, 1.9-8.9). There were no differences between the incidence of RP and NRP in children previously diagnosed with CA (RR=1.28; 95% CI, 0.5-3.0). CONCLUSIONS: A special follow-up needs to be carried out on all children diagnosed with RP in primary care, since the possibility of presenting with CA is higher in these cases.

[Antibiotic use in primary care. Do we know what parents think?]. / Utilización adecuada de antibióticos en atención primaria: sabemos qué piensan los padres?

INTRODUCTION: In Spain, studies that investigate parents' beliefs on antibiotic use are lacking. Mistaken beliefs lead to inappropriate antibiotic use and encourage overuse. The aim of the present study was to determine parents' knowledge about antibiotic use. MATERIAL AND METHODS: We performed a cross sectional, descriptive study in two health centers through a self-administered questionnaire completed by 348 parents. The response variable consisted of beliefs evaluated when the parents answered the following three statements in the affirmative: a) there are currently some infections with inadequate response to antibiotic treatment; b) if antibiotics are used too often, they can cease to have an effect; c) if your child frequently receives antibiotic treatment, subsequent use may have no effect. Independent variables consisted of sex of the responder, educational level, parental age and ethnicity, attendance at school (public or private), attendance at kindergarten, usual healthcare (public-private), and number of siblings. Statistical analysis consisted of logistic regression. RESULTS: A total of 31.6 % (95 % CI: 26.7-36.5) responded affirmatively to the three statements. Adequate knowledge was associated with the non-immigrant population (OR: 5.7; 95 % CI: 1.37-24.9) and high parental education (OR: 2.04; 95 % CI: 1.16-3.06). CONCLUSIONS: Parents' knowledge of antibiotic use is low compared with that in other countries. Health education programs to remedy this situation are urgently required.

[Usefulness of physical examination at a primary health centre to diagnose infant pneumonia caught in the community]. / Utilidad de la exploración física para el diagnóstico de neumonía infantil adquirida en la comunidad en un centro de atención primaria.

OBJECTIVE: To determine the diagnostic usefulness of three clinical signs (temperature, cough, crepitant stertor) for diagnosing pneumonia in children. To evaluate the agreement of two radiologists in evaluating thoracic x-rays (TXR). DESIGN: Study of diagnostic tests. SETTING: Primary care. PARTICIPANTS: 350 clinical histories of children who had an urgent TXR to diagnosis pneumonia between 1st January 1996 and 30th June 1999. MAIN MEASUREMENTS: a) Prevalence of pneumonia in the entire sample and two age-based sub-groups: aged 5 years and under, and over 5; b) positive probability quotients (PQ+) and negative ones (PQ-) and 95% confidence intervals (95% CI). The TXR was seen as the reference standard, and c) kappa index (kappa) for inter-radiologist concordance. RESULTS: Prevalence: the entire sample, 22.9% (95% CI, 18.5-27.3); children aged 5 or less, 20.4% (95% CI, 15.6-25.2); aged over 5, 31.3% (95% CI, 21.1-41.4). The signs studied were only of any use in confirming the diagnosis in children over 5: PQ+ was 3.52 (1.28-9.69). Radiologists coincided in their diagnosis in 93.1% of the TXR (kappa=0.8; 95% CI, 0.77-0.83). CONCLUSIONS: This study did not prove that there was a sub-grouping of clinical signs which confirmed unmistakably the diagnosis of pneumonia in children.

[Influence of type of infant feeding and other factors on the incidence of respiratory tract infections in infants followed at a primary care center]. / Influencia del tipo de lactancia y otros factores sobre la incidencia de infecciones del tracto respiratorio en lactantes controlados en un centro de atención primaria.

OBJECTIVE: To determine the influence of type of infant feeding on the incidence of lower (LRTI) and upper respiratory tract infections during the first 12 months of life. DESIGN: Historical cohort study. SETTING: Primary care centers. PARTICIPANTS: A total of 250 babies born at term between October 1, 1994 and February 1, 1998. INCLUSION CRITERIA: current medical record available at a participating primary care center, participation in a Healthy Baby Program, residence in the basic health area involved in the study, birth weight #>2500 g. Interventions. Breastfeeding alone or in combination with formula feeding; artificial feeding alone. MAIN OUTCOME MEASURES AND RESULTS: Attending day care, antecedents of atopy, fathers and mothers smoking habit, parents level of education, number of persons in the household, mothers age. There was no association between type of feeding and the incidence of respiratory infections. All 95% confidence intervals (95% CI) of the odds ratios (OR) included the value of 1. At age 3 months, LRTI was associated with the number of persons in the household (OR, 1,87; 95% CI, 1.18-2.95) and with antecedents of atopy (OR, 2.96; 95% CI, 1.19-7.4). At age 6 months, LRTI was associated with the number of persons in the household (OR, 1.62; 95% CI, 1.07-2.44) and with attending day care (OR, 4.52; 95% CI, 1.20-17.1). CONCLUSIONS: In the present study breastfeeding was not effective in lowering the incidence of respiratory infections.

