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Urban water management has been increasingly relying on infiltration to limit the environmental impact of stormwater, secondary treated effluent and gray water. The infiltration systems used are generally based on non-renewable drainage materials featuring a pronounced ecological footprint (i.e., excavation and transport), such as gravel. This paper investigates the possibility of using woodchips instead of traditional drainage materials. Our study examines flow dynamics in woodchip-filled infiltration trenches at four decentralized gray water sites, on a silty clay soil. Infiltration tests were conducted using the Beerkan method to measure soil infiltration capacity both beneath the woodchip-filled trenches and in adjacent soil. Soil hydraulic functions were determined according to the BEST method, then comparisons were drawn between the woodchip-filled trench and natural soil. Results indicate that woodchips locally maintain or enhance soil infiltration rates, with a hydraulic conductivity up to 200 times higher in woodchip-treated soil. Additional soil measurements and analyses serve to formulate hypotheses on how the woodchips actually contribute to these effects. Dye tracer experiments revealed preferential pathways facilitated by macro fauna (earthworms) and, most likely, plant roots. This last information input has been corroborated since earthworm counts did prove to be significantly higher in the woodchips than in the soil. A chemical analysis of the soils also showed a significant enrichment of carbon and nitrogen under the trench, which may also improve soil structure and stability and perhaps indirectly enhance water infiltration capacity. In summary, the presence of woodchips in infiltration trenches improves the soil hydraulic conductivity at saturation for systems that have been in use for 5 to 10 years. These findings underscore the potential of woodchips in sustainable urban water management in order to enhance the functionality and efficiency of drainage materials by means of limiting the clogging effect.

Introduction Intranasal esketamine has been approved as a treatment for patients with treatment-resistant depression. We analyzed the results of its efficacy in 15 patients. Objectives To evaluate the efficacy of intranasal Esketamine as a treatment in patients with treatment-resistant depression Methods Case series Results For the last 8 months, since the treatment with intranasal esketamine was approved for resistant depression, we have treated 14 patients with this drug. Through this process, we followed a standardized method consisting in the following steps: On the first esketamine session (DAY 1) the patient has to fill a CGI and a MADRS scale. On the second esketamine session (DAY 7) the patient has to fill a CGI, a MADRS scale, a form about the level of satisfaction with the drug and a last form in which they can include the secondary effects. On week 6 since the start of the treatment, the patient has to fill again a CGI, a MADRS scale, a form about the level of satisfaction with the drug and a last form in which they can include the secondary effects. In the 6th month since the start of the treatment, the patient has to fill again a CGI, a MADRS scale, a form about the level of satisfaction with the drug and a last form in which they can include the secondary effects they have perceived. We analyzed and compared all of the previous data and obtained the following results: At day 7: 64% of the patients had a response in the form of improvement, of which 66% were feeling “slightly better” and 33% were feeling “better”. At week 6: 71% of the patients had a response in the form of improvement, of which 50% were feeling “slightly better” and the other 50% were feeling “better”. At month 6: only 28% of the patients completed the treatment; of which 100% had a response in the form of improvement: 50% were feeling “slightly better”, 25% were feeling “better” and 25% were feeling “far better”. Conclusions Although our data suggests that intranasal esketamine has been effective in short term depressive symptoms, we have yet no information about its medium and long-term efficacy or secondary effects. Nevertheless, other potential factors should be evaluated as they could affect the results in the long-term such as the difficulty in maintaining the treatment for more than 6 weeks. In addition, the patients who experienced the most improvement according to our data were patients with a TAB diagnosis, so this could be an interesting research focus. Disclosure of Interest None Declared

Introduction: Since Hypersensitivity Pneumonitis (HP) categorization in fibrotic and nonfibrotic/inflammatory types seems to be more consistent with the distinctive clinical course and outcomes, recent international guidelines recommended the use of this classification. Moreover, fibrotic subtype may share immunogenetic and pathophysiological mechanisms with other fibrotic lung diseases. Aim: To investigate HLA -A, -B, -DRB1 and TNF-α –308 gene polymorphisms among fibrotic and nonfibrotic HP patients due to avian exposure, also in comparison with asymptomatic exposed controls. Methods: We prospectively enrolled 40 HP patients, classified as fibrotic or nonfibrotic/inflammatory, and 70 exposed controls. HLA and TNF-α polymorphisms were determined by polymerase chain reaction–sequence specific primer amplification. Results: While HLA alleles were not associated to HP susceptibility, fibrotic HP patients showed increased frequencies of HLA A*02 (46.7% vs 25.7%; OR=2.53, p = 0.02) and HLA DRB1*14 (10.0% vs 0.7%; OR=15.44, p=0.02) alleles when compared with exposed controls, although not statistically significant after correction for multiple comparisons. TNF-α G/G genotype (associated with low TNF-α production) frequencies were significantly increased among the non-fibrotic/inflammatory HP patients comparatively to fibrotic presentations (88% vs 60%; RR=0.44; p=0.04) and controls (88% vs 63%, OR 4.33, p=0.037). Also, these patients had a significantly increased frequency of the G allele (94.0% vs 73.3%, RR=0.44, p=0.01), while fibrotic HP patients predominantly presented the A allele (26.7% vs 6.0%, RR=2.28, p=0.01). Conclusions: Our results support the hypothesis that fibrotic and non-fibrotic HP subtypes exhibit a distinct profile of TNF-α and HLA polymorphisms, which may be relevant to predict disease course and better define treatment strategies.

The elimination of the need for an Ohmic heating solenoid may be the most impactful design driver for the realization of economical compact fusion tokamak reactor systems. However, this would require fully non-inductive start-up and current ramp-up from zero plasma current and low electron temperature of sub-keV to the full plasma current of ∼10–15 MA at 20–30 keV electron temperature. To address this challenge, an efficient solenoid-free start-up and ramp-up scenario utilizing a low-field-side-launched extraordinary mode at the fundamental electron cyclotron harmonic frequency (X–I) is proposed, which has more than two orders of magnitude higher electron cyclotron current drive (ECCD) efficiency than the conventional ECCD for the sub-keV start-up regime. A time dependent model was developed to simulate the start-up scenarios. For the Spherical Tokamak Advanced Reactor (STAR) (Menard et al 2023 Next-Step Low-Aspect-Ratio Tokamak Design Studies (IAEA)), it was found that to fully non-inductively ramp-up to 15 MA, it would take about 25 MW of EC power at 170 GHz. Because of the relatively large plasma volume of STAR, radiation losses must be considered. It is important to make sure that high Z impurities are kept sufficiently low during the early current start-up phase where the temperature is sub-keV range. Since the initial current ramp up takes place at a factor of ten lower density compared to the sustained regimes, it is important to transition into a higher bootstrap fraction discharge at lower density to minimize the ECCD power requirement during the densification. For the sustainment phase an array of eight gyrotron launchers with a total of about 60 MW of fundamental O-mode was found to be sufficient to provide the required axis-peaked external current drive. High efficiencies between 19–57 kA MW ^−1 were found with optimal aiming, and these were resilient to small changes in aiming angles and density and temperature profiles.

Cow's milk protein allergy (CMPA) is the most frequent cause of food allergy in the first months of life. Despite the fact that there are different guidelines and recommendations on the management of children with CMPA, there continues to be great variability in diagnostic and therapeutic criteria in Latin America. The Food Allergy Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition summoned a group of Latin American experts to reach a consensus and formulate a document to unify diagnostic and therapeutic criteria for CMPA. Three teams were formed, each with a coordinator, and the members of each team developed a series of statements for their corresponding module: a) clinical manifestations and diagnosis; b) diagnostic tools, and c) treatment. A search of the medical literature was carried out to support the information presented in each module and 28 statements were then selected. The statements were discussed, after which they were evaluated by all the experts, utilizing the Delphi method. Their opinions on statement agreement or disagreement were anonymously issued. The final statements selected were those with above 75% agreement and their corresponding recommendations were formulated, resulting in the document presented herein. Resumen: La alergia a las proteínas de leche de vaca (APLV) constituye la causa más frecuente de alergia alimentaria en los primeros meses de vida. A pesar de la existencia de diferentes guías y recomendaciones sobre el manejo de niños con APLV, en Latinoamérica sigue observándose una gran variabilidad de criterios diagnósticos y terapéuticos. El grupo de trabajo de Alergia Alimentaria de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica se dio a la tarea de convocar a un grupo de expertos de la región, realizar un consenso y elaborar un documento con el objetivo de unificar criterios diagnósticos y terapéuticos para APLV. Se dividió el grupo en tres equipos bajo un coordinador para cada equipo, y los miembros de cada grupo formularon una serie de enunciados correspondientes a uno de tres módulos diferentes: a) manifestaciones clínicas; b) herramientas diagnósticas, y c) tratamiento. Se buscó la información en la literatura médica para sustentar la información de cada uno de ellos, y posteriormente se seleccionaron 28 enunciados, los cuales fueron discutidos y posteriormente evaluados por todos los expertos, a través de método Delphi, quienes emitieron su opinión sobre acuerdo o desacuerdo sobre las mismas de forma anónima. Todos los enunciados obtuvieron porcentajes de acuerdo mayores al 75%, por lo que permanecieron, y con base en ellos se elaboraron las recomendaciones y se presentan.

