Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 133 num. 10 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>La Facultad de Medicina de la Pontificia Universidad Católica de Chile</b>: <b>75 años de progreso para la medicina nacional</b>]]> The Pontifