El ultrasonido, de la cabecera del paciente al aula / Ultrasound, from the Patient's Bedside to the Classroom

Resumen: En los últimos años la ecografía a la cabecera del paciente ha crecido exponencialmente. Su aplicación es observada en el quirófano, en las unidades de cuidados intensivos, en urgencias, en la atención de primer nivel e incluso en el trabajo de campo. Es tan versátil que facilita el diagnóstico, mejora la monitorización de los pacientes y apoya en los procedimientos invasivos, todo esto de forma segura y eficaz. En el área de la educación médica ha permeado hasta el pregrado, donde ya se le propone como una herramienta didáctica que permite la vinculación entre el conocimiento de las ciencias básicas y la aplicación clínica. La ecografía corresponde a uno de los instrumentos más versátiles en la medicina contemporánea, por lo que se hace obligada y prioritaria una mayor capacitación e investigación en el tema.

Abstract: In recent years, ultrasound at the patient's bedside has exponentially grown. Its application has been observed in the operating room, intensive care units, emergency rooms, first-level care and even in field work. It is so versatile that it facilitates diagnosis, improves patient monitoring and supports invasive procedures, all in a safe and effective manner. It has been used as a didactic tool in medical education that helps create a link between basic sciences and clinical application. Ultrasound is one of the most versatile instruments in contemporary medicine, hence, more training and research in the subject is a must and a priority.

Anticonvulsant Effect of Time-Restricted Feeding in a Pilocarpine-Induced Seizure Model: Metabolic and Epigenetic Implications.

A new generation of antiepileptic drugs has emerged; however, one-third of epilepsy patients do not properly respond to pharmacological treatments. The purpose of the present study was to investigate whether time-restricted feeding (TRF) has an anticonvulsant effect and whether this restrictive diet promotes changes in energy metabolism and epigenetic modifications in a pilocarpine-induced seizure model. To resolve our hypothesis, one group of rats had free access to food and water ad libitum (AL) and a second group underwent a TRF schedule. We used the lithium-pilocarpine model to induce status epilepticus (SE), and behavioral seizure monitoring was analyzed. Additionally, an electroencephalography (EEG) recording was performed to verify the effect of TRF on cortical electrical activity after a pilocarpine injection. For biochemical analysis, animals were sacrificed 24 h after SE and hippocampal homogenates were used to evaluate the proteins related to metabolism and chromatin structure. Our results showed that TRF had an anticonvulsant effect as measured by the prolonged latency of forelimb clonus seizure, a decrease in the seizure severity score and fewer animals reaching SE. Additionally, the power of the late phase EEG recordings in the AL group was significantly higher than the TRF group. Moreover, we found that TRF is capable of inducing alterations in signaling pathways that regulate energy metabolism, including an increase in the phosphorylation of AMP dependent kinase (AMPK) and a decrease in the phosphorylation of Akt kinase. Furthermore, we found that TRF was able to significantly increase the beta hydroxybutyrate (ß-HB) concentration, an endogenous inhibitor of histone deacetylases (HDACs). Finally, we found a significant decrease in HDAC activity as well as an increase in acetylation on histone 3 (H3) in hippocampal homogenates from the TRF group. These findings suggest that alterations in energy metabolism and the increase in ß-HB mediated by TRF may inhibit HDAC activity, thus increasing histone acetylation and producing changes in the chromatin structure, which likely facilitates the transcription of a subset of genes that confer anticonvulsant activity.

TRH regulates action potential shape in cerebral cortex pyramidal neurons.

Thyrotropin releasing hormone (TRH) is a neuropeptide with a wide neural distribution and a variety of functions. It modulates neuronal electrophysiological properties, including resting membrane potential, as well as excitatory postsynaptic potential and spike frequencies. We explored, with whole-cell patch clamp, TRH effect on action potential shape in pyramidal neurons of the sensorimotor cortex. TRH reduced spike and after hyperpolarization amplitudes, and increased spike half-width. The effect varied with dose, time and cortical layer. In layer V, 0.5µM of TRH induced a small increase in spike half-width, while 1 and 5µM induced a strong but transient change in spike half-width, and amplitude; after hyperpolarization amplitude was modified at 5µM of TRH. Cortical layers III and VI neurons responded intensely to 0.5µM TRH; layer II neurons response was small. The effect of 1µM TRH on action potential shape in layer V neurons was blocked by G-protein inhibition. Inhibition of the activity of the TRH-degrading enzyme pyroglutamyl peptidase II (PPII) reproduced the effect of TRH, with enhanced spike half-width. Many cortical PPII mRNA+ cells were VGLUT1 mRNA+, and some GAD mRNA+. These data show that TRH regulates action potential shape in pyramidal cortical neurons, and are consistent with the hypothesis that PPII controls its action in this region.

