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L’ensenyament de les matemàtiques implica l’adquisició d’habilitats de planificació matemàtica i la capacitat d’identificar les matemàtiques en els contexts. En aquest sentit, l’Aprenentatge Basat en Projectes és una oportunitat perquè les matemàtiques recuperinaquest paper de motor. En aquest article es descriuen quatre propostes didàctiques al voltant de diverses temàtiques (superfícies i volums, construcció de formes geomètriques, Teorema de Thales, Estadística, Diagrames de Voronoi) en connexió amb diversos contextos del món real que fan rellevant el procés d’aprenentatge de les matemàtiques (disseny d’envasos, distribució de serveis municipals, efectes cinematogràfics, creació de formes artístiques). Es discuteix l’aportació d’aquest tipus d’activitats i es proporcionen orientacions per al seu desenvolupament., Mathematics learning implies the development of planning skills and the ability to identify mathematics in Contexts. Project-Based Learning is an opportunity to give to Mathematics this role as a driving force. In this article, we propose four Project-Based Learning activities in several Mathematic topics (Surfaces and volumes, construction of geometric shapes, Thales theorem, Statistics, Voronoi diagrams) in connection with real-world contexts (packaging design, distribution of municipal services, cinema effects, creation of artisticobjects). We discuss the didactic properties of this kind of activities and propose orientations for its development and application.

(1) Background: Although a meta-analysis reported that the sensitivity of CD3+ TCRγδ+ cells for coeliac disease diagnosis was &gt, 93%, a recent study has suggested that sensitivity decreased to 65% in elderly patients. (2) Aim: To evaluate whether the sensitivity of intraepithelial lymphocyte cytometric patterns for coeliac disease diagnosis changes with advanced age. (3) Methods: We performed a multicentre study including 127 coeliac disease patients ≥ 50 years: 87 with baseline cytometry (45 aged 50–59 years, 23 aged 60–69 years, 19 aged ≥ 70 years), 16 also with a follow-up cytometry (on a gluten-free diet), and 40 with only follow-up cytometry. (4) Results: In Marsh 3 patients, a sensitivity of 94.7%, 88.9% and 86.7% was observed for each age group using a cut-off value of TCRγδ+ &gt, 10% (p = 0.27), and a sensitivity of 84.2%, 83.4% and 53.3% for a cut-off value &gt, 14% (p = 0.02, 50–69 vs. ≥70 years), with difference between applying a cut-off of 10% or 14% (p = 0.008). The TCRγδ+ count in the ≥70 years group was lower than in the other groups (p = 0.014). (5) Conclusion: In coeliac patients ≥ 70 years, the TCRγδ+ count decreases and the cut-off point of &gt, 10% is more accurate than &gt, 14%.

In recent years there have been advances in the management of non-variceal upper gastrointestinal bleeding that have helped reduce rebleeding and mortality. This document positioning of the Catalan Society of Digestologia is an update of evidence-based recommendations on management of gastrointestinal bleeding peptic ulcer.

In recent years there have been advances in the management of non-variceal upper gastrointestinal bleeding that have helped reduce rebleeding and mortality. This document positioning of the Catalan Society of Digestologia is an update of evidence-based recommendations on management of gastrointestinal bleeding peptic ulcer.

Background: Guidelines recommend using prognostic scales for risk stratification in patients with non-variceal upper gastrointestinal bleeding. It remains unclear whether risk scores offer greater accuracy than clinical evaluation. Objective: Compare the diagnostic accuracy of the endoscopist&rsquo, s judgment against different risk-scoring systems (Rockall, Glasgow&ndash, Blatchford, Baylor and the Cedars&ndash, Sinai scores) for predicting outcomes in peptic ulcer bleeding (PUB). Methods: Between February 2006 and April 2010 we prospectively recruited 401 patients with peptic ulcer bleeding, 225 received endoscopic treatment. The endoscopist recorded his/her subjective assessment (&ldquo, endoscopist judgment&rdquo, ) of the risk of rebleeding and death immediately after endoscopy for each patient. Independent evaluators calculated the different scores. Area under the receiver-operating-characteristics (ROC) curve, sensitivity, specificity, positive and negative predictive values were calculated for rebleeding and mortality. Results: The areas under ROC curve of the endoscopist&rsquo, s clinical judgment for rebleeding (0.67&ndash, 0.75) and mortality (0.84&ndash, 0.9) were similar or even superior to the different risk scores in both the whole group and in patients receiving endoscopic therapy. Conclusions: The accuracy of the currently available risk scores for predicting rebleeding and mortality in PUB patients was moderate and not superior to the endoscopist&rsquo, s judgment. More precise prognostic scales are needed.

