Scielo RSS <![CDATA[Revista médica de Chile]]> https://scielo.conicyt.cl/rss.php?pid=0034-988720180007&lang=es vol. 146 num. 7 lang. es <![CDATA[SciELO Logo]]> https://scielo.conicyt.cl/img/en/fbpelogp.gif https://scielo.conicyt.cl <![CDATA[El polimorfismo <em>rs12979860</em> C>T en el gen <em>Interferón lambda 4</em> no está asociado a riesgo de fibrosis hepática en pacientes chilenos con hepatitis crónica por virus C]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700823&lng=es&nrm=iso&tlng=es Background. Host genetic predispositions may be important determinants of liver fibrosis in patients with chronic hepatitis C (CHC). The association between Interferon-L 4 (IFNL4) rs12979860 C&gt;T polymorphism and risk of liver fibrosis in CHC is contradictory. Aim: To evaluate the impact of IFNL4 rs12979860 polymorphism on the risk of fibrosis in patients with CHC. Material and Methods: One hundred fifty patients with CHC aged 50 ± 11 years (89 females) were genotyped for IFNL4 rs12979860 using real time PCR. Fibrosis present in liver biopsies was assessed using the METAVIR score, comparing patients with either no fibrosis, mild fibrosis, or intermediate fibrosis (F0+F1+F2, n = 96), with patients with severe fibrosis or cirrhosis (F3+F4, n = 54). Results: In F0-F2 patients the distribution of rs12979860 genotypes was 22 CC, 57 CT and 17 TT, whereas in patients F3-F4 the distribution was 10, 29 and 15, respectively. No association between IFNL4 rs12979860 genotype and risk of fibrosis was observed in uni or multivariate analyses. Conclusions: IFNL4 rs12979860 C&gt;T polymorphism is not associated with risk of liver fibrosis in this group of patients with CHC. <![CDATA[Ecuación para predecir el consumo máximo de oxígeno a partir de la prueba de caminata de seis minutos en jóvenes sanos]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700830&lng=es&nrm=iso&tlng=es Background: The six-minute walk test (SMWT) is an easy-to-use test that measures walking distance. Aim: To elaborate an equation to estimate the maximum oxygen consumption (VO2 max) using the results of the SMWT. Material and Methods: Forty men and 40 women aged 22.5 ± 2 years, underwent a SMWT to measure the total walked distance and the recovery heart rate (RhR) Also, VO2 max was estimated from the maximal workload achieved in a cyclo-ergometer using the Storer test. A multivariate regression analysis resulted in a prediction equation that was validated with distributional assumptions of normality, independence and homoscedasticity. The limits of concordance of the predictive model were checked with the Bland-Altman diagram. Results: Body mass index (BMI), sex, RhR and total walked distance explained VO2 max variance by 3.4, 73.1, 17.9 and 32.8%, respectively. The prediction equation achieved was VO2 max (ml.min−1) = −3672.585 + (966.472 × Sex [1: female, 2: male]) + (-18.492 X RhR [beats.minute−1]) + (9.191 X Distance [m]) + (87.707 × BMI). The R2 of the equation was 0.91 (p &lt; 0.01). Conclusions: This equation predicts VO2 max in Chilean university students according to sex, BMI, cardiovascular response and performance in the SMWT. <![CDATA[Neumonía neumocócica bacteriémica en adultos en hospital regional de Chile]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700839&lng=es&nrm=iso&tlng=es Background: Bacteremic pneumococcal pneumonia (BPP) is a preventable disease with high morbimortality. Aim: To evaluate clinical aspects and mortality on BPP patients admitted to a Chilean regional hospital. Patients and Methods: We looked for adult patients with Streptococcus pneumoniae isolated from blood cultures between 2010 and 2014 years and reviewed clinical records of those who were admitted with pneumonia. Results: We identified 70 BPP patients: 58% were men, mean age was 56 years, 30% were &gt; 65 years, 70% with basic public health insurance, 26% were alcoholics, 86% had comorbidities. Only two patients were vaccinated against S. pneumoniae. CURB-65 severity index for community acquired pneumonia was &gt; 3 in 37% of patients. Twenty-four patients were admitted to ICU, twenty required mechanical ventilation and twenty-four died (34%). Mortality was associated with an age over 65 years, presence of comorbidities and complications of pneumonia. A total of 22 serotypes of S. pneumoniae were identified, five of them (1,3,7F,14 y 9V) were present in 57% of cases. Conclusions: Elevated mortality of our BNN patients was associated with comorbidities and possibly with socio economic factors, which conditioned a late access to medical care. <![CDATA[Efecto de la metformina en la etapa de inducción en pacientes con leucemia aguda linfoblástica y su impacto clínico en la supervivencia]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700846&lng=es&nrm=iso&tlng=es Background: Metformin has antineoplastic and cancer protective effects in vitro, sensitizing leukemia cells to chemotherapeutic agents, inducing apoptosis and cell cycle arrest. Aim: To assess the effect of metformin on the induction stage in patients with ALL and its impact on overall survival and