Evaluation of Expanded Criteria Donors Using the Kidney Donor Profile Index and the Preimplantation Renal Biopsy.

The increasing comorbidity of kidney transplant (KT) donors make it necessary to develop scores to correctly assess the quality of kidney grafts. This study analyzes the usefulness of the preimplantation biopsy and the Kidney Donor Profile Index (KDPI) as indicators of KT survival from expanded criteria donors (ECD). Retrospective study of KT in our center between January 2010 to June 2019 who received a kidney from an ECD and underwent a preimplantation biopsy. 266 KT were included. Graft survival was categorized by KDPI quartiles: Q1 = 86%, Q2 = 95%, Q3 = 99% and Q4 = 100%. KT from KDPI Q1 presented better survival (p = 0.003) and Q4 donors had worse renal function (p = 0.018) and poorer glomerular filtration rate (3rd month; p = 0.017, 1st year; p = 0.010). KT survival was analyzed according to KDPI quartile and preimplantation biopsy score simultaneously: Q1 donors with biopsy score ≤3 had the best survival, especially comparing against Q3 with a biopsy score >3 and Q4 donors (p = 0.014). In multivariable analysis, hyaline arteriopathy, glomerulosclerosis, and KDPI Q4 were predictors for graft survival. High KDPI and a greater histological injury in the preimplantation biopsy, especially glomerular and vascular lesions, were related to a higher rate of KT loss from ECD.

Factors associated with quality of care in inflammatory bowel diseases: a view from patient's side using the IQCARO quality of care decalogue.

BACKGROUND: Quality of care (QoC) is a highly important topic in inflammatory bowel disease (IBD). We recently elaborated a decalogue of QoC indicators (IQCARO-QoC) developed by IBD patients. The aim of the present study was to assess the factors associated with patients' evaluation of QoC in Spain using the IQCARO-QoC Decalogue recently developed by IBD patients. METHODS: A survey including patients' socio-demographic and clinical characteristics, and the IQCARO-QoC Decalogue, was completed by IBD patients. We described patients' assessment of QoC across Spanish patients. A univariable and multivariable analysis was performed to explore the associations between patients' characteristics and QoC. RESULTS: Questionnaires from 788 participant patients were analysed. Participants' mean age was 43.4 years, 63% were females and 58% had Crohn's disease. The mean QoC score was 8.1 (± 2.4 SD) points out of a maximum of 10. Items with the lowest score were related to the provision of information and the implication of the medical team throughout the entire patient care. Factors associated with better QoC scores included: being employed better disease control, fewer numbers of unscheduled visits, and being followed by a gastroenterologist specialized in IBD. CONCLUSIONS: Spanish patients' reported QoC seems to be globally good although there is room for improvement, especially in providing adequate information to patients. Care provided by specialized IBD gastroenterologists seems to be related with higher QoC scores.

Talipes Equinovarus Treatment in Infants Treated by the Ponseti Method Compared With Posterior-Only Release: A Mid-Childhood Comparison of Results.

The aim of this study is to evaluate children in middle childhood with clubfoot treated with Ponseti method vs posterior-only release and to compare their results to a control group with 4 modules (physical examination, gait study, radiographic measurements, and questionnaires). From 01/01/2004 until 01/01/2009, 31 children (45 feet) were treated with the posterior-only release protocol and 22 patients (34 feet) were treated with the Ponseti method. In 2016, patients were evaluated and compared with 25 children without neuromuscular disorders. Parents completed 3 outcome questionnaires. Radiographs evaluated residual deformity and osteoarthritis. A physical examination and a 3-dimensional gait analysis were performed to evaluate range of motion, kinematic, and kinetic data. Recurrence rate was similar between treatment groups; however, type of surgery to treat residual deformity was more aggressive in the posterior-only release (91% required major surgery), p = .024. Radiographic examination showed similar residual deformity with greater hindfoot varus in posterior-only release (68%), p = .02. Reduced cadence, increased stance dorsiflexion, calcaneus gait and forced eversion prior to swing were the main characteristics of gait in posterior-only release. Four (11%) feet treated with posterior-only release vs 11 (33%) feet treated with Ponseti method had a normal gait, p = .016. Our study showed that biomechanical function and long-term outcomes of children in middle childhood treated with the Ponseti method more closely compare with healthy individuals than those treated using posterior-only surgical technique.