Resumen Introduccion Se desconoce la incidencia de anemia ferropenica (AF) tras un episodio de hemorragia digestiva no asociada a hipertension portal (HDA). Objetivos El objetivo principal fue estudiar la incidencia de AF tras una HDA, y los secundarios describir los factores predictivos de AF y elaborar modelos que permitan detectar aquellos pacientes que se beneficiarian de ferroterapia. Material y metodo Desde abril de 2007 hasta mayo de 2009 se valoraron de forma prospectiva 391 pacientes con HDA. Se excluyeron todas las hemorragias secundarias a hipertension portal y pacientes con condiciones clinicas y/o biologicas que pudieran artefactuar el patron ferrocinetico. Se practico una analitica con parametros ferricos al ingreso, al 5.° y al 30.° dia de la HDA. Se utilizo un modelo de regresion logistica multiple y un modelo de arboles de decision. Resultados De los 124 pacientes incluidos 76 (61,3%) presentaron AF a los 30 dias de la HDA. Las variables predictoras de AF: edad > 75 anos (p = 0,037; OR 3,9; IC 95%: 1,3-11,6), urea inicial > 80 mg/dl (p = 0,027; OR 2,9; IC 95%: 1,1-7,6), ferritina inicial ≤ 65 ng/dl (p = 0,002; OR 7,6; IC 95%: 2,9-18,5), Hb inicial ≤ 100 g/l (p = 0,003; OR 3,2; IC 95%: 1,3-8,0), Hb al 5.° dia ≤ 100 g/l (p Conclusiones La mayoria de pacientes con HDA presentan AF a los 30 dias del episodio hemorragico. La identificacion de los factores predictivos de la misma permite establecer una indicacion de ferroterapia tras la HDA.

SummaryLow-grade chronic inflammation plays a pathogenic role in cardiovascular disease. An increase in the ratio of circulating neutrophils to lymphocytes (N/L ratio) may serve as a marker of cardiovascular risk in adults. It was the study objective to study whether N/L ratio associates with vascular parameters in children. Subjects were 501 prepubertal and early pubertal Caucasian children (mean age 8.0 years; mean body mass index (BMI) Z-score 0.2 ± 0.9; 266 boys and 235 girls) recruited within an ongoing population-based study. The subjects were stratified into three groups according to age. Neutrophil, lymphocyte, BMI, waist circumference, systolic blood pressure (SBP) and carotid intima-media thickness (cIMT), assessed in all children. The N/L ratio, derived from the absolute neutrophil and lymphocyte counts. In children aged < 7 years (n=190, all prepubertal), no associations were observed between N/L ratio and either anthropometric or cardiovascular parameters. In children aged 7–9 years (n=171, 1.7 % early pubertal), higher N/L ratio associated with higher BMI Z-score and waist circumference (p=0.008 to p< 0.0001). In children aged > 9 years (n=140, 29.2 % early pubertal), N/L ratio associated again with BMI Z-score and waist circumference and also positively with SBP and cIMT (all p=0.008 to p< 0.0001). These associations remained significant in linear regression models following adjustment for possible confounding variables such as age, gender, fasting triglycerides, C-reactive protein and puberty (and for SBP and cIMT, adjustment also for BMI). In conclusion, our results provide the first evidence that a higher N/L ratio is associated with a less favourable cardiovascular profile in children and delineate the development of these associations from late childhood onwards.

