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Purpose: To evaluate the efficacy of anti-suppression exercises in children with small-angle esotropia in achieving binocular vision. Methods: A retrospective review of patients aged 3–8 years who underwent anti-suppression exercises for either monocular or alternate suppression between January 2016 and December 2021 was conducted. Patients with esotropia less than 15 prism diopters (PD) and visual acuity ≥ 6/12 were included. Patients with previous intra-ocular surgery or less than three-month follow-up were excluded. Success was defined as the development of binocular single vision (BSV) for distance, near, or both (measured clinically with either the 4 prism base out test or Worth four dot test) and maintained at two consecutive visits. Qualified success was defined as the presence of diplopia response for both distance and near. Additionally, improvement in near stereo acuity was measured using the Stereo Fly test. Results: Eighteen patients with a mean age of 5.4 ± 1.38 years (range 3–8 years) at the time of initiation of exercises were included in the study. The male female ratio was 10:8. The mean best corrected visual acuity was 0.18 LogMAR unit(s) and the mean spherical equivalent was +3.8 ± 0.14 diopters (D). The etiology of the esotropia was fully accommodative refractive esotropia (8), microtropia (1), post–operative infantile esotropia (4), partially accommodative esotropia (1), and post-operative partially accommodative esotropia (4). Patients received either office-based, home-based, or both modes of treatment for an average duration of 4.8 months (range 3–8). After therapy, BSV was achieved for either distance or near in 66.6 % of patients (95 % CI = 40.03–93.31 %). Binocular single vision for both distance and near was seen in 50 % of children. Qualified success was observed in 38.46% of patients. Persistence of suppression was observed in one patient (5.5 %)... (AU)

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Breast Cancer (BC) is one of the most common cancers diagnosed in population femmale and it has several subtypes, one of them being theexpressing human epidermal growth factor receptor 2 positive (HER2 +), one of the treatments for HER2+ breast cancer consists of chemotherapy plus trastuzumab deruxtecan. Several clinical trials have shown the effectiveness and safety of trastuzumabe deruxtecano in cancer patients, however, several Adverse Events (AEs) have been described and the decrease in left ventricular ejection has been singled out for more prominent analysis. Objective: We conducted a systematic review and meta-analysis to investigate the cardiovascular effects of Trastuzumab Deruxtecano and whether it can influence the appearance of reduced left ventricular ejection fraction.. METHODS: We performed a systematic search in Embase, PubMed and Cochrane databases for randomized controlled trials (RCTs) showed a decrease in left ventricular ejection fraction in patients using trastuzumab deruxtecan against Her-2-positive breast cancer compared to patients to used another's treatments against this disease. Mean difference (MD) with 95% confidence intervals (CI) were calculated using a random effects model. The heterogeneity was examined in the I2 statistic. P-values > 0.05 were considered statistically significant. The statistical analysis was carried out using R software version 4.2.3. RESULTS: A total of 3 RCTs were included, with a total of 1656 patients evaluated, 928 patients randomized to the use of Trastuzumab Deruxtecan and 728 patients to the use of other treatments according to medical choice, follow-up ranged from 10 to 38 months. There was a visible in the decrease in left ventricular ejection fraction, with a higher incidence in the group that used trastuzumab compared to the placebo group (RR: 5.73%; 95% CI 1.51 - 21.78; I2 33% ; P= 0.010466). Another important point is the discontinuation of treatment due to grade 2 adverse events, classified as reduced LVEF, where a higher incidence is seen in the group that used Trastuzumab Deruxtecan compared to the placebo group (RR 2.11%; 95% CI 1.54 - 2.89; P = 0.000003),7. CONCLUSION: In this meta-analysis, Trastuzumab Deruxtecan showed a relationship with a decrease in left ventricular ejection fraction, displaying the need for more studies to evaluate the cardiotoxicity of trastuzumab and its effects as a whole on the cardiovascular system.

