Efficacy and Safety of Text Messages Targeting Adherence to Cardiovascular Medications in Secondary Prevention: TXT2HEART Colombia Randomized Controlled Trial.

BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality worldwide, with a prevalence of approximately 100 million patients. There is evidence that antiplatelet agents and antihypertensive medications could reduce the risk of new vascular events in this population; however, treatment adherence is very low. An SMS text messaging intervention was recently developed based on behavior change techniques to increase adherence to pharmacological treatment among patients with a history of ASCVD. OBJECTIVE: This study aims to evaluate the efficacy and safety of an SMS text messaging intervention to improve adherence to cardiovascular medications in patients with ASCVD. METHODS: A randomized controlled clinical trial for patients with a prior diagnosis of cardiovascular events, such as acute myocardial infarction, unstable angina, cerebrovascular disease, or peripheral artery disease, in one center in Colombia was conducted. Patients randomized to the intervention arm were assigned to receive SMS text messages daily for the first 4 weeks, 5 SMS text messages on week 5, 3 SMS text messages each in weeks 6 and 7, and 1 SMS text message weekly from week 8 until week 52. In contrast, patients in the control arm received a monthly SMS text message reminding them of the next study appointment and the importance of the study, requesting information about changes in their phone number, and thanking them for participating in the study. The primary endpoint was the change in low-density lipoprotein cholesterol (LDL-C) levels, whereas the secondary endpoints were the changes in thromboxane B2 levels, heart rate, systolic and diastolic blood pressure, medication adherence, cardiac and noncardiac mortality, and hospitalization. Linear regression analyses and bivariate tests were performed. RESULTS: Of the 930 randomized patients, 805 (86.5%) completed follow-up and were analyzed for the primary endpoint. There was no evidence that the intervention changed the primary outcome (LDL-C levels; P=.41) or any of the secondary outcomes evaluated (all P>.05). There was also no evidence that the intervention was associated with adverse events. CONCLUSIONS: In this study, there was no evidence that a behavior modification intervention delivered by SMS text messaging improved LDL-C levels, blood pressure levels, or adherence at 12 months. More research is needed to evaluate whether different SMS text messaging strategies, including personalized messages and different timings, are effective; future studies should include mixed methods to better understand why, for whom, and in which context (eg, health system or social environment) SMS text messaging interventions work (or not) to improve adherence in patients with ASCVD. TRIAL REGISTRATION: ClinicalTrials.gov NCT03098186; https://clinicaltrials.gov/ct2/show/NCT03098186. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2018-028017.

Revisión sistemática de nuevos anticoagulantes orales frente a warfarina en fibrilación auricular no valvular / Systematic review of new oral anticoagulants versus warfarin in non valvular atrial fibrillation

RESUMEN INTRODUCCIÓN: Los nuevos anticoagulantes orales son el más reciente avance en anticoagulación oral. Existen suficientes estudios publicados, pero muy poca síntesis de la información. MÉTODOS: Se realizó una búsqueda sistemática de los estudios en Medline, Cochrane y Embase con los términos predefinidos. Se aplicaron los criterios de inclusión y exclusión definidos, se definieron las variables utilizadas en este estudio según el beneficio (reducción de la mortalidad y reducción del ACV) y el riesgo en la anticoagulación (sangrado intracraneal, sangrado gastrointestinal, sangrado mayor y otros sangrados). Se seleccionaron los artículos y se extrajo la información en una hoja de cálculo para análisis. RESULTADOS: Se incluyeron 24 meta-análisis y 62 subanálisis; 77 % de los meta-análisis mostraron reducción de ACV, 65 % mortalidad, 71 % reportó disminución de hemorragia intracraneal y 45 % de sangrado mayor, pero hubo aumento de sangrado gastrointestinal en el 5 4% de los estudios. En relación a los resultados de los subanálisis, 4 estudios mostraron algún dato estadísticamente significativo para apixabán, 5 para dabigatrán, 3 para edoxabán y 5 estudios para rivaroxabán. Existen diferencias en algunas variables como sexo, riesgo de ACV, resultados a 30 días, función renal; diferentes dosis (dabigatrán y edoxabán), según la edad, síntomas gastrointestinales, relación con el INR; niveles séricos del medicamento, uso de amiodarona, uso previo de warfarina; enfermedad arterial periférica, transición a warfarina; factores de riesgo de HGI y sangrado mayor para cada anticoagulante en particular. CONCLUSIONES: Los nuevos anticoagulantes orales muestran mejor perfil de seguridad y de eficacia frente a warfarina.