relapse. Material and Methods. We included 123 patients treated with metformin and without metformin. The dose used was 850 mg PO at 8 h intervals. The survival analysis was used by Kaplan-Meier method, the difference between the distinct groups was performed using the log Rank test. Results. The overall survival at a median follow up of 700 days of follow-up was 43%, with a disease-free survival of 47%. Regarding the treatment groups, patients with metformin had a lower rate of relapse compared to the group receiving only chemotherapy (6.5% vs 17.1%, p = 0.006). Conclusions. The addition of metformin to the conventional treatment of ALL was associated with an improvement in survival, this association being independent of the type of biological risk at diagnosis. <![CDATA[Evaluación de aproximaciones al aprendizaje clínico a través de CEACLIN: Resultados en estudiantes de medicina en una universidad chilena]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700854&lng=es&nrm=iso&tlng=es Background: Throughout medical education, students are gradually incorporated into authentic clinical practice scenarios. Aim: To describe the use of clinical learning strategies by Chilean students and compare them according to sex and year of training. Material and Methods: The Clinical Learning Strategies Questionnaire (CEACLIN) was applied to 336 students from the 4th to 6th year of medicine at a Chilean university. Results: The most frequently reported strategies were related to the search for autonomy, reliable environments for learning, observation of others and attention to emotions. The less frequent was the handling of academic burden. Gender accounted for significant differences in eight of the 11 strategies identified by CEACLIN, while years of training accounted for five of the 11. The cluster analysis identified two groups: the first group comprised nine CEACLIN strategies, with a slightly higher proportion of women and 5th and 6th year students. The second group consisted mainly of men in the 4th year. Conclusions: Reported strategies include a set of actions oriented to the development of autonomy and confidence through the search for valid information and learning from and with others. These findings are associated with sex and year of training. <![CDATA[Prevalencia de pacientes con alto riesgo de caídas en un servicio médico-quirúrgico de un hospital universitario]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700862&lng=es&nrm=iso&tlng=es Background: Detecting patients at risk of falls during hospital stay is of utmost importance to implement preventive measures. Aim: To determine the frequency of patients with a high risk of falls admitted to a medical-surgical ward. To assess the preventive measures implemented. Materials and Methods: Review of medical records of 376 patients aged 20 to 97 years (28% older than 70 years) admitted to a clinical hospital in a period of four months. Results: Eleven percent of patients had a history of falls, 50% had a sensory deficit, 68% had unstable gait, 8% had a neurological risk condition, 8% had drowsiness or disorientation, 4% had psychomotor agitation or delirium, 86 % used high risk medications, 73% used 2 or more high risk drugs and 72% were using devices that decrease mobility. One hundred forty-one patients (38%) had a high risk of falling. The mean age of the latter was 77 years, 89% had a sensory deficit, 96% had unstable gait, 4% had psychomotor agitation or delirium and 98% used high risk drugs. Less than 1% had a medical prescription of a caregiver, physical restraints or antipsychotics, however, 21% of patients had a caregiver. Conclusions: The percentage of patients with a high risk of falling is important. The main risk factors were sensory deficit, unstable gait and the use of high risk medications. The low frequency of preventive measures prescriptions is striking. <![CDATA[Mieloma múltiple en Chile: pasado, presente y futuro del programa nacional de drogas antineoplásicas (PANDA). Revisión de 1.103 pacientes]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700869&lng=es&nrm=iso&tlng=es Background: Multiple myeloma (MM) is one of the most common malignancies found in hematology. Aim: To describe the features of patients with MM and perform a survival analysis according to the different treatment protocols used between 2000 and 2016. Material and Methods: Analysis of the database of the Chilean national anti-neoplastic drug program. Information was obtained from 1,103 patients, with a median age of 64.5 years (range 27-95) and a male to female ratio of 1:1.2. Results: The mean overall survival (OS) of patients receiving or not receiving Thalidomide was 46 and 30 months, respectively (p &lt; 0.01). The mean OS of patients treated before 2007 (treated with melphalan and prednisone) and between 2007 and 2012 (treated with thalidomide and dexamethasone) was 36 and 48 months respectively. In the group starting in 2013 (treated with cyclophosphamide, thalidomide and dexamethasone) the median survival had not been reached at 20 months of follow up (p = 0.01 for all