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The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.

The production of waxes from vegetable oils, such as palm oil, for use as a base material in products for human applications is an alternative to those derived from petroleum and animals. Seven palm oil–derived waxes, called biowaxes (BW1–BW7) in this work, were obtained by catalytic hydrotreating of refined and bleached African palm oil and refined palm kernel oil. They were characterized by three properties: compositional, physicochemical (melting point, penetration value, and pH), and biological (sterility, cytotoxicity, phototoxicity, antioxidant, and irritant). Their morphologies and chemical structures were studied by SEM, FTIR, UV–Vis, and 1H NMR. The BWs presented structures and compositions similar to natural biowaxes (beeswax and carnauba). They had a high concentration of waxy esters (17%–36%) with long alkyl chains (C, 19–26) per carbonyl group, which are related to high melting points (

Tofacitinib is an oral Janus kinase inhibitor for the treatment of ulcerative colitis (UC). Aim:This post hoc analysis evaluated tofacitinib persistence in patients with UC in OCTAVE Open, an open-label, long-term extension study of patients receiving tofacitinib 5 or 10 mg twice daily. Methods: Kaplan-Meier estimates for tofacitinib drug survival and reasons for discontinuations were evaluated. Baseline factors were analysed as predictors of persistence. Results:This analysis included 603 patients: 280 entered OCTAVE Open with a clinical response (164 in remission and 116 not in remission), 220 were delayed responders, 75 were retreatment responders and 35 were dose escalation responders, treated for up to 7 years in OCTAVE Open. Of these, 118 (42.1%) responders, 121 (55.0%) delayed responders, 40 (53.3%) retreatment responders and 17 (48.6%) dose escalation responders discontinued tofacitinib with a median time to discontinuation of 5.6, 4.5, 4.0 and 4.4 years, respectively. The estimated 2- and 5-year drug survival rates in the responders (including patients in remission and not in remission) were 73.9% and 54.5%, respectively. Corresponding persistence values for delayed responders were 69.5% and 45.2%, for retreatment responders, 70.7% and 40.0%, and for dose escalation responders, 74.3% and 32.8%. ConclusionIn: OCTAVE Open, a high proportion of patients maintained tofacitinib treatment, with the median survival by group ranging from 4.0 to 5.6 years although these analyses are post hoc and limited by sample size. Further research should focus on factors to enhance persistence with tofacitinib treatment in patients with UC, This study was sponsored by Pfizer. Medical writing support, under the guidance of the authors, was provided by Helen Findlow, PhD, CMC Connect, McCann Health Medical Communications and was funded by Pfizer Inc, New York, NY, USA in accordance with Good Publication Practice (GPP3) guidelines (Ann Intern Med. 2015;163:461–464)

Objective This study aimed to evaluate ustekinumab efficacy, effectiveness, and safety as a treatment for ulcerative colitis in adult patients. Methods A systematic review of the efficacy, effectiveness, and safety of ustekinumab in ulcerative colitis was carried out. The search was conducted via PubMed, Embase, and the Cochrane library. Two reviewers independently assessed the quality of studies and extracted study data. Results Of the 892 studies identified, 17 were included: 1 randomized controlled trial (RCT), 3 long-term extensions, and 13 observational studies. In the randomized clinical trial evaluating efficacy at week 8, clinical remission was achieved in 16% of patients, whereas clinical response was achieved in 51% and 62% of patients who received intravenous ustekinumab at a dose of 130 mg and 6 mg/kg, respectively. At 3 years’ follow-up, symptomatic remission was achieved in 68% of patients. On the other hand, the effectiveness of ustekinumab was evaluated in 13 observational studies. In these studies, clinical remission at induction was achieved in 24% to 61% of cases, whereas clinical response at induction was achieved in 47% to 77% of cases. Moreover, clinical remission was achieved in 33% to 79% of cases at 52 weeks of follow-up. The adverse events ranged from 2.6% to 77% of all the studies that reported safety data. Adverse events leading to discontinuation ranged from 2.6% to 8.1%, and serious adverse events were uncommon and ranged from 3.7% to 6.0%. Conclusions Ustekinumab has demonstrated efficacy (in RCTs), effectiveness (in real clinical practice), and safety for the treatment of ulcerative colitis.