Immunomodulatory Therapy Does Not Increase the Risk of Cancer in Persons With Inflammatory Bowel Disease and a History of Extracolonic Cancers.

OBJECTIVES: Immunosuppressant therapies (IMTs; thiopurines, anti-tumor necrosis factor agents) may influence the immunologic control of cancer and might facilitate the spread and recurrence of cancer. This study assesses the impact of the use of IMTs on the development of incident cancers (recurrent or new) in patients with inflammatory bowel disease (IBD) and a history of malignancy. METHODS: Patients with IBD included in the ENEIDA registry with a history of cancer without being exposed to IMTs were identified and retrospectively reviewed and compared regarding further treatment with IMTs or not by means of a log-rank test. RESULTS: Overall, 520 patients with previous extracolonic cancer naive to IMTs before the diagnosis of cancer were identified. Of these, 146 were subsequently treated with IMTs (exposed), whereas 374 were not (nonexposed). The proportion of patients with incident cancers was similar in both exposed (16%) and nonexposed (18%) patients (P = 0.53); however, there was more than a 10-year difference in the age at index cancer between these 2 groups. Cancer-free survival was 99%, 98%, and 97% at 1, 2, and 5 years in exposed patients, and 97%, 96%, and 92% at 1, 2, and 5 years in non-exposed patients, respectively (P = 0.03). No differences in incident cancer rates were observed between exposed and nonexposed patients when including only those who were exposed within the first 5 years after cancer diagnosis. DISCUSSION: In patients with IBD and a history of cancer not related to immunosuppression, the use of IMTs is not associated with an increased risk of new or recurrent cancers even when IMTs are started early after cancer diagnosis.

Impact and risk factors of non-adherence to 5-aminosalicylates in quiescent ulcerative colitis evaluated by an electronic management system.

BACKGROUND AND OBJECTIVE: To determine the impact of non-adherence to 5-Aminosalicylates (5-ASA) on the risk of flares and to identify risk factors of non-adherence. METHODS: Observational, cohort study of ulcerative colitis (UC) patients in clinical remission at least 6 months on 5-ASA monotherapy maintenance prescribed by an electronic management program. Adherence was considered when 80% of the prescribed 5-ASA had been dispensed at the pharmacy. The study analyzed the existence and degree of 5-ASA adherence, disease course, UC phenotypic expression, and 5-ASA dose and regimen, and consumption of non-UC chronic drugs during 2-year follow-up. RESULTS: The study included 274 patients, 49% males with a median age of 38 (27-49) years old. Overall, 41% of patients were non-adherent to 5-ASA. Risk of flares was reduced in the adherent group (36% vs 54%; OR = 0,484; p = 0,004), mainly the mild ones (26% vs 38%; OR = 0,559; p = 0,031). Non-adherence was associated with younger age at diagnosis (32 (26-45) vs 41.5 (21-50), p = 0.000) and no-consumption of other chronic treatments (1.1 vs 2.1; OR = 1709; p = 0,048). CONCLUSION: Non-adherence to 5-ASA evaluated by the pharmaceutical management system was at 41% with a higher risk of relapse. Younger patients and patients who do not receive non-UC chronic treatments showed lower adherence rate.

Antimicrobial susceptibilities of Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis strains from periodontitis patients in Morocco.

