"Cap polyposis", refractory to drug treatment, including infliximab.

Cap polyposis is a rare disease characterized by the presence of inflammatory polyps with an adherent fibrin sheath ("cap"), in variable number and size, in the rectum and sigmoid. It presents with tenesmus, mucous stools and rectorrhagia. There is currently no standardized treatment, having been treated empirically with aminosalicylates, oral or rectal steroids, metronidazole, H. pylori eradication therapy and infliximab with variable results. In refractory cases, endoscopic resection of polyps may be used and surgery may even be necessary. We present the case of a 36-year-old patient diagnosed in our center with cap polyposis, refractory to both pharmacological and endoscopic treatment, and therefore treatment with infliximab was decided out of indication. The case we present is the fourth case of cap polyposis treated with infliximab available in the current literature and highlights the difficulty of achieving a clinical response with pharmacological treatment, including biologic drugs such as infliximab.

Psychometric properties of the Spanish version of the Health of Nation Outcome Scales for schizophrenia patients.

Accessible Summary What is known on the subject? Functioning is one of the most affected areas in schizophrenia. Social, occupational and personal domains are affected, and these deficits are responsible for a major part of the disability associated with the disorder. There are several instruments to measure functioning, but the HoNOS provides a wide assessment of impairment in 12 areas of functioning. What does the paper add to existing knowledge? The Spanish version of the HoNOS shows good properties in terms of reliability and validity for use in schizophrenia patients. Although some authors divide the scale according to proposed underlying dimensions, in schizophrenia this division may not be appropriate. What are the implications for practice? A reliable and easy-to-use measure of impairment in different areas of functioning is useful for optimizing the treatment and rehabilitation of patients with schizophrenia. ABSTRACT: INTRODUCTION: The HoNOS scale was designed for the assessment of psychosocial impairment in various domains. While it is widely used in psychiatric settings, it has not been validated in Spanish for use in patients with schizophrenia. AIM: To examine the psychometric properties of the Spanish version of the HoNOS scale in a sample of schizophrenia patients. METHOD: A total of 194 individuals aged 18 to 65 with schizophrenia spectrum diagnoses were evaluated using the HoNOS. Illness severity and level of functioning were also assessed. RESULTS: The HoNOS showed moderate internal consistency, good inter-observer reliability and good test-retest reliability. Factor analysis revealed an internal structure consisting of four factors, with item distribution differing from the theoretical dimensions proposed for the original scale. DISCUSSION: The Spanish version of the HoNOS scale is a reliable and valid instrument for assessing psychosocial impairment in individuals diagnosed with schizophrenia spectrum disorders. However, further research is needed to determine its internal structure more accurately. IMPLICATIONS FOR PRACTICE: The HoNOS scale provides researchers and clinicians with a valid measure of impairment in twelve different domains, which can facilitate and guide the treatment of schizophrenia patients.

Pregnancy outcomes in 1869 pregnancies in a large cohort from the Spanish Society of Rheumatology Lupus Register (RELESSER).

INTRODUCTION: Obstetric complications are more common in women with systemic lupus erythematosus (SLE) than in the general population. OBJECTIVE: To assess pregnancy outcomes in women with SLE from the RELESSER cohort after 12 years of follow-up. METHODS: A multicentre retrospective observational study was conducted. In addition to data from the RELESSER register, data were collected on obstetric/gynaecological variables and treatments received. The number of term pregnancies was compared between women with pregnancies before and after the diagnosis of SLE. Further, clinical and laboratory characteristics were compared between women with pregnancies before and after the diagnosis, on the one hand, and with and without complications during pregnancy, on the other. Bivariate and multivariate analyses were carried out to identify factors potentially associated with complications during pregnancy. RESULTS: A total of 809 women were included, with 1869 pregnancies, of which 1395 reached term. Women with pregnancies before the diagnosis of SLE had more pregnancies (2.37 vs 1.87) and a higher rate of term pregnancies (76.8% vs 69.8%, p < 0.001) compared to those with pregnancies after the diagnosis. Women with pregnancies before the diagnosis were diagnosed at an older age (43.4 vs 34.1 years) and had more comorbidities. No differences were observed between the groups with pregnancies before and after diagnosis in antibody profile, including anti-dsDNA, anti-Sm, anti-Ro, anti-La, lupus anticoagulant, anticardiolipin or anti-beta-2-glycoprotein. Overall, 114 out of the 809 women included in the study experienced complications during pregnancy, including miscarriage, preeclampsia/eclampsia, foetal death, and/or preterm birth. Women with complications had higher rates of antiphospholipid syndrome (40.5% vs 9.9%, p < 0.001) and higher rates of positivity for IgG anticardiolipin (33.9% vs 21.3%, p = 0.005), IgG anti-beta 2 glycoprotein (26.1% vs 14%, p = 0.007), and IgM anti-beta 2 glycoprotein (26.1% vs 16%, p = 0.032) antibodies, although no differences were found regarding lupus anticoagulant. Among the treatments received, only heparin was more commonly used by women with pregnancy complications. We did not find differences in corticosteroid or hydroxychloroquine use. CONCLUSIONS: The likelihood of term pregnancy is higher before the diagnosis of SLE. In our cohort, positivity for anticardiolipin IgG and anti-beta-2- glycoprotein IgG/IgM, but not lupus anticoagulant, was associated with a higher risk of poorer pregnancy outcomes.

