Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 147 num. 3 lang. es <![CDATA[SciELO Logo]]> <![CDATA[Nuevas secciones en la Revista Médica de Chile]]> <![CDATA[Macroglobulinemia de Waldenström. Experiencia de 15 años en el Hospital del Salvador, Santiago, Chile]]> Background: Waldenström macroglobulinemia (WM) is an uncommon indolent B-cell lymphoma, due to the proliferation of lymphoplasmacytic cells, and secretion of a monoclonal IgM protein. Aim: To evaluate the clinical characteristics, management and results of treatment of patients with WM at a public hospital in Chile. Patients and Methods: Review of medical records of 31 patients aged 43 to 85 years (16 males) with WM diagnosed between 2002 and 2017. Clinical features and survival were recorded. Results: All patients had bone marrow compromise, and 31%, extranodal involvement. According to the International Prognostic Score System for WM (IPSSWM) 16, 58 and 26% were at low, intermediate and high risk, respectively. Twenty-five patients (81%) were treated, 32% with plasmapheresis and 36% with rituximab. Four cases (16%) achieved complete remission. Median follow up was 35 months (range 6-159). Estimated overall survival (OS) at 5 and 10 years was 74% and 53%, respectively. According to IPSSWM, the estimated five-year OS was 80, 92 and 39%, for low, intermediate and high-risk patients, respectively. Conclusions: OS was similar to that reported abroad, except for low risk patients, probably due to the low number of cases and short follow up. An improved survival should be expected with the routine use of immunochemotherapy. <![CDATA[El tratamiento postnatal con melatonina modula la expresión de agentes prostanoides en pulmón de neonatos de oveja con hipertensión pulmonar]]> Background: Living above 2,500 meters in hypobaric conditions induces pulmonary arterial hypertension of the neonate (PAHN), a syndrome whose main features are: pathological remodeling of the pulmonary vessels, abnormal vascular reactivity and increased oxidative stress. Melatonin could have pulmonary antioxidant, anti-remodeling and vasodilating properties for this condition. Aim: To determine the effect of melatonin at the transcript level of prostanoid pathways in the lung of neonatal lambs gestated and born under hypobaric hypoxia. Material and Methods: Vehicle (1.4% of ethanol, n = 6) or melatonin (1 mg * kg1, n = 5) were administered from the postnatal day 4 to 21 to lambs gestated and born at 3,600 meters above sea level. After one week of treatment completion, lung tissue was obtained, the transcript and protein levels of prostanoid synthases and receptors were assessed by RT-PCR and Western Blot. Results: Melatonin induced the expression of prostacyclin synthase transcript and increased protein expression of the prostacyclin receptor. In addition, the treatment decreased the expression of transcript and protein of cyclooxygenase-2, without changes in the expression of the prostanoid vasoconstrictor (thromboxane) pathway. Conclusions: Postnatal treatment with melatonin increases the expression of the prostacyclin-vasodilator pathway without changing the vasoconstrictor thromboxane pathway. Further, the decreased COX-2 induced by melatonin could be an index of lesser oxidative stress and inflammation in the lung. <![CDATA[Potencia aeróbica máxima en el obeso: Valores de referencia]]> Background: The evaluation of physical fitness is important to determine workloads and to assess the effectiveness of exercise interventions in obese people. Aim: To determine the maximum aerobic power output (MAPO) in overweight and obese individuals and to establish reference parameters for the Chilean population. Material and Methods: One hundred five men and 218 women performed a cycle ergometer test up to 85% of their maximum heart rate. MAPO was determined by linear extrapolation of the theoretical maximum heart rate. Results: Among men, MAPO values were 234.9 ± 48.4 w for body mass index (BMI) values between 30 and 34.9 kg/m2, 235.1 ± 69.7 w for BMI between 35 and 39.9 kg/m2, 270.2 ± 86.5 w for BMI over 40 kg/m2. MAPO relative values were 2.27 ± 0.5, 2.16 ± 0.6 and 1.96 ± 0.8 w/kg, respectively. Among women, MAPO was 172.6 ± 36.1 w for a BMI &lt; 30 kg/m2, 169.2 ± 39.4 w for BMI between 30 and 34.9 kg/m2, 179.5 ± 48.8 w f179.5 ± 48.8 w for BMI between 35 and 39.9 kg/m2 and 202.3 ± 57.3 w