Surfactant protein A, exposure to endotoxin, and asthma in garbage collectors and in wastewater workers.

Endotoxin causes an inflammation at the bronchial and alveolar level. The inflammation-induced increase in permeability of the bronchoalveolar epithelial barrier is supposed to cause a leakage of pneumoproteins. Therefore, their concentrations are expected to increase in the bloodstream.This study aimed at examining the association between occupational exposure to endotoxin and a serum pneumoprotein, surfactant protein A, to look for nonoccupational factors capable of confounding this association, and examine the relation between surfactant protein A and spirometry. There were 369 control subjects, 325 wastewater workers, and 84 garbage collectors in the study. Exposure to endotoxin was assessed through personal sampling and the Limulus amebocytes lysate assay. Surfactant protein A was determined by an in house sandwich enzyme-linked immunosorbent assay (ELISA) in 697 subjects. Clinical and smoking history were ascertained and spirometry carried out according to American Thoracic Society criteria. Multiple linear regression was used for statistical analysis. Exposure was fairly high during some tasks in wastewater workers but did not influence surfactant protein A. Surfactant protein A was lower in asthmatics. Interindividual variability was large. No correlation with spirometry was found. Endotoxin has no effect on surfactant protein A at these endotoxin levels and serum surfactant protein A does not correlate with spirometry. The decreased surfactant protein A secretion in asthmatics requires further study.

Combination therapy with venlafaxine and carbamazepine in depressive patients not responding to venlafaxine: pharmacokinetic and clinical aspects.

The chiral antidepressant venlafaxine (VEN) is both a serotonin and a norepinephrine uptake inhibitor. CYP2D6 and CYP3A4 contribute to its metabolism, which has been shown to be stereoselective. Ten CYP2D6 genotyped and depressive (F32x and F33x, ICD-10) patients participated in an open study on the pharmacokinetic and pharmacodynamic consequences of a carbamazepine augmentation in VEN non-responders. After an initial 4-week treatment with VEN (195 +/- 52 mg/day), the only poor metabolizer out of 10 depressive patients had the highest plasma concentrations of S-VEN and R-VEN, respectively, whereas those of R-O-demethyl-VEN were lowest. Five non-responders completed the second 4-week study period, during which they were submitted to a combined VEN-carbamazepine treatment. In the only non-responder to this combined treatment, there was a dramatic decrease of both enantiomers of VEN, O-demethylvenlafaxine, N-desmethylvenlafaxine and N, O-didesmethylvenlafaxine in plasma, which suggests non-compliance, although metabolic induction by carbamazepine cannot entirely be excluded. The administration of carbamazepine [mean +/- SD, range: 360 +/- 89 (200-400) mg/day] over 4 weeks did not result in a significant modification of the plasma concentrations of the enantiomers of VEN and its O- and N-demethylated metabolites in the other patients. In conclusion, these preliminary observations suggest that the combination of VEN and carbamazepine represents an interesting augmentation strategy by its efficacy, tolerance and absence of pharmacokinetic modifications. However, these findings should be verified in a more comprehensive study.

Diagnostic performance of Fluorine-18-Fluorodeoxyglucose positron emission tomography in the assessment of pleural abnormalities in cancer patients: A systematic review and a meta-analysis.

