Manejo inicial de la hiperamonemia aguda en pediatría / Initial management of acute hyperammonemia in pediatrics

La hiperamonemia constituye una emergencia médica. No existen publicaciones que hagan referencia a la disponibilidad de recursos, insumos y conocimientos necesarios para el manejo inicial de esta por parte del pediatra en nuestro país, pero, según la experiencia de los autores, los recursos necesarios no se encuentran disponibles los 365 días del año en una gran porción de nuestro territorio. Sobre la base de este estado de situación, de una revisión bibliográfica internacional sobre el tema y de la experiencia de los autores, se elaboraron una serie de recomendaciones para el manejo pediátrico inicial de esta emergencia, que tienen como objetivo poder reducir las deficiencias, permitir una sospecha clínica adecuada que lleve a un diagnóstico y tratamiento de emergencia oportunos, con utilización racional de recursos farmacológicos (algunos de ellos de alto costo), para reducir la morbimortalidad que asocia la patología.

Hyperammonemia is a medical emergency. There are no publications regarding the availability of resources, supplies, and knowledge necessary for the initial management of hyperammonemia by pediatricians in Argentina; however, according to the authors' experience, the necessary resources are not available all year round in a large portion of our territory. Based on such state of affairs, an international bibliographic review on this topic and the authors' experience, we developed a series of recommendations for the initial pediatric management of this emergency, with the objective of reducing deficiencies, allowing adequate clinical suspicion leading to a timely diagnosis and emergency management and a rational use of pharmacological resources (some of which are costly) to reduce the morbidity and mortality associated with hyperammonemia.

Phase I NT-501 Ciliary Neurotrophic Factor Implant Trial for Primary Open-Angle Glaucoma: Safety, Neuroprotection, and Neuroenhancement.

Purpose: To assess the safety and efficacy of a ciliary neurotrophic factor (CNTF) intraocular implant on neuroprotection and neuroenhancement in glaucoma. Design: Open-label, prospective, phase I clinical trial. Participants: A total of 11 participants were diagnosed with primary open-angle glaucoma (POAG). One eye of each patient was assigned as the study (implant) eye. Methods: The study eye was implanted with a high-dose CNTF-secreting NT-501 implant, whereas the other eye served as a control. All patients were followed up for 18 months. Analysis was limited to descriptive statistics. Main Outcome Measures: Primary outcome was safety through 18 months after implantation assessed by serial eye examinations, structural and functional testing, and adverse events (AEs) recording. Parameters measured included visual acuity (VA), Humphrey visual field (HVF), pattern electroretinogram, scanning laser polarimetry with variable corneal compensation (GDx VCC), and OCT. These parameters were also used for secondary analysis of efficacy outcome. Results: All NT-501 implants were well tolerated with no serious AEs associated with the implant. The majority of AEs were related to the implant placement procedure and were resolved by 12 weeks after surgery. Foreign-body sensation was the most commonly reported AE and was self-limited to the postoperative period. The most common implant-related AE was pupil miosis; no patients underwent explant. Visual acuity and contrast sensitivity decreased more in fellow eyes than in study eyes (VA, -5.82 vs. -0.82 letters; and contrast sensitivity, -1.82 vs. -0.37 letters, for fellow vs. study eyes, respectively). The median HVF visual field index and mean deviation measurements worsened (decreased) in fellow eyes (-13.0%, -3.9 dB) and improved (increased) in study eyes (2.7%, 1.2 dB). Implanted eyes showed an increase in retinal nerve fiber layer thickness measured by OCT and by GDx VCC (OCT, 2.66 µm vs. 10.16 µm; and GDx VCC, 1.58 µm vs. 8.36 µm in fellow vs. study eyes, respectively). Conclusions: The NT-501 CNTF implant was safe and well tolerated in eyes with POAG. Eyes with the implant demonstrated both structural and functional improvements suggesting biological activity, supporting the premise for a randomized phase II clinical trial of single and dual NT-501 CNTF implants in patients with POAG, which is now underway. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.