for BMI of 40 kg/m2 or over. The relative values were 2.33 ± 0.5; 2.02 ± 0.5; 1.91 ± 0.5 and 1.81 ± 0.5 w / kg (p &lt; 0.05). Conclusions: MAPO estimation with a cycle ergometer test is well tolerated in overweight and obese individuals. MAPO decreased along with BMI increments in women. No association between BMI and MAPO in men was observed. <![CDATA[Diseño de una propuesta de protocolo de estandarización y gestión de calidad para el proceso de procuramiento de órganos]]> Background: Organ donation rates for transplantation are low in Chile and there is a paucity of a technical-structured-normalized procurement process. Aim: To design a protocol to standardize the organ procurement process based on the Chilean reality. Material and Methods: After a first phase of bibliographic reviews and analyzing de Chilean legislative and normative frame, a proposal was elaborated in collaboration with five expert coordinators. In the second phase, two Delphi rounds with the local coordinators of the organ procurement centers were carried out. Their responses were analyzed and the stages and criteria to standardize the organ procurement process were determined. Results: The expert defined organ procurement process, validated by local coordinators, comprised nine stages and 36 criteria. The expert opinion coincidence was high and significant (Cronbach's alpha &gt; 0.8, p &lt; 0.01). Conclusions: The protocol describing the procurement process, constructed and validated by experts, will allow to standardize a clinical protocol contributing to a successful national organ procurement. <![CDATA[Estructura y funciones de la Atención Primaria de Salud según el <em>Primary Care Assessment Tool</em> para prestadores en la comuna de Conchalí - Santiago de Chile]]> Background: The Chilean public health system is based on Primary Health Care (PHC), whose assessment is challenging due to the heterogeneity of services and multi-dimensionality of expected results. The Primary Care Assessment Tool was adapted and validated for Chile. Aim: To analyze, from the provider's perspective, the structure and functioning of the health centers, to determine the achievement of PHC's core functions: access, continuity, coordination, comprehensiveness of care, cultural competence, family centeredness and community orientation. Material and Methods: All professionals working in primary care in a commune of Metropolitan Santiago were invited to answer an online version of the Primary Care Assessment Tool. Results: One hundred and nine professionals (51% of those invited) from four Family Health Centers, two Community Health Centers, and a Community Mental Health Center, answered the online questionnaire. Their distribution by profession and health units does not resemble the whole research population, which should be considered when interpreting the results. Data show a good performance of the system: general and domain specific scores are all near three for a maximum score of four. Family centeredness obtained the highest score, whereas cultural competence had the lowest. Conclusions: Reinforcing intercultural skills and a wider approach to psycho-social problems is recommended to strengthen the new healthcare model implementation. <![CDATA[Estigma de obesidad, cortisol e ingesta alimentaria: un estudio experimental con mujeres]]> Background: Weight-based stigmatization is frequent among overweight and obese people. Aim: To determine the association between weight-based stigmatization, psychological stress, cortisol, negative emotions, and eating behavior in a sample of middle-aged women. Material and Methods: Eighty-two women aged 45 ± 8 years, 55% with overweight or obesity, were randomly allocated to watch a video called “Stigma: the human cost of obesity” or a control video about planet earth. The effect of watching either video on calorie consumption, psychological stress and cortisol reactivity was assessed. Cortisol was measured on four salivary samples. Psychological stress and negative emotions were self-reported. Results: Among women who watched the stigmatizing video, there was a direct association between psychological stress and calorie intake, but negative emotions did not mediate this association. Moreover, psychological stress moderated the association between watching the stigmatizing video and the cortisol output (β = 0.32; p = 0.005). Conclusions: Women with high psychological stress have a greater intake of calories. After watching the stigmatizing video, a greater psychological stress is associated with greater cortisol output. <![CDATA[Tendencia de las defunciones ocurridas en mayores de 1 año según lugar de ocurrencia y su relación con características sociodemográficas, Chile 1997-2014]]> Background: The place of death is a fundamental indicator for the debate on equity and access to health care. Aim: To describe the place of death of the deceased population over 1 year of age in Chile between the years 1997 and 2014. To analyze tendencies in this variable and its association with socio-demographic characteristics. Material and Methods: Time series study covering deaths occurred between 1997 and 2014 in Chile. National death records were used, provided by the Department of Health Statistics and Information (DEIS) of the Chilean Ministry of Health. The following variables were chosen: place of death (home, hospital, other), sex, marital status, age, level of education, activity and area of residence. Temporal trends were evaluated using Prais Winsten regressions. Logistic regression was used to assess the association of the place of death with socio-demographic characteristics. Results: Between 1997 and 2014 there were 1,576,392 deaths, at a mean age of 69 years (p25-p75:60-83 years). No temporal variations in the place of death were observed with the Prais Winsten regression, hospital (P-W coefficient (coef) = 0.06 (confidence intervals (CI): −0.30; 0.19), p = 0.64), home (P-W coef = −0.03 (CI: −0.15; 0.09), p = 0.57), and other places (P-W coef = 0.07; (CI: −0.08 – 0.22), p = 0.32). The multivariate analysis showed that being women under 70 years of age, being married or widowed, having a higher educational level, being inactive and living in a rural area were factors associated with a greater chance of dying at home. Conclusions: No significant temporal variation in the place of death was observed. <![CDATA[Pacientes elegibles para las nuevas terapias de la insuficiencia cardíaca en un policlínico especializado]]> Background: Pharmacological treatment improves survival in patients with heart failure with reduced ejection fraction. The use of sacubutril/valsartan and ivabradine has been recently approved and incorporated in the latest guidelines. Aim: To identify candidates eligible for these therapies among patients treated in a heart failure clinic, considering the inclusion criteria for the PARADIGM-HF and SHIFT trials. Material and Methods: Cross-sectional study on 158 patients aged 62 ± 11 years (67% male) with heart failure and reduced ejection fraction, with at least three months of follow-up and without decompensation. The percentage of patients complying for the inclusion criteria for the PARADIGM-HF y SHIFT trials was determined. Results: In 37%, the etiology of heart failure was ischemic, 49% were in functional class I, their ejection fraction was 33 ± 11% and their median Pro-brain natriuretic peptide was 800 pg/mL. Ninety five percent were treated with vasodilators, 97% with beta-blockers and 82% with aldosterone antagonists. Using PARADIGM-HF and SHIFT criteria, 11 patients (7%) were eligible for sacubitril / valsartan and 21 patients (13.3%) for ivabradine. Among the main causes of non-eligibility for sacubitril / valsartan were being functional class I (48.7%) and not achieving a stable dose of enalapril ≥ 20 mg / day or losartan ≥ 100 mg / day (24.7%). In the case of ivabradine, apart from those in functional class I, the absence of sinus rhythm and a heart rate &lt; 70 / min when receiving a maximal tolerated dose of beta-blockers, were present in 22%. Conclusions: A low percentage of our patients were eligible for these therapies. Among the causes that explain these results were clinical stability, a high percentage of patients in functional class I and being in a disease modifying treatment. <![CDATA[Importancia de la orientación diagnóstica en hemofilia A adquirida]]> Acquired hemophilia A (AHA) is a rare and life-threatening autoimmune hemorrhagic disorder where autoantibodies are developed against factor VIII. An early diagnosis is challenging and mandatory: an immediate hemostatic control is required to reduce morbidity and mortality. Laboratory features of AHA are: presence of autoantibodies against factor VIII, prolonged