Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 129 num. 12 lang. es <![CDATA[SciELO Logo]]> <![CDATA[Estudio clínico-molecular de pacientes chilenas con síndrome de McCune-Albright]]> Background: McCune-Albright Syndrome (MAS) is characterized by precocious puberty, "cafe au lait" skin lesions and polyostotic fibrous dysplasia. It is caused by 4 post-zygotic mutations of Gas protein with a mosaic distribution. Aim: To describe the clinical presentation and to investigate the presence of the Arg by his substitution (R201H) in 14 girls with MAS. Patients and methods: We performed a clinical analysis of the patients and specific allele PCR in DNA obtained from leukocytes. Results: Twelve of 14 patients presented with precocious puberty, one with cyclical vaginal bleeding and one with pathological bone fractures. Eight girls had polyostotic fibrous dysplasia, one had hyperthyroidism, four had pathological fractures, ten had ovarian cysts, six had breast hyperpigmentation and ten had "cafe au lait" skin lesions. We detected the R2O1H mutation in 10 of 14 patients. We found no difference in the severity of symptoms or in the age of presentation between the patients with and without the mutation. Conclusions: The R201H mutation can be detected in white blood cells, in approximately 70% of cases. Patients exhibit wide clinical variability with the same molecular defect. This suggests that tissues have different proportions of mutant cells (Rev Méd Chile 2001; 129: 1365-72) <![CDATA[Heparina e insulina en el tratamiento de la pancreatitis aguda por hipertrigliceridemia: Experiencia en 5 casos]]> Background: Hypertriglyceridemia over 1,000 mg/dl can provoke acute pancreatitis and its persistence can worsen the clinical outcome. On the contrary, a rapid decrease in triglyceride level is beneficial. Plasmapheresis has been performed in some patients to remove chylomicrons from the circulation, while heparin and/or insulin have been administered in some other cases to rapidly reduce blood triglycerides. Heparin and insulin stimulate lipoprotein-lipase activity and accelerate chylomicron degradation. Aim: To report five patients with acute pancreatitis treated with heparin and insulin. Patients and methods: Five patients (4 females and 1 male) seen in the last two years, who suffered acute pancreatitis induced by hypertriglyceridemia are reported. Initial blood triglyceride levels were above 1,000 mg/dl (range 1,590-8,690 mg/dl). Besides the usual treatment of acute pancreatitis, heparin and/or insulin were administered intravenously in continuous infusion. Heparin dose was guided by usual parameters of blood coagulation, and insulin dose, by serial determinations of blood glucose. Pancreatic necrosis was demonstrated in 4 patients. Results: Serum triglyceride levels decreased to <500 mg/dl within 3 days in all cases. No complication of treatment was observed and all patients survived. Early and late complications of pancreatitis occurred in one patient. Conclusion: Administration of heparin and/or insulin is an efficient alternative to reduce triglyceride levels in patients with acute pancreatitis and hypertriglyceridemia (Rev Méd Chile 2001; 129: 1373-8) <![CDATA[¿Es aplicable el sistema de vigilancia epidemiológica de las infecciones intrahospitalarias que recomienda el CDC- americano (sistema NNIS) en un hospital chileno?]]> Background: The National Nosocomial Infections Surveillance System (NNIS system) is the method for surveying nosocomial infections used by the Centers for Disease Control (CDC). This strategy allows the comparison of different hospitals, using rate adjustments. In Chile, this system is not used. Aim: To report the application of this system in a tertiary reference hospital in Chile. Materials and methods: We performed a six months prospective cohort study. The active surveillance was carried out by using the intensive care unit and surgery components of the NNIS system. Tabulation and analysis of the data were done according to the NNIS system. In a parallel prevalence study, we determined the NNIS system sensitivity to detect nosocomial infections. Results: A total of 492 patients were followed with a global nosocomial infection rate of 14%, for discharged patients. The calculated sensitivity and specificity of the system was 84.2 and 97% respectively. In the intensive care unit, 45 of 169 patients had nosocomial infections, with an adjusted rate of 2.8% for mean hospitalization time and severity of illness. In the cardiovascular and thoracic surgical units, 216 and 107 procedures were surveyed, respectively. The global rates of nosocomial infections were 7.4 and 7.5%, respectively. The adjusted rates according to risk factors were 0.9 and 2.3%, respectively. Conclusions: These data indicate that the surgical units had surgical site infections rates similar to those reported by the CDC. Nosocomial infections rates in Chile can be compared with rates observed in other countries. The epidemiological data collected can be useful to focus intervention or preventive strategies (Rev Méd Chile 2001; 129: 1379-86) <![CDATA[Ligadura elástica complementada de esclerosis en el tratamiento de várices esofágicas: Experiencia en la hemorragia activa y en el tratamiento electivo]]> Background: Endoscopic ligation is the treatment of choice for bleeding esophageal varices. The