[Folic acid: Primary prevention of neural tube defects. Literature Review]. / Ácido fólico: prevención primaria de los defectos del tubo neural. Revisión bibliográfica.

Neural tube defects (NTD) are the most common congenital malformations of the nervous system, they have a multifactorial etiology, are caused by exposure to chemical, physical or biological toxic agents, factors deficiency, diabetes, obesity, hyperthermia, genetic alterations and unknown causes. Some of these factors are associated with malnutrition by interfering with the folic acid metabolic pathway, the vitamin responsible for neural tube closure. Its deficit produce anomalies that can cause abortions, stillbirths or newborn serious injuries that cause disability, impaired quality of life and require expensive treatments to try to alleviate in some way the alterations produced in the embryo. Folic acid deficiency is considered the ultimate cause of the production of neural tube defects, it is clear the reduction in the incidence of Espina Bifida after administration of folic acid before conception, this leads us to want to further study the action of folic acid and its application in the primary prevention of neural tube defects. More than 40 countries have made the fortification of flour with folate, achieving encouraging data of decrease in the prevalence of neural tube defects. This paper attempts to make a literature review, which clarify the current situation and future of the prevention of neural tube defects.

Enuresis. Diagnóstico diferencial y tratamiento específico / Enuresis. Differential diagnosis and specific treatment

Introducción. A pesar de su gran prevalencia y antigüedad, esta patología tiene importantes interrogantes etiológicos, diagnósticos y terapéuticos. Hay que partir de dos grupos completamente diferentes: la enuresis (E) monosintomática o no complicada y el síndrome (S) enurético o E complicada con sus respectivos subgrupos, cada uno con etiología diferente que además es multifactorial. Diagnóstico diferencial. Se estructura en 3 niveles: 1º ¿E. monosintomática o S. enurético?; 2º ¿Patalogía o malos hábitos?; 3º ¿Disfunción de llenado o vaciado? Historia. Se describen tratamientos utilizados en diferentes culturas y épocas, demostrando la diversidad y a veces antagonismo que persiste hasta hoy, como demostración de la necesidad de un diagnóstico diferencial y un tratamiento etiológico. Tratamiento actual. Tras estudio de metaanálisis y revisiones sistemáticas se han ordenado por nivel de evidencia (NE) y grado de recomendación (GR) los estudios más válidos de tratamientos de E. monosintomática. La desmopresina, la alarma y la asociación de ambas tienen el máximo NE y GR, mientras que los antidepresivos tienen el mismo NE pero el menor GR por riesgo de efectos adversos. Los anticolinérgicos asociados a desmopresina están en el 2º nivel de NE y GR. Tratamiento personalizado. Se expone un tratamiento integral personalizado multidisciplinar. Se expone un tratamiento integral personalizado y multidisciplinar. Se inicia con diagnóstico diferencial y valoración psicológica. En E. monosintomática se inicia 1º un tratamiento básico conductal, seguido de un 2º paso con desmopresina y/o alarma según características personales. Si el resultado con uno de ellos es insuficiente se aconseja un 3º paso asociando el otro o añadiendo anticolinérgicos. Si es necesario un 4º paso se proponer biofeedback. El soporte psicológico de la familia y del niño es importante para la motivación, adhesión al tratamiento y mantenimiento de éxito. Conclusiones. Cada enurético es distinto y precisa un diagnóstico diferencial adecuado, además de una investigación personalizada, identificando sus factores influyentes. En la E. monosintomática el mejor NE y GR actualmente corresponden a la desmopresina, a la alarma y a ambas juntas. Hay que conocer todos los recursos terapéuticos disponibles, para diseñar un tratamiento lo más individualizado posible. Con frecuencia la combinación de tratamiento es efectiva. En la experiencia de los autores, el tratamiento multidisciplinar en equipo puede ser la mejor opción (AU)

Introduction. In spite of its great prevalence and antiquity, this condition has significant etiological, diagnostic and therapeutic questions. Two completely different groups must be considered: monosymptomatic or uncomplicated enuresis (E) and enuretic or complicated E syndrome (S) with their respective subgroups, each one with different etiology that is also multifactorial. Differential diagnosis. This diagnosis is structured into 3 levels: 1) Monosymptomatic E or enuretic syndrome?; 2) Disease or poor habits?; 3) Filling or emptying dysfunction? History. Treatments used in different cultures and periods that demonstrate the diversity and sometimes antagonisms that persists up to the current date are described as a demonstration of the need for a differential diagnosis and etiological treatment. Current treatment. After the meta-analysis study and systematic reviews, the most valid studies of treatments of monosymptomatic E. were ordered by level of evidence (LE) and recommendation grade (RG). Desmopressin, the alarm and the association of both have a maximum LE and while antidepressants have the same LE, but a lower RG, due to the risk of adverse events. The anticholinergics associated to desmopressin are on the second level of the LE and RG. Personalized treatment. A personalized comprehensive and multidisciplinary treatment is explained. It is begun with the differential diagnosis and psychological evaluation. In monosymptomatic E, a first basic behavioural treatment is initiated followed by a second step with desmopressin and/or o alarm according to personal characteristics. If the result with one of them is insufficient, a third step is recommended by means of associating the other or adding anticholinergics. If a four step is necessary, biofeedback is proposed. The psychological support of the family and of the child is important for motivation, treatment adherence, and maintenance of success. Conclusions. Each enuretic is differential diagnoses in addition to a personalized study, identifying their influencing factors. In Monosymptomatic E, the best LE and RG currently correspond to desmopressin, to the alarm and to both of them. It is necessary to know all the therapeutic resources available to design the most individualized treatment possible. The combination of treatments is frequently effective. In the experience of the authors, team multidisciplinary treatment may be the best option (AU)