The presence of cirrhosis increases the mortality of patients with peptic ulcer bleeding (PUB). Both acute variceal bleeding (AVB) and PUB are associated with substantial mortality in cirrhosis. This multicenter cohort study was performed to assess whether the mortality of patients with cirrhosis with PUB is different from that of those with AVB. Patients with cirrhosis and acute gastrointestinal bleeding were consecutively included and treated with somatostatin and proton pump inhibitor infusion from admission and with antibiotic prophylaxis. Emergency endoscopy with endoscopic therapy was performed within the first 6 hours. 646 patients with AVB and 144 with PUB were included. There were baseline differences between groups, such as use of gastroerosive drugs or β-blockers. Child-Pugh and Model for End-Stage Liver Disease MELD scores were similar. Further bleeding was more frequent in the AVB group than those in the PUB group (18% vs. 10%; odds ratio [OR] = 0.50; 95% confidence interval [CI] = 0.29-0.88). However, mortality risk at 45 days was similar in both groups (19% in the AVB group vs. 17% in the PUB group; OR = 0.85; 95% CI = 0.55-1.33; P = 0.48). Different parameters, such as Child-Pugh score, acute kidney injury, acute on chronic liver failure, or presence of shock or bacterial infection, but not the cause of bleeding, were related to the risk of death. Only 2% of the PUB group versus 3% of the AVB group died with uncontrolled bleeding (P = 0.39), whereas the majority of patients in either group died from liver failure or attributed to other comorbidities. Conclusion Using current first-line therapy, patients with cirrhosis and acute peptic ulcer bleeding have a similar survival than those with variceal bleeding. The risk of further bleeding is higher in patients with variceal hemorrhage. However, few patients in both groups died from uncontrolled bleeding, rather the cause of death was usually related to liver failure or comorbidities. (Hepatology 2018;67:1458-1471).

In recent years there have been advances in the management of non-variceal upper gastrointestinal bleeding that have helped reduce rebleeding and mortality. This document positioning of the Catalan Society of Digestologia is an update of evidence-based recommendations on management of gastrointestinal bleeding peptic ulcer.

Resumen Objetivo Valorar los recursos disponibles en los hospitales comarcales catalanes para la asistencia urgente de la hemorragia digestiva alta. Metodo Se analiza una encuesta enviada a 32 hospitales, sobre la existencia, composicion y recursos del turno de guardia (TDG) de endoscopia, referida al ano 2009. Resultados Respondieron 24 centros, que cubrian la asistencia de 3.954.000 habitantes. Tenian TDG 12 hospitales. No disponian de TDG en su centro de referencia 1.483.000 habitantes. Los centros con TDG tenian mas camas y cubrian mas poblacion. Los TDG estaban formados por 4,5 endoscopistas (rango 2-11), que cubrian 82,1 (33,2-182,5) guardias/ano. Diecisiete centros reportaban 1.571 episodios (51 por centro, rango 3-280, 39,68/100.000 hab.). Los centros con TDG reportaban mas casos (76 vs. 43, p = 0,047). Los que no disponen de TDG derivaron mas pacientes (147 vs . 17, p= 0,001). Los pacientes en urgencias estaban a cargo de medicina interna en 4 centros, de cirugia en 14 y repartidos entre ambos servicios en 6. Si ingresaban, quedaron a cargo de Digestivo solo en 6 hospitales. Los recursos mas utilizados eran la ligadura en la hemorragia varicosa y las terapias de inyeccion en la no varicosa. Un 21% de centros no realizaban tratamiento combinado. Conclusiones Una proporcion significativa de la poblacion no dispone de endoscopista de guardia en su centro de referencia. La constitucion de TDG en hospitales comarcales supone importantes cargas asistenciales. La coordinacion entre profesionales y centros permitiria la aplicacion eficiente de los recursos terapeuticos y el establecimiento de TDG en centros que no tienen.

High dose of somatostatin infusion achieves a greater reduction of hepatic venous pressure gradient (HVPG) than the usual dose, and terlipressin decreases HVPG through mechanisms other than somatostatin. Our aim was to assess the hemodynamic effects of terlipressin and high somatostatin dose during acute variceal bleeding in nonresponders to the usual somatostatin dose.Hemodynamic studies were performed in 80 patients with cirrhosis and variceal bleeding during the first 3 days of admission. After baseline measurements, somatostatin was administered (250 microg/h with an initial bolus of 250 microg). Patients were considered responders when the HVPG decreased by10% from baseline (n = 31). Nonresponders were randomized under double-blind conditions to a control group (n = 7), or to receive terlipressin (2 mg IV bolus, n = 22), or high dose of somatostatin (500 microg/h, n = 20). Final measurements were obtained 30 min later.Terlipressin caused a decrease in HVPG (from 22.2 +/- 5 to 19.1 +/- 5.2, p0.01) and heart rate (p0.01), while mean arterial pressure increased (p0.01). High somatostatin dose also reduced HVPG (from 21.8 +/- 3.4 to 19.6 +/- 3.1, p0.01), although this decrease was more pronounced with terlipressin (15%+/- 9%vs 10%+/- 6% from baseline, p= 0.05). Both terlipressin and high somatostatin dose achieved a significantly higher rate of response than that in the control group. A decrease in HVPG20% was observed in 36% of cases with terlipressin versus 5% with high somatostatin dose (p= 0.02).In nonresponders to usual somatostatin dose, both terlipressin and high-dose of somatostatin infusion significantly decreased HVPG and increased the rate of hemodynamic responders. Such effects were greater with terlipressin. Both treatments may be an alternative when standard somatostatin fails.