NMDA receptor up-regulates pyroglutamyl peptidase II activity in the rat hippocampus.

Ecto-peptidases hydrolyze peptides in the extracellular fluid of the brain. This process is critical for defining the strength of peptidergic communication. A few studies suggest that brain ecto-peptidase activities are regulated by brain function but the extracellular messengers involved are generally unknown. Pyroglutamyl peptidase II (PPII) is specific for thyrotropin releasing hormone (TRH), a tripeptide with multiple homeostatic functions in brain. The purpose of this study was to identify regulators of brain PPII activity. Electrical stimulation (multiple tetani) did not change PPII activity in cortical or hippocampal slices. However, in hippocampal slices, blockade of calcium channels with high magnesium, or of L-type calcium channels (LTCC) or NMDA receptors, decreased PPII activity, while blockade of AMPA or GABA(A) receptors did not. Blockade of NMDA receptors did not change PPII mRNA levels but decreased PPII levels. The activity of another ecto-peptidase, aminopeptidase N, was also down regulated by a magnesium blockade, not regulated by NMDA receptor blockade and increased by LTCC blockade. The data show a differential regulation of the activity of ecto-peptidases by that of Ca(2+) channel and that synaptic activity, through the NMDA receptor, specifically regulates that of pyroglutamyl peptidase II.

Measurement of variability dynamics in cortical spike trains.

We propose a method for the time-resolved joint analysis of two related aspects of single neuron variability, the spiking irregularity measured by the squared coefficient of variation (CV(2)) of the ISIs and the trial-by-trial variability of the spike count measured by the Fano factor (FF). We provide a calibration of both estimators using the theory of renewal processes, and verify it for spike trains recorded in vitro. Both estimators exhibit a considerable bias for short observations that count less than about 5-10 spikes on average. The practical difficulty of measuring the CV(2) in rate modulated data can be overcome by a simple procedure of spike train demodulation which was tested in numerical simulations and in real spike trains. We propose to test neuronal spike trains for deviations from the null-hypothesis FF=CV(2). We show that cortical pyramidal neurons, recorded under controlled stationary input conditions in vitro, comply with this assumption. Performing a time-resolved joint analysis of CV(2) and FF of a single unit recording from the motor cortex of a behaving monkey we demonstrate how the dynamic change of their quantitative relation can be interpreted with respect to neuron intrinsic and extrinsic factors that influence cortical variability in vivo. Finally, we discuss the effect of several additional factors such as serial interval correlation and refractory period on the empiric relation of FF and CV(2).

Spike timing and reliability in cortical pyramidal neurons: effects of EPSC kinetics, input synchronization and background noise on spike timing.

In vivo studies have shown that neurons in the neocortex can generate action potentials at high temporal precision. The mechanisms controlling timing and reliability of action potential generation in neocortical neurons, however, are still poorly understood. Here we investigated the temporal precision and reliability of spike firing in cortical layer V pyramidal cells at near-threshold membrane potentials. Timing and reliability of spike responses were a function of EPSC kinetics, temporal jitter of population excitatory inputs, and of background synaptic noise. We used somatic current injection to mimic population synaptic input events and measured spike probability and spike time precision (STP), the latter defined as the time window (Deltat) holding 80% of response spikes. EPSC rise and decay times were varied over the known physiological spectrum. At spike threshold level, EPSC decay time had a stronger influence on STP than rise time. Generally, STP was highest (6 ms) triggered spikes at lower temporal precision (>or=6.58 ms). We found an overall linear relationship between STP and spike delay. The difference in STP between fast and slow compound EPSCs could be reduced by incrementing the amplitude of slow compound EPSCs. The introduction of a temporal jitter to compound EPSCs had a comparatively small effect on STP, with a tenfold increase in jitter resulting in only a five fold decrease in STP. In the presence of simulated synaptic background activity, precisely timed spikes could still be induced by fast EPSCs, but not by slow EPSCs.