SUMMARY INTRODUCTION: New oral anticoagulants are the latest advancement in oral anticoagulation. Several studies are published, but a few studies of synthesis information. METHODS: A systematic review of the studies in MEDLINE, COCHRANE and EMBASE was performed with the predefined terms. The defined inclusion and exclusion criteria were applied; variables used in this study were defined according to benefits (reduction of mortality and reduction of stroke) and anticoagulation risks (intracranial bleeding, gastrointestinal bleeding, major bleeding and other bleeding). Articles were selected and information was extracted into a spreadsheet for analysis. RESULT: Were included 24 meta-analyzes and 62 sub-analyzes; 77% of meta-analyzes showed stroke reduction, 65% in mortality, 71% reported decreased of intracranial hemorrhage and 45% in major bleeding, but there was an increase in gastrointestinal bleeding in 54% of the studies. Regarding the results of the sub-analysis, 4 studies for apixaban, 5 for dabigatran, 3 for edoxaban and 5 studies for rivaroxaban showed some statistically significant data. There are differences in some variables such as sex, stroke risk, 30-day results, renal function; Different doses (dabigatran and Edoxaban), according to age, gastrointestinal symptoms, relation with INR; Serum levels of the drug, use of amiodarone, prior use of warfarin; Peripheral arterial disease, transition to warfarin; Risk factors for gastrointestinal bleeding and major bleeding for each particular anticoagulant. CONCLUSION: The new oral anticoagulants shows better safety and efficacy profile against Warfarin.

Repetitive Transcranial Magnetic Stimulation for Phantom Limb Pain in Land Mine Victims: A Double-Blinded, Randomized, Sham-Controlled Trial.

UNLABELLED: We evaluated the effects of repetitive transcranial magnetic stimulation (rTMS) in the treatment of phantom limb pain (PLP) in land mine victims. Fifty-four patients with PLP were enrolled in a randomized, double-blinded, placebo-controlled, parallel group single-center trial. The intervention consisted of real or sham rTMS of M1 contralateral to the amputated leg. rTMS was given in series of 20 trains of 6-second duration (54-second intertrain, intensity 90% of motor threshold) at a stimulation rate of 10 Hz (1,200 pulses), 20 minutes per day, during 10 days. For the control group, a sham coil was used. The administration of active rTMS induced a significantly greater reduction in pain intensity (visual analogue scale scores) 15 days after treatment compared with sham stimulation (-53.38 ± 53.12% vs -22.93 ± 57.16%; mean between-group difference = 30.44%, 95% confidence interval, .30-60.58; P = .03). This effect was not significant 30 days after treatment. In addition, 19 subjects (70.3%) attained a clinically significant pain reduction (>30%) in the active group compared with 11 in the sham group (40.7%) 15 days after treatment (P = .03). The administration of 10 Hz rTMS on the contralateral primary motor cortex for 2 weeks in traumatic amputees with PLP induced significant clinical improvement in pain. PERSPECTIVE: High-frequency rTMS on the contralateral primary motor cortex of traumatic amputees induced a clinically significant pain reduction up to 15 days after treatment without any major secondary effect. These results indicate that rTMS is a safe and effective therapy in patients with PLP caused by land mine explosions.

