Dating the evolution of the complex thalloid liverworts (Marchantiopsida): total-evidence dating analysis supports a Late Silurian-Early Devonian origin and post-Mesozoic morphological stasis.

Divergence times based on molecular clock analyses often differ from those derived from total-evidence dating (TED) approaches. For bryophytes, fossils have been excluded from previous assessments of divergence times, and thus, their utility in dating analyses remains unexplored. Here, we conduct the first TED analyses of the complex thalloid liverworts (Marchantiopsida) that include fossils and evaluate macroevolutionary trends in morphological 'diversity' (disparity) and rates. Phylogenetic analyses were performed on a combined dataset of 130 discrete characters and 11 molecular markers (sampled from nuclear, plastid and mitochondrial genomes). Taxon sampling spanned 56 extant species - representing all the orders within Marchantiophyta and extant genera within Marchantiales - and eight fossil taxa. Total-evidence dating analyses support the radiation of Marchantiopsida during Late Silurian-Early Devonian (or Middle Ordovician when the outgroup is excluded) and that of Ricciaceae in the Middle Jurassic. Morphological change rate was high early in the history of the group, but it barely increased after Late Cretaceous. Disparity-through-time analyses support a fast increase in diversity until the Middle Triassic (c. 250 Ma), after which phenotypic evolution slows down considerably. Incorporating fossils in analyses challenges previous assumptions on the affinities of extinct taxa and indicates that complex thalloid liverworts radiated c. 125 Ma earlier than previously inferred.

Liverwort oil bodies: diversity, biochemistry, and molecular cell biology of the earliest secretory structure of land plants.

Liverworts are known for their large chemical diversity. Much of this diversity is synthesized and enclosed within oil bodies (OBs), a synapomorphy of the lineage. OBs contain the enzymes to biosynthesize and store large quantities of sesquiterpenoids and other compounds while limiting their cytotoxicity. Recent important biochemical and molecular discoveries related to OB formation, diversity, and biochemistry allow comparison with other secretory structures of land plants from an evo-devo perspective. This review addresses and discusses the most recent advances in OB origin, development, and function towards understanding the importance of these organelles in liverwort physiology and adaptation to changing environments. Our mapping of OB types and chemical compounds to the current liverwort phylogeny suggests that OBs were present in the most recent common ancestor of liverworts, supporting that OBs evolved as the first secretory structures in land plants. Yet, we require better sampling to define the macroevolutionary pattern governing the ancestral type of OB. We conclude that current efforts to find molecular mechanisms responsible for the morphological and chemical diversity of secretory structures will help understand the evolution of each major group of land plants, and open new avenues in biochemical research on bioactive compounds in bryophytes and vascular plants.

Defying death: incorporating fossils into the phylogeny of the complex thalloid liverworts (Marchantiidae, Marchantiophyta) confirms high order clades but reveals discrepancies in family-level relationships.

In recent years, the use of extensive molecular and morphological datasets has clarified the phylogenetic relationships among the orders of complex thalloid liverworts (Marchantiidae). However, previous studies excluded extinct taxa; thereby, undersampling the actual taxonomic diversity of the group. Here, we conducted a total-evidence analysis of Marchantiidae incorporating fossils. The combined dataset consisted of 11 genes-sampled from the nuclear, mitochondrial and plastid genomes-and 128 morphological characters. Sixty-two species, representing all classes and orders within Marchantiophyta and genera within Marchantiidae were included in the analyses. Six fossils were scored from literature: two assigned to the outgroup (Metzgeriothallus sharonae and Pallaviciniites sandaolingensis) and four to the ingroup (Marchantites cyathodoides, M. huolinhensis, Ricciopsis ferganica and R. sandaolingensis). Tree searches were conducted using parsimony as the optimality criterion. Clade sensitivity was assessed across a wide range of weighting regimes. Also, we evaluated the influence of fossils on the inferred topologies and branch support. Our results were congruent with previously inferred clades above the order level: Neohodgsoniales was sister to a clade formed by Sphaerocarpales and Marchantiales. However, relationships among families within Marchantiales contradicted recent studies. For instance, a clade consisting of Monosoleniaceae, Wiesnerellaceae and Targioniaceae was sister to the morphologically simple taxa instead of being nested within them as in previous studies. Novel synapomorphies were found for several clades within Marchantiales. Outgroup fossils were more influential than Marchantiidae fossils on overall topologies and branch support values. Except for a single weighting scheme, sampling continuous characters and down-weighting characters improved fossil stability. Ultimately, our results challenge the widespread notion that bryophyte fossils are problematic for phylogenetic inference.

