Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 131 num. 3 lang. es <![CDATA[SciELO Logo]]> <![CDATA[Endocarditis Infecciosa: Morbimortalidad en Chile. Resultados del Estudio Cooperativo Nacional de Endocarditis Infecciosa (ECNEI: 1998-2002)]]> Background: Infective endocarditis is a severe condition, with a mortality that fluctuates between 16 and 25% in the Metropolitan area of Chile. Aim: To perform a prospective assessment of clinical and microbiological features of patients with infective endocarditis in Chile. Material and methods: Collaborative study of regional hospitals in the whole country and teaching hospitals in Santiago. Patients with a possible or definitive infective endocarditis, according to Duke's criteria, were included in the protocol and a structured data entry form was completed. Results: Three hundred twenty one patients (65% male, mean age 49±16.5 years) were studied. According Duke's criteria, 89% had a definitive and 11% a possible endocarditis. The subacute form occurred in 64% of patients. The most frequent predisposing cardiopathies were rheumatic in 25%, prosthetic valves in 15% and congenital in 13%. There was no evidence of cardiopathy in 20%. Twenty percent of patients were on hemodialysis, 11% were diabetic and only one patient abused intravenous drugs. The most frequent complication was cardiac failure in 59% of cases, followed by renal failure in 32% and embolism in 28%. The most frequent causing organism was coagulase positive Staphylococcus in 35%. Blood cultures were negative in 28% of cases from the metropolitan region, in 56% of cases from the north and 38% of cases from the south. Echocardiographic diagnosis was done in 92% of cases. Aortic valve was involved in 42% and mitral valve in 29%. Successful antimicrobial treatment was achieved in 59% of patients. Thirty five percent of patients were subjected to surgical procedures with a 78% survival. Overall mortality was 29%. Univariate analysis identified sepsis, an age over 60 years and the presence of cardiac or renal failure as prognostic indicators of mortality. On multivariate analysis, the identified prognostic indicators were the presence of sepsis, renal failure, mitroaortic involvement associated to combined surgery and failure of antimicrobial treatment not associated to surgery. Conclusions: Subacute form is the most common presentation of infective endocarditis and rheumatic valve disease is the most common underlying cardiac lesion. Intravenous drugs users infective endocarditis is exceptional in Chile. The most frequent causing agent is coagulase positive Staphylococcus and the most frequent complication is cardiac failure. Surgical and overall mortality were 22 and 29% respectively. Sepsis, renal failure, combined surgical procedures, failure of medical treatment were identified as prognostic indicators of mortality (Rev Méd Chile 2003; 131: 237-50). <![CDATA[Hidronefrosis del recién nacido: Cintigrafía renal dinámica con Tc99m MAG3 durante el primer mes de vida]]> Background: The early and accurate diagnosis of obstructive uropathy in the newborn, prevents secondary complications and kidney damage. Aim: To study the usefulness of Tc99M MAG3 diuretic renogram in newborns with hydronephrosis. Material and methods: Forty newborns, aged 1 to 30 days, with hydronephrosis, were studied. A Tc99M MAG3 diuretic renogram (DR) was done and its results were compared with clinical features and other imaging studies. Each kidney and its ureter, were considered a renal unit. Results: Seventy six renal units were evaluated. Twenty six were normal on prenatal ultrasound examination and DR. In 11 of the 50 renal units with hydronephrosis, renal function was impaired. Thus, it was impossible to obtain an excretory curve. In 17 of the 39 remaining renal units, the absence of obstructive uropathy was demonstrated clinically. In 16 of these, the DR showed absence of obstruction. In 20 of 21 renal units with confirmed obstructive uropathy, DR showed an obstructive pattern. Conclusions: In newborns, there is an adequate Tc99M MAG3 uptake and diuretic response. Thus, DR becomes a good functional assessment method in newborns with hydronephrosis (Rev Méd Chile 2003; 131: 251-8). <![CDATA[Resistencia insulínica y otras expresiones del síndrome metabólico en niños obesos chilenos]]> Background: Infantile obesity is a probable risk factor for the early appearance