Initial management of acute hyperammonemia in pediatrics. / Manejo inicial de la hiperamonemia aguda en pediatría.

Hyperammonemia is a medical emergency. There are no publications regarding the availability of resources, supplies, and knowledge necessary for the initial management of hyperammonemia by pediatricians in Argentina; however, according to the authors' experience, the necessary resources are not available all year round in a large portion of our territory. Based on such state of affairs, an international bibliographic review on this topic and the authors' experience, we developed a series of ecommendations for the initial pediatric management of this emergency, with the objective of reducing deficiencies, allowing adequate clinical suspicion leading to a timely diagnosis and emergency management and a rational use of pharmacological resources (some of which are costly) to reduce the morbidity and mortality associated with hyperammonemia.

La hiperamonemia constituye una emergencia médica. No existen publicaciones que hagan referencia a la disponibilidad de recursos, insumos y conocimientos necesarios para el manejo inicial de esta por parte del pediatra en nuestro país, pero, según la experiencia de los autores, los recursos necesarios no se encuentran disponibles los 365 días del año en una gran porción de nuestro territorio. Sobre la base de este estado de situación, de una revisión bibliográfica internacional sobre el tema y de la experiencia de los autores, se elaboraron una serie de recomendaciones para el manejo pediátrico inicial de esta emergencia, que tienen como objetivo poder reducir las deficiencias, permitir una sospecha clínica adecuada que lleve a un diagnóstico y tratamiento de emergencia oportunos, con utilización racional de recursos farmacológicos (algunos de ellos de alto costo), para reducir la morbimortalidad que asocia la patología.

Structural and Metabolic Imaging After Short-term Use of the Balance Goggles System in Glaucoma Patients: A Pilot Study.

PRCIS: Short-term use of the Balance Goggles System (BGS) in glaucoma patients was not associated with the observable changes in conventional ocular coherence tomography (OCT) imaging, but metabolic imaging using peripapillary flavoprotein fluorescence (FPF) may represent a useful adjuctive investigation. OBJECTIVE: To determine whether the intraocular pressure (IOP)-lowering effects of the BGS are accompanied by changes in retinal thickness measured by OCT, retinal vascular density measured by ocular coherence tomography-angiography (OCTA), or novel peripapillary metabolic profiling using FPF measured by a fundus camera. DESIGN: Prospective comparative case-series. SUBJECTS: Eight eyes from 8 patients with open angle glaucoma ranging from mild to severe. METHODS: In this prospective, single-center, open-label, nonrandomized, and single-arm study patients received a baseline evaluation including retinal imaging, then 1 hour of negative pressure application through the BGS, followed by repeat retinal imaging. Participants then used the BGS at home for 1 month and underwent a repeat evaluation at the conclusion of the trial. MAIN OUTCOME MEASURES: Changes in nerve fiber layer thickness, OCTA vascular parameters, and FPF scores. RESULTS: Mean baseline IOP was 18.0±3.1 mmHg and there was no significant change in IOP at follow-up. At 1 month compared with baseline, there was a statistically significant improvement in FPF optic nerve head rim scores (12.7±11.6 to 10.5±7.5; P =0.04). In addition, there was a trend toward an increase in retinal nerve fiber layer thickness after 1 month (69.5±14.2 to 72.0±13.7; P =0.1), but there were no statistically significant differences observable with any of the OCTA vascular parameters either at 1 hour or after 1 month. CONCLUSIONS: There were no significant changes observable using conventional OCT imaging after short-term use of the BGS, although metabolic imaging using FPF may be a useful potential biomarker to complement existing investigations. Additional studies are warranted to further investigate these changes.

Phase 1b Randomized Controlled Study of Short Course Topical Recombinant Human Nerve Growth Factor (rhNGF) for Neuroenhancement in Glaucoma: Safety, Tolerability, and Efficacy Measure Outcomes.