A sentinel COVID-19 case in Houston, Texas: Informing frontline emergency department screening and preparedness.

In December 2019, a cluster of severe pneumonia cases of unknown cause was reported in Wuhan, Hubei province, China. A novel strain of coronavirus belonging to the same family of viruses that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) was identified. In February 2020, cases began being identified in the United States. We describe a sentinel COVID-19 patient in Houston, Texas, who first presented on March 1, 2020. The patient did not meet criteria for a Person Under Investigation (PUI) as recommended by the Centers for Disease Control and Prevention (CDC) at the time. This case has broad implications for emergency department screening and preparedness for COVID-19 and other future infectious diseases.

The Effect of Simulation Wars on EM Residents' Global Rating Scales and In-Training Examination Scores.

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) restricted the duty hours for residents training in 2004. With less time to learn medicine, residents may not develop the clinical reasoning skills needed. Simulation can provide a remedy for this lack of time by allowing residents to practice skills and develop clinical reasoning in a simulated environment. Simulation Wars (SimWars), a clinical reasoning simulation has been shown to improve clinical reasoning skills. The purpose of the study was to investigate the effect of Simulation Wars on In-Training Examination (ITE) Scores and Global Rating Scale (GRS) Scores in Emergency Medicine (EM) residents. METHODS: The Quasi-Experimental design was used in this retrospective study. The main comparison was between historical controls, the residents who did not participate in the Simulation Wars, and the intervention group comprised of residents who participated in the SimWars. RESULTS: A total of 127 residents were participants in this study including 70 from the intervention and 57 from the historical control group. There were no significant differences found in GRS scores between both groups except for Communication and Professionalism (p<0.001). No overall improvement in ITE scores for the control group and for the intervention group was found. Furthermore, within the intervention group, while comparing those residents who participated in certain subcategories of SimWars and those who did not, there was a significant improvement in ITE scores in the subcategories of Thoracic Disorders, Abdominal/Gastrointestinal, Trauma Disorders and OBGyn. CONCLUSION: SimWars in the subcategories of Abdominal/Gastrointestinal, Thoracic, OBGyn and Trauma were found to be associated with improved ITE scores in those subcategories. Since Emergency Medicine utilizes extensive clinical reasoning skills, SimWars may provide better educational opportunities for EM residents.

Reassessing the role of morphology in bryophyte phylogenetics: Combined data improves phylogenetic inference despite character conflict.

Morphological data has gained renewed attention and has been shown to be crucial in clarifying the phylogenetic relationship in a wide range of taxa. In the last decades, phylogenetic analyses of sequence-level data have radically modified the systematic schemes within bryophytes (early non-vascular land plants) and have revealed a widespread pattern of conflict with morphology-based classifications. Yet, a comprehensive evaluation of character conflict has not yet been performed in the context of combined matrices. In this study, we evaluate the impact of morphology on bryophyte phylogeny following a total-evidence approach across 10 published matrices. The analysed matrices span a wide range of bryophytes, taxonomic levels, gene sampling and number of morphological characters and taxa. Data conflict was addressed by measuring: (i) the topological congruence between individual partitions, (ii) changes in support values of the combined data relative to the molecular partition and (iii) clade stability. The association between these measures and the number of morphological characters per taxon (Nc/T ratio) and the proportion of non-fixed characters (i.e., inapplicable, polymorphic and missing data) was explored. In the individual partition analyses, the Nc/T ratio correlated positively with the topological congruence in six to seven datasets depending on the weighting scheme. The proportion of non-fixed cells had a minor influence on congruence between data partitions. The number of characters and proportion of non-fixed data varied significantly between morphological datasets that improved congruence between data types. This variation suggests that morphological datasets affect the results of combined analyses in different ways, depending on the taxa studied. Combined analyses revealed that, despite the low congruence values between partitions, integrating data types improves support values and stability. However, while non-fixed data had no negative effect on support values, stability was reduced as the proportion of non-fixed cells increased. Nc/T ratio was negatively associated with support values and it showed ambiguous responses in stability evaluations. Overall, the results indicate that adding morphology may contribute to the inference of phylogenetic relationships of bryophytes despite character conflict. Our findings suggest that merely comparing (a) morphology-based classifications with molecular phylogenies or (b) the outcome from individual data partitions can misestimate data conflict. These findings imply that analyses of combined data may provide conservative assessments of data conflict and, eventually, lead to an improved sampling of morphological characters in large-scale analyses of bryophytes.

Skin Autofluorescence Measurement in Subclinical Atheromatous Disease: Results from the ILERVAS Project.

AIM: Advanced glycation end-products (AGEs) have been involved in the atherogenic process in the high-risk population. The goal of this study was to demonstrate that AGEs are related to subclinical atheromatous disease in subjects with low to moderate vascular risk. METHODS: A cross-sectional study in which 2,568 non-diabetic subjects of both sexes without cardiovascular disease were included. Subcutaneous content of AGEs was assessed by skin autofluorescence (SAF) and subclinical atheromatous disease was measured by assessing the atheromatous plaque burden in carotid and femoral regions using ultrasonography. In addition, serum pentosidine, carboxymethyl-lysine (CML) and AGE receptors (RAGE) were assessed in a nested case-control study with 41 subjects without plaque and 41 individuals subjects with generalized disease. RESULTS: Patients with atheromatous plaque had a higher SAF than those with no plaque (1.9 [1.7 to 2.3] vs. 1.8 [1.6 to 2.1] arbitrary units (AU), p＜0.001). The SAF correlated with the total number of affected regions (r= 0.171, p＜0.001), increasing progressively from 1.8 [1.6 to 2.1] AU in those without atheromatous disease to 2.3 [1.9 to 2.7] AU in patients with ≥ 8 plaques (p＜0.001). A correlation was also observed between SAF and the total plaque area (r=0.113, p＜0.001). The area under the Receiver Operating Characteristic curve was 0.65 (0.61 to 0.68) for identifying male subjects with atheromatous disease. The multivariable logistic regression model showed a significant and independent association between SAF and the presence of atheromatous disease. However, no significant differences in serum pentosidine, CML, and RAGE were observed. CONCLUSIONS: Increased subcutaneous content of AGEs is associated with augmented atheromatous plaque burden. Our results suggest that SAF may provide clinically relevant information to the current strategies for the evaluation of cardiovascular risk, especially among the male population.

Combined phylogenetic analysis of the subclass Marchantiidae (Marchantiophyta): towards a robustly diagnosed classification.

The most extensive combined phylogenetic analyses of the subclass Marchantiidae yet undertaken was conducted on the basis of morphological and molecular data. The morphological data comprised 126 characters and 56 species. Taxonomic sampling included 35 ingroup species with all genera and orders of Marchantiidae sampled, and 21 outgroup species with two genera of Blasiidae (Marchantiopsida), 15 species of Jungermanniopsida (the three subclasses represented) and the three genera of Haplomitriopsida. Takakia ceratophylla (Bryophyta) was employed to root the trees. Character sampling involved 92 gametophytic and 34 sporophytic traits, supplemented with ten continuous characters. Molecular data included 11 molecular markers: one nuclear ribosomal (26S), three mitochondrial genes (nad1, nad5, rps3) and seven chloroplast regions (atpB, psbT-psbH, rbcL, ITS, rpoC1, rps4, psbA). Searches were performed under extended implied weighting, weighting the character blocks against the average homoplasy. Clade stability was assessed across three additional weighting schemes (implied weighting corrected for missing entries, standard implied weighting and equal weighting) in three datasets (molecular, morphological and combined). The contribution from different biological phases regarding node recovery and diagnosis was evaluated. Our results agree with many of the previous studies but cast doubt on some relationships, mainly at the family and interfamily level. The combined analyses underlined the fact that, by combining data, taxonomic enhancements could be achieved regarding taxon delimitation and quality of diagnosis. Support values for many clades of previous molecular studies were improved by the addition of morphological data. The long-held assumption that morphology may render spurious or low-quality results in this taxonomic group is challenged. The morphological trends previously proposed are re-evaluated in light of the new phylogenetic scheme.