OBJECTIVE: To systematically review and meta-analyze published data about the diagnostic performance of Fluorine-18-Fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) and PET/computed tomography (PET/CT) in the assessment of pleural abnormalities in cancer patients. METHODS: A comprehensive literature search of studies published through June 2013 regarding the role of (18)F-FDG-PET and PET/CT in evaluating pleural abnormalities in cancer patients was performed. All retrieved studies were reviewed and qualitatively analyzed. Pooled sensitivity, specificity, positive and negative likelihood ratio (LR+ and LR-) and diagnostic odd ratio (DOR) of (18)F-FDG-PET or PET/CT on a per patient-based analysis were calculated. The area under the summary ROC curve (AUC) was calculated to measure the accuracy of these methods in the assessment of pleural abnormalities. Sub-analyses considering (18)F-FDG-PET/CT and patients with lung cancer only were carried out. RESULTS: Eight studies comprising 360 cancer patients (323 with lung cancer) were included. The meta-analysis of these selected studies provided the following results: sensitivity 86% [95% confidence interval (95%CI): 80-91%], specificity 80% [95%CI: 73-85%], LR+ 3.7 [95%CI: 2.8-4.9], LR- 0.18 [95%CI: 0.09-0.34], DOR 27 [95%CI: 13-56]. The AUC was 0.907. No significant improvement considering PET/CT studies only and patients with lung cancer was found. CONCLUSIONS: (18)F-FDG-PET and PET/CT demonstrated to be useful diagnostic imaging methods in the assessment of pleural abnormalities in cancer patients, nevertheless possible sources of false-negative and false-positive results should be kept in mind. The literature focusing on the use of (18)F-FDG-PET and PET/CT in this setting remains still limited and prospective studies are needed.

Marqueurs biologiques des statuts vitaminiques B12 et D: aspects analytiques d'importance clinique [Biological markers for the status of vitamins B12 and D: the importance of some analytical aspects in relation to clinical interpretation of results].

Biological markers for the status of vitamins B12 and D: the importance of some analytical aspects in relation to clinical interpretation of results When vitamin B12 deficiency is expressed clinically, the diagnostic performance of total cobalamin is identical to that of holotranscobalamin II. In subclinical B12 deficiency, the two aforementioned markers perform less well. Additional analysis of a second, functional marker (methylmalonate or homocysteine) is recommended. Different analytical approaches for 25-hydroxyvitamin D quantification, the marker of vitamin D deficiency, are not yet standardized. Measurement biases of up to +/- 20% compared with the original method used to establish threshold values are still observed.

Combination therapy with venlafaxine and carbamazepine in depressive patients non-responding to venlafaxine : pharmacokinetic and clinical aspects

Résumé L'antidépresseur chiral venlafaxine (VEN) est à la fois un inhibiteur de la récapture de la sérotonine et de la noradrénaline. Le CYP2D6 et le CYP3A4 contribuent à son métabolisme stéreosélectif. Dix patients génotypés au CYP2D6 et dépressifs (F32x et F33x, ICD-10) ont participé à cette étude ouverte sur les conséquences pharmacocinétiques et pharmacodynamiques d'une « augmentation » avec la carbamazepine chez des non-répondeurs à la venlafaxine. Après une première période de traitement de quatre semaines avec VEN (195 - 52 mg/ jour), le seul patient qui présentait un déficience génétique de CYP2D6 (poor metaboliser), avait les taux plasmatiques de S-VEN et R-VEN les plus élevés, tandis que ceux de R-0-déméthyl-VEN étaient les plus bas dans ce groupe. Comme seulement 4 patients ont été des répondeurs après 4 semaines de traitement, 6 patients ont été inclus dans la deuxième période de traitement combiné VEN et carbamazépine. Cinq patients non-répondeurs ont complété cette deuxième période d'étude de quatre semaines. Chez l'unique non-répondeur au traitement combiné, on pouvait observer à la fin de la période d'étude une diminution importante des deux énantiomères de VEN, 0-desmethy'lvenlafaxine (ODV), N-desmethylvenlafaxine (NDV) et N, 0-didesmethylvenlafaxine (NODV) dans le plasma. Cela suggère un manque de compliance chez ce patient, mais une induction métabolique par la carbamazepine ne peut pas être exclue entièrement. L'administration de la carbamazepine (moyen ± s.d. (range) ; 360 ± 89 (200-400) mg/jour)) pendant quatre semaines n'a pas eu comme résultat une modification significative des concentrations plasmatiques des énantiomères de VEN et de ses métabolites 0- et N-démethylés chez les autres patients. En conclusion, ces observations préliminaires suggèrent qu'une combinaison de VEN et de carbamazepine représente une stratégie intéressante par son efficacité, sa tolérance et l'absence de modifications pharmcocinétiques, mais ces résultats devraient être vérifiés dans une plus grande étude.

