High Schools Struggle to Adopt Evidence Based Practices for the Management of Exertional Heat Stroke.

CONTEXT: Exertional heat stroke (EHS) deaths can be prevented by adhering to best practices. OBJECTIVE: We investigated the adoption of policies and procedures for the recognition and treatment of EHS and the factors influencing the adoption of a comprehensive policy. DESIGN: Cross Sectional. SETTING: Online questionnaire. PATIENTS OR OTHER PARTICIPANTS: Athletic trainers (ATs) practicing in the high school (HS) setting. MAIN OUTCOME MEASURE(S): Using the NATA Position Statement: Exertional Heat Illness, an online questionnaire was developed and distributed to ATs to ascertain their schools' current written policies for the use of rectal temperature and cold-water immersion (CWI). The Precaution Adoption Process Model (PAPM), allowed for responses to be presented across the various health behavior stages ("Unaware if have the policy", "Unaware for the need for the policy", "Unengaged", "Undecided", "Decided Not to Act", "Decided to Act", "Acting", and "Maintaining"). Additional questions included perceptions of facilitators and barriers. Data are presented as proportions. RESULTS: A total of 531 ATs completed this questionnaire. Overall, 16.9% (n=62) report adoption of all components for proper recognition and treatment of EHS. The policy component with the highest adoption was "cool first transport second" with 74.1% (n=110) of ATs reporting "Acting" or "Maintaining." The most variability in the PAPM responses was for a rectal temperature policy, with 28.7% (n=103) of ATs reporting "Decided not to Act" and 20.1% (n=72) reporting "Maintaining." The most commonly reported facilitator and barrier for rectal temperature included state mandate from state HS athletics association (n=274,51.5%) and resistance or apprehension from parents or legal guardians (n=311,58.5%), respectively. CONCLUSIONS: ATs in the HS setting appear to be struggling to adopt a comprehensive EHS strategy, with rectal temperature continuing to appear as the biggest undertaking. Tailored strategies based on health behavior, facilitators and barriers may aid in changing this paradigm.

An incidental finding in newborn screening leading to the diagnosis of a patient with ECHS1 mutations.

Short-chain enoyl-CoA hydratase (ECHS1) is a mitochondrial beta-oxidation enzyme involved in the metabolism of acyl-CoA fatty acid esters, as well as in valine metabolism. ECHS1 deficiency has multiple manifestations, including Leigh syndrome early at birth or in childhood with poor prognosis, to cutis laxa, exercise-induced dystonia and congenital lactic acidosis. Here we describe the case of a newborn with mutations in ECHS1 that caught our attention after the incidental finding of 3-hydroxy-butyryl\3-hydroxy-isobutyryl\malonylcarnitine (C4OH\C3DC) and tiglylcarnitine (C5:1) on blood spot in the newborn screening (NBS) program. Diagnosis was suspected based on the analysis of organic acids on dried urine spot. A moderate increase of 2-methyl-2,3-dihydroxybutyric acid, was detected, which is a known marker of this disease. Exome analysis showed c.404A>G (p.Asn135Ser) mutation in homozygosis in the ECHS1 gene. The child was therefore admitted to the hospital. Initial examination showed little response to auditory stimuli and mild hypertonia of the extremities. Clinical deterioration was evident at 4 months of age, including neurological and cardiac involvement, and the patient died at 5 months of age. This case illustrates how an incidental detection in the NBS Program can lead to the diagnosis ECHS1 deficiency. Although it is a severe disease, with no treatment available, early detection would allow adequate genetic counseling avoiding the odyssey that suffered most of these families.

[The neural networks of facial expression]. / Redes neuronales de la expresion facial.

INTRODUCTION: Face perception involves a broad network of connections between cortical and subcortical regions for the exchange and synchronization of information using white matter fibers. This precise communication system can be affected by the structures and the pathways that connect them. AIMS: To establish the neural substrate underlying the perception of facial expression and to analyze the different factors involved in modulating the integrity of this neural network, with the aim being to introduce improvements into rehabilitation programs. DEVELOPMENT: When the complex neural network involved in the perception of facial expression is altered by trauma, neurodegenerative disorders, developmental disorders, social isolation or negative contexts, the adaptive capacity to interact with the environment also deteriorates. CONCLUSIONS: Maintaining the neural network integrity responsible for processing facial expression requires considering different variables. To a greater or lesser extent, these variables modify the structure or function of neural networks, such as aerobic training, transcranial magnetic stimulation, transcranial electrical stimulation, and learning. These variables are affected by age, and the type and course of the condition or generator context, and raise the need for rehabilitation protocols that are adapted and designed to delimit the deficient neuronal substrate.

TITLE: Redes neuronales de la expresion facial.Introduccion. La percepcion de caras involucra una amplia red de conexiones entre regiones corticales y subcorticales que intercambian y sincronizan informacion a traves de haces de sustancia blanca. Este preciso sistema de comunicacion puede verse afectado tanto a traves de las propias estructuras como por las vias que las conectan. Objetivos. Delimitar el sustrato neuronal que subyace a la percepcion de la expresion facial y analizar los diferentes factores que participan modulando la integridad de esta red neuronal, con el fin de proponer mejoras en los programas de rehabilitacion. Desarrollo. Cuando la compleja red de conexiones que participa en la percepcion de la expresion facial se altera por traumatismos, patologias neurodegenerativas, trastornos del desarrollo, incluso por aislamiento social o contextos negativos, se deteriora tambien la capacidad para interactuar de manera adaptativa con el entorno. Conclusiones. La posibilidad de restaurar la integridad de la red neuronal encargada del procesamiento de la expresion facial pasa por tener en cuenta diferentes variables que en mayor o menor grado se han mostrado capaces de modificar la estructura o funcionalidad de las redes neuronales, como el entrenamiento aerobico, la estimulacion magnetica transcraneal, la estimulacion electrica transcraneal y el aprendizaje, sin bien estas variables estarian condicionadas por la edad, el tipo y evolucion del trastorno o el contexto generador, lo que plantearia la necesidad de protocolos de rehabilitacion ajustados y orientados a delimitar el sustrato neuronal del deficit.

Inhibition of PKC-dependent extracellular Ca2+ entry contributes to the depression of contractile activity in long-term pressure-overloaded endothelium-denuded rat aortas

We examined the contractile responsiveness of rat thoracic aortas under pressure overload after long-term suprarenal abdominal aortic coarctation (lt-Srac). Endothelium-dependent angiotensin II (ANG II) type 2 receptor (AT2R)-mediated depression of contractions to ANG II has been reported in short-term (1 week) pressure-overloaded rat aortas. Contractility was evaluated in the aortic rings of rats subjected to lt-Srac or sham surgery (Sham) for 8 weeks. ANG I and II levels and AT2R protein expression in the aortas of lt-Srac and Sham rats were also evaluated. lt-Srac attenuated the contractions of ANG II and phenylephrine in the aortas in an endothelium-independent manner. However, lt-Srac did not influence the transient contractions induced in endothelium-denuded aortic rings by ANG II, phenylephrine, or caffeine in Ca2+-free medium or the subsequent tonic constrictions induced by the addition of Ca2+ in the absence of agonists. Thus, the contractions induced by Ca2+ release from intracellular stores and Ca2+ influx through stored-operated channels were not inhibited in the aortas of lt-Srac rats. Potassium-elicited contractions in endothelium-denuded aortic rings of lt-Srac rats remained unaltered compared with control tissues. Consequently, the contractile depression observed in aortic tissues of lt-Srac rats cannot be explained by direct inhibition of voltage-operated Ca2+ channels. Interestingly, 12-O-tetradecanoylphorbol-13-acetate-induced contractions in endothelium-denuded aortic rings of lt-Srac rats were depressed in the presence but not in the absence of extracellular Ca2+. Neither levels of angiotensins nor of AT2R were modified in the aortas after lt-Srac. The results suggest that, in rat thoracic aortas, lt-Srac selectively inhibited protein kinase C-mediated activation of contraction that is dependent on extracellular Ca2+ entry.

Inhibition of PKC-dependent extracellular Ca2+ entry contributes to the depression of contractile activity in long-term pressure-overloaded endothelium-denuded rat aortas.