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O tratamento endodôntico envolve procedimentos como abertura coronária, modelagem, limpeza, desinfecção e selamento tridimensional. Apesar de apresentar um índice de insucesso de cerca de 4%, retratamentos podem ser realizados por cirurgiões-dentistas habilitados. Quando o retratamento não é indicado, a cirurgia parendodôntica, que inclui curetagem, apicectomia e retro obturação do sistema de canais, surge como uma alternativa eficaz para manter o dente em função e estética na cavidade bucal, antes de considerar a extração. O presente trabalho busca revisar a literatura respeito da cirurgia parendodôntica. Os trabalhos foram selecionados nas plataformas Scielo, PubMed, Google Acadêmico e BVS, publicados nos últimos 5 anos em português e inglês. Pôde-se concluir que a cirurgia parendodôntica é uma alternativa efetiva em casos de insucesso do tratamento endodôntico, devendo ser considerada e indicada de maneira apropriada.

Endodontic treatment, commonly performed in dentistry, involves procedures such as coronal opening, modeling, cleaning, disinfection, and three-dimensional sealing. Despite having a failure rate of around 4%, portraits can be carried out by qualified dental surgeons. When retreatment is not indicated, endodontic surgery, including curettage, apicoectomy and retrofilling of the canal system, appears as an effective alternative to maintain dental function and oral aesthetics in the mouth, before considering extraction. The present work seeks to review the literature regarding paraendodontic surgery. The works were selected on the Scielo, PubMed, Google Scholar and VHL platforms, published in the last 5 years in Portuguese and English. It was concluded that endodontic surgery is an effective alternative in cases of unsuccessful endodontic treatment and should be considered and indicated appropriately.

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BACKGROUND: The association between atrial fibrillation (AF) and mental health is well-documented, but the relative benefits of catheter ablation versus medical therapy on mental health and quality of life are not clearly understood. This study assesses the impact of these interventions on AF patients' mental health and quality of life. METHODS: Through a systematic review of PubMed, Scopus, and Cochrane databases, randomized controlled trials (RCTs) comparing catheter ablation to medical therapy for AF were analyzed. The study focused on a range of outcomes, particularly mental health and quality of life, measured by tools including the SF-36 mental component, HADS, SF-36 physical component, and AFEQT scores, among others. Analyses were stratified by AF type (paroxysmal versus persistent) and synthesized using random or fixed-effects models to calculate mean differences (MDs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs). RESULTS: From 24 RCTs totaling 6,353 patients (51.4% receiving catheter ablation, 71.1% male, average age 59), catheter ablation was found to significantly improve mental health (SMD 0.34; 95% CI 0.05-0.63; p = 0.02) and quality of life as indicated by PCS SF-36 (MD 2.64; 95% CI 1.06-4.26; p < 0.01) and AFEQT scores (MD 6.24; 95% CI 4.43-8.05; p < 0.01), with no significant difference in outcomes between AF subtypes. CONCLUSION: Catheter ablation offers significant improvements in mental health and quality of life over medical therapy for AF patients, demonstrating its efficacy across different types of AF.

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La utilización de la terapia de ultrasonidos pulsados de baja intensidad para la cicatrización ósea y el tratamiento de fracturas es considerada cada vez más como una alternativa terapéutica de coste económico moderado y con efectos adversos nulos o mínimos (p. ej. leve reacción al gel conductor).Con todo, existe cierta controversia con relación a su evidencia científica. La presente revisión busca arrojar algo de luz sobre esta controversia y cubrir un espacio de estudio no ocupado por trabajos previos ni actuales sobre la terapia mediante ultrasonidos. Es necesario conocer el impacto real del tratamiento con ultrasonidos pulsados de baja intensidad en pacientes sometidos a osteotomía, así como su aplicabilidad como protocolo poscirugía para mejorar los procesos de recuperación, rehabilitación y, con ello, disminuir los tiempos de incapacidad. (AU)