BACKGROUND AND OBJECTIVE: Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis have been frequently isolated in periodontitis patients in Morocco. Its persistence after the subgingival debridement of the biofilm has been correlated with worse clinical outcomes. The aim of this study was to evaluate the antimicrobial susceptibilities of A. actinomycetemcomitans and P. gingivalis, to amoxicillin, amoxicillin plus clavulanate, metronidazole, and azithromycin. In addition, microbiological profiles of patients harbouring A. actinomycetemcomitans, P. gingivalis, or both were compared. MATERIAL AND METHODS: In 45 consecutive periodontitis Moroccan patients, subgingival samples were taken and processed by culture. Twenty-four A. actinomycetemcomitans and 30 P. gingivalis colonies were isolated (54 strains) and susceptibility tests, using the epsilometric method, were run for amoxicillin, amoxicillin plus clavulanate, metronidazole, and azithromycin. Minimum inhibitory concentrations for 50 (MIC50) and 90% (MIC90) of the organisms were calculated. RESULTS: The prevalence of A. actinomycetemcomitans and P. gingivalis was 79.5 and 84.4%, respectively. A. actinomycetemcomitans showed susceptibility to amoxicillin, amoxicillin plus clavulanate, while 28% of the isolated strains were resistant to azithromycin and 61.7% towards metronidazole. No P. gingivalis resistance towards amoxicillin, amoxicillin plus clavulanate, metronidazole, and azithromycin was found. CONCLUSION: A. actinomycetemcomitans and P. gingivalis were frequently detected in Moroccan patients with periodontitis, while antimicrobial resistance was only detected for A. actinomycetemcomitans to metronidazole and azithromycin. CLINICAL RELEVANCE: A. actinomycetemcomitans resistance against some antimicrobials in periodontitis patients in Morocco can influence the selection of the therapeutic approaches.

Contribution of crop model structure, parameters and climate projections to uncertainty in climate change impact assessments.

Climate change impact assessments are plagued with uncertainties from many sources, such as climate projections or the inadequacies in structure and parameters of the impact model. Previous studies tried to account for the uncertainty from one or two of these. Here, we developed a triple-ensemble probabilistic assessment using seven crop models, multiple sets of model parameters and eight contrasting climate projections together to comprehensively account for uncertainties from these three important sources. We demonstrated the approach in assessing climate change impact on barley growth and yield at Jokioinen, Finland in the Boreal climatic zone and Lleida, Spain in the Mediterranean climatic zone, for the 2050s. We further quantified and compared the contribution of crop model structure, crop model parameters and climate projections to the total variance of ensemble output using Analysis of Variance (ANOVA). Based on the triple-ensemble probabilistic assessment, the median of simulated yield change was -4% and +16%, and the probability of decreasing yield was 63% and 31% in the 2050s, at Jokioinen and Lleida, respectively, relative to 1981-2010. The contribution of crop model structure to the total variance of ensemble output was larger than that from downscaled climate projections and model parameters. The relative contribution of crop model parameters and downscaled climate projections to the total variance of ensemble output varied greatly among the seven crop models and between the two sites. The contribution of downscaled climate projections was on average larger than that of crop model parameters. This information on the uncertainty from different sources can be quite useful for model users to decide where to put the most effort when preparing or choosing models or parameters for impact analyses. We concluded that the triple-ensemble probabilistic approach that accounts for the uncertainties from multiple important sources provide more comprehensive information for quantifying uncertainties in climate change impact assessments as compared to the conventional approaches that are deterministic or only account for the uncertainties from one or two of the uncertainty sources.

Extracolonic Cancer in Inflammatory Bowel Disease: Data from the GETECCU Eneida Registry.

OBJECTIVES: The objective of this study was (a) To know the prevalence and distribution of extracolonic cancer (EC) in patients with inflammatory bowel disease (IBD); (b) To estimate the incidence rate of EC; (c) To evaluate the association between EC and treatment with immunosuppressants and anti-tumor necrosis factor (TNF) agents. METHODS: This was an observational cohort study. INCLUSION CRITERIA: IBD and inclusion in the ENEIDA Project (a prospectively maintained registry) from GETECCU. EXCLUSION CRITERIA: Patients with EC before the diagnosis of IBD, lack of relevant data for this study, and previous treatment with immunosuppressants other than corticosteroids, thiopurines, methotrexate, or anti-TNF agents. The Kaplan-Meier method was used to evaluate the impact of several variables on the risk of EC, and any differences between survival curves were evaluated using the log-rank test. Stepwise multivariate Cox regression analysis was used to investigate factors potentially associated with the development of EC, including drugs for the treatment of IBD, during follow-up. RESULTS: A total of 11,011 patients met the inclusion criteria and were followed for a median of 98 months. Forty-eight percent of patients (5,303) had been exposed to immunosuppressants or anti-TNF drugs, 45.8% had been exposed to thiopurines, 4.7% to methotrexate, and 21.6% to anti-TNF drugs. The prevalence of EC was 3.6%. In the multivariate analysis, age (HR=1.05, 95% CI=1.04-1.06) and having smoked (hazards ratio (HR)=1.47, 95% confidence interval (CI)=1.10-1.80) were the only variables associated with a higher risk of EC. CONCLUSIONS: Neither immunosuppressants nor anti-TNF drugs seem to increase the risk of EC. Older age and smoking were associated with a higher prevalence of EC.

