Pre-operative embolization for staged treatment of infantile choroid plexus papilloma.

Choroid plexus papillomas (CPPs) are benign but rare neuroepithelial neoplasms of the choroid plexus that represent the non-malignant form of a spectrum of tumors of the choroid plexus. The vast majority of CPPs present in children under 5 years of age. Some CPPs are diagnosed prenatally, but many of them reach a large size before diagnosis. CPPs typically present with signs and symptoms of hydrocephalus. Treatment of these tumors has traditionally been with surgical resection. Large CPPs in young children present a challenge due to risk of high blood loss during resection. Here, the authors describe the case of a 3-month-old presenting with hydrocephalus and a large CPP of the third ventricle that was managed with a staged strategy of embolization followed by a delayed resection, allowing the tumor to involute prior to surgery.

Pharmacokinetics and Pharmacodynamics of Cefepime in Adults with Hematological Malignancies and Febrile Neutropenia after Chemotherapy.

Patients with chemotherapy-induced febrile neutropenia (CIFN) may have changes in the pharmacokinetics (PK) compared to patients without malignancies or neutropenia. Those changes in antibiotic PK could lead to negative outcomes for patients if the therapy is not adequately adjusted to this. In this, open-label, non-randomized, prospective, observational, and descriptive study, a PK model of cefepime was developed for patients with hematological neoplasms and post-chemotherapy febrile neutropenia. This study was conducted at a cancer referral center, and study participants were receiving 2 g IV doses of cefepime every 8 h as 30-min infusions. Cefepime PK was well described by a two compartment model with a clearance dependent on a serum creatinine level. Using Monte Carlo simulations, it was shown that continuous infusions of 6g q24h could have a good achievement of PK/PD targets for MIC levels below the resistance cut-off point of Enterobacteriaceae. According to the simulations, it is unnecessary to increase the daily dose of cefepime (above 6 g daily) to increase the probability of target attainment (PTA). Cumulative fraction of response (CFR) using interment dosing was suboptimal for empirical therapy regimens against K. pneumoniae and P. aeruginosa, and continuous infusions could be used in this setting to maximize exposure. Patients with high serum creatinine levels were more likely to achieve predefined PK/PD targets than patients with low levels.

Safety and efficacy of brainstem biopsy in children and young adults.

OBJECTIVE: Biopsies of brainstem lesions are performed to establish a diagnosis in the setting of an atypical clinical or radiological presentation, or to facilitate molecular studies. A better understanding of the safety and diagnostic yield of brainstem biopsies would help guide appropriate patient selection. METHODS: All patients who underwent biopsy of a brainstem lesion during the period from January 2011 to June 2019 were reviewed. Demographic, radiological, surgical, and outcome data were collected. RESULTS: A total of 58 patients underwent 65 brainstem biopsies during the study period. Overall, the median age was 7.6 years (IQR 3.9-14.2 years). Twenty-two of the 65 biopsies (34%) were open, 42 (65%) were stereotactic, and 1 was endoscopic. In 3 cases (5%), a ventriculoperitoneal shunt was placed, and in 9 cases (14%), a posterior fossa decompression was performed during the same operative session as the biopsy. An intraoperative MRI (iMRI) was performed in 28 cases (43%). In 3 of these cases (11%), the biopsy was off target and additional samples were obtained during the same procedure. New neurological deficits were noted in 5 cases (8%), including sensory deficits, ophthalmoparesis/nystagmus, facial weakness, and hearing loss; these deficits persisted in 2 cases and were transient in 3 cases. A pseudomeningocele occurred in 1 patient; no patients developed a CSF leak or infection. In 8 cases (13%) an additional procedure was needed to obtain a diagnosis. CONCLUSIONS: Brainstem biopsies are safe and effective. Target selection and approach should be a collaborative effort. iMRI can be used to assess biopsy accuracy in real time, thereby allowing any adjustment if necessary.

Evaluation and treatment of children with radiation-induced cerebral vasculopathy.

