Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 146 num. 5 lang. es <![CDATA[SciELO Logo]]> <![CDATA[El sinsabor que deja el mejor año en la donación de órganos para trasplante en Chile]]> Background: In October 2016, television stations began a campaign to increase organ donation rates. During the months that followed, a sustained increase in donation rate was observed, reaching 10 per million people. Health authorities considered that this increase was a consequence of an improvement in the search and maintenance of potential donors and TV executives considered that is was due to a reduction in organ donation refusal by relatives of potential donors. Aim: To analyze the year after the TV campaign and determine its relative effect in the improvement of effective organ donation for transplantation. Material and Methods: Monthly figures of donors published on the websites of the National Transplant Corporation and the Ministry of Health and the historical figures for the 2013-2016 period were analyzed. Using this information, the expected behavior was modeled for the number of expected donors for the year 2017 and expected family refusal rates. Results: We found that the number of effective donors for 2017 did not differ substantially from the estimation and that the apparent substantial increase in the rate of organ donation was due to a marked but transitory reduction in the rate of donation refusal by relatives of potential donors. Conclusions: The whole process leading to effective donation should we reanalyzed. New strategies, such as information technologies should be incorporated to improve the detection and management of potential donors. The TV campaign, although successful, was very expensive and very difficult to sustain over time. <![CDATA[Disminución en la frecuencia de infección por <em>Helicobacter pylori</em> en endoscopías digestivas altas]]> Background: Helicobacter pylori (HP) is the most widespread chronic human infection worldwide and the most important pathogenic factor of gastric cancer. The calculated prevalence at the Clinical Hospital of the University of Chile from 2002 to 2005 was 44.9%. Aim: To determine the current prevalence of HP in patients undergoing an upper gastrointestinal endoscopy (UGI) and analyze its distribution according to age and endoscopic findings. Material and Methods: We reviewed 3.433 UGI performed during the year 2015, selecting those in which rapid urease test (RUT) was done. A positive RUT or a positive gastric biopsy (GB) were considered as HP infection. Results: RUT was done in 1862 UGI (55%) performed in patients aged 51 ± 17 years, (66% women). In 23% of these endoscopies, the RUT was positive. A GB was obtained 43% of endoscopies and 30% were positive for HP. In 105 patients the RUT was negative and the GB positive (rendering a 19.5% false negative rate). HP was detected by RUT and GB in 29% of endoscopies. The highest prevalence of infection (38.1%) was found between 40 and 49 years. HP infection had odds ratio of 4.24 for nodular gastropathy, 2.63 for gastric ulcer and 2.14 for duodenal ulcer (p &lt; 0.05). Conclusions: HP prevalence in our center decreased significantly from 44.9% to 28.9% in 11 years. False negative RUT results may bias this finding. The use of proton pump inhibitors and antimicrobials that can interfere with the detection of HP should be registered to properly analyze the results of the RUT. <![CDATA[Estimulación cerebral profunda en enfermedad de Parkinson]]> Background: Deep brain stimulation is an essential therapeutic tool in Parkinson's disease. Aim: To assess the results of a series of patients with Parkinson's disease treated with micro-electrode guided subthalamic nucleus stimulation. Material and Methods: Twenty patients with idiopathic Parkinson's disease were studied (10 males). Three months after surgery, we analyzed the change in motor disturbances, medication need to control symptoms and quality of life. Results: We observed a significant improvement in all the assessed variables. Motor involvement determined as OFF hours and expressed as percentage of the day changed from 30 ± 15 to 10 ± 7% in the preoperative and postoperative periods, respectively. ON hours without dyskinesia changed from 17 ± 16 to 78 ± 21%. ON hours with dyskinesia changed from 53 ± 23 to 12 ± 15%. Medication need changed from 1,505 ± 499 to 1,214 ± 528 levodopa equivalents. Parkinson's Disease Questionnaire 39 score changed from 62.9 ± 22.7 to 34.3 ± 18.5. During the 5-year