Friedreich ataxia with minimal GAA expansion presenting as adult-onset spastic ataxia.

Around a quarter of Friedreich ataxia (FA) patients, despite being homozygous for GAA expansion within the FRDA gene, show atypical presentations. Our aim is to describe the case of three brothers with long-term follow-up suffering from late onset FA manifested with spastic ataxia. The three patients belong to a family with occipital dysplasia (OD) and Chiari I malformation previously reported by us. We have carried out serial examinations since 1977. Electrophysiological and neuroimaging studies, and molecular genetic analyses of hereditary ataxias are available in all three patients. Onset of symptoms occurred between 25 and 35 years. The clinical picture consisted of progressive spastic gait, truncal and limb ataxia, dysarthria, nystagmus, hyperreflexia with knee and ankle clonus and extensor plantar response, and mild hypopallesthesia. Ages at present vary between 50 and 59. One patient is wheelchair-bound but the other two are able to walk with support. Leaving OD aside, skeletal anomalies are not prominent. All three patients showed cardiomyopathy. MR imaging revealed atrophy of the cerebellum and spinal cord. Motor and sensory nerve conduction velocities were normal. Central conduction time of both motor and sensory pathways was delayed or unobtainable. All three patients were homozygous for the GAA expansion, the smaller expanded allele ranging between 131 and 156 repeats. Four heterozygotic carriers were detected among non-ataxic relatives including one with OD; furthermore, an asymptomatic OD patient showed normal genotype. We conclude that adult onset spastic ataxia is a distinctive FA phenotype associated with minimal GAA expansion. This phenotype represents a new cause of selective distal degeneration of central sensory axons. The present concurrence of OD and FA reflects coincidental cosegregation of two different inherited disorders.

[Isolated posterior cord syndrome in Lyme s disease: a clinico neurophysiological study]. / Síndrome cordonal posterior aislado en la enfermedad de Lyme: estudio cliniconeurofisiológico.

INTRODUCTION: Lyme disease, caused by spirochete Borrelia burgdorferi, is a multisystemic infectious disorder with prominent neurologic involvement, affecting both the peripheral and the central nervous system. Meningitis, cranial neuritis and radiculoneuritis are the usual manifestations in the acute phase, and peripheral neuropathy in the chronic phase. Other less common manifestations have been also described. Here we report one case of Lyme disease confirmed by PCR, with a previously undescribed neurological manifestation, and the neurophysiological studies performed before and after treatment. CLINICAL CASE: Our patient showed a chronic and progressive clinical picture consisting of instability on walking and distal paresthesia of lower limbs, suggestive of posterior column disfunction. The neurophysiological exam performed prior to treatment with ceftriaxone revealed bilateral absence of lower limbs somatosensory evoked potentials (SEPs), without alterations in the distal nervous conduction or in upper limbs SEPs. The exam performed after treatment revealed a partial recovery of lower limb SEP with presence of an evoked response in SEP of left lower limb, coincident with a transitory clinical improvement of paresthesia in the same extremity. CONCLUSIONS: Our findings reveal that posterior column disfunction can be a neurological manifestation of Lyme disease. Furthermore the neurophysiological study shows that this manifestation is partially reversible following treatment. Our study emphasize the importance of the neurophysiological tests for the diagnosis and follow up of neurological manifestations of Lyme disease.

[Electrophysiological study during the initial stage of the Guillain- Barré syndrome]. / Estudio electrofisiológico en la fase inicial del síndrome de Guillain-Barré.

INTRODUCTION: In typical Guillain-Barré syndrome the clinical symptomatology is more pronounced in lower extremities. So, this is the territory of election to demonstrate electrophysiological abnormalities early in the disease. PATIENTS AND METHODS: We presented the results of the electrophysiological study of 37 patients, who showed abnormalities in peroneal nerve territory as soon as 15 days from the onset of the disorder, and were maintained at least up to 30 days later. Since Guillain-Barré syndrome is an heterogeneous syndrome, which can differ in extension and severity in the different patients, is necessary a more extensive electrophysiological study. Furthermore, subtypes of the disorder are recognized in relation to different electrophysiological patterns. Therefore, it is important to analyze data of each patient individually and to make control evolutive studies. For these reasons we also describe in detail the electrophysiological study of a selected patient affected by Guillain-Barré syndrome. In this case motor and sensory abnormalities were localized in distal nerve segments, and there was not denervation potentials in EMG. RESULTS: We considered these findings indicative of a mainly distal sub-pattern with a good prognosis. The occurrence of A-waves was an early finding in this case of Guillain-Barré syndrome. During the course of the disease the behavior of these A-waves was variable in the different nerves of the lower extremities, and they disappeared in parallel with the clinical improvement of the patient.