of chronic illnesses like Type 2 Diabetes Mellitus, Dislipidemia and Hypertension. Insulin Resistance (IR) appears as the common etiological mechanism. Aim: To describe metabolic complications associated to obesity in a group of Chilean children and to correlate them with IR, estimated through the homeostasis model assessment index (HOMA). Subjects and methods: We studied 88 children, 12±2.4 years old. Fifty two had severe obesity, 19 were overweight, and 17 had a normal weight (body mass index z score (BMIz): 4.7±1.6, 1.7±0.5 and 0.2±0.6 respectively, p <0.001). In obese children, an oral glucose tolerance test, measuring basal and 30 min insulin levels, was performed and serum lipid levels were measured. Results: Eleven percent of the severely obese children were glucose intolerant, 67% had basal hyperinsulinemia (>20 uU/ml) and 79% had IR (HOMA >3.8). These children also had a higher prevalence of acantosis nigricans than the overweight and normal counterparts (63, 10.5 and 0% respectively, p <0.001), higher basal insulinemia: (24.4±10, 16.4±4 and 12.2±3 mU/ml respectively) and HOMA (5.3±2, 3.4±0.8 and 2.3±0.5 respectively, p <0.001). By multiple stepwise regression analysis, BMIz was the only significant predictor for basal hyperinsulinemia, HOMA and diastolic blood pressure. Age and BMIz were independent predictors for systolic blood pressure. The strongest predictor for plasma lipid levels was the family history of dislipidemia. Conclusions: Obese children have a high prevalence of metabolic complications, which are related to the severity of obesity. Most of the severely obese children have hyperinsulinism and IR. BMIz is the principal predictor for high blood pressure. Familiar history is the better predictor for dislipidemia (Rev Méd Chile 2003; 131: 259-68). <![CDATA[Prevalencia de tabaquismo en enfermeras de la IX Región, Chile]]> Background: Smoking is noxious for health and is considered a public health priority. The prevalence of smoking is increasing, specially in women. Among nurses, its prevalence is 42.7%. Aim: To study the prevalence of smoking among Chilean nurses. Material and methods: A cross sectional analysis of the prevalence of smoking among 290 female nurses living in 9th Region of Chile. A nicotine addiction scale was applied to smokers. Results: The prevalence of smoking was 37.9% and the percentage of former smokers was 18.3%. Twenty percent of the sample was an occasional smoker. The starting age for the habit was between 17 and 20 years (49.4%). Twenty seven percent of nurses without children and 42% of those with children smoked. Having a couple or not, did not influence the smoking habit. Ninety percent of smokers had a very low addiction to nicotine. Conclusions: The prevalence of smoking obtained in a sample of nurses is similar to that obtained by former studies in other population samples in Chile (Rev Méd Chile 2003; 131: 269-74). <![CDATA[Contrapruebas en el diagnóstico y seguimiento de niños con alergia alimentaria]]> Background: The prevalence of food allergy increased worldwide in the last century. In Chile we became aware of this increase 10-15 years ago, after an epidemiological transition on health. Aim: To assess the most frequent clinical presentations of food allergy, results of circulating immunologlobulins (total IgE, specific IgE and IgG4 against cow's milk) and usefulness of a standardized challenge test. Patients and methods: Cross sectional assessment of 49 patients with cow's milk allergy (9 months - 8 years of age), diagnosed at INTA, University of Chile between 1991-2001. Results: All patients had cow's milk allergy and 37% of them were additionally intolerant to other allergens. Seventy eight percent had digestive symptoms and 84% had non digestive symptoms. The cause of consultation was a non-digestive manifestation in 16% of cases. At least one of the immunoglobulins (total IgE total, specific IgE or IgG4) was over the cut off point in 92% of patients. Between 1990-1995 six patients were diagnosed with cow's milk allergy and malabsorption syndrome. Suppression of the specific allergen resulted in disappearance of symptoms in 78% of patients; when a second dietary modification was necessary 87% of cases showed a good response. Thirty five of 56 challenge tests performed were done at home, by relatives, in a non-controlled fashion. All of them were aimed to determine the desensitization