OBJECTIVE: Stenoocclusive cerebral vasculopathy is an infrequent delayed complication of ionizing radiation. It has been well described with photon-based radiation therapy but less so following proton-beam radiotherapy. The authors report their recent institutional experience in evaluating and treating children with radiation-induced cerebral vasculopathy. METHODS: Eligible patients were age 21 years or younger who had a history of cranial radiation and subsequently developed vascular narrowing detected by MR arteriography that was significant enough to warrant cerebral angiography, with or without ischemic symptoms. The study period was January 2011 to March 2019. RESULTS: Thirty-one patients met the study inclusion criteria. Their median age was 12 years, and 18 (58%) were male. Proton-beam radiation therapy was used in 20 patients (64.5%) and photon-based radiation therapy was used in 11 patients (35.5%). Patients were most commonly referred for workup as a result of incidental findings on surveillance tumor imaging (n = 23; 74.2%). Proton-beam patients had a shorter median time from radiotherapy to catheter angiography (24.1 months [IQR 16.8-35.4 months]) than patients who underwent photon-based radiation therapy (48.2 months [IQR 26.6-61.1 months]; p = 0.04). Eighteen hemispheres were revascularized in 15 patients. One surgical patient suffered a contralateral hemispheric infarct 2 weeks after revascularization; no child treated medically (aspirin) has had a stroke to date. The median follow-up duration was 29.2 months (IQR 21.8-54.0 months) from the date of the first catheter angiogram to last clinic visit. CONCLUSIONS: All children who receive cranial radiation therapy from any source, particularly if the parasellar region was involved and the child was young at the time of treatment, require close surveillance for the development of vasculopathy. A structured and detailed evaluation is necessary to determine optimal treatment.

Evaluación de la prescripción profiláctica de omeprazol y ranitidina mediante la identificación de factores de riesgo de sangrado gastrointestinal / Evaluation of prophylactic prescription of omeprazole and ranitidine by identifying risk factors for gastrointestinal bleeding

RESUMEN La información actual sobre el uso de inhibidores de la producción de ácido clorhídrico (inhibidores de bomba de protones y antagonistas de los receptores de histamina H2), en pacientes no críticos hospitalizados para la profilaxis de úlceras por estrés es controversial. Con el fin de evaluar la pertinencia de este grupo de medicamentos en conformidad con el riesgo de sangrado gastrointestinal medido por la escala de Herzig et al. {Risk factors for nosocomial gastrointestinal bleeding and use of acid-suppres-sive medication in non-critically ill patients, J. Gen. Intern. Med, 28(5), 683-690 (2013)}, se realizó un estudio observacional descriptivo longitudinal con recolección retrospectiva de la información, el cual incluyó todos los pacientes mayores de 18 años sin sangrado gastrointestinal y con más de tres días de hospitalización, en el servicio de medicina interna de un hospital de tercer nivel de Bogotá. Según esta escala, el 64% de los pacientes se clasificó en bajo riesgo, el 22,3% en medio-bajo, el 6,7% en medio-alto, y el 6,7% en alto. La prescripción profiláctica de inhibidores de la secreción ácida se realizó en el 67% de los pacientes de bajo riesgo, en el 57% de los de medio-bajo y en el 100% de los pacientes de riesgo medio-alto y alto. Cerca de la mitad (55,35%) de los pacientes recibieron un antiulceroso sin requerirlo; por lo tanto, se recomienda realizar actividades educativas dirigidas al personal prescriptor, con el fin de hacer un uso adecuado de este grupo de medicamentos.

SUMMARY Current information on the use of inhibitors of the production of hydrochloric acid (proton-pump inhibitor (PPI) ATC A02BC and histamine H2 receptor antagonists (Anti H2) ATC A02BC) in non-critical patients for the prophylaxis of stress ulcers is controversial. A descriptive longitudinal observational study with a retrospective collection of information, that included patients over 18 years with more than three days of hospitalization in internal medicine, without active gastrointestinal bleeding using the scale of Herzig et al. {Risk factors for nosocomial gastrointestinal bleeding and use of acid-suppressive medication in non-critically ill patients, J. Gen. Intern. Med., 28(5), 683-690 (2013)}, to assess the risk gastrointestinal bleeding was carried out. According to the risk score, patients were classified 64% as low risk, 22.3% medium-low risk, 6.7% medium-high risk and 6.7% high risk. Prophylactic prescription inhibiting acid secretion was performed in 67% of patients at low risk, 57% in medium-low risk and 100% for patients with medium-high and high risk. More than half (55.33%) of the patients received a PPI/anti H2 without requiring it. Educational activities are recommended to the prescribing staff in order to make proper use of this group of drugs.

