Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 147 num. 1 lang. es <![CDATA[SciELO Logo]]> <![CDATA[Sociedad Médica de Santiago Sociedad Chilena de Medicina Interna 150 años al Servicio de la Medicina]]> <![CDATA[Resultados de pacientes con linfoma del manto: impacto de terapias basadas en citarabina y trasplante hematopoyético]]> Background: Mantle cell lymphoma (MCL) has high relapse and mortality rates. There is a survival benefit when treatment is intensified with cytarabine (AraC), hematopoietic cell transplantation (HCT) and maintenance with rituximab. Aim: To assess the outcomes of patients with MCL treated in a university hospital. Material and Methods: Review of an oncology center database and medical records identifying patients with MCL treated between 2006 and 2017. Death dates were obtained from the death certificate database of the National Identification Service. We analyzed the response rate, overall survival (OS) and progression-free survival (PFS). As a secondary objective, the survival impact of AraC, HCT and maintenance with rituximab, was also analyzed. Results: Information on 20 patients aged 62 ± 11 years, followed for a median of 45 months was retrieved. Eighty-five percent were diagnosed at an advanced stage. The most used first-line regime was R-CHOP in 11 patients, followed by R-HyperCVAD in five. Only 47% achieved complete response. 4-year PFS and OS were of 30 and 77% respectively. Mantle Cell Lymphoma International Prognostic Index (MIPI) significantly predicted PFS and OS. Maintenance with rituximab or HCT was associated with better PFS (48 vs 21 months, p &lt; 0.01). The exposure to AraC or HCT, in refractory or relapsed disease, was associated with an increase in PFS from 9 to 28 months (p = 0,02) and 4-year OS from 40 to 100% (p = 0.05). OS increased even more, from 25 to 100% in those with high-risk MIPI (p = 0.04). Conclusions: The incorporation of AraC, HCT and maintenance with rituximab in the therapeutic backbone of MCL, especially for high-risk cases, was associated with improved survival. <![CDATA[Leucemia de células plasmáticas primaria: experiencia en un hospital público chileno]]> Background: Primary plasma cell leukemia (pPCL) is uncommon, aggressive and has a different biology than multiple myeloma (MM). Aim: To report the features of patients with pPCL. Material and Methods: Review of databases of the Hematology Department and the Hematology laboratory. Results: Of 178 patients with monoclonal gammopathies, five (2.8%) patients aged 33 to 64 years (three females) had a pPCL. The mean hemoglobin was 7.3 g/dL, the mean white blood cell count was 52,500/mm3, with 58% plasma cells, and the mean platelet count was 83,600/mm3. The mean bone marrow infiltration was 89%, LDH was 2,003 IU/L, serum calcium was 13 mg/dL, and creatinine 1.5 mg/dL. Two patients had bone lesions. Three were IgG, one IgA lambda and one lambda light chain. CD20 was positive in one, CD56 was negative in all and CD117 was negative in 3 cases. By conventional cytogenetic analysis, two had a complex karyotype. By Fluorescence in situ Hybridization, one was positive for TP53 and another for t (11; 14). One patient did not receive any treatment, three patients received VTD PACE and one CTD. None underwent transplant. Three patients are alive. The mean survival was 14 months. Conclusions: These patients with pPCL were younger and had a more aggressive clinical outcome than in multiple myeloma. <![CDATA[Caracterización de cepas clínicas y ambientales de <em>Salmonella enterica</em> subsp. <em>enterica</em> serovar Heidelberg aisladas en Chile]]> Background: Salmonella Heidelberg (S. Heidelberg) causes gastroenteritis and sometimes bacteremia and endocarditis. In other countries, this serovar has multidrug resistance including extended-spectrum β-lactamases (ESBLs) and AmpC (β-lactamases (AmpC), associated with the blaCMY-2 gene. In Chile, an outbreak by S. Heidelberg occurred in 2011, the phenotypic and genetic characteristics of Chilean strains are unknown. Aim: To determine the antimicrobial susceptibility, presence of plasmids and virulence factor genes in S. Heidelberg strains isolated in Chile over the period 2006-2011. Material and Methods: In sixty-one S. Heidelberg clinical and environmental strains collected by the Public Health Institute in Chile during 2006-2011, antimicrobial susceptibility, plasmids and virulence factor genes (invA, sifA, pefA, agfA, lpfA and, stkD) were studied. Results: S. Heidelberg had a high susceptibility to sulfamethoxazole-trimethoprim, gentamicin, ceftriaxone, ceftiofur, chloramphenicol, amoxicillin-clavulanic acid and ampicillin. However, 52% had decreased susceptibility to ciprofloxacin and 33% resistance to