Respuesta inflamatoria en pacientes con un primer ataque cerebrovascular isquémico: evaluación por género / Inflammatory response in a first ischemic stroke: differences by gender

Introducción. Se han descrito diferencias por género en la incidencia, la severidad y mortalidad asociadas al ataque cerebrovascular isquémico. Objetivo. Describir el comportamiento de la respuesta inflamatoria en hombres y mujeres con un primer episodio de ACV isquémico. Material y Métodos. Se incluyeron 50 mujeres postmenopáusicas mayores de 45 años y 50 hombres mayores de 45 años con un primer episodio de ataque cerebrovascular isquémico. Se evaluaron y analizaron diferencias en la presentación de síntomas, antecedentes, severidad, respuesta inflamatoria y mortalidad entre ambos géneros. Resultados. Las mujeres tuvieron un promedio de edad mayor al momento de presentar un primer ataque cerebrovascular isquémico (72,9 ± 9,8 años vs. 69,7 ± 9,03 años; p= 0,09), sin diferencias en la severidad del evento (mediana NIHSS 10,4 ± 7,61 en mujeres vs. 10,46 ± 4,96 en hombres), con mayores niveles de colesterol total (216,39 ± 50,61 vs. 188,76 ± 49,56; p=0,007), LDL (140,40 ± 39,57 vs. 121,3 ± 45,36; p=0,032), HDL (44,69 ± 15,52 vs. 37,67 ± 12,23; p= 0,013), triglicéridos (158,03 ± 74,65 vs. 144,05 ± 55,64; p=0,291) y glicemia (142,77 ± 71,60 vs. 138,16 ± 115,75; p=0,826), menor respuesta inflamatoria evaluada por PCR ultrasensible, IL-6 y TNFα, y mortalidad hospitalaria que los hombres (6,52% vs. 14%; p=0,231). Conclusión. Se propone que las diferencias por género en el comportamiento del ACV isquémico observadas en este estudio podrían ser explicadas por la protección cardiovascular hormonal extendida o la existencia de factores inherentes en las mujeres que les confieren un estado de protección ante un ACV isquémico.

Introduction. Controversy persists regarding gender differences in the incidence, severity and mortality associated with ischemic stroke. Objective. To describe the inflematory response in patients with a first ischemic stroke behavior in women and men over 45 year-old. Materials and Methods. 50 postmenopausal women and 50 men, over 45 years old with a first-ever ischemic stroke were included. Differences in symptoms, medical history, severity, inflammatory response and mortality were evaluated and analyzed among both genders. Results: Postmenopausal women were older at the first-ever ischemic stroke (72,9 + 9,8 years vs. 69,7 + 9,03 years, p=0,09), with no differences in stroke severity (NIHSS median score 10,4 + 7,61 in women vs. 10,46 + 4,96 in men), with higher levels of total cholesterol (216,39 + 50,61 vs. 188,76 + 49,56; p=0,007), LDL cholesterol (140,40 + 39,57 vs. 121,3 + 45,36; p=0,032), HDL cholesterol (44,69 + 15,52 vs. 37,67 + 12,23; p= 0,013), triglycerides (158,03 + 74,65 vs. 144,05 + 55,64; p=0,291) and blood glucose (142,77 + 71,60 vs. 138,16 + 115,75; p=0,826); less inflammatory response assessed by CRP, IL-6 and TNF-α, and hospital mortality than men (6,52% vs. 14%, p=0,231). Conclusion. Gender differences in ischemic stroke behavior observed in this study could be explained by the cardiovascular protection of premenopausal hormonal factors or inherent factors in women that confers a protection state against ischemic stroke.

[Correlation between socioeconomic factors and in-hospital mortality from ischemic stroke in a hospital cohort in Colombia, 2003-2006]. / Asociación entre factores socioeconómicos y mortalidad intrahospitalaria por accidente cerebrovascular isquémico en una cohorte hospitalaria de Colombia, 2003-2006.