PURPOSE: No approved therapies directly target retinal ganglion cells (RGCs) for neuroprotection or neuroenhancement in glaucoma. Recombinant human nerve growth factor (rhNGF) has been shown to promote RGC survival and function in animal models of optic neuropathy. Here we evaluate the safety, tolerability, and efficacy of short-term, high-dose rhNGF eye drops versus placebo in a cohort of glaucoma patients. DESIGN: This was a prospective, phase 1b, single-center, randomized, double-masked, vehicle-controlled, parallel-group study. METHODS: This study was designed to assess safety and tolerability as well as short-term neuroenhancement of structure and function (clinicaltrials.gov NCT02855450). A total of 60 open-angle glaucoma patients were randomized 40:20 to receive either 180 µg/mL rhNGF or vehicle control eye drops in both eyes, 3 times daily for 8 weeks, with a 24-week post-treatment follow-up. One eye was officially selected as the study eye, although both eyes were studied and dosed. Primary endpoints were safety, as assessed by adverse events, and tolerability, as assessed by patient-reported outcomes. Secondary outcome measures included best corrected visual acuity (BCVA), Humphrey visual field, electroretinograpy (ERG), and optical coherence tomography (OCT) of retinal nerve fiber layer (RNFL) thickness at baseline, after 8 weeks of treatment, and at 4 and 24 weeks after treatment (12 and 32 weeks total). RESULTS: Of the 60 randomized patients, 23 were female (38%) and the average age was 66.1 years. Through week 32, there were no treatment-related serious adverse events, including no unexpectedly severe progression of optic neuropathy, no adverse events affecting ocular function or pressure, and no drug-related systemic toxicity. Topical high-dose rhNGF was tolerated well, with a low level of symptom burden mainly eliciting periocular ache (in 52% of treated group and 5% of placebo group) and only 3 patients (7.5%) discontinuing treatment because of discomfort, of whom 1 patient (2.5%) prematurely withdrew from the study. There were no statistically significant differences in global indices of Humphrey visual field and no meaningful differences in total, quadrant, or clock-hour mean RNFL thickness between the groups, although both of these function and structure measures showed nonsignificant trends toward significance in favor of rhNGF. Real-world participant data was used to generate an estimate of cohort size needed to power subsequent studies. CONCLUSIONS: Use of rhNGF is safe and tolerable in a topical 180-µg/mL formulation. Although no statistically significant short-term neuroenhancement was detected in this trial, given the strong effects of NGF in preclinical models and the trends detected in this study, analysis for efficacy in a neuroprotection trial is warranted. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

SALT Trial: Steroids after Laser Trabeculoplasty: Impact of Short-Term Anti-inflammatory Treatment on Selective Laser Trabeculoplasty Efficacy.

PURPOSE: This study examined whether short-term use of topical nonsteroidal anti-inflammatory drug (NSAID) or steroid therapy affected the efficacy of selective laser trabeculoplasty (SLT). DESIGN: Double-masked, randomized, placebo-controlled, dual-center, multisurgeon trial. PARTICIPANTS: Patients older than 18 years with intraocular pressure (IOP) of more than 18 mmHg for whom the clinician decided SLT was the appropriately indicated therapy were randomized to 1 of 3 groups in a ratio of 1:1:1 as follows: ketorolac 0.5%, prednisolone 1%, or saline tears. METHODS: After SLT, patients randomized into each group were instructed to use an unmarked drop 4 times daily starting the day of SLT and continuing for 4 additional days. The Kruskal-Wallis test and Wilcoxon rank-sum test were used for continuous variables when comparing 2 or 3 treatment groups, respectively. The Fisher exact test was used for categorical variables. MAIN OUTCOME MEASURES: The primary outcome of this study was IOP at 12 weeks. Secondary outcome measures included IOP at 1 and 6 weeks, patient-reported pain, and detectable anterior chamber inflammation. RESULTS: Ninety-six eyes of 85 patients fit inclusion criteria and were enrolled between the 2 sites. The NSAID, steroid, and placebo groups were similar in baseline demographics and baseline IOP (mean, 23.3±3.9 mmHg; P = 0.57). There was no statistically significant difference in IOP decrease among groups at week 6. Both the NSAID and steroid groups showed a statistically significantly greater decrease in IOP at week 12 compared with the placebo group (mean, -6.2±3.1 mmHg, -5.2±2.7 mmHg, and -3±4.3 mmHg, respectively; P = 0.02 [analysis of variance] and P = 0.002 [t test] for NSAID vs. placebo groups; P = 0.02 for steroid vs. placebo groups). CONCLUSIONS: Significantly better IOP reduction at 12 weeks was measured in eyes treated with steroid or NSAID drops after SLT. Short-term postoperative use of NSAID or steroid drops may improve IOP reduction after SLT. Longer-term follow-up studies are indicated.