follow-up a continuous improvement of symptoms was observed. Conclusions: Micro-electrode guided subthalamic nucleus functional surgery in patients with Parkinson's disease has good immediate and late results. <![CDATA[Capacidad física y reserva cognitiva como factores protectores de las funciones atencionales en adultos mayores]]> Background: Attention is considered a central control mechanism in cognitive processing systems. Attention deficits contribute to the symptomatic profile of Alzheimer's disease (AD). Physical exercise and cognitive reserve, could delay cognitive impairment and constitute a protective factor against clinical manifestations of AD. Aim: To relate the functionality of the attentional networks with physical activity and cognitive reserve. Material and Methods: Three groups of 20 older adults each (control, physical activity and with osteoarthritis) were studied. The Functional capacity assessment test, Cognitive Reserve Questionnaire and the Attention Networks Test - for Interactions and Vigilance or ANTI-V were applied to participants. Results: Significant differences were observed in the response times of the alert, orientation and executive network, and the percentage of success in the network orientation and executive network. No differences between groups were observed for the different indicators of vigilance. Conclusions: These results confirm the benefits of physical exercise as a protective factor for attentional functioning. <![CDATA[Cáncer de cabeza y cuello: validación de cuestionario QLQ-H&N35]]> Background: Head and neck cancer affects esthetic and anatomical parameters, causing pain and functional impotence, affecting vital functions such as eating and breathing, hampering the quality of life of patients. EORTCQLQ-C30 questionnaire with its supplementary module QLQ-H &amp; N35 evaluates the quality of life of these patients. Aim: To statistically validate the QLQ-H &amp; N35 questionnaire in patients with head and neck cancer. Material and Methods: In a cross-sectional study, we studied patients with head and neck cancer who attended a rehabilitation unit. Reliability was measured using Cronbach's α and validity was determined by the diagnostic efficiency of the QLQ-H &amp; N35 scale as compared with the SF-36 quality of life survey. A Receiver Operational Characteristic (ROC) curve was generated. Results: The Cronbach's α global internal consistency of the questionnaire was &gt; 0.70 and its discrimination capacity was 74.2%, which are considered acceptable. Conclusions: These results confirm the statistical validity of the QLQ-H &amp; N35 questionnaire, specifically for patients with head and neck cancer in Chile. <![CDATA[No cumplir con las recomendaciones de actividad física se asocia a mayores niveles de obesidad, diabetes, hipertensión y síndrome metabólico en población chilena]]> Background: Physical inactivity is an important cardiovascular risk factor. Aim: To investigate the association of physical inactivity with obesity, metabolic markers, type 2 diabetes mellitus, hypertension and metabolic syndrome in Chilean adults. Material and Methods: Participants from the National Health Survey 2009-10 (n = 5,157) were included in this study. Body mass index, waist circumference, metabolic markers (blood glucose, glycosylated hemoglobin and lipid profile) were the outcomes. Type 2 diabetes, hypertension and metabolic syndrome were determined using international criteria. Physical activity levels were determined using the Global Physical Activity Questionnaire and physical inactivity was defined as &lt; 600 METs/minutes/week. Results: Compared to their physically active peers, inactive men and women had a higher odds ratio (OR) for obesity (OR: 1.77 [95% confidence intervals (CI): 1.29-2.42], p &lt; 0.01 and 1.25 [95% CI: 102-1.54], p &lt; 0.035, respectively), diabetes (OR: 2.47 [1.80-3.38], p &lt; 0.01 and 1.72 [1.35-2.19], p = 0.002, respectively) and hypertension (OR: 1.66 [1.31-2.09], p &lt; 0.01 and 1.83 [1.54-2.18] respectively. An association of physical inactivity with central obesity and metabolic syndrome was observed only in men (OR: 1.92 [1.42- 2.58], p &lt; 0.01 and 1.74 [1.23-2.47], p &lt; 0.01, respectively). Conclusions: Not meeting the physical activity recommendations is associated with obesity, diabetes, hypertension and metabolic syndrome, which are important cardiovascular risk factors. <![CDATA[Prevalencia de cepas cagA-positivo en la región de Coquimbo, determinada mediante nested-qPCR en