Phase II Trial on Extending the Maintenance Flushing Interval of Implanted Ports.

PURPOSE: Retrospective studies suggest that it may be safe to extend the maintenance flushing interval of implanted ports from once every month, as recommended by the manufacturer, to once every 3 months, but no prospective cohort studies have been done specifically assessing the safety and feasibility of this intervention. METHODS: This was a phase II study in oncologic patients who retained a functional port after completion of systemic chemotherapy. Patients enrolled in the study had their port flushed once every 3 months and were observed until completion of five scheduled flushes (one on enrollment and four additional flushes, one every 3 months) or development of any port-related complication, including infections, thrombosis, and occlusions. The primary end points were frequency of port-related complications and port failure requiring removal. RESULTS: A total of 87 patients were enrolled in the study. The median follow-up time was 308 days, accounting for a total of 24,202 catheter-days. There were 10 port-related complications (11.49%; 95% CI, 4.85% to 18.14%). No infection or symptomatic thrombosis occurred. The mean time to port-related complication was 184 days. No patients developed port failure while on protocol, but on subsequent medical record review, four patients developed a complication that required port removal or port revision within 30 days of being removed from the trial (4.6%; 95% CI, 0.4% to 8.8%; 0.17/1,000 catheter-days). CONCLUSION: Extending the maintenance flushes of implanted ports in adult oncologic patients to once every 3 months is safe, effective, and likely to increase patient adherence and satisfaction while decreasing the associated cost.

Costos directos e impacto sobre la morbimortalidad hospitalariade eventos adversos prevenibles a medicamentosen una institución de tercer nivel de Bogotá / Direct costs and impact on hospital morbidity and mortality of preventable adverse drug events in a tertiary institution in Bogota

Introducción. La implementación de actividades de farmacovigilancia permite supervisar y evaluar aspectos relacionados con la atención médica. Es necesario que la información recolectada permita identificar oportunidades para mejorar la calidad de la atención en salud. Se propone un análisis de los eventos adversos a medicamentos desde la óptica preventiva y económica, estableciendo su impacto local.Objetivo. Determinar el porcentaje de eventos adversos prevenibles a medicamentos, reportados en una institución de tercer nivel, para establecer su impacto sobre la morbimortalidad y el económico desde la óptica del pagador y mostrando la relevancia de usar un método que permita identificarlos y evitar o disminuir su presentación. Materiales y métodos. A partir de los reportes generados durante actividades de farmacovigilancia en el año 2007 en un hospital de tercer nivel de Bogotá, se revisaron las historias clínicas de los pacientes involucrados y se evaluó la relación de causalidad, la gravedad y el carácter prevenible de los eventos adversos a medicamentos. Se calcularon los costos directos generados, agrupándolos en pruebas diagnósticas, tiempo de estancia adicional, procedimientos y medicamentos adicionales. Resultados. Se revisaron 448 reportes de eventos adversos a medicamentos en 283 pacientes y se encontró que 24,8 % de los eventos reportados eran prevenibles, con mortalidad de 1,1 % y costos totales asociados con su atención entre $ 33´620.346 (US$ 16.687) y $ 37´754.856 (US$ 18.739). Los factores más frecuentemente asociados con la prevención fueron las interacciones farmacológicas y las dosis o frecuencias inadecuadas de administración.Conclusiones. Es importante tomar medidas tendientes a disminuir la presentación de eventos adversos prevenibles a medicamentos, ya que repercuten negativamente tanto sobre la salud de los pacientes, como en el consumo de recursos.