The use of low intensity pulsed ultrasound (LIPUS) therapy for bone healing and fracture treatment is increasingly considered as a therapeutic alternative with moderate economic cost and none or minimal adverse effects (e.g., low reaction to the conductive gel).However, there is some controversy regarding its scientific evidence. The present review seeks to shed some light on this controversy and to cover an area of study not occupied by previous or current work on ultrasound therapy. It is necessary to know the real impact of the treatment with low intensity pulsed ultrasound in patients with osteotomy, as well as its applicability as a post-surgery protocol to improve the recovery and rehabilitation processes and, at the end of the day, to reduce the time of disability. (AU)

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Contextualização: A suplementação de zinco tem sido recomendada para o tratamento e a prevenção de muitas doenças, mas já foi demonstrado que os achados in vitro não são os mesmos evidenciados na clínica, havendo carência de evidências científicas em humanos, relativa ao real benefício dessa suplementação para o organismo humano. Objetivos: Sumarizar as evidências de revisões sistemáticas da Cochrane, referentes à efetividade da suplementação de zinco para tratamento e prevenção de doenças. Métodos: Trata-se de overview de revisões sistemáticas Cochrane. Procedeu-se à busca na Cochrane Library (2024), sendo utilizado o descritor "ZINC". Todas as revisões sistemáticas de ensaios clínicos foram incluídas. O desfecho primário de análise foi a melhora clínica, a redução dos sintomas ou a prevenção da doença. Resultados: Quatorze estudos foram incluídos, totalizando 221 ensaios clínicos e 265.113 participantes. Discussão: há evidência de benefício do zinco na anemia falciforme (redução de crises e infecções); na prevenção de diarreia aguda ou persistente em regiões com taxas elevadas de desnutrição; na prevenção da diarreia e melhora no crescimento de crianças de 6 meses a 12 anos de idade; na redução da mortalidade e no ganho de peso a curto prazo em prematuros; e na redução da incidência e prevalência de pneumonia em crianças de 2 a 59 meses de idade. É necessário cautela, pois não há robustez dos resultados e o nível de evidência é limitado. Conclusão: Há evidência de efetividade do zinco em algumas intervenções, mas a evidência é limitada, sugerindo-se a realização de novos estudos prospectivos de qualidade.

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Objetiv Describir los resultados obtenidos en UCI españolas en el estudio ETHICUS II. Diseño Subestudio planificado de pacientes del ETHICUS II. Ámbito 12 UCI españolas. Pacientes o participantes Pacientes que fallecieron o en los que se decidió una limitación de tratamiento de soporte vital (LTSV) durante un periodo de reclutamiento de 6 meses. Intervenciones Se realizó seguimiento hasta el alta de la UCI y 2 meses tras la decisión de LTSV o fallecimiento. Variables de interés principales Características demográficas, clínicas, tipo de decisión de LTSV. Se clasificaron en 4 categorías: omisión o retirada de tratamientos de soporte, acortar el proceso de morir, resucitación cardiopulmonar ineficaz y muerte cerebral. Resultados Un total de 12 UCI participaron en el ETHICUS II. Incluyeron 795 pacientes; 129 fallecieron tras realizarse RCP, 129 desarrollaron muerte encefálica. Se decidió LTSV en 537, fallecieron en UCI 485, el 90,3%. La edad media fue 66,19 años±14,36, el 63,8% fueron hombres. En un 41% se decidió retirada de tratamientos de soporte total y en un 59% se procedió a no iniciar medidas. Diecinueve pacientes (2,38%) disponían de documento de voluntades vitales anticipadas. Conclusiones El perfil clínico predominante cuando se estableció una LTSV fue el de pacientes varones mayores de 65 años con comorbilidad mayoritariamente cardiovascular. La supervivencia fue mayor en las decisiones de LTSV que comprendían la omisión de tratamientos respecto a aquellas en las que se decidió la retirada. España ha ocupado un papel destacado en este estudio multicéntrico de ámbito mundial. (AU)