[Are occupation and education interchangeable as social indicators in community health? A study in an employed population]. / Son la ocupación y la educación intercambiables como indicadores sociales en salud comunitaria? Un estudio en población ocupada.

OBJECTIVE: Epidemiological studies and interventions to reduce inequalities in community health require the assignation of exhaustive and easy-to-obtain social indicators. Occupation and education are two of the most often used. In this study we attempt to evaluate the association between education and occupation among adult working population because if, in the absence of one of these two variables, it will be feasible to use the remaining with the lesser lost of socio-economic information. DESIGN: From a representative sample (n = 3091) of general population (18-65 years old) drawn out from a prevalence survey on chronic disease risk factors performed in the Region of Murcia, a log-lineal analysis has been made between education and occupation among working people (65.8% of males and 34.2% of females from the original sample). RESULTS: Men present significant association between managerial positions and university education. The association drops between clerks and high school graduates to increase among all manual workers with or without primary schooling education. Among women--with a lesser number of participants--the education/occupation association describes the same pattern but with higher magnitudes in the positive associations between managerial positions and university education. For both genders, the greatest associations are found in both diagonals of the education by occupation tables indicating: better occupation, more education, and the opposite. CONCLUSIONS: The classification of working people according to education and occupation presents association, internal consistency and gradient. In absence of comprehensive information regarding occupation, education could be an alternative as socio-economic indicator.

[A descriptive study of community-acquired pneumonia in childhood. A primary care perspective]. / Estudio descriptivo de la neumonía adquirida en la comunidad en la edad pediátrica. Una perspectiva desde atención primaria.

MAIN OBJECTIVE: To determine the incidence of child pneumonia in our health district. SECONDARY OBJECTIVES: to establish its clinical and epidemiological characteristics, to establish the percentage resolution of the illness within primary care (PC), to describe the treatments given, and to compare admission rates according to whether the first consultation was in PC or hospital casualty. DESIGN: A retrospective, longitudinal, descriptive study. SETTING: Primary care. PARTICIPANTS: 63 episodes diagnosed between 30-8-96 and 1-9-97 in 1604 children under 15. MEASUREMENTS: Statistical measurements included: 95% confidence intervals, the ji squared test, Fisher's exact test. RESULTS: Incidence was 3.9% (CI: 3-4.9%); female predominance, 53.3% (CI: 40.7-66%); seasonal predominance, autumn-winter 64.5% (CI: 52.6-76.4%). The most common signs were: high temperature, 93.3% (CI: 87-99.6%); cough, 66.1% (CI: 54-78.2%). 90.5% (CI: 83.2-97.7%) of pneumonia cases treated in PC evolved satisfactorily. 9.5% (CI: 2.3-16.8%) needed hospital admission. Patients who attended hospital on their own initiative went into hospital more often than those who attended the PC paediatrics clinic as their first option (p = 0.002). CONCLUSIONS: The incidence of pneumonia among children is lower than in other countries. The majority are treated and resolved properly in PC. Analytic studies are needed to determine whether first attending a hospital casualty department instead of a PC paediatric clinic involves a greater risk of hospital admission.

[Miller-Fisher syndrome: electrophysiological serial study of five patients]. / Síndrome de Miller Fisher: estudio electrofisiológico evolutivo en cinco pacientes.

OBJECTIVE: The object of the present study is to show the spectrum of neurophysiological findings during clinical course of Miller Fisher syndrome (MFS), avoiding the controversy over a combined central and peripheral pathology. PATIENTS AND METHODS: We report five patients with a syndrome of ophthalmoplegia, ataxia and areflexia. A similar episode had been suffered previously by 2 of these patients, 14 and 13 years before. In one of them the second episode evolved to a typical Guillain-Barré syndrome (GBS). Motor and sensory conduction velocity of upper and lower limbs, F waves, blink-reflex and somatosensory evoked potentials were recorded in all cases. Needle electromyography in four and brainstem evoked potentials in three of them and the jaw-reflex in another one. RESULTS: In all patients there was a markedly reduced amplitude of the distal sensory evoked response, and no signs of denervation in the EMG. The other results were variable both interindividually and intraindividually. The severity of abnormalities was also different between different patients. The clinical recovery was always accompanied by a improvement of neurophysiological parameters. CONCLUSIONS: The electrophysiological findings in MFS can be variable but they appear always related with the clinical symptomatology. We report for the first time a case in whom the jaw-reflex was abnormal whereas the blink-reflex was normal.