Clinical characterization of long-term multiple sclerosis (COLuMbus) patients in Argentina: A cross-sectional non-interventional study.

BACKGROUND: Most Multiple Sclerosis (MS) clinical trials fail to assess the long-term effects of disease-modifying therapies (DMT) or disability. METHODS: COLuMbus was a single-visit, cross-sectional study in Argentina in adult patients with ≥10 years of MS since first diagnosis. The primary endpoint was to determine patient disability using the Expanded Disability Status Scale (EDSS). The secondary endpoints were to evaluate the distribution of diagnoses between relapsing-remitting MS (RRMS) and secondary progressive MS (SPMS), patient demographics, disease history, and the risk of disability progression. The relationship between baseline characteristics and the current disability state and the risk of disability progression was assessed. RESULTS: Out of the 210 patients included, 76.7 % had a diagnosis of RRMS and 23.3 % had been diagnosed with SPMS, with a mean disease duration of 17.9 years and 20.5 years, respectively. The mean delay in the initial MS diagnosis was 2.6 years for the RRMS subgroup and 2.8 years for the SPMS subgroups. At the time of cut-off (28May2020), 90.1 % (RRMS) and 75.5 % (SPMS) of patients were receiving a DMT, with a mean of 1.5 and 2.0 prior DMTs, respectively. The median EDSS scores were 2.5 (RRMS) and 6.5 (SPMS). In the RRMS and SPMS subgroups, 23 % and 95.9 % of patients were at high risk of disability, respectively; the time since first diagnosis showed a significant correlation with the degree of disability. CONCLUSIONS: This is the first local real-world study in patients with long-term MS that highlights the importance of recognizing early disease progression to treat the disease on time and delay disability.

Guillain-Barré Syndrome and COVID-19 Vaccine: A Multicenter Retrospective Study of 46 Cases.

ABSTRACT: In the context of the global vaccination campaign against COVID-19, several cases of postvaccinal Guillain-Barré syndrome (GBS) were reported. Whether a causal relationship exists between these events has yet to be established. We investigated the clinical and electromyographic characteristics of patients who developed GBS after COVID-19 vaccination and compare these with findings in patients with GBS, without a history of recent vaccination. We included 91 cases between March 2020 and March 2022, treated at 10 referral hospitals of Buenos Aires, Argentina. Of these, 46 had received vaccination against COVID-19 within the previous month. Although Medical Research Council sum-scores were similar in both groups (median 52 vs. 50; P = 0.4), cranial nerve involvement was significantly more frequent in the postvaccination group (59% vs. 38%; P = 0.02), as was bilateral facial paralysis (57% vs. 24%; P = 0.002). No differences were found in clinical or neurophysiological phenotypes, although 17 subjects presented the variant of bilateral facial palsy with paresthesias (11 vs. 6; P = 0.1); nor were significant differences observed in length of hospital stay or mortality rates. Future vaccine safety monitoring and epidemiology studies are essential to demonstrate any potential causal relationship between these events.

Pregabalin for neuropathic pain in primary care settings: recommendations for dosing and titration.

Pregabalin is one of the first-line treatments approved for the management of neuropathic pain (NeP). While many patients benefit from treatment with pregabalin, they are often treated with suboptimal doses, possibly due to unfamiliarity around prescribing the drug and/or side effects that can occur with up-titration. This narrative review discusses key aspects of initiating, titrating, and managing patients prescribed pregabalin therapy, and addresses concerns around driving and the potential for abuse, as well as when to seek specialist opinion. To ensure that patients derive maximum therapeutic benefit from the drug, we suggest a 'low and slow' dosing approach to limit common side effects and optimize tolerability alongside patients' expectations. When requiring titration to higher doses, we recommend initiating 'asymmetric dosing,' with the larger dose in the evening. Fully engaging patients in order for them to understand the expected timeline for efficacy and side effects (including their resolution), can also help determine the optimal titration tempo for each individual patient. The 'low and slow' approach also recognizes that patients with NeP are heterogeneous in terms of their optimal therapeutic dose of pregabalin. Hence, it is recommended that general practitioners closely monitor patients and up-titrate according to pain relief and side effects to limit suboptimal dosing or premature discontinuation.