Correction: A Personalized Ontology-Based Decision Support System for Complex Chronic Patients: Retrospective Observational Study.

[This corrects the article DOI: 10.2196/27990.].

Frequency of microsatellite instability (MSI) in upper tract urothelial carcinoma: comparison of the Bethesda panel and the Idylla MSI assay in a consecutively collected, multi-institutional cohort.

AIMS: Upper tract urothelial carcinoma (UTUC) is a rare malignancy with a poor prognosis which occurs sporadically or in few cases results from a genetic disorder called Lynch syndrome. Recently, examination of microsatellite instability (MSI) has gained importance as a biomarker: MSI tumours are associated with a better response to immunomodulative therapies. Limited data are known about the prevalence of MSI in UTUC. New detection methods using the fully automated Idylla MSI Assay facilitate analysis of increased patient numbers. METHODS: We investigated the frequency of MSI in a multi-institutional cohort of 243 consecutively collected UTUC samples using standard methodology (Bethesda panel), along with immunohistochemistry of mismatch repair (MMR) proteins. The same tumour cohort was retested using the Idylla MSI Assay by Biocartis. RESULTS: Using standard methodology, 230/243 tumours were detected as microsatellite stable (MSS), 4/243 tumours as MSI and 9/243 samples as invalid. In comparison, the Idylla MSI Assay identified four additional tumours as MSS, equalling 234/243 tumours; 4/243 were classified as MSI and only 5/243 cases as invalid. At the immunohistochemical level, MSI results were supported in all available cases with a loss in MMR proteins. The overall concordance between the standard and the Idylla MSI Assay was 98.35%. Time to result differed between 3 hours for Idylla MSI Assay and 2 days with the standard methodology. CONCLUSION: Our data indicate a low incidence rate of MSI tumours in patients with UTUC. Furthermore, our findings highlight that Idylla MSI Assay can be applied as an alternative method of MSI analysis for UTUC.

A Personalized Ontology-Based Decision Support System for Complex Chronic Patients: Retrospective Observational Study.

BACKGROUND: Due to an increase in life expectancy, the prevalence of chronic diseases is also on the rise. Clinical practice guidelines (CPGs) provide recommendations for suitable interventions regarding different chronic diseases, but a deficiency in the implementation of these CPGs has been identified. The PITeS-TiiSS (Telemedicine and eHealth Innovation Platform: Information Communications Technology for Research and Information Challenges in Health Services) tool, a personalized ontology-based clinical decision support system (CDSS), aims to reduce variability, prevent errors, and consider interactions between different CPG recommendations, among other benefits. OBJECTIVE: The aim of this study is to design, develop, and validate an ontology-based CDSS that provides personalized recommendations related to drug prescription. The target population is older adult patients with chronic diseases and polypharmacy, and the goal is to reduce complications related to these types of conditions while offering integrated care. METHODS: A study scenario about atrial fibrillation and treatment with anticoagulants was selected to validate the tool. After this, a series of knowledge sources were identified, including CPGs, PROFUND index, LESS/CHRON criteria, and STOPP/START criteria, to extract the information. Modeling was carried out using an ontology, and mapping was done with Health Level 7 Fast Healthcare Interoperability Resources (HL7 FHIR) and Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT; International Health Terminology Standards Development Organisation). Once the CDSS was developed, validation was carried out by using a retrospective case study. RESULTS: This project was funded in January 2015 and approved by the Virgen del Rocio University Hospital ethics committee on November 24, 2015. Two different tasks were carried out to test the functioning of the tool. First, retrospective data from a real patient who met the inclusion criteria were used. Second, the analysis of an adoption model was performed through the study of the requirements and characteristics that a CDSS must meet in order to be well accepted and used by health professionals. The results are favorable and allow the proposed research to continue to the next phase. CONCLUSIONS: An ontology-based CDSS was successfully designed, developed, and validated. However, in future work, validation in a real environment should be performed to ensure the tool is usable and reliable.