Paracentesis-induced circulatory dysfunction (PICD) is a recently described complication that can be prevented with the administration of plasma expanders. The aim of this study was to compare the efficacy of saline versus albumin in the prevention of PICD. Patients were randomized to receive albumin or saline after total paracentesis. Patients readmitted as a consequence of a second episode of tense ascites were treated with total paracentesis and the alternative plasma expander. After randomization, 35 patients received saline and 37 received albumin. Twenty-one patients were readmitted for tense ascites and treated with the alternative expander. Significant increases in plasma renin activity (PRA) were found 24 hours and 6 days after paracentesis when saline was used (baseline, 5.6 +/- 5.7; 24 hours, 7.6 +/- 6.9; 6 days, 8.5 +/- 8.0 ng x mL(-1). hr(-1); P

There are few studies on iron deficiency anemia (IDA) after non-variceal acute upper gastrointestinal bleeding (UGIB) in patients without portal hypertension.To define the incidence of IDA after UGIB, to characterize the predictive factors for IDA and to design algorithms that could help physicians identify those patients who could benefit from iron therapy.We registered 391 patients with UGIB between April 2007 and May 2009. Patients with portal hypertension and those with clinical or/and biological conditions that could affect the ferrokinetic pattern were excluded. Blood analyses were performed, including ferric parameters upon admission, on the 5th day, and on the 30th day after the hemorrhage episode. We used a multiple logistic regression model and a classification and regression tree model.A total of 124 patients were included, of which 76 (61.3%) developed IDA 30 days after UGIB. The predictive variables were age75 years (P=.037; OR 3.9; 95% CI: 1.3-11.6), initial urea level80mg/dL (P=.027; OR 2.9; 95% CI: 1.1-7.6), initial ferritin level ≤65ng/dL (P=.002; OR 7.6; 95% CI: 2.9-18.5), initial hemoglobin level ≤100g/L (P=.003; OR 3.2; 95% CI: 1.3-8.0), hemoglobin level on the 5th day ≤100g/L (P.001; OR 14.9; 95% CI: 3.6-61.1) and the value of the transferrin saturation index on the 5th day10% (p0.001; OR 7.2; 95% CI: 2.6-20.3).Most patients with UGIB developed IDA 30 days after the episode. Identification of the predictive factors for IDA may help to establish guidelines for the administration of iron therapy.

To evaluate the resources available in Catalan regional hospitals for the emergency care of upper gastrointestinal hemorrhage.We analyzed a survey sent to 32 hospitals on the availability, composition and resources of a duty endoscopy service for the year 2009.Responses were obtained from 24 centers, covering 3,954,000 inhabitants. Duty endoscopists were available in 12 hospitals. A total of 1,483,000 inhabitants were unable to access a duty endoscopist in the referral center. Centers with duty endoscopists had more beds and had a larger catchment area. Duty services were composed of 4.5 endoscopists (range 2-11), covering 82.1 (33.2-182.5) duty shifts/year. Seventeen centers reported 1,571 episodes (51%, range: 3-280, 39.68/100,000 inhabitants). Centers with a duty service reported a greater number of cases (76 vs. 43, p=0.047). Centers without this service referred a greater number of patients (147 vs. 17, p=0.001). Patients in the emergency department were under the care of the internal medicine department in four centers, the surgery department in 14 centers and under the care of both departments in six. Admitted patients were under the care of the gastroenterology department in only six hospitals. The most widely used procedures were ligation of varicose bleeding and injection therapies in non-varicose bleeding. Twenty-one percent of centers did not perform combined treatment.A significant proportion of the population does not have access to a duty endoscopist in referral centers. Duty shifts represent significant workload in regional hospitals. Coordination among health professionals and centers would allow the efficient application of therapeutic resources and a duty endoscopy service to be established in centers lacking this resource.

