EFNS guideline on the management of status epilepticus in adults.

The objective of the current article was to review the literature and discuss the degree of evidence for various treatment strategies for status epilepticus (SE) in adults. We searched MEDLINE and EMBASE for relevant literature from 1966 to January 2005 and in the current updated version all pertinent publications from January 2005 to January 2009. Furthermore, the Cochrane Central Register of Controlled Trials (CENTRAL) was sought. Recommendations are based on this literature and on our judgement of the relevance of the references to the subject. Recommendations were reached by informative consensus approach. Where there was a lack of evidence but consensus was clear, we have stated our opinion as good practice points. The preferred treatment pathway for generalised convulsive status epilepticus (GCSE) is intravenous (i.v.) administration of 4-8 mg lorazepam or 10 mg diazepam directly followed by 18 mg/kg phenytoin. If seizures continue more than 10 min after first injection, another 4 mg lorazepam or 10 mg diazepam is recommended. Refractory GCSE is treated by anaesthetic doses of barbiturates, midazolam or propofol; the anaesthetics are titrated against an electroencephalogram burst suppression pattern for at least 24 h. The initial therapy of non-convulsive SE depends on type and cause. Complex partial SE is initially treated in the same manner as GCSE. However, if it turns out to be refractory, further non-anaesthetising i.v. substances such levetiracetam, phenobarbital or valproic acid should be given instead of anaesthetics. In subtle SE, in most patients, i.v. anaesthesia is required.

EFNS guideline on the management of status epilepticus.

The objective of the current paper was to review the literature and discuss the degree of evidence for various treatment strategies for status epilepticus (SE) in adults. We searched MEDLINE and EMBASE for relevant literature from 1966 to January 2005. Furthermore, the Cochrane Central Register of Controlled Trials (CENTRAL) was sought. Recommendations are based on this literature and on our judgement of the relevance of the references to the subject. Recommendations were reached by informative consensus approach. Where there was a lack of evidence but consensus was clear we have stated our opinion as good practice points. The preferred treatment pathway for generalised convulsive status epilepticus (GCSE) is intravenous (i.v.) administration of 4 mg of lorazepam or 10 mg of diazepam directly followed by 15-18 mg/kg of phenytoin or equivalent fosphenytoin. If seizures continue for more than 10 min after first injection another 4 mg of lorazepam or 10 mg of diazepam is recommended. Refractory GCSE is treated by anaesthetic doses of midazolam, propofol or barbiturates; the anaesthetics are titrated against an electroencephalogram burst suppression pattern for at least 24 h. The initial therapy of non-convulsive SE depends on the type and the cause. In most cases of absence SE, a small i.v. dose of lorazepam or diazepam will terminate the attack. Complex partial SE is initially treated such as GCSE, however, when refractory further non-anaesthetising substances should be given instead of anaesthetics. In subtle SE i.v. anaesthesia is required.

Planktonic primary production in a tidally influenced mangrove forest on the Pacific coast of Costa Rica.

The seasonal variation of planktonic primary productivity was measured during one year in the main channel in the interior part of the mangrove forest of the Estero de Morales (Estero de Punta Morales), a mangrove system located in the Golfo de Nicoya at the Pacific coast of Costa Rica. Samples were incubated at the surface, 0.5 m and 1.0 m depth and the "light and dark bottle technique" was employed. The annual gross primary productivity (PPg) was 457 and the net primary productivity (PPn) was 278 g C m(-2) a(-1). Daily PPg ranged from 0.29 to 3.88 and PPn from 0.12 to 2.76 g C m(-2) d(-1). The highest rates observed in May and September were due to red tide blooms. The seasonal variation of primary productivity inside the mangrove forest depends closely on the PP in the adjacent area of the upper Golfo de Nicoya. Obviously the PP was light-limited since the compensation depth in the ebb current was found at only 1 m depth. In the flood current it was somewhat deeper. The planktonic primary productivity inside the mangrove forest was completely restricted to the open channels. A simultaneous measurement demonstrated that PPn of the phytoplankton could not take place under the canopy of the mangroves. Additional studies on the time course of the oxygen concentration in the mouth of the main channel over 24 hrs demonstrated a relation between the O2 and the tidal curves. The ebb current had always lower O2 concentrations than the flood current, regardless of the time of the day. The difference to the foregoing high tide, however, was much smaller when the low tide occurred during the day. This indicates that under the canopy the net primary production and hence O2 liberation of the attached macro- and microalgae, together with the high PPn of the phytoplankton in the channels, helped the oxygen concentration not to decrease as far as during the night. Nevertheless it shows that the consumtion of organic material in the submersed part of the mangrove forest exceeds always its production.

