Scielo RSS <![CDATA[Revista médica de Chile]]> https://scielo.conicyt.cl/rss.php?pid=0034-988720170010&lang=en vol. 145 num. 10 lang. en <![CDATA[SciELO Logo]]> https://scielo.conicyt.cl/img/en/fbpelogp.gif https://scielo.conicyt.cl <![CDATA[Direct antivirals for the treatment of chronic hepatitis C virus infection. Experience in 106 patients]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001235&lng=en&nrm=iso&tlng=en Background: The availability of direct-acting antivirals (DAA) for the treatment of chronic hepatitis C virus (HCV) infection is just starting to expand in Chile. Aim: To report the initial experience of patients treated with DAA and their evolution after treatment. Material and Methods: Prospective cohort study, from June 2013 to August 2016 of patients treated with DAA for HCV in three clinical centers. The presence of cirrhosis, clinical and laboratory features; adverse events (AE) and post-treatment changes in liver function were evaluated. Sustained viral response at 12 weeks post-treatment (SVR12) was determined. Results: One hundred six patients aged 58 ± 13 years, 54% males, were included. HCV genotype 1b was present in 88% and 47% had cirrhosis. Treatment regimens were asunaprevir + daclatasvir (DCV) in 17% of patients, paritaprevir / ritonavir / ombitasvir + dasabuvir in 33%, sofosbuvir (SOF) + DCV in 19%, and SOF + ledipasvir in 30%. Twenty five percent of patients used generic drugs. SVR12 was 92.1%, with no differences between generic and brand-name drugs. Serious AE were recorded in 22% of patients, being more common in those with cirrhosis (34% vs 11.5%, p &lt; 0.01). At 12 weeks post-treatment follow-up, there was a decrease in aminotransferase values (p &lt; 0.01), improvement in Child-Pugh score (5.9 vs. 5.5, p = 0.03) and decreased presence of ascites (p = 0.02). Conclusions: In our setting, DAA for HCV was highly effective and safe in non-cirrhotic patients. Hepatic function and inflammation improved at 12 weeks of follow-up. AE were common in patients with cirrhosis, suggesting that these patients should be treated by experienced teams. Generic drugs had similar effectiveness compared to originals. <![CDATA[Effectiveness and safety of oral anticoagulation treatment with acenocoumarol in non-valvular atrial fibrillation]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001243&lng=en&nrm=iso&tlng=en Background: Vitamin K antagonists significantly decrease the incidence of stroke but increase the risk of bleeding. Aim: To assess the effectiveness and risk of bleeding of vitamin K antagonists in non-valvular atrial fibrillation. Material and Methods: Retrospective cohort study of 524 patients, 236 women (45%) and 288 men (55%) with non-valvular atrial fibrillation (NVAF) admitted to the oral anticoagulation treatment (OAT) clinic at four public hospitals, between 2009 and 2012. They were followed until March 2013, measuring the quality of OAT, ischemic and bleeding events. Results: The mean follow-up was 26.1 months, with 1,154.7 person-years of follow-up accrued. The percentage of time in therapeutic range (TTR) was 35.2 ± 18%; this was deemed to represent the quality of OAT. The cumulative incidence of ischemic events, either stroke or systemic embolism, was 2.25/100 person-years, being greater in patients with previous embolism (Risk ratio 5.21, 95% confidence intervals 2.31– 11.73, p &lt; 0.01). The cumulative incidence of major bleeding events-extracranial and intracraneal-was 4.08/100 person-years. The main site of extracranial major bleeding was the gastrointestinal tract (32%). Conclusions: In our clinical practice, the effectiveness of OAT with acenocoumarol in NVAF patients is similar to that published abroad. However, the incidence of bleeding complications is higher. The quality of the OAT measured by the TTR was lower than abroad. <![CDATA[Electrophysiological severity of carpal tunnel syndrome according to age in adult patients]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001252&lng=en&nrm=iso&tlng=en Background: Carpal tunnel syndrome (CTS) represents 90% of entrapment neuropathies. Severity may be greater in older patients. Aim: To describe the electrophysiological findings in adult patients with CTS and determine if severity is related to age. Material and Methods: Descriptive and retrospective study of electrophysiological findings in patients over 18 years of age with clinical suspicion of CTS, studied between January 2011 and December 2015. Neurophysiological severity was classified in 3 grades, comparing them by age, gender and laterality. Results: Of 1156 patients subjected to electrophysiological studies due to a clinical suspicion of CTS, 690 (60%) had electrophysiological features of the disease. In 274 patients (24%) the compromise was mild, in 162 (14%) it was moderate and in 254 (22%) it was severe. There was a positive association between age and CTS severity (p &lt; 0.01). Severity was significantly greater in males than females (p &lt; 0.01). Bilateral CTS was present in 471 patients (68%), which was associated with increased age and severity (p &lt; 0.01). Conclusions: Electrophysiological severity in CTS increases with age. Other factors associated with higher severity