We examined the contractile responsiveness of rat thoracic aortas under pressure overload after long-term suprarenal abdominal aortic coarctation (lt-Srac). Endothelium-dependent angiotensin II (ANG II) type 2 receptor (AT2R)-mediated depression of contractions to ANG II has been reported in short-term (1 week) pressure-overloaded rat aortas. Contractility was evaluated in the aortic rings of rats subjected to lt-Srac or sham surgery (Sham) for 8 weeks. ANG I and II levels and AT2R protein expression in the aortas of lt-Srac and Sham rats were also evaluated. lt-Srac attenuated the contractions of ANG II and phenylephrine in the aortas in an endothelium-independent manner. However, lt-Srac did not influence the transient contractions induced in endothelium-denuded aortic rings by ANG II, phenylephrine, or caffeine in Ca2+-free medium or the subsequent tonic constrictions induced by the addition of Ca2+ in the absence of agonists. Thus, the contractions induced by Ca2+ release from intracellular stores and Ca2+ influx through stored-operated channels were not inhibited in the aortas of lt-Srac rats. Potassium-elicited contractions in endothelium-denuded aortic rings of lt-Srac rats remained unaltered compared with control tissues. Consequently, the contractile depression observed in aortic tissues of lt-Srac rats cannot be explained by direct inhibition of voltage-operated Ca2+ channels. Interestingly, 12-O-tetradecanoylphorbol-13-acetate-induced contractions in endothelium-denuded aortic rings of lt-Srac rats were depressed in the presence but not in the absence of extracellular Ca2+. Neither levels of angiotensins nor of AT2R were modified in the aortas after lt-Srac. The results suggest that, in rat thoracic aortas, lt-Srac selectively inhibited protein kinase C-mediated activation of contraction that is dependent on extracellular Ca2+ entry.

Gut microbiota composition is associated with body weight, weight gain and biochemical parameters in pregnant women.

Obesity is associated with complications during pregnancy and increased health risks in the newborn. The objective of the present study was to establish possible relationships between gut microbiota, body weight, weight gain and biochemical parameters in pregnant women. Fifty pregnant women were classified according to their BMI in normal-weight (n 34) and overweight (n 16) groups. Gut microbiota composition was analysed by quantitative real-time PCR in faeces and biochemical parameters in plasma at 24 weeks of pregnancy. Reduced numbers of Bifidobacterium and Bacteroides and increased numbers of Staphylococcus, Enterobacteriaceae and Escherichia coli were detected in overweight compared with normal-weight pregnant women. E. coli numbers were higher in women with excessive weight gain than in women with normal weight gain during pregnancy, while Bifidobacterium and Akkermansia muciniphila showed an opposite trend. In the whole population, increased total bacteria and Staphylococcus numbers were related to increased plasma cholesterol levels. Increased Bacteroides numbers were related to increased HDL-cholesterol and folic acid levels, and reduced TAG levels. Increased Bifidobacterium numbers were related to increased folic acid levels. Increased Enterobacteriaceae and E. coli numbers were related to increased ferritin and reduced transferrin, while Bifidobacterium levels showed the opposite trend. Therefore, gut microbiota composition is related to body weight, weight gain and metabolic biomarkers during pregnancy, which might be of relevance to the management of the health of women and infants.

Conversion from bladder to enteric drainage for complications after pancreas transplantation.

OBJECTIVE: Bladder drainage (BD) of exocrine secretions is associated with urological and pancreatitis complications. Herein we have analyzed our experience with conversion from BD to enteric drainage (ED). PATIENTS AND METHODS: From March 1995 to September 2008, 118 patients underwent pancreas transplantation. There were 68 men and 50 women of a overall mean age at transplantation of 37.8 years. There were 66 patients with bladder drainage (BD) and 52 with enteric drainage (ED). RESULTS: Eight of 66 BD pancreas recipients (12.1%) underwent ED conversion. The mean time from pancreas transplantation to ED conversion was 29.3 +/- 30.6 months (range, 1-91 months). The major indications for conversion were recurrent reflux pancreatitis and chronic urinary tract infections in 7 patients; metabolic acidosis in 8; urethritis with severe perineoscrotal swelling in 1; and duodenocystostomy leak in 1. A comparative analysis of converted ED and not converted BD showed only a significantly prolonged period in the intensive care unit for patients who needed ED conversion (89 vs 47 hours; P < .01). Only 1 patient showed a duodenoenteric leak and peritonitis after conversion that required removal of the pancreas graft. The remaining 7 patients did not develop any postoperative complications and are currently well, showing normal pancreas graft function at a mean follow-up of 51.7 months after ED conversion. Patient and graft survivals were 100% and 87.5%, respectively. After ED conversion all urological complications disappeared; patients discontinued the use of oral bicarbonate. CONCLUSION: ED conversion in pancreas transplant recipients with urological and reflux pancreatitis complications was a safe, effective procedure.