Versatilidad del colgajo dorsal en cirugía de reconstrucción de sarcoma de pared torácica. Reporte de caso / Versatility of the dorsal flap in reconstruction surgery of toracica wall sarcoma. Case report

Entre los tumores malignos de la pared torácica, los sarcomas representan menos del 1% de los casos. A pesar de ser infrecuentes, es importante resaltar el manejo multidisciplinario de estos tipos de tumores ya que se caracterizan por ser de gran tamaño y afectar una amplia superficie torácica y por consiguiente de los tejidos blandos anexos a los mismos. De ahí la real importancia de la participación de cirujanos plásticos, torácicos y oncólogos en el tratamiento de estos tumores. La confección del colgajo dorsal en cirugías de sarcomas de la pared torácica ha permitido completar el tratamiento resectivo de dichos tumores. Presentamos el caso de un paciente varón de 64 años, con un sarcoma de la parrilla costal, quien fue sometido a resección amplia de la lesión que comprometia a la 7ma, 8va y 9na costillas, reconstrucción inmediata con próstesis de titanio y malla de polipropileno y cobertura del defecto con confección de colgajo del dorsal ancho. A 5 meses de seguimiento, sin evidencia de actividad de la enfermedad

Among malignant tumors of the chest wall, sarcomas account for less than 1% of cases. Despite being infrequent, it is important to highlight the multidisciplinary management of these types of tumors since they are characterized by being large and affecting a wide chest area and therefore the soft tissues attached to them. Hence the real importance of the participation of pásticos, thoracic and oncologos surgeons in the treatment of these tumors.The confection of the dorsal flap in surgeries of sarcomas of the thoracic wall has allowed to complete the treatment of these tumors. We present the case of a 64-year-old male patient with a sarcoma of the rib cage, who underwent extensive resection of the lesion involving the 7th, 8th and 9th ribs, immediate reconstruction with titanium prosthesis and mesh. polypropylene and coverage of the defect with flap made of the latissimus dorsi. At 5 months of follow-up, without evidence of disease activity.

Lesión de vías biliares como complicación de una colecistectomía / Injury of bile ducts as a complication of a cholecystectomy

La lesión quirúrgica de vías biliares es un accidente que puede ocurrir durante una cirugía del árbol biliar. Su incidencia aumentó en la última década con la extensión del uso de la cirugía laparoscópica. Su frecuencia llega hasta el 0,2% de todas las colecistectomías según varias series. El diagnóstico precoz favorece las chances de una reparación rápida y con mejor pronóstico para el paciente. Presentamos el caso de una mujer de 44 años que presentó ictericia obstructiva en el curso de su post operatorio de colecistectomía convencional. A la CRMN se constató sección completa de la vía biliar a la altura de la confluencia. En la reintervención se realizó una derivación hepático yeyunal termino lateral en Y de Roux con sutura manual con buena evolución.

Surgical injury of the bile ducts is an accident that can occur during a bile tree surgery. Its incidence increased in the last decade with the extension of the use of laparoscopic surgery. Its frequency reaches 0.2% of all cholecystectomies according to several series. The early diagnosis favors the chances of a quick repair and with a better prognosis for the patient. We present the case of a 44-year-old woman who presented jaundice in the course of her post-operative conventional cholecystectomy. A complete section of the biliary tract was found at IMR at the confluence level. We performed reintervention with jejunal hepatic bypass with manual suture with good evolution.