BackgroundBiological agents cross the placenta, resulting in detectable blood levels in the neonate. Neonatal vaccinations are essential to prevent serious infections.AimTo review the effectiveness and safety of vaccines in children exposed to biological drugs in utero and/or those whose mothers received biological agents during lactation.MethodsA systematic bibliographic search was performed.ResultsInfants exposed in utero to anti-tumour necrosis factor drugs [anti-TNFs], vedolizumab or ustekinumab mount adequate serological responses to vaccines. No relevant adverse events for non-live inactivated vaccines have been reported in newborns exposed in utero to biologics. Studies assessing the safety of live-attenuated vaccines administered to infants exposed to biologics in utero have not observed, in general, serious adverse events. However, although no severe complications have been reported with rotavirus live vaccination, several fatal disseminated tuberculosis infections after administration of the BCG live vaccine in infants exposed to anti-TNFs in utero have been reported. Infliximab, adalimumab, and probably also vedolizumab and ustekinumab treatments are considered compatible with breastfeeding, although minuscule amounts of these biologics have been detected in breast milk of treated nursing mothers. Based on the literature available, the benefits from breastfeeding while receiving infliximab [or any other anti-TNF] and at the same time adhering to national infant immunization programmes probably outweigh any hypothetical risk for the infant.ConclusionsVaccines appear to be effective in infants exposed to biologics in utero. Inactivated vaccines are probably safe, whereas live-attenuated vaccines should be avoided while the children have detectable levels of biological drugs. Vaccines [non-live and live] are probably safe in children breastfed by mothers treated with biologics.

BackgroundOne-third of patients with acute severe ulcerative colitis [ASUC] are steroid-refractory. We aimed to review the different options for the management of steroid-refractory ASUC, including not only the standard treatment [cyclosporine and infliximab], but also most recently developed agents [such as vedolizumab, ustekinumab, and tofacitinib].MethodsWe performed a bibliographical search to identify studies focusing on the treatment of steroid-refractory ASUC.ResultsCyclosporine and infliximab currently represent the mainstays of salvage therapy and they are generally considered comparable. However, long-term persistence is higher in infliximab therapy, and many clinicians prefer to use infliximab given its ease of use. However, cost of cyclosporine is lower. Sequential rescue therapy after cyclosporine or infliximab failure [with infliximab and cyclosporine, respectively] could be considered in referral centres for highly selected cases. Tofacitinib, due to its rapid effect, represents an attractive rescue option mainly in biologic-experienced patients. The good safety profile of vedolizumab and ustekinumab makes them ideal candidates for use as maintenance therapy in combination with cyclosporine as induction therapy, especially for patients previously exposed to anti-TNFs or thiopurines.ConclusionsAlthough cyclosporine and infliximab still represent the mainstays of salvage therapy for steroid-refractory ASUC, new therapeutic agents may also play a role. Tofacitinib, due to its rapid effect, is an attractive therapeutic rescue option. Vedolizumab and ustekinumab, as maintenance therapy in combination with the fast-acting cyclosporine as induction therapy, may represent a promising bridging strategy, especially in patients with previous failure to thiopurines and/or anti-TNF agents.

Background and AimsSolid organ transplantation, with the exception of liver, has rarely been reported in patients affected by inflammatory bowel diseases [IBD].MethodsThis is an ECCO-CONFER project collecting cases of solid organ transplants [with the exclusion of liver] that were performed in IBD patients. We evaluated the change in the IBD therapy, need for bowel resection due to medically refractory IBD, or need for hospitalisation due to IBD relapse [‘severe IBD course’] before and after transplantation.Resultsin total, 34 organ transplantations [28 kidney, five heart, one lung] in 33 IBD patients were collected [67% male, 55% Crohn’s disease, mean age 53 ± 16 years]. The median follow-up was 4.3 years (interquartile range [IQR] 3.2–10.7); 29 patients [87.9%] were treated with tacrolimus, 25 [76%] with systemic steroids, 22 [67%] with mycophenolate mofetil, 11 [33%] with everolimus, six with cyclosporine [18%]. One patient was treated with infliximab, two patients with adalimumab, two patients with vedolizumab, one patient with ustekinumab. Overall, a severe IBD course was observed in three [9.3%] patients before transplantation and in four [11.7%] in the post-transplant setting [p = 0.26]. Three cases of cancer [excluding skin non-melanoma] [9.1%] were recorded in the post-transplantation period versus two in the pre-transplantation period [6.1%, p = 0.04]. Six patients [18.2%] died during the period of observation. No deaths were associated with IBD or complications of the transplant.ConclusionsIn IBD patients, solid organ transplantation does not seem to impact on the IBD severity. However, the risk of malignancy needs further investigation.