Objective The aim of this study is to describe the results of Spanish ICUs in ETHICUS II study. Design Planned substudy of patients from ETHICUS II study. Setting 12 Spanish ICU. Patients or participants Patients admitted to Spanish ICU who died or in whom a limitation of life-sustaining treatment (LLST) was decided during a recruitment period of 6 months. Interventions Follow-up of patients was performed until discharge from the ICU and 2 months after the decision of LLST or death. Main variables of interest Demographic characteristics, clinical profile, type of decision of LLST, time and form in which it was adopted. Patients were classified into 4 categories according to the ETHICUS II study protocol: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, failed cardiopulmonary resuscitation and patients with brain death. Results A total of 795 patients were analyzed; 129 patients died after CPR, 129 developed brain death. LLST was decided in 537 patients, 485 died in the ICU, 90.3%. The mean age was 66.19 years±14.36, 63.8% of male patients. In 221 (41%) it was decided to withdraw life-sustaining treatments and in 316(59%) withholding life-sustaining treatments. Nineteen patients (2.38%) had advance living directives. Conclusions The predominant clinical profile when LTSV was established was male patients over 65 years with mostly cardiovascular comorbidity. We observed that survival was higher in LLST decisions involving withholding of treatments compared to those in which withdrawal was decided. Spain has played a leading role in both patient and ICU recruitment participating in this worldwide multicenter study. (AU)

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Aging is a complex and multifaceted process involving a variety of interrelated molecular mechanisms and cellular systems. Phenotypically, the biological aging process is accompanied by a gradual loss of cellular function and the systemic deterioration of multiple tissues, resulting in susceptibility to aging-related diseases. Emerging evidence suggests that aging is closely associated with telomere attrition, DNA damage, mitochondrial dysfunction, loss of nicotinamide adenine dinucleotide levels, impaired macro-autophagy, stem cell exhaustion, inflammation, loss of protein balance, deregulated nutrient sensing, altered intercellular communication, and dysbiosis. These age-related changes may be alleviated by intervention strategies, such as calorie restriction, improved sleep quality, enhanced physical activity, and targeted longevity genes. In this review, we summarise the key historical progress in the exploration of important causes of aging and anti-aging strategies in recent decades, which provides a basis for further understanding of the reversibility of aging phenotypes, the application prospect of synthetic biotechnology in anti-aging therapy is also prospected.

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Objetivo: Avaliar as principais evidências científicas acerca da eficácia da ozonioterapia em feridas diabéticas. Métodos: Foi utilizado o modelo de revisão integrativa da literatura. A coleta de dados aconteceu no mês de maio de 2021, obtendo as bases de dados: Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Medical Literature Analysis and Retrievel System Online (Medline) e Índice Bibliográfico Español en Ciencias de la Salud (IBECS), ambos acessados pela Biblioteca Virtual em Saúde (BVS), onde foram selecionados nove artigos após o processo de filtragens, critérios de inclusão e exclusão. Resultados: A ozonioterapia apresenta propriedades analgésicas, antiinflamatórias, ação fungicida, bactericida e cicatrizante. Ressalta-se, ainda, os efeitos benéficos com uso do ôzonio e suas ferramentas terapéuticas eficientes para reversão do quadro agudo e/ou crônico das lesões de pele. Conclusão: Espera-se que esta pesquisa possa contribuir para uma reflexão sobre o uso da ozonioterapia em diabéticos, pois esta técnica constatou ser segura e eficaz. (AU)