Eco-etología básica del caracol rosa Strombus gigas (Mesogastropoda: Strombidae), en Xel-Há, Yucatán, Caribe mexicano / Basic eco-ethology of the queen conch, Strombus gigas (Mesogastropoda: Strombidae) in Xel-Há, Yucatán, Mexican Caribbean

The queen conch Strombus gigas is an important fishery in the Caribbean, whose populations are currently overexploited. Since the decade of 1980 there have been several studies on aquaculture, resource management and area rehabilitation. However, little is known about its behavior in a natural environment and the influence of environmental parameters. Monthly surveys, from January to November 2012 were conducted in in Xel Ha, to observe and quantify six behaviors of S. gigas: rest, feeding, movement, burying, copulation and spawning. The observations were made every hour from 8h to 17h by free diving through three transects with three replicates each. Each behavior was observed 90 times each month. Salinity, temperature and dissolved oxygen were registered at the bottom. We found the highest number of snails at rest in July and the lowest in March and September. Feeding and movements had a peak in August. Most buried in October and November. Copulation was first observed on March with a peak in June and July to October’s spawning. In daytime observations restingt had a peak at 8h; feeding and moving at 12 to 17h. Copulation and spawning did not have a clear pattern. Variations between months and hours (resting, feeding, moving and buried) were significant (p<0.05). Resting correlated with temperature and being buried with oxygen level (r=-0.5803; p=0.0536). Feeding and moving correlated with temperature and salinity. These results should be useful for the conservation, restoration and aquaculture programs. Rev. Biol. Trop. 62 (Suppl. 3): 215-222. Epub 2014 September 01.

El caracol rosa Strombus gigas tiene importancia pesquera en el Caribe, cuyas poblaciones se encuentran sobreexplotadas. Desde la década de 1980 se han desarrollado estudios de acuacultura, manejo del recurso y rehabilitación de áreas con la finalidad de proteger e incrementar sus poblaciones. Sin embargo, poco se sabe sobre el comportamiento del caracol rosa en su medio natural y la influencia de los parámetros ambientales. Mensualmente de enero a noviembre de 2012 en la caleta de Xel Há se observaron y cuantificaron seis comportamientos de S. gigas: reposo, alimentación, movimiento, cópula, enterrados y desove. Las observaciones se realizaron cada hora de 8h a 17h por medio de buceo libre en tres transectos con tres repeticiones cada uno. Cada comportamiento fue observado 90 veces cada mes. Se registraron datos de salinidad, temperatura y oxígeno disuelto en el fondo. El comportamiento anual de S. gigas presentó el mayor número de caracoles en reposo en julio. La alimentación y el movimiento tuvieron un máximo en agosto. La mayoría de caracoles enterrados se encontró en octubre y noviembre. La cópula comenzó a observarse en marzo con un máximo en junio y el desove de julio a octubre. En las observaciones diurnas e independientemente de los meses, el reposo tuvo un pico a las 8h, alimentación a las 12 y movimiento a las 17h. La cópula y el desove no presentaron un patrón en su comportamiento. Existieron variaciones significativas entre meses y horas (reposo, alimentación, movimiento y enterrado) (p<0.05). El reposo se correlacionó con la temperatura y los enterrados con el oxígeno (r=-0.5803; p=0.0536). La alimentación con temperatura, salinidad y oxígeno. El movimiento con temperatura y salinidad. Estos resultados son útiles para programas de conservación, restauración y cultivo de la especie.

Enfermedad de Pompe. Presentación de un caso / Pompe disease. A case report

Presentamos el caso de una niña de 6 meses de ascendencia china con enfermedad de Pompe diagnosticada a partir de una miocardopatia hipertrófica biventricular e hipotonía global. En esta enfermedad el acumulo de glucógeno lisosomal principalmente en el corazón y músculo esquelético ocasiona la mayoría de la sintomatología clínica. En este paciente la hipotonía generalizada, macroglosia, debilidad en el llanto y la confirmación ecocardiográfica de una miocardiopatía hipertrófica biventricular fueron el punto inicial para la sospecha clínica de la enfermedad que, junto a la elevación de encimas musculares y hepáticas, condujo al estudio de alfa-glucosidasa ácida (AGA) que confirmo el diagnóstico. Desde el 2006 existe terapia de reemplazo enzimático que permite mejorar la sobrevida y la calidad de vida si el diagnóstico se realiza precozmente