activated partial thromboplastin time (with normal prothrombin time and thrombin time) and decreased factor VIII levels. In some cases, the results of laboratory tests may be incorrect due to errors in analysis, blood extraction or manipulation of samples; also worth of consideration are limitations in the measurement range and low sensitivity of the tests. This review highlights the importance of adequate screening in patients with suspected AHA to make an adequate diagnosis and reduce overall fatal outcomes. <![CDATA[Miopatías inflamatorias idiopáticas: una mirada actualizada al diagnóstico y el manejo]]> Idiopathic inflammatory myopathies (IIM) are a heterogeneous group of acquired immune-mediated diseases, which typically involve the striated muscle with a variable involvement of the skin and other organs. Clinically, they are characterized by proximal muscle weakness, elevation of muscle enzymes, myopathic changes on electromyography and an abnormal muscle biopsy. The different IIM have been classified according to their distinctive histopathologic features in dermatomyositis (DM), polymyositis (PM), inclusion body myositis (IBM) and immune-mediated necrotizing myopathy (IMNM). Several myositis-specific antibodies are associated with the different phenotypes, as well as with different risk of neoplastic disease and systemic complications. The basis for the treatment of DM, PM, and IMNM is immunosuppression. For IBM there are only symptomatic treatments. Steroids, associated or not with other immunosuppressant drugs, are the first line of treatment. Biologic drugs will allow future individualized therapies. The 10-year survival of DM, PM and IMNM is 62 to 90%. The leading causes of death are neoplastic, lung and cardiac complications. IBM does not impair survival, although it affects the quality of life. <![CDATA[La enfermedad de Johann Sebastian Bach y su mediático médico inglés]]> Johann Sebastian Bach suffered during the last year of his life of a progressive visual defect despite two operations done by a famous but quite controversial English ocular surgeon of that time. The exact diagnosis of his ocular problems is unclear but cataracts and complicated glaucoma seem the most plausible. A septic complication following the ocular surgery could have weakened Bach's health leading to his death only three months after the last intervention. In this paper diverse less known aspects of Bach's disease and life are reported. <![CDATA[Diabetes Mellitus tipo 2: desafíos para los modelos de cuidados crónicos en Chile]]> The increase in chronic noncommunicable diseases is one of the main concerns worldwide. Therefore, it is pertinent to ask how care system organizations responded to the requirements currently being posed by chronic diseases, specifically type 2 diabetes mellitus (T2DM). In the world, different models have been developed considering elements that transcend the biological stability of the disease. Chile has the great challenge of exploring new models that emphasize the promotion and prevention of health rather than the management of the disease. The impact of variables such as health literacy, self-efficacy and subjective well-being on T2DM should be explored. In addition, it is necessary to validate and implement guidelines and protocols of care that incorporate the aforementioned variables. <![CDATA[Las primeras médicas de Chile y Latinoamérica: Eloísa Díaz Insunza y Ernestina Pérez Barahona]]> Dr. Eloísa Díaz Insunza (1866-1950) was the first woman to become a doctor-surgeon in Chile and Latin America in 1887. Less known is her distinguished colleague, Dr. Ernestina Pérez Barahona (1865-1951), the second woman graduated in Chile as a physician, only seven days after Dr. Diaz. Dr. Diaz entered the School of Medicine of the University of Chile in 1881 and Dr. Pérez in 1883. However, both graduated from Bachelor of Medicine and Pharmacy in 1885 and received their degree in 1887. This paper highlights the extraordinary parallelism in their medical studies. <![CDATA[Determinación de pensamiento creativo en estudiantes de medicina de una universidad chilena]]> Background: Creativity is a highly valued quality in different fields. Despite this, it is rarely included in the curricula of medical careers. Aim: To assess creative thinking among undergraduate medical students. Material and Methods: Sixty-seven