Relaparotomy after pancreas transplantation: causes and outcomes.

INTRODUCTION: Surgical complications after pancreas transplantation, and subsequently relaparotomies, are frequently associated with graft loss, important morbidities, and occasionally patient death. PATIENTS AND METHODS: From March 1995 to September 2008, 118 diabetic patients underwent pancreas transplantation: 109 simultaneous pancreas-kidney and nine pancreas after kidney. There were 68 men and 50 women. Mean age at transplantation was 37.8 +/- 7.8 years (range = 25-66). We analyzed donor and recipient characteristics, rate of relaparotomies, risk factors, as well as patient and graft survivals. RESULTS: Forty patients (33.9%) underwent one or more relaparotomies. The causes for relaparotomy were: graft thrombosis in 15 patients (12.7%), bleeding in 14 (11.9%), duodenal stump leak in 7 (5.9%), severe pancreatitis and/or abscess in 5 (4.2%), and small bowel obstruction in 3 (2.5%). Graft pancreatectomy was performed in 52.5% (21 patients). The causes of graft loss were: graft thrombosis in 15 patients (12.7%), bleeding in 14 (11.9%), and duodenal stump leaks in 7 (5.9%). Mortality rate after relaparotomy was 3.38% (four patients). Relaparotomy rate for thrombosis was higher among the portoiliac than the portocaval vein anastomosis group (20.0% vs 10.2%; P = NS), and significantly higher for the bladder drainage than the enteric drainage technique (18.2% vs 5.8%; P < .05). Patients without relaparotomy experienced a significantly higher 5-year graft survival rate than those who underwent relaparotomy (87.2% vs 37.9%; P < .001), but 5-year patient survivals were similar (96.8% without relaparotomy vs 89.6% with relaparotomy). CONCLUSIONS: Abdominal complications and the necessity for relaparotomy were associated with important morbidity and significantly reduced pancreas graft survival.

[An electro-stimulating oral splint for dry mouth treatment].

Dentists encounter regularly patients with xerostomia, which is the accepted term for dry mouth complaint. Left untreated, xerostomia can lead to psychosocial distress and to impaired quality of life. Oral complications of the most frequent cause of xerostomia, salivary gland hypofunction, include dental caries and candidiasis. In addition, quality of life is significantly hampered. The etiology of xerostomia is multiple, but the most common conditions are Sjögren's syndrome, radiotherapy to the head and neck and use of medications. Current therapies offered by dentists rely on saliva substitutes and stimulants such as chewing gum, and are somewhat limited by their short-term efficacy. Oral mucosal electro-stimulation increases salivary secretion and relieves symptoms of dry mouth in patients with xerostomia. Therefore, intra-oral electronic devices have been developed aimed at stimulating salivary gland function. They offer promise as an optional safe and non-chemical treatment of xerostomia.

Determination of pesticides in olives by gas chromatography using different detection systems.

A multiresidue method has been developed and optimized for the quantitative analysis of 32 pesticides in olives. The extraction was based on homogenization with light petroleum using a high speed homogenizer. A gel permeation chromatography (GPC) clean-up process with ethyl acetate/cyclohexane (1:1) as mobile phase was applied to the extracts to separate the low-molecular mass pesticides from the high-molecular mass fat constituents of the oil. The target compounds were quantified in the final extract by gas chromatography (GC) using thermoionic specific detection (TSD) and electron-capture detection (ECD). In the case of positive samples, the amounts found were confirmed by GC-MS/MS. The obtained recovery (with mean values between 70 and 121, 71 and 114, and 82 and 134% for ECD, TSD and MS/MS systems, respectively) and RSD values (repeatability, n=10) below 16% in all cases confirm the usefulness of the proposed method for the analysis of this complex sample. Diuron, terbuthylazine and endosulfan sulfate were the most frequently detected residues in olive samples collected during the harvest 2004-2005. Finally, in order to know the proportion of pesticides that are transferred to the oil during olive oil production in olive mills, obtained results in some of the sampled olives applying the proposed method were compared to levels found in the corresponding olive oil, which was obtained by means of the Abencor method.