Objective: To evaluate the main scientific evidence about the effectiveness of ozone therapy in diabetic wounds. Methods: The integrative literature review model was used. Data collection took place in May 2021, obtaining the following databases: Latin American and Caribbean Literature on Health Sciences (LILACS), Medical Literature Analysis and Retrievel System Online (Medline) and Bibliographic Index Español en Ciencias de la Salud (IBECS), both accessed by the Virtual Health Library (VHL), where nine articles were selected after the filtering process, inclusion and exclusion criteria. Results: Ozone therapy has analgesic, anti-inflammatory, fungicidal, bactericidal and healing properties. The beneficial effects of using ozone and its efficient therapeutic tools for reversing the acute and/or chronic condition of skin lesions should also be highlighted. Conclusions: It is hoped that this research can contribute to a reflection on the use of ozone therapy in diabetics, as this technique was found to be safe and effective. (AU)

Objetivo: Evaluar las principales evidencias científicas sobre la efectividad de la ozonoterapia en heridas diabéticas. Métodos: Se utilizó el modelo de revisión integradora de la literatura. La recolección de datos se realizó en mayo de 2021, obteniendo las siguientes bases de datos: Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS), Sistema de Análisis y Recuperación de Literatura Médica en Línea (Medline) e Índice Bibliográfico Español en Ciencias de la Salud (IBECS), ambos accedidos por la Biblioteca Virtual en Salud (BVS), donde se seleccionaron nueve artículos tras el proceso de filtrado, criterios de inclusión y exclusión. Resultados: La ozonoterapia tiene propiedades analgésicas, antiinflamatorias, fungicidas, bactericidas y cicatrizantes. También deben destacarse los efectos beneficiosos del uso de ozono y sus eficaces herramientas terapéuticas para revertir la condición aguda y / o crónica de las lesiones cutáneas. Conclusiones: Se espera que esta investigación pueda contribuir a una reflexión sobre el uso de la ozonoterapia en diabéticos, ya que esta técnica resultó segura y eficaz. (AU)

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Objetivo: Mejorar el conocimiento acerca de la práctica clínica habitual en el tratamiento del dolor agudo pediátrico en España.MétodosSe llevó a cabo una encuesta telemática a través de Internet en una muestra representativa de profesionales sanitarios involucrados en el tratamiento del dolor agudo pediátrico (concretamente anestesiólogos) en España. La encuesta incluyó 28 cuestiones acerca de su práctica clínica habitual en la valoración y el tratamiento del dolor agudo, así como aspectos formativos y organizativos en el dolor agudo pediátrico.ResultadosLa encuesta fue completada durante el mes de marzo de 2021 por 150 especialistas en anestesiología. Los encuestados presentaron una amplia experiencia en el tratamiento del dolor agudo pediátrico (media de años de experiencia: 14,3; DE: 7,8) y básicamente en dolor agudo postoperatorio (97% casos). Aunque el 80% de los mismos utilizaba de modo habitual escalas validadas de valoración de dolor agudo pediátrico, solo el 2,6% utilizaba las específicas adaptadas para pacientes con discapacidad cognitiva. La mayoría de los encuestados empleaba habitualmente fármacos analgésicos como el paracetamol (99%) o el metamizol (92%), pero solo el 84% los complementaba con alguna técnica de bloqueo loco-regional u otra medicación tipo antiinflamatorio no esteroideo (62%). Además, únicamente un 62,7% reconocía haber recibido formación específica en dolor agudo pediátrico, solo un 45% seguía protocolos institucionales hospitalarios y un escaso 28% lo hacía a través de unidades de dolor infantil.ConclusionesLa encuesta identificó importantes puntos de mejora en la formación y organización del tratamiento del dolor agudo de los pacientes españoles en edad pediátrica. (AU)