Resumen: La alergia a las proteínas de leche de vaca (APLV) constituye la causa más frecuente de alergia alimentaria en los primeros meses de vida. A pesar de la existencia de diferentes guías y recomendaciones sobre el manejo de niños con APLV, en Latinoamérica sigue observándose una gran variabilidad de criterios diagnósticos y terapéuticos. El grupo de trabajo de Alergia Alimentaria de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica se dio a la tarea de convocar a un grupo de expertos de la región, realizar un consenso y elaborar un documento con el objetivo de unificar criterios diagnósticos y terapéuticos para APLV. Se dividió el grupo en tres equipos bajo un coordinador para cada equipo, y los miembros de cada grupo formularon una serie de enunciados correspondientes a uno de tres módulos diferentes: a) manifestaciones clínicas; b) herramientas diagnósticas, y c) tratamiento. Se buscó la información en la literatura médica para sustentar la información de cada uno de ellos, y posteriormente se seleccionaron 28 enunciados, los cuales fueron discutidos y posteriormente evaluados por todos los expertos, a través de método Delphi, quienes emitieron su opinión sobre acuerdo o desacuerdo sobre las mismas de forma anónima. Todos los enunciados obtuvieron porcentajes de acuerdo mayores al 75%, por lo que permanecieron, y con base en ellos se elaboraron las recomendaciones y se presentan. Abstract: Cow's milk protein allergy (CMPA) is the most frequent cause of food allergy in the first months of life. Despite the fact that there are different guidelines and recommendations on the management of children with CMPA, there continues to be great variability in diagnostic and therapeutic criteria in Latin America. The Food Allergy Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition summoned a group of Latin American experts to reach a consensus and formulate a document to unify diagnostic and therapeutic criteria for CMPA. Three teams were formed, each with a coordinator, and the members of each team developed a series of statements for their corresponding module: a) clinical manifestations and diagnosis; b) diagnostic tools, and c) treatment. A search of the medical literature was carried out to support the information presented in each module and 28 statements were then selected. The statements were discussed, after which they were evaluated by all the experts, utilizing the Delphi method. Their opinions on statement agreement or disagreement were anonymously issued. The final statements selected were those with above 75% agreement and their corresponding recommendations were formulated, resulting in the document presented herein.

Introduction Steroids are a necessary treatment for hypoxic respiratory failure; however there are many side effects that should be taken into account. A 44- year-old-woman with asthma and no past psychiatric history was admitted due to COVID-19 pneumonia and Respiratory syncytial virus (RSV) infection, presenting hypoxic respiratory failure. After two days of intravenous methylprednisolone administration, the patient presented acute psychosis and agitation. It has been previously described that steroid use can cause effects such as mania, anxiety, agitation, delirium and psychosis amongst other. However they are a necessary treatment in respiratory illnesses and are sometimes unavoidable. Objectives The aim was to examine the appropriate medical response to steroid induced psychosis in patients with acute hypoxic failure. Methods A bibliographical review was done in PubMed database searching recent cases of steroid induced psychosis using the words (“Steroid”, “Psychosis” and “COVID-19”). Results According to literature, it has been shown that partial or complete reduction of steroid use and/or use of psychotropic has been successfully used to treat steroid induced psychosis. Following the research it was decided to reduce intravenous methylprednisolone dose from 20mg/ 8h to 20mg/12h and start oral haloperidol 5mg/8h the first 24h and reducing the dose progressively as the patient recovered. After the first 24 hours the patient presented adequate response to steroids as well as partial response to antipsychotic treatment; presenting no further agitation, absence of hallucinations and partial persistence of the persecutory delusion. A couple of days later there was complete remission of the psychotic symptoms and the patient was on the way to recovery from COVID-19 and RSV. Conclusions There is evidence that suggests that medications such as steroids used to treat COVID-19 and other respiratory illnesses can lead to psychotic episodes. It is very important to pay attention to possible side effects when treating with steroids and evaluate the patient history as well as suggest having a follow up visit after the hospital discharge. Disclosure of Interest None Declared

Introduction Haploinssufficiency of AUTS2 gene has been associated with a syndromic form of neurodevelopmental delay called AUTS2 Syndrome (AUTS2S). It is characterized for having attention/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), mild global development delay (GDD) and intellectual disability (ID). Clinicians also reported microcephaly, feeding difficulties, generalized hypotonia and ptosis.Due to its great variability, the AUTS2 Syndrome Severity Scoring System (ASSS) was established to assess the severity of the syndrome presentation. It is based on 32 characteristics including items of growth, feeding, neurodevelopment and congenital anomalies. At the molecular level, the AUTS2 gene consists of 19 exons that are divided into a non-conserved N-terminal region and a conserved 3’ terminal end. There is a short isoform expressed primarily in the brain that initiates at an alternative transcription site and includes the last 11 exons. Variants that disrupt this final part of the gene have been associated with a severe phenotype. Objectives To describe and compare 3 patients affected with AUTS2 syndrome using the ASSS. Methods (1) Case series: Comparison of the patients diagnosed with AUTS2 Syndrome using the AUTS2 Syndrome Severity Score. (2) Narrative review of the AUTS2 syndrome and the genotype-phenotype correlation through PubMed database (1990-2020). Key terms: “AUTS2”, “AUTS2 syndrome”, “ADHD”, “neurodevelopmental disorder”, “autism”. Results 1 (ASSS score: 12). Interstitial duplication long arm of chromosome 7. Characteristics: microcephaly, GDD, ASD features, ADHD, auditory hypersensitivity. Finger flexion and syndactylia, arched eyebrows, palpebral fissures, epicanthus, nares, micrognathia, narrow mouth. 2 (ASSS score: 13). Pathogenic variant exon 9. Characteristics: GDD, feeding problems, ID, ASD features, auditory hypersensitivity, ADHD, hypotonia, cerebral anomalies, hypertelorism, anteverted nostrils, broad nasal bridge, micrognathia, low-set ears, narrow mouth. 3 (ASSS score: 13). Pathogenic variant exon 16. Characteristics: ID, short stature, feeding problems, auditory hypersensitivity, ADHD, hypotonia, umbilical hernia, hypertelorism, proptosis, short palpebral fissures, epicanthus, prominent nasal tip, anteverted nares, low-set ears. Conclusions Currently, 65 patients with pathogenic variants in AUTS2 are described in the literature. Significantly higher ASSS values have been found in patients with pathogenic variants affecting the 3’ end of the gene. Further research is needed, since genetic diagnosis of affected patients contributes to improved clinical protocols and personalized treatment. Disclosure of Interest None Declared

SARS-CoV-2 is a new beta coronavirus, similar to SARS-CoV-1, that emerged at the end of 2019 in the Hubei province of China. It is responsible for coronavirus disease 2019 (COVID-19), which was declared a pandemic by the World Health Organization on March 11, 2020. The ability to gain quick control of the pandemic has been hampered by a lack of detailed knowledge about SARS-CoV-2-host interactions, mainly in relation to viral biology and host immune response. The rapid clinical course seen in COVID-19 indicates that infection control in asymptomatic patients or patients with mild disease is probably due to the innate immune response, as, considering that SARS-CoV-2 is new to humans, an effective adaptive response would not be expected to occur until approximately 2–3 weeks after contact with the virus. Antiviral innate immunity has humoral components (complement and coagulation-fibrinolysis systems, soluble proteins that recognize glycans on cell surface, interferons, chemokines, and naturally occurring antibodies) and cellular components (natural killer cells and other innate lymphocytes). Failure of this system would pave the way for uncontrolled viral replication in the airways and the mounting of an adaptive immune response, potentially amplified by an inflammatory cascade. Severe COVID-19 appears to be due not only to viral infection but also to a dysregulated immune and inflammatory response. In this paper, the authors review the most recent publications on the immunobiology of SARS-CoV-2, virus interactions with target cells, and host immune responses, and highlight possible associations between deficient innate and acquired immune responses and disease progression and mortality. Immunotherapeutic strategies targeting both the virus and dysfunctional immune responses are also addressed.