usefulness of additional sclerotherapy is not clear. Aim: To assess the effectiveness of ligation followed by sclerotherapy in the treatment of variceal bleeding. Patients and methods: Forty eight patients with variceal bleeding admitted for emergency treatment and 73 patients admitted for elective treatment were studied. Varices were ligated until a significant reduction in size was achieved. Eradication was completed with the injection of 1% polidocanol. Results: In 34 of 48 patients admitted for emergency treatment, the site of variceal rupture was identified. In all these subjects, and in 13 of 14 patients in whom the rupture site was not identified, hemorrhage was stopped with the procedure. Varices were eradicated in 108 of the 121 patients. Hemorrhage recidivated in 12.5% of patients admitted for emergency treatment, in a period of 14 months of follow up and in 9.6% of those admitted for elective treatment, in a period of 16 months follow up. Mortality was 14, 18 and 57% among patients classified as Child Pugh A, B or C, respectively. Conclusions: Endoscopic ligation is effective in the treatment of variceal bleeding. Adding sclerotherapy, variceal eradication is achieved in a high percentage of patients. Survival depends on hepatic function (Rev Méd Chile 2001; 129: 1387-94) <![CDATA[Estudio comparativo de costos anuales en salud entre usuarios de oxígeno domiciliario y pacientes en lista de espera]]> Background: Home oxygen therapy is the only intervention that significantly prolongs survival of patients with chronic obstructive pulmonary disease. Since this therapy is expensive, it is imperative to calculate its cost-benefit ratio. Aim: To compare health care costs for patients in a home oxygen therapy program, with those of a similar group of patients in a waiting list for this therapy. Material and methods: A retrospective analysis of 21 patients on home oxygen therapy for 36 months or less and a group of 13 patients in the waiting list during a similar lapse. Medical consultations, drugs delivered and the cost of oxygen therapy were considered among ambulatory costs. Hospitalization costs included the number of days on regular or intermediary care beds, laboratory tests and drugs delivered. Results: The annual health care costs for patients on home oxygen therapy were 709,656 Chilean pesos and the costs for patients in the waiting list were 797,320 Chilean pesos. Conclusions: The overall health care costs of home oxygen therapy are similar to the costs required by patients with chronic obstructive pulmonary disease remaining in waiting lists (Rev Méd Chile 2001; 129: 1395-403). <![CDATA[Violencia conyugal en la ciudad de Temuco: Un estudio de prevalencia y factores asociados]]> Background: Violence against women is a recognized public health problem in developed countries. There is increasing awareness on family violence in Chile, but there is scant information about its prevalence. Aim: To determine the prevalence of family violence against women in a population sample in Temuco, Chile. Material and methods: A standardized questionnaire about family violence was applied to a sample of 422 women at their homes. The questionnaire had six sections that included a list of violent behaviors from husbands or partners, a standardized instrument to assess mental health and alcohol consumption by the couple, history of child abuse, community support, type of employment and years of school education. Results: Forty nine percent of women reported psychological aggression, 13% reported physical violence and 5.5%, sexual violence. The presence of anxiety or depressive symptoms, being witness of violence between parents during childhood, a lower educational level, being a housewife, alcohol abuse and lack of community support were risk factors for violence among women. Among men, the history of child abuse, a lower education level, and alcohol abuse were identified as risk factors for violent behaviors. Conclusions: Conjugal violence is a significant mental health problem in Temuco, Chile (Rev Méd Chile 2001; 129: 1405-12) <![CDATA[Impacto de la violencia doméstica sobre la salud reproductiva y neonatal]]> Background: Domestic violence can have an important influence on mother and child health. Aim: To assess the consequences of remote and actual, emotional or physical, domestic violence on the reproductive and newborn health in pregnant women. Material and methods: A longitudinal epidemiological observation from an Urban Primary Health Care Center from Valdivia, Chile, in 1998. Two cohorts were studied: Pregnant women that experienced domestic violence (index group) and pregnant women not exposed to domestic violence (control group). Women were followed during pregnancy and at labor. The newborn was also assessed. Results: The index group had a higher relative risk (RR) for impending abortion (RR 1.44, 95% confidence interval (CI): 1.07-1.93), hypertensive syndrome of pregnancy (RR 1.5, 95% CI: 1.18-1.96), intrahepatic cholestasis (RR 1.5, 95% CI: 1.1-1.94). Women that experienced violence during pregnancy had a higher risk of urinary tract infection (RR 2.88, 95% CI: 1.28-6.43), intrauterine growth retardation (RR 3.7, 95% CI: 1.77-7.93) and intrahepatic cholestasis. Newborns from the index group had lower weight, size and gestational age. Conclusions: Domestic violence is