The mossy north: an inverse latitudinal diversity gradient in European bryophytes.

It remains hotly debated whether latitudinal diversity gradients are common across taxonomic groups and whether a single mechanism can explain such gradients. Investigating species richness (SR) patterns of European land plants, we determine whether SR increases with decreasing latitude, as predicted by theory, and whether the assembly mechanisms differ among taxonomic groups. SR increases towards the south in spermatophytes, but towards the north in ferns and bryophytes. SR patterns in spermatophytes are consistent with their patterns of beta diversity, with high levels of nestedness and turnover in the north and in the south, respectively, indicating species exclusion towards the north and increased opportunities for speciation in the south. Liverworts exhibit the highest levels of nestedness, suggesting that they represent the most sensitive group to the impact of past climate change. Nevertheless, although the extent of liverwort species turnover in the south is substantially and significantly lower than in spermatophytes, liverworts share with the latter a higher nestedness in the north and a higher turn-over in the south, in contrast to mosses and ferns. The extent to which the similarity in the patterns displayed by spermatophytes and liverworts reflects a similar assembly mechanism remains, however, to be demonstrated.

COMPASS 31: a refined and abbreviated Composite Autonomic Symptom Score.

OBJECTIVE: To develop a concise and statistically robust instrument to assess autonomic symptoms that provides clinically relevant scores of autonomic symptom severity based on the well-established 169-item Autonomic Symptom Profile (ASP) and its validated 84-question scoring instrument, the Composite Autonomic Symptom Score (COMPASS). PATIENTS AND METHODS: We assessed the internal consistency of COMPASS using Cronbach α coefficients based on the ASP of 405 healthy control subjects recruited and seen in the Mayo Clinic Autonomic Disorders Center between March 1, 1995, and March 31, 2010. Applying a simplified scoring algorithm, we then used exploratory factor analysis with orthogonal rotation and eigenvalue calculations to extract internally consistent domains and to reduce dimensionality. This analysis was followed by expert revisions to eliminate redundant content and to retain clinically important questions and final assessment of the new instrument. RESULTS: The new simplified scoring algorithm alone resulted in higher Cronbach α values in all domains. Factor analysis revealed 7 domains with a total of 54 questions retained. Expert revisions resulted in further reduction of questions and domains with a remaining total of 31 questions in 6 domains (COMPASS 31). Measures of internal consistency were much improved compared to those for COMPASS. Following appropriate weighting, this instrument provides an autonomic symptom score from 0 to 100. CONCLUSION: COMPASS 31 is a refined, internally consistent, and markedly abbreviated quantitative measure of autonomic symptoms. It is based on the original ASP and COMPASS, applies a much simplified scoring algorithm, and is suitable for widespread use in autonomic research and practice.

Cutis laxa en una lactante / Cutis laxa in an infant

Se describe el caso clínico de una lactante de 18 meses de edad, quien fue atendida en la consulta externa del Hospital Oftalmológico "Amistad Argelia-Cuba" de la Wilaya de Djelfa en la República Democrática y Popular de Argelia, por caída de los párpados. En el examen físico se observó facies tosca, piel laxa, arrugada, caída e hiperextensible, con grandes pliegues, así como aspecto de envejecimiento, blefarocalasia y ectropion. No se detectaron alteraciones musculoesqueléticas, hernia inguinal o umbilical, ni otras manifestaciones gastrointestinales, genitourinarias o cardiorrespiratorias. Por las características clínicas se concluyó que la paciente presentaba cutis laxa.

The clinical case of an infant aged 18 months is described, who was attended in the Outpatient Department from "Amistad Argelia-Cuba" Ophthalmology Hospital of the Wilaya of Djelfa in the People's Democratic Republic of Algeria due to eyelid drooping. On physical examination coarse facies, hiperextensible and sagging, wrinkled lax skin with large folds were observed, as well as aging appearance, blepharochalasis and ectropion. There were not musculoskeletal changes, groin or umbilical hernia, or other gastrointestinal, genitourinary or cardiopulmonary manifestations. Taking into account clinical characteristics it was concluded that the patient presented with cutis laxa.