Therapy with anti-tumor necrosis factor (TNF) has dramatically changed the natural history of Crohn’s disease (CD). However, these drugs are not without adverse events, and up to 40% of patients could lose efficacy in the long term. We aimed to identify reliable markers of response to anti-TNF drugs in patients with CD. A consecutive cohort of 113 anti-TNF naive patients with CD was stratified according to clinical response as short-term remission (STR) or non-STR (NSTR) at 12 weeks of treatment. We compared the protein expression profiles of plasma samples in a subset of patients from both groups prior to anti-TNF therapy by SWATH proteomics. We identified 18 differentially expressed proteins (p ≤ 0.01, fold change ≥ 2.4) involved in the organization of the cytoskeleton and cell junction, hemostasis/platelet function, carbohydrate metabolism, and immune response as candidate biomarkers of STR. Among them, vinculin was one of the most deregulated proteins (p < 0.001), whose differential expression was confirmed by ELISA (p = 0.054). In the multivariate analysis, plasma vinculin levels along with basal CD Activity Index, corticosteroids induction, and bowel resection were factors predicting NSTR.

Resumen Saber elaborar correctamente un proyecto de investigacion supone un autentico reto. Y ser capaz de preparar un buen –mejor, un excelente– proyecto de investigacion se convierte en una exigencia para poder competir, con garantias de exito, para obtener financiacion. Con esta filosofia, en el presente manuscrito pretendemos compartir con el lector nuestra experiencia como solicitantes (fallidos en muchos casos) sobre los aspectos mas importantes para elaborar un proyecto de investigacion y que este sea premiado con su aprobacion y financiacion. La intencion del presente articulo no es enumerar, sin mas, una serie de recomendaciones teoricas, sino compartir algunas sugerencias personales y, por tanto, de indole eminentemente practica, sobre los siguientes apartados o elementos del proyecto de investigacion: el titulo, el resumen, la introduccion, los objetivos, la metodologia, el plan de trabajo o cronograma, la coherencia de la propuesta, su viabilidad, la aplicabilidad de la misma, la importancia del investigador principal y del equipo investigador, las limitaciones y alternativas del proyecto, su presupuesto, la bibliografia y, finalmente, el fondo y la forma del proyecto de investigacion. En resumen, el proyecto de investigacion es un plan escrito minuciosamente que contempla todos los aspectos, cientificos, eticos y logisticos del estudio que nos proponemos llevar a cabo. Redactar un buen proyecto de investigacion requiere un notable esfuerzo y una gran inversion de tiempo; pero merece la pena.

Knowing how to properly prepare a research proposal is a real challenge — and being able to prepare an excellent research proposal is increasingly a requirement to compete for funding with assurances of success. With this in mind, we aim to share with the reader our experience (in many cases, unsuccessful) as applicants on the most important aspects of preparing a research proposal and securing its approval and funding. This article aims not only to list theoretical recommendations but also to share some personal and eminently practical suggestions on the following elements of a research proposal: the title, the abstract, the introduction, the objectives, the methodology, the work plan or schedule, the proposal's consistency and coherence, its viability, its applicability, the importance of the principal investigator and the research team, the proposal’s limitations and alternatives, its budget, its references, and, finally, the research proposal's form or wording. In summary, a research proposal is a carefully written plan that includes all the scientific, ethical and logistical aspects of the study to be conducted. Writing a good research proposal requires considerable effort and a great deal of time, but it's worth it.