Introduction Co-morbid psychiatric disorders are common in Down syndrome (DS). Evidence is limited for pharmacotherapy, specifically antipsychotics, for psychiatric co-morbidity in DS. Objectives To describe a case of a patient with DS who developed a first-episode psychosis (FEP) and who responded to lurasidone in monotherapy and to review recent literature on the treatment of psychosis in patients with DS. Methods (1) Case report: FEP in DS patient treated with lurasidone 37 mg/day. (2) Narrative review on the treatment of psychosis in DS patients through PubMed database (1990-2020). Key terms: “psychosis”, “Down Syndrome”, “pharmacological treatment”, “antipsychotic drugs”. Results A 21-year-old woman with DS, without psychiatric history, presenting with behavioural anomalies, aggressiveness, soliloquies, and unmotivated laughs was referred to our outpatient clinic by her general practitioner. Symptoms began one year prior and progressively worsened, impairing her daily functionality. Previous blood workup was normal. She was diagnosed with FEP and began treatment with lurasidone 37 mg. At 4-week follow-up, she showed total remission of the psychotic symptoms, had no tolerability complaints, and returned to baseline functionality levels. Discussion: No reports of lurasidone use in psychosis in DS have been published. To treat psychotic symptoms in DS, most literature reports describe the use of typical antipsychotics, which are usually effective, but often poorly tolerated; atypical antipsychotics such as risperidone and aripiprazole have also been used. Conclusions Lurasidone may be a useful option in patients with FEP in DS. Further research is warranted on treatment of psychosis in this population. Disclosure No significant relationships.

Introduction The influence of sexual hormones on mental disorders have been extensively reported. In fact, recent studies suggest that sex hormones may play a relevant role in the pathophysiology of psychosis, may be a precipitant when exogenously administered or even be used as a treatment agent of psychotic disorders. Objectives To describe the case of a patient with a recent diagnosis of delusional disorder (DD) with an onset in the perimenopausal period. Methods Case report and narrative review focused on the impact of sexual hormones on depressive symptoms and alcohol use comorbidity during perimenopause in DD women by using PubMed database. Results Case report: A 48-year-old woman diagnosed with DD. The clinical assessment of climacteric symptoms, as well as the gonadotropins (elevated levels of follicle-stimulating hormone -FSH- and luteinizing hormone -LH-) and estrogen levels monitoring (variations on 17-β-estradiol -E2-) enabled to link the endocrine changes with the onset and course of the psychiatric disorder. During the development of the disease, the patient also presented comorbid depressive symptoms and alcohol use disorder. Review: Estrogen depletion seems to increase the risk of psychosis, while scientific literature is not conclusive in establishing a definitive relationship between depressive symptoms and hormonal imbalance in DD. Alcohol use disorder is a common comorbidity in both perimenopausal women and patients with DD. Conclusions Multiaxial management of the case helped clinicians to achieve clinical stabilization. Sex differences as well as hormonal pattern disturbances should receive special attention due to the seminal implications in pharmacotherapy and clinical outcomes. Disclosure No significant relationships.

Introduction and aim: There are discrepancies in the diagnosis and management of cow’s milk protein allergy (CMPA) in Spain and Latin America. The aim of the present study was to find out how Spanish and Latin American pediatric gastroenterologists diagnose and treat CMPA. Materials and methods: Pediatric gastroenterologists, members of the Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición, were invited to fill out a structured survey, the results of which were then compared with the 2012 and 2014 diagnosis and treatment guidelines, respectively. Results: The survey results showed that 17% of the participants follow the diagnostic recommendations based on the published consensus and guidelines. To diagnose non-IgE-mediated CMPA, 15% of the participants utilize IgE-specific skin prick tests, 22% use IgE-specific blood tests, and 45% employ oral food challenges. To diagnose IgE-mediated CMPA the percentages for the same diagnostic methods were 57%, 83% and 22%, respectively. Once diagnosis is confirmed, 98% of the participants provide dietary recommendations. In children that are not breastfed, 89% of the participants prescribe an initial extensively hydrolyzed formula, 9% an amino acid formula, 1% a soy formula, and 1% a hydrolyzed rice formula. In patients with IgE-mediated CMPA, 34% of the participants carry out an oral challenge once treatment is completed, 39% according to symptom severity, and 27% in relation to IgE-specific testing. Conclusion: CMPA management is diverse and there is poor adherence to the clinical practice guidelines. Resumen: Introducción: Existen discrepancias en el diagnóstico y manejo de alergia a las proteínas de la leche de vaca (APLV) en Iberolatinoamérica. El objetivo del estudio fue conocer la forma como el gastroenterólogo pediatra en iberolatinoamerica realiza el diagnóstico y el tratamiento de APLV. Material y métodos: Se invitó a los gastroenterólogos pediatras miembros de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición a contestar una encuesta estructurada y se comparó con las pautas de diagnóstico y tratamiento expresadas en el consenso y la guía publicadas en 2012 y 2014 respectivamente. Resultados: El 17% sigue las recomendaciones diagnósticas basadas en la evidencia del consenso y guía publicada. Para la APLV no mediada por IgE (APLV-No IgE) el 15% utiliza pruebas cutáneas IgE específicas vs. 57% en las mediadas por IgE (APLV-IgE); el 22% vs. 83% realiza determinación de IgE específica en sangre, respectivamente. La confirmación diagnóstica con prueba de reto oral es realizada por el 45% vs. 22% respectivamente. Una vez confirmado el diagnóstico, el 98% entrega recomendaciones dietarias. En niños no alimentados con leche materna, el 89% inicia con fórmula extensamente hidrolizada, 9% con aminoacídica, 1% fórmula de soja y 1% fórmula de arroz hidrolizada. La prueba de tolerancia en APLV-IgE se realiza en el 34% una vez cumplido el tiempo de tratamiento, en el 39% según la gravedad de los síntomas, y en 27% con la negativización de test IgE específicos. Conclusión: Existe mucha diversidad en el manejo de la APLV y pobre adherencia a las guías de práctica clínica.

Resumen: Introducción: Existen discrepancias en el diagnóstico y el manejo de la alergia a las proteínas de la leche de vaca (APLV) en Iberolatinoamérica. El objetivo del estudio fue conocer la forma como el gastroenterólogo pediatra en Iberolatinoamérica realiza el diagnóstico y el tratamiento de la APLV. Material y métodos: Se invitó a los gastroenterólogos pediatras miembros de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición a contestar una encuesta estructurada y se comparó con las pautas de diagnóstico y tratamiento expresadas en el consenso y la guía publicadas en 2012 y 2014, respectivamente. Resultados: El 17% sigue las recomendaciones diagnósticas basadas en la evidencia del consenso y guía publicada. Para la APLV no mediada por IgE, el 15% utiliza pruebas cutáneas IgE específicas vs. el 57% en las mediadas por IgE; el 22 vs. 83% realiza determinación de IgE específica en sangre, respectivamente. La confirmación diagnóstica con prueba de reto oral es realizada por el 45 vs. el 22%, respectivamente. Una vez confirmado el diagnóstico, el 98% entrega recomendaciones dietarias. En niños no alimentados con leche materna, el 89% inicia con fórmula extensamente hidrolizada, el 9% con aminoacídica, el 1% con fórmula de soja y el 1% con fórmula de arroz hidrolizada. La prueba de tolerancia en APLV-IgE se realiza en el 34% una vez cumplido el tiempo de tratamiento, en el 39% según la gravedad de los síntomas, y en 27% con la negativización de test IgE específicos. Conclusión: Existe mucha diversidad en el manejo de la APLV y una pobre adherencia a las guías de práctica clínica. Abstract: Introduction: There are discrepancies in the diagnosis and management of cow's milk protein allergy (CMPA) in Spain and Latin America. The aim of the present study was to find out how Spanish and Latin American pediatric gastroenterologists diagnose and treat CMPA. Material and methods: Pediatric gastroenterologists, members of the Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición, were invited to fill out a structured survey, the results of which were then compared with the 2012 and 2014 diagnosis and treatment guidelines, respectively. Results: The survey results showed that 17% of the participants follow the diagnostic recommendations based on the published consensus and guidelines. To diagnose non-IgE-mediated CMPA, 15% of the participants utilize IgE-specific skin prick tests, 22% use IgE-specific blood tests, and 45% employ oral food challenges. To diagnose IgE-mediated CMPA the percentages for the same diagnostic methods were 57, 83 and 22%, respectively. Once diagnosis is confirmed, 98% of the participants provide dietary recommendations. In children that are not breastfed, 89% of the participants prescribe an initial extensively hydrolyzed formula, 9% an amino acid formula, 1% a soy formula, and 1% a hydrolyzed rice formula. In patients with IgE-mediated CMPA, 34% of the participants carry out an oral challenge once treatment is completed, 39% according to symptom severity, and 27% in relation to IgE-specific testing. Conclusion: CMPA management is diverse and there is poor adherence to the clinical practice guidelines.

