We review post-infectious and post-vaccination neurological syndromes involving peripheral and central nervous system (CNS) and report an illustrative case of simultaneous occurrence of Guillain-Barré syndrome (GBS), confirmed by nerve conduction velocities, plus MRI-demonstrated transverse myelitis (TM) and acute encephalitis [acute disseminated encephalomyelitis] (ADEM+GBS) affecting a 24-year-old woman from Cúcuta, Colombia, who developed acute Zika virus (ZIKV) infection confirmed by serum reverse transcriptase-polymerase chain reaction (RT-PCR) and convalescent ZIKV IgG antibodies. With intensive care treatment, respiratory support, steroids, and intravenous immunoglobulin (IVIg), patient survived with residual flaccid paraparesis. She had preexisting immunity against Chikungunya virus (CHIKV) and Dengue virus (DENV) acquired before the arrival of ZIKV in Colombia. From reports in the Caribbean, Central and South America we review 19 cases of ZIKV-associated TM, encephalitis and ADEM occurring after a mean latent period of 10.5 days (range 1-96) post-infection. Although GBS and ADEM are usually considered post-infectious and associated with development of antibodies against peripheral nerve and CNS epitopes, we postulate that our case of ADEM+GBS is para-infectious, induced by acute ZIKV neurotropism boosted by active immunity against other arboviruses. Animal models of ZIKV demonstrated strong viral neurotropism enhanced by passive immunity with antibodies against arboviruses such as West Nile virus, CHIKV, or DENV. These considerations are relevant to prevent potential ZIKV vaccine-induced reactions involving central and peripheral nervous system.

In the last decade, efforts have been made in Latin America and the Caribbean to advance in the methodological development of evidence based clinical practice guidelines, among other strategies to improve the health provision of services and indicators. To build an evidence map to show the regional GRADE impact in developing clinical practice guidelines and contrast the results with current needs. A systematic literature search was conducted in databases, developer’s websites, health ministries, repositories and grey literature. Documents were included when they were evidence based clinical practice guidelines developed in Latin American and Caribbean countries in the last decade. Data from the Global Burden of Disease was used to highlight relevant health conditions. Nine thousand seven hundred seventy-six documents were retrieved. 98 guidelines, with specific mention of the use of GRADE methodology were identified. 81% of the guidelines were developed within the last 4 years. 68% are from Colombia, 13% from Peru, 9% from Chile, 3% from Argentina and Costa Rica and Brazil, Honduras and Dominican Republic account 1%. 67% were developed for non-communicable diseases, 10% for communicable diseases, 9% for neonatal pathologies and 5% for maternal problems, 1% injuries and 7% other topics (nutrition, oral health). Our findings show a slow and increasing incorporation of the GRADE methodology in the region. GRADE guidelines have been adopted mainly by Colombia and slowly by other countries. Topics for guidelines continue to be comparable to the high-income countries and they don’t address communicable diseases or other relevant health issues in the region, such as violence or malnutrition; thus, the evidence based guidelines for clinical practice are only a tool within a complex multimodal strategy to tackle the challenges of the health determinants. A prioritizing strategy for relevant regional health topics and the use of robust methodological approaches must be in the political agenda in the region. GRADE methods could help to improve the quality and validity of recommendations not only for chronic pathologies but also for ancient and challenging maladies prevalent in the region, as part of a multimodalintersectoral strategy.

Background: Biomarkers are essential for identification of individuals at high risk of mild cognitive impairment (MCI) for potential prevention of dementia. We investigated DNA methylation in the APOE gene and apolipoprotein E (ApoE) plasma levels as MCI biomarkers in Colombian subjects with MCI and controls. Methods: In total, 100 participants were included (71% women; average age, 70 years; range, 43–91 years). MCI was diagnosed by neuropsychological testing, medical and social history, activities of daily living, cognitive symptoms and neuroimaging. Using multivariate logistic regression models adjusted by age and gender, we examined the risk association of MCI with plasma ApoE and APOE methylation. Results: MCI was diagnosed in 41 subjects (average age, 66.5 ± 9.6 years) and compared with 59 controls. Elevated plasma ApoE and APOE methylation of CpGs 165, 190, and 198 were risk factors for MCI (p < 0.05). Higher CpG-227 methylation correlated with lower risk for MCI (p = 0.002). Only CpG-227 was significantly correlated with plasma ApoE levels (correlation coefficient = −0.665; p = 0.008). Conclusion: Differential APOE methylation and increased plasma ApoE levels were correlated with MCI. These epigenetic patterns require confirmation in larger samples but could potentially be used as biomarkers to identify early stages of MCI.

Few methodological studies address the prioritization of clinical topics for the development of Clinical Practice Guidelines (CPGs). The aim of this study was to validate a methodology for Priority Determination of Topics (PDT) of CPGs. Firstly, we developed an instrument for PDT with 41 criteria that were grouped under 10 domains, based on a comprehensive systematic search. Secondly, we performed a survey of stakeholders involved in CPGs development, and end users of guidelines, using the instrument. Thirdly, a pilot testing of the PDT procedure was performed in order to choose 10 guideline topics among 34 proposed projects; using a multi-criteria analysis approach, we validated a mechanism that followed five stages: determination of the composition of groups, item/domain scoring, weights determination, quality of the information used to support judgments, and finally, topic selection. Participants first scored the importance of each domain, after which four different weighting procedures were calculated (including the survey results). The process of weighting was determined by correlating the data between them. We also reported the quality of evidence used for PDT. Finally, we provided a qualitative analysis of the process. The main domains used to support judgement, having higher quality scores and weightings, were feasibility, disease burden, implementation and information needs. Other important domains such as user preferences, adverse events, potential for health promotion, social effects, and economic impact had lower relevance for clinicians. Criteria for prioritization were mainly judged through professional experience, while good quality information was only used in 15% of cases. The main advantages of the proposed methodology are supported by the use of a systematic approach to identify, score and weight guideline topics selection, limiting or exposing the influence of personal biases. However, the methodology was complex and included a number of quantitative and qualitative approaches reflecting the difficulties of the prioritization process.

La enfermedad de Alzheimer (EA) es la más común de las demencias; es un problema de salud pública en el Mundo, pero en Colombia no hace parte de las prioridades del Estado. El presente ensayo aborda cómo el sistema de salud colombiano reconoce, identifica y provee servicios a los pacientes con EA, desde una óptica de la Justicia Social. En primera medida se evalúa la información generada por la academia, su correlato con la normativa vigente y su articulación. Se explora la lógica utilitarista del sistema de salud colombiano y el incentivo a la maximización de ganancias de los aseguradores y cómo esto ha llevado a los pacientes a exigir la restitución de derechos a través de la acción de tutela. Se explora el sistema de codificación y diagnostico usado para la generación de información y como esta es imprecisa en los canales de información consolidada. Por otra parte, se valora como el rol de la familia se hace parte fundamental del proceso, y cómo esta termina siendo víctima del mismo. Finalmente, se plantea reflexiones de cómo pueden abordarse las dificultades identificadas desde una perspectiva de la Justicia Social.