When to consider "mixed pain"? The right questions can make a difference!

The term "mixed pain" is increasingly applied for specific clinical scenarios, such as low back pain, cancer pain and postsurgical pain, in which there "is a complex overlap of the different known pain types (nociceptive, neuropathic, nociplastic) in any combination, acting simultaneously and/or concurrently to cause pain in the same body area." Whether mixed pain is the manifestation of neuropathic and nociceptive mechanisms operating simultaneously or concurrently, or the result of an entirely independent pathophysiological mechanism - distinct from nociceptive, nociplastic and neuropathic pain - is currently unknown. At present, the diagnosis of mixed pain is made based on clinical judgement following detailed history-taking and thorough physical examination, rather than by formal confirmation following explicit screening or diagnostic criteria; this lack of formalized screening or diagnostic tools for mixed pain is problematic for physicians in primary care, who encounter patients with probable mixed pain states in their daily practice. This article outlines a methodical approach to clinical evaluation of patients presenting with acute, subacute or chronic pain, and to possibly identifying those who have mixed pain. The authors propose the use of nine simple key questions, which will provide the practicing clinician a framework for identifying the predominant pain mechanisms operating within the patient. A methodical, fairly rapid, and comprehensive assessment of a patient in chronic pain - particularly one suffering from pain with both nociceptive and neuropathic components - allows validation of their experience of chronic pain as a specific disease and, importantly, allows the institution of targeted treatment.

EDUCACIÓN EN DIÁLISIS PERITONEAL CRÓNICA EN LOS PROGRAMAS DE POSGRADO DE NEFROLOGÍA EN LATINOAMÉRICA / Chronic peritoneal dialysis training in Latin American Nephrology Post graduate programs

Introducción: Diversos factores pueden influir en la preferencia del uso de hemodiálisis crónica (HDC) sobre diálisis peritoneal crónica (DPC) como terapia de enfermedad renal crónica en pacientes estado 5 en programas de diálisis crónica (ERC5D) en diversos países del mundo. Objetivos: Determinar si la falta de educación adecuada y suficiente en DPC en algunos programas de postgrado de nefrología, es la causa principal por la cual los nefrólogos prefieren utilizar HDC, la terapia mejor conocida. Material y Métodos: Se analizó el programa de entrenamiento en DPC que reciben los estudiantes de postgrado de nefrología en diversos países de Centro y Suramérica. La información se obtuvo con base en la respuesta a una encuesta que se envió a uno o más nefrólogos de cada país, entre febrero 1 y julio 31 de 2011, dirigida a quienes trabajan en el medio académico y conocen, dirigen o pertenecen a programas de postgrado de nefrología. Resultados: 114 programas de postgrado de Nefrología existen en Latinoamérica en la actualidad. Se encuentra una clara variedad en el periodo de entrenamiento en diálisis peritoneal crónica, de acuerdo con cada programa y en cada país. El volumen de pacientes en diálisis peritoneal crónica varía entre 25 y más de 280, con lo cual es claro que el entrenamiento y la experiencia adquirida en el manejo de pacientes con DPC es diferente. Discusión: El entrenamiento insuficiente en DPC podría traer como consecuencia que el nefrólogo al momento de escoger una terapia se decida por la mejor conocida, y esta podría ser una de las razones por la cual la DPC sea menos utilizada en muchas partes del mundo. La unificación de programas de entrenamiento podría favorecer un mayor conocimiento de la terapia, pudiéndose utilizar así en forma más balanceada.

Introduction: Several factors may influence the preferential use of chronic hemodialysis (CHD) over chronic peritoneal dialysis (CKD) as a therapy for stage 5 chronic kidney disease patients in chronic dialysis (5DCKD) programs in several countries around the world. Objectives: To determine if a lack of adequate chronic peritoneal dialysis (CPD) education in some nephrology postgraduate programs is the main reason why nephrologists prefer to use HDC, the best known therapy. Material and Methods: We analyzed the CPD training program received by nephrology postgraduate students in several countries of Central and South America. The obtained information was based on a survey that was sent to one or more nephrologists from each country between February 1 and July 31, 2011, addressed to those who work in the academic environment and who know, direct or belong to nephrology postgraduate programs. Results: 114 postgraduate nephrology programs exist in Latin America today. A clear variation is found in CPD training period, according to each program and country. The volume of patients on CPD varies from 25 to more than 280, thus making clear that training and experience gained in care of patients with CPD is unbalanced. Discussion: Insufficient DPC training may end-up in nephrologists choosing the best known therapy, being this way one of the reasons why DPC is less often used in many parts of the world. Unification of training programs could favor a better knowledge of this therapy, being then able to use it in a more balanced way.