Introduction and objective: Eosinophilic esophagitis is a chronic, immune-mediated disease described in case series and publications worldwide. Over the past twenty years, the authors of different studies have attempted to evaluate its incidence and prevalence. The objetive of the present study was to estimate the prevalence of eosinophilic esophagitis in a group of children seen at 36 pediatric gastroenterology centers in ten Latin American countries. Materials and methods: A multicenter, observational, and cross-sectional study was conducted that estimated the period prevalence of eosinophilic esophagitis in children seen at outpatient consultation and that underwent diagnostic upper gastrointestinal endoscopy for any indication at 36 centers in 10 Latin American countries, within a 3-month time frame. Results: Between April and June 2016, 108 cases of eosinophilic esophagitis were evaluated. Likewise, an average of 29,253 outpatient consultations and 4,152 diagnostic upper gastrointestinal endoscopies were carried out at the 36 participating centers. The period prevalence of eosinophilic esophagitis in the population studied (n = 29,253) was 3.69 cases × 1,000 (95% CI: 3.04 to 4.44), and among the children that underwent routine upper gastrointestinal endoscopy (n = 4,152), it was 26 x 1,000 (95% CI: 22.6 to 29.4). Conclusions: The general period prevalence of eosinophilic esophagitis in a group of children evaluated at 36 Latin American pediatric gastroenterology centers was 3.69 × 1,000, and in the children that underwent endoscopy, it was 26 × 1,000. There was important prevalence variability between the participating countries and centers. The present analysis is the first study conducted on the prevalence of pediatric eosinophilic esophagitis in Latin America. Resumen: Introducción y objetivo: La esofagitis eosinofílica es una enfermedad crónica, mediada inmunológicamente, descrita en series y publicaciones alrededor del mundo. En los últimos 20 años diversos estudios han intentado evaluar la incidencia y prevalencia de la enfermedad. El objetivo del presente trabajo es estimar la prevalencia de esofagitis eosinofílica en un grupo de niños atendidos en 36 centros de gastroenterología pediátrica de 10 países latinoamericanos. Materiales y métodos: A través de un protocolo multicéntrico, observacional y transversal se estimó la prevalencia de período de esofagitis eosinofílica entre los niños atendidos en consulta externa y sometidos a endoscopia superior diagnóstica por cualquier motivo en 36 centros de 10 países latinoamericanos durante un período de 3 meses. Resultados: Entre abril y junio de 2016 108 casos de esofagitis eosinofílica fueron evaluados. Asimismo, un promedio de 29,253 consultas ambulatorias y 4,152 endoscopias superiores de carácter diagnóstico fueron realizadas en los 36 centros participantes. La tasa de prevalencia de esofagitis eosinofílica en la población estudiada (n = 29,253) fue de 3,69 casos × 1,000 (IC 95%: 3.04 a 4.44) y entre los niños sometidos a endoscopia superior de rutina (n = 4,152) fue de 26 x 1,000 (IC 95%: 22.6 a 29.4). Conclusión: La tasa general de prevalencia de período de esofagitis eosinofílica en un grupo de niños evaluados en 36 centros latinoamericanos de gastroenterología pediátrica resultó de 3,69 × 1,000, y entre aquellos sometidos a endoscopia fue de 26 × 1,000. La prevalencia mostró una importante variabilidad entre los países y centros participantes. Este es el primer estudio de prevalencia de esofagitis eosinofílica pediátrica en Latinoamérica. Keywords: Esophagitis, Eosinophilic, Children, Prevalence, Latin America, Palabras clave: Esofagitis, Eosinofílica, Niños, Prevalencia, Latinoamérica

Resumen: Introducción y objetivo: La esofagitis eosinofílica es una enfermedad crónica, mediada inmunológicamente, descrita en series y publicaciones alrededor del mundo. En los últimos 20 años diversos estudios han intentado evaluar la incidencia y prevalencia de la enfermedad. El objetivo del presente trabajo es estimar la prevalencia de esofagitis eosinofílica en un grupo de niños atendidos en 36 centros de gastroenterología pediátrica de 10 países latinoamericanos. Materiales y métodos: A través de un protocolo multicéntrico, observacional y transversal se estimó la prevalencia de período de esofagitis eosinofílica entre los niños atendidos en consulta externa y sometidos a endoscopia superior diagnóstica por cualquier motivo en 36 centros de 10 países latinoamericanos durante un período de 3 meses. Resultados: Entre abril y junio de 2016 108 casos de esofagitis eosinofílica fueron evaluados. Asimismo, un promedio de 29,253 consultas ambulatorias y 4,152 endoscopias superiores de carácter diagnóstico fueron realizadas en los 36 centros participantes. La tasa de prevalencia de esofagitis eosinofílica en la población estudiada (n = 29,253) fue de 3,69 casos × 1,000 (IC 95%: 3.04 a 4.44) y entre los niños sometidos a endoscopia superior de rutina (n = 4,152) fue de 26 x 1,000 (IC 95%: 22.6 a 29.4). Conclusión: La tasa general de prevalencia de período de esofagitis eosinofílica en un grupo de niños evaluados en 36 centros latinoamericanos de gastroenterología pediátrica resultó de 3,69 × 1,000, y entre aquellos sometidos a endoscopia fue de 26 × 1,000. La prevalencia mostró una importante variabilidad entre los países y centros participantes. Este es el primer estudio de prevalencia de esofagitis eosinofílica pediátrica en Latinoamérica. Abstract: Introduction and objective: Eosinophilic esophagitis is a chronic, immune-mediated disease described in case series and publications worldwide. Over the past twenty years, the authors of different studies have attempted to evaluate its incidence and prevalence. The objetive of the present study was to estimate the prevalence of eosinophilic esophagitis in a group of children seen at 36 pediatric gastroenterology centers in ten Latin American countries. Materials and methods: A multicenter, observational, and cross-sectional study was conducted that estimated the period prevalence of eosinophilic esophagitis in children seen at outpatient consultation and that underwent diagnostic upper gastrointestinal endoscopy for any indication at 36 centers in 10 Latin American countries, within a 3-month time frame. Results: Between April and June 2016, 108 cases of eosinophilic esophagitis were evaluated. Likewise, an average of 29,253 outpatient consultations and 4,152 diagnostic upper gastrointestinal endoscopies were carried out at the 36 participating centers. The period prevalence of eosinophilic esophagitis in the population studied (n = 29,253) was 3.69 cases × 1,000 (95% CI: 3.04 to 4.44), and among the children that underwent routine upper gastrointestinal endoscopy (n = 4,152), it was 26 x 1,000 (95% CI: 22.6 to 29.4). Conclusions: The general period prevalence of eosinophilic esophagitis in a group of children evaluated at 36 Latin American pediatric gastroenterology centers was 3.69 × 1,000, and in the children that underwent endoscopy, it was 26 × 1,000. There was important prevalence variability between the participating countries and centers. The present analysis is the first study conducted on the prevalence of pediatric eosinophilic esophagitis in Latin America. Palabras clave: Esofagitis, Eosinofílica, Niños, Prevalencia, Latinoamérica, Keywords: Esophagitis, Eosinophilic, Children, Prevalence, Latin America

Hypersensitivity pneumonitis (HP) is an immune-mediated syndrome triggered by inhalation of a wide variety of allergens, to which an individual has previously been sensitized. More than 200 agents responsible for the disease have already been identified; however, HP occurs only in a small number of individuals exposed to causal antigens. The present report provides an overview of the role of antigen role in HP, highlighting its diversity, research methods, and prevention strategies, as well as the impact on disease prognosis following elimination of antigen. HP is an underdiagnosed disease and, therefore, it is difficult to accurately estimate its incidence. Triggering antigens can be divided into six broad categories: bacteria, fungi, mycobacteria, animal and plant proteins, chemicals, and metals, represented by disease prototypes. The identification of causal antigen is a major challenge; it is impossible to obtain in about 30–60% of cases. The acute form of HP, with early detection and immediate eviction of causal antigen, tends to have an excellent prognosis. In the chronic form, partial recovery of disease is still possible; however, some cases tend to progress to fibrosis, even after removal from exposure. In conclusion, HP diagnosis should be based on a proactive search for potential antigen sources, although their identification is hampered by the lack of standardized methods of demonstrating the specific antigen sensitization. Antigen avoidance is a critical determinant in disease prognosis. Keywords: Hypersensitivity pneumonitis, Antigen, Research methods, Diagnosis, Prognosis

