Clinical characteristics and outcomes of patients with inflammatory and autoimmune rheumatological diseases admitted for intensive care in Colombia.

OBJECTIVE: Contemporary studies reporting outcomes of critical care in patients with inflammatory and autoimmune rheumatological diseases are scarce. This study describes 15 years of experience from 2005-2019 in a Colombian referral hospital. METHODS: This observational, descriptive, consecutive case series study was performed on adult patients with inflammatory and autoimmune rheumatic diseases who were admitted to the intensive care unit (ICU) of the San Ignacio University Hospital in Bogotá (Colombia), from January 1, 2005, to December 21, 2019. We describe the sociodemographic characteristics, admission causes and criteria, lengths of stay, immunosuppressive treatment, systemic support, and mortality. RESULTS: The study included 300 patients with a median age of 48 years [interquartile range (IQR) 31-62 years], predominantly female (76%). Disease exacerbations (30%), infections (17.6%), and cardiovascular diseases (15%) were the main causes of admission. Respiratory failure (23%) most commonly caused by septic shock (24%) was the principal indication for intensive care admission. The most frequent infections were community-acquired pneumonia (11.6%) and soft-tissue infections (9%). In 40.3% of patients, inotropic and vasopressor support was required. The median length of stay was 4 days (IQR 2-8), and global mortality was 21.6%. CONCLUSIONS: Rheumatic diseases in the ICU are still associated with high morbidity and mortality. Patients with inflammatory and autoimmune rheumatic diseases require a meticulous clinical approach, strict clinical monitoring, frequent assessment of complications, evaluation of systemic support needs, and specific management.

La anestesia subaracnoidea no produce disfunción ventricular izquierda transitoria en pacientes mayores de 60 años sin enfermedad cardiovascular / Spinal anesthesia does not cause left ventricular dysfunction in patients older than 60 years without cardiovascular disease

Objetivos: Evaluar la función sistólica ventricular izquierda por ecocardiograma transtorácico en pacientes mayores de 60 años, sin enfermedad cardiovascular, bajo anestesia subaracnoidea instaurada. Pacientes y métodos: Estudio observacional prospectivo con un total de 54 pacientes mayores de 60 años sin enfermedad cardiovascular, a quienes, tras la instauración de una anestesia subaracnoidea con bupivacaína hiperbárica al 0,5% con bloqueo sensitivoT10 o mayor, se les midió la función sistólica ventricular izquierda a partir del movimiento sistólico del anillo mitral (mitral anular plane systolic excursion [MAPSE].) Además, se midió el índice de colapsabilidad de vena cava inferior (ICVCI), la integral velocidad tiempo del tracto de salida del ventrículo izquierdo (ITTSVI) y del gasto cardiaco (GC). Los valores a los 5min del bloqueo se compararon con los obtenidos previamente al mismo. Resultados: Se evidenció una disminución del 3,3% del MAPSE y una ligera disminución del IVTTSVI y GC, en ningún caso con significación estadística ni clínica. El 14,8% de los pacientes presentó presión arterial media (PAM) igual o inferior a 60mmHg. La comparación de los cambios ecocardiográficos entre estos pacientes y los que no presentaron hipotensión no fueron estadísticamente significativos ni clínicamente relevantes. Discusión: Se demuestra que la anestesia subaracnoidea con nivel anestésico T10 o superior en pacientes mayores de 60 años sin enfermedad cardiovascular, es una técnica segura ya que no altera de forma significativa parámetros ecocardiográficos de medición de la función sistólica ventricular izquierda.(AU)

Background: Elderly patients are undergoing surgery more frequently than ever. In this population, spinal anesthesia, which is known to cause sympathetic blockade associated with arterial vasodilation, is proposed as an excellent option. However, its effects on left ventricular systolic function have not been studied. Objectives: To evaluate left ventricular systolic function by transthoracic echocardiography in patients older than 60 years, without prior cardiovascular disease, under spinal anesthesia. Patients and methods: Prospective observational study with a total of 54 patients older than 60 years without prior cardiovascular disease, in whom, after the completion of subarachnoid anesthesia with hyperbaric 0.5% bupivacaine with sensory block equal to or greater than T10, left ventricular systolic function was measured using MAPSE. In addition, CI-IVC, LVOT-VTI and CO were measured. Values at 5 minutes after the blockade were compared with those obtained previously. Results: A 3.3% decrease in MAPSE and a slight decrease in LVOT-VTI and CO were found, with no statistical or clinical significance. The 14.8% of the patients presented MAP equal to or less than 60mmHg. Comparison of echocardiographic changes between hypotensive and non-hypotensive patients was not statistically significant or clinically relevant. Discussion: Our study shows that spinal anesthesia with anesthetic level T10 or higher in patients older than 60 years without cardiovascular disease is a safe technique since it does not significantly alter echocardiographic parameters measuring left ventricular systolic function.(AU)