[Irritable bowel syndrome with constipation and functional constipation in adults: Treatment (Part 2 of 2)]. / Guía de práctica clínica del síndrome del intestino irritable con estreñimiento y estreñimiento funcional en adultos: tratamiento. (Parte 2 de 2).

In this Clinical practice guide we examine the diagnostic and therapeutic management of adult patients with constipation and abdominal discomfort, at the confluence of the spectrum of irritable bowel syndrome and functional constipation. Both fall within the framework of functional intestinal disorders and have major personal, health and social impact, altering the quality of life of the patients affected. The former is a subtype of irritable bowel syndrome in which constipation and altered bowel habit predominate, often along with recurring abdominal pain, bloating and abdominal distension. Constipation is characterised by infrequent or hard-to-pass bowel movements, often accompanied by straining during defecation or the sensation of incomplete evacuation. There is no underlying organic cause in the majority of cases; it being considered a functional bowel disorder. There are many clinical and pathophysiological similarities between the two conditions, the constipation responds in a similar way to commonly used drugs, the fundamental difference being the presence or absence of pain, but not in an "all or nothing" way. The severity of these disorders depends not only on the intensity of the intestinal symptoms but also on other biopsychosocial factors: association of gastrointestinal and extraintestinal symptoms, degree of involvement, forms of perception and behaviour. Functional bowel disorders are diagnosed using the Rome criteria. This Clinical practice guide adapts to the Rome IV criteria published at the end of May 2016. The first part (96, 97, 98) examined the conceptual and pathophysiological aspects, alarm criteria, diagnostic test and referral criteria between Primary Care and Gastroenterology. This second part reviews all the available treatment alternatives (exercise, fluid ingestion, diet with soluble fibre-rich foods, fibre supplements, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antdepressants, psychological treatment, acupuncture, enemas, sacral root neurostimulation and surgery), and practical recommendations are made for each.

[Clinical practice guidelines: Irritable bowel syndrome with constipation and functional constipation in adults: Concept, diagnosis, and healthcare continuity. (Part 1 of 2)]. / Guía de práctica clínica: síndrome del intestino irritable con estreñimiento y estreñimiento funcional en adultos: concepto, diagnóstico y continuidad asistencial. (Parte 1 de 2).

In this Clinical practice guide, an analysis is made of the diagnosis and treatment of adult patients with constipation and abdominal discomfort, under the spectrum of irritable bowel syndrome and functional constipation. These have an important personal, health and social impact, affecting the quality of life of these patients. In irritable bowel syndrome with a predominance of constipation, this is the predominant change in bowel movements, with recurrent abdominal pain, bloating and frequent abdominal distension. Constipation is characterised by infrequent or difficulty in bowel movements, associated with excessive straining during bowel movement or sensation of incomplete evacuation. There is often no underling cause, with an intestinal functional disorder being considered. They have many clinical and pathophysiological similarities, with a similar response of the constipation to common drugs. The fundamental difference is the presence or absence of pain, but not in a way evaluable way; "all or nothing". The severity depends on the intensity of bowel symptoms and other factors, a combination of gastrointestinal and extra-intestinal symptoms, level of involvement, forms of perception, and behaviour. The Rome criteria diagnose functional bowel disorders. This guide is adapted to the Rome criteria IV (May 2016) and in this first part an analysis is made of the alarm criteria, diagnostic tests, and the criteria for referral between Primary Care and Digestive Disease specialists. In the second part, a review will be made of the therapeutic alternatives available (exercise, diet, drug therapies, neurostimulation of sacral roots, or surgery), making practical recommendations for each one of them.