associated with hypertension during pregnancy and intrauterine growth retardation. The incorporation of bio-psychological evaluation and monitoring systems could attenuate the consequences of domestic violence (Rev Mé 2001; 1413-24) <![CDATA[Maltrato infantil en la ciudad de Temuco: Estudio de prevalencia y factores asociados]]> Background: Child maltreatment is recognised as a significant health problem in developed countries. There is increasing awareness on family violence in Chile, becoming a health priority in the last five years, but there is scant information about its prevalence. Aim: Determine prevalence of child abuse, and associated factors in a population sample from Temuco, Chile. Material and methods: A standardised questionnaire was applied to a sample of 422 women at their homes. Instrument had questions about disciplinary practices by caretakers, a standardised questionnaire to assess mental health, as measures of risk and protective factors for violence Results: The prevalence of psychological aggression delivered by mothers or fathers was 17.5% and 6.8 % respectively. The figures for corporal punishment delivered by mother or fathers were 42.3% and 17% respectively. Three percent of mothers and 1.2% of fathers recognised severe physical abuse. Associated factors were mother impaired mental health, antecedents of child abuse in both parents, parents alcohol abuse and child emotional/behavioral problem. Conclusion: Child abuse is a extended significant problem in Temuco that requires multidisciplinary intervention programs (Rev Méd Chile 2001; 129: 1425-32) <![CDATA[Colangiocarcinoma primario asociado a enfermedad de Caroli]]> A 68 years old male presented with right hypochondrium abdominal pain and jaundice with no other clinical finding. CAT Scan and Ultrasonography showed right lobe bile duct dilatation. Magnetic Resonance Cholangiopancreatography gave an outstanding vision of a restricted right lobe bile duct dilatation associated to choledocholithiasis. A right hepatectomy and bile duct exploration were performed. The histopathological study disclosed a Caroli disease associated to a primary cholangiocarcinoma. Caroli disease is a congenital disorder characterized by intrahepatic cystic bile duct dilatation with a high risk association with cholangiocarcinoma (Rev Méd Chile 2001; 129: 1433-8) <![CDATA[Aneurisma roto de aorta torácica descendente: tratamiento endovascular]]> In 1991, a technique to exclude aortic aneurysms from circulation inserting an endoluminal graft through the femoral artery, was described. This procedure, usually used for elective abdominal aneurysms, can also be used in the thoracic aorta. We report a 41 years old male with a Marfan syndrome, presenting with a descending aorta aneurysm that ruptured to the mediastinum and pleural cavity. He was compensated hemodynamically and an endovascular stent-graft was deployed at the ruptured zone, through the femoral artery. The postoperative evolution of the patient was uneventful. This technique will allow a less invasive treatment of ruptured aortic aneurysms (Rev Méd Chile 2001; 129: 1439-43) <![CDATA[Metástasis en la médula espinal: una localización infrecuente. Experiencia en 2 casos]]> Spinal cord metastases are an uncommon secondary location of a malignant neoplasm. They are rarely diagnosed during life and when that is the case, it is in the clinical setting of a disseminated cancer and very seldom as the first clinical manifestation. We report two patients, with no previous disease, who developed a progressive myelopathy. An intramedullary spinal cord tumor was diagnosed, based on the clinical picture and imaging studies. They were operated and biopsies showed spinal cord metastases whose primary tumor was a lung neoplasm. We discuss the clinical features in these patients, the diagnosis of progressive myelopathy in cancer patients, treatment and prognosis of this unusual secondary cancer location (Rev Méd Chile 2001; 129: 1445-8) <![CDATA[Neutropenia febril en el niño con cáncer: Conceptos actuales sobre criterios de riesgo y manejo selectivo]]> The risk for invasive bacterial infection (IBI) in cancer pediatric patients with febrile neutropenia, is variable. Clinicians worldwide are increasingly considering selective strategies for children at low risk for IBI, including shortened antimicrobial course, early hospital discharge, oral antimicrobial treatment, and management as outpatients. These strategies would significantly benefit these children and health care systems. The critical issue is to identify the most reliable risk factors useful for selection of those individuals who are at low risk for IBI. In Chile, during the past 10 years, a group of physicians from the Subcommittee of Infectious Diseases of the National Child Program of Antineoplastic Drugs and the University of Chile have worked to develop more selective strategies for pediatric patients with cancer, fever and neutropenia. During 1996-1997 we identified risk factors of IBI in a group of 447 febrile neutropenic episodes. During 1999-2000 we validated these risk factors in a prospective study that included 263 febrile neutropenic episodes. A model of risk prediction was developed and is currently being evaluated for the selection of low risk patients who are treated as inpatients for 24 hours, followed by outpatient