Introduction Prevalence rates of panic attacks have been reported to be around 24-63% in psychotic patients. Common underlying biological substrates for panic and paranoia have been proposed, suggesting that delusional disorder (DD) may be preceded by the development of anxiety disorders. Objectives The main objective of this study was to investigate anxiety comorbidity in DD. As a second objective, we set ourselves to know prescription rates for the use of antidepressants and benzodiazepines in anxiety disorders in the context of DD. Methods A systematic literature search was performed using PubMed (1980- September 2020) according to the PRISMA guidelines. The following search terms were used: (delusional disorder) AND (anxiety OR anxiety disorder OR anxi*). Research studies and case reports were included if they met the following criteria: DD diagnosis (DSM, ICD), publication in peer-review journal and investigations containing information on anxiety comorbidity in DD. Results Four studies fulfilled our criteria, including 155 patients: 65 (42%) women, mean age 42.7 years (SD:14.96). Thirty-three of the 155 patients (21.29%) presented at least one comorbid anxiety disorder: 14 specific phobias, 9 panic attacks, 5 social phobias and 2 agoraphobias. Treatment was not reported for many patients (n= 28). Four patients received fluoxetine and 1 patient benzodiazepines. All of them showed partial improvement of symptoms. Conclusions Less than a third of DD patients showed an anxiety disorder. The effectiveness of antidepressant and benzodiazepine treatment has been poorly described. Future studies may be focused on the investigation of preceding comorbid anxiety disorders in patients with DD.

Introduction Antipsychotics have been classically considered the treatment of choice for delusional disorder (DD) and antidepressant medications have been restricted to patients with comorbid depression. Objectives Our aim is to describe the case of a patient with DD with delusions of parasitosis, who responded to paroxetine as monotherapy. We also aimed to review the recent literature on the potential use of antidepressants as the main treatment for somatic type DD. Methods After the case report, we present a narrative review on the use of antidepressants in DD, somatic type (DSM-criteria) by using PubMed database from inception until 2020. Results Case: 74 year-old woman without previous psychiatric diagnosis who suffered from long-term cutaneous and vulvar pruritus. She was referred to psychiatry from dermatology to assess thought content and sensoperceptive disturbances. In the past, she had received unsuccessful treatment with antihistamines. The patient brought a collection of “the identified parasite” (matchbox sign) to our first appointment. On assessment, she was diagnosed with DD with delusions of parasitosis. Risperidone 1mg/day was poorly tolerated (excessive sedation). She refused further antipsychotic treatment, so we started paroxetine up to 20mg/day. The patient went into total remission of her pruritus and delusions of parasitosis. Review. In line with our case, 6 studies reported on the successful use of antidepressants as monotherapy for DD, somatic type. Most of studies report the successful use of an antipsychotic/antidepressant combination (case-series, case reports). Conclusions Although antipsychotics are the treatment of choice, antidepressant medications may be an effective alternative in somatic type DD when patients refuse antipsychotics.

Introduction Several neuroimaging studies on psychosis spectrum have been published in the last decades, most of them based on schizophrenia. In the context of neuroanatomical dysfunctions, clinical and prognosis implications have been reported. Nevertheless, only a few studies have been focused on delusional disorder (DD). Objectives To present the case of a patient diagnosed with DD who suffered from two cerebrovascular events after the onset of the psychiatric disease. Our aim is to elucidate potential implications of those lesions on the course of DD. We also reviewed the literature to assess evidence for specific changes in DD on brain structures and functions. Methods Case report and non-systematic narrative review in PubMed (2000-2020). Results Case report: A 66-year-old female with DD presenting, during the course of the disease, general atrophy and consecutive ischemic lesions on parietal, occipital and cerebellar areas. Clinical stabilization was achieved 12-16 months after risperidone 1.5mg/day treatment. Review: 19 studies were included: Structural brain data (n=15), Functional data (n=13). Most of the structural neuroimaging studies reported white and gray matter abnormalities, particularly in temporal, parietal and frontal lobes, and in limbic structures. Functional neuroimaging studies pointed to temporal and parietal lobes, as well as basal ganglia and limbic related structures. Conclusions Temporal, parietal, frontal, basal ganglia and limbic-related structures, as well as dysfunctions in other specific brain regions, may be implicated in the core symptoms of DD. These findings might be further investigated as potential neuroimaging markers of prognosis, such as partial or delayed response to antipsychotic treatment, as presented in our case.

Introduction Day care programs have been extensively used to treat people with acute psychiatric disorders. Day hospitals (DH) can act as an alternative to admission in patients with acute symptoms, shorten the duration of admission, be useful for rehabilitation and maintenance care or enhance treatment in patients with poor adherence to outpatient care. Few research has been conducted in delusional disorder (DD). Objectives To investigate whether DH care increases adherence with psychiatric appointments in patients with DD. To describe functions of partial hospitalization in DD. Methods Comparative study including DD patients who attended a DH (Group 1:n=12) versus patients who did not receive DH care (Group 2;n=7). Patients attending DH were classified into 3 groups according to the program function at referral. Adherence with outpatient follow-up appointments (primary outcome) and pharmacy refill data (secondary outcome) were assessed after discharge over a 6-month period (DH) and compared with group 2. For statistical analyses, non-parametric tests were performed. Results Program function (DH): alternative to admission (n=4); shortening of admission (n=5) and enhancing outpatient treatment (n=3). Patients receiving DH care were more frequently referred from the inpatient unit or emergency department compared to those who did not attend DH (commonly referred from primary care services). No statistically significant differences were found between both groups in adherence to psychiatric appointments. Patients who attended DH showed higher compliance with antipsychotics (89.29% vs.72.62, p

Introduction Autism spectrum disorder (ASD) is a neurodevelopmental disorder with a biological basis overlapped with obsessive compulsive disorders and body dysmorphic disorder (BDD). The combination of pharmacological treatment and psychological interventions have been considered the gold-standard Objectives Our main objective was to present the case of a patient with ASD and comorbid BDD. As a second objective, we reviewed recent works on the common neurobiological substrate and therapeutic options for both conditions. Methods (1)Clinical case: Patient with ASD and BDD, treated with fluoxetine 60 mg/day and aripiprazole 30 mg/day. (2)Non-systematic narrative review focused on neurobiological substrate and treatment of ASD and BDD. The electronic search was performed by the PubMed database (1990-2020) using the following key terms: “autism spectrum disorder”, “body dysmorphic disorder”, “dysmorphophobia”, “neurobiology”, “pharmacological treatment”, “psychological treatment” and “treatment”. Results Our patient is a 31-year-old single male fulfilling DSM-5 criteria for ASD, diagnosed in childhood, and BDD. He received pharmacological treatment and CBT. He also verbalized having been concerned with his lips and mouth for the last 10 years. This discomfort leads to passive ideas of death. Review: All articles (n=4) supported the use of selective serotonin reuptake inhibitors (SSRIs) and CBT in this comorbidity. None of them reported the use of antipsychotics. Oone article described the use of Repetitive transcranial magnetic stimulation (rTMS) and oxytocin. Conclusions ASD and BDD share the basis of corticostriatal circuits. ISRS and CBT may be effective in treatment. Other options (oxytocin or rTMS) should be further investigated. Examining this comorbidity could be useful for discovering possible endophenotypes.

Introduction In order to prevent relapse and increase medication adherence, primary care physicians and psychiatric inpatient units should consider referring patients with delusional disorder (DD) to specialized outpatient clinics for treatment and follow-up. Objectives This poster describes a sample of DD patients referred to a specialized unit for DD and documents rates of follow-up care. Methods Over a 2-year period, 29 individuals were consecutively referred to the Parc Tauli -Delusional Syndrome Working Group, which provides treatment and clinical care for patients with delusional disorders for a catchment area of nearly 450.000 inhabitants in Sabadell (Barcelona, Spain). Criteria for inclusion in the program are relatively flexible. Referred patients are evaluated at baseline and at 6 months following their first appointment. Treatment and case management are offered by a multidisciplinary team consisting of psychiatric, nursing, and social work personnel. Psychological interventions are also offered. Results Of the 29 persons initially referred, 27 attended at least one scheduled appointment. Twenty-one out of the 27 patients received a confirmed diagnosis of DD (14 women,7 men), 2 suffered from schizophrenia and 4 were diagnosed with other psychiatric disorders and referred to other programs: primary care (n=2), affective program (n=1) and addictions unit (n=1). A breakdown of DD subtypes follows: persecutory (n=10,47.6%), jealous (n=4,19%), somatic (n=5,23.81%), mixed (n=2,9.5%). Three patients with DD (14.3%) were lost to follow-up. Attendance rates of the 21 DD patients: 80.4% (Women:77.67%, Men:100%). Conclusions For a traditionally difficult-to-engage population, adherence to multidisciplinary clinic appointments was relatively high. Loss to follow-up was lower than would have been expected. Conflict of interest AGR has received honoraria, registration for congresses and/or travel costs from Janssen, Lundbeck-Otsuka and Angelini.