muestras fecales]]> Background: Helicobacter pylori is the most significant pathogen associated with gastric diseases, including gastric cancer. Infected patients with strains that are CagA-positive generally have worse outcomes than those infected with CagA-negative strains. Patients infected with CagA-positive strains have a higher risk for developing gastric cancer. Aim: To determine the prevalence of CagA-positive H. pylori strains in fecal samples of patients from the Coquimbo Region of Chile, using a non-invasive, nested-qPCR method. Material and Methods: We evaluated 160 patients with gastrointestinal symptoms subjected to an upper gastrointestinal endoscopy. DNA was extracted from fecal samples and tested for the presence of H. pylori using nested-qPCR for the ureC gene, and subsequently compared with the results of histology-Giemsa stain from the patients' endoscopic biopsies. When H. pylori was found, the presence of CagA-positive strains was determined via nested-qPCR. Results: The histology-Giemsa stain was positive for H. pylori infection in 123 patients (76.9%), while the analysis of fecal samples detected H. pylori in 129 patients (80.6%). The sensitivity and specificity of nested-qPCR to detect the bacterium was 96.7 and 73.0% respectively. Among patients with the infection, 25% had CagA-positive strains. Conclusions: In this sample of patients, there is a low prevalence of CagA-positive H. pylori strains. <![CDATA[Efectividad de las intervenciones educativas con enfoque multifactorial y seguimiento vía telefónica sobre la rehospitalización en pacientes con insuficiencia cardiaca: revisión sistemática y meta-análisis]]> We performed a systematic review of the literature to analyze the effect on readmission rates of multifactorial educational interventions at the moment of discharge from the hospital and telephone follow up for patients with heart failure. The quality of reports was analyzed using the CONSORT verification list and the GRADE guide. Using Rev Manager 5.3, the relative risk heterogeneity (RR) of readmission was assessed using I2 and Q statistics, and those considered as homogeneous were combined into a single RR as the confidence interval. We included four reports in the review and three were meta-analyzed. The RR for readmission was 1.01 (95% confidence interval (CI): 0.73-1.40; p = 0.96) with educational interventions and telephone follow-up among patients who visited an emergency room (ER). When studies that included readmission (without ER visit) were combined, the RR was 0.83 (95% CI:0.58-1.17). When studies with visits to ER and readmissions were combined, the RR was 0.91 (95% CI:0.73-1.14). We conclude that educational interventions did not have a significant effect on the rate of readmissions of patients with heart failure. <![CDATA[Disglucemia asociada a fluoroquinolonas: una revisión estructurada]]> Fluoroquinolone type antimicrobials can cause hypo or hyperglycemia in certain patients. We performed a structured review about this side effect, searching articles published in English or Spanish with full text access in PubMed/Medline. The following MESH terms were used: Hypoglycemia, Hyperglycemia, Quinolones, Ciprofloxacin, Levofloxacin, Moxifloxacin. Additionally, we evaluated the clinical relevance of potential drug interactions, based on the probability of occurrence and the severity of the interaction effect. We obtained 42 publications about the issue; 22 references were selected, where the severity of the interaction in patients with risk factors was evaluated. Patients receiving antidiabetic medications and with risk factors such as advanced age and renal failure may be more likely to have a severe hypoglycemia. In these patients, this drug interaction should be considered clinically relevant since its risk is high or very high. <![CDATA[Hipertensión arterial pulmonar: el entrenamiento físico como complemento de la terapia farmacológica]]> Cardiopulmonary rehabilitation is a promising therapy for Pulmonary arterial hypertension (PAH) whose survival does not exceed 65% at five years. We performed a literature search about rehabilitation on PAH in MEDLINE, LILACS and COCHRANE databases, considering articles from 2005 to 2017. Fifteen articles were incorporated in the final analysis. We obtained information about safety parameters, type of exercises applied, duration and frequency of sessions. The interventions included aerobic, resistance and respiratory muscle training exercises. The results showed improvements