[Evaluation of a pharmaceutical care program to improve adherence to antiretroviral therapy]. / Evaluación de un programa de atención farmacéutica dirigido a mejorar la adherencia al tratamiento antirretroviral.

OBJECTIVE: To establish the impact of a pharmaceutical care program on the improvement of adherence to antiretroviral therapy, and on patient immunologic and virologic outcome. MATERIALS AND METHODS: A multicenter, observational, prospective study in a HIV-infected patient cohort under treatment with antiretrovirals selected by random sampling in 19 Spanish hospitals. The study lasted 12 months, in which the program was applied through a baseline preprocedural visit and 4 quarterly visits. Adherence estimation was based on pill counting. An adherence > or = 90, or > or = 95% was considered adequate (in two time points). RESULTS: 541 patients were included, most of them were males (68.8%) between 20 and 78 years of age. Major risk groups included injecting drug users (43.4%) and heterosexuals (29.4%). Sixty percent had already received treatment for more than 3 years. Mean baseline viral load and CD4 count values were 32,866 copies/ml and 485 cells/mm3, respectively. Throughout the study a slight increase in the percentage of adherent patients was seen; however, statistical significance was not reached (64.3 and 79.2% of patients showed an adherence > 95 and > 90%, respectively, during the fourth quarter, versus 59.8 and 75.5% at baseline). A statistically significant decrease in viral load and increase in CD4 cells was seen following program application. The percentage of patients with a viral load < 200 copies/ml was 72.2, 76.7, and 75.0% at the 2nd, 3rd, and 4th quarters, respectively, versus 64.2% at baseline. CD4 cell counts increased by 50 cells/mm3 on average from the start to the end of follow-up. CONCLUSIONS: Patients included in the program had a good immunologic and virologic outcome, and a trend towards an increased percentage of patients with good adherence was also seen. These results confirm the need to implement follow-up programs for patients receiving antiretrovirals in order to ensure maximum therapeutic benefits.

Genetic diversity in wild Spanish populations of Thinopyrum junceum and Thinopyrum junceiforme using endosperm proteins and PCR-based markers.

The genetic variation of sixteen wild, Spanish populations of Thinopyrum junceum and Thinopyrumjunceiforme and their interspecific relationships were analyzed. The relationships between these species and the diploids T. bessarabicum and T. elongatum were also investigated. The number of phenotypes and the composition of bands yielded by the electrophoretic separation of endosperm proteins were used to estimate intra- and interpopulational variability. DNA polymorphism generated by 24 arbitrary 10-mer primers and 14 specific 20-mer primers was used to determine interpopulational variability and interspecific relationships. Jaccard's coefficient of similarity was used to analyze presence and absence data in the DNA polymorphism and endosperm protein determinations of individual plants. Pearson's product-moment correlation coefficient was used to analyse interpopulational variation using endosperm protein band frequency data. Dendrograms were constructed using an unweighted pair group method with arithmetical average (UPGMA). The high level of intrapopulational variability found in T. junceum and T. junceiforme was inconsistent with the traditional classification of these species as self-pollinating. The level of interpopulational variation varied according to the degree of polymorphism of the corresponding markers. The endosperm proteins and random amplified polymorphic DNAs (RAPDs) proved to be the most polymorphic markers to those used although only the former were able to distinguish between the different populations. Interspecific relationships were consistently confirmed by all the PCR-based markers, and were also in agreement with the results of other authors.

Identification of two homologous antigenic peptides derived from L1 HPV-16 and 18 proteins specific for the HLA-B*3901 allele.

In this work we present evidence that the homologous peptides IHSMNSTIL and IHSMNSSIL derived from L1 HPV-16 and 18 proteins respectively, and with high specificity for the allele HLA-B*3901, according with an algorithm prediction program, induced T cell stimulation in patients with advanced cervical cancer positive for HPV-16 or 18 infection and for the HLA-B*3901 allele. Interestingly, T lymphocytes derived from a patient with HPV-18 infection and stimulated with the peptide IHSMNSTIL were capable to kill a cervical cancer cell line named Rova, derived from the tumor of the same patient. In addition, the cytotoxic activity was strongly increased when this cell line was previously treated with hrIFN-gamma. These results suggest that the CTL immune response to L1 HPV-16 and 18 protein derived epitopes is maintained in patients with advanced cervical cancer within specific alleles, and opens the possibility that homologous epitopes may be used in the generation of prophylactic vaccines for cervical tumors bearing different HPV-types.