comparisons). Autologous transplantation (AT) was carried out in only 18% of the eligible patients. The median OS of the patients who receive an AT had not been reached at 48 month compared with 36 month among those who did not received the procedure (p &lt; 0.01). Conclusions: Even though overall survival has improved with time, new drugs must be introduced in our protocols to obtain similar results to those obtained worldwide. <![CDATA[Farmacovigilancia activa de metoclopramida 10 mg oral en pacientes del Programa de Alivio del Dolor y Cuidados Paliativos o diabetes mellitus tipo 2 en cinco hospitales del Servicio de Salud Viña del Mar-Quillota]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700876&lng=es&nrm=iso&tlng=es Background: In 2013 the Chilean regulatory sanitary agency issued a warning concerning dose adjustment and use restriction to avoid severe adverse effects of metoclopramide such tardive dyskinesia. Aim: To study dyskinesia type adverse effects in a population using metoclopramide. Material and Methods: A cross sectional observational study was conducted among patients pertaining to palliative care and diabetes mellitus programs and consuming 10 mg/day or more of metoclopramide. Patients were interrogated looking for extrapiramidal signs and symptoms using a questionnaire validated by two neurologists. Results: In 40% of diabetic patients with gastroparesia and 35% of palliative care patients, extrapyramidal adverse reactions to metoclopramide were suspected. Palliative Care patients suffered the largest number of adverse events. The period of use and individual doses of the drug were largely above Chilean regulatory agency recommendations in all cases. Conclusions: A significant number of patients using metoclopramide could experience extrapyramidal adverse reactions. <![CDATA[Tiempos de atención de urgencias neurológicas en un hospital regional de alta complejidad]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700885&lng=es&nrm=iso&tlng=es Background: Neurological emergencies constitute 10-15% of medical emergencies. Doctor Hernán Henríquez Aravena Hospital has in house neurologists present permanently at the Emergency Room since July 2013. Aim: To estimate the waiting times for neurological consultations; to compare the waiting times between neurovascular (UV) and non-vascular (UNV) emergencies; and to compare the waiting times of two prioritization (triage) models. Material and Methods: A convenience sample of the consultations made during shift # 1 at the emergency room between January and December 2016, was analyzed. Results: There were 859 consultations in the period, 570 for UNV and 289 for UV. Mean age of consultants was 57 years and 52% were women. The median time for having an evaluation by a neurologist was 106 min (132 and 81 min for UNV and UV respectively). Twenty seven percent of patients were evaluated in less than one hour (23 and 36% of UNV and UV, respectively). The change of the prioritization model decreased the waiting time by 81 and 32 min for UNV and UV, respectively. Conclusions: There were significant differences in waiting times between neurovascular and non-vascular emergencies. Most patients were not evaluated in less than 60 minutes. The change in the initial stratification model was associated with a significant reduction in the waiting times for neurological emergencies. <![CDATA[Medicina traslacional e innovación en salud: mecanismos y perspectivas]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700890&lng=es&nrm=iso&tlng=es Many new discoveries in Life Sciences cannot be translated into products, services or new applications to improve human health. Translational medicine, defined as “from bench to bedside”, refers to the transfer of results or new knowledge achieved in the laboratory into health innovation. We aim to review the state of art of translational medicine, its relationship with innovation processes and the different perspectives to consider. Finally, we contextualize the situation of Research and Development (R&amp;D) in Chile and the main issues of the biotechnology market in the country. <![CDATA[Relevancia de profilaxis antibiótica ante procedimientos dentales generadores de bacteriemias transitorias]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700899&lng=es&nrm=iso&tlng=es This review examines the evidence about the relationship between dental procedures and the incidence of transient bacteremia. One of the main obstacles was to define “invasive dental procedure” as an indication for antimicrobial prophylaxis for patients with high risk of bacteremia. A search in WorldWideScience and ScienceDirect was performed and 20 articles were selected for review. Two contradictions stood out. There is no concrete evidence that a transient bacteremia arising during a dental procedure may be a risk factor for the appearance of bacterial endocarditis. There is no certainty about the effectiveness of antimicrobial prophylaxis, due to the lack of clinical trials of good quality. There is a similitude between bacteremia resulting from invasive and non-invasive