in peak oxygen uptake, six minutes walking test, quality of life and inspiratory muscle strength, among others. We conclude that the evidence supports the recommendation of physical rehabilitation in selected patients with stable PAH as a complementary strategy to the available pharmacological therapy. <![CDATA[Fundamentos para la clasificación de los programas de médico especialista en un marco de cualificaciones nacional]]> Qualification of learning outcomes in terms of knowledge, skills, responsibility and autonomy provided by medical specialist programs is of interest to State authorities, educational service providers, employers, and specialists. Countries that are signatories to the Bologna Process and others outside Europe, established that the guaranteed primary degree for medical studies is the Master in Medicine (second cycle). There is agreement that medical specialist programs are more advanced than a Master of Medicine but are different from the Doctor of Medicine (third cycle) in their clinical orientation. These programs usually do not have research components and occasionally they are not carried out in the higher education system. However, the level of qualification of medical specialist programs has not been established due to lack of consensus. In Chile, this decision becomes even more complicated due to the certification of “licenciatura” (first cycle) that medical schools provide. There are also gaps in the educational classification procedure employed by the country. However, the review of national qualification frameworks and government acts shows that some countries have validated these certifications as third cycle. Medical specialties certainly do not correspond to PhD programs and the eligibility of the qualification level must be guaranteed to all stakeholders, who require an agreement on the specific national framework of learning outcomes and competencies. <![CDATA[Simulación clínica colaborativa para el desarrollo de competencias de trabajo en equipo en estudiantes de medicina]]> In health sciences and medicine, collaborative learning has an important role in the development of competences to solve clinical situations. Adequate cooperation, coordination and communication skills have a direct effect on patient safety. Computer Supported Collaborative Learning (CSCL) and Clinical Simulation (CS), separately, are effective and efficient educational methods to develop competences in undergraduate medical students. To our knowledge, educational models that combine both teaching methods, including a personalized attention of the student, educational infrastructure, materials, teaching techniques and assessment competencies, have not been proposed previously. This article describes the application of a combined model of CSCL and CS for teaching clinical competences to medical students. Since 2015, the collaborative clinical simulation model is part of the training agenda of the Universidad de Talca Medical School in Chile. During 2016 and 2017 it was also applied on students of the Universidad de Barcelona Faculty of Medicine in Spain. According to the experience acquired, implementation of this method is feasible with commonly used resources, although its real efficacy remains to be evaluated. <![CDATA[Experiencia en el Foro Global de Bioética en Investigación. Desafíos para la revisión ética en Chile]]> The Global Forum on Bioethics in Research annually convenes a number of researchers, bioethicists and stakeholders with a shared interest in the ethics of conducting research in low and middle-income countries (LMIC). It provides a useful platform to discuss ethical issues that affect research practice in different scenarios, promoting ethically conducted research, global development for health research ethics and partnerships between the global north and south. As participant of the last three meetings, in this article the author analyzes the main ethical issues that were discussed in this forum, namely “Emerging epidemic infections and experimental medical treatments” (Annecy, France, 2015); “Ethics of research in pregnancy” (Buenos Aires, Argentina, 2016), and “The ethics of alternative clinical trial designs and methods in LMIC research” (Bangkok, Thailand, 2017). Local research ethics committees are not well prepared to face the new ethical challenges associated with research conducted in emergency situations or in pregnant women, or to evaluate new methods, such as alternative clinical trial designs (cluster