students aged 18 to 31 years (45% women) from the first (16), third (26) and seventh year (25) of medical school answered a sociodemographic questionnaire and the Torrance Test of Creative Thinking (TTCT). Results: Median creativity index according to age was in percentile 52 (range 2-99). Percentiles for fluency, originality, elaboration, abstraction of titles and resistance for premature closure were 31, 32, 79, 53 and 17 respectively. There were no significant differences between students of different levels (p = 0.73). Conclusions: In this group of students, there is a high performance in elaboration and a low score in Resistance to premature closure. <![CDATA[El trasplante de hígado es un procedimiento plausible, efectivo y seguro en pacientes con hemofilia. Caso clínico]]> Due to blood derivative requirements, many patients with hemophilia were exposed to Hepatitis C virus infection (HCV) before the availability of HCV testing. We report a 46-year-old male with Hemophilia A with a hepatitis virus C infection since 2004 causing a cirrhosis. Due to a hepatopulmonary syndrome, he received a liver allograph using a factor VIII replacement protocol, after eradicating the virus C. He had a good postoperative evolution, and no more factor VIII was required after transplantation until his last assessment. <![CDATA[Fibrodisplasia osificante progresiva plus por una variante patogénica del gen ACVR1: Caso clínico]]> Fibrodysplasia ossificans progressiva (FOP) or myositis ossificans, is a genetic disease, with a prevalence of 1 in 2.000.000. It is caused by pathogenic variants in ACVR1 gene and characterized by soft tissue heterotopic ossification, starting in the second decade of life. It is associated to early mortality caused by respiratory complications. It evolves in flare-ups, triggered by soft tissue injuries; therapy is symptomatic, using analgesia, steroids and diphosphonates. We report a 12-year-old female with left renal agenesis, hallux valgus and intellectual disability, presenting with a six months history of thoracic kyphosis, tender nodules in the thorax, and rigidity of right elbow and left knee. Clinical examination revealed dysmorphic facial features. A magnetic resonance showed heterotopic ossification nodules, which was confirmed with spinal radiography. These findings prompted the diagnosis of FOP. Pain treatment was started, and prednisone was used during flare-ups. The ACVR1 gene was analyzed and a pathogenic variant, p. Arg206His, was found, confirming the diagnosis of FOP. <![CDATA[Recurrencia de Síndrome de Goodpasture con negativización de anticuerpos anti-membrana basal glomerular: Caso clínico]]> Goodpasture Syndrome is described as a single episode disease entity. It is diagnosed with the demonstration of antiglomerular basement (anti-GBM) antibodies in plasma or renal tissue. Although the recurrence of anti-GBM disease is rare, it has been reported in up to 3% of cases. Recurrence with negative anti-GBM antibodies in plasma is even less frequent We report a 63 years old male in whom anti-GBM disease recurred without detectable anti-GBM antibodies in plasma, despite having positive antibodies at the onset. <![CDATA[Urgencias neurológicas y modelos organizativos]]> Goodpasture Syndrome is described as a single episode disease entity. It is diagnosed with the demonstration of antiglomerular basement (anti-GBM) antibodies in plasma or renal tissue. Although the recurrence of anti-GBM disease is rare, it has been reported in up to 3% of cases. Recurrence with negative anti-GBM antibodies in plasma is even less frequent We report a 63 years old male in whom anti-GBM disease recurred without detectable anti-GBM antibodies in plasma, despite having positive antibodies at the onset. <![CDATA[Registro de paro cardiorrespiratorio en un hospital universitario en el período 2006-2017]]> Goodpasture Syndrome is described as a single episode disease entity. It is diagnosed with the demonstration of antiglomerular basement (anti-GBM) antibodies in plasma or renal tissue. Although the recurrence of anti-GBM disease is rare, it has been reported in up to 3% of cases. Recurrence with negative anti-GBM antibodies in plasma is even less frequent We report a 63 years old male in whom anti-GBM disease recurred without detectable anti-GBM antibodies in plasma, despite having positive antibodies at the onset.