Anomalías del sistema urinario / Anomalies of the urinary system

Se realiza una descripción de las principales malformaciones del sistema nefrourológico: Agenesia renal, Ectopia renal, Riñón en herradura, Displasia renales, Hidronefrosis y Anomalías dilatadas con sus características de diagnóstico intraútero. (AU)

Hipertiroidismo en la enfermedad de graves-basedow. ¿podemos predecir la remisión? / Hyperthiroidism in Graves-Basedow' s disease. Can we predict remission?

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Pharmacokinetic interaction between nevirapine and rifampicin in HIV-infected patients with tuberculosis.

To determine whether rifampicin reduces serum concentrations of nevirapine and whether nevirapine modifies serum concentrations of rifampicin, levels of these agents were determined at steady state by high-performance liquid chromatography in 10 HIV-infected patients with tuberculosis. The median area under the curve (AUC) 0-12h of nevirapine before and after rifampicin was 56.2 and 32.8 microg/ml per hour, respectively ( p =.04). This represents a 31% reduction in serum nevirapine concentrations. The C(max) decreased from 5.6 to 4.5 microg/ml ( p =.04), which represented a 36% reduction. A 21% decrease in the C(min) was not statistically significant. Exposure to rifampicin did not significantly differ between those patients who were receiving and were not receiving nevirapine. However, our study shows that rifampicin reduces serum exposure to nevirapine. The clinical implications for this reduction remain to be established. Given that the lowest trough serum concentration of nevirapine exceeded by more than 40 times the protein binding adjusted median infective dose (IC(50)) of wild-type HIV in all patients, we suggest that there is no need to increase nevirapine dosage when it is given with rifampicin.

Rifampin reduces concentrations of trimethoprim and sulfamethoxazole in serum in human immunodeficiency virus-infected patients.

To determine whether rifampin reduces concentrations of trimethoprim (TMP) and sulfamethoxazole (SMX) in serum of human immunodeficiency virus (HIV)-infected persons, levels of these agents were determined by high-performance liquid chromatography before and after more than 12 days of standard antituberculosis treatment for 10 patients who had been taking one double-strength tablet of co-trimoxazole once daily for more than 1 month. Statistically significant, 47 and 23% decreases in TMP and SMX mean areas under the concentration-time curve from 0 to 24 h (AUC(0-24)), respectively, were observed after administration of rifampin. N-Acetyl-SMX profiles without and with rifampin were similar. The steady-state AUC(0-24) metabolite/parent drug ratio increased by 32% with rifampin administration. Our study shows that rifampin reduces profiles of TMP and SMX in serum of HIV-infected patients.

[Anemia secondary to lead poisoning. Our experience with 12 cases]. / Anemia secundaria a intoxicación por plomo. Nuestra experiencia a propósito de 12 casos.

BACKGROUND: A decrease in hemoglobin production is probably the main cause of anemia observed in patients poisoned by lead although hemolysis caused by the effects on membrane or by inhibition of other enzymes such as 5'-pyrimidine nucleotidase may also play a key role. The main lead exposure source comes from lead use in industry; however, outside occupational exposure, food and water consumption is the main cause of lead exposure. MATERIALS AND METHODS: Clinical and analytical characteristics are reported of twelve patients with lead poisoning of food and water source occurred in the last 14 years in two health areas in north Extremadura. RESULTS: The exposure source was wine, vinegar and olives in one case, hand-made brandy in five, water consumption in houses with lead piping, and in two cases the cause was not determined. The clinical picture was similar in all cases with the exception of one female patient who had encephalopathy and hepatic failure. Diagnosis was suggested by regenerative anemia with basophilic stippling of erythrocytes. All patients received oral calcium disodium EDTA. CONCLUSIONS: Lead poisoning in non-industrial areas is a rare entity. Nevertheless, owing to the use of artisanal procedures for wine elaboration and derivatives, its occurrence is increasing. In a patient with symptoms of lead poisoning and regenerative anemia, a peripheral blood smear should be reviewed.