Characterization of A. actinomycetemcomitans strains in subgingival samples from periodontitis subjects in Morocco.

OBJECTIVE: Aggregatibacter actinomycetemcomitans, specially its highly leucotoxic strain (JP2 clone), represents an etiological factor for the onset and progression of aggressive types of periodontitis. The aims of this investigation were to investigate the most relevant periodontal pathogens in the subgingival microbiota of periodontitis patients from Morocco and to describe the clinical and microbiological characteristics of subjects positive for A. actinomycetemcomitans, including serotype, leukotoxin gene, and operon of the cytolethal distending toxin (cdt) distribution. MATERIAL AND METHODS: In consecutive Moroccan subjects diagnosed of periodontitis, subgingival samples were taken and processed by culture. From the positive samples for A. actinomycetemcomitans, one to three isolates were subcultured and characterized by means of polymerase chain reaction (PCR), assessing their specific serotype distribution, the variation in the sequences of the leukotoxin gene, and the operon of the cdt. RESULTS: Twenty-one (35.6 %) out of 59 periodontitis patients harbored A. actinomycetemcomitans. These patients demonstrated statistically significant deeper pockets (p = 0.035) and higher proportions of P. micra (p = 0.045) than did the negative group. The 39 studied isolates were serotype "b"; in 16 out of 17 patients, there was mono-colonization with this serotype. Five isolates, from two patients, presented the 530-bp deletion in the leukotoxin's promoter region. Thirty-two isolates (78 % of the strains) were cdt-positive. CONCLUSION: A. actinomycetemcomitans was frequently found (35.6 %) in our sample. All strains were serotype "b," and most (78 %) were also cdt-positive. The JP2 strain type was only detected in 12.2 % of the strains. CLINICAL RELEVANCE: A. actinomycetemcomitans can be frequently found in Morocco. This fact can influence the therapeutic approach of this type of patients.

Surgical Wound Dehiscence in Kidney Transplantation: Risk Factors and Impact on Graft Survival.

BACKGROUND: Surgical wound dehiscence (SWD) is a frequent complication after kidney transplantation (KT) but there is not enough evidence of its impact on graft survival. METHODS: A retrospective cohort study including all KT patients with SWD in our center from January 2015 to July 2020 was performed. A case-control study was performed and for each case of SWD, 2 controls were selected (2:1). To identify risk factors for SWD, a logistic regression analysis was carried out and a multivariable Cox regression was used to describe risk factors for graft survival. RESULTS: In our center, 503 KT were performed, and 39 patients presented SWD. They were older (62.1 vs 57.1 years; P = .030), most had diabetes mellitus (59% vs 28.6%; P = .002) and their body mass index was higher (31 vs 26.9 kg/m2; P < .001). In multivariable logistic regression analysis, diabetes mellitus (P = .024) and a body mass index ≥30 kg/m2 at time of transplantation (P = .018) were predictors of SWD. A higher rate of delayed graft function was described in SWD (P = .013) and it was associated with a longer hospital stay (20.9 vs 15 days; P = .004). Graft survival was lower in patients with SWD (P = .036). In multivariable Cox regression analysis, time in renal replacement therapy (P = .020) and SWD (P = .028) were predictors of shorter graft survival. CONCLUSION: SWD is a risk factor for graft survival. The presence of diabetes mellitus and a higher body mass index are predictors for the appearance of this complication.

Liver dysfunction related to hepatitis B and C in patients with inflammatory bowel disease treated with immunosuppressive therapy.