Cutis laxa en una lactante / Cutis laxa in an infant

Se describe el caso clínico de una lactante de 18 meses de edad, quien fue atendida en la consulta externa del Hospital Oftalmológico Amistad Argelia-Cuba de la Wilaya de Djelfa en la República Democrática y Popular de Argelia, por caída de los párpados. En el examen físico se observó facies tosca, piel laxa, arrugada, caída e hiperextensible, con grandes pliegues, así como aspecto de envejecimiento, blefarocalasia y ectropion. No se detectaron alteraciones musculoesqueléticas, hernia inguinal o umbilical, ni otras manifestaciones gastrointestinales, genitourinarias o cardiorrespiratorias. Por las características clínicas se concluyó que la paciente presentaba cutis laxa(AU)

The clinical case of an infant aged 18 months is described, who was attended in the Outpatient Department from Amistad Argelia-Cuba Ophthalmology Hospital of the Wilaya of Djelfa in the People's Democratic Republic of Algeria due to eyelid drooping. On physical examination coarse facies, hiperextensible and sagging, wrinkled lax skin with large folds were observed, as well as aging appearance, blepharochalasis and ectropion. There were not musculoskeletal changes, groin or umbilical hernia, or other gastrointestinal, genitourinary or cardiopulmonary manifestations. Taking into account clinical characteristics it was concluded that the patient presented with cutis laxa(AU)

Uniform demyelination and more severe axonal loss distinguish POEMS syndrome from CIDP.

OBJECTIVE: POEMS syndrome (the acronym reflects the common features: Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein and Skin changes) is a paraneoplastic disorder with a 'demyelinating' peripheral neuropathy that is often mistaken for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). The nerve conduction study (NCS) and electromyography (EMG) attributes that might differentiate POEMS from CIDP and lead to earlier therapeutic intervention were explored. METHODS: NCS/EMG of POEMS patients identified through retrospective review from 1960 to 2007 were compared with matched CIDP controls. RESULTS: 138 POEMS patients and 69 matched CIDP controls were compared. POEMS patients demonstrated length dependent reduction in compound muscle action potentials, low conduction velocities, prolonged distal latencies and prolonged F wave latencies. Compared with CIDP controls, POEMS patients demonstrated: (1) greater reduction of motor amplitudes, (2) greater slowing of motor and sensory conduction velocities, (3) less prolonged motor distal latencies, (4) less frequent temporal dispersion and conduction block, (5) no sural sparing, (6) greater number of fibrillation potentials in a length dependent pattern and (7) higher terminal latency indices (TLI). TLI ≥0.38 in the median nerve demonstrated a sensitivity of 70% and specificity of 77% in discriminating POEMS from CIDP. CONCLUSIONS: NCS/EMG of POEMS syndrome suggests both axonal loss and demyelination. Compared with CIDP, there is greater axonal loss (reduction of motor amplitudes and increased fibrillation potentials), greater slowing of the intermediate nerve segments, less common temporal dispersion and conduction block, and absent sural sparing. These findings imply that the pathology of POEMS syndrome is diffusely distributed (uniform demyelination) along the nerve where the pathology of CIDP is probably predominantly proximal and distal. Median motor TLI may be useful in clinically distinguishing these disorders.

Vereckei criteria used as a diagnostic tool by emergency medicine residents to distinguish between ventricular tachycardia and supra-ventricular tachycardia with aberrancy.

