Recommendations and quality criteria to improve the early diagnosis of primary biliary cholangitis. / Recomendaciones y criterios de calidad para mejorar el diagnóstico precoz de la colangitis biliar primaria.

OBJECTIVE: The study aimed to establish recommendations and quality criteria to enhance the healthcare process of PBC. PATIENTS AND METHODS: It was conducted using qualitative techniques, preceded by a literature review. A consensus conference involving five specialists in the field was held, followed by a Delphi process developed in two waves, in which 30 specialist physicians in family and community medicine, digestive system and internal medicine were invited to participate. RESULTS: Seven recommendations and 15 sets of quality criteria, indicators and standards were obtained. Those with the highest consensus were «Know the impact on the patient's quality of life. Consider their point of view and agree on recommendations and care¼ and «Evaluate possible fibrosis at the time of diagnosis and during PBC follow-up, assessing the evolution of factors associated with poor disease prognosis: noninvasive fibrosis (elastography > 2.1 kPa/year), GGT, ALP and bilirubin annually¼, respectively. CONCLUSIONS: The implementation of the consensus recommendations and criteria would provide better patient care. The need for multidisciplinary follow-up and an increased role of primary care is emphasized.

Neurofibromatosis Type 1: Diagnostic Timelines in Children. / Cronología del diagnóstico de la neurofibromatosis tipo 1 en la infancia.

BACKGROUND AND OBJECTIVES: The neurofibromatosis 1 (NF1) diagnosis is challenging in young children without a family history of NF1. The aims of this study were to estimate diagnostic delays in children without a family history of NF1 and to examine the effects of using café au lait macules and skin fold freckling as a single diagnostic criterion. PATIENTS AND METHODS: Retrospective, descriptive, observational study of all patients diagnosed with NF1 before the age of 18 years who were seen at our hospital. The medical records of those included were reviewed to identify the date on which the diagnostic criteria of NF1 were objectified. The patients were categorized into 2 groups: those with a known parental history of NF1 and those without. Café au lait macules and skin fold freckling were assessed as a single diagnostic criterion, and genetic evidence was considered to confirm highly suspicious cases. RESULTS: We studied 108 patients younger than the age of 18 years with a diagnosis of NF1. Mean (SD) age at diagnosis was 3.94 (±3.8) years for the overall group, 1 year for patients with a parental history of NF1, and 4 years and 8 months for those without. Diagnosis was therefore delayed by 3 years and 8 months in patients without a family history. CONCLUSION: Skin lesions were the first clinical manifestation of NF1 in most patients. We believe that the National Institutes of Health's diagnostic criteria for NF1 should be updated to aid diagnosis in young children.

Using decision science to evaluate global biodiversity indices.

Global biodiversity indices are used to measure environmental change and progress toward conservation goals, yet few indices have been evaluated comprehensively for their capacity to detect trends of interest, such as declines in threatened species or ecosystem function. Using a structured approach based on decision science, we qualitatively evaluated 9 indices commonly used to track biodiversity at global and regional scales against 5 criteria relating to objectives, design, behavior, incorporation of uncertainty, and constraints (e.g., costs and data availability). Evaluation was based on reference literature for indices available at the time of assessment. We identified 4 key gaps in indices assessed: pathways to achieving goals (means objectives) were not always clear or relevant to desired outcomes (fundamental objectives); index testing and understanding of expected behavior was often lacking; uncertainty was seldom acknowledged or accounted for; and costs of implementation were seldom considered. These gaps may render indices inadequate in certain decision-making contexts and are problematic for indices linked with biodiversity targets and sustainability goals. Ensuring that index objectives are clear and their design is underpinned by a model of relevant processes are crucial in addressing the gaps identified by our assessment. Uptake and productive use of indices will be improved if index performance is tested rigorously and assumptions and uncertainties are clearly communicated to end users. This will increase index accuracy and value in tracking biodiversity change and supporting national and global policy decisions, such as the post-2020 global biodiversity framework of the Convention on Biological Diversity.