of the child. Conclusions: Digestive and non-digestive manifestations were observed in these patients with food allergy. Although not designed to assess laboratory tests, results show that serum immunoglobulin determinations were helpful in guiding diagnosis. Mothers and relatives should be educated to accept diagnostic challenges and avoid carrying out non-controlled challenges (Rev Méd Chile 2003; 131: 275-82). <![CDATA[Cintigrafía tiroidea (CT) con Tc<SUP>99m</SUP>- pertecnectato en recién nacidos (RN) con hipotiroidismo congénito (HC)]]> Background: Congenital hypothyroidism is one of the most frequent endocrine diseases of the newborn and requires an early diagnosis to avoid its deleterious effects on neurological and intellectual functions. Aim: To evaluate thyroid scintigraphy (TS) findings in newborns with congenital hypothyroidism (CH), detected in the national program of newborn screening, which is working in Chile since 1992. Material and methods: TS findings of 189 newborns with CH (68% female) were analyzed. Tc99m pertechnetate TS was performed at 19 ± 11 days of life. The gland was classified as eutopic, ectopic or absence of contrast (AC). Eutopic glands were classified by visual and quantitative criteria as: normal, goiter and decreased contrast (DC). TS results were compared by gender and hormonal levels. Results: Forty seven percent of newborns had ectopy, 29.1% eutopy and 24.3% AC. Eutopic gland predominated in males (44.2% vs 22.7%) and ectopy was more frequent in girls (53.1% vs 32.8%, p <0.05). Newborns with AC had the most severe hormonal alterations, without gender differences. Newborns with normal TS had less hormonal alterations than those with goiter. Conclusions: TS allows an etiological classification of CH. Thyroid dysgenesis is the most frequent cause, most of which correspond to ectopy, especially in girls. Eutopic glands are present in one third of newborns with CH. Goiter predominates, especially in males (Rev Méd Chile 2003; 131: 283-9). <![CDATA[Síndromes linfoproliferativos crónicos en Chile: Estudio prospectivo de 132 casos]]> Background: Chronic lymphoproliferative disorders include a variety of diseases which are often a diagnostic problem for clinical hematologists. Aim: To study prospectively the distribution and incidence of chronic lymphoproliferative disorders in Chile and compare them with those of other Western, Latin American and Oriental countries. Patients and methods: A group of 132 patients were studied in a 36 months period (1999-2001), with a panel of monoclonal antibodies. A score for chronic lymphocytic leukemia was employed to differentiate it from other B-cell disorders. Results: The median age was 63 years old (range 32-94). Most patients had B-cell tumors (109) and the rest (23), T-cell tumors (82% vs 18%). Forty five percent of patients with B-cell tumors had a chronic lymphocytic leukemia (CLL), while the others were disseminated lymphomas. The incidence of T-cell tumors was slightly higher than that of other Western countries. Noteworthy is that the most common of these disorders was adult T cell leukemia/lymphoma (ATLL), in concordance with the high HTLV-1 seroprevalence in Chile. Conclusions: A morphologic, immunophenotypic and pathological study in a large number of patients with chronic lymphoproliferative disorders in Chile, shows a relatively low incidence of CLL when compared to other chronic B-cell tumors and a high representation of ATLL associated to HTLV-1 infection, compared with other Western countries. The lower incidence of CLL in our study might be due to patient's selection and/or underdiagnosis of this disease as a substantial proportion of CLL are asymptomatic (Rev Méd Chile 2003; 131: 291-8). <![CDATA[Susceptibilidad antifúngica de levaduras mediante Etest ®: Comparación de 3 medios]]> Background: The increasing frequency of systemic fungal infections and the emergence of secondary resistance to antifungals in the lasts years, has stimulated the use of methods for antifungal susceptibility testing. Etest(r) is an easily performed quantitative method that has a good agreement with the broth microdilution reference method (NCCLS), if appropriate media are used. Aim: To compare the susceptibility to Amphotericin B (AmB) and Fluconazole (Flu) of 22 opportunistic yeast isolates (C albicans (7), C tropicalis (9), C parapsilosis (3) and Cryptococcus neoformans (3) by Etest ®., using three different media and to choose the best medium for each tested drug. The studied media were RPMI 1640, Casitone (Cas) and Sabouraud. Results: The interpretation of minimal inhibitory concentration (MIC) endpoints on Sabouraud was difficult for AmB. The American Type Culture Collection (ATCC) strains MICs were out of the acceptable range in this medium. RPMI and Cas were suitable media to test AmB and Flu, but best endpoints were obtained for AmB in RPMI and Flu in Cas. Conclusions: The use of appropriate media for each antifungal drug optimizes the MIC readings by Etest(r). AmB should be tested in RMPI and Flu in Cas. Sabouraud must not be used (Rev Méd Chile 2003; 131: 299-302). <![CDATA[Síndrome de hiper-IgM asociado a colangitis esclerosante y neoplasia vesicular: Caso clínico]]> We report a 11 years old male diagnosed as a X-linked hyper-IgM syndrome that presented with recurrent infections and sclerosing cholangitis and later developed a gallbladder cancer. Immunological evaluation showed decreased levels of serum IgG and IgA with elevated levels of IgM. Study of CD40 ligand expression on mitogen activated peripheral blood mononuclear cells revealed total absence of this marker on T lymphocytes. Molecular analysis detected, in the patient and his mother, a nonsense mutation in exon 1 of the transmembrane segment of the CD40 ligand. He also presented elevation of alkaline phosphatases and mild elevation of liver enzymes. Liver biopsy demonstrated the presence of idiopathic sclerosing cholangitis. The patient was started on monthly IVIG therapy at 400 mg/kg, as well as ursodeoxycholic acid and vitamin E, with normalization of his IgG and IgM levels a decrease in the incidence of infections and normalization of liver function. Three years after diagnosis, we detected the presence of polyps inside the gallbladder that were reported at biopsy as adenocarcinoma. He underwent hepatic bisegmentectomy (VI B-V) and local lymphadenectomy (Rev Méd Chile 2003; 131: 303-8). <![CDATA[Transección traumática aguda de la aorta torácica: Tratamiento endovascular]]> Traumatic rupture of the aorta has a near 80% mortality. Most patients die on the site of the accident. Conventional surgical repair of these lesions has a high morbidity and mortality, generally associated to the severity of associated lesions. Over the last decade, endovascular treatment has become an effective therapeutic alternative. We report a 40 years old male, that suffered a traumatic rupture of the descending thoracic aorta in a car accident. A successful endovascular repair was performed, installing an endoprothesis on the site of the lesion, using a femoral artery approach. The patient had a good postoperative evolution and was discharged from the hospital once complete rehabilitation of his associated lesions was obtained (Rev Méd Chile 2003; 131: 309-13). <![CDATA[Mucolipidosis tipo II: comunicación de un caso]]> We report a female newborn with type II mucolipidoses. This condition is characterized clinically by Hurler like features, progressive psychomotor retardation and death during the first or second year of life. Most cases present during the first year of life, with poor weight gain and coarse facies features. The cause of this rare autosomal recessive hereditary disease is the deficiency of the enzyme N-acetylglucosamine-1-phosphotransferase, required for the synthesis of mannose-6-phosphate, the ligand that allows the transport of acid hydrolases into lysosomes. The patient had clinical features commonly found in mucolipidosis II, including disproportionate dwarfism, retarded psychomotor development, coarse facies features, gibbous and restricted joint mobility. The diagnosis was proved by an extremely elevated activity of lysosomal enzymes in the serum, secondary to non-regulated secretion and subsequent intracellular depletion of these proteins. The child suffered recurrent pneumonia and died at 22 months of age (Rev Méd Chile 2003; 131: 314-9). <![CDATA[Inequidad de ingreso y autopercepción de salud: un análisis desde la perspectiva contextual en las comunas chilenas]]> Background: The correlation between income inequality and life expectancy was demonstrated 10 years ago, but later, several studies suggested that the negative impact of a low economic income on the health status was disappearing. Aim: To assess the independent effects of community income