Spinal anesthesia does not cause left ventricular dysfunction in patients older than 60 years without cardiovascular disease.

BACKGROUND: Elderly patients are undergoing surgery more frequently than ever. In this population, spinal anesthesia, which is known to cause sympathetic blockade associated with arterial vasodilation, is proposed as an excellent option. However, its effects on left ventricular systolic function have not been studied. OBJECTIVES: To evaluate left ventricular systolic function by transthoracic echocardiography in patients older than 60 years, without prior cardiovascular disease, under spinal anesthesia. PATIENTS AND METHODS: Prospective observational study with a total of 54 patients older than 60 years without prior cardiovascular disease, in whom, after the completion of subarachnoid anesthesia with hyperbaric 0.5% bupivacaine with sensory block equal to or greater than T10, left ventricular systolic function was measured using MAPSE. In addition, CI-IVC, LVOT-VTI and CO were measured. Values at 5 min after the blockade were compared with those obtained previously. RESULTS: A 3.3% decrease in MAPSE and a slight decrease in LVOT-VTI and CO were found, with no statistical or clinical significance. 14.8% of the patients presented MAP equal to or less than 60 mmHg. Comparison of echocardiographic changes between hypotensive and non-hypotensive patients was not statistically significant or clinically relevant. DISCUSSION: Our study shows that spinal anesthesia with anesthetic level T10 or higher in patients older than 60 years without cardiovascular disease is a safe technique since it does not significantly alter echocardiographic parameters measuring left ventricular systolic function.

Effectiveness of rosuvastatin plus colchicine, emtricitabine/tenofovir and combinations thereof in hospitalized patients with COVID-19: a pragmatic, open-label randomized trial.

BACKGROUND: The use of rosuvastatin plus colchicine and emtricitabine/tenofovir in hospitalized patients with SARS-CoV-2 disease (COVID-19) has not been assessed. The objective of this study was to assess the effectiveness and safety of rosuvastatin plus colchicine, emtricitabine/tenofovir, and their combined use in these patients. METHODS: This was a randomized, controlled, open-label, multicentre, parallel, pragmatic study conducted in six referral hospitals in Bogotá, Colombia. The study enrolled hospitalized patients over 18 years of age with a confirmed diagnosis of COVID-19 complicated with pneumonia, not on chronic treatment with the study medications, and with no contraindications for their use. Patients were assigned 1:1:1:1. 1) emtricitabine with tenofovir disoproxil fumarate (FTC/TDF, 200/300 mg given orally for 10 days); 2) colchicine plus rosuvastatin (COLCH+ROSU, 0.5 mg and 40 mg given orally for 14 days); 3) emtricitabine with tenofovir disoproxil plus colchicine and rosuvastatin at the same doses and for the same period of time (FTC/TDF+COLCH+ROSU); or 4) the Colombian consensus standard of care, including a corticosteroid (SOC). The primary endpoint was 28-day all-cause mortality. A modified intention-to-treat analysis was used together with a usefulness analysis to determine which could be the best treatment. The trial was registered at ClinicalTrials.gov: NCT04359095. FINDINGS: Out of 994 candidates considered between August 2020 and March 2021, 649 (65.3%) patients agreed to participate and were enrolled in this study; among them, 633 (97.5%) were included in the analysis. The mean age was 55.4 years (SD ± 12.8 years), and 428 (68%) were men; 28-day mortality was significantly lower in the FTC/TDF+COLCH+ROSUV group than in the SOC group, 10.7% (17/159) vs. 17.4% (28/161) (hazard ratio [HR] 0.53; 95% CI 0.29 to 0.96). Mortality in the FTC/TDF group was 13.8% (22/160, HR 0.68, 95% CI 0.39 to 1.20) and 14.4% in the COLCH+ROSU group (22/153) (HR 0.78, 95% CI 0.44 to 1.36). A lower need for invasive mechanical ventilation was observed in the FTC/TDF+COLCH+ROSUV group than in the SOC group (risk difference [RD] - 0.08, 95% CI 0.11 to 0.04). Three patients presented severe adverse events, one severe diarrhoea in the COLCH+ROSU and one in the FTC/TDF+COLCH+ROSU group and one general exanthema in the FTC/TDF group. INTERPRETATION: The combined use of FTC/TDF+COLCH+ROSU reduces the risk of 28-day mortality and the need for invasive mechanical ventilation in hospitalized patients with pulmonary compromise from COVID-19. More randomized controlled trials are needed to compare the effectiveness and cost of treatment with this combination versus other drugs that have been shown to reduce mortality from SARS-CoV-2 infection and its usefulness in patients with chronic statin use.