Safety and Tolerability of Fingolimod in Latin American Patients with Relapsing-Remitting Multiple Sclerosis: The Open-Label FIRST LATAM Study.

INTRODUCTION: Fingolimod 0.5 mg is an orally active sphingosine 1-phosphate receptor modulator approved for use in adults with relapsing multiple sclerosis (MS). The efficacy and safety profile of fingolimod has been well characterized in a large clinical development program. Here, we report the safety and tolerability of fingolimod in relapsing-remitting MS (RRMS) patients from Latin America. METHODS: A total of 162 patients with RRMS, predominantly from Latin American countries (138/162), were enrolled in this 16-week, single treatment arm, open-label, multi-center study. Unlike the phase III pivotal studies, this study permitted enrollment of patients with controlled diabetes, certain cardiac and pulmonary conditions, older age, and higher baseline Expanded Disability Status Scale. All patients were monitored clinically for a minimum of 6 hours after the first dose. Safety and tolerability assessments were based on adverse events, clinically notable laboratory abnormalities, vital signs, ophthalmic examinations, and electrocardiograms. RESULTS: Overall, the safety and tolerability profile was consistent with that reported previously in phase 3 studies and the FIRST study. Adverse events (AEs) were predominantly mild (n = 49, 35.5%) or moderate (n = 27, 19.6%). Three patients (2.2%) discontinued fingolimod due to AEs. Infections were reported in 33 patients (23.9%) and were predominantly mild in nature (n = 28, 20.3%). Increases in alanine aminotransferase enzymes of ≥3, ≥5 and ≥10 upper limit of normal were reported in five (3.7%), three (2.2%) and one (0.7%) patients, respectively. Hypertension cases (n = 3; 2.2%) did not result in treatment discontinuation and were controlled with antihypertensive therapy. Following first-dose administration, the majority of patients (90.6%) were discharged at 6 h. During the first-dose monitoring, 5 cases of bradycardia were reported; none required extended monitoring or treatment for symptomatic bradycardia. CONCLUSION: The first dose of fingolimod 0.5 mg was well tolerated in RRMS patients from Latin America. The overall safety profile was clinically manageable and consistent with previous fingolimod studies. FUNDING: Novartis. TRIAL REGISTRATION: ClinicalTrials.gov #NCT01497262.

ENCOMS: Argentinian survey in cost of illness and unmet needs in multiple sclerosis.

UNLABELLED: The objective of the study was to assess the cost of multiple sclerosis (MS) patients in Argentina categorized by disease severity using a societal perspective. METHOD: Cross-sectional study including MS patients from 21 MS centers in 12 cities of Argentina. Patients were stratified by disease severity using the expanded disability status scale (EDSS) (group 1 with EDSS score between 0 and 3; group 2 with EDSS >3 and <7; group 3 with EDSS ≥7). Direct and indirect costs were analyzed for the second quarter of 2012 from public sources and converted to US Dollars. RESULTS: 266 patients were included. Mean annual cost per MS patient was USD 36,025 (95%CI 31,985-38,068) for patients with an EDSS between 0-3; USD 40,705 (95%CI 37,199-46,300) for patients with EDSS >3 and <7, and USD 50,712 (95%CI 47,825-62,104) for patients with EDSS ≥7. CONCLUSIONS: This is the first Argentine study evaluating the costs of MS considering disease severity.