tetracycline. ESBLs were detected in three strains isolated from blood cultures, environment and human feces. The latter strain was positive for AmpC and blaCMY-2 gene. Fifty three of 61 strains showed one to seven plasmids of 0.8 to approximately 30 kb. Most plasmids were small with sizes between 0.8 and 2 kb. All isolates were positive for all genes except pefA. Conclusions: S. Heidelberg isolated from Chilean samples was susceptible to first-line antimicrobials, except tetracycline and ciprofloxacin. The emergence of strains with ESBLs and AmpC should be a warning. The strains were homogeneous for virulence genes, but heterogeneous in their plasmids. <![CDATA[Registro de paro cardiorrespiratorio perioperatorio en un hospital universitario en el período 2006-2017]]> Background: Perioperative cardiac arrest (PCA) is a rare but important event in the operating room. Aim: To describe PCA events at a Clinical Hospital in Santiago, Chile. Material and Methods: Registry of PCA that occurred in the operating room (OR) and during procedures not carried out in the OR between September 2006 and November 2017. Precipitating events, type of anesthesia and results of resuscitation maneuvers were described. Results: Eighty events (five outside of the OR) during 170,431 surgical procedures were recorded, resulting in an incidence of 4.4 events per 10,000 interventions. Hypotension/hypoperfusion was the most frequently found preexisting condition (42.5%). The main cause was the presence of preoperative complications (57.5%). Nineteen cases (23.8%) were attributable to anesthesia, with an incidence of 1.11 per 10,000 anesthetic procedures. Survival rate at hospital discharge was 52.5%. The figure for PCA caused by anesthesia was 84.2%. Conclusions: The incidence of PCA and its survival is similar to that reported abroad. In general, PCA has a better prognosis than other types of cardiac arrest, especially if it has an anesthetic cause. <![CDATA[Dolor pélvico crónico secundario a síndrome de congestión pélvica. Resultados del tratamiento endovascular de la insuficiencia venosa pelviana y várices genitales]]> Background: Pelvic venous insufficiency may cause pelvic congestion syndrome that is characterized by chronic pelvic pain exacerbated by prolonged standing, sexual activity or menstrual cycle. It may be treated by embolizing the dysfunctional pelvic venous drainage and sometimes resecting vulvar, perineal and thigh varices. Aim: To assess the results of embolization of insufficient pelvic or ovarian veins on pelvic congestion syndrome. Material and Methods: Analysis of 17 female patients aged 32 to 53 years, who underwent subjected to a selective coil embolization of insufficient pelvic and/or ovarian veins through the jugular, basilic or cephalic veins. In the preoperative period, all patients had a lower extremity venous duplex pelvic ultrasound examination and some had an abdominal and pelvic CT angiogram. Results: The technical success of the procedure was 100% and no complications were registered. During a 32 month follow up, no patient had symptoms of pelvic venous insufficiency or relapse of vulvar or thigh varices. Conclusions: Embolization of insufficient pelvic and ovarian veins is a safe and successful procedure for the treatment of pelvic venous insufficiency or vulvar varices. <![CDATA[Trastornos de la conducta alimentaria: alteraciones cardiovasculares al ingreso y evolución a 3 meses]]> Background: Cardiovascular complications can occur in up to 80% of adolescent patients with eating disorders (ED) and account for 30% of their mortality. Aim: To evaluate cardiovascular complications in adolescents with ED and their evolution after refeeding. Patients and Methods: In adolescents with ED admitted to treatment, we assessed the nutritional status, weight loss prior to consultation, presence of bradycardia (BC, defined as heart rate &lt; 60 bpm), we performed an electrocardiogram (ECG) and an echocardiography and measured thyroid hormones. Results: We studied 53 women aged 16.4 ± 2.3 years. Fifteen had a diagnosis of Anorexia Nervosa (AN), seven of Bulimia (BN), eight a not otherwise specified ED (ED-NOS), four a Binge Eating Disorder (BED), sixteen an Atypical Anorexia (AAN) and three an Atypical Bulimia (ABN). Thirty four percent were malnourished and 3.8% overweight. The most common cardiac problem was BC in 51%. In eight of 26 patients in whom an echocardiogram was done, it was abnormal. Six had a decreased ventricular mass, three a pericardial effusion and three valvular involvement. There was a significant association between bradycardia and malnutrition, weight loss and low free triiodothyronine levels. BC was significantly more common in patients with AN, but it also