Pharmaceutical companies fund most clinical trials on drugs. However, there are clinical issues that might not be a priority from a commercial point of view, but that should certainly be addressed, given their importance for patients and society in general. Independent clinical research represents a fundamental pillar here and its basic element is investigator-initiated studies/trials. In these studies, it is the researcher who conceives the idea, develops the project and also acts as the sponsor. Most researchers are familiar with participating as collaborators in studies sponsored by pharmaceutical companies. In these studies, the company is in charge of all the scientific, legal and financial aspects, leaving the responsibility of the researcher mainly limited to the inclusion of patients and compliance with the protocol. On the contrary, the start-up and development of an independent research study requires considerable resources - of knowledge, money and time - and careful planning on the part of the researcher. In this manuscript, we will review the main characteristics of the studies initiated by the researcher and their fundamental differences with those sponsored by the pharmaceutical industry. We will also outline what its strengths and limitations are. Finally, we will propose some solutions to the main challenges they pose. Our ultimate goal is to stimulate potential researchers to undertake the challenge of conducting an independent clinical research project.

Background The long-term outcome of patients after antitumour necrosis factor alpha (anti-TNF) discontinuation is not well known. Aims To assess the risk of relapse in the long-term after anti-TNF discontinuation. Methods This was an extension of the evolution after anti-TNF discontinuation in patients with inflammatory bowel disease (EVODIS) study (Crohn's disease or ulcerative colitis patients treated with anti-TNFs in whom these drugs were withdrawn after achieving clinical remission) based in the same cohort of patients whose outcome was updated. Clinical remission was defined as a Harvey-Bradshaw index ≤4 points in Crohn's disease, a partial Mayo score ≤2 in ulcerative colitis and the absence of fistula drainage despite gentle finger compression in perianal disease. Results This was an observational, retrospective, multicenter study. A total of 1055 patients were included. The median follow-up time was 34 months. The incidence rate of relapse was 12% per patient-year (95% confidence interval [CI] = 11-14). The cumulative incidence of relapse was 50% (95% CI = 47-53): 19% at one year, 31% at 2 years, 38% at 3 years, 44% at 4 years and 48% at 5 years of follow-up. Of the 60% patients retreated with the same anti-TNF after relapse, 73% regained remission. Of the 75 patients who did not respond, 48% achieved remission with other therapies. Of the 190 patients who started other therapies after relapse, 62% achieved remission with the new treatment. Conclusions A significant proportion of patients who discontinued the anti-TNF remained in remission. In case of relapse, retreatment with the same anti-TNF was usually effective. Approximately half of the patients who did not respond after retreatment achieved remission with other therapies.

This research sought to characterize consumers and consumption in the UNIMINUTO Agroecological Fair and the Minuto de Dios Solidarity Market, which both have a low number of consumers and sales. A survey was designed and implemented through a Google form and in person, between September and October 2019. The total sample was 146 consumers (90% reliability, 5% error). The results were analyzed through descriptive statistics and comparison with other studies. The consumer’s profile is mostly university students of natural sciences, young adults of low and low-middle income strata from small households, and women; the age, gender, and educational level are common features with similar studies. The consumer lacks knowledge about the products, the participatory certification, and pricing, which can be remedied through consumer education. The supply and quality of agroecological products must also be improved.

Inflammatory bowel disease (IBD) has become a global disease encompassing a group of progressive disorders characterized by recurrent chronic inflammation of the gut with variable disease courses and complications. Despite recent advances in the knowledge of IBD pathophysiology, the elucidation of its etiopathology and progression is far from fully understood, requiring complex and multiple approaches. Therefore, limited clinical progress in diagnosis, assessment of disease activity, and optimal therapeutic regimens have been made over the past few decades. This review explores recent advances and challenges in tissue proteomics with an emphasis on biomarker discovery and better understanding of the molecular mechanisms underlying IBD pathogenesis. Future multi-omic studies are required for the comprehensive molecular characterization of disease biology in real time with a future impact on early detection, disease monitoring, and prediction of the clinical outcome.