ENCOMS: Argentinian survey in cost of illness and unmet needs in multiple sclerosis / ENCOMS: encuesta argentina sobre costos de la enfermedad y necesidades no cubiertas en pacientes con esclerosis múltiple

The objective of the study was to assess the cost of multiple sclerosis (MS) patients in Argentina categorized by disease severity using a societal perspective. Method: Cross-sectional study including MS patients from 21 MS centers in 12 cities of Argentina. Patients were stratified by disease severity using the expanded disability status scale (EDSS) (group 1 with EDSS score between 0 and 3; group 2 with EDSS >3 and <7; group 3 with EDSS ≥7). Direct and indirect costs were analyzed for the second quarter of 2012 from public sources and converted to US Dollars. Results: 266 patients were included. Mean annual cost per MS patient was USD 36,025 (95%CI 31,985-38,068) for patients with an EDSS between 0-3; USD 40,705 (95%CI 37,199-46,300) for patients with EDSS >3 and <7, and USD 50,712 (95%CI 47,825-62,104) for patients with EDSS ≥7. Conclusions: This is the first Argentine study evaluating the costs of MS considering disease severity. .

El objetivo del estudio fue evaluar el costo de los pacientes con esclerosis múltiple (EM) en Argentina categorizados por severidad de la enfermedad. Método: Estudio de corte transversal que incluyó pacientes con EM en 12 ciudades de Argentina. Los pacientes se estratificaron según expanded disability status scale (EDSS) (grupo 1 EDSS entre 0 y 3; grupo 2 EDDS >3 y <7; grupo 3 EDSS ≥7). Los costos directos e indirectos fueron analizados para el segundo trimestre de 2012 y convertidos a dólares estadounidenses. Resultados: 266 pacientes fueron incluidos. El coste medio anual por paciente con EM fue de USD 36,025 (31,985-38,068 IC95%) para los pacientes con un EDSS entre 0-3; USD 40,705 (37,199-46,300 IC95%) para los pacientes con EDSS >3 y <7 y USD 50,712 (47,825-62,104 IC95%) para los pacientes con EDSS ≥7. Conclusiones: Primer estudio argentino evaluar los costes de la EM considerado la gravedad de la enfermedad. .

Hemimasticatory spasm: report of a case and review of the literature†.

BACKGROUND: Hemimasticatory spasm is a very rare movement disorder characterized by unilateral, involuntary, paroxysmal contractions of the jaw-closing muscles, causing clinically brief twitches and/or spasms. CASE REPORT: A 62-year-old female consulted us with a 30-year history of unusual involuntary twitches in the preauricular region and spasms that hampered jaw opening. During these spasms, she could not open her mouth. On physical examination, we also observed hypertrophy of the masseter and temporalis muscles, which can be features of hemimasticatory spasm. She was treated with botulinum toxin type A, with excellent response. Here, we present her case and review the literature. DISCUSSION: Hemimasticatory spasm is a rare movement disorder. Given the excellent response to botulinum toxin type A treatment, it should be considered within the spectrum of facial spasms.

Síndrome de anemia cardiorrenal Studio de casos y controles anidado en una cohorte / Cardiorenal anemia syndrome Cohort nested case-control study

La enfermedad renal crónica (ERC) y la anemia son patologías coexistentes, complicaciones frecuentes y factores importantes de la progresión de la insuficiencia cardiaca (IC), por lo cual Silverberg (1) en 2006 denominó esta asociación síndrome de anemia cardiorrenal: CRAS (por su siglas en inglés: Cardio Renal Anemia Syndrome). Según el Primer Consenso Colombiano de CRAS en 2007 (2), se estableció el diagnóstico con base en los siguientes criterios: 1. IC: diagnosticada según los criterios de la Sociedad Europea de Cardiología, con signos y síntomas de IC y evidencia de disfunción sistólica o diastólica, de preferencia por ecocardiograma. 2. ERC: determinada por filtración glomerular (FG) < 60 cc / min. / 1.73 m2 3. Anemia: con hemoglobina (Hg) < 12 g/dL en mujeres y < 13 g/dL en hombres. Se calcula que hay más de cinco millones de pacientes con IC en EEUU y 550000 nuevos casos por año (3), mientras en Europa 15 millones de habitantes tiene IC (4). El CRAS se ha relacionado con aumento de la morbimortalidad en IC. La IC puede causar ERC progresiva y ambas pueden llevar a anemia, que su vez empeora la IC y la ERC (1).