High IGKC-Expressing Intratumoral Plasma Cells Predict Response to Immune Checkpoint Blockade.

Resistance to Immune Checkpoint Blockade (ICB) constitutes the current limiting factor for the optimal implementation of this novel therapy, which otherwise demonstrates durable responses with acceptable toxicity scores. This limitation is exacerbated by a lack of robust biomarkers. In this study, we have dissected the basal TME composition at the gene expression and cellular levels that predict response to Nivolumab and prognosis. BCR, TCR and HLA profiling were employed for further characterization of the molecular variables associated with response. The findings were validated using a single-cell RNA-seq data of metastatic melanoma patients treated with ICB, and by multispectral immunofluorescence. Finally, machine learning was employed to construct a prediction algorithm that was validated across eight metastatic melanoma cohorts treated with ICB. Using this strategy, we have unmasked a major role played by basal intratumoral Plasma cells expressing high levels of IGKC in efficacy. IGKC, differentially expressed in good responders, was also identified within the Top response-related BCR clonotypes, together with IGK variants. These results were validated at gene, cellular and protein levels; CD138+ Plasma-like and Plasma cells were more abundant in good responders and correlated with the same RNA-seq-defined fraction. Finally, we generated a 15-gene prediction model that outperformed the current reference score in eight ICB-treated metastatic melanoma cohorts. The evidenced major contribution of basal intratumoral IGKC and Plasma cells in good response and outcome in ICB in metastatic melanoma is a groundbreaking finding in the field beyond the role of T lymphocytes.

Combination of mifepristone and misoprostol vs misoprostol monotherapy for treatment of second-trimester pregnancy loss.

OBJECTIVE: Our main goal was to evaluate whether a treatment protocol based on the combination of mifepristone and misoprostol for second-trimester foetal loss was more effective than misoprostol monotherapy. METHODS: This was an observational, retrospective, cross-sectional two-centre study of women receiving treatment for second-trimester pregnancy loss. Patients were recruited in two centres that used different treatment protocols: combined mifepristone-misoprostol treatment or misoprostol monotherapy. RESULTS: A total of 99 patients were included in the study: 41 in the mifepristone-misoprostol combined treatment group and 58 in the misoprostol monotherapy group. The combined treatment group had shorter times to expulsion and shorter hospitalisations, as well as higher rates of hospital discharge within 24 h and complete abortion within the first 6 h and 12 h. There were no differences regarding secondary effects and complication rates. CONCLUSION: A combination of mifepristone and misoprostol appears to be a feasible option for the treatment of second-trimester pregnancy loss.

Hemolysis and methemoglobinemia in a child with left ventricular assist Levitronix PediMag.

A 5-month-old male was treated with left ventricular assist device due to cardiac failure secondary to dilated cardiomyopathy. The patient developed acute severe intravascular hemolysis with methemoglobinemia and renal failure, related to a mechanical problem due to pump cylinder misalignment. Secondary severe methemoglobinemia has not been previously described in patients undergoing ventricular assist device. Early detection of the signs and symptoms of hemolysis is crucial to prevent further complications.

Efectividad de las intervenciones basadas en telemedicina sobre resultados en salud en pacientes con multimorbilidad en atención primaria: revisión sistemática / Effectiveness of interventions based on telemedicine on health outcomes in patients with multimorbidity in Primary Care: A systematic review