treatment (Rev Méd Chile 2001; 129: 1449-1454) <![CDATA[Errores en Medicina]]> Untoward effects can result from the various procedures involved in patients care. Because of its risks and consequences it is very important to determine the causal factors of these events to improve the procedures at stake and be sure to obtain from them the results to be expected. Several recent and somehow disturbing reports about the magnitude and type of these said medical errors, have raised interest to review the subject and phase this problem under the scope of a quality control system, as to prevent its occurrence or mitigate its effects when there is no chance to avoid them properly (Rev Méd Chile 2001; 129: 1455-8) <![CDATA[Fuentes de error en clínica]]> The clinical setting is everything that contact us with the patient's reality, including physical, instrumental and laboratory exploration, and we use it for diagnostic and treatment purposes. Diagnosis is the synthesis by which physicians conclude an elaborated analysis of subjective and objective data, obtained by physical exam and technology. This procedure involves data collection about the patient and his disease, the results of various tests and laboratory findings, the interpretation of the data and a diagnostic summary. Medical errors may be derived from insufficiency in any of these phases. It is evident that technology will never replace the intellectual data recollection, analysis and reasoning that is the physician's art. This contribution underlines some of the defects frequently observed in clinical practice that may cause medical errors (Rev Méd Chile 2001; 129: 1459-62) <![CDATA[Consideraciones éticas sobre el error en medicina]]> It is usually inevitable to save the physician-patient relationship from the effects of medical errors. It is so because either the professional responsibility, the patients trust and the principles that govern the medical action are compromised by such events. The possibility to learn from it, prevent its appearance, improve the procedures and curtail its consequences, is linked to developing ethical attitudes to overcome these circumstances without further legal accountability (Rev Méd Chile 2001: 129: 1463-5) <![CDATA[Definiciones respecto al error en medicina: <I>Some definitions</I>]]> Medical errors can be defined as value laden facts, in relation to guidelines or expectations, to the responsibility involved, to the obligations abated, to the pertinence of excuses afforded because of complexity, compliance and prudence or its aggravation through recklessness. Due care is related to prevention and corresponding attitudes. Professionalism, continuous education and quality control systems to detect errors without dispensing inexcusable faults, are the main tools to avoid medical errors (Rev Méd Chile 2001; 129: 1466-9) <![CDATA[Manejo de los errores en medicina]]> If negligent actions are ruled out, medical errors must be prevented or attenuated enhancing security in all the health care system. Prudent and confidential information and assessment are crucial to obtain good results, discarding to look for whom to blame and assuming collectively the supervision of suspected conditions. Massive introduction of technology, intervention of multiple agents in the care of patients and the number of alternatives offered to manage health problems, contribute to increase medical errors. Not of lesser importance are the increasing expectations of patients on health benefits, that must be synchronized to the continuous improvement in medical care (Rev Méd Chile 2001; 129: 1470-2) <![CDATA[Planificando la educación médica para las próximas décadas]]> Accelerated changes in source and contents of knowledge, methodologies and scenarios used in learning, and in the meaning and goals of the educational process, are typical of these times. To characterize future needs, roles and expectations of the various actors involved, is also very unreliable and unpredictable. Performing reiterative strategic analysis, monitoring procedures, doing continuous assessment of results and making permanent adaptations in the educational process to the environmental conditions, are unavoidable means to get secure and pertinent effects from the implemented actions. From this perspective, the University of Chile Faculty of Medicine is formulating its proposals to innovate in curriculum, and strengthen its academic resources and students development (Rev Méd Chile 2001; 129: 1473-8) <![CDATA[Examen de VIH y consentimiento informado]]> Accelerated changes in source and contents of knowledge, methodologies and scenarios used in learning, and in the meaning and goals of the educational process, are typical of these times. To characterize future needs, roles and expectations of the various actors involved, is also very unreliable and unpredictable. Performing reiterative strategic analysis, monitoring procedures, doing continuous assessment of results and making permanent adaptations in the educational process to the environmental conditions, are unavoidable means to get secure and pertinent effects from the implemented actions. From this perspective, the University of Chile Faculty of Medicine is formulating its proposals to innovate in curriculum, and strengthen its academic resources and students development (Rev Méd Chile 2001; 129: 1473-8)