inequality on self rated health in Chile. Material and methods: Multilevel analysis of the 2000 National Socio Economic Characterization Survey (CASEN) data from Chile. Individual level information included self rated health, age, sex, ethnicity, marital status, education, income, type of health insurance and residential setting (urban/rural). Community level variables included the Gini coefficient and median income. The main outcome measure was dichotomized self rated health (0 if excellent, very good or good; 1 if fair or poor). Results: 101,374 individuals (at level 1) aged 18 and above, nested within 285 communities (at level 2) and 13 regions (at level 3) were studied. Controlling for a range of individual level predictors, a significant gradient was observed between income and poor self rated health, with very poor most likely to report poor health (10.5%) followed by poor (9.5%) low (9%) middle (7%), high (6%) and very high (4.5%) income earners. Controlling for individual and community effects of income, a significant non linear effect of community income inequality was observed, with the most unequal communities being associated with approximately 5% higher likelihood of reporting poor health compared to the most equal communities. Conclusions: Individual income does not explain any of the between community differences and neither does it wash the significant effects of income inequality on poor self rated health. The contextual effect of inequality is almost as large as the differential observed in poor health comparing the very poor to the very rich individual income categories (Rev Méd Chile 2003; 131: 321-30). <![CDATA[Hacia el médico que nuestros países necesitan: <B><I>Emphasis on communications and training of academics</B></I>]]> Changes in physicians education and practice induce, nowadays persistent modifications in program's curricula and contents and in learning methodologies, in almost all medical schools and countries. In many of these, and in Chile, this process shows some peculiarities due to the unusual proliferation of medical schools and their differing proposals about the profile of the professional training based on epidemiological considerations and teaching resources. The institutional initiatives leading to reforms, have defined quality and pertinence of these programs and profiles, as it has been the case of the curricular renewal in the University of Chile School of Medicine. Relevant to this reform have been: 1) the introduction of communication skills, pursuing to increase humanistic contents, to improve patient doctor relationship and to accomplish the actual goals of medicine, and 2) capacitating the faculty in the proper disciplines and competencies, for better application of new knowledge and teaching tools to improve learning of the health professionals. Prospective evaluation of these changes will allow us to assess, with best evidence, its definitive role, that is momentarily availed by student's satisfaction (Rev Méd Chile 2003; 131: 331-7). <![CDATA[¿Por qué un Departamento Académico de Medicina Familiar?]]> Over the last fifty years, Family Medicine has became not only an important part of many health systems around the world but also an established academic discipline. However, in the Iberoamerican context its development has been slow and with a number of difficulties. After a decade of work at the Family and Community Medicine Programme of the Catholic University of Chile, the role of Family Medicine as an academic discipline requires a reflection. A definition of Family Medicine is advanced in line with a recent proposal of WONCA Europe including some fundamental aspects in the practice of any family doctor. A set of criteria for considering a medical subject as a discipline is analyzed and discussed with reference to Family Medicine. A unique field of action, an established body of knowledge, a set of analytical techniques, an specific area of research, its own philosophy, and a training which is intellectually rigorous, are all criteria that Family Medicine fulfils. Family Medicine is a medical discipline with a clear definition and it can be considered an academic discipline. Therefore, it is possible to establish an academic department within a Faculty of Medicine in Chile, which will contribute to a more balanced and complete medical education in the country (Rev Méd Chile 2003; 131: 338-42).