Factors Related to the Acute Cellular Rejection During the First Year After Heart Transplant.

INTRODUCTION: The acute cellular rejection is recognized as a factor related to the long-term viability of the heart graft. We intend to establish which factors are associated with the acute cellular rejection during the first year post heart transplant using a longitudinal model with repeated measures. METHODS: A retrospective cohort study was performed with all the patients who underwent heart transplant between 2005-2018 at the Hospital Universitario San Ignacio in Bogota, Colombia. In order to determine the factors associated with the development of acute cellular rejection, a generalized estimating equation approach was used, with an interchangeable correlation structure. The lowest value of quasi-likelihood information criterion and P < .05 was considered significant. RESULTS: Fifty-five patients (49.3 ± 11.1 years old) were included. The mortality during the first month was 16.3% and the accumulated mortality during the first year was 23.6%. The incidence of the acute cellular rejection was higher during the third month after the transplant (79.9%); most of them were acute cellular rejection grade 1. The factors associated with the development of the rejection were the cyclosporine levels out of the therapeutic range in several periods of evaluation (P < .03) and the age of the receptor (P = .049). CONCLUSIONS: Using advanced modeling methodologies of longitudinal data we identified that the factors associated with acute cellular rejection during the first year after the transplant are related to the therapeutic levels of the calcineurin inhibitor (cyclosporin) during the first 6 months of follow-up and the age of the receptor.

Efecto de la cirugía de estrabismo de larga evolución en los potenciales evocados visuales binoculares / Effect of surgery on longstanding strabismus on binocular visual evoked potential

ObjetivoAnalizar el efecto de la cirugía sobre los potenciales evocados visuales binoculares (PEVB), en adultos con estrabismo de larga evolución.MétodoEstudio prospectivo en 40 pacientes adultos con historia antigua de estrabismo. Registramos la respuesta de potenciales evocados visuales binocular y monocular, en el preoperatorio y a los 3 meses de la cirugía. Analizamos la función visual binocular mediante los test de Worth y TNO antes y después de la cirugía.ResultadosNo se encontraron diferencias entre la desviación posquirúrgica y los resultados de los PEVB tras la cirugía p=0,82. La media de los PEVB y el porcentaje de incremento de respuesta evocada visual binocular posquirúrgicos (10,5, y 27,14%), fueron superiores a los prequirúrgicos (9,87 y 16,6%), p=0,32 y 0,17 respectivamente. Respecto al TNO hubo diferencias en los resultados tras la cirugía (p=0,03) y en la comparación con la desviación posquirúrgica (p=0,02); sin embargo no la hubo entre el TNO y los PEVB posquirúrgicos (p=0,29). Existió diferencia en los resultados del test de Worth tras la cirugía y en la comparación con la desviación y los PEVB (p=0,00, p=0,01 y p=0,07).ConclusionesLa cirugía de estrabismo en adultos corrige la desviación y parece mejorar la respuesta evocada visual binocular, pero no hemos podido confirmar este hecho. Los datos obtenidos no permiten considerar que los PEVB sean un test objetivo para la valoración de la función binocular, si bien podría haber relación entre los PEVB y la respuesta al TNO(AU)

