Cost-Effectiveness of Rituximab (Fixed Schedule vs Tailored Dose) Compared With Azathioprine Maintenance Therapy in Adults With Generalized Antineutrophil Cytoplasm Antibody-Associated Vasculitis in Colombia.

OBJECTIVES: Azathioprine has been the therapy of choice for the maintenance of remission in patients with antineutrophil cytoplasm antibody (ANCA)-associated systemic vasculitis, but recent studies show that rituximab could be more effective. To evaluate the cost-effectiveness of azathioprine, fixed-schedule rituximab, and tailored-dose rituximab for ANCA-associated systemic vasculitis. METHODS: A Markov model from the perspective of the Colombian healthcare system was designed with annual cycles and a 5-year time horizon, charting the following states: remission, minor relapse, major relapse, and death. The discount rate was 5%. Transition probabilities were obtained from a systematic literature review. The costs (1 US dollar = 2956 Colombian pesos in 2018) were estimated based on national drug registries and official fee manuals for procedures, along with other resources. The main outcomes were quality-adjusted life-years (QALYs) taken from the Tufts registry. Univariate and multivariate sensitivity analyses were performed. RESULTS: Final costs were $1446 for azathioprine, $4898 for tailored-dose rituximab, and $6311 for fixed-schedule rituximab. QALYs gained were 3.18, 4.08, and 3.98, respectively. Rituximab was cost-effective (cost per incremental QALY gained: $4919, and $6865), and tailored-dose administration had a lower cost. Sensitivity analyses did not affect the results. CONCLUSIONS: Tailored-dose rituximab was the most cost-effective treatment for ANCA-associated vasculitis. Azathioprine presented worse effectiveness and lower cost, and fixed-schedule rituximab was dominated by tailored-dose rituximab.

EEG representation approach based on Kernel Canonical Correlation Analysis highlighting discriminative patterns for BCI applications.

Brain-Computer Interface (BCI) is applied in the study of different cognitive processes or clinical conditions as enhancing cognitive skills, motor rehabilitation, and control. However, many approaches focus on using a robust classifier instead of providing a better feature space. This work develops a feature representation methodology through the kernel canonical correlation analysis to reveal nonlinear relations between filter-banked common spatial patterns (CSP) extracted. Our approach reveals nonlinear relations between ranked filter-banked multi-class CSP features and the labels in a finite-dimensional canonical space. We tested the performance of our methodology on the BCI Competition IV dataset 2a. The introduced feature representation using a classic linear SVM achieves accuracy rates competitive with the state-of-the-art BCI strategies. Besides, the processing pipeline allows identifying the spatial and spectral features driven by the underlying brain activity and best modeling the motor imagery intentions.Clinical relevance- This BCI strategy assesses the nonlinear relationships between time series to improve the interpretation of brain electrical activity, taking into account the spatial and spectral features driven by the underlying brain dynamic.

Paquimeningitis hipertrófica en vasculitis anca positivo: reporte de caso y revisión de la literatura / Hypertrophic pachymeningitis in positive ANCA vasculitis: case report and literature review

La paquimeningitis hipertrófica (PH), es una manifestación poco frecuente de la vasculitis asociada a anticuerpos anti-citoplasma de neutrófilo (ANCA). La literatura describe compromiso de sistema nervioso central (SNC) en 2-8% de los casos en pacientes con vasculitis pauciinmune. Se presenta el caso de un paciente con antecedente de vasculitis anti-mieloperoxidasa (MPO) con un mes de evolución de cefalea hemicraneana izquierda. La resonancia magnética cerebral contrastada evidencia marcado engrosamiento y realce meníngeo dural en el hemicráneo izquierdo, predominante en el tentorio y la fosa posterior. Se descartaron causas infecciosas por lo que se llegó a la conclusión de compromiso meníngeo asociado a vasculitis. Se inició manejo inmunosupresor con mejoría del cuadro clínico. La rápida identificación y manejo de esta entidad puede cambiar su pronóstico sombrío. Se realizó una revisión de la literatura para brindar una herramienta para la toma de decisiones para los médicos que se enfrentan a esta entidad.