Mineralização do carbono e nitrogênio de resíduos aplicados ao solo em campo

A definição das doses de aplicação de resíduos orgânicos de origens agrícola, urbana ou industrial, com vistas a seu aproveitamento agrícola, deve estar fundamentada na taxa de sua mineralização no solo. Neste trabalho, os objetivos foram utilizar e analisar diferentes métodos de estimativa das frações mineralizadas dos estercos de bovinos, suínos e galinhas, bem como do lodo de esgoto e do composto de lixo urbano, em campo, quando incorporados ou dispostos sobre um Latossolo Vermelho-Amarelo distrófico (LVAd). O experimento foi conduzido por um período de 360 dias, sendo feita coleta mensal de amostras do solo/resíduo, em que foram quantificadas as concentrações de carbono facilmente oxidável (COfo), o nitrogênio total, o amônio e o nitrato, possibilitando a estimativa do nitrogênio orgânico (NO). Verificou-se que estimativas das frações mineralizadas em resíduos dispostos superficialmente estão mais sujeitas a erros que as incorporadas, em razão das diferentes proporções resíduo/solo coletadas durante o período de monitoramento. Recomendou-se a obtenção das frações mineralizadas a partir de dados de concentração de COfo no solo/resíduo, tendo em vista que as de Ninorg e, consequentemente, de NO estão sujeitas à forte influência da ocorrência de chuvas, gerando valores pouco confiáveis. As frações mineralizadas de COfo e NO estimadas, considerando-se as adições de material orgânico (COfo(adic) ou NO(adic)), foram, após 120 dias de incubação do resíduo, superiores a 89,3 %, sejam nos resíduos incorporados ou dispostos superficialmente.

Influence of mineral fertilization on edaphic fauna in Acacia auriculiformis (A. Cunn) plantations

Fertilization and/or the accumulation of organic matter from plant residues can influence the composition of soil and litter community. The goal of this study was to evaluate the effects of P and K fertilization on total faunal and nematode faunal composition and richness in plant litter and soil for 360 days in an area reforested with Acacia auriculiformis (A. Cunn), located in the municipality of Conceição de Macabu in the State of Rio de Janeiro. For each treatment (fertilized and unfertilized plots), samples of litter and soil (to a depth of 5 cm) were collected and transferred into a Berlese-Tüllgren funnels for the extraction of fauna. Mesofauna and macrofauna were quantified, and the major taxa identified. Nematodes were extracted by centrifugal flotation in sucrose solution and identified according to feeding habits. Density (number of individuals m-2) of total fauna, microphages, social insects and saprophages varied significantly per treatment and sampling time in both litter and soil. The total number of individuals collected was 5,127, and the total number of nematodes 894. Phosphorus and potassium fertilization resulted in an increase in total fauna density and richness in the litter due to an increased abundance of social insects, saprophages and herbivores. In the soil, fertilization increased the saprophage and predator densities. Saprophages were the predominant taxa in the litter, while social insects (Formicidae) prevailed in the soil. Litter nematode populations were favored by mineral fertilization. Bacteriophages were the predominant nematode group in both litter and soil.

Método alternativo para quantificação do intervalo hídrico ótimo em laboratório

O intervalo hídrico ótimo (IHO) é definido pela amplitude do teor de água (θ) no solo em que são mínimas as limitações ao crescimento vegetal, associadas à disponibilidade de água, aeração e resistência do solo à penetração (RP). Em geral, a determinação do IHO exige equipamentos de elevado custo, sendo laboriosa a obtenção dos dados de retenção de água e RP. O uso de membranas de pressão e placas porosas de Richards exige longo tempo para definir a curva de retenção de água no solo (CRA) em função do tempo de equilíbrio hidráulico, o qual depende das dimensões da amostra, do tipo de solo e da pressão aplicada. Atualmente, há disponibilidade de equipamentos para determinar o potencial de água do solo (ψ) com rapidez e menor custo como tensiômetros e equipamentos psicrométricos. O objetivo deste trabalho foi quantificar o IHO a partir do secamento de amostras indeformadas de solo em estufa elétrica com ventilação de ar e temperatura de 40 ºC (tempos de secamento de 20, 40, 60, 80, 100, 120, 180, 240, 300, 360 e 420 min), com subsequentes medições de ψ, utilizando tensiômetro ou psicrômetro, e medidas de RP, usando um penetrômetro eletrônico com aquisição automatizada de dados. A CRA e a curva de resistência do solo à penetração (CRS) foram adequadamente descritas utilizando o método proposto, que permitiu obter dados de θ e de RP em 10 dias e possibilitou ajuste acurado dos dados para descrever o IHO e alcançar a densidade crítica do solo (Dsc).