are male gender and bilateral disease. <![CDATA[Correlates of physical inactivity: Findings from the Chilean National Health Survey 2009-2010]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001259&lng=en&nrm=iso&tlng=en Background: Physical inactivity is an important risk factor for cardiovascular diseases. Aim: To identify factors associated with physical inactivity in Chilean adults. Material and Methods: Participants from the Chilean Health Survey (5,133 individuals) were included in this study. Physical activity was measured using the Global physical activity questionnaire (GPAQ). Physical inactivity was defined as &lt; 600 MET. min.week−1 of moderate to vigorous intensity physical activity. Logistic regression was used to identify correlates of physical inactivity. Results: The main finding of this study were that women (odds ratio (OR): 1.51 [95% confidence intervals (CI): 1.32-1.72]) were more likely to be inactive compared to men and that older adults were more likely to be inactive than their younger or middle age counterparts (OR: 3.06 [95% CI: 2.45-3.82]). Other correlates of physical inactivity were individuals with obesity (OR: 1.43 [95% CI: 1.20-1.70]), diabetes (OR: 1.96 [95% CI: 1.61-2.38]), hypertension (OR: 1.72 [95% CI: 1.50-1.97]), metabolic syndrome (OR: 1.42 [95% IC: 1.18-1.70]), a low education level (OR: 1.26 [95% CI: 1.06-1.49]) and higher levels of sedentary behavior (OR: 2.77 [95% CI: 2.36-3.25]). Conclusions: Women, older people and sedentary subjects with chronic non-transmissible conditions are at higher risk of being physically inactive. <![CDATA[Tako-tsubo syndrome. Analysis of 37 cases]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001268&lng=en&nrm=iso&tlng=en Background: Tako-tsubo Syndrome (TTS) is characterized by transient regional systolic dysfunction of the left ventricle (LV), mimicking myocardial infarction. It accounts for 0.9-1.2% of all acute coronary syndromes (ACS). Aim: To describe the incidence and characteristics of TTS within our population. Material and Methods: All patients diagnosed with ACS and TTS were selected from a clinical registry of all the coronary angiographies done in our hospital. Clinical features during initial presentation, hospital evolution and one year follow-up were analyzed. Results: The first case diagnosed in our hospital occurred in 2001. Since then, 4,433 coronary angiographies were done to patients with ACS until 2014 and 37 corresponded to TTS (0.83% incidence). The mean age of patients was 64 years, 73% were female, and 62% had hypertension. All patients had an identifiable trigger factor, abnormal EKG and elevated troponin. The coronary angiography did not show lesions in 97%. However, all had the characteristic extensive segmental-motility alteration with a mean ejection fraction of 44%. All patients were treated initially as an ACS. Seven patients had complications, namely acute cardiac failure in six and stroke in one. No patient died. At one year of follow-up, 100% showed normal segmental motility and ejection fraction, no patient had a new episode of TTS and all were alive. Conclusions: TTS is rare and the incidence found in this study is slightly lower than that reported elsewhere. TTS mimics ACS and it should be suspected by its clinical, electrocardiographic and enzymatic particularities. Coronary angiography helps to rule out other diagnosis. All patients normalize motility and ventricular function, which is the definitive differential feature respect to ACS. <![CDATA[Impact of different overhead cost allocation methods of public hospitals on the cost-effectiveness ranking of 47 health programs]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001276&lng=en&nrm=iso&tlng=en Background: Costs allocation methods are important for economic evaluation of health care. Aim: To evaluate the impact of overhead costs rates of different hospitals on the cost-effectiveness rankings of health programs. Material and Methods: Using the cost reports from eight hospitals, a Montecarlo simulation was implemented, programming the complete micro-costing algorithm to calculate the final cost of 47 health care interventions, from the health sector perspective. The independent variables considered were the overhead cost rates per establishment and the actual overhead costs. Changing these variables, resulted in changes of the final cost of interventions and cost-effectiveness ratios. Finally the probabilities of changes in the cost-effectiveness ranking of each intervention were calculated. Results: Thirteen programs did not change their ranking order. However, 34 interventions modified their position with different occurrence probabilities. In the new proposed ranking, 21 programs changed their position from one to six places. Conclusions: Different overhead cost rates, representing different assignation forms, have a relative impact in the cost-effectiveness order. Montecarlo simulation can help to improve the accuracy of ranking assignment. <![CDATA[Interdisciplinary experience for the design of health care products]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001289&lng=en&nrm=iso&tlng=en Background: Training of innovative health professionals is necessary