OBJETIVO: Evaluar la efectividad de intervenciones basadas en telemedicina para mejorar resultados en salud en pacientes con multimorbilidad en atención primaria. DISEÑO: Revisión sistemática. Fuentes de datos: INAHTA, Guía Salud, NICE, Cochrane Library, Medline/PubMed y EMBASE hasta abril de 2018. Selección de estudios: CRITERIOS DE INCLUSIÓN: pacientes (adultos con 2 o más enfermedades crónicas o índice de Charlson mayor de 3); intervención (programa de telemedicina desarrollada en atención primaria); comparador (práctica habitual); resultados (mortalidad, ingresos hospitalarios, consultas a urgencias, calidad de vida relacionada con la salud y satisfacción); diseño (guía de práctica clínica, revisión sistemática, metaanálisis, ensayo clínico controlado aleatorizado o cuasiexperimental). Publicación en inglés o español. Se localizaron 236 referencias. Extracción de datos: Exclusión de duplicados; valoración de criterios de selección sobre título, resumen y texto completo; valoración crítica; extracción y análisis cualitativo. Dos revisores y un tercero para discrepancias. RESULTADOS: Se incluyeron 5 artículos de 3 estudios, 2 ensayos clínicos controlados aleatorizados y en cuasiexperimental. No se observaron resultados significativos en la reducción de la mortalidad o mejora de la calidad de vida relacionada con la salud. La efectividad de la telemedicina sobre el número de ingresos hospitalarios o consultas a urgencias mostró resultados contradictorios. La satisfacción no fue medida en los estudios incluidos. CONCLUSIONES: El escaso número de estudios, la relativa heterogeneidad y limitaciones metodológicas no permiten confirmar la efectividad de las intervenciones basadas en telemedicina en pacientes con multimorbilidad en atención primaria, sobre la mejora de la mortalidad, el número de ingresos hospitalarios o consultas a urgencias y calidad de vida relacionada con la salud, respecto a la práctica habitual

OBJECTIVE: To evaluate the effectiveness of telemedicine interventions to improve health outcomes in patients with multiple morbidities in Primary Health Care. DESIGN: A systematic review. Data sources: INAHTA, Health Guidelines, NICE, Cochrane Library, Medline/PubMed and EMBASE up to April 2018. Study selection: Inclusion criteria: patients (adults with 2 or more chronic diseases or a Charlson index greater than three); intervention (telemedicine intervention developed entirely in Primary Health Care); comparator (usual care); health outcomes (mortality, hospital admissions, emergency department visits, health-related quality of life, and satisfaction); study design(clinical practice guideline, systematic review, meta-analysis, randomised controlled clinical trial),and quasi-experimental design). English and Spanish language publication. A total of236 references were located. Data extraction: Duplicated articles were removed. Titles, abstracts, and full text of references identified were assessed using the selection criteria; methodological quality assessment; data extraction, and qualitative analysis. RESULTS: Five articles, corresponding to 3 studies, were included, with 2 randomised controlled clinical trials and one quasi-experimental design. No significant results were observed in reducing mortality or improving health-related quality of life. The effectiveness of telemedicine on the number of hospital admissions or emergency visits showed contradictory results. Satisfaction was not measured in the studies included. CONCLUSIONS: The relatively small number of studies, heterogeneity characteristics, and methodological limitations did not confirm the effectiveness of telemedicine intervention on the improvement of mortality, number of hospital admissions, emergency department visits, and health-related quality of life, compared to usual care

Insulina tópica en el tratamiento de úlcera corneal refractaria en un paciente no diabético: a propósito de un caso / Insulin eye drops for treating corneal ulcer in a non-diabetic patient: regarding a case

Las úlceras corneales se incluyen dentro de un grupo heterogéneo de lesiones oculares, las cuales pueden ser de gravedad variable. Cuando los pacientes no responden al tratamiento, incluyendo incluso el trasplante corneal, se crea la necesidad de explorar otras alternativas. Presentamos el caso de un paciente que sufrió una salpicadura ocular del contenido de una batería de automóvil por accidente. Esta lesión corneal, fue refractaria al tratamiento farmacológico e incluso quirúrgico. Tras cuatro años de persistencia de la úlcera corneal, se inició un tratamiento tópico con insulina 50 UI/ml. Se observó mejoría de forma evidente y actualmente el paciente ha recuperado completamente el epitelio corneal. Hoy en día, las evidencias disponibles del uso tópico de la insulina para el tratamiento de las úlceras corneales se centran en pacientes diabéticos. En los pacientes no diabéticos, la evidencia se limita a una serie de casos de úlceras neurotróficas corneales y al caso de un paciente que presentó un defecto epitelial persistente después de la resección de un neurinoma. Este caso, presenta la experiencia de uso de una formulación magistral de insulina oftálmica con eficacia y ausencia de toxicidad en un paciente no diabético con una úlcera corneal post-cáustica resistente al resto de tratamientos

Corneal ulcers are included in a heterogeneous group of eye injuries. When patients do not respond to treatment, including even corneal transplant, other alternatives need to be explored.We present a case of a patient who suffered an accidental spillage from the contents of a car battery. This corneal lesion was refractory to both surgical and pharmacological treatment. After four years of a persistent ulcer, insulin topical treatment 50 IU/mL was started. Improvement began to be observed and currently the patient has completely recovered the corneal epithelium. Nowadays, evidence of the topical insulin use for the treatment of corneal ulcers is higher in diabetic patients. In non-diabetic patients, evidence is restricted to a series of cases of neurotrophic corneal ulcers and a case report of a patient who presented a persistent epithelial defect after resection of a neurinoma. This case presents the experience of using an insulin drop formulation with effectiveness and absence of toxicity in a patient non-diabetic with a post-caustic corneal ulcer

Insulin eye drops for treating corneal ulcer in a non-diabetic patient: regarding a case.