BACKGROUND: Accurate electrocardiographic (ECG) differentiation of ventricular tachycardia (VT) from supraventricular tachycardia with aberrancy (SVT-A) on ECG is key to therapeutic decision-making in the emergency department (ED) setting. OBJECTIVE: The goal of this study was to test the accuracy and agreement of emergency medicine residents to differentiate VT from SVT-A using the Vereckei criteria. METHODS: Six emergency medicine residents volunteered to participate in the review of 114 ECGs from 86 patients with a diagnosis of either VT or SVT-A based on an electrophysiology study. The resident reviewers initially read 12-lead ECGs blinded to clinical information, and then one week later reviewed a subset of the same 12-lead ECGs unblinded to clinical information. RESULTS: One reviewer was excluded for failing to follow study protocol and one reviewer was excluded for reviewing less than 50 blinded ECGs. The remaining four reviewers each read 114 common ECGs blinded to clinical data and their diagnostic accuracy for VT was 74% (sensitivity 70%, specificity 80%), 75% (sensitivity 76%, specificity 73%), 61% (sensitivity 81%, specificity 25%), and 68% (sensitivity 84%, specificity 40%). The intraclass correlation coefficient (ICC) was 0.31 (95% CI 0.22-0.42). Eliminating two of the four reviewers who left a disproportionately high number of ECGs unclassified resulted in an increase in overall mean diagnostic accuracy (70-74%) and agreement (0.31-0.50) in the two remaining reviewers. Three reviewers read 45 common ECGs unblinded to clinical information and had accuracies for VT 93%, 93% and 78%. CONCLUSION: The new single lead Vereckei criteria, when applied by emergency medicine residents achieved only fair-to-good individual accuracy and moderate agreement. The addition of clinical information resulted in substantial improvement in test characteristics. Further improvements (accuracy and simplification) of algorithms for differentiating VT from SVT-A would be helpful prior to clinical implementation.

Valores percentilares de peso, talla e índice de masa corporal en escolares argelinos de la Wilaya de Djelfa / Percentile values of weight, height and body mass index in Algerian schoolchildren of Wilaya de Djelfa

Se realizó un estudio descriptivo y transversal de 3 324 escolares argelinos de 5 a 14 años, pertenecientes a 10 comunas de la Wilaya de Djelfa en la República Argelina Democrática y Popular, atendidos por la Brigada Médica Cubana Vilma Espín Guillois desde septiembre de 2007 hasta mayo de 2009. La investigación se basó en determinar los percentiles de peso, talla e índice de masa corporal por edad y sexo de la mencionada población, según las normas cubanas y las referencias de la Organización Mundial de la Salud y el Centro Nacional de Estadísticas de la Salud, a partir de cuyos resultados se elaboraron las tablas correspondientes para poder evaluar el proceso de crecimiento y estado nutricional de todos los niños y niñas de esas edades en dicho país.

A descriptive and cross-sectional study was carried out in 3 324 Algerian schoolchildren aged between 5 to 14 years, belonging to 10 communes of Wilaya de Djelfa in the Democratic and Popular Republic of Algeria, attended by Vilma Espín Guillois Cuban Medical Brigade from September 2007 to May 2009. The investigation was based on determining the percentiles of weight, height and body mass index by age and sex of this population, according to the Cuban regulations and references of the World Health Organization and National Center for Health Statistics, from which results tables were made to evaluate the process of growth and nutritional status in children of those ages in this country.

Valores percentilares de peso, talla e índice de masa corporal en escolares argelinos de la Wilaya de Djelfa / Percentile values of weight, height and body mass index in Algerian schoolchildren of Wilaya de Djelfa

Se realizó un estudio descriptivo y transversal de 3 324 escolares argelinos de 5 a 14 años, pertenecientes a 10 comunas de la Wilaya de Djelfa en la República Argelina Democrática y Popular, atendidos por la Brigada Médica Cubana Vilma Espín Guillois desde septiembre de 2007 hasta mayo de 2009. La investigación se basó en determinar los percentiles de peso, talla e índice de masa corporal por edad y sexo de la mencionada población, según las normas cubanas y las referencias de la Organización Mundial de la Salud y el Centro Nacional de Estadísticas de la Salud, a partir de cuyos resultados se elaboraron las tablas correspondientes para poder evaluar el proceso de crecimiento y estado nutricional de todos los niños y niñas de esas edades en dicho país(AU)

A descriptive and cross-sectional study was carried out in 3 324 Algerian schoolchildren aged between 5 to 14 years, belonging to 10 communes of Wilaya de Djelfa in the Democratic and Popular Republic of Algeria, attended by Vilma Espín Guillois Cuban Medical Brigade from September 2007 to May 2009. The investigation was based on determining the percentiles of weight, height and body mass index by age and sex of this population, according to the Cuban regulations and references of the World Health Organization and National Center for Health Statistics, from which results tables were made to evaluate the process of growth and nutritional status in children of those ages in this country(AU)

Neurofibromatosis de von Recklinghausen en la niñez / Von Recklinghausen's neurofibromatosis in the childhood