Factores de riesgo de enfermedad renal crónica / Chronic renal disease risk factors / Fatores de risco de doença renal crônica

La enfermedad renal crónica es una patología muy frecuente asociado con múltiples coomorbilidades. La fisiopatología del daño endotelial es diferente en los pacientes con enfermedad renal crónica y en este es un campo de investigación en la actualidad. El propósito de esta revisión es analizar la evidencia actual alrededor de los diferentes factores de riesgo asociados con la aparición de enfermedad renal crónica...

The chronic renal disease is a very frequent pathology associated with multiple comorbidities. The pathophysiology of the endothelial damage is different in chronic renal disease patients and this is presently a research domain. The aim of this review is to analyze the current evidence around the different risk factors associated with the appearing of chronic renal disease...

A doença renal crônica é uma patologia muito frequente associada com múltiplas coomorbilidades. A fisiopatologia do dano endotelial é diferente nos pacientes com doença renal crônica e este é um campo de pesquisa na atualidade. O propósito desta revisão é analisar a evidência atual ao redor dos diferentes fatores de risco associados com a aparição de doença renal crônica...

Aneurisma cerebral posterior izquierdo segemento P2 / Posterior cerebral artery aneurysm at the left P2 segment

Objetivo. 1. Conocer, mediante la presentación de un caso, las distintas opciones para abordar quirúrgicamente a esta patología. 2. Destacar las dificultades y los cuidados que se deben tener al momento de abordar este tipo de aneurismas. Descripción. Paciente mujer de 48 años, que ingresa por cefalea, vómitos, rigidez de nuca, diplopía (Hunt y Hess II) y TAC de ingreso que muestra hemorragia subaracniodea (Fisher III). Con angiografía cerebral que evidencia aneurisma del segmento P2 de la arteria cerebral posterior.Intervención. Es intervenida quirúrgicamente realizándose un abordaje subtemporal consiguiéndose el clipado del aneurisma sin comprometer el segmento distal de la arteria. Conclusiones. Los aneurismas del segmento P2 son muy poco frecuentes y ofrecen grandes dificultades técnicas para su abordaje debido a su ubicación en la profundidad del lóbulo temporal en relación con las cisternas peritroncales. Todas las medidas que faciliten una menor retracción cerebral constituyen junto con el minucioso conocimiento anatómico de la zona, la base para el abordaje de los mismos, obteniéndose los mejores resultados.

¿Qué pasa con los pacientes luego de que ses diagnostica Apneas del Sueño? / What happens with patients after they have been diagnosed Sleep Apnea?

Numerosos pacientes con diagnóstico de SAHOS moderado severo no reciben finalmente tratamiento efectivo. El objetivo del estudio es evaluar el grado de utilización de las medidas terapéuticas necesarias entre estos enfermos y los motivos de no tratamiento o tratamiento insuficiente. Métodos: Muestra consecutiva de pacientes derivados al Laboratoriode Sueño del IADIN entre agosto y diciembre de 2006 con solicitud de Polisomnografía por síntomas de apneas del sueño, la que diagnosticó SAHOS moderado severo. Durante julio de 2007 se les realizó una encuesta telefónica. Resultados: 100 pacientes encuestados, 85 varones, IPR 51.9±30.9ev/h, edad 52,38±12.2, IMC 34.1±10.6.47 pacientes no hicieron tratamiento alguno. 52 comenzaron tratamiento con CPAP, pero 12 lo suspendieron. 2 pacientes fueron sometidos a tratamiento quirúrgico. 90 pacientespresentaban un IMC mayor de 25, 64p > 30 y 32p > 35. 30 consultaron un nutricionista, 21 pacientes bajaron de peso, solo 3 lograron bajar más del 20% del basal. Los pacientesno tratados presentaron un IPR menor (p 0.02). Conclusiones: Si bien se ha incrementado el nivel de conciencia y alerta acerca de las implicancias del SAHOS entre los médicos y en la población general, lo que acrecentó la pesquisa de estos cuadros, se detectanconsiderables fallas en la aplicación de los tratamientos necesarios para revertir el cuadro y prevenir las consecuencias que se le atribuyen.