Corneal ulcers are included in a heterogeneous group of eye injuries. When  patients do not respond to treatment, including even corneal transplant, other  alternatives need to be explored.We present a case of a patient who suffered an accidental spillage from the  contents of a car battery. This corneal lesion was refractory to both surgical and  pharmacological treatment. After four years of a persistent ulcer, insulin topical  treatment 50 IU/mL was started. Improvement began to be observed and  currently the patient has completely recovered the corneal epithelium.Nowadays, evidence of the topical insulin use for the treatment of corneal ulcers  is higher in diabetic patients. In non-diabetic patients, evidence is restricted to a series of cases of neurotrophic corneal ulcers and a case report of a patient who  presented a persistent epithelial defect after resection of a neurinoma. This case  presents the experience of using an insulin drop formulation with effectiveness  and absence of toxicity in a patient nondiabetic with a post-caustic corneal ulcer.

Las úlceras corneales se incluyen dentro de un grupo heterogéneo de lesiones  oculares, las cuales pueden ser de gravedad variable. Cuando los pacientes no  responden al tratamiento, incluyendo incluso el trasplante corneal, se crea la  necesidad de explorar otras alternativas.Presentamos el caso de un paciente que sufrió una salpicadura ocular del  contenido de una batería de automóvil por accidente. Esta lesión corneal, fue  refractaria al tratamiento farmacológico e incluso quirúrgico. Tras cuatro años de persistencia de la úlcera corneal, se inició un tratamiento tópico con insulina 50  UI/ml. Se observó mejoría de forma evidente y actualmente el paciente ha  recuperado completamente el epitelio corneal.Hoy en día, las evidencias disponibles del uso tópico de la insulina para el  tratamiento de las úlceras corneales se centran en pacientes diabéticos. En los  pacientes no diabéticos, la evidencia se limita a una serie de casos de úlceras  neurotróficas corneales y al caso de un paciente que presentó un defecto  epitelial persistente después de la resección de un neurinoma. Este caso,  presenta la experiencia de uso de una formulación magistral de insulina  oftálmica con eficacia y ausencia de toxicidad en un paciente no diabético con  una úlcera corneal post-cáustica resistente al resto de tratamientos.

Recomendaciones de la Sociedad Española de Reumatología sobre síndrome antifosfolípido primario. Parte I: diagnóstico, evaluación y tratamiento / Recommendations of the Spanish Rheumatology Society for primary antiphospholipid syndrome. Part I: diagnosis, evaluation and treatment

OBJETIVO: La dificultad para el diagnóstico y la variedad de manifestaciones clínicas que pueden determinar la elección del tratamiento del síndrome antifosfolípido (SAF) primario ha impulsado a la Sociedad Española de Reumatología (SER) en la elaboración de recomendaciones basadas en la mejor evidencia posible. Estas recomendaciones pueden servir de referencia para reumatólogos y otros profesionales implicados en el manejo de pacientes con SAF. MÉTODOS: Se creó un panel formado por cuatro reumatólogos, una ginecóloga y una hematóloga, expertos en SAF, previamente seleccionados mediante una convocatoria abierta o por méritos profesionales. Las fases del trabajo fueron: identificación de las áreas claves para la elaboración del documento, análisis y síntesis de la evidencia científica (utilizando los niveles de evidencia del Scottish Intercollegiate Guidelines Network [SIGN]) y formulación de recomendaciones a partir de esta evidencia y de técnicas de «evaluación formal» o «juicio razonado». RESULTADOS: Se han elaborado 46 recomendaciones que abordan cinco áreas principales: diagnóstico y evaluación, medidas de tromboprofilaxis primaria, tratamiento del SAF primario o tromboprofilaxis secundaria, tratamiento del SAF obstétrico y situaciones especiales. Se incluye también el papel de los nuevos anticoagulantes orales, el problema de las recurrencias o los principales factores de riesgo identificados en estos individuos. En este documento se reflejan las 21 primeras recomendaciones, referidas a las áreas de diagnóstico, evaluación y tratamiento del SAF primario. El documento contiene una tabla de recomendaciones y algoritmos de tratamiento. CONCLUSIONES: Se presentan las recomendaciones de la SER sobre SAF primario. Este documento corresponde a la parte I, relacionada con el diagnóstico, la evaluación y el tratamiento. Estas recomendaciones se consideran herramientas en la toma de decisiones para los clínicos, teniendo en consideración tanto la decisión del médico experto en SAF como la opinión compartida con el paciente. Se ha elaborado también una parte II, que aborda aspectos relacionados con el SAF obstétrico y situaciones especiales