Enfermedad de Pompe: presentación de un caso / Pompe disease: a case report

Presentamos el caso de una niña de 6 meses de ascendencia china con enfermedad de Pompe diagnosticada a partir de una miocardopatia hipertrófica biventricular e hipotonía global. En esta enfermedad el acumulo de glucógeno lisosomal principalmente en el corazón y músculo esquelético ocasiona la mayoría de la sintomatología clínica. En este paciente la hipotonía generalizada, macroglosia, debilidad en el llanto y la confirmación ecocardiográfica de una miocardiopatía hipertrófica biventricular fueron el punto inicial para la sospecha clínica de la enfermedad que, junto a la elevación de encimas musculares y hepáticas, condujo al estudio de alfa-glucosidasa ácida (AGA) que confirmo el diagnóstico. Desde el 2006 existe terapia de reemplazo enzimático que permite mejorar la sobrevida y la calidad de vida si el diagnóstico se realiza precozmente.

Successful application of hyperbranched multidisplacement genomic amplification to detect HIV-1 sequences in single neurons removed from autopsy brain sections by laser capture microdissection.

To confirm studies suggesting that HIV-1 infects neurons and to determine whether CD8(+) T lymphocytes traffic to HIV-1-infected neurons, we used laser capture microdissection to remove hippocampal neurons with and without perineuronal CD8(+) T cells from AIDS patients with HIV-1 encephalitis (HIVE) or without HIVE and from normal controls. We used hyperbranched multidisplacement amplification for whole gene amplification (MDA-WGA) plus two rounds of PCR to amplify housekeeping sequences (HK(+)) and, in HK(+) samples, to amplify HIV-1 gag, nef, and pol sequences. Sample size and, in single neurons, MDA-WGA correlated with housekeeping gene amplification (P < 0.05), whereas patient group and postmortem interval did not (P > 0.05). Neuronal viral sequences correlated with HIVE (43% vs. 13% and 0 in non-HIVE and controls, respectively) and, in HIVE cases, with perineuronal CD8(+) T lymphocytes (70% in CD8(+) samples vs. 37% of CD8(-) samples). Our results suggest that MDA-WGA is a useful technique when analyzing DNA from single cells from autopsy brains, supporting prior studies that show that neurons may contain HIV-1 neuronal sequences in vivo. The association between neuronal infection and perineuronal CD8(+) T cells supports our hypothesis that these cells specifically traffic to infected neurons but raises the possibility that CD8(+) T cells, if infected, could transmit virus to neurons.

Secondary stem anatomy and uses of four drought-deciduous species of a tropical dry forest in México

Wood and bark anatomy and histochemistry of Acacia bilimekii Humb. & Bonpl., Acacia cochliacantha Mcbride., Conzatia multiflora (Rob) Stand. and Guazuma ulmifolia Lam.are described from stem samples collected in a tropical dry forest (Morelos,Mexico). Enzyme activities were tested in tangential, radial and transverse cuts of fresh material. Histochemistry and stem anatomy were studied on similar cuts previously softened in a solution of water-glicerol-PEG. Our results show that the anatomical patterns of bark and wood, as well as the histochemical patterns and specific gravity, are influenced by water accessibility and climate; these patterns could guarantee mechanical and anti-infection strategies to support extreme conditions. Enzyme cytochemistry reveals biochemical activities probably related to lipid utilization routes for the lignification processes and for synthesis of extractives; these results suggest that the formation and maturation of woody tissue is very active at the beginning of the rainy season. These species are widely used by the local population. Traditional uses include firewood, dead and live fences, fodder, construction, supporting stakes, handcrafts, farming tools, extraction of tanning products, and medicine. There is no relationship between use and abundance. Alternative uses are proposed according to a density index