PurposeTo analyse the effect of surgery on binocular visual evoked potential (BVEP) in adults with longstanding strabismus.MethodsA prospective study was performed on 40 patients with a history of longstanding strabismus. Visual evoked potentials to binocular and monocular pattern reversal stimulation were recorded before surgery and 3 months after surgery. Binocular visual function was analysed by Worth and TNO tests before and after surgery.ResultsWe did not find any differences between deviation and BVEP postoperatively (P=0.82). The mean of BVEP and the percentage of increment of the BVEP response (10.5 and 27.14%) were larger postoperatively, than preoperatively (9.87 and 16.6%), P=0.32 and P=0.17, respectively. There were differences in the TNO results after surgery (P=0.03) and when compared with postoperative deviation (P=0.02), but not between TNO and BVEP postoperatively (P=0.29). There were differences in the Worth results after surgery, and comparing with deviation and BVEP (P=0.00, P=0.01 and P=0.07).ConclusionsSurgery in adults with longstanding strabismus could improve the deviation and seemed to improve BVEP response, but this point could not be confirmed. The results are not enough to show that the BVEP would be an objective test for binocular function evaluation, although there could be a relationship between BVEP and the TNO response(AU)

[Effect of surgery on longstanding strabismus on binocular visual evoked potential]. / Efecto de la cirugía de estrabismo de larga evolución en los potenciales evocados visuales binoculares.

PURPOSE: To analyse the effect of surgery on binocular visual evoked potential (BVEP) in adults with longstanding strabismus. METHODS: A prospective study was performed on 40 patients with a history of longstanding strabismus. Visual evoked potentials to binocular and monocular pattern reversal stimulation were recorded before surgery and 3 months after surgery. Binocular visual function was analysed by Worth and TNO tests before and after surgery. RESULTS: We did not find any differences between deviation and BVEP postoperatively (P = 0.82). The mean of BVEP and the percentage of increment of the BVEP response (10.5 and 27.14%) were larger postoperatively, than preoperatively (9.87 and 16.6%), P = 0.32 and P = 0.17, respectively. There were differences in the TNO results after surgery (P = 0.03) and when compared with postoperative deviation (P = 0.02), but not between TNO and BVEP postoperatively (P = 0.29). There were differences in the Worth results after surgery, and comparing with deviation and BVEP (P = 0.00, P = 0.01 and P = 0.07). CONCLUSIONS: Surgery in adults with longstanding strabismus could improve the deviation and seemed to improve BVEP response, but this point could not be confirmed. The results are not enough to show that the BVEP would be an objective test for binocular function evaluation, although there could be a relationship between BVEP and the TNO response.

[Epilepsy and sleep apnea syndrome]. / Epilepsia y síndrome de apnea del sueño.

INTRODUCTION: The reciprocal influence between Epilepsy and Sleep Apnea Syndrome (SAS/OSAS) may aggravate the prognosis of both processes. Hypoxemia during sleep in patients with SAS and sleep fragmentation as a consequence of periodic apneas, that provokes a chronic sleep deprivation, could decrease the convulsive threshold in epileptic patients. MATERIAL AND METHODS: We have carried out a descriptive and retrospective study in 20 patients with epilepsy and SAS, of which EEG recordings, video-polysomnography (PSG) and nocturnal oximetry were available. RESULTS: 90% were males. 75% had partial epilepsies and 25% generalized. The mean duration of epilepsy was 14.5 years. The mean seizures frequency was one per month. 35% had nocturnal seizures, 15% diurnal and 50% of the patients had diurnal and nocturnal seizures. Other symptoms associated with seizures were: Snoring (100%), daytime sleepiness (70%), nocturnal respiratory pauses (30%), arterial hypertension (30%), overweight (25%) and morning headache (15%). The PSG showed epileptic interictal discharges in 95% of the cases, focal in 80%, and a disturbance of the sleep architecture, with a decreased sleep efficiency and continuity. The mean hypopnea-apnea index was 38. CONCLUSIONS: The association Epilepsy-SAS in adult patients affected of localized epilepsy, with risk factors for SAS (male gender, obesity, snoring, adverse effects of drugs) must be taken into account and a video-PSG-oximetric study is indicated to confirm it. It should be noted that anticonvulsant therapy could cause breathing dysfunction during sleep or aggravate a pre-existing or latent SAS. It be expected that the satisfactory treatment of SAS could improve the control of the seizures in these patients.