BACKGROUND: There is no information about the frequency of liver dysfunction in patients with inflammatory bowel disease (IBD) treated with immunosuppressants and infected with hepatitis B (HBV) and/or C virus (HCV). AIM: To assess the influence of immunosuppressants on the course of HBV and HCV infection in IBD. METHODS: Patients with IBD with HBV and/or HCV infection from 19 Spanish hospitals were included. Clinical records were reviewed for the type of immunosuppressant used, treatment duration, liver function tests and viral markers before, during and after each immunosuppressant. Logistic and Cox regression analysis were used to identify predictors of outcome. RESULTS: 162 patients were included; 104 had HBV markers (25 HBsAg positive) and 74 had HCV markers (51 HCV-RNA positive), and 16 patients had markers of both infections. Liver dysfunction was observed in 9 of 25 HBsAg positive patients (36%), 6 of whom developed hepatic failure. Liver dysfunction in HCV was observed in 8 of 51 HCV-RNA positive patients (15.7%), and only one developed hepatic failure. The frequency and severity of liver dysfunction was significantly higher in HBV-infected patients than in HCV-infected patients (p=0.045 and p=0.049, respectively). Treatment with ≥2 immunosuppressants was an independent predictor of HBV reactivation (OR 8.75; 95% CI 1.16 to 65.66). The majority of patients without reactivation received only one immunosuppressant for a short period and/or prophylactic antiviral treatment. No definite HBV reactivations were found in anti-HBc positive patients lacking HBsAg. CONCLUSION: Liver dysfunction in patients with IBD treated with immunosuppressants is more frequent and severe in those with HBV than in HCV carriers and is associated with combined immunosuppression.

Normal values in ambulatory oesophageal pH monitoring at two levels in Spain.

AIM: Upper oesophageal pH monitoring may play a significant role in the study of extra-oesophageal GERD, but limited normal data are available to date. Our aim was to develop a large series of normal values of proximal oesophageal acidification. METHODS: 155 healthy volunteers (74 male) participated in a multi-centre national study including oesophageal manometry and 24 hours oesophageal pH monitoring using two electrodes individually located 5 cm above the LOS and 3 cm below the UOS. RESULTS: 130 participants with normal manometry completed all the study. Twelve of them were excluded for inadequate pH tests. Twenty-seven subjects had abnormal conventional pH. The remaining 91 subjects (37 M; 18-72 yrs age range) formed the reference group for normality. At the level of the upper oesophagus, the 95th percentile of the total number of reflux events was 30, after eliminating the meal periods 22, and after eliminating also the pseudo-reflux events 18. Duration of the longest episodes was 5, 4 and 4 min, respectively (3.5 min in upright and 0.5 min in supine). The upper limit for the percentage of acid exposure time was 1.35, 1.05 and 0.95%, respectively. No reflux events were recorded in the upper oesophagus in 8 cases. CONCLUSION: This is the largest series of normal values of proximal oesophageal reflux that confirm the existence of acid reflux at that level in healthy subjects, in small quantity and unrelated to age or gender. Our data support the convenience of excluding pseudo-reflux events and meal periods from analysis.

The ideal lateral internal sphincterotomy: clinical and endosonographic evaluation following open and closed internal anal sphincterotomy.

OBJECTIVE: To evaluate the relationship between extent of internal sphincter division following open and closed sphincterotomy, as assessed by anal endosonography, with fissure persistence/recurrence and faecal incontinence. METHOD: A total of 140 consecutive patients undergoing lateral internal sphincterotomy (LIS) for idiopathic chronic anal fissure were prospectively studied. Preoperative clinical assessment was performed together with a postoperative clinical and endosonographic examination. Three zones of the internal sphincter, identifiable by endosonography, were used to describe the uppermost extent of LIS. Primary end-points were fissure persistence/recurrence and faecal incontinence. RESULTS: A total of 140 patients, median age 49.5 years (IQR: 38-56 years) were included. Seventy-five (53.6%) and 65(46.4%) patients underwent percutaneous LIS (PLIS) and open LIS (OLIS) respectively. Median follow-up was 21 months (IQR: 14-29 months). Persistence and recurrence rates were 2.9% (4/140) and 5.7% (8/140) respectively. 7.9% (11/140) patients scored > 3 on the Jorge and Wexner Faecal Incontinence scale. PLIS was associated with a trend towards higher fissure persistence/recurrence rates than OLIS (12.0%vs 4.6%, P = 0.141). OLIS was significantly associated with a higher proportion of complete sphincterotomies (CS) than PLIS (56/65 vs 48/75, P = 0.003). A CS was associated with a lower fissure persistence or recurrence rate (1/104 vs 11/36, P < 0.001) but higher incontinence scores (11/104 vs 0/36 cases with Wexner scores > 3, P = 0.042) than following incomplete sphincterotomy. There was a strongly significant increase in incontinence scores (P < 0.001) and decrease in recurrence rates (P < 0.001) with increasing length of sphincterotomy. CONCLUSION: We recommend a short and CS using either PLIS or OLIS for the treatment of idiopathic anal fissure.