Background: Dysautonomia has been independently associated with training and exercise-induced bronchoconstriction. In addition, neurogenic airway inflammation was recently associated with swimmers-asthma. We aimed to assess the relation between autonomic nervous system and airway responsiveness of asthmatic elite swimmers. Methods: Twenty-seven elite swimmers, 11 of whom had asthma, were enrolled in this exploratory cross-sectional study. All performed spirometry with bronchodilation, skin prick tests and methacholine challenge according to the guidelines. Pupillometry was performed using PLR-200⢠Pupillometer. One pupil light response curve for each eye was recorded and the mean values of pupil's maximal and minimal diameters, percentage of constriction, average and maximum constriction velocities (parasympathetic parameters), dilation velocity, and total time to recover 75% of the initial size (sympathetic parameters) were used for analysis. Asthma was defined using IOC-MC criteria; subjects were divided into airway hyperesponsiveness (AHR) severity according to methacholine PD20 in: no AHR, borderline, mild, moderate and severe AHR. Differences for pupillary parameters between groups and after categorization by AHR severity were assessed using SPSS 20.0 (p â¤Â 0.05). In individuals with clinically relevant AHR, correlation between PD20 and pupillary parameters was investigated with Spearman's correlation test. Results: No statistically significant differences were observed between asthmatic and non-asthmatic swimmers regarding parasympathetic parameters. When stratified by AHR, maximal and minimal diameters and percentage of constriction were significantly lower among those with severe AHR. Among swimmers with clinically relevant AHR (n = 18), PD20 correlated with parasympathetic activity: maximal (r = 0.67, p = 0.002) and minimal diameters (r = 0.75, pÂ

Objective: To review medicines pregnancy category and establish the degree of conformity between the two systems more used: FDA (Food and Drug Administration) and ACPM (advisory Committee on Prescription Medicines). Methods: drugs used in most frequent pathologies during pregnancy have been selected and found its pregnancy category according to FDA and ACPM. The degree of conformity has been established between both categorisation systems. Results: a total of 270 medicines were reviewed. 260 drugs had pregnancy category by FDA and 245 by ACPM system. 232 drugs had pregnancy category defined by both classifications (FDA and ACPM). We found 70,2% of them in the same pregnancy category. Conclusions: The discrepancies found in both pregnancy categorisation systems can be confused in order to prescribe and know its safety statement of medicines during pregnancy which can limits its utility. It would be desirable more studies after medicines registered to get more information which could help to use safety drugs during pregnancy and minimize discrepancies between both pregnancy categorisation systems.

Introduction: Induced sputum with hypertonic saline has been suggested as a safer and cheaper alternative to bronchoalveolar lavage for evaluation of patients with interstitial lung diseases (ILD). Objective: To evaluate the safety and feasibility of sputum induction in ILD and to compare sputum cellular profiles with paired bronchoalveolar lavage fluid results. Materials and methods: Twenty patients underwent sputum induction with 4.5% saline within 2 weeks of bronchoalveolar lavage. Total, differential cell counts and cellular viability were assessed. Wilcoxon test and Spearman's rank correlation coefficient were used and a pÂ

Resumo: Introdução: A indução de esputo com soro hipertónico tem sido apontada como uma alternativa, mais económica e segura, ao lavado broncoalveolar na avaliação de doentes com doença pulmonar intersticial (DPI). Objetivo: Avaliar a segurança e a exequibilidade do esputo induzido nas DPI e comparar os perfis celulares do estudo com os resultados obtidos por lavado broncoalveolar. Material e métodos: Vinte doentes realizaram indução de esputo com soro hipertónico (4,5%) num intervalo de 2 semanas após a realização de lavado broncoalveolar. Foram analisadas as contagens diferenciais e a viabilidade celular. Para a análise foram utilizados os testes de Wilcoxon e a correlação de Spearman's e um valor de pÂ

Se ha comparado la abundancia de árboles viejos en la provincia de Salamanca (España) con la distribución de las especies de vertebrados forestales amenazados presentes, observándose que existe una correlación significativa entre ambos parámetros para las siguientes especies estudiadas: águila imperial (Aquila adalberti), buitre negro (Aegypus monachus), lince ibérico (Lynx pardinus), milano real (Milvus milvus) y un grupo de especies de quirópteros forestales (Miniopterus schreibersii, Myotis bechsteinii, Myotis emarginatus, Myotis mystacinus, Myotis myotis, Nyctalus lasiopterus, Nyctalus noctula, Rhinolophus euryale, Rhinolophus ferrumequinum y Rhinolophus mehelyi). Se ha demostrado que existe un incremento de la biodiversidad de vertebrados forestales amenazados paralelo al aumento de la densidad de árboles viejos en los municipios de la provincia. Por ello, se puede deducir que la densidad de árboles viejos es un buen parámetro indicador del estado de conservación del ecosistema forestal y clave para el mantenimiento de dichas especies amenazadas.

A pesar de que se han reconocido distintos factores precipitantes en la paniculitis mesentérica, su etiología en determinados casos es incierta. Presentamos un análisis retrospectivo de 8 pacientes afectados de paniculitis mesentérica en un periodo comprendido entre mayo 2000 hasta diciembre 2006. En nuestra serie la edad media de presentación fue 63 años, siendo la mayoría de pacientes varones (proporción 3:1). Las manifestaciones clínicas más frecuentes fueron el dolor abdominal (n = 4) y la astenia (n = 4). Tres casos se presentaron como cuadro de obstrucción y tres casos presentaron antecedentes de cirugía abdominal. El antecedente más común fue el tabaquismo (5 casos eran fumadores activos y 2 exfumadores) y hubo un paciente que desarrolló un linfoma folicular en el seguimiento. Revisamos la literatura para analizar nuestros resultados y formular una hipótesis. En nuestra opinión, pensamos que debe ser analizada de forma más exhaustiva la relación entre el tabaco y sus componentes con la aparición de la enfermedad debido a la fuerte asociación encontrada en este estudio.Although several etiological factors have been associated with mesenteric panniculitis, the exact etiology in some cases remains unknown. Herein, we present a retrospective analysis of 8 patients affected with this disorder performed between May 2000 and December 2006. In our series the mean age at which patients presented was 63 years. The majority of the patients were male (with a male: female ratio of 3:1). The most common clinical manifestations were abdominal pain (n = 4) and asthenia (n = 4). Three cases presented with obstructive symptoms and three had a history of abdominal surgery. Notably, seven had a background of tobacco use (five smokers and two ex-smokers) and one patient developed follicular lymphoma. A literature research was carried out to analyze our results and formulate a new hypothesis. In our opinion, we believe that the study of causal factors such as tobacco and its components is required due to the strong association found in this study.

Estudiamos el acoplamiento de sistemas naturales y humanos en diversos sitios y culturas construyendo modelos de simulación de cuatro sitios que incluyen áreas protegidas; dos en Texas, Estados Unidos, y dos en Venezuela. En los sitios de Texas, se están convirtiendo legalmente los bosques en espacios urbanos de uso residencial, comercial, e industrial, mientras que en Venezuela se talan legal e ilegalmente los bosques para transformarlos en sistemas agrícolas de subsistencia. Las técnicas contemporáneas de modelación facilitan simulaciones de decisiones humanas y de la dinámica del ecosistema que pueden revelar patrones inesperados. Tales acoplamientos de los sistemas humanos y los sistemas naturales se reconocen actualmente como una forma de biocomplejidad. Nuestra metodología es flexible, para permitir la adaptación a cada uno de los sitios del estudio, capturando las características esenciales de los cambios respectivos de la utilización del territorio, y de las reacciones naturales y decisiones humanas. Las interacciones entre los humanos se simulan usando los modelos multi-agentes que actúan sobre modelos del paisaje forestal, y perciben la respuesta de los efectos de estas acciones en forma de cambios de hábitat ecológicos y dinámica hidrológica.

Esta investigación analiza las causas del desprendimiento de un revestimiento de gres porcelánico colocado en fachada. En el momento de abordar este trabajo comprobamos que hay métodos normalizados para la determinación de las características de los adhesivos para las baldosas cerámicas y de las propias baldosas, pero en ambos casos, son métodos a aplicar durante el proceso de fabricación. No existen métodos normalizados para la determinación de las características de aplacados en servicio, cuestión que aborda este trabajo. Las técnicas de diagnosis empleadas han consistido en la comprobación de la capacidad de adherencia del adhesivo, la localización de juntas de movimiento, el análisis de las juntas de colocación y la detección de anclajes mecánicos ocultos. Finalmente, los resultados obtenidos tras la aplicación de dicha metodología para el análisis de la patología han permitido establecer las causas que han originado los daños, proponiéndose como método de diagnosis del desprendimiento de un aplacado cerámico en servicio.