dental procedures. The importance of periodontal health as a preventive measure for bacterial endocarditis among high risk patients is highlighted. <![CDATA[Aplicación de grafos acíclicos dirigidos en la evaluación de un set mínimo de ajuste de confusores: un complemento al modelamiento estadístico en estudios epidemiológicos observacionales]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700907&lng=es&nrm=iso&tlng=es Background: Confusion in observational epidemiological studies distorts the relationship between exposure and event. “Step by step” regression models, diverts the decision to a statistical algorithm with little causal basis. Directed Acyclic Graphs (DAGs), qualitatively and visually assess the confusion. They can complement the decision on confounder control during statistical modeling. Aim: To evaluate the minimum set of confounders to be controlled in a cause-effect relationship with the use of “step-by-step regression” and DAGs, in a study of arsenic exposure. Material and Methods: We worked with data from Cáceres et al., 2010 in 66 individuals from northern Chile. The interindividual variability in the urinary excretion of dimethyl arsenic acid attributable to the GSTT1 polymorphism was estimated. A causal DAG was constructed using DAGitty v2.3 with the list of variables. A multiple linear regression model with the step-by-step backwards methodology was carried out. Results: The causal diagram included 12 non-causal open pathways. The minimum adjustment set corresponded to the variables “sex”, “body mass index” and “fish and seafood ingest”. Confusion retention of the multivariate model included normal and overweight status, gender and the interaction between “water intake” and GSTT1. Conclusions: The use of DAG prior to the modeling would allow a more comprehensive, coherent and biologically plausible analysis of causal relationships in public health. <![CDATA[Jurisprudencia sobre transfusión de sangre y consentimiento informado de Testigos de Jehová]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700914&lng=es&nrm=iso&tlng=es The law N° 20.584 established the informed consent. This could suggest that patients have a right to refuse a blood transfusion. However, the dominant jurisprudence in protection claims filed against Jehovah Witnesses who rejected a blood transfusion, reveals that they do not have such a right. There were two exceptions in 2008, where courts acknowledged the patient's autonomy and denied the petition to authorize a blood transfusion. Most cases precede law N° 20.584. However, those cases which were upheld by the courts after the promulgation of the law, although few, follow exactly the same doctrine as before the appearance of this act. <![CDATA[Educación médica y diversidad cultural en Chile. Un diálogo pendiente]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700922&lng=es&nrm=iso&tlng=es Medical education in Chile has a good research productivity. National educators are skilled in complex curricular design processes and in didactic innovation. However, the question of what it means to be doctor in a society that moves towards interculturality, has not been addressed thoroughly. Using the structure of a clinical record, we outline our critical view about the relationship between medical education and diversity. To describe the medical history, we refer to some variables of the training process such as the Hegemonic Model of Medicine, the epistemological beliefs of the students, the hidden curriculum and the educational environment. Then, the empirical evidence of the clinical picture, diagnosis and internationally recommended treatment is described, to end with a local therapeutic proposal. <![CDATA[Hallazgo de una nueva mutación en una familia chilena con diabetes monogénica. Caso clínico]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700929&lng=es&nrm=iso&tlng=es We report a 21 years old woman, without offspring, with diabetes mellitus diagnosed at 17 years of age, without ketosis or weight loss. Her body mass index was 18 kg/m2. Her C peptide was normal (2.3 ng/ml) and diabetes mellitus type 1 autoantibodies were negative. A monogenic diabetes Maturity Onset Diabetes of the Young (MODY) was proposed. Her family study disclosed a diabetic father and a brother with altered fasting glucose levels. The University of Exeter score for MODY yielded a 75.5% probability of MODY2. In the genetic-molecular study of the glucokinase gene (MODY2), the patient had a mutation at position 1343 of exon 10, corresponding to a heterozygous substitution of guanine by adenine (1343 G &gt;A). The same mutation was found in her father and brother. This mutation is different from those previously described in the literature. The described change determines that a glycine is replaced by aspartic at amino acid 448 of the enzyme (non-synonymous substitution). The diagnosis of MODY2 was therefore confirmed in the patient and her father. The mutation was inherited by paternal line. <![CDATA[Remisión espontánea de acromegalia y enfermedad de Cushing en adultos mayores. Casos