Many patients with confirmed diagnosis of moderate to severe Sleep Apnea don’t receive efective treatment. The objective of this study is to evaluate the use of specific therapeutic measures in those subjects and to detect the posible reasons of ineffective treatment.Methods: consecutive sample of patients who attended to our Sleep Lab between August and December of 2006 for a PSG because of symptoms of sleep apneas, which diagnosed moderate to severe SAS. During july of 2007 a telephonic survey was performed. Results:100 patients surveyed, 85 males, AHI 51.9±30.9ev/h, age 52,38±12.2, BMI 34.1±10.6. 47 patients don’t received any treatament. 52 began nCPAP therapy, but 12 discontinued it later. 2 subjects received surgical treatment. 90 patients had a BMI >25, 64p >30 and32p >35. 30 visited a nutricionist; 21 patients were able to lose weight, but only 3 lost more than 20% from baseline. Untreated patients presented a smaller AHI (p 0.02). Conclusions: Although there is more consciusness and awareness regarding SAS and its consecuences between physicians and general population, we detected considerable failures in the onset of necesary treatment to revert the symptoms and prevent itsconsequences.

Compromiso renal en un paciente con esclerosis tuberosa / Kidney Affection in a Patient with Tuberous Sclerosis

La esclerosis tuberosa es una enfermedad hereditaria, autosómica dominante y multisistémica, que cursa generalmente con crisis de epilepsia, retraso mental y tumores benignos en el cerebro y en otros órganos vitales como riñones, corazón, ojos, pulmones y piel. Objetivo. Describir las características clínicas y la evolución de un paciente con esclerosis tuberosa. Diseño. Reporte de caso. Materiales y métodos. Se revisó y describió la historia clínica de un paciente que fue hospitalizado en el Hospital Universitario San Ignacio para trasplante renal de donante cadavérico con enfermedad renal estado 5, con antecedentes de esclerosis tuberosa. Posteriormente, se revisó la literatura existente acerca de ®esclerosis tuberosa y trasplante renal” en PubMed, Ovid y Highwire. Conclusiones. La esclerosis tuberosa es una enfermedad poco común en nuestro medio, con compromiso renal dado por angiomiolipomas, con progresión a falla renal y estado terminal, que requiere soporte dialítico, a mediano plazo.

Tratamiento quirúrgico de la miastenia gravis / Surgical treatment of myasthenia gravis

Antecedentes: Los avances en el estudio y tratamiento de la miastenia gravis (MG) han mejorado sustancialmente su pronóstico. La timectomía es considerada uno de los pilares terapéuticos en la MG generalizada. Objetivos: Presentar la experiencia de los últimos 30 años en el tratamiento clínico y quirúrgico de pacientes con MG. Lugar de aplicación: Centro Municipal de referencia de la Ciudad de Buenos Aires. Hospital Ramos Mejía. Material y Métodos: Desde marzo de 1974 hasta el mismo mes de 2004 se estudiaron 328 pacientes, con diagnóstico de MG. Se agruparon de acuerdo a la clasificación de Osserman. Se indicó la timectomía en 112 enfermos con cuadro clínico de MG generalizada leve a moderada (II A de Osserman) y aquellos con timomas. Las vías de abordaje fueron: 15 cervicotomías, 41 transsesternales verticales totales, 51 esternales verticales parciales, 3 esternales transversales y 2 toracotomías posterolaterales. La evolución clínica, fue clasificada de acuerdo a una escala convencional. Los datos obtenidos fueron procesados mediante los tests de T de Student y de Kruskall-Wellis. Resultados: Se observó una tendencia bimodal en las edades de comienzo de la MG; 65,5 por ciento eran mujeres. Se expone la efectividad de los distintos procedimientos diagnósticos. Se obtuvieron mejores resultados en los timectomizados que en los que recibieron sólo tratamiento médico; también en los menores de 35 años, pertenecientes al grupo IIa y operados antes de los dos años de comienzo de los síntomas; 4 pacientes fueron reintervenidos por persistencia de la sintomatología clínica asociada a la visualización de restos tímicos en las imágenes. Los 4 correspondían a hiperplasias tímicas y habían sido abordados por cervicotomías puras. Se reoperaron por vía transesternal vertical total, efectuándose vaciamientos mediastinales anteriores. Se describen los diagnósticos histopatológicos, 22 por ciento eran timomas. Una enferma falleció en el post operatorio inmediato. Conclusion...