Heritability of the retinal microcirculation in flemish families.

BACKGROUND Few population studies have described the heritability and intrafamilial concordance of the retinal microvessels, or the genetic or environmental correlations of the phenotypes of these vessels. METHODS We randomly selected 413 participants from 70 families (mean age, 51.5 years; 50.1% women) from a Flemish population. We postprocessed retinal images using IVAN software to generate the central retinal arteriole equivalent (CRAE), central retinal venule equivalent (CRVE), and arteriole-to-venule-ratio (AVR) from these images. We used SAGE version 6.2 and SAS version 9.2 to compute multivariate-adjusted estimates of heritability and intrafamilial correlations of the CRAE, CRVE, and AVR of the retinal microvessels in the images. RESULTS Sex, age, mean arterial pressure, and smoking explained up to 12.7% of the variance of the phenotypes of the retinal microvessels of the study participants. With adjustments applied for these covariates, the heritability estimates of CRAE, CRVE, and AVR were 0.213 (P = 0.044), 0.339 (P = 0.010), and 0.272 (P = 0.004), respectively. The parent-offspring correlations for CRAE, CRVE, and AVR were 0.118 (NS), 0.225 (P < 0.01), and 0.215 (P < 0.05), respectively. The corresponding values were 0.222 (P < 0.05), 0.213 (P < 0.05), and 0.390 (P < 0.001) for sib-sib correlations, respectively. The genetic and environmental correlations between CRAE and CRVE were 0.360 and 0.545 (P < 0.001 for both). CONCLUSION Our study showed moderate heritability for CRAE, CRVE, and AVR, and a significant genetic correlation of CRAE with CRVE in the Flemish population of our study. These findings suggest that genetic factors influence the diameter of the retinal microvessels, and that CRAE and CRVE share some genetic determinants.

Fontes e doses de nitrogênio e alterações nos atributos químicos de um latossolo cultivado com capim-mombaça

O fornecimento de N tem sido importante meio para aumento da produtividade das gramíneas forrageiras tropicais no Brasil, pois, na maioria das áreas cultivadas, os teores desse nutriente no solo não atendem satisfatoriamente a necessidade das culturas. Avaliou-se o efeito da aplicação de diferentes fontes e doses de N sobre os atributos químicos de um Latossolo Amarelo e a produção do Panicum maximum cv. Mombaça. O experimento foi desenvolvido no Instituto Federal do Espírito Santo, campus Santa Teresa. O delineamento experimental utilizado foi em blocos casualizados, com três repetições, em esquema fatorial 3 × 6, sendo três fertilizantes nitrogenados (ureia, sulfato de amônio e nitrato de cálcio) e seis doses de N (0, 120, 240, 360, 480 e 600 kg ha-1), totalizando 54 unidades experimentais. As doses de N foram aplicadas a cada 28 dias, sempre após o corte da forrageira, totalizando sete aplicações durante o período experimental de 196 dias. Após o término do experimento, foram coletadas, com o auxílio de um trado holandês, amostras de solo na profundidade de 0-20 e 20-40 cm, para avaliar o efeito da aplicação dos tratamentos sobre os atributos químicos do solo nas diferentes profundidades. Os resultados experimentais evidenciaram que o sulfato de amônio apresentou elevado potencial de acidificação do solo. As alterações provocadas no pH do solo resultaram em alterações nos teores de Al trocável, na acidez potencial e na disponibilidade de P no solo. A aplicação de elevadas doses de N na forma de sulfato de amônio e nitrato de cálcio promoveu a lixiviação de bases, especialmente do K para a profundidade de 20-40 cm.