Hypertrophic pachymeningitis (PH) is a rare manifestation of vasculitis associated with anti-neutrophil cytoplasm antibodies (ANCA). The literature describes central nervous system (CNS) involvement in 2-8% of cases in patients with pauciimmune vasculitis. We present the case of a patient with a history of anti-Myeloperoxidase (MPO) vasculitis with a 1-month history of left-sided headache. Contrast brain magnetic resonance was performed with evidence of marked thickening and dural meningeal enhancement in the left hemicranium, predominantly in the region of the tentorium and posterior fossa. Infectious causes were ruled out and the meningeal compromise associated with vasculitis was concluded. Immunosuppressive management was started with improvement of the clinical picture. Rapid identification and management of this entity can change its bleak outlook. A systematic review of the literature was carried out in order to provide a decision-making tool for physicians facing this entity.

Cardiac sympathetic denervation for conventional treatment refractory arrhythmias.

Objective: Cardiac sympathetic denervation (CSD) using video-assisted thoracoscopy is a therapeutic alternative for cardiac arrhythmias refractory to conventional treatment in patients with ventricular structural heart disease, mainly due to ischemia, and in patients with hereditary conditions associated with sudden death such as long QT syndrome. In general, it is performed in cases with recurrent episodes of ventricular tachycardia or electrical storm, in spite of conventional treatment. The objective of this study is to show the experience of this institution with DSCI in refractory patients to conventional management and the results derived from its application. Methods: This was an observational retrospective study. The records of patients with a history of ventricular arrhythmias treated in our center with pharmacological treatment, catheter ablation, or implantation of an implantable cardioverter-defibrillator (ICD), who underwent video-assisted CSD were analyzed and described. Results: A total of six patients were included in the study. Patients with structural heart disease were the most frequent, median age was 56 ± 16 years; 67% were male. The procedure evolved without complications in any of the patients and an overall significant improvement was observed. A 24-month follow-up was conducted; two patients had recurrence episodes presenting as slow ventricular tachycardia without severe symptoms and a third patient presented an episode of ventricular fibrillation aborted by the ICD. Conclusion: Video-assisted CSD should be considered as a treatment option for patients with potentially dangerous arrhythmias that do not respond to conventional treatment, especially in recurrent ventricular tachycardia.

Objetivo: La denervación simpática cardiaca izquierda (DSCI) por toracoscopia se ha convertido en una alternativa terapéutica para el manejo de arritmias cardíacas refractarias al tratamiento convencional en pacientes con cardiopatía estructural, principalmente isquémicos, y enfermedades hereditarias asociadas con muerte súbita como el síndrome de QT largo. Generalmente se realiza en quienes manifiestan episodios recurrentes de arritmias ventriculares o incluso tormenta eléctrica a pesar del tratamiento convencional. El objetivo de este estudio es mostrar la experiencia de esta institución con la DSCI en pacientes refractarios al manejo convencional y los resultados derivados de su aplicación. Métodos: Se revisaron los registros de 6 pacientes con antecedente de arritmias ventriculares tratados previamente con medicamentos y en algunos casos con ablación con catéter y la mayoría con desfibrilador automático implantable, que fueron llevados DSCI por toracoscopia video-asistida (VATS). Resultados: La principal enfermedad de base fue la cardiopatía estructural, la indicación más prevalente fue tormenta arrítmica incontrolable, la edad promedio fue de 56 ± 16 años, el 67% de los individuos fueron hombres. Este procedimiento no mostró complicaciones en ninguno de los pacientes y se encontró mejoría sintomática en todos los casos. Se realizó seguimiento por 24 meses; dos pacientes tuvieron recurrencias por taquicardia ventricular lenta sin síntomas severos y uno por fibrilación ventricular. Conclusion: La DSCI por VATS debe considerarse como opción terapéutica para pacientes con arritmias de difícil manejo.