OBJECTIVE: To determine if there is a correlation between socioeconomic conditions and in-hospital mortality (IHM) from ischemic stroke in a sample of the Colombian population and identify the chain of events that determine that association. METHODS: Prospective study of a hospital cohort of patients with ischemic stroke in four Colombian clinical referral institutions-located in Floridablanca, Bucaramanga, Bogotá, and Medellín-between February 2003 and December 2006. Hierarchical analysis was used to group the socioeconomic variables into three levels, and their relationship to IHM due to ischemic stroke was assessed in a Cox proportional hazards model. RESULTS: The IHM rate was 9.4% in the 253 patients included in the study. In the analysis by levels, mortality was inversely associated with educational level (advanced to primary), monthly income (≥ minimum wage), and participation in the contributory health system. When the three levels were combined in the hierarchical analysis, affiliation with the contributory system was the only association that maintained its statistical significance (RR 0.35; CI 95%: 0.13-0.96; P = 0.04). CONCLUSIONS: The results indicate that, in Colombia, being affiliated with the contributory health system is an independent protective factor against IHM after an ischemic stroke. The education-income-access to health services sequence is a possible explanation for the relationship between socioeconomic conditions and the clinical outcome of these events. Strategies should be designed to mitigate the differences in the quality and distribution of health services in the Colombian population.

Hidrocefalia y aracnoiditis en neurocisticercosis / Hydrocephalus and arachnoiditis in neurocysticercosis

La neurocisticercosis es una enfermedad con alta prevalencia en países tropicales y de bajos recursos, sin embargo su incidencia ha aumentado en países desarrollados. Este es el caso de una mujer de 49 años con neurocisticercosis subaracnoidea generalizada asociada a compromiso encefálico y medular, una presentación rara de este parásito neurotrópico,con convulsiones y limitación motora severa. Las imágenes muestran respuesta inflamatoria generalizada del cerebro y el espacio subaracnoideo, hidrocefalia y múltiples lesiones calcificadas, reafirmando la importancia de las neuroimágenes para la correlación clínica y el diagnóstico de las enfermedades infecciosas cerebrales como la neurocisticercosis, con variabilidad en la presentación y múltiples compromisos del sistema nervioso central.

Neurocysticercosis is a disease of high prevalence in tropical and low-income countries and its incidence has been increased in developed countries. This is the case of 49-year-old woman with generalized subarachnoid neurocysticercosis associated to encephalic and medullar compromise, a rare presentation of this neurotropic parasite, with seizures and severe motor limitation. Images showed generalized inflammatory response of the brain and spinal subarachnoid space, hydrocephalus and multiple calcified lesions, demonstrating and reaffirming the importance of neuroimaging tools for the clinical correlation and diagnosis of brain infectious diseases as neurocysticercosis with variability on the presentation and multiple central nervous system involvement.

Asociación entre factores socioeconómicos y mortalidad intrahospitalaria por accidente cerebrovascular isquémico en una cohorte hospitalaria de Colombia, 2003-2006 / Correlation between socioeconomic factors and in-hospital mortality from ischemic stroke in a hospital cohort in Colombia, 2003-2006