Effect of Nitrogen and Potassium Rates on Early Development of Macaw Palm

ABSTRACT The economic exploitation of macaw palm [Acrocomia aculeate(Jacq.) Lodd. ex Mart.] is currently in transition, from extractivism to agricultural cultivation, thus requiring studies on the fertilization of the crop. This study evaluated the response of three genotypes of macaw palm to increasing rates of nitrogen and potassium, grown in the field until the 2nd year and to establish reference contents of mineral nutrients in the leaf. The experiment was a split-plot randomized block design with five main treatments (N and K rates) and three secondary treatments (genotypes), with three replications, each plot containing three plants. Plant height, leaf number, vigor, and nutrient contents in leaf tissues were evaluated at the end of 2nd year of cultivation. Differential responses were observed among genotypes, indicating that some genotypes are more efficient in the use of mineral inputs. There was a differentiated and positive response to increasing side-dressed N and K rates in the vegetative development of macaw genotypes until the 2nd year of field cultivation, indicating variability in the species in terms of nutrient use efficiency. The N and K fertilization rate corresponding to 360 g N + 480 g K2O per plant, in four split applications over the two years of cultivation, was insufficient to induce maximum vegetative development in the three macaw genotypes. There was no variation in macro- and micronutrient contents in leaf dry matter of the three macaw genotypes.

DECOMPOSIÇÃO DE LODO DE ESGOTO E COMPOSTO DE LODO DE ESGOTO EM NITOSSOLO HÁPLICO

RESUMO O uso agrícola de lodo de esgoto e derivados no Estado de São Paulo é regulamentado por norma federal e por norma paulista, que recomendam que esses materiais quando incorporados a solos agrícolas devem apresentar no mínimo 30 % de degradação do carbono total. Para observar as frações de degradação de um lodo de esgoto e de um composto, produzido a partir do mesmo lodo juntamente com poda de árvore urbana triturada, realizaram-se dois ensaios de biodegradação de C. As doses dos resíduos foram adicionadas em frascos contendo 500 g de solo coletado na profundidade de 0,00-0,20 m de um Nitossolo Háplico Álico textura argilosa. No ensaio I, as doses de lodo (L) e composto (C) utilizadas consideraram percentuais da necessidade em N para a cultura da cana-de-açúcar, e expressas em Mg ha-1 de resíduo (base úmida): L1 21,2 (100 %); L2 42,4 (200 %); C1 69,4 (50 %); C2 138,9 (100 %); e C3 277,8 (200 %). O ensaio II foi realizado apenas com o lodo de esgoto, utilizando-se doses 5, 10, 15 e 20 vezes maiores que aquelas recomendadas no ensaio I: L3 120; L4 240; L5 360; e L6 480, simulando sucessivas aplicações do resíduo no solo. O C-CO2liberado foi quantificado por meio da medida de condutividade elétrica. O lodo de esgoto no ensaio I apresentou menores frações de degradação quando comparado ao composto orgânico, mas a taxa de decomposição do composto foi menor, provavelmente pela presença de substâncias recalcitrantes resultantes do processo de humificação. A fração de degradação dos resíduos no solo atingiu valor próximo a 30 % apenas para a dose de lodo de esgoto 20 vezes superior à dose exigida pela cultura, e assim não poderiam ser utilizados em solos agrícolas argilosos. Observou-se a necessidade de revisão desse valor adotado pela legislação paulista de uso de resíduos orgânicos em solos.