Objectives: the aim of this retrospective study was to evaluate early experience with laparoscopic restorative proctocolectomy by analyzing the perioperative results of surgical treatment. Patients and methods: seven major surgeries were performed in six patients with familial adenomatous polyposis and ulcerative colitis. All procedures were performed under laparoscopy at our third-level hospital from June 2003 to October 2004. Results: mean surgical time was 287.5 ± 80.7 min, and median blood loss was 300 ± 249.0 cc. There were no conversions; return of peristalsis began at 32 ± 12.4 h; average time to first oral intake was 64.0 ± 32.8 h, and mean duration of hospital stay was 9.3 ± 1.2 days. There was one case of perineal sepsis due to ileal pouch-anal anastomotic leakage, which was successfully treated with oral intake restriction, parenteral nutrition, and intra-rectal drainage. The most common postoperative complication was postoperative ileus. Conclusions: we believe that the laparoscopic approach to restorative proctocolectomy may be considerably improved in our center. Particular aspects for improvement include efforts to achieve lower operating and hospitalization times to equate our results with those reported by multicenter studies for laparoscopic colon cancer surgery. In our opinion, learning and further training opportunities should be encouraged to improve surgeon experience in the field of laparoscopy, preferably at centers specializing in restorative proctocolectomy.

Los sistemas de información integrados y compartidos permiten obtener un elevado nivel de información sobre los procesos, costes y resultados, y reducir considerablemente los errores de medicación. La prescripción electrónica asistida, en el área de nutrición parenteral total, integrado con otras bases de datos del hospital y con el sistema de gestión de medicamentos del hospital, es una herramienta que permite aumentar la seguridad del paciente (disminuyendo los errores de medicación), mejorar la calidad de la asistencia, mejorar los sistemas de información y la gestión de la misma y la eficiencia de los recursos empleados. En este trabajo se describe la implantación de un sistema de prescripción electrónica asistida aplicada a la nutrición parenteral en un hospital general, y la reingeniería de procesos llevado a cabo en el área de nutrición. Esta implantación se ha llevado a cabo por los facultativos médicos del servicio de Nutrición y Dietética y por farmacéuticos del Servicio de Farmacia del Hospital Ramón y Cajal utilizando para ello el programa informático "Nutriwin". Durante dos meses antes y después de su implantación, se ha realizado un seguimiento del tiempo empleado en el circuito prescripción-validación-elaboración-dispensación de las nutriciones parenterales. Tras la implantación las órdenes de tratamiento llegan, en promedio, 1 h 15 minutos antes al Servicio de Farmacia; al evitarse la trascripción se produce, además de la disminución de errores potenciales, un ahorro de 3 min/ nutrición en los cálculos a realizar; la elaboración de las nutriciones puede comenzarse como promedio 1h 20 minutos antes que si se realizara la prescripción manual. Así mismo los prescriptores pueden conocer en tiempo real el perfil nutricional de cada paciente en el episodio en curso así como su histórico. La prescripción electrónica de las órdenes de tratamiento en éste área ha supuesto para nuestro hospital una optimización de los recursos empleados, una disminución de los errores potenciales que se pueden producir, una mejora en la gestión de consumos, y un aumento en la calidad de todo el proceso.Integrated and shared information systems allow obtaining a high degree of information about processes, costs and outcomes, and considerably reducing prescription errors. Assisted electronic prescription, in the setting of total parenteral nutrition, integrated with other hospital databases and with the hospital drugs management system, is a tool that allows increasing patient' safety (by reducing prescription errors), improving quality assistance, improving information systems and information management and the efficiency of used resources. In this work, implementation of an assisted electronic prescription system applied to parenteral nutrition in a hospital and processes reengineering performed in the nutrition setting are described. This implementation was performed by medical staff from the Nutrition and Diet Department and pharmacists from the Pharmacy Department of Ramón y Cajal Hospital using "Nutriwin" computer software. For two months prior and after its implementation, a follow-up of time consumed in the circuit prescription-validation-elaboration-dispensation of parenteral nutrition formulas has been performed. After implementation, treatment orders reach on average 1 h and 15 minutes sooner the Pharmacy Department; by avoiding transcription, a saving of 3 min per nutrition formula calculations is achieved, besides reducing potential errors; elaboration of nutrition formulas can be started on average 1 h and 20 minutes sooner as compared to manual prescription. Besides, the staff that writes down the prescription may know in real time the nutritional profile for each patient in the current episode and the patient's historic. Electronic prescription of treatment orders in this area has represented for our hospital an optimization of the employed resources, a reduction of potential errors that may occur, an improvement in consumption management, and an increase in the whole process quality.

Applications of REBCO coated conductors are now being developed for a very wide range of temperatures and magnetic fields and it is not yet clear whether vortex pinning strategies aimed for high temperature, low field operation are equally valid at lower temperatures and higher fields. A detailed characterization of the superconducting properties of a 15 mol. % Zr-added REBCO thin film made by metal organic chemical vapor deposition, from 4.2 to 77 K under magnetic fields up to 31 T is presented in this article. Even at a such high level of Zr addition, Tc depression has been avoided (Tc = 91 K), while at the same time an exceptionally high irreversibility field Hirr ≈ 14.8 T at 77 K and a remarkably high vortex pinning force density Fp ≈ 1.7 TN/m3 at 4.2 K have been achieved. We ascribe the excellent pinning performance at high temperatures to the high density (equivalent vortex matching field ∼7 T) of self-assembled BZO nanorods, while the low temperature pinning force is enhanced by large additional pinning which we ascribe to strain-induced point defects induced in the REBCO matrix by the BZO nanorods. Our results suggest even more room for further performance enhancement of commercial REBCO coated conductors and point the way to REBCO coil applications at liquid nitrogen temperatures since the critical current density Jc(H//c) characteristic at 77 K are now almost identical to those of fully optimized Nb-Ti at 4 K.

La Cuenca de Tabernas está situada en la zona interna de la Cordillera Bética, se da una cronología para los depósitos formados por abanicos aluviales y se plantea a través de datos paleontológicos y sedimentológicos un modelo paleochmátlco para el Cuaternano en el sureste de España.

O diagnóstico de asma é fundamentalmente clínico, no entanto, a utilização de medidas de função pulmonar e de inflamação brônquica poderá ser útil.Pretendemos avaliar a utilização destas medidas na distinção de indivíduos com e sem asma, num rastreio com voluntários adultos recrutados através dos media. Cada indivíduo realizou medição da fracção de óxido nítrico exalado (eNO, AerocrineÒ), espirometria com broncodilatação (PFRBD) e questionário de despiste e impacto da asma (QVA, ACAAI).Dos 61 incluídos, 38% eram homens, tinham idade de 46±16 anos (média±dp), queixas nasais 79%; fumadores 20%; QVA 10±5; eNO 34,6±41,3 ppb; FEV1 previsto 102±16% e fev1/fvc 96±13% A medição do eNO demorou entre 2,3 e 11,6 minutos (mediana 4,8). Foram efectuadas 317 manobras (165 válidas) para medição no eNO (por doente entre 3-9; mediana -5).Considerando as normas da ATS, 48(79%) indivíduos tiveram uma medição correcta de eNO e 39(64%) de PFRBD.Considerando os critérios diagnósticos para as PFRBD do GINA e um cut-off de 20 ppb para o eNO, foram identificados como asmáticos respectivamente 45% e 46% dos doentes com QVA ³13. A utilização de PFRBD e do eNO numa avaliação de despiste de asma é exequível e útil mas actualmente insuficiente para um diagnóstico adequado. : The asthma diagnosis is primarily based on clinical data, sometimes, however, objective measures are useful. We aimed to study the use of Exhaled Nitric Oxide (eNO) and spirometry before and after inhaled albuterol (PFT) in asthma screening of adult volunteers recruited through media announcements. Each individual also answered structured questionnaires including the LQ Test (ACAAI), a valid test for asthma screening and disease impact.Sixty one patients were analyzed, 38% were men, with mean±SD age of 46±16 years, nasal symptoms 79%; smokers 20%; LQ 10±5; eNO 34.6±41.3 ppb; FEV1 % predicted 102±16% e fev1/fvc 96±13%.The eNO measurement duration ranged between 2,3 and 11,6 minutes (median 4,8) and a total of 317 (165 valid) exhalations were performed (3-9 per individual; median -5).All ATS guideline measurement criteria were fulfilled for 48(79%) individuals for eNO and 39(64%) for PFT.When applying GINA PFT criteria for asthma diagnosis 45% of patients with LQ³13 were identified as asthmatics, and when using a cut-off of 20 ppb for eNO, 46% were identified.The use of eNO and PFT in asthma screening can be technically performed and useful, nevertheless are, at present, insufficient for diagnosis of asthma. Palavras-chave: asma, óxido nítrico exalado, rastreio, Key-words: Asthma, Exhaled Nitric Oxide, Screening