Cardiac sympathetic denervation for conventional treatment refractory arrhythmias / Denervación simpática cardíaca en arritmias refractarias al tratamiento convencional

Abstract Objective: Cardiac sympathetic denervation (CSD) using video-assisted thoracoscopy is a therapeutic alternative for cardiac arrhythmias refractory to conventional treatment in patients with ventricular structural heart disease, mainly due to ischemia, and in patients with hereditary conditions associated with sudden death such as long QT syndrome. In general, it is performed in cases with recurrent episodes of ventricular tachycardia or electrical storm, in spite of conventional treatment. The objective of this study is to show the experience of this institution with DSCI in refractory patients to conventional management and the results derived from its application. Methods: This was an observational retrospective study. The records of patients with a history of ventricular arrhythmias treated in our center with pharmacological treatment, catheter ablation, or implantation of an implantable cardioverter-defibrillator (ICD), who underwent video-assisted CSD were analyzed and described. Results: A total of six patients were included in the study. Patients with structural heart disease were the most frequent, median age was 56 � 16 years; 67% were male. The procedure evolved without complications in any of the patients and an overall significant improvement was observed. A 24-month follow-up was conducted; two patients had recurrence episodes presenting as slow ventricular tachycardia without severe symptoms and a third patient presented an episode of ventricular fibrillation aborted by the ICD. Conclusion: Video-assisted CSD should be considered as a treatment option for patients with potentially dangerous arrhythmias that do not respond to conventional treatment, especially in recurrent ventricular tachycardia.

Resumen Objetivo: La denervación simpática cardiaca izquierda (DSCI) por toracoscopia se ha convertido en una alternativa terapéutica para el manejo de arritmias cardíacas refractarias al tratamiento convencional en pacientes con cardiopatía estructural, principalmente isquémicos, y enfermedades hereditarias asociadas con muerte súbita como el síndrome de QT largo. Generalmente se realiza en quienes manifiestan episodios recurrentes de arritmias ventriculares o incluso tormenta eléctrica a pesar del tratamiento convencional. El objetivo de este estudio es mostrar la experiencia de esta institución con la DSCI en pacientes refractarios al manejo convencional y los resultados derivados de su aplicación. Métodos: Se revisaron los registros de 6 pacientes con antecedente de arritmias ventriculares tratados previamente con medicamentos y en algunos casos con ablación con catéter y la mayoría con desfibrilador automático implantable, que fueron llevados DSCI por toracoscopia video-asistida (VATS). Resultados: La principal enfermedad de base fue la cardiopatía estructural, la indicación más prevalente fue tormenta arrítmica incontrolable, la edad promedio fue de 56 +- 16 años, el 67% de los individuos fueron hombres. Este procedimiento no mostró complicaciones en ninguno de los pacientes y se encontró mejoría sintomática en todos los casos. Se realizó seguimiento por 24 meses; dos pacientes tuvieron recurrencias por taquicardia ventricular lenta sin síntomas severos y uno por fibrilación ventricular. Conclusion: La DSCI por VATS debe considerarse como opción terapéutica para pacientes con arritmias de difícil manejo.

Cardiac sympathetic denervation for conventional treatment refractory arrhythmias.

Objetivo: La denervación simpática cardiaca izquierda (DSCI) por toracoscopia se ha convertido en una alternativa terapéutica para el manejo de arritmias cardíacas refractarias al tratamiento convencional en pacientes con cardiopatía estructural, principalmente isquémicos, y enfermedades hereditarias asociadas con muerte súbita como el síndrome de QT largo. Generalmente se realiza en quienes manifiestan episodios recurrentes de arritmias ventriculares o incluso tormenta eléctrica a pesar del tratamiento convencional. El objetivo de este estudio es mostrar la experiencia de esta institución con la DSCI en pacientes refractarios al manejo convencional y los resultados derivados de su aplicación. Métodos: Se revisaron los registros de 6 pacientes con antecedente de arritmias ventriculares tratados previamente con medicamentos y en algunos casos con ablación con catéter y la mayoría con desfibrilador automático implantable, que fueron llevados DSCI por toracoscopia video-asistida (VATS). Resultados: La principal enfermedad de base fue la cardiopatía estructural, la indicación más prevalente fue tormenta arrítmica incontrolable, la edad promedio fue de 56 ± 16 años, el 67% de los individuos fueron hombres. Este procedimiento no mostró complicaciones en ninguno de los pacientes y se encontró mejoría sintomática en todos los casos. Se realizó seguimiento por 24 meses; dos pacientes tuvieron recurrencias por taquicardia ventricular lenta sin síntomas severos y uno por fibrilación ventricular. Conclusion: La DSCI por VATS debe considerarse como opción terapéutica para pacientes con arritmias de difícil manejo.