randomized trials, adaptive platforms, or controlled human infection models, among others). According to this scenario, research ethics committees should be trained to carefully assess the risks and benefits of approving this type of research. In this context, it is necessary to harmonize local regulations with the new international standards in research ethics. <![CDATA[Fascitis necrotizante de la pared abdominal como presentación infrecuente de una hernia de Garengeot: Caso clínico]]> Garengeot's hernia corresponds to the presence of the appendix within a femoral hernia, associated or not with acute appendicitis. The diagnosis of this uncommon situation is usually done during surgery. Furthermore, the clinical presentation as necrotizing fasciitis is a rare condition. We report a 54 years old obese hypertensive woman with rheumatoid arthritis of 40 years of evolution treated with methotrexate and prednisone. She consulted for pain and erythema in the right inguinal region. Laboratory revealed leukocytosis and an elevated C-reactive Protein. Suspecting a cellulitis, the patient was admitted for antimicrobial therapy. A pelvic magnetic resonance imaging showed a perforated acute appendicitis in an inguinal hernia with extensive pelvic cellulitis associated with signs of fasciitis. At surgery, an extensive groin and pubic fasciitis was evident, with a necrotic and perforated appendix within a femoral hernia. Surgical debridement, open appendectomy, and femoral hernioplasty without mesh were carried out. Vacuum-assisted closure was installed in the coverage defect. Three surgical debridement procedures were required for the closure of the wound. Two weeks after the first surgical procedure, the patient was discharged in good condition. During the follow-up, she evolved with a surgical wound dehiscence, which was managed with wound dressings until closure. <![CDATA[Supraversión de la mirada en intoxicación mortal por bupropión]]> Upgaze or sustained elevation of the eyes, is an alteration of ocular motility initially described in hypoxic coma. We report a 65-year-old woman admitted with hypotension and alteration of sensorium due to the ingestion of 9.5 g of Bupropion. She presented two seizures of short duration, without epileptic activity on the EEG. She had a persistent asynchronous myoclonus in extremities, tachycardia and prolonged Q-t. She suffered a cardiac arrest caused by asystole, which recovered quickly in five minutes. At that moment, upgaze appeared, associated with a persistent ocular opening, which persisted for days, but finally disappeared, without remission of coma. A magnetic resonance imaging done at the eighth day, showed hyperintensity of the oval center and corpus callosum which disappeared in a new imaging study done 30 days later, where images of hypoxia in the basal nuclei and cortex appeared. The patient died forty seven days after admission. Up-gaze is an ominous oculomotor alteration linked to an important but incomplete damage in the cerebral cortex, a condition that perverts some sequences of the ocular opening, reversing the Bell phenomenon and producing eyelid retraction. <![CDATA[Mieloma múltiple en pacientes con lupus eritematoso sistémico: presentación de dos casos]]> There is an increased incidence of hematological malignancies, particularly non-Hodgkin lymphoma (NHL) in systemic lupus erythematosus (SLE). In contrast, the concurrence with Multiple Myeloma (MM) is very rare, and the possible pathogenetic mechanisms underlying this association remain unclear. We report two patients who developed MM 15 and four years after being diagnosed as having SLE. <![CDATA[Donación y trasplante de órganos en Chile]]> There is an increased incidence of hematological malignancies, particularly non-Hodgkin lymphoma (NHL) in systemic lupus erythematosus (SLE). In contrast, the concurrence with Multiple Myeloma (MM) is very rare, and the possible pathogenetic mechanisms underlying this association remain unclear. We report two patients who developed MM 15 and four years after being diagnosed as having SLE. <![CDATA[Ronald Wainstein Gewölb 1961-2018]]> There is an increased incidence of hematological malignancies, particularly non-Hodgkin lymphoma (NHL) in systemic lupus erythematosus (SLE). In contrast, the concurrence with Multiple Myeloma (MM) is very rare, and the possible pathogenetic mechanisms underlying this association remain unclear. We report two patients who developed MM 15 and four years after being diagnosed as having SLE.