Uso de las Ciencias de la Decisión para Evaluar los Índices Globales de Biodiversidad Resumen Los índices globales de biodiversidad se usan para medir el cambio ambiental y el avance hacia los objetivos de conservación, aunque pocos han sido evaluados completamente en cuanto a su capacidad para detectar las tendencias de interés como las declinaciones de especies amenazadas o la función del ecosistema. Evaluamos cualitativamente nueve índices de uso común para dar seguimiento a la biodiversidad a escala global y regional contra cinco criterios relacionados con los objetivos, diseño, comportamiento, incorporación de la incertidumbre y restricciones (p. ej.: costos y disponibilidad de datos) mediante una estrategia estructurada basada en las ciencias de la decisión. La evaluación se basó en la literatura de referencia para los índices disponibles al momento del análisis. Identificamos cuatro vacíos importantes en los índices estudiados: las vías para lograr los objetivos (objetivos medios) no fueron siempre claras o relevantes para los resultados deseados (objetivos fundamentales); el análisis del índice y el entendimiento del comportamiento esperado casi siempre fueron escasos; pocas veces se consideró o explicó la incertidumbre; y casi nunca se consideraron los costos de la implementación. Estos vacíos pueden hacer que los índices sean inadecuados en ciertos contextos de toma de decisiones y son problemáticos para los índices vinculados a los objetivos de biodiversidad y las metas de sustentabilidad. Es de suma importancia asegurarse que los objetivos del índice sean claros y que su diseño esté respaldado por un modelo de procesos relevantes para tratar con los vacíos identificados en nuestro estudio. La aceptación y el uso productivo de los índices mejorarán si el desempeño del índice es evaluado rigurosamente y las suposiciones e incertidumbres se les comunican claramente a los usuarios finales. Lo anterior aumentará la precisión y valor del índice en el seguimiento de los cambios de la biodiversidad y en el apoyo a las decisiones políticas nacionales y mundiales, como el marco de trabajo para la biodiversidad post-2020 establecido por la Convención sobre la Diversidad Biológica.

Use of standardized methods to improve extinction-risk classification.

Standardized classification methods based on quantifiable risk metrics are critical for evaluating extinction threats because they increase objectivity, consistency, and transparency of listing decisions. Yet, in the United States, neither federal nor state agencies use standardized methods for listing species for legal protection, which could put listing decisions at odds with the magnitude of the risk. We used a recently developed set of quantitative risk metrics for California herpetofauna as a case study to highlight discrepancies in listing decisions made without standardized methods. We also combined such quantitative metrics with classification tree analysis to attempt to increase the transparency of previous listing decisions by identifying the criteria that had inherently been given the most weight. Federally listed herpetofauna in California scored significantly higher on the risk-metric spectrum than those not federally listed, whereas state-listed species did not score any higher than species that were not state listed. Based on classification trees, state endemism was the most important predictor of listing status at the state level and distribution trend (decline in a species' range size) and population trend (decline in a species' abundance at localized sites) were the most important predictors at the federal level. Our results emphasize the need for governing bodies to adopt standardized methods for assessing conservation risk that are based on quantitative criteria. Such methods allow decision makers to identify criteria inherently given the most weight in determining listing status, thus increasing the transparency of previous listing decisions, and produce an unbiased comparison of conservation threat across all species to promote consistency, efficiency, and effectiveness of the listing process.