The annual cycle of primary productivity in a tropical estuary: the inner regions of the Golfo de Nicoya, Costa Rica.

A one year cycle of primary productivity (PP) was studied using the "light and dark bottle" technique in the Golfo de Nicoya, located at 10 degrees N and 85 degrees W at the Pacific coast of Costa Rica. Samples were always incubated at 0, 1, 2, 3 and 4 m depth for 5 hrs from 8:30 till 13:30. The measurements were performed twice per month, first around high tide and one week later at low tide to account for tidal influences. This routine study was supplemented by special measurements about regional and short-term variations of primary productivity using the 14C-method, which mainly served to account for the shortcomings of the routinely employed incubation technique. The upper Golfo de Nicoya is an extremely productive, phytoplankton dominated estuarine system with an annual gross PP of 1037, a net PP of 610 and a community respiration of 427 g C m(-2) a(-1). Highest monthly PP values occurred during the dry season and at the beginning of the rainy season. Peaks in primary productivity coincided with massive blooms of red tide forming algae. Internal biological dynamics, estuarine circulation and land run-off are the most important nutrient sources. High water turbidity reduces the euphotic layer to 4-5 m depth, making the underwater light regime the rate limiting factor. On an annual basis, 41% of the organic carbon produced in the system is already consumed in the euphotic layer. Considering the entire water column (mean depth at mean tidal water level is around 7.7 m) 79% is consumed in the pelagial. Taking into account the organic material consumed and stored in the sediments the carbon budget of the upper gulf is probably balanced. Since, however, the system receives a considerable amount of organic material from its terrestrial surroundings (especially from the mangrove forests), a surplus of organic carbon is exported from the upper Golfo de Nicoya, which enhances the overall water productivity of the lower gulf and the adjacent area.

The nature and incidence of cryoproteins in hepatitis B antigen (HbsAg) positive patients.

Hepatitis B (HbsAg) surface antigen has been detected in the serum of patients with a variety of diseases and immune complexes of this antigen and antibody have been implicated in tissue damage to various organs. Previously we have demonstrated that serum cryoproteins occur in a variety of immune complex disorders and represent pathogenic complexes of antigen and specific antibody. Sera from patients with acute HbsAg positive hepatitis, chronic hepatitis B antigenemia, acute and chronic HbsAg negative hepatitis, as well as a variety HbsAg negative miscellaneous liver diseases and normals were studied for the presence and nature of cryoproteins. Cryoproteins were detected in a large number of patients with acute and chronic HbsAg positive hepatitis and chronic HbsAg carriers. The quantity of these cold insoluble precipitates was highest in acute hepatitis. Cryoproteins were detected with much less frequency in HbsAg negative patients and were not found in normals. The precipitates in HbsAg patients contained either HbsAg, anti-HBsAg or both, along with immunoglobulins and occasionally complement and rheumatoid factor. The cryoproteins in these patients had biological properties attributable to immune complexes and several of the patients had clinical manifestations of acute or chronic serum sickness. Cryoproteins from HbsAg negative patients did not contain HbsAg or antibody to HbsAg and did not have biologic properties of immune complexes. In HbsAg positive patients HbsAg and antibody to HbsAg were concentrated in the cryoprecipitate. The preliminary studies suggest that investigation on cryoproteins in hepatitis may be of clinical and immunopathogenic value.