Aims i] To evaluate the evolution of pregnancies and offspring after inflammatory bowel disease [IBD] surgery during pregnancy; and ii] to describe the indications, the surgical techniques, and the frequency of caesarean section concomitant with surgery. Methods Patients operated on due to IBD during pregnancy after 1998 were included. Participating clinicians were asked to review their databases to identify cases. Data on patients’ demographics, IBD characteristics, medical treatments, IBD activity, pregnancy outcomes, surgery, delivery, and foetal and maternal outcomes, were recorded. Results In all, 44 IBD patients were included, of whom 75% had Crohn’s disease; 18% of the surgeries were performed in the first trimester, 55% in the second, and 27% in the third trimester. One patient had complications during surgery, and 27% had postsurgical complications. No patient died. Of deliveries, 70% were carried out by caesarean section. There were 40 newborns alive. There were four miscarriages/stillbirths [one in the first, two in the second, and one in the third trimester]; two occurred during surgery, and another two occurred 2 weeks after surgery; 14% of the surgeries during the second trimester and 64% of those in the third trimester ended up with a simultaneous caesarean section or vaginal delivery. Of the 40 newborns, 61% were premature and 47% had low birth weight; 42% of newborns needed hospitalisation [25% in the intensive care unit]. Conclusions IBD surgery during pregnancy remains an extremely serious situation. Therefore, surgical management should be performed in a multidisciplinary team, involving gastroenterologists, colorectal surgeons, obstetricians, and neonatal specialists.

Hay una corrección posterior a este artículo: http://hdl.handle.net/10486/701800, Este artículo tiene una primera parte: http://hdl.handle.net/10486/701802, El tratamiento de la reservoritis es un escenario complejo que requiere una estrecha colaboración médico-quirúrgica. El tratamiento de elección de la reservoritis aguda es el ciprofloxacino o el metronidazol. Ante un primer episodio de reservoritis se recomienda la profilaxis de recidiva con una mezcla de probióticos; sin embargo, no está tan clara su utilidad como profilaxis primaria para prevenir un primer episodio de reservoritis tras la cirugía. El tratamiento de la reservoritis crónica refractaria debe iniciarse con una combinación de antibióticos, y si esta fracasa el siguiente escalón terapéutico es la budesonida oral. Algunas formas refractarias necesitarán terapias biológicas, siendo los anti-TNF α la primera opción, reservándose otros biológicos para pacientes refractarios. La ileostomía definitiva puede ser una opción final en los pacientes más graves, Pouchitis treatment is a complex entity that requires a close medical and surgical relationship. The elective treatment for acute pouchitis is antibiotics. After a first episode of pouchitis it is recommended prophylaxis therapy with a probiotic mix, nevertheless it is not clear the use of this formulation for preventing a first episode of pouchitis after surgery. First-line treatment for chronic pouchitis is an antibiotic combination. The next step in treatment should be oral budesonide. Selected cases of severe, chronic refractory pouchitis may benefit from biologic agents, and anti-TNF α should be recommended as the first option, leaving the new biologicals for multi-refractory patients. Permanent ileostomy may be an option in severe refractory cases to medical treatment

Pouchitis treatment is a complex entity that requires a close medical and surgical relationship. The elective treatment for acute pouchitis is antibiotics. After a first episode of pouchitis it is recommended prophylaxis therapy with a probiotic mix, nevertheless it is not clear the use of this formulation for preventing a first episode of pouchitis after surgery. First-line treatment for chronic pouchitis is an antibiotic combination. The next step in treatment should be oral budesonide. Selected cases of severe, chronic refractory pouchitis may benefit from biologic agents, and anti-TNF α should be recommended as the first option, leaving the new biologicals for multi-refractory patients. Permanent ileostomy may be an option in severe refractory cases to medical treatment.