Clinical evaluation of a new artificial saliva in spray form for patients with dry mouth.

OBJECTIVES: To determine the efficacy of a new saliva substitute in spray form, for patients with dry mouth. STUDY DESIGN: Thirty-seven patients with dry mouth were selected (16 males and 21 females), with an age of over 60 years and meeting the following inclusion criteria: xerostomia and hyposialia confirmed by sialometry (resting whole saliva / stimulated whole saliva). A new artificial saliva in spray format was applied, with evaluation of the degree of improvement (VAS scale), frequency of application, time to improvement in minutes, duration in minutes, and assessment of organoleptic properties. RESULTS: Twenty of the 37 patients showed almost immediate improvement after application. The mean number of applications/day was 3.89, with a mean duration of effect of 15.3 min. (65% > 15 min.). The flavor was rated as pleasant by 18 patients. CONCLUSIONS: Application of the spray is simple and effective, affording immediate relief, and with reasonable acceptance among patients with dry mouth.

Absence of cardiovascular autonomic dysfunction and vagal pancreatic impairment in idiopathic achalasia of the oesophagus.

Extra-oesophageal autonomic dysfunction in idiopathic achalasia is not well documented, due to contradictory results reported. We aimed to study the cardiovascular and pancreatic autonomic function in patients with idiopathic achalasia. Thirty patients with idiopathic achalasia (16M/14F; 34.5 +/- 10.8 years) and 30 healthy volunteers (13M/17F; 34.8 +/- 10.7 years) were prospectively studied. Age >60 years and conditions affecting results of autonomic evaluation were excluded. Both groups underwent the sham feeding test and plasmatic levels of pancreatic polypeptide (PP) were determined by radioimmunoassay (basal, at 5, 10, 20 and 30 min). Cardiovascular parasympathetic (deep breathing, standing, Valsalva) and sympathetic function (postural decrease of systolic blood pressure, Handgrip test) were assessed. Statistical comparison of basal and increase levels of PP and parasympathetic/sympathetic cardiovascular parameters was performed between groups. Basal levels of PP were similar in controls and patients and maximum increase of PP during sham feeding test. A similar rate of abnormal cardiovascular tests was found between groups (P > 0.05). E/I ratio was the mostly impaired parameter (patients: 36.7% vs controls: 20%, P = 0.15, chi-squared test). Autonomic cardiovascular tests and pancreatic response to vagal stimulus are not impaired in patients with primary achalasia of the oesophagus.

[Clinical practice guidelines: Irritable bowel syndrome with constipation and functional constipation in adults: Concept, diagnosis, and healthcare continuity. (Part 1 of 2)]. / Guía de práctica clínica: síndrome del intestino irritable con estreñimiento y estreñimiento funcional en adultos: concepto, diagnóstico y continuidad asistencial. (Parte 1 de 2).