occurred in half of the patients with AAN and in one of three patients with other types of ED. At follow up, bradycardia significantly improved with refeeding. Conclusions: There is an association between all types of ED and bradycardia, as well as anatomical and functional cardiac anomalies. <![CDATA[Propiedades psicométricas del PHQ-9 (<em>Patient Health Questionnaire</em>) en centros de atención primaria de Chile]]> Background: Simple and brief questionnaires with adequate psychometric properties are useful for the early detection of depressive disorders. Aim: To analyze the psychometric behavior of the Patient Health Questionnaire (PHQ-9) in Chile. Material and Methods: Data were collected from 1,738 adult patients, consulting in primary health care centers. The values obtained in the PHQ-9 were compared with those of the Composite International Diagnostic Interview (CIDI). Results: The mean score of PHQ-9 was 4.85 ± 5.57. Internal consistency indices were high. McDonald's ω coefficient of was 0.90 and Cronbach alpha 0.89. A confirmatory factor analysis showed a good fit of the one-dimensional model. Using a cutoff score of seven determined with the receiver operating characteristic (ROC) curve, the sensitivity and specificity of the instrument were 0.8 and 0.7, when compared with CIDI diagnoses. Conclusions: PHQ-9 is a useful instrument for the screening of depressive disorders in primary health care centers in Chile. <![CDATA[Características citogenéticas y detección de anormalidades de alto riesgo en mieloma múltiple]]> Background: Cytogenetic abnormalities observed in the bone marrow of patients with multiple myeloma (MM) are an important prognostic factor for risk stratification. Aim: To investigate karyotype characteristics and frequency of the high-risk cytogenetic abnormalities t(4;14), t(14;16) and del(17p) in Chilean patients with MM. Material and Methods: We studied 30 patients with MM by conventional cytogenetics (CC) and fluorescent in situ hybridization of plasma cells selected using cytoplasmic immunoglobulin staining (cIg-FISH). Results: Overall, the two techniques in combination allowed us to identify clonal genetic abnormalities in 47% of patients. The t(4;14) abnormality was observed in 19% of patients, del(17p) was observed in 10% of patients, and t(14;16) was not detected. Conclusions: Our results showed frequencies of high-risk abnormalities similar to those reported abroad. Cytogenetic studies should be performed routinely for all MM patients at the moment of diagnosis. <![CDATA[Atención de salud de personas transgéneros para médicos no especialistas en Chile]]> The health care demand for transgenders has increased in Chile and worldwide. However, in Chile health care professionals are not trained to understand and face this problem. We herein review issues that should be considered in the training of non-specialist physicians to provide health care to transgenders, issues about terminology of body reassignment treatments and gender identity and the way Chilean professionals should deal with transgender persons. <![CDATA[Manejo de hemorragia asociada a anticoagulantes orales directos: estado actual de las estrategias de reversión]]> Direct oral anticoagulants (DOACs), including the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban and edoxaban have at least comparable efficacy as vitamin K antagonists along with a better safety profile, reflected by a lower incidence of intracranial hemorrhage. Specific reversal agents have been developed in recent years. Namely, idarucizumab, a specific antidote for dabigatran, is currently approved in most countries. Andexanet, which reverses factor Xa inhibitors, has been recently approved by the FDA, and ciraparantag, a universal antidote targeted to reverse all DOACs, is still under investigation. In this review we provide an update on the pharmacology of DOACs, the risk of hemorrhagic complications associated with their use, the measurement of their anticoagulant effect and the reversal strategies in case of DOAC-associated bleeding. <![CDATA[Panorama de la dependencia en Chile: avances y desafíos]]> Chile is facing a process of rapid aging which poses several challenges. Among these challenges is the increase of dependency in the population. Despite its relevance, the topic has not been prioritized in the agenda. One explanation for this low-priority is the lack of information on the concept of dependency. This article shows that, in fact, no consensus exists in Chile on how to define and measure dependency. Additionally, it provides an updated estimation of dependency in the country, aiming to foster further debate on the topic. <![CDATA[Mascotas felinas, medicina y arte]]> The author in this