Uso de Métodos Estandarizados para Mejorar la Clasificación del Riesgo de Extinción Resumen Los métodos estandarizados de clasificación basados en medidas cuantificables del riesgo de extinción son sumamente importantes para evaluar las amenazas de extinción ya que incrementan la objetividad, consistencia y transparencia de las decisiones de listado. Aún así, en los Estados Unidos, ni las agencias federales ni las estatales usan métodos estandarizados para enlistar a las especies para su protección legal, lo que podría poner en discrepancia a las decisiones de listado con la magnitud del riesgo. Usamos un conjunto de medidas cuantitativas del riesgo, desarrollado recientemente para la herpetofauna de California, como un estudio de caso que nos permitiera resaltar las discrepancias en las decisiones de listado hechas sin métodos estandarizados. También combinamos dichas medidas cuantitativas con un análisis de árbol de clasificación para intentar incrementar la transparencia de las decisiones de listado previas al identificar los criterios a los cuales se les había otorgado mayor peso inherentemente. La herpetofauna de California que se encontraba enlistada a nivel federal tuvo un puntaje significativamente más alto en el espectro de la medida del riesgo que aquellas especies que no estaban enlistadas, mientras que las especies enlistadas a nivel estatal no tuvieron un puntaje más alto que aquellas especies que no estaban enlistadas a nivel estatal. Con base en los árboles de clasificación, el endemismo estatal fue el indicador más importante del estado de listado a nivel estatal y tanto la tendencia de distribución (declinación del tamaño de la extensión de una especie) y como la tendencia poblacional (declinación de la abundancia de una especie en sitios localizados) fueron los indicadores más importantes a nivel federal. Nuestros resultados enfatizan la necesidad que tienen los cuerpos de gobierno de adoptar los métodos estandarizados que están basados en criterios cuantitativos para la evaluación del riesgo de conservación. Dichos métodos permiten que quienes toman las decisiones identifiquen los criterios a los cuales se les otorga inherentemente el mayor peso al determinar el estado de listado, lo que incrementa la transparencia de las decisiones previas de listado, y produce una comparación sin sesgos de la amenaza de conservación en todas las especies para promover la regularidad, eficiencia y efectividad de los procesos de listado.

[The impact of patient identification on an integrated program of palliative care in Basque Country]. / Impacto de la identificación de pacientes en un programa de cuidados paliativos del País Vasco.

OBJECTIVE: Evaluate the process and the economic impact of an integrated palliative care program. DESIGN: Comparative cross-sectional study. LOCATION: Integrated Healthcare Organizations of Alto Deba and Goierri Alto-Urola, Basque Country. PARTICIPANTS: Patients dead due to oncologic and non-oncologic causes in 2012 (control group) and 2015 (intervention group) liable to need palliative care according to McNamara criteria. INTERVENTIONS: Identification as palliative patients in primary care, use of common clinical pathways in primary and secondary care and arrange training courses for health professionals. MAIN MEASURES: Change in the resource use profile of patients in their last 3 months. Propensity score by genetic matching method was used to avoid non-randomization bias. The groups were compared by univariate analysis and the relationships between variables were analysed by logistic regressions and generalized linear models. RESULTS: One thousand and twenty-three patients were identified in 2012 and 1,142 patients in 2015. In 2015 doubled the probability of being identify as palliative patient in deaths due to oncologic (19-33%) and non-oncologic causes (7-16%). Prescriptions of opiates rise (25-68%) and deaths in hospital remained stable. Contacts per patient with primary care and home hospitalization increased, while contacts with hospital admissions decreased. Cost per patient rise 26%. CONCLUSIONS: The integrated palliative care model increased the identification of the target population. Relationships between variables showed that the identification had a positive impact on prescription of opiates, death outside the hospital and extension to non-oncologic diseases. Although the identification decreased admissions in hospital, costs per patient had a slight increase due to home hospitalizations.

[Identifying potentially inappropriate prescriptions in patients over 65 years-old using original Beers criteria and their Spanish adaptation]. / Prescripción potencialmente inadecuada en mayores de 65 años según los criterios de Beers originales y su versión adaptada.

OBJECTIVE: To compare the detection of potentially inappropriate medication (PIM) using the original Beers criteria, a global reference for evaluating prescriptions in the elderly, and their Spanish version. DESIGN: Retrospective observational study LOCATION: A Primary Care area in the province of Murcia, Spain. PARTICIPANTS: A total of 7,856 subjects aged 65 and over, with at least one drug prescribed in a Primary Care Area of Spain during study period. METHOD: Illnesses and treatments registered in the Primary Care computerised medical history of patients were analysed during a 12month study period (2012). The original Beers criteria and their Spanish adaptation were used to evaluate PIM, considering both sets of criteria overall, and individually. RESULTS: The median age of the patients was 76.0years, with the majority females (56.6%). Patients received a median of 13 active substances and 66 medical prescriptions. The percentage of patients prescribed PIM ranged from 44.8% according to the original Beers criteria to 49.4% with the Spanish adaptation. CONCLUSIONS: PIMs are frequent in our context. The original Beers criteria, if not adapted to the local drug catalogue, underestimated the frequency of PIM in the elderly population studied.