This article aims to share our experience with those who consider dedicating themselves to research. In this way, the characteristics, qualities or competences that, in our opinion, a good researcher should fulfill are listed, and therefore the keys that can help you achieve a successful research career. The intention of this article is not to simply list a series of theoretical recommendations but to share some personal suggestions based on our experience and, therefore, of an eminently practical nature. The fundamental qualities to be discussed are: Ethics and honesty. Curiosity, passion, enthusiasm and motivation. Persistence, dedication and discipline. Ambition and leadership. Compromise and responsibility. Organization and planning. Acquire knowledge of research methodology. Critical and positive attitude towards difficulties and failure. Prioritization of objectives and time management. The importance of a good mentor. Establishment of a network of collaborators and teamwork. Maintain a balance between clinical and research activity. Combine public and private investigation. Balance between professional and personal life. And, finally, humility, generosity and thanks. Research represents a fundamental pillar of medical activity and it is evident that the highest quality of care arises from the integration of excellent clinical practice and research activity. With the philosophy that most of the qualities to develop an excellent research activity depend on attitude, and can be learned, developed and improved, in this manuscript we share with the reader a series of recommendations that we consider essential to be a good researcher.

© The Author(s) 2020., Adipose tissue secretes molecules that can promote activity in Crohn’s disease. We aimed to evaluate the role of serum adipokines as possible biomarkers in Crohn’s disease. Serum samples were obtained from 40 patients with endoscopically active or quiescent Crohn’s disease and 36 healthy controls. Serum leptin, ghrelin, resistin and adiponectin levels were analysed by Multiplex in a Luminex 200 system technology. Receiver Operating Characteristic curves were performed to evaluate the adipokines discriminatory capacity. A logistic regression adjusted by possible confounders (i.e. gender, age, BMI) was performed for those adipokines that showed an area under the curve > 0.7. No differences were found in age, gender or BMI among groups. Distribution for serum resistin was different among the three groups of study, and only this adipokine showed an area under the curve of 0.75 comparing actives patients and healthy control groups. Resistin median concentration was selected as a cut-off for a logistic regression analysis; odds ratio along its 95% confidence interval adjusted by gender, age, and BMI yielded a value of 5.46 (1.34–22.14) comparing actives patients and healthy controls. High concentration of serum resistin is probably associated to activity, being this association independent of gender, age or BMI., This work was supported by Ayudas Atracción de Talento modalidad 2 2017, BMD-5800 (Universidad Autónoma de Madrid and Comunidad de Madrid), the Ramón y Cajal Research Programme from the Spanish Ministry of Science (RYC-2017-21606), and the Sara Borrell fellowship from the Instituto de Salud Carlos III (CD17/00014). This study was possible thanks to Dr. Domingo Barber, scientifc director of Instituto de Medicina Molecular Aplicada (IMMA), Facultad de Medicina, Universidad San Pablo CEU, Madrid, Spain.

Following the development of a framework of sustainability indicators for the Red de Mercados Agroecologicos de Bogota Region – RMABR, in 2016, it was identified, that only 56% of its producers wer...