short text remembers the passing of a beloved pet cat. Cats are beautiful animals and wonderful companions. They evolved together with humans in Africa, subsequently spread over the five continents with them, and became the subject of many human cultural activities, including art, poetry and religion. Abandoned and roaming free, cats readily return to the wild, potentially acquiring many zoonotic infections. Surprisingly, feline company is increasingly used for therapy of mental and other illnesses such as cardiovascular disorders. Responsible ownership and good veterinary care of these marvelous animals under the One Health paradigm are essential to their well-being as well as to that of humans. They are an ethical and small price to pay for the affectively rewarding relationships humans have with these endearing and evocative animals. <![CDATA[William Hunter (1718-1783): su legado a trescientos años de su nacimiento]]> The aim of this paper is to evaluate some aspects of the life of William Hunter (1718-1783), and to argue that he deserves a better place in history as he was one of the most outstanding figures in British medicine of the 18th century. A Scotsman, Presbyterian, from a family without means or connections, he underwent a classic education at the University of Glasgow, completed with apprenticeships with William Cullen and Alexander Monro first in Scotland, and then in London, with William Smellie, James Douglas and James Wilkie, in anatomy, obstetrics and surgery, respectively. Despite initial disadvantages, he was highly successful as an anatomist, educator, surgeon, man-midwife, artist, gentleman and collector. He moved and had influences in the highest medical, cultural and social circles of his time, was named Physician Extraordinary to Queen Charlotte, and was a member of many scientific, medical and cultural societies in Great Britain and in France, such as the Royal Society, the Royal College of Physicians and the Societé Royale de Médicine of Paris. His museum was notable in its magnitude and its diversity, including anatomical preparations, coins, shells, plants, birds, insects, fossils, and minerals. He donated his great museum to the University of Glasgow. His figure has been relegated mainly due to the absence of heirs, individuals or institutional, that could have cared for, maintained, and increased his legacy as happened with his brother John. <![CDATA[Repercusiones de “ObamaCare” para la reforma sanitaria en Chile]]> Health care raises structural issues in a democratic society, such as the role assigned to the central government in the management of health risk and the redistributive consequences generated by the implementation of social insurance. These are often cause of strong political controversy. This paper examines the United States of America health reform, popularly known as “ObamaCare”. Its three main elements, namely individual mandate, creation of new health insurance exchanges, and the expansion of Medicaid, generated a redistribution of health risks in the insurance market of that country after almost a century of frustrated legislative efforts to guarantee minimum universal coverage. The article proposes that a change of this magnitude in the United States will produce effects in a forthcoming parliamentary discussion on the health reform in Chile, which still maintains a highly deregulated private health system. <![CDATA[Calidad de vida de estudiantes de medicina en Brasil. Un estudio comparativo]]> ABSTRACT Background: VERAS survey multicenter project, carried out in 2011-2012, evaluated the quality of life (QoL) of students from 22 Brazilian medical schools. Aim: To evaluate QoL of undergraduate medical students, taking Veras-q national data as comparison. Material and Methods: We evaluated the QoL of 197 medical students in a Brazilian private medical school at Salvador, Bahia, Brazil in 2014. Students in the first two years were grouped in Phase I; those in years three and four were grouped in Phase II. Those in the internship (fifth and sixth years) were grouped in Phase III. Results: Students from Phase I group had better QoL averages than those from Phase II. Phase I students presented significantly (p &lt; 0.05) better scores in the Psychological and Use of Time domains. Compared to Phase II students, those in Phase III obtained better scores in the Physical and Environmental domains. Female students had significantly lower (p &lt; 0.01) scores than male students in Physical, Psychological and Use of Time domains. Compared to the national sample survey, these students had higher (p &lt; 0.01) scores in all domains, except for the Physical domain in Phase II (p &lt; 0.4352). Conclusions: These students had a better quality of life than those surveyed in the national Veras-q study. Female students had lower scores. Adjusted schedules and lower work overload, as consequences of effective interdisciplinarity in curricular components, may have contributed to higher students' QoL.