Advances for improved diagnosis of microscopic colitis in patients with chronic diarrhoea. / Colitis microscópica: avances para una mejor identificación en los pacientes con diarrea crónica.

Microscopic colitis is a generic term that includes 2 main forms, collagenous colitis and lymphocytic colitis, and describes a form of inflammatory bowel disease with a chronic and relapsing course. The incidence of microscopic colitis is between 2 and 8 times higher in women than in men, although age, more than sex, increases the risk of collagenous colitis (odds ratio [OR] 8.3 for age ≥65 vs. <65 and OR 2.8 for women). The main symptom is chronic non-bloody watery diarrhoea. Other common symptoms include abdominal pain (50%-70%), with the result that many patients with microscopic colitis meet criteria for irritable bowel syndrome. Colonoscopy with multiple colonic biopsies is currently recommended, as histological changes are the main characteristic feature. The colonic mucosa is macroscopically normal, although certain minimal endoscopic abnormalities have been described.

Quality criteria in bariatric surgery: Consensus review and recommendations of the Spanish Association of Surgeons and the Spanish Society of Bariatric Surgery. / Criterios de calidad en cirugía bariátrica: revisión de conjunto y recomendaciones de la Asociación Española de Cirujanos y de la Sociedad Española de Cirugía de la Obesidad.

Bariatric surgery has proven to be highly effective in controlling obesity and metabolic syndrome; the results of this surgery are not only expressed in terms of weight loss, but also in terms of resolution of comorbidities, improved quality of life and complications. The different parameters used to measure these outcomes require uniformity and reference patterns. Therefore, it is essential to identify those indicators and quality criteria that are helpful in defining the «best practice¼ principles in bariatric surgery. In this regard, the Section of Obesity of the Spanish Association of Surgeons, in collaboration with the Spanish Society for Bariatric Surgery (SECO), present as an objective to identify the key points that define «quality¼ in this type of surgery. We describe the main indicators based on the published literature as well as the criteria for referral of the main comorbidities according to the evidence found and grades of recommendation.

Integration of ecological-biological thresholds in conservation decision making.

In the Anthropocene, coupled human and natural systems dominate and only a few natural systems remain relatively unaffected by human influence. On the one hand, conservation criteria based on areas of minimal human impact are not relevant to much of the biosphere. On the other hand, conservation criteria based on economic factors are problematic with respect to their ability to arrive at operational indicators of well-being that can be applied in practice over multiple generations. Coupled human and natural systems are subject to economic development which, under current management structures, tends to affect natural systems and cross planetary boundaries. Hence, designing and applying conservation criteria applicable in real-world systems where human and natural systems need to interact and sustainably coexist is essential. By recognizing the criticality of satisfying basic needs as well as the great uncertainty over the needs and preferences of future generations, we sought to incorporate conservation criteria based on minimal human impact into economic evaluation. These criteria require the conservation of environmental conditions such that the opportunity for intergenerational welfare optimization is maintained. Toward this end, we propose the integration of ecological-biological thresholds into decision making and use as an example the planetary-boundaries approach. Both conservation scientists and economists must be involved in defining operational ecological-biological thresholds that can be incorporated into economic thinking and reflect the objectives of conservation, sustainability, and intergenerational welfare optimization.

Functional and motor gastrointestinal disorders. / Trastornos funcionales y motores digestivos.

This article discusses the most interesting presentations at Digestive Disease Week, held in San Diego, in the field of functional and motor gastrointestinal disorders. One of the most important contributions was undoubtedly the presentation of the new Rome IV diagnostic criteria for functional gastrointestinal disorders. We therefore devote some space in this article to explaining these new criteria in the most common functional disorders. In fact, there has already been discussion of data comparing Rome IV and Rome III criteria in the diagnosis of irritable bowel syndrome, confirming that the new criteria are somewhat more restrictive. From the physiopathological point of view, several studies have shown that the aggregation of physiopathological alterations increases symptom severity in distinct functional disorders. From the therapeutic point of view, more data were presented on the efficacy of acotiamide and its mechanisms of action in functional dyspepsia, the safety and efficacy of domperidone in patients with gastroparesis, and the efficacy of linaclotide both in irritable bowel syndrome and constipation. In irritable bowel syndrome, more data have come to light on the favourable results of a low FODMAP diet, with emphasis on its role in modifying the microbiota. Finally, long-term efficacy data were presented on the distinct treatment options in achalasia.