espanol[Introduccion]: Analisis de impactos ambientales en la produccion de huevos, muestran diferencias significativas entre sistemas convencionales y organicos, relacionados con la alimentacion, la eficiencia energetica, la distribucion y la gestion de residuos; sin embargo, se desconocen los impactos ambientales en sistemas agroecologicos para la produccion de huevo. [Objetivo]: Evaluar los impactos ambientales de la produccion agroecologica de huevos empleando un analisis de ciclo de vida. [Metodologia]: La evaluacion se realizo para 350 gallinas de raza Hy Line Brow de granjas agroecologicas en Cundinamarca, Colombia, contemplando toda la cadena de produccion de 1 kg de huevos, es decir, desde la cuna hasta la tumba, siguiendo los lineamientos de la ISO 14040. La informacion se recolecto durante un ano contemplando la elaboracion de alimentos, la produccion, la distribucion, consumo y disposicion final. Se consideraron cantidades de materiales, energia y residuos, para posteriormente, evaluar los impactos con la metodologia CML-2001. [Resultados]: Los impactos ambientales de un huevo agroecologico son menores hasta en un 30 %, comparado con los de un huevo convencional, principalmente, por la alimentacion, que en este caso es producida de forma agroecologica en la misma finca, al aprovechamiento de todos los residuos, el uso de energias alternativas y a que se reducen intermediarios en la cadena de comercializacion. [Conclusiones]: Aunque, la produccion de huevos agroecologicos tiene menores impactos, es necesario lograr una mayor eficiencia en la gestion del nitrogeno, buscar desinfectantes con menores impactos en el suelo, implementar sistemas de distribucion mas cortos y menos contaminantes y ademas propiciar una reutilizacion de los empaques. English[Introduction]: Analysis of environmental impacts in egg production show significant differences between conventional and organic systems, associated with food, energy efficiency, distribution and waste management. However, the environmental impacts of agroecological egg production systems are unknown. [Objective]: to assess the environmental impacts of agroecological egg production using a life cycle analysis. [Methodology]: The study was performed for 350 Hy Line Brow hens from agroecological farms in Cundinamarca, Colombia. The analysis covered the entire production chain of 1 kg of eggs, that is, from the cradle to the grave, following the guidelines of ISO 14040. The information was collected during one-year, contemplating food production, production, distribution, consumption, and final disposal. Quantities of materials, energy, and waste were considered to evaluate the impacts with the CML-2001 methodology subsequently. [Results]: the outcome revealed that the environmental effects of an agroecological egg were up to 30% lower than those of a conventional egg. This result is mainly due to feed, which is produced in an agroecological way in the same farm; it is also due to waste treatment, use of alternative energy, and reduction of intermediaries along the commercial chain. [Conclusions]: Although the impacts of agroecological eggs are lower, it requires greater efficiency in nitrogen management, the search of disinfectants with lower impacts on the soil, the implementation of shorter and cleaner distribution systems, and the promotion of packaging material reuse. portugues[Introducao]: Analises de impactos ambientais na producao de ovos mostram diferencas significativas entre sistemas convencionais e orgânicos relacionados com a alimentacao, a eficiencia energetica, a distribuicao e a gestao de residuos; contudo, sao desconhecidos os impactos ambientais em sistemas agroecologicos para a producao de ovo. [Objetivo]: Avaliar os impactos ambientais da producao agroecologica de ovos aplicando uma analise de ciclo de vida. [Metodologia]: A analise foi realizada com 350 galinhas da raca Hy-Line Brown de granjas agroecologicas em Cundinamarca, Colombia, considerando toda a cadeia de producao de 1 kg de ovos, ou seja, desde o berco ate a tumba conforme as orientacoes da ISO 14040. A informacao foi coletada durante um ano contemplando a producao de alimentos, a producao, a distribuicao, o consumo e a disposicao final. Foram considerados quantidades de materiais, energia e residuos para, logo, avaliar os impactos com a Metodologia CML-2001. [Resultados]: Os impactos ambientais de um ovo agroecologico sao ate 30% menores em comparacao com os de um ovo convencional, principalmente pela alimentacao que, neste caso, e produzida de forma agroecologica na mesma granja, com o aproveitamento de todos os residuos, o uso de energias alternativas e com a reducao de intermediarios na cadeia de comercializacao. [Conclusoes]: Ainda que a producao de ovos agroecologicos tenha menores impactos, e preciso alcancar uma maior eficiencia na gestao do nitrogenio, buscar desinfetantes com menores impactos no solo, implementar sistemas de distribuicao mais curtos e menos contaminantes e tambem propiciar uma reutilizacao das embalagens.