Novel anesthetics and other treatment strategies for refractory status epilepticus

Refractory status epilepticus (RSE)-that is, seizures resistant to at least two antiepileptic drugs (AEDs)-is generally managed with barbiturates, propofol, or midazolam, despite a low level of evidence (Rossetti, 2007). When this approach fails, the need for alternative pharmacologic and nonpharmacologic strategies emerges. These have been investigated even less systematically than the aforementioned compounds, and are often used, sometimes in succession, in cases of extreme refractoriness (Robakis & Hirsch, 2006). Several possibilities are reviewed here. In view of the marked heterogeneity of reported information, etiologies, ages, and comedications, it is extremely difficult to evaluate a given method, not to say to compare different strategies among them. Pharmacologic Approaches Isoflurane and desflurane may complete the armamentarium of anesthetics,' and should be employed in a ''close'' environment, in order to prevent intoxication of treating personnel. c-Aminobutyric acid (GABA)A receptor potentiation represents the putative mechanism of action. In an earlier report, isoflurane was used for up to 55 h in nine patients, controlling seizures in all; mortality was, however, 67% (Kofke et al., 1989). More recently, the use of these inhalational anesthetics was described in seven subjects with RSE, for up to 26 days, with an endtidal concentration of 1.2-5%. All patients required vasopressors, and paralytic ileus occurred in three; outcome was fatal in three patients (43%) (Mirsattari et al., 2004). Ketamine, known as an emergency anesthetic because of its favorable hemodynamic profile, is an N-methyl-daspartate (NMDA) antagonist; the interest for its use in RSE derives from animal works showing loss of GABAA efficacy and maintained NMDA sensitivity in prolonged status epilepticus (Mazarati & Wasterlain, 1999). However, to avoid possible neurotoxicity, it appears safer to combine ketamine with GABAergic compounds (Jevtovic-Todorovic et al., 2001; Ubogu et al., 2003), also because of a likely synergistic effect (Martin & Kapur, 2008). There are few reported cases in humans, describing progressive dosages up to 7.5 mg/kg/h for several days (Sheth & Gidal, 1998; Quigg et al., 2002; Pruss & Holtkamp, 2008), with moderate outcomes. Paraldehyde acts through a yet-unidentified mechanism, and appears to be relatively safe in terms of cardiovascular tolerability (Ramsay, 1989; Thulasimani & Ramaswamy, 2002), but because of the risk of crystal formation and its reactivity with plastic, it should be used only as fresh prepared solution in glass devices (Beyenburg et al., 2000). There are virtually no recent reports regarding its use in adults RSE, whereas rectal paraldehyde in children with status epilepticus resistant to benzodiazepines seems less efficacious than intravenous phenytoin (Chin et al., 2008). Etomidate is another anesthetic agent for which the exact mechanism of action is also unknown, which is also relatively favorable regarding cardiovascular side effects, and may be used for rapid sedation. Its use in RSE was reported in eight subjects (Yeoman et al., 1989). After a bolus of 0.3 mg/kg, a drip of up to 7.2 mg/kg/h for up to 12 days was administered, with hypotension occurring in five patients; two patients died. A reversible inhibition of cortisol synthesis represents an important concern, limiting its widespread use and implying a careful hormonal substitution during treatment (Beyenburg et al., 2000). Several nonsedating approaches have been reported. The use of lidocaine in RSE, a class Ib antiarrhythmic agent modulating sodium channels, was reviewed in 1997 (Walker & Slovis, 1997). Initial boluses up to 5 mg/kg and perfusions of up to 6 mg/kg/h have been mentioned; somewhat surprisingly, at times lidocaine seemed to be successful in controlling seizures in patients who were refractory to phenytoin. The aforementioned dosages should not be overshot, in order to keep lidocaine levels under 5 mg/L and avoid seizure induction (Hamano et al., 2006). A recent pediatric retrospective survey on 57 RSE episodes (37 patients) described a response in 36%, and no major adverse events; mortality was not given (Hamano et al., 2006 Verapamil, a calcium-channel blocker, also inhibits P-glycoprotein, a multidrug transporter that may diminish AED availability in the brain (Potschka et al., 2002). Few case reports on its use in humans are available; this medication nevertheless appears relatively safe (under cardiac monitoring) up to dosages of 360 mg/day (Iannetti et al., 2005). Magnesium, a widely used agent for seizures elicited by eclampsia, has also been anecdotally