Objective: To improve knowledge about routine clinical practice in the management of paediatric acute pain in Spain.MethodsA telematic survey was conducted via the Internet on a representative sample of healthcare professionals involved in the management of paediatric acute pain (specifically anaesthesiologists) in Spain. The survey included 28 questions about their usual clinical practice in the assessment and treatment of acute pain, and also training and organisational aspects in paediatric acute pain.ResultsThe survey was completed during March 2021 by 150 specialists in anaesthesiology. The respondents widely experienced in the management of acute paediatric pain (mean years of experience: 14.3: SD: 7.8), essentially in acute postoperative pain (97% of cases). Although 80% routinely used validated paediatric acute pain assessment scales, only 2.6% used specific scales adapted for patients with cognitive impairment. Most of the respondents routinely used analgesic drugs such as paracetamol (99%) or metamizole (92%), but only 84% complemented these drugs with a loco-regional blocking technique or other non-steroidal anti-inflammatory drugs (62%). Furthermore, only 62.7% acknowledged having received specific training in paediatric acute pain, only 45% followed hospital institutional protocols, and a scant 28% did so through paediatric pain units.ConclusionsThe survey identified important points for improvement in the training and organisation of acute pain management in Spanish paediatric patients. (AU)

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La depresión postsíndrome coronario agudo (post-SCA) aumenta el riesgo cardíaco; sin embargo, la eficacia de las terapias antidepresivas para su tratamiento no está suficientemente demostrada. Nuestro objetivo es metaanalizar ensayos controlados con muestras homogéneas que permitan explicar la inconsistencia de los resultados obtenidos hasta el momento. Tras revisar 1525 artículos, dos revisores independientes identificaron 7 estudios que cumplían criterios muy restrictivos para asegurar la homogeneidad de las muestras. Los resultados indicaron que los pacientes tratados con intervenciones de eficacia demostrada para la depresión reducen sus niveles de trastorno depresivo significativamente más que los sujetos sin este tratamiento, y que existen diferencias significativas en el número de pacientes que reducen los síntomas depresivos de forma clínicamente relevante. Además, se observaron menos eventos cardiovasculares adversos durante el tratamiento, aunque esta diferencia fue mínimamente significativa y no se mantuvo tras el seguimiento. Estos resultados sugieren que la inconsistencia de los datos actualmente disponibles podría deberse a dificultades metodológicas que evidencian la necesidad de nuevas investigaciones que aclaren el efecto del tratamiento de la depresión sobre el pronóstico post-SCA.(AU)

Depression post-acute coronary syndrome (ACS) increases the cardiac risk;however, the efficacy of antidepressant therapies for its treatment has not beensufficiently demonstrated. Our aim is to meta-analyze controlled trials withhomogeneous samples that allow us to explain the inconsistency of the resultsobtained so far. After reviewing 1525 articles, two independent reviewersidentified 7 studies that met very restrictive criteria to ensure homogeneity of thesamples. The results indicated that patients treated with interventions of provenefficacy for the depression, reduce their levels of depressive disorder significantlymore than subjects without this treatment and that there are significantdifferences in the number of patients who reduce depressive symptoms in clinically relevant way. In addition, fewer adverse cardiovascular events wereobserved during treatment, although this difference was minimally significant andwas not maintained after the follow-up. These results suggest that theinconsistency of the currently available data could be due to methodologicaldifficulties evidencing the need for further research to clarify the effect ofdepression treatment on post-ACS prognosis.K EY WORDS : coronary heart disease, acute coronary syndrome, depressiontreatment, meta-analysis.(AU)

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La trombosis venosa cerebral forma parte de las llamadas trombosis en sitios inusuales. Se define como una oclusión en el territorio venoso cerebral. Su incidencia se encuentra en aumento progresivo, especialmente en países en vías de desarrollo. Se observa con más frecuencia en mujeres jóvenes, siendo los factores hormonales, como el embarazo o la anticoncepción hormonal, factores de riesgo principales en el desarrollo de esta afección. La clínica va a depender fundamentalmente de la topografía de la trombosis, con un diagnóstico de confirmación basado principalmente en las pruebas de imagen. El tratamiento consiste generalmente en la anticoagulación, pudiendo plantearse otras opciones según la gravedad del cuadro. En general, el pronóstico es mejor que el de otros trastornos vasculares intracraneales. En esta revisión se describe la evidencia actual disponible acerca de la trombosis venosa cerebral.(AU)