for the development of an effective health system in a limited resources context. However, the professionals underestimate their innovative role and receive sparse training in this issue. Meanwhile, industrial designers are trained to innovate but have a weak knowledge about health issues. Aim: To describe the outcomes of a study based on Challenge-Based Learning (CBL) where health and industrial design students learned about product development aimed to solve health problems. Material and Methods: Twenty industrial design students, seven health care students and nine teachers of both disciplines participated in a User Centered Design workshop. Using the CBL method, they were challenged to develop products to tackle a health problem. At the end of the challenge, teachers and students evaluated the products using a semantic differential method and answered a questionnaire assessing the activity. Results: In the semantic differential method, all participants evaluated usefulness, functionality and organization of the product rather than its originality. The greatest discrepancies in evaluation were found between design and health teachers. Students positively evaluated the challenge, although the weakest point was its coordination. Conclusions: CBL and interdisciplinary work are adequate tools for the development of innovative competences, as well as understanding the central elements of innovation. <![CDATA[Psychosocial risks and professional integration of foreign physicians: a study on conflict management in Chile]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001300&lng=en&nrm=iso&tlng=en Background: The way in which communicative conflicts are confronted, as part of the acculturation process, can constitute a psychosocial risk factor that may affect the effectiveness of health care delivery. Aim: To describe the levels of dominance, adaptability and evasion as indicators of the way in which conflict situations are faced in the workplace by foreign physicians in the management of communicative conflicts. Materials and Methods: A self-report questionnaire was answered by 51 foreign physicians (63% women, 76% Venezuelans, 64% aged between 31 and 40 years old) who work in public healthcare institutions in a southern region of Chile. Results: The highest scores were recorded for the adaptable style of conflict management (69%), while the lowest scores were recorded for the evasive style (6%). Higher levels of dominance were identified for women than for men. There was a positive association between dominance and time progression, where the level of dominance increased as participants gained greater professional experience and workplace seniority. Conclusions: The foreign physicians who participated in this study have a clear constructive attitude towards the negotiation of conflicts. However, this effort to adapt can also become a psychosocial risk factor that affects professional integration in intercultural workplace contexts. <![CDATA[Out of hospital cardiac arrest events at an urban Hospital in Chile]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001308&lng=en&nrm=iso&tlng=en Background: The incidence of out of hospital cardiac arrest (OHCA) is approximately 20 to 140 per 100.000 inhabitants. International registries, based on Utstein criteria have allowed standardized reporting of OHCA profiles and outcomes in different countries. We proposed to create a local OHCA registry. Aim: To assess the quality of the information about OHCA currently recorded in medical records according to Utstein guidelines. Material and Methods: A retrospective analysis of medical records of patients arriving in the emergency room of a public hospital with OHCA during a 3-year period. Data regarding the patient characteristics, event and outcomes were analyzed. Results: During the revision period, 317 patients arrived with an OHCA. None of the medical records had complete data on items that are considered a minimum requirement by Utstein guidelines. Mean age of patients was 63 years old, 60% were men, the most common arrest rhythm was asystole (43%) and 8% of patients were discharged alive. Conclusions: Data recorded in medical records is insufficient to inform the profile of OHCA. A prospective registry is currently being implemented based on the information provided by this study. This registry should optimize reporting and data analysis. <![CDATA[Decision making and consents given by demented patients. Are they valid?]