reported in RSE (Fisher et al., 1988; Robakis & Hirsch, 2006), but with scarce results even at serum levels of 14 mm. The rationale may be found in the physiologic blockage of NMDA channels by magnesium ions (Hope & Blumenfeld, 2005). Ketogenic diet has been prescribed for decades, mostly in children, to control refractory seizures. Its use in RSE as ''ultima ratio'' has been occasionally described: three of six children (Francois et al., 2003) and one adult (Bodenant et al., 2008) were responders. This approach displays its effect subacutely over several days to a few weeks. Because ''malignant RSE'' seems at times to be the consequence of immunologic processes (Holtkamp et al., 2005), a course of immunomodulatory treatment is often advocated in this setting, even in the absence of definite autoimmune etiologies (Robakis & Hirsch, 2006); steroids, adrenocorticotropic hormone (ACTH), plasma exchanges, or intravenous immunoglobulins may be used alone or in sequential combination. Nonpharmacologic Approaches These strategies are described somewhat less frequently than pharmacologic approaches. Acute implantation of vagus nerve stimulation (VNS) has been reported in RSE (Winston et al., 2001; Patwardhan et al., 2005; De Herdt et al., 2009). Stimulation was usually initiated in the operation room, and intensity progressively adapted over a few days up to 1.25 mA (with various regimens regarding the other parameters), allowing a subacute seizure control; one transitory episode of bradycardia/asystole has been described (De Herdt et al., 2009). Of course, pending identification of a definite seizure focus, resective surgery may also be considered in selected cases (Lhatoo & Alexopoulos, 2007). Low-frequency (0.5 Hz) transcranial magnetic stimulation (TMS) at 90% of the resting motor threshold has been reported to be successful for about 2 months in a patient with epilepsia partialis continua, but with a weaning effect afterward, implying the need for a repetitive use (Misawa et al., 2005). More recently, TMS was applied in a combination of a short ''priming'' high frequency (up to 100 Hz) and longer runs of low-frequency stimulations (1 Hz) at 90-100% of the motor threshold in seven other patients with simple-partial status, with mixed results (Rotenberg et al., 2009). Paradoxically at first glance, electroconvulsive treatment may be found in cases of extremely resistant RSE. A recent case report illustrates its use in an adult patient with convulsive status, with three sessions (three convulsions each) carried out over 3 days, resulting in a moderate recovery; the mechanism is believed to be related to modification of the synaptic release of neurotransmitters (Cline & Roos, 2007). Therapeutic hypothermia, which is increasingly used in postanoxic patients (Oddo et al., 2008), has been the object of a recent case series in RSE (Corry et al., 2008). Reduction of energy demand, excitatory neurotransmission, and neuroprotective effects may account for the putative mechanism of action. Four adult patients in RSE were cooled to 31_-34_C with an endovascular system for up to 90 h, and then passively rewarmed over 2-50 h. Seizures were controlled in two patients, one of whom died; also one of the other two patients in whom seizures continued subsequently deceased. Possible side effects are related to acid-base and electrolyte disturbances, and coagulation dysfunction including thrombosis, infectious risks, cardiac arrhythmia, and paralytic ileus (Corry et al., 2008; Cereda et al., 2009). Finally, anecdotic evidence suggests that cerebrospinal fluid (CSF)-air exchange may induce some transitory benefit in RSE (Kohrmann et al., 2006); although this approach was already in use in the middle of the twentieth century, the mechanism is unknown. Acknowledgment A wide spectrum of pharmacologic (sedating and nonsedating) and nonpharmacologic (surgical, or involving electrical stimulation) regimens might be applied to attempt RSE control. Their use should be considered only after refractoriness to AED or anesthetics displaying a higher level of evidence. Although it seems unlikely that these uncommon and scarcely studied strategies will influence the RSE outcome in a decisive way, some may be interesting in particular settings. However, because the main prognostic determinant in status epilepticus appears to be related to the underlying etiology rather than to the treatment approach (Rossetti et al., 2005, 2008), the safety issue should always represent a paramount concern for the prescribing physician. Conclusion The author confirms that he has read the Journal's position on issues involved in ethical publication and affirms that this paper is consistent with those guidelines.