Se estudió la anatomía e histoquímica del tallo secundario de Acacia bilimekii, Acacia cochliacantha, Conzatia multiflora y Guazuma ulmifolia. Las muestras de tallo se colectaron en una selva baja caducifolia del estado de Morelos, México. La actividad enzimática se estudió en cortes frescos de caras tangenciales, radiales y transversales. La anatomía e histoquímica se hizo en cortes similares de muestras previamente ablandadas con una mezcla de agua-glicerol-PEG. Los resultados muestran que el patrón anatómico de la corteza y madera, así como las características histoquímicas no enzimáticas están relacionados con el acceso al agua y el clima; estos patrones garantizan que las estrategias mecánicas de resistencia al deterioro les permitan sobrevivir a condiciones extremas. Los resultados de la histoquímica y la citoquímica enzimática sugieren que la lignificación y la síntesis de extractivos a partir de los lípidos de reserva se encuentra activa desde el principio de la estación de lluvias. Se sugieren usos potenciales para las especies estudiads de acuerdo con las densidades relativas

Secondary stem anatomy and uses of four drought-deciduous species of a tropical dry forest in México.

Wood and bark anatomy and histochemistry of Acacia bilimekii Humb. & Bonpl., Acacia cochliacantha Mcbride, Conzatia nultiflora (Rob) Stand. and Guazuma ulmifolia Lam. are described from stem samples collected in a tropical dry forest (Morelos, Mexico). Enzyme activities were tested in tangential, radial and transverse cuts of fresh material. Histochemistry and stem anatomy were studied on similar cuts previously softened in a solution of water-glicerol-PEG. Our results show that the anatomical patterns of bark and wood, as well as the histochemical patterns and specific gravity, are influenced by water accessibility and climate; these patterns could guarantee mechanical and anti-infection strategies to support extreme conditions. Enzyme cytochemistry reveals biochemical activities probably related to lipid utilization routes for the lignification processes and for synthesis of extractives; these results suggest that the formation and maturation of woody tissue is very active at the beginning of the rainy season. These species are widely used by the local population. Traditional uses include firewood, dead and live fences, fodder, construction, supporting stakes, handcrafts, farming tools, extraction of tanning products, and medicine. There is no relationship between use and abundance. Alternative uses are proposed according to a density index.

Hiperinsulinismo congenito de inicio neonatal / Congenital hyperinsulinemia of neonatal onset

Se presenta el caso de un (RN) derivado por hipoglucemia persistente y necesidad de aporte endovenoso de glucosa con flujo superiores a 15-20 mg/kg/minuto. Se expone un algorritmo racional de uso de laboratorio para establecer el diagnostico y el tratamiento

Hiperinsulinismo congenito de inicio neonatal / Congenital hyperinsulinemia of neonatal onset

Se presenta el caso de un (RN) derivado por hipoglucemia persistente y necesidad de aporte endovenoso de glucosa con flujo superiores a 15-20 mg/kg/minuto. Se expone un algorritmo racional de uso de laboratorio para establecer el diagnostico y el tratamiento

Un modelo de intervención clínica en un hospital mental / A model of clinical intervention in a mental hospital

En este trabajo se presenta un modelo de intervención clínica que consiste en la realización de un programa experimental de tratamiento y rehabilitación en pacientes psicóticos hospitalizados. Se utiliza una metodología científica de investigación aplicada para la realización del modelo. Se describen los aspectos teóricos, objetivos, áreas, estructura, equipo hospitalario y funcionamiento del programa, los instrumentos de investigación utilizados, resultados preliminares y conclusiones (AU)

Un modelo de intervención clínica en un hospital mental / A model of clinical intervention in a mental hospital

En este trabajo se presenta un modelo de intervención clínica que consiste en la realización de un programa experimental de tratamiento y rehabilitación en pacientes psicóticos hospitalizados. Se utiliza una metodología científica de investigación aplicada para la realización del modelo. Se describen los aspectos teóricos, objetivos, áreas, estructura, equipo hospitalario y funcionamiento del programa, los instrumentos de investigación utilizados, resultados preliminares y conclusiones