Introduction. Implementing pharmacovigilance activities consists of monitoring and assessment of activities related to medical attention. However, additional data are necessary to identify conditions where care quality can be improved. Therefore, a focus on adverse drug events analysis from a prevention and economic perspective is needed, with emphasis on its local impact.Objective. Preventable adverse drug events were summarized to establishing their impact on morbidity and mortality, as well as to estimate the ensuing economic burden. Materials and methods. The data were gathered from a level 3 hospital (high complexity), located in Bogotá, Colombia, where specific pharmacovigilance activities were recorded in 2007. Patient charts were reviewed to characterize adverse drug events according to their causality, severity and preventability. Direct costs were estimated by grouping diagnostic tests, length of hospitalization, procedures and additional drugs required. Results. The charts of 283 patients and 448 reports were analyzed. These data indicated that 24.8% of adverse drug events were preventable and that an associated mortality of 1.1% had occurred. The associated direct costs were between USD $16,687 and $18,739. Factors more commonly associated with preventability were drug-drug interactions, as well as inappropriate doses and unsuitable frequencies at which the drugs were administrated. Conclusions. The data recommended that actions be taken to decrease preventable adverse drug events, because of negative impact on patient’s health, and unnecessary consumption of healthcare resources.

Y después del estatus convulsivo? / What about post-ictal state

El periodo posterior a un estatus epiléptico o a una crisis epiléptica ha despertado marcado interés debido a susrepercusiones funcionales y cognoscitivas. El estado post-ictal es la condición anormal que ocurre entre el fin dela crisis epiléptica o el estatus epiléptico y el retorno a la condición de base. El pronóstico de un paciente en estadopostictal depende directamente de la causa subyacente y del tiempo de duración del estado convulsivo. La utilidaddel electroencefalograma en el periodo post-ictal está dada por su capacidad, no solamente para determinar el fin dela crisis y el inicio del periodo post-ictal, sino también, en algunos casos permite determinar el área o hemisferio deinicio ictal y descartar la presencia de estatus no convulsivo. Las alteraciones en el estado de ánimo como depresióny psicosis deben ser evaluadas y tratadas de manera temprana en el estado post-ictal. Medicaciones antiepilépticascomo levetiracetam y lacosamida muestran frente al placebo una diferencia significativa en el control de eventospost-ictales con más rápida recuperación del estado de conciencia y control del comportamiento. Los efectospositivos de la estimulación del nervio vago en el fenómeno post-ictal permiten una mejor calidad de vida para lospacientes con epilepsias refractarias. El desarrollo de nuevas medicaciones o dispositivos que busquen emular losmecanismos endógenos anti-ictales desencadenados en el periodo post-ictal, serán los verdaderos medicamentosantiepileptogénicos.

Qué rumbo debe tomar el sistema de salud colombiano? la justificación de una comisión independiente para definir prioridades: [editoriales] / Where to next for Colombia’s health system?: the case for an independent priority setting agency: [editorial]

A pesar de los grandes avances realizados para lograr la cobertura de salud total a sus ciudadanos (1-3) el sistema de salud colombiano se enfrenta a una crisis. Hay preocupación respecto a la equidad del sistema y de si el POS y POSS realmente proporcionan la atención en salud esencial. Este fue el raciocinio del fallo de la Corte Suprema de Justicia (T760) que estableció que el POS y el POSS deberían ofrecer el mismo nivel de atención y que el faltante fuese aportado por el gobierno central (este fallo representa 800 mil millones de pesos). Enfrentado al hecho de tener que pagar por los servicios adicionales o reorganizar el sistema de salud, el gobierno propuso que los individuos que requirieran servicios de alto costo usaran sus ahorros pensionales y prestacionales para cubrir estos servicios. Esta propuesta fue muy impopular y finalmente fue retirada. Actualmente el gobierno estudia otra alternativa y es la de aumentar el gravamen de las bebidas alcohólicas, cigarrillos y juegos de azar...