Description of series of 10 patients with hypnic headache: Discussion of the diagnostic criteria.

INTRODUCTION: Hypnic headache is a rare primary headache. The diagnostic criteria of the International Headache Classification (IHS) for this condition are discussed, as they have been modified in the new edition of the 2013. PATIENTS AND METHODS: The clinical characteristics, and fulfilment of the criteria of the IHS classification in a series of 10patients diagnosed in our Headaches Clinic, are analyzed. RESULTS: The mean age of onset of symptoms was 52.1years (SD: 13.4; range: 28-69). The pain was reported as oppressive in 60% of the patients, and as sharp in 30%. The headache was described as holocranial in 60% and hemicranial in 40%. They occurred exclusively during night-time sleep in 80% of the patients. The mean duration of headache was 136.5minutes (range: 10-480). The mean number of days per month was 16.4 (range: 3-30), and 50% had less than 15 headache days per month. No patient had autonomic manifestations, 70% had phonophobia, 50% had photophobia, and 50% had both. All of them (100%) had a VAS score equal to or higher than 8. CONCLUSIONS: The criteria for hypnic headache of the new classification are best suited to the characteristics of these patients. Our results show the major changes in the criteria: pain is not always dull, headache frequency may be less than 15days a month, and it can occur in people under age 50. There may be phonophobia or photophobia only, or both. Although it does not form part of the diagnostic criteria, the pain intensity in our series was higher than described.

Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient.

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues.

Klatskin tumor: Diagnosis, preoperative evaluation and surgical considerations.

Hiliar cholangiocarcinoma is the most common type of cholangiocarcinoma, an represent around 10% of all hepatobiliary tumors. It is an aggressive malignancy, resectable in around 47% of the patients at diagnosis. Complete resection is the most effective and only potentially curative therapy, with a survival rate of less than 12 months in unresectable cases. Axial computerized tomography and magnetic resonance are the most useful image techniques to determine the surgical resectability. Clinically, jaundice and pruritus are the most common symptoms at diagnosis;preoperative biliary drainage is recommended using endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography. Surgery using extended liver resections with an en bloc resection of the liver with vascular reconstruction is the technique with the highest survival. Complete resection with histologically negative resection margins (R0), nodal involvement and metastases are the most important prognostic factors.

Outcomes of liver transplant with donors over 70 years of age.

UNLABELLED: Organ shortage has forced transplant teams to progressively expand the acceptance of marginal donors. METHODS: We performed a comparative analysis of the post-transplant evolution depending on donor age (group I: less than 70 years old (n=474) vs. group II: 70 or more years old [n=105]) over a 10 year period (2002-2011). RESULTS: Donors over 70 years old were similar to donors less than 70 years old in terms of ICU stay, gender, weight, laboratory results, and use of vasoactive drugs. However, the younger donor group presented with cardiac arrest more often (GI: 14 vs. GII: 3%, P=.005). There were no differences in initial poor function (GI: 6% vs. GII: 7,7%; P=.71), ICU stay (GI: 2.7±2 vs. GII: 3.3±3.8, P=.46), hospital stay (GI: 13.5±10 vs. GII: 15.5±11, P=.1), or hospital mortality (GI: 5.3 vs. GII: 5.8%, P=.66) between receptors of more or less than 70 year old grafts. After a median follow up of 32 months, no differences were found in the incidence of biliary tract complications (GI: 17 vs. GII: 20%, P=.4) or vascular complications (GI: 11 vs. GII: 9%, P=.69). The actuarial 5 year survival was similar for both study groups (GI: 70 vs. GII: 76%, P=.54). CONCLUSIONS: In our experience, the use of grafts from donors older than 70 years, when other risk factors are avoided (cold ischemia, steatosis, sodium levels), does not worsen the results of liver transplantation on the short or long term.