Se presenta el caso clínico de una niña argelina de 7 años de edad, con exoftalmos del ojo derecho de 3 años de evolución, que acudió a la consulta externa del Hospital Oftalmológico Amistad Argelia-Cuba de la Willaya de Djelfa en la República Democrática y Popular de Argelia. En el examen físico se encontraron numerosas manchas de color café con leche diseminadas por todo el cuerpo y tumor exofítico palpebral del lado derecho; y en el oftalmológico especializado: nódulos de Lisch. Por medio de la tomografía axial computarizada de cráneo se comprobó un proceso tumoral intraocular y tumor palpebral derechos, que infiltraban los músculos oculomotores: oblicuo menor y externo derecho. Se concluyó que la paciente presentaba neurofibromatosis de von Recklinghausen.

The clinical case of a 7-year-old Algerian girl with 3 year-exophthalmos of the right eye is reported who went to the outpatient department of the Ophthalmology Hospital Amistad Argelia-Cuba from Wilaya de Djelfa in the Democratic and People's Republic of Algeria. On physical examination numerous coffee-and-milk spots spread throughout the body and lid exophytic tumor of the right side were found, and in the specialized ophthalmologic testing: Lisch nodules. Cranial computerized axial tomography revealed a right intraocular tumor process and right palpebral tumor infiltrating oculomotor muscles: inferior oblique and right external. It was concluded that the patient presented with von Recklinghausen's neurofibromatosis.

Neurofibromatosis de von Recklinghausen en la niñez / Von Recklinghausen's neurofibromatosis in the childhood

Se presenta el caso clínico de una niña argelina de 7 años de edad, con exoftalmos del ojo derecho de 3 años de evolución, que acudió a la consulta externa del Hospital Oftalmológico Amistad Argelia-Cuba de la Willaya de Djelfa en la República Democrática y Popular de Argelia. En el examen físico se encontraron numerosas manchas de color café con leche diseminadas por todo el cuerpo y tumor exofítico palpebral del lado derecho; y en el oftalmológico especializado: nódulos de Lisch. Por medio de la tomografía axial computarizada de cráneo se comprobó un proceso tumoral intraocular y tumor palpebral derechos, que infiltraban los músculos oculomotores: oblicuo menor y externo derecho. Se concluyó que la paciente presentaba neurofibromatosis de von Recklinghausen(AU)

The clinical case of a 7-year-old Algerian girl with 3 year-exophthalmos of the right eye is reported who went to the outpatient department of the Ophthalmology Hospital Amistad Argelia-Cuba from Wilaya de Djelfa in the Democratic and People's Republic of Algeria. On physical examination numerous coffee-and-milk spots spread throughout the body and lid exophytic tumor of the right side were found, and in the specialized ophthalmologic testing: Lisch nodules. Cranial computerized axial tomography revealed a right intraocular tumor process and right palpebral tumor infiltrating oculomotor muscles: inferior oblique and right external. It was concluded that the patient presented with von Recklinghausen's neurofibromatosis(AU)

Effect of position on valsalva maneuver: supine versus 20 degree position.

Blood pressure changes in response to the Valsalva maneuver (VM), which reflect the integrity of the baroreflex that regulates blood pressure. Performing this maneuver in the standard supine position often prevents adequate venous preload reduction, resulting in a rise rather than a fall in blood pressure, the "flat-top" Valsalva response. We determined whether performing the VM at a 20 degree angle of head-up tilt (20 degrees ) improves preload reduction, thereby reducing the frequency of flat-top responses, improving reflex vasoconstriction, and increasing the Valsalva ratio. One hundred thirty patients were evaluated in a prospective study. Each patient performed the VM in both supine and 20 degrees positions.Flat-top responses were present in 18% of subjects when supine. Twenty degree angle of head-up tilt position reduced the flat-top response by 87%. The components of the response that are dependent on preload reduction (Valsalva ratio and phases II_E, II_L, and IV) also showed significant improvement with 20 degrees .A 20 degree angle of tilt is sufficient to reduce venous preload, decreasing flat-top response rate and improving the Valsalva ratio and the morphology of the VM. We recommend this modification for laboratory evaluation of the VM, whenever a flat-top response is seen.