Objective: Cardiac sympathetic denervation (CSD) using video-assisted thoracoscopy is a therapeutic alternative for cardiac arrhythmias refractory to conventional treatment in patients with ventricular structural heart disease, mainly due to ischemia, and in patients with hereditary conditions associated with sudden death such as long QT syndrome. In general, it is performed in cases with recurrent episodes of ventricular tachycardia or electrical storm, in spite of conventional treatment. The objective of this study is to show the experience of this institution with DSCI in refractory patients to conventional management and the results derived from its application. Methods: This was an observational retrospective study. The records of patients with a history of ventricular arrhythmias treated in our center with pharmacological treatment, catheter ablation, or implantation of an implantable cardioverter-defibrillator (ICD), who underwent video-assisted CSD were analyzed and described. Results: A total of six patients were included in the study. Patients with structural heart disease were the most frequent, median age was 56 ± 16 years; 67% were male. The procedure evolved without complications in any of the patients and an overall significant improvement was observed. A 24-month follow-up was conducted; two patients had recurrence episodes presenting as slow ventricular tachycardia without severe symptoms and a third patient presented an episode of ventricular fibrillation aborted by the ICD. Conclusion: Video-assisted CSD should be considered as a treatment option for patients with potentially dangerous arrhythmias that do not respond to conventional treatment, especially in recurrent ventricular tachycardia.

Blastocystis sp: EVIDENCIAS DE SU ROL PATÓGENO / Blastocystis sp: EVIDENCE OF ITS PATHOGENIC ROLE

Blastocystis sp. es un parásito de distribución mundial, que se transmite por vía fecal-oral, colonizando el tracto gastrointestinal, tanto de animales como de humanos. Existen múltiples factores que favorecen su transmisión tales como el pobre saneamiento, el consumo de alimentos contaminados y la propagación de vectores. Este parásito ha despertado gran interés científico y clínico en los últimos años, por su potencial asociación con enfermedad; sin embargo, no ha sido posible establecer con exactitud su rol patógeno. También ha sido considerado agente oportunista, por su alta prevalencia en pacientes inmunosuprimidos, específicamente en aquellos con VIH/SIDA y cáncer. Actualmente, en el GenBank se han descrito secuencias de 33 subtipos (STs) diferentes, si bien en la literatura solo se encuentran reportados 17 subtipos hasta el momento, de los cuales 9 han sido aislados en el ser humano. Aunque buena parte de los estudios reportan a ST3 como el de mayor prevalencia, unos cuantos autores sugieren predominio de ST1 y ST4 en ciertas zonas, indicando que algunos subtipos varían dependiendo de la distribución geográfica. Varios de estos STs se han relacionado directamente con sintomatología gastrointestinal aguda y crónica e incluso con manifestaciones clínicas extraintestinales, encontrándose con mayor frecuencia el ST3 en pacientes sintomáticos, generalmente seguido de ST1 y en algunos casos de ST2. Además, se han reportado infecciones mixtas, de las cuales la más común se ha presentado entre los ST1 - ST3. En Latinoamérica, y particularmente en Colombia, se han desarrollado pocas investigaciones orientadas a identificar y definir la prevalencia, coinfección y potencial patógeno de las diferentes formas y subtipos conocidos de Blastocystis sp., por lo cual el conocimiento que se tiene hasta el momento es escaso e inespecífico, requiriéndose más estudios que permitan obtener mayor información al respecto.