Chronic idiopathic anal pain. Results of a diagnostic-therapeutic protocol in a colorectal referral unit.

INTRODUCTION: Chronic idiopathic anal pain (CIAP) remains a diagnosis of exclusion. Its study and management still lack a standardized protocol. The aim of this study is to evaluate the results obtained with the diagnostic-therapeutic protocol established in our service. MATERIAL AND METHODS: We performed a retrospective study of patients diagnosed with CIAP at the Colorectal Unit of the General University Hospital of Elche, between 2005 and 2011. RESULTS: We evaluated 57 patients with a diagnosis of chronic anal pain for functional anorectal disease (FAD). After the application of our diagnostic protocol, final diagnosis of chronic anal pain (CAP) was achieved in 43 cases (75%), including 22 cases of descending perineum syndrome, 12 of proctalgia fugax, 2 of pudendal neuritis and 7 of coccydynia. In 14 patients exclusion diagnosis of CIAP was established. Among the therapies used on patients with CIAP, biofeedback combined with conservative measures improved symptoms in 43% of the cases. Sacral nerve stimulation was assessed in patients who did not respond to other treatments. CONCLUSION: Through proper anamnesis, physical examination and complementary tests, a specific diagnosis of the cause of CAP by FAD can be achieved, reducing exclusion diagnosis of CIAP to 25% of cases. Conservative measures combined with biofeedback achieved an improvement in pain in more than 40% of the cases of CIAP in our study. Sacral nerve stimulation can be considered as a treatment option in refractory cases.

Understanding publication bias in reintroduction biology by assessing translocations of New Zealand's herpetofauna.

The intentional translocation of animals is an important tool for species conservation and ecosystem restoration, but reported success rates are low, particularly for threatened and endangered species. Publication bias further distorts success rates because the results of successful translocations may be more likely to be published than failed translocations. We conducted the first comprehensive review of all published and unpublished translocations of herpetofauna in New Zealand to assess publication bias. Of 74 translocations of 29 species in 25 years, 35 have been reported in the published literature, and the outcomes of 12 have been published. Using a traditional definition of success, publication bias resulted in a gross overestimate of translocation success rates (41.7% and 8.1% for published and all translocations, respectively), but bias against failed translocations was minimal (8.3% and 6.8%, respectively). Publication bias against translocations with uncertain outcomes, the vast majority of projects, was also strong (50.0% and 85.1% for published and all translocations, respectively). Recent translocations were less likely to be published than older translocations. The reasons behind translocations were related to publication. A greater percentage of translocations for conservation and research were published (63.3% and 40.0%, respectively) than translocations for mitigation during land development (10.0%). Translocations conducted in collaboration with a university were more frequently published (82.7% and 24.4%, respectively). To account for some of this publication bias, we reassessed the outcome of each translocation using a standardized definition of success, which takes into consideration the species' life history and the time since release. Our standardized definition of translocation success provided a more accurate summary of success rates and allows for a more rigorous evaluation of the causes of translocation success and failure in large-scale reviews.

[Hepatitis B infection transmission by anti-HBc-positive grafts]. / Transmisión de la infección B por injertos anti-HBc positivos.

In Spain, the rate of anti-HBc positive, HBsAg-negative carriers is approximately 10% of adults between the ages of 26 and 65 years. It is therefore impossible to exclude these donors without increasing the mortality of recipients on waiting lists. The incidence of de novo hepatitis B infection in HBsAg-negative recipients of anti-HBc-positive donors is high without prophylaxis and is related to the serological state of the recipient against HBV. Anti-HBc and anti-HBs-positive recipients have low risk, with or without prophylaxis. This patient group therefore does not require prophylaxis but rather periodic posttransplantation checkups. For the other recipient groups (naïve, anti-Hbc and anti-HBs isolates), prophylaxis with IgG HB, lamivudine or combined therapy decreases the incidence of infection. These patients should be treated with prophylaxis immediately after transplantation. Depending on the risk, cost and benefit, patients should currently be treated with lamivudine 100mg/d indefinitely or for longer periods (>10 years). Periodic checkups of HBsAg should be conducted, and if there is graft dysfunction then HBV DNA should be checked. IF HBV DNA is discovered in the donor and found to be positive in serum or in the biopsy, the prophylaxis should be an analogue with a high barrier to resistance from the start. Grafts from anti-HBc-positive donors are not considered at-risk grafts and are used according to donor severity, without being determined by the recipient's serological profile.