OBJECTIVE: The difficulty in diagnosis and the spectrum of clinical manifestations that can determine the choice of treatment for primary antiphospholipid syndrome (APS) has fostered the development of recommendations by the Spanish Society of Rheumatology (SER), based on the best possible evidence. These recommendations can serve as a reference for rheumatologists and other specialists involved in the management of APS. METHODS: A panel of four rheumatologists, a gynaecologist and a haematologist with expertise in APS was created, previously selected by the SER through an open call or based on professional merits. The stages of the work were: identification of the key areas for drafting the document, analysis and synthesis of the scientific evidence (using the Scottish Intercollegiate Guidelines Network [SIGN] levels of evidence) and formulation of recommendations based on this evidence and formal assessment or reasoned judgement techniques (consensus techniques). RESULTS: 46 recommendations were drawn up, addressing five main areas: diagnosis and evaluation, measurement of primary thromboprophylaxis, treatment for APS or secondary thromboprophylaxis, treatment for obstetric APS and special situations. These recommendations also include the role of novel oral anticoagulants, the problem of recurrences or the key risk factors identified in these subjects. This document reflects the first 21, referring to the areas of: diagnosis, evaluation and treatment of primary APS. The document provides a table of recommendations and treatment algorithms. CONCLUSIONS: An update of the SER recommendations on APS is presented. This document corresponds to part I, related to diagnosis, evaluation and treatment. These recommendations are considered tools for decision-making for clinicians, taking into consideration both the decision of the physician experienced in APS and the patient. A part II has also been prepared, which addresses aspects related to obstetric SAF and special situations

Recomendaciones de la Sociedad Española de Reumatología sobre síndrome antifosfolípido primario. Parte II: síndrome antifosfolípido obstétrico y situaciones especiales / Recommendations of the Spanish Rheumatology Society for Primary Antiphospholipid Syndrome. Part II: Obstetric Antiphospholipid Syndrome and Special Situations

OBJETIVO: La dificultad para el diagnóstico y la variedad de manifestaciones clínicas que pueden determinar la elección del tratamiento del síndrome antifosfolípido (SAF) primario ha impulsado a la Sociedad Española de Reumatología (SER) en la elaboración de recomendaciones basadas en la mejor evidencia posible. Estas recomendaciones pueden servir de referencia para reumatólogos y otros profesionales implicados en el manejo de pacientes con SAF. MÉTODOS: Se creó un panel formado por 4 reumatólogos, una ginecóloga y una hematóloga, expertos en SAF, previamente seleccionados mediante una convocatoria abierta o por méritos profesionales. Las fases del trabajo fueron: identificación de las áreas claves para la elaboración del documento, análisis y síntesis de la evidencia científica (utilizando los niveles de evidencia de SIGN, Scottish Intercollegiate Guidelines Network) y formulación de recomendaciones a partir de esta evidencia y de técnicas de «evaluación formal» o «juicio razonado». RESULTADOS: Se han elaborado 46 recomendaciones que abordan 5áreas principales: diagnóstico y evaluación, medidas de tromboprofilaxis primaria, tratamiento del SAF o tromboprofilaxis secundaria, tratamiento del síndrome antifosfolípido obstétrico y situaciones especiales. Está incluido también el papel de los nuevos anticoagulantes orales, el problema de las recurrencias o los principales factores de riesgo identificados en estos individuos. En este documento se reflejan las últimas 25, referidas a las áreas de: SAF obstétrico y situaciones especiales. El documento contiene una tabla de recomendaciones y algoritmos de tratamiento. CONCLUSIONES: Se presentan las recomendaciones de la SER sobre SAF. Este documento corresponde a la parte 2.ª relacionada con el SAF obstétrico y las situaciones especiales. Estas recomendaciones se consideran herramientas en la toma de decisiones para los clínicos, teniendo en consideración tanto la decisión del médico experto en SAF como la opinión compartida con el paciente. Se ha elaborado también una parte I que aborda aspectos relacionados con el diagnóstico, evaluación y tratamiento