Introduccion No existen estudios comparativos entre los diferentes modelos matematicos para la prediccion de recidiva y mortalidad en pacientes con hemorragia digestiva alta por ulcera peptica (HDAxUP). Se desconoce tambien si dichos modelos predictivos son superiores al juicio clinico. Objetivo Comparar la precision de los modelos de Rockall, Baylor, Cedars-Sinai y Blatchford frente al juicio clinico del endoscopista en la prediccion de recidiva y mortalidad en pacientes con HDAxUP. Pacientes y metodo Durante un periodo de 2 anos se incluyeron 238 pacientes con HDAxUP en los 3 centros participantes. Todos los pacientes se trataron con IBP i.v, y se realizo endoscopia urgente entre las 12 horas siguientes al ingreso. Se practico tratamiento endoscopico combinado (inyeccion de adrenalina mas polidocanol o clip) en 136 pacientes con ulcera de alto riesgo. Tras ello, el endoscopista clasifico a los pacientes segun su juicio clinico como de riesgo alto-medio-bajo para recidiva y mortalidad, y posteriormente calculo los diferentes modelos matematicos. Se calcularon las curvas ROC, sensibilidad, especificidad, valores predictivos positivo (VPP) y negativo (VPN) para recidiva y mortalidad de cada modelo matematico y del juicio clinico del endoscopista. Resultados Las tasas de recidiva y mortalidad fueron 14% (19/136) y 5,1% (7/136) respectivamente. Las comparaciones entre el juicio clinico del endoscopista y los diferentes modelos matematicos se muestran las tablas. Conclusion Los resultados del presente estudio sugieren que los modelos matematicos disponibles no son mejores que el juicio clinico del endoscopista para la prediccion de recidiva. Ademas, tanto el juicio clinico como dichos modelos no identifican entre un 4% y 10% de pacientes que resangran tras tratamiento endoscopico. Parece adecuado el desarrollo de modelos mas precisos para prediccion de recidiva en pacientes con HDAxUP de alto riesgo. Prediccion Recidiva Juicio clinico Rockall Cedars-Sinai Baylor Blatchford Sensib. (%) 84 79 95 63 79 Especifi. (%) 34 49 21 59 61 VPP (%) 17 20 16 20 25 VPN (%) 93 93 96 91 95 Area bj ROC 0,680 0,665 0,666 0,661 0,695 Prediccion Mortalidad Juicio clinico Rockall Cedars-Sinai Baylor Blatchford Sensi. (%) 100 100 100 71 86 Especifi. (% 71 24 19 57 57 VPP (%) 16 7 6 8 10 VPN (%) 100 100 100 97.5 97 Area ROC 0,866 0,874 0,701 0,735 0,804

Portal hypertensive gastropathy (PHG) is a rare but relevant cause of gastrointestinal bleeding for which few options of medical therapy are available. Argon plasma coagulation (APC) is an endoscopic method of non-contact electrocoagulation which can be delivered by tangential application and has only limited deep of penetration. Subsequently, APC appeal for treating widespread vascular disorders such as PHG. The aim of this study was to assess the efficacy of APC for the treatment of chronic bleeding from PHG which did not respond to the pharmacological therapy of portal hypertension. METHODS: 9 patients with cirrhosis (Pugh class A/B in 3/6 and posthepatitic etiology in 6) were included. All had PHG with recurrent bleeding despite iron therapy plus isosorbide mononitrate alone (in 4 cases with intolerance to β-blockers) or combined with nadolol (3 cases) while 2 patients had no previous treatment. APC was delivered by multiple and brief pulses applied over wide areas of visible angioectasias. Sessions were performed every 2 to 3 weeks. PHG was diffuse in 4 cases and mainly antral in 5. RESULTS: a median of 6 sessions of APC were performed (range 4 to 12) during a mean period of 6±4 months. The mean follow-up was of 28±12 months. Hemoglobin value significantly improved after APC (from 76±13 to 106±19 G/L, P= 0.006) although iron therapy could be discontinued only in 1 case. Transfusional requirements decreased from a median of 4 (range 2 to 13) Units of Red Cells in the 12 months before APC to 0 (0 to 4) during the 12 months after starting APC (P=0.001). The endoscopic severity of PHG (graded from 1 for mild, to 3 for severe) also improved (from 2.9±0.3 to 2±0.5, P=0.002). There were no serious complications due to APC (3 patients complained of transient pain). Only 1 patient died 18 months after APC due to liver failure. CONCLUSIONS: endoscopic therapy with APC is a safe and effective treatment for PHG which do not respond to the pharmacological therapy of portal hypertension. In these patients APC should be considered before more aggressive approaches