clínicos]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700933&lng=es&nrm=iso&tlng=es Pituitary diseases such as acromegaly and Cushing's disease require surgical or medical therapy. In some functioning pituitary tumors, a spontaneous remission of hormonal hypersecretion is observed, mainly associated to apoplexy or pituitary infarction. We report the evolution of two female patients older than 70 years at the time of diagnosis, with multiple comorbidities. In case 1, acromegaly was diagnosed at 74 years of age. Sellar CT scan showed a 10-mm adenoma. During her follow-up, IGF1 levels remained normal. Nine years later, a magnetic resonance (MR) showed a 7-mm adenoma. In case 2, clinical and biochemical diagnosis of Cushing's disease was done being 71 years old. Sellar MR showed a 6-mm adenoma. Three years later, urinary cortisol normalized with no changes in adenoma at MR. Seven years later, she remains without clinical or biochemical signs of hypercortisolism. In both cases, no signs of hemorrhage were observed at MR. <![CDATA[Fibrosis pulmonar aguda asociada a intoxicación por Paraquat: caso clínico]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700938&lng=es&nrm=iso&tlng=es Paraquat, a non-selective bipyridyl pesticide, is one of the leading causes of death from intoxication in many parts of Asia and America. It is the second most sold herbicide worldwide, being widely used in Chile. Its ingestion generates toxicity due to the release of superoxide radicals, mainly affecting kidneys, lungs and liver. There is no antidote available. We report a 31 years old male who ingested Paraquat for suicidal purposes. He developed an acute renal and hepatic failure and a rapidly progressive severe respiratory failure with images compatible with acute pulmonary fibrosis. No response to immunosuppressive treatment was observed. He died eight days after admission. The use of cyclophosphamide associated with glucocorticoids could lower risk of death the in these patients, although the pathophysiology of respiratory failure is still under study. <![CDATA[Abordando los desafíos en salud global]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700942&lng=es&nrm=iso&tlng=es Paraquat, a non-selective bipyridyl pesticide, is one of the leading causes of death from intoxication in many parts of Asia and America. It is the second most sold herbicide worldwide, being widely used in Chile. Its ingestion generates toxicity due to the release of superoxide radicals, mainly affecting kidneys, lungs and liver. There is no antidote available. We report a 31 years old male who ingested Paraquat for suicidal purposes. He developed an acute renal and hepatic failure and a rapidly progressive severe respiratory failure with images compatible with acute pulmonary fibrosis. No response to immunosuppressive treatment was observed. He died eight days after admission. The use of cyclophosphamide associated with glucocorticoids could lower risk of death the in these patients, although the pathophysiology of respiratory failure is still under study. <![CDATA[Síndrome de Procusto en la Medicina]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700943&lng=es&nrm=iso&tlng=es Paraquat, a non-selective bipyridyl pesticide, is one of the leading causes of death from intoxication in many parts of Asia and America. It is the second most sold herbicide worldwide, being widely used in Chile. Its ingestion generates toxicity due to the release of superoxide radicals, mainly affecting kidneys, lungs and liver. There is no antidote available. We report a 31 years old male who ingested Paraquat for suicidal purposes. He developed an acute renal and hepatic failure and a rapidly progressive severe respiratory failure with images compatible with acute pulmonary fibrosis. No response to immunosuppressive treatment was observed. He died eight days after admission. The use of cyclophosphamide associated with glucocorticoids could lower risk of death the in these patients, although the pathophysiology of respiratory failure is still under study. <![CDATA[Ciencia de Implementación en la evaluación de programas y servicios de salud en Chile]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000700945&lng=es&nrm=iso&tlng=es Paraquat, a non-selective bipyridyl pesticide, is one of the leading causes of death from intoxication in many parts of Asia and America. It is the second most sold herbicide worldwide, being widely used in Chile. Its ingestion generates toxicity due to the release of superoxide radicals, mainly affecting kidneys, lungs and liver. There is no antidote available. We report a 31 years old male who ingested Paraquat for suicidal purposes. He developed an acute renal and hepatic failure and a rapidly progressive severe respiratory failure with images compatible with acute pulmonary fibrosis. No response to immunosuppressive treatment was observed. He died eight days after admission. The use of cyclophosphamide associated with glucocorticoids could lower risk of death the in these patients, although the pathophysiology of respiratory failure is still under study.