In this Clinical practice guide, an analysis is made of the diagnosis and treatment of adult patients with constipation and abdominal discomfort, under the spectrum of irritable bowel syndrome and functional constipation. These have an important personal, health and social impact, affecting the quality of life of these patients. In irritable bowel syndrome with a predominance of constipation, this is the predominant change in bowel movements, with recurrent abdominal pain, bloating and frequent abdominal distension. Constipation is characterised by infrequent or difficulty in bowel movements, associated with excessive straining during bowel movement or sensation of incomplete evacuation. There is often no underling cause, with an intestinal functional disorder being considered. They have many clinical and pathophysiological similarities, with a similar response of the constipation to common drugs. The fundamental difference is the presence or absence of pain, but not in a way evaluable way; "all or nothing". The severity depends on the intensity of bowel symptoms and other factors, a combination of gastrointestinal and extra-intestinal symptoms, level of involvement, forms of perception, and behaviour. The Rome criteria diagnose functional bowel disorders. This guide is adapted to the Rome criteria IV (May 2016) and in this first part an analysis is made of the alarm criteria, diagnostic tests, and the criteria for referral between Primary Care and Digestive Disease specialists. In the second part, a review will be made of the therapeutic alternatives available (exercise, diet, drug therapies, neurostimulation of sacral roots, or surgery), making practical recommendations for each one of them.

[Irritable bowel syndrome with constipation and functional constipation in adults: Treatment (Part 2 of 2)]. / Guía de práctica clínica del síndrome del intestino irritable con estreñimiento y estreñimiento funcional en adultos: tratamiento. (Parte 2 de 2).

In this Clinical practice guide we examine the diagnostic and therapeutic management of adult patients with constipation and abdominal discomfort, at the confluence of the spectrum of irritable bowel syndrome and functional constipation. Both fall within the framework of functional intestinal disorders and have major personal, health and social impact, altering the quality of life of the patients affected. The former is a subtype of irritable bowel syndrome in which constipation and altered bowel habit predominate, often along with recurring abdominal pain, bloating and abdominal distension. Constipation is characterised by infrequent or hard-to-pass bowel movements, often accompanied by straining during defecation or the sensation of incomplete evacuation. There is no underlying organic cause in the majority of cases; it being considered a functional bowel disorder. There are many clinical and pathophysiological similarities between the two conditions, the constipation responds in a similar way to commonly used drugs, the fundamental difference being the presence or absence of pain, but not in an "all or nothing" way. The severity of these disorders depends not only on the intensity of the intestinal symptoms but also on other biopsychosocial factors: association of gastrointestinal and extraintestinal symptoms, degree of involvement, forms of perception and behaviour. Functional bowel disorders are diagnosed using the Rome criteria. This Clinical practice guide adapts to the Rome IV criteria published at the end of May 2016. The first part (96, 97, 98) examined the conceptual and pathophysiological aspects, alarm criteria, diagnostic test and referral criteria between Primary Care and Gastroenterology. This second part reviews all the available treatment alternatives (exercise, fluid ingestion, diet with soluble fibre-rich foods, fibre supplements, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antdepressants, psychological treatment, acupuncture, enemas, sacral root neurostimulation and surgery), and practical recommendations are made for each.

Oesophageal motility disorders in type 1 diabetes mellitus and their relation to cardiovascular autonomic neuropathy.

The relationship between cardiovascular autonomic neuropathy (CVAN) and oesophageal dysfunction in diabetes mellitus has not been well established because reports are contradictory. The aim of this study was to assess oesophageal function and its correlation with CVAN in type 1 diabetic patients without oesophageal symptoms. Forty-six type 1 diabetic patients without oesophageal symptoms (DG) and 34 healthy volunteers (CG) were studied. Both groups underwent CVAN tests and oesophageal manometry and pH-metry. Differences between groups regarding results of cardiovascular autonomic tests and oesophageal studies were statistically analysed. Compared with the CG, the DG group showed insufficient lower oesophageal sphincter (LOS) relaxation and a higher percentage of simultaneous waves (P < 0.01). Patients with CVAN (n = 22) showed a higher prevalence of pathological simultaneous contractions (>10%), and the prevalence of simultaneous waves related to the degree of autonomic neuropathy was: 9% of patients without CVAN, 7% of those suspected to have it and 50% of patients with CVAN (P < 0.001). Factors associated with the presence of pathological simultaneous waves (>10%) were the presence of CVAN and duration of diabetes (P < 0.05, logistic regression analysis). Increase in simultaneous waves and impaired relaxation of LOS are more frequent in diabetic patients with CVAN.