Two new biological drugs (vedolizumab and ustekinumab) and one small molecule (tofacitinib) have been recently approved for the treatment of inflammatory bowel disease. Therefore, we must be familiar with the safety of these “new” drugs during pregnancy and breastfeeding. In the present article, we critically review available data on the safety of new biologics (vedolizumab and ustekinumab) and small molecules (tofacitinib) during pregnancy and breastfeeding, with special focus on women with inflammatory bowel disease. Bibliographical searches (MEDLINE) up to April 2020 were performed. The timing and mechanisms of placental transfer of vedolizumab and ustekinumab are expected to be similar to anti-TNF agents. Animal studies show no evidence of adverse effects on pre- or post-natal development after administration of vedolizumab and ustekinumab. Just a few studies including patients treated with vedolizumab or ustekinumab during pregnancy have been published, reporting uneventful pregnancies in most cases. The clinical programme of both drugs and post-marketing studies showed no new safety concerns. Due to the expected safety of vedolizumab and ustekinumab during pregnancy, it may be recommended to plan the final pregnancy dose approximately 8 or 12 weeks, respectively, before the estimated date of delivery. Live vaccines should be avoided for up to a year in children exposed in utero to vedolizumab or ustekinumab unless drug elimination has been documented. Miniscule amounts of vedolizumab and ustekinumab are transferred to breast milk, so breastfeeding is probably safe. There is no evidence of adverse effect of vedolizumab or ustekinumab paternal exposure. Regarding tofacitinib, it is reasonable to assume that this molecule crosses the placenta from the beginning of pregnancy. In animal studies, tofacitinib was feticidal and teratogenic in rats and rabbits, although at exposures many times greater than the standard human dose. Reported outcomes of pregnancy cases identified from tofacitinib randomised controlled trials, post-approval and non-interventional studies, and spontaneous adverse-event reporting appear similar to those observed in the general population. Nevertheless, at present, the use of tofacitinib during pregnancy should be avoided. Although no human studies have reported outcomes of breastfeeding with small molecules such as tofacitinib, this drug is present in lactating rat milk so, at present, breastfeeding should be avoided. Pregnancy among patients with paternal exposure to tofacitinib appears to be safe. In summary, we can conclude that new biologic agents (vedolizumab and ustekinumab) and small molecules (tofacitinib) should be used during pregnancy only if the benefits to the mother outweigh the risks to the mother and unborn child.

Resumen La tasa de no adherencia al tratamiento medico en la enfermedad inflamatoria intestinal (EII) esta en torno al 50%, empeorando asi los resultados de los tratamientos, la morbilidad y el coste. Objetivos Determinar mediante una encuesta online entre gastroenterologos con especial dedicacion a la EII el conocimiento sobre la adherencia al tratamiento de sus pacientes y los metodos utilizados para mejorarla. Metodos Desde la secretaria tecnica de GETECCU se envio un correo a los socios con un enlace a la encuesta a traves de un sistema online. Resultados Se invito a 760 socios. Se obtuvieron 184 encuestas (28,5%). El 68% de los encuestados tenia publicaciones sobre EII indexadas, solo el 13% eran sobre adherencia. A pesar de que casi el 99% consideraban la adherencia como muy importante/importante, el 25% de los medicos no la media. Pese a que el 100% consideraba que mejorar la adherencia implicaria un mejor pronostico, el 47% no utilizaba sistemas para mejorarla. Los factores asociados con la medicion y mejora de la adherencia fueron: hospital universitario (81,4%), que el paciente recibiera tratamiento combinado con tiopurinicos y biologicos (44,6%), medico de sexo femenino (63,1%), dedicar ≥ 6 h semanalmente a la EII (71,6%), que el medico tenga publicaciones indexadas sobre EII (68,5%) y sobre adherencia en EII (12,5%) y que el medico considere la adherencia importante o muy importante (98,9%). Conclusiones Aunque el conocimiento sobre la relevancia de la adherencia al tratamiento medico en EII esta generalizado, entre los gastroenterologos con dedicacion especial a la EII que fueron encuestados casi la mitad no utiliza ningun sistema objetivo para cuantificarla. Se debe hacer un esfuerzo para cuantificar y mejorar la adherencia al tratamiento de estos pacientes.

Recommendations are advice that is given and considered to be beneficial; however, they are still suggestions and are therefore open to different interpretations. In this sense, the final objective of the review has been to try to homogenize, with the evidence available, the approach to the diagnosis and medical/surgical treatment of one of the most complex manifestations of Crohn's disease, such as simple and complex perianal fistulas.

Resumen Las recomendaciones son consejos dados por considerarse beneficiosos y no dejan de ser sugerencias, abiertas por tanto a diferentes interpretaciones. En ese sentido, el objetivo final de la revision ha sido, con las evidencias disponibles, intentar homogeneizar al maximo la aproximacion al diagnostico y tratamiento medicoquirurgico de una de las manifestaciones mas complejas de la enfermedad de Crohn como son las fistulas perianales simples y complejas