OBJETIVO: Determinar si existe asociación entre las condiciones socioeconómicas y la mortalidad intrahospitalaria (MIH) por accidente cerebrovascular (ACV) isquémico en una muestra de población colombiana e identificar la cadena de eventos que determinan esa asociación. MÉTODOS: Estudio prospectivo de una cohorte hospitalaria de pacientes con ACV isquémico registrados en cuatro instituciones clínicas de referencia colombianas -ubicadas en Floridablanca, Bucaramanga, Bogotá y Medellín- entre febrero de 2003 y diciembre de 2006. Mediante análisis jerárquico se evaluaron las variables socioeconómicas agrupadas en tres niveles para determinar su relación con la MIH por ACV isquémico en un modelo de riesgos proporcionales de Cox. RESULTADOS: En los 253 pacientes incluidos, la MIH fue de 9,4 %. En el análisis por niveles, la mortalidad estuvo inversamente asociada con el nivel educacional (estudios superiores a primaria), los ingresos mensuales (≥ salario mínimo) y la vinculación al régimen contributivo. En el análisis jerárquico, al combinar los 3 niveles, solo la asociación inversa con la afiliación al régimen contributivo mantuvo su significación estadística (RR 0,35; IC95%: 0,13-0,96; P = 0,04). CONCLUSIONES: Los resultados indican que en Colombia, el estar afilado al régimen contributivo de salud es un factor protector independiente contra la MIH tras un ACV isquémico. La secuencia educación-ingresos-acceso a servicios de salud constituye una vía de explicación de la relación entre las condiciones socioeconómicas y el desenlace clínico de estos eventos. Se deben diseñar estrategias para mitigar las diferencias en la calidad y la distribución de los servicios de salud en la población colombiana.

OBJECTIVE: To determine if there is a correlation between socioeconomic conditions and in-hospital mortality (IHM) from ischemic stroke in a sample of the Colombian population and identify the chain of events that determine that association. METHODS: Prospective study of a hospital cohort of patients with ischemic stroke in four Colombian clinical referral institutions-located in Floridablanca, Bucaramanga, Bogotá, and Medellín-between February 2003 and December 2006. Hierarchical analysis was used to group the socioeconomic variables into three levels, and their relationship to IHM due to ischemic stroke was assessed in a Cox proportional hazards model. RESULTS: The IHM rate was 9.4% in the 253 patients included in the study. In the analysis by levels, mortality was inversely associated with educational level (advanced to primary), monthly income (≥ minimum wage), and participation in the contributory health system. When the three levels were combined in the hierarchical analysis, affiliation with the contributory system was the only association that maintained its statistical significance (RR 0.35; CI 95%: 0.13-0.96; P = 0.04). CONCLUSIONS: The results indicate that, in Colombia, being affiliated with the contributory health system is an independent protective factor against IHM after an ischemic stroke. The education-income-access to health services sequence is a possible explanation for the relationship between socioeconomic conditions and the clinical outcome of these events. Strategies should be designed to mitigate the differences in the quality and distribution of health services in the Colombian population.

Cefaleas secundarias a alteraciones vasculares cerebrales / Headache secondary to cerebrovascular disorders

Las cefaleas vasculares secundarias conforman el grupo 6 de la clasificación de la Sociedad Internacional de Cefaleas, las más importantes son la hemorragia subaracnoidea, el infarto cerebral, la trombosis venosa cerebral, la hemorragia intracerebral y el síndrome de Sturge-Weber. La cefalea puede ser el primer síntoma de una alteración vascular cerebral, por lo cual es importante considerar siempre esa posibilidad cuando llega un paciente con cefalea intensa, para establecer un diagnóstico y un tratamiento oportuno, que puede salvar la vida de los pacientes. Las neuroimágenes son una herramienta de gran ayuda para el diagnóstico de estas enfermedades. En este artículo se describen las manifestaciones clínicas, la fisiopatología, los métodos de diagnóstico y el tratamiento de estas alteraciones.

In the classification of the International Society of Headaches, secondary headaches atributed to vascular disorders are included in the Group 6, the most important are subarachnoid hemorrhage, cerebral infarction, venous cerebral thrombosis, intracerebral hemorrhage and the Sturge-Weber syndrome. The headache can be the first symptom of a cerebral vascular alteration, and for this reason it is important to consider always this possibility in patients with severe pain, to establish an opportune diagnosis and treatment which can save the live of the patient. Neuroimages are helpful tools for the diagnosis of these disorders. In the present review are described the clinical manifestations, pathophysiology, diagnoses and treatment of these alterations.