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Superior Court Justice Robert Murray set bail at $500,000 cash for each defendant, an amount neither is likely to be able to meet with no option for third-person surety. They also are barred from being around any children younger than 15.

Both co-defendants qualified for court-appointed attorneys because of their lack of financial resources. Murray assigned Rockland-based attorney Steven Peterson to Julio Carrillo, while Christopher MacLean, a defense attorney from Camden, will represent Sharon Carrillo.

Peterson and MacLean said after the appearance that they hadn’t had a chance to review the evidence in the case at this early stage, so they didn’t offer much comment. Both said they plan to have their clients’ mental health evaluated.

The state has filed a motion to try the Carrillos together, but their defense attorneys said they’ll decide whether to resist that motion after reviewing the case.

MacLean hinted that he would be “looking closely” at Julio Carrillo and what influence he might have had over his wife, as well as the extent of his role in the alleged abuse of Marrissa.

“I think there’s a lot going on in this family,” MacLean said.

Macomber said that Sharon Carrillo had no evident criminal history, while her husband has a domestic violence conviction out of Kentucky dating back to 2000. State police have said that local police were sent to the Stockton Springs condo the Carrillos were staying in as well as their previous address in Bangor for reported domestic disputes.

The Carrillos allegedly told detectives they “punished” Marrissa regularly since October by forcing her to kneel on the kitchen’s tile floor and hold her hands above her head while either Sharon or Julio struck her in the abdomen or ribs with a belt or their fists. They said they had her kneel on the tile because it was the most uncomfortable surface in the house, according to court documents.

Julio Carrillo also allegedly told investigators they’d used a metal mop in place of the belt during one of these ritual “punishment sessions,” and struck the girl so hard the mop snapped in half, the affidavit states.

Both parents told investigators they decided not to seek medical help for Marrissa when she stopped moving and her speech started slurring after one of these beatings on Feb. 22 or 23. They “punished” her again because they believed she was pretending.

After Marrissa died of her injuries, the Carrillos allegedly attempted to stage a scene in the basement in hopes of tricking police into believing that the girl had fallen while playing. Julio Carrillo called 911 on the afternoon of Feb. 24, claiming he’d discovered the girl unresponsive and bleeding from the mouth in the basement next to the furnace.

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Even if there is no independent gold/reference standard to diagnose syncope, there is strong consensus that the initial evaluation may lead to certain or highly likely diagnosis when the diagnostic criteria listed in the table of recommendations are met.

Diagnostic criteria with initial evaluation

AV = atrioventricular; BBB = bundle branch block; b.p.m. = beats per minute; ECG = electrocardiogram; ICD = implantable cardioverter defibrillator; OH = orthostatic hypotension; SCD = sudden cardiac death; SVT = supraventricular tachycardia; VT = ventricular tachycardia; VVS = vasovagal syncope.

a

Class of recommendation.

b

Level of evidence.

Diagnostic criteria with initial evaluation

AV = atrioventricular; BBB = bundle branch block; b.p.m. = beats per minute; ECG = electrocardiogram; ICD = implantable cardioverter defibrillator; OH = orthostatic hypotension; SCD = sudden cardiac death; SVT = supraventricular tachycardia; VT = ventricular tachycardia; VVS = vasovagal syncope.

a
b

When a diagnosis is nearly certain or highly likely, no further evaluation is needed, and treatment—if any—can be planned. In other cases, the initial evaluation may suggest a diagnosis when the features listed in Table 5 are present, or otherwise is unable to suggest any diagnosis.

Table 5

Clinical features that can suggest a diagnosis on initial evaluation

ARVC = arrhythmogenic right ventricular cardiomyopathy; AV = atrioventricular; BBB = bundle branch block; b.p.m. = beats per minute; ECG = electrocardiogram; OH = orthostatic hypotension; VT = ventricular tachycardia.

Table 5

Clinical features that can suggest a diagnosis on initial evaluation

ARVC = arrhythmogenic right ventricular cardiomyopathy; AV = atrioventricular; BBB = bundle branch block; b.p.m. = beats per minute; ECG = electrocardiogram; OH = orthostatic hypotension; VT = ventricular tachycardia.

The management of TLOC of suspected syncopal nature in the ED should answer the following three key questions:

Is there a serious underlying cause that can be identified?

What is the risk of a serious outcome?

Should the patient be admitted to hospital?

Figure 5 shows a flow chart for the management and risk stratification of patients referred to the ED for TLOC suspected to be syncope (modified from Casagranda et al. 40 ).

Figure 5
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The management of patients presenting to the emergency department for transient loss of consciousness suspected to be syncope (modified from Casagranda ). ED = emergency department; TLOC = transient loss of consciousness.

For example, this includes pulmonary embolism presenting with shortness of breath, pleuritic chest pain, and syncope, but not trauma secondary to syncope.

Figure 5
View large Download slide

The management of patients presenting to the emergency department for transient loss of consciousness suspected to be syncope (modified from Casagranda ). ED = emergency department; TLOC = transient loss of consciousness.

For example, this includes pulmonary embolism presenting with shortness of breath, pleuritic chest pain, and syncope, but not trauma secondary to syncope.

Question 1: Is there a serious underlying cause that can be identified in the ED?

Previously, two independent studies demonstrated that mouse ES cells could form germ cells in vitro ( 15 , 16 ). Both groups took advantage of the ease of genetic manipulation of mouse ES cells and generated undifferentiated ES cell lines that could be sorted for a fluorescent GFP marker under the control of germ cell specific promoters. In one study, putative germ cells were selected for GFP positive cells under the control of the germ cell-specific Oct4 promoter ( 15 ). In these studies, expression of mouse Vasa in the putative germ-cell population was noted after 7 days of ES cell differentiation. In a second study, putative germ cells were marked by a GFP reporter under the control of the germ cell-specific mvh ( mouse vasa homolog ) promoter ( 16 ). In this study, expression from the vasa locus was first identified after 3 days of EB differentiation ( 16 ). Although both of these studies relied upon reporter constructs to potentially capture germ cells as they differentiated, it was noted that germ cell differentiation occurred spontaneously and at an easily observed frequency. In fact, the reporter constructs were not required to diagnose germ cell development. Here, we report results that correlate closely with those of Toyooka and colleagues in that expression of human VASA was initiated after 3 days of EB differentiation and VASA-positive cells were most often present in clusters rather than dispersed throughout the EB ( 16 ). Moreover, in this study, we found that transcription of later stages of germ cell differentiation including that of the meiotic genes SCP1 , SCP3 , GDF9 and TEKT1 was only initiated upon differentiation of ES cells to EBs. However, we also observed that the fidelity of meiosis, as judged by SCP3 and MLH1 staining, was severely compromised and we did not observe formation of haploid germ cells in vitro . Like the current study, previous studies also identified Gdf9 and Scp3 expression in differentiating mouse ES cells ( 15 ). However, the formation of sister chromatids and the axial alignment of Scp3 along the length of chromosomes was not demonstrated in these studies nor was any evidence of a haploid genome ( 15 ). In contrast, in studies of male germ cell development, putative germ cells were transplanted to the testis and thus may have transited meiosis more faithfully than in vitro studies ( 16 ). In addition, more recently, a second group has differentiated male gametes in vitro from embryonic stem cells and found that haploid cells form, albeit at low frequency ( 17 ). Taken together, results from in vitro studies in mice and our current studies of human ES cells indicated that germ cell differentiation from ES cells to the stage of VASA expression can be achieved by spontaneous differentiation in vitro . However, it seems likely that completion of meiosis in vitro is inefficient at best.

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