<hr/> Antecedentes: El proyecto multicéntrico VERAS evaluó la calidad de vida de estudiantes de medicina en los años 2011-2012. Objetivo: Evaluar la calidad de vida de un grupo de estudiantes de medicina y compararla con los datos del proyecto VERAS. Material y Métodos: Se evaluó calidad de vida en 197 estudiantes de medicina de universidades privadas de Salvador, Bahía, Brasil en 2014. Los estudiantes de los dos primeros años fueron agrupados en la fase I, aquellos de tercer y cuarto año en fase II y los del internado en fase III. Resultados: Los estudiantes en fase I tuvieron mejor calidad de vida que aquellos en fase II. Los estudiantes en fase I tuvieron mejores puntajes en los dominios psicológico y uso del tiempo. Los estudiantes en fase III tuvieron mejores puntajes en los dominios físico y ambiental que los estudiantes en fase II. Las mujeres obtuvieron menores puntajes en los dominios físico, psicológico y uso del tiempo, que los hombres. Al comparar con el estudio nacional, estos estudiantes tuvieron mejores puntajes en todos los dominios, excepto el físico en estudiantes en fase II. Conclusiones: Estos estudiantes tuvieron mejor calidad de vida que sus pares estudiados previamente. Las mujeres tuvieron puntajes más bajos que los hombres. Una menor carga de trabajo, como consecuencia de un currículo multidisciplinario, puede haber influido en esta mejor calidad de vida. <![CDATA[Síndrome de DRESS con compromiso pulmonar extenso. Una presentación inhabitual]]> Drug rash with eosinophilia and systemic symptoms or DRESS Syndrome is a rare, serious and potentially fatal adverse drug reaction. It is characterized by widespread morbilliform and edematous skin lesions, associated with eosinophilia, lymphadenopathy and internal organ involvement and unusually associated with pulmonary symptoms. We report a 47-year-old male with DRESS syndrome, manifested with typical skin lesions and extensive pulmonary involvement, responding satisfactorily to systemic corticosteroids. <![CDATA[Gastropatía hipertrófica por IgG4. Reporte del primer caso en Chile]]> IgG4 related disease is a systemic autoimmune disease, which can affect different organs. The most common digestive manifestation is autoimmune pancreatitis (AIP), followed by involvement of bile ducts and the major papilla. The stomach is only rarely involved. We report a 71-year-old diabetic woman consulting for jaundice and weight loss. Abdominal CAT scan, cholangio resonance imaging, endosonography and a serum IgG4 of five times the normal value, lead to the diagnosis of an autoimmune pancreatitis. An upper gastrointestinal endoscopy showed a diffuse thickening of gastric folds. The pathological study confirmed the presence of IgG4 positive plasma cells. The patient was successfully treated with steroids. <![CDATA[Hipercalcemia severa en el curso de rabdomiolisis: caso clínico]]> Rhabdomyolysis (RD) is the process that leads to cell destruction of striated muscle. Causes include inherited metabolic defects or acquired disorders. RD is frequently associated with acute kidney injury (AKI) and disorders of calcium metabolism. We report a 33 year old man that after amphetamine consumption and an uninterrupted 3,000 km driving presented vomiting, muscle pain and dark urine. He had elevated creatinkinase levels, severe hypocalcemia and an acute renal failure. He was treated with hemodialysis and calcitriol. He was transferred to our hospital and on admission a serum calcium of 18 mg/dl was detected. He continued on hemodialysis, recovering renal function and with normalization of creatinkinase levels and serum calcium level. <![CDATA[Desarrollo cerebral y aprendizaje en adolescentes: Importancia de la actividad física]]> Rhabdomyolysis (RD) is the process that leads to cell destruction of striated muscle. Causes include inherited metabolic defects or acquired disorders. RD is frequently associated with acute kidney injury (AKI) and disorders of calcium metabolism. We report a 33 year old man that after amphetamine consumption and an uninterrupted 3,000 km driving presented vomiting, muscle pain and dark urine. He had elevated creatinkinase levels, severe hypocalcemia and an acute renal failure. He was treated with hemodialysis and calcitriol. He was transferred to our hospital and on admission a serum calcium of 18 mg/dl was detected. He continued on hemodialysis, recovering renal function and with normalization of creatinkinase levels and serum calcium level.