Cerebral venous thrombosis is part of the so-called thrombosis in unusual sites. It is defined as an occlusion in the cerebral venous territory. Its incidence is progressively increasing, especially in developing countries. It is more frequently observed in young women, with hormonal factors such as pregnancy or hormonal contraception being significant risk factors in the development of this condition. The clinical presentation will depend fundamentally on the topography of the thrombosis, with a confirmatory diagnosis based mainly on imaging tests. The treatment generally consists of anticoagulation, and other options may be considered depending on the severity of the case. Overall, the prognosis is better than that of other intracranial vascular disorders. This review describes the current evidence available regarding cerebral venous thrombosis.(AU)

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Objetivo: Elaborar recomendaciones multidisciplinares, basadas en la evidencia disponible y el consenso de expertos, para el manejo terapéutico de los pacientes con síndrome de Behçet refractario (difícil de tratar, resistente grave, recidivante grave) al tratamiento convencional. Métodos: Un panel de expertos identificó preguntas clínicas de investigación relevantes para el objetivo del documento. Estas preguntas fueron reformuladas en formato PICO –paciente, intervención, comparación, outcome o desenlace–. A continuación, se realizaron revisiones sistemáticas; la evaluación de la calidad de la evidencia se realizó siguiendo la metodología del grupo internacional de trabajo Grading of Recommendations, Assessment, Development, and Evaluation. Tras esto, el panel multidisciplinar formuló las recomendaciones. Resultados: Se seleccionaron 4 preguntas PICO relativas a la eficacia y seguridad de los tratamientos farmacológicos sistémicos en los pacientes con síndrome de Behçet con manifestaciones clínicas refractarias a terapia convencional, relacionadas con los fenotipos mucocutáneo y/o articular, vascular, neurológico-parenquimatoso y gastrointestinal. Se formularon un total de 7 recomendaciones estructuradas por pregunta, con base en la evidencia encontrada y el consenso de expertos. Conclusiones: El tratamiento de las manifestaciones clínicas más graves del síndrome de Behçet carece de evidencia científica sólida y no existen documentos de recomendaciones específicas para los pacientes con enfermedad refractaria a la terapia convencional. Con el fin de aportar una respuesta a esta necesidad, se presenta el primer documento de recomendaciones de la Sociedad Española de Reumatología específicas para el abordaje terapéutico de estos pacientes, que servirá de ayuda en la toma de decisiones clínica y la reducción de la variabilidad en la atención.(AU)

Objective: To develop multidisciplinary recommendations based on available evidence and expert consensus for the therapeutic management of patients with refractory Behçet's syndrome (difficult to treat, severe resistant, severe relapse) to conventional treatment. Methods: A group of experts identified clinical research questions relevant to the objective of the document. These questions were reformulated in PICO format –patient, intervention, comparison and outcome–. Systematic reviews of the evidence were conducted; the quality of the evidence was evaluated following the methodology of the international working group Grading of Recommendations, Assessment, Development, and Evaluation. After that, the multidisciplinary panel formulated the specific recommendations. Results: Four PICO questions were selected regarding the efficacy and safety of systemic pharmacological treatments in patients with Behçet's syndrome with clinical manifestations refractory to conventional therapy related to mucocutaneous and/or articular, vascular, neurological parenchymal and gastrointestinal phenotypes. A total of 7 recommendations were made, structured by question, based on the identified evidence and expert consensus. Conclusions: The treatment of most severe clinical manifestations of Behçet's syndrome lacks solid scientific evidence and, besides, there are no specific recommendation documents for patients with refractory disease. With the aim of providing a response to this need, here we present the first official recommendations of the Spanish Society of Rheumatology for the management of these patients. They are devised as a tool for assistance in clinical decision making, therapeutic homogenisation and to reduce variability in the care of these patients.(AU)

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