OBJECTIVE: The difficulty in diagnosis and the spectrum of clinical manifestations that can determine the choice of treatment for antiphospholipid syndrome (APS) has fostered the development of recommendations by the Spanish Society of Rheumatology (SER), based on the best possible evidence. These recommendations can serve as a reference for rheumatologists and other specialists involved in the management of APS. METHODS: A panel of 4rheumatologists, a gynaecologist and a haematologist with expertise in APS was created, previously selected by the SER through an open call or based on professional merits. The stages of the work were: identification of the key areas for the document elaboration, analysis and synthesis of the scientific evidence (using the Scottish Intercollegiate Guidelines Network, SIGN levels of evidence) and formulation of recommendations based on this evidence and formal assessment or reasoned judgement techniques (consensus techniques). RESULTS: Forty-six recommendations were drawn up, addressing 5 main areas: diagnosis and evaluation, measurement of primary thromboprophylaxis, treatment for APS or secondary thromboprophylaxis, treatment for obstetric APS and special situations. These recommendations also include the role of novel oral anticoagulants, the problem of recurrences or the key risk factors identified in these subjects. This document reflects the last 25, referring to the areas of: obstetric APS and special situations. The document provides a table of recommendations and treatment algorithms. CONCLUSIONS: Update of SER recommendations on APS is presented. This document corresponds to part II, related to obstetric SAF and special situations. These recommendations are considered tools for decision-making for clinicians, taking into consideration both the decision of the physician experienced in APS and the patient. A part I has also been prepared, which addresses aspects related to diagnosis, evaluation and treatment

Nutrición en niños tratados con técnicas de depuración extrarrenal continua / Nutrition in children with continuous renal replacement therapy

INTRODUCCIÓN: El objetivo de este estudio ha sido analizar el estado de nutrición, la alimentación y las complicaciones digestivas de los niños que precisan técnicas de depuración extrarrenal continua (TDEC). MATERIAL Y MÉTODOS: Estudio retrospectivo realizado sobre una base de datos prospectiva de los niños tratados con TDEC entre 2013 y 2017. Se analizaron las características de los pacientes, la técnica de depuración, el tipo de nutrición, el aporte calórico y proteico, las complicaciones digestivas y la evolución clínica. RESULTADOS: Sesenta y cinco niños (61,5% varones) fueron tratados con TDEC y 24 (37%) precisaron soporte con oxigenación con membrana extracorpórea. Un 27,7% tenían un peso inferior al percentil 3 y un 48,4% una talla inferior al percentil 3. Al inicio de la TDEC 31 niños (47,7%) recibían nutrición enteral y 52 (80%) al final de la misma. La nutrición enteral fue por sonda transpilórica en el 76% de los casos. La mediana de aporte calórico fue de 63 kcal/kg/día y la del aporte proteico de 1,6 g/kg/día. Cuarenta y ocho pacientes (73,8%) presentaron complicaciones digestivas: 29 (44,6%) distensión gástrica o restos gástricos excesivos, 22 (33,8%) estreñimiento, 8 (12,3%) vómitos y 4 (6,1%) diarrea. Un paciente con oxigenación con membrana extracorpórea presentó isquemia intestinal. En 3 pacientes (4,6%) se tuvo que suspender la nutrición enteral por complicaciones. No existió relación entre las complicaciones y el tipo de alimentación o la asistencia en oxigenación con membrana extracorpórea. CONCLUSIONES: Un elevado porcentaje de niños tratados con TDEC presentan malnutrición, pero la mayoría pueden ser alimentados con nutrición enteral. Aunque el porcentaje de complicaciones digestivas es elevado, en pocos pacientes se tiene que suspender la nutrición enteral

INTRODUCTION: The aim of this study was to analyse the nutritional state, diet and gastrointestinal complications of children that require continuous renal replacement therapy (CRRT). MATERIAL AND METHODS: A retrospective analysis of a database, which included the information about patients who required CRRT between the years 2013 and 2017. Data were collected on the replacement technique, type of nutrition, calorie and protein intake, gastrointestinal complications, and clinical course. RESULTS: A total of 65 children (61.5% male) were treated with CRRT, and 24 patients (37%) also needed ECMO support. Just over one-quarter (27.7%) of patients had a weight less than P3, and 48.4% of them a height less than P3. At the beginning of the technique, 31 children (47.7%) received enteral nutrition, at the end, there were 52 patients receiving enteral nutrition (80%). The transpyloric tube was used to provide nutrition in 76% of the cases. The median caloric intake was 63kcal/kg/day, and the protein intake was 1.6g/kg/day. There were gastrointestinal difficulties during the process in 48 patients (73.8%), with 29 (44.6%) patients being diagnosed with gastric distension or excessive gastric remains, 22 (33.8%) with constipation, 8 (12.3%) with vomiting, and 4 (6.1%) diarrhoea. One patient treated with ECMO presented with intestinal ischaemia. Enteral nutrition was cancelled in 3 patients (4.6%) due to the complications. There was no relationship between complications and type of diet or ECMO assistance. CONCLUSIONS: A high percentage of children treated with CRRT showed undernutrition but they had adequate tolerance to the enteral nutrition. Although the gastrointestinal complications percentage was high in few subjects, these complications are the reason why enteral nutrition was stopped