Blastocystis sp. is a globally distributed parasite which is transmitted by the fecal-oral route by colonizing the gastrointestinal tract of both animals and humans. There are many factors which allow its transmiBion such as poor sanitation, the consumption of contaminated food and vectors propagation. This parasite has awakened scientific and clinical interest in recent years because of its aBociation with disease. However, its pathogen role has not been accurately established. Also, it has been considered as an opportunistic agent due to its high prevalence in immunosuppreBed patients, specifically in those with HIV / AIDS and cancer. Currently, in GenBank database the sequences of 33 different subtypes (STs) have been described even though only 17 subtypes are reported in the literature so far, from which nine have been isolated in humans. Although many studies indicate the subtype 3 (ST3) as the most prevalent, some authors suggest the predominance of ST1 and ST4 in particular areas, suggesting that some subtypes vary depending on the geographical distribution. Several of these STs have been directly related to acute and chronic gastrointestinal symptoms and even with clinical extraintestinal manifestations, being ST3 found with more frequency in symptomatic patients followed by ST1 and ST2 in some cases. Furthermore, mixed infections have been reported of which the most common has been present between ST1 - ST3. In Latin America, and particularly in Colombia, little research has been developed that aims to identify and define the prevalence, coinfection, and pathogenic potential of different forms and known subtypes of Blastocystis sp., therefore the knowledge at hand so far is scarce and unspecific, requiring more studies which allow obtaining more information about it.

Niveles séricos de marcadoresinflamatorios en pacientes hipertensosde la E.S.E. Imsalud, Cúcuta, Colombia / Serum levels of inflammatory markers in hypertensive patients of E.S.E. Imsalud, Cucuta, Colombia

Introducción: la hipertensión arterial es una condición clínica multifactorial, caracterizada por la elevación de la presión arterial sistólica o diastólica, establecida como un factor de riesgo importante en la aparición de enfermedades cardiovasculares. Objetivos: determinar los niveles séricos de IFN-γ, TNF-α y proteína C reactiva, relacionándolos con la hipertensión arterial en pacientes que asisten a la E.S.E. Imsalud-Unidad Materno Infantil la Libertad (Cúcuta, Colombia). Materiales y métodos: se realizó un estudio descriptivo, correlacional en individuos hipertensos y controles sanos seleccionados mediante encuesta estructurada. Los niveles séricos del IFN-γ y el TNF-α fueron analizados por ELISA y los de la proteína C reactiva ultrasensible por inmunoturbimetría. Resultados: el 52,8% y el 29,3% de los hipertensos presentaron concentraciones moderadamente altas de IFN-γ y TNF-α respectivamente. De acuerdo a los niveles séricos de proteína C reactiva ultrasensible, el 81,2% de los hipertensos se ubicaron en riesgo cardiovascular bajo, el 6,2% en medio y el 12,5% en alto. Conclusiones: los niveles elevados de IFN-γ en los pacientes hipertensos respecto a los controles sugierenque esta citoquina puede ser considerada un marcador útil como herramienta de evaluación del pronóstico de desarrollo de complicaciones cardiovasculares. Aunque el TNF-α no se encontró aumentado en los pacientes hipertensos, podría ser empleado en aquellos con difícil control de la enfermedad o en quienes no han iniciado el tratamiento antihipertensivo. La proteína C reactiva ultrasensible se reitera como un marcador útil en la estratificación de los niveles de riesgo en los hipertensos, abarcando desde bajo hasta alto de afectación cardiovascular.

Introduction: hypertension is a multifactorial clinical condition characterized by elevated systolic or diastolic blood pressure that it is establishing itself as a major risk factor in the onset of cardiovascular disease. Objectives: To determine serum levels of IFN-γ, TNF-α and C-reactive protein, relating to hypertension in patients attending the E.S.E. Imsalud - Unidad Materno Infantil La Libertad (Cucuta, Colombia). Material and methods: A correlational descriptive study was realized in hypertensive individuals and healthy controls selected through structured survey. Serum levels of IFN-γ and TNF-α were analyzed by ELISA and high-sensitivity C-reactive protein levels by turbidimetric immunoassays. Results: The 52.8% and 29.3% of hypertensive subjects had moderately high concentrations of IFN-γ and TNF-α, respectively. According to serum levels of high-sensitivity C-reactive protein, 81.2% of hypertensive stood at low cardiovascular risk, 6.2% on average, and 12.5% at high risk. Conclusions: Elevated levels of IFN-γ found in hypertensive patients respect to controls, suggest that this cytokine could be consider as a viable marker as a valuable tool in forecasting the development of cardiovascularcomplications. Although TNF-α not increased in hypertensive patients, could be used in those with difficult disease control or who have not initiated antihypertensive treatment. The high-sensitivity C-reactive protein can be reiterate as a marker useful in the stratification of the levels of risk in hypertensivepatients, ranging from low to high risk of cardiovascular involvement.