Behavioural variant frontotemporal dementia: clinical and therapeutic approaches.

INTRODUCTION: Behavioural variant frontotemporal dementia (bvFTD) is the most frequent presentation in the clinical spectrum of frontotemporal dementia (FTD) and it is characterised by progressive changes in personality and conduct. Major breakthroughs in molecular biology and genetics made during the last two decades have lent us a better understanding of this syndrome, which may be the first manifestation in many different neurodegenerative diseases. DEVELOPMENT: We reviewed the main epidemiological, clinical, diagnostic and therapeutic aspects of bvFTD. Most cases manifest sporadically and the average age of onset is 58 years. Current criteria for bvFTD propose three levels of diagnostic certainty: possible, probable, and definite. Clinical diagnosis is based on a detailed medical history provided by family members and caregivers, in conjunction with neuropsychological testing. Treatments which have been used in bvFDT to date are all symptomatic and their effectiveness is debatable. New drugs designed for specific molecular targets that are implicated in frontotemporal lobar degeneration are being developed. CONCLUSIONS: BvFDT is a frequent cause of dementia. It is a non-specific syndrome associated with heterogeneous histopathological and biomolecular findings. The definition of clinical subtypes complemented by biomarker identification may help predict the underlying pathology. This knowledge, along with the development of drugs designed for molecular targets, will offer new treatment possibilities.

[Symptoms. Localizations: knee, hip, hands, spine, other localizations]. / Clínica. Localizaciones: rodilla, cadera, manos, columna, otras localizaciones.

The symptoms of osteoarthritis vary widely from patient to patient, depending especially on the localization on the disease. There is a poor correlation between radiological involvement and pain. In general, symptom onset is gradual and symptoms increase slowly but progressively. The most commonly affected joints are the knees, hips, hands, and spine. The main signs and symptoms are pain, stiffness, joint deformity, and crepitus. Pain is mechanical and its causes are multifactorial; in the initial phases, pain usually manifests in self-limiting episodes but may subsequently be almost constant. The criteria of the American college of Rheumatology for the classification of osteoarthritis of the knee, hip and hands are an aid to classification and standardization but are not useful for diagnosis. Hip osteoarthritis usually produces inguinal pain in the internal and anterior sections of the muscle extending to the knee and, with progression, tends to limit mobility. Knee osteoarthritis is more frequent in women and is usually associated with hand osteoarthritis and obesity. In hand osteoarthritis, the most commonly affected joints are the distal interphalangeal joints, followed by the proximal interphalangeal joints and the trapeziometacarpal joints; the development of Heberden and Bouchard nodes is common; involvement of the trapeziometacarpal joint is called rhizarthrosis and is one of the forms of osteoarthritis that produces the greatest limitation on hand function. Osteoarthritis of the spine affects the facet joints and the vertebral bodies. Other, less frequent, localizations are the foot, elbow and shoulder, which are generally secondary forms of osteoarthritis.

Spanish adaptation of the European guidelines for the evaluation and treatment of actinic keratosis.

Current trends in our setting indicate that the prevalence of actinic keratosis and similar diseases will increase in coming years and impose a greater burden on health care resources. A long list of clinical features must be taken into account when approaching the treatment of actinic keratosis. Until recently, therapeutic approaches focused solely on ablative procedures and the treatment of individual lesions and did not take into account areas of field cancerization. Now that the therapeutic arsenal has grown, standardized criteria are needed to guide the optimal choice of treatment for each patient. The elaboration of evidence-based consensus recommendations for the diagnosis and treatment of actinic keratosis generates knowledge that will help clinicians to deliver the highest level of care possible, standardizing decision-making processes and enhancing awareness among all the health professionals involved in the care pathway.