Recommendations of the Spanish Rheumatology Society for Primary Antiphospholipid Syndrome. Part II: Obstetric Antiphospholipid Syndrome and Special Situations. / Recomendaciones de la Sociedad Española de Reumatología sobre síndrome antifosfolípido primario. Parte II: síndrome antifosfolípido obstétrico y situaciones especiales.

OBJECTIVE: The difficulty in diagnosis and the spectrum of clinical manifestations that can determine the choice of treatment for antiphospholipid syndrome (APS) has fostered the development of recommendations by the Spanish Society of Rheumatology (SER), based on the best possible evidence. These recommendations can serve as a reference for rheumatologists and other specialists involved in the management of APS. METHODS: A panel of 4rheumatologists, a gynaecologist and a haematologist with expertise in APS was created, previously selected by the SER through an open call or based on professional merits. The stages of the work were: identification of the key areas for the document elaboration, analysis and synthesis of the scientific evidence (using the Scottish Intercollegiate Guidelines Network, SIGN levels of evidence) and formulation of recommendations based on this evidence and formal assessment or reasoned judgement techniques (consensus techniques). RESULTS: Forty-six recommendations were drawn up, addressing 5main areas: diagnosis and evaluation, measurement of primary thromboprophylaxis, treatment for APS or secondary thromboprophylaxis, treatment for obstetric APS and special situations. These recommendations also include the role of novel oral anticoagulants, the problem of recurrences or the key risk factors identified in these subjects. This document reflects the last 25, referring to the areas of: obstetric APS and special situations. The document provides a table of recommendations and treatment algorithms. CONCLUSIONS: Update of SER recommendations on APS is presented. This document corresponds to part II, related to obstetric SAF and special situations. These recommendations are considered tools for decision-making for clinicians, taking into consideration both the decision of the physician experienced in APS and the patient. A part I has also been prepared, which addresses aspects related to diagnosis, evaluation and treatment.

Recommendations of the Spanish Rheumatology Society for Primary Antiphospholipid Syndrome. Part I: Diagnosis, Evaluation and Treatment. / Recomendaciones de la Sociedad Española de Reumatología sobre síndrome antifosfolípido primario. Parte I: Diagnóstico, evaluación y tratamiento.

OBJECTIVE: The difficulty in diagnosis and the spectrum of clinical manifestations that can determine the choice of treatment for primary antiphospholipid syndrome (APS) has fostered the development of recommendations by the Spanish Society of Rheumatology (SER), based on the best possible evidence. These recommendations can serve as a reference for rheumatologists and other specialists involved in the management of APS. METHODS: A panel of four rheumatologists, a gynaecologist and a haematologist with expertise in APS was created, previously selected by the SER through an open call or based on professional merits. The stages of the work were: identification of the key areas for drafting the document, analysis and synthesis of the scientific evidence (using the Scottish Intercollegiate Guidelines Network [SIGN] levels of evidence) and formulation of recommendations based on this evidence and formal assessment or reasoned judgement techniques (consensus techniques). RESULTS: 46 recommendations were drawn up, addressing five main areas: diagnosis and evaluation, measurement of primary thromboprophylaxis, treatment for APS or secondary thromboprophylaxis, treatment for obstetric APS and special situations. These recommendations also include the role of novel oral anticoagulants, the problem of recurrences or the key risk factors identified in these subjects. This document reflects the first 21, referring to the areas of: diagnosis, evaluation and treatment of primary APS. The document provides a table of recommendations and treatment algorithms. CONCLUSIONS: An update of the SER recommendations on APS is presented. This document corresponds to partI, related to diagnosis, evaluation and treatment. These recommendations are considered tools for decision-making for clinicians, taking into consideration both the decision of the physician experienced in APS and the patient. A partII has also been prepared, which addresses aspects related to obstetric SAF and special situations.