Modelos empleados para la toma de decisiones en el cuidado de la salud / Models used for decision-making in health care

El análisis de decisiones es un grupo de herramientas que permiten apoyar y manejar un proceso de evaluación estructurado. Esta metodología se usa ampliamente en la evaluación económica para planeación o programas de salud. Este artículo delinea algunas características de las decisiones complejas y muestra los fundamentos y etapas que deben considerarse cuando se toman decisiones en un escenario de incertidumbre (definición del problema, selección de un marco temporal de análisis adecuado, estructuración del problema, desarrollo de un modelo para análisis, selección de la mejor alternativa y realización de análisis de sensibilidad). Finalmente se presentan algunas críticas que se han hecho a esta metodología.

Decision analysis consists of a set of tools supporting and handling structured evaluation. Such methodology is widely used for the economic evaluation of health care planning and programmes. This article outlines some characteristics regarding complex decision-making and shows the fundamental issues and stages considered when making decisions in an uncertain scenario (problem definition, choosing an appropriate time-frame, structuring the problem, developing a model for analysing it, selecting the best alternative and analysing sensitivity). Some criticism of this decision-making method is then made.

Evaluación económica de tecnología sanitaria / Economic evaluation of health technology

El presente ensayo revisa los conceptos básicos de la evaluación económica de la tecnología sanitaria, los tipos de información necesarios, y el estado del arte reportado en la literatura medica. La necesidad de evaluar económicamente los resultados de la investigación clínica ha llevado a desarrollar una nueva disciplina, la evaluación económica de la tecnología sanitaria (Farmacoeconomía). La metodología se ha desarrollado con rapidez en los últimos 10 años. Como se revisó en este ensayo, la información se basa tanto en modelos sofisticados de análisis de decisión como en la recolección prospectiva dentro de los estudios clínicos, que han mejorado nuestro entendimiento de los costos y beneficios clínicos de las tecnologías sanitarias. Esta información es importante para los clínicos, para las autoridades sanitarias para determinar el uso más adecuado de los limitados recursos para la salud. Los métodos de evaluación de nuevos productos farmacéuticos han incrementado su grado de sofisticación de manera muy rápida. En gran parte, este desarrollo es estimulado por los cambios analíticos hechos para la evaluación farmacoeconómica de la información obtenida de la investigación clínica. En Colombia, la investigación sobre estos temas deberá orientar los esfuerzos hacia el futuro, siendo necesaria además la consolidación en el país de una comunidad académica en el área

Evaluation of small mass spectrometer systems for permanent gas analysis.

This work is aimed at understanding the aspects of designing a miniature mass spectrometer (MS) system. Several types of small MS systems are evaluated and discussed, including linear quadrupole, quadrupole ion trap, time of flight, and sector. Analysis of hydrogen, helium, oxygen, and argon in a nitrogen background with the concentrations of the components of interest ranging from 0 to 5000 parts per million (ppm). The performance of each system in terms of accuracy, precision, limits of detection, response time, recovery time, scan rate, size, and weight is assessed. The relative accuracies of the systems varied from <1% to approximately 40% with an average below 10%. Relative precisions varied from 1% to 20%, with an average below 5%. The detection limits had a large distribution, ranging from 0.2 to 170 ppm. The systems had a diverse response time ranging from 4 to 210 s, as did the recovery time with a 6-to-210-s distribution. Most instruments had scan times near 1 s; however, one instrument exceeded 13 s. System weights varied from 9 to 52 kg and sizes ranged from 15 x 10(3) cm3 to 110 x 10(3) cm3. A performance scale is set up to rank each system, and an overall performance score is given to each system.

Estudio genético multiloci en la población colombiana. II distribución del complejo CcDdEe del grupo sanguíneo Rh / Genetic multiloci study in the Colombian population. II. Distribution of the CcDdEe complex in the Rh blood group

La población colombiana se caracterizó para el complejo CcDdEe del grupo sanguíneo Rh; se estudiaron diez regiones para dos generaciones; las regiones mostraron ser genéticamente homogéneas para el fator Rh, mientras que para el complejo CcDdEe y para los sistemas codominantes Cc y Ee fueron heterogéneas. La influencia de las diferentes razas en la población colombiana fue detectada a través de los fenotipos CCD-EE, CcD-Ee, CCddee, Ccddee, ccD-ee, ccddEe y ccddee