La válvula Mitroflow (Sorin Group) ha sido utilizada frecuentemente como sustituto protésico en la valvulopatía aórtica. Sin embargo algunos estudios han favorecido la duda acerca del deterioro estructural acelerado de dicha prótesis incluso en pacientes de edad avanzada. Analizamos de forma retrospectiva nuestra experiencia en los últimos 10 años. El seguimiento medio fue de 4,2 años y completo en el 97%. En el periodo de enero de 2001 a 2010 se implantaron 181 prótesis Mitroflow. Edad media al implante 76,0 ± 5,6 años (83,4% mayores de 69 años); 61,4% mujeres; 95% estenosis aórtica (EAo) predominante; 53 pacientes (29,2%) con procedimientos asociados. La población a estudio presentaba 90% hipertensión arterial (HTA); 51% diabetes mellitus; 48% dislipemia, y 12,1% insuficiencia renal crónica (IRC). El 85% de las prótesis fueron de tamaño 19–21. Se analiza el deterioro estructural progresivo y necesidad de reintervención mediante controles ecocardiográficos (anuales). Resultados: Durante el periodo estudiado la supervivencia del grupo a los 3, 5 y 10 años fue del 98, 92 y 82%, respectivamente. La presencia de mismatch teórico en el postoperatorio inmediato fue del 4,9% (EAo/SC < 0,8 cm2/m2). La evolución de gradientes en pacientes con EAo/SC inferior a 1,00 cm2/m2 es mayor que en el grupo superior a 1,00 cm2/m2 sin estar relacionado con un aumento en el deterioro estructural. Conclusiones: – Los gradientes transprotésicos en pacientes con EOA/SC superior a 1 cm2/m2 fueron bajos y se mantuvieron estables en el seguimiento a largo plazo. – Durante el seguimiento tres pacientes se reintervinieron por deterioro estructural, a los 6, 5 y 3 años.

La operación de Ross es una alternativa para pacientes jóvenes con valvulopatía aórtica. Uno de sus problemas a corto plazo es la tendencia a la estenosis del homoinjerto pulmonar. La interposición de una porción de tejido aórtico propio sobre el homoinjerto pulmonar puede atenuar la tendencia estenótica del mismo. Analizamos de forma retrospectiva la evolución ecocardiográfica del homoinjerto pulmonar de 88 pacientes a los cuales se realizó una intervención de Ross. La edad media de los pacientes fue de 48,5 ± 10,1 años y el seguimiento medio de 60 meses (rango 18–96). En 62 pacientes (grupo A) se implantó un homoinjerto pulmonar, mientras que en 26 pacientes (grupo B) se utilizó una porción romboidal de tejido de la aorta nativa sobrante del paciente y se interpuso en el cuerpo del homoinjerto. En todos los pacientes se hicieron controles ecocardiográficos al alta, 6 meses y anualmente. Resultados: En el seguimiento de los primeros 2 años, 7 pacientes del grupo A requirieron actuación percutánea (dilatación + stent) sobre el homoinjerto pulmonar por estenosis grave del mismo. La evolución de los gradientes del homoinjerto pulmonar mostró diferencias significativas entre los dos grupos, siendo menor la evolución de gradientes en el grupo B. Conclusiones: La interposición de tejido aórtico del propio paciente sobre el homoinjerto pulmonar parece atenuar la evolución de los gradientes y disminuir la posibilidad de estenosis grave del homoinjerto.

Las complicaciones tromboembólicas y hemorrágicas a largo plazo tras sustitución valvular mitral con prótesis mecánicas han sido comunicadas en la literatura. Sin embargo, existen escasos estudios con la válvula mecánica On-X Conform (MCRI). La prótesis mitral On-X Conform tiene un único tamaño (25–33), con un orificio efectivo de 3,73 cm2, y se implanta en posición supraanular (cara auricular). Entre 2000-2009 se implantó la prótesis On-X Conform en posición mitral en 353 pacientes. Todos los pacientes fueron estudiados retrospectivamente a partir de los registros de la base de datos del servicio de cirugía cardíaca y se realizó un seguimiento vía telefónica, visita médica y búsquedas en historia clínica. De ese grupo, se analizan 138 pacientes con patología mitral (±tricúspide) aislada, y con un mínimo de 1 año de seguimiento. El seguimiento fue del 100%, con un seguimiento máximo de 7,66 años y medio de 4,53 (591,87 patient-years-follow-up). Todos los pacientes iniciaron tratamiento anticoagulante con Sintrom® con índice internacional normalizado (INR) diana entre 2,5–3,5 y fueron controlados en su hospital o CAP de referencia (n.o medio controles/año 10,8). Conclusiones: 1) La prótesis On-X Conform mitral puede implantarse de forma segura en cualquier paciente que requiera sustitución valvular mitral; 2) En el seguimiento, las complicaciones relacionadas con la válvula han sido muy bajas, con tasas de tromboembolia del 1% ppy y hemorragia del 0,3% ppy.

Evaluar los resultados de la ablación epicárdica de las venas pulmonares mediante ultrasonidos de alta intensidad (HIFU). Material y métodos: Desde marzo de 2006 – agosto de 2011, 67 pacientes intervenidos en nuestro servicio han recibido algún tipo de ablación por fibrilación auricular (FA). De ellos, 58 han sido tratados exclusivamente con ablación epicárdica de las venas pulmonares con HIFU. En 19 (33%), la FA era paroxística, en 5 (9%) persistente y en 34 (58%) permanente. El 68% varones, edad media 65 ± 11 años (36–79). Tiempo medio de evolución de la FA de 7 ± 10 años (1 mes – 46 años). El tamaño medio de la aurícula izquierda fue 50 ± 7 mm (35–77). Resultados: Globalmente, al mes un 54% de los pacientes están en ritmo sinusal, 63% a los 6 meses y 1 año, 69% a los 2 años, y 74% a los 3 años. En las FA paroxísticas, la tasa de ritmo sinusal al mes es del 82%, 79% a los 6 meses, 90% al año y 100% a los 2 y 3 años. En las FA persistentes y permanentes, la tasa de ritmo sinusal al mes es del 42%, 56% a los 6 meses, 54% al año, 62% a los 2 años y 69% al tercer año. Conclusiones: La ablación epicárdica de las venas pulmonares mediante HIFU permite conseguir ritmo sinusal en un 74% de pacientes a 3 años. El beneficio es claramente superior en los casos de FA paroxística, aunque hasta un 69% de pacientes con FA persistente/permanente mantienen ritmo sinusal a 3 años.

En octogenarios con enfermedad valvular aórtica, la cirugía ha sido hasta ahora el único tratamiento. Actualmente existe la posibilidad de implantar válvulas de manera percutánea. Por ello, revisamos nuestra experiencia con énfasis en la mortalidad y supervivencia a medio plazo en este grupo de pacientes. Material y métodos: Desde noviembre de 2000 a enero de 2009, se han intervenido 103 pacientes, 72 con sustitución valvular aórtica aislada, 30 con pontaje coronario y 1 con aorta. La edad media fue de 81,7 (80-87), 57 mujeres y 46 hombres. La enfermedad fue en el 92% la estenosis aórtica y en 23 existían lesiones coronarias. El EuroSCORE logístico medio fue 13,3% (6-50%). Resultados: El seguimiento medio ha sido de 4,1 años (0-8) y del 100%. Los días de estancia en unidad de cuidados intensivos (UCI) fueron 6, y postoperatoria 17. La mortalidad fue de cinco pacientes (4,8%) y en el seguimiento de 17. Las causas fueron cardíacas en nueve y otras en el resto. De los 81 supervivientes, el 88% está en GFI-II. La supervivencia actuarial a los 7 años es del 72%, llegando al 90% incluyendo sólo muerte cardíaca, y están libres de tromboembolia el 94% a los 8 años. Se valoran las curvas de supervivencia según sexo, EuroSCORE y enfermedad coronaria añadida. Conclusiones: La cirugía valvular en octogenarios presenta unos resultados a corto y medio plazo excelentes. Estos resultados deben tenerse en cuenta antes de proponer de manera generalizada técnicas percutáneas.