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001312&lng=en&nrm=iso&tlng=en In Chile, more than 180 thousand people (1% of the population) have some form of dementia. The figure should increase to approximately 600,000 (3% of Chileans) by 2050. This disease poses major challenges to the society. One of them is the effective recognition of the autonomy and responsibility of the person living with this condition. This article aims to review the clinical assessment of competence, its agreement with the Chilean legal system and the challenges that the assessment of competence poses in clinical decision-making and the capacity of an individual make decisions, according to the new international obligations subscribed by Chile. It is concluded that inclusion is a pending challenge, reflected among other things, by the non-compliance with binding rules such as Article 12 of the Convention on the Rights of Persons with Disabilities, which affirms that persons with disabilities have the right to be recognized as a person everywhere, before the law. <![CDATA[Prognostic factors of ulcerative colitis at the moment of diagnosis]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001319&lng=en&nrm=iso&tlng=en The clinical presentation of ulcerative colitis at the moment of diagnosis is variable, and its clinical course is difficult to predict. It can range from a quiescent to a refractory chronic course that may require hospitalization and surgical procedures. It can also have complications such as colorectal cancer. In this review we discuss the role of demographic, clinical, endoscopic, histological and associated factors, which can help to predict the clinical course of the disease at the moment of diagnosis, and to individualize therapy according to this clinical risk. Accurate identification of patients with a newly diagnosed ulcerative colitis who are at high risk of an unfavorable outcome is still a challenge. However, an effective evaluation allows an early diagnosis, a timely and effective treatment. <![CDATA[Concern for residents’ wellbeing, an issue discussed at the latin american conference on resident education (LACRE) 2017]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001330&lng=en&nrm=iso&tlng=en At the end of May 2017, the third version of the Latin American Conference on Resident Education, LACRE, was held in Chile; it convened 433 people from 14 regional countries. Chronic stress and emotional exhaustion of residents was one of the topics discussed. Reports from different countries documented that about half of residents suffer from burnout. This is, they are emotionally drained, indifferent towards their patients and with a sense of low personal fulfillment at work. This article describes the contributions presented in LACRE about interventions or institutional programs designed to reduce burnout and promote self-care of residents. The relevance of these initiatives is discussed in the current global context, considering the available evidence on the effectiveness of interventions to promote well-being among residents. International experts are making renewed and eloquent calls to medical educators and organizations to get involved in the solution of the erosion of resident wellbeing during the residence. <![CDATA[Fundal variceal bleeding treated with balloon occluded endoscopic inyection sclerotherapy. Report of two cases]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001336&lng=en&nrm=iso&tlng=en Management of gastrointestinal bleeding caused by fundal varices is particularly difficult to manage. The options are: transjugular intrahepatic portosystemic shunt (TIPS), endoscopic injection of cyanoacrylate or balloon-occluded retrograde transvenous obliteration (BRTO). We report a 63 year-old male with a cirrhosis caused by hepatitis C and a 66 year-old female with a cirrhosis caused by a non-alcoholic steatohepatitis. Both patients had a gastrointestinal bleeding caused by fundal varices and were treated with sclerotherapy with cyanoacrylate assisted with BRTO. Flow was interrupted in the gastro-renal shunt by a femoral access in both patients. The male patient had a new bleeding two months later and died. In the female patient an endosonography performed nine months after the procedure showed absence of remaining varices. <![CDATA[Rectal diffuse large B cell lymphoma appearing after immunosuppression for ulcerative colitis. Report of one case]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001342&lng=en&nrm=iso&tlng=en Primary colorectal lymphoma is a rare form of presentation of gastrointestinal tract lymphomas. Inflammatory bowel disease and its treatment are risk factors for its development. We report a 47-year-old male patient with Ulcerative Colitis of two years of evolution, treated initially with azathioprine and later on with infliximab. Due to a relapse in symptoms after the second dose of infliximab, a new coloncoscopy was performed showing a rectal ulcerative lesion, corresponding to a large cell Non-Hodgkin's Lymphoma. The patient was successfully treated with RCHOP chemotherapy (Rituximab cyclophosphamide doxorubicin vincristine prednisone). He is currently in disease remission. <![CDATA[Lupus enteritis as initial manifestation of systemic lupus erythematosus. Report of one case]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001349&lng=en&nrm=iso&tlng=en Although gastrointestinal symptoms are not rare in Systemic lupus erythematosus, enteritis is an atypical manifestation of the disease. We report a 54 year-old woman who presented acute symptoms of diarrhea, fever and abdominal pain, receiving empiric antibiotic therapy for bacterial enteritis with no response. Computed tomography showed diffuse small intestine inflammation and serositis. Antinuclear antibodies, anti-Ro and anti-La were positive on blood tests. A lupic enteropathy was diagnosed and steroid treatment was initiated, with subsequent clinical improvement. <![CDATA[Non-bacterial thrombotic endocarditis. Report of one case]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001353&lng=en&nrm=iso&tlng=en Marantic or nonbacterial thrombotic endocarditis is characterized for the presence of vegetations formed by a meshwork of fibrin and other cellular material similar a blood clot, without the presence of microorganisms. It is often related with tumors and chronic inflammatory states. We report a 49 years old female with a history of weight loss and asthenia, presenting with multiple cerebrovascular attacks and fever. Blood cultures were negative and the fever did not subside with antibiotic treatment. Trans esophageal echocardiogram showed a mitral valve vegetation and thickening of the free edge of both leaflets. In search of the etiology of such a case, a primary pancreatic cancer with distant metastases was found. We cannot rule out the differential diagnosis with bacterial endocarditis with negative blood cultures, although the clinical context supports a non-infectious etiology. <![CDATA[Review of the internal structure of a satisfaction survey]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001359&lng=en&nrm=iso&tlng=en Marantic or nonbacterial thrombotic endocarditis is characterized for the presence of vegetations formed by a meshwork of fibrin and other cellular material similar a blood clot, without the presence of microorganisms. It is often related with tumors and chronic inflammatory states. We report a 49 years old female with a history of weight loss and asthenia, presenting with multiple cerebrovascular attacks and fever. Blood cultures were negative and the fever did not subside with antibiotic treatment. Trans esophageal echocardiogram showed a mitral valve vegetation and thickening of the free edge of both leaflets. In search of the etiology of such a case, a primary pancreatic cancer with distant metastases was found. We cannot rule out the differential diagnosis with bacterial endocarditis with negative blood cultures, although the clinical context supports a non-infectious etiology. <![CDATA[Work-life balance: A new indicator of the wellbeing of healthcare professionals]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001361&lng=en&nrm=iso&tlng=en Marantic or nonbacterial thrombotic endocarditis is characterized for the presence of vegetations formed by a meshwork of fibrin and other cellular material similar a blood clot, without the presence of microorganisms. It is often related with tumors and chronic inflammatory states. We report a 49 years old female with a history of weight loss and asthenia, presenting with multiple cerebrovascular attacks and fever. Blood cultures were negative and the fever did not subside with antibiotic treatment. Trans esophageal echocardiogram showed a mitral valve vegetation and thickening of the free edge of both leaflets. In search of the etiology of such a case, a primary pancreatic cancer with distant metastases was found. We cannot rule out the differential diagnosis with bacterial endocarditis with negative blood cultures, although the clinical context supports a non-infectious etiology. <![CDATA[Increase in body mass index during the last four decades in Chile: from undernutrition to obesity]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001363&lng=en&nrm=iso&tlng=en Marantic or nonbacterial thrombotic endocarditis is characterized for the presence of vegetations formed by a meshwork of fibrin and other cellular material similar a blood clot, without the presence of microorganisms. It is often related with tumors and chronic inflammatory states. We report a 49 years old female with a history of weight loss and asthenia, presenting with multiple cerebrovascular attacks and fever. Blood cultures were negative and the fever did not subside with antibiotic treatment. Trans esophageal echocardiogram showed a mitral valve vegetation and thickening of the free edge of both leaflets. In search of the etiology of such a case, a primary pancreatic cancer with distant metastases was found. We cannot rule out the differential diagnosis with bacterial endocarditis with negative blood cultures, although the clinical context supports a non-infectious etiology. <![CDATA[CORRECTION]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872017001001364&lng=en&nrm=iso&tlng=en Marantic or nonbacterial thrombotic endocarditis is characterized for the presence of vegetations formed by a meshwork of fibrin and other cellular material similar a blood clot, without the presence of microorganisms. It is often related with tumors and chronic inflammatory states. We report a 49 years old female with a history of weight loss and asthenia, presenting with multiple cerebrovascular attacks and fever. Blood cultures were negative and the fever did not subside with antibiotic treatment. Trans esophageal echocardiogram showed a mitral valve vegetation and thickening of the free edge of both leaflets. In search of the etiology of such a case, a primary pancreatic cancer with distant metastases was found. We cannot rule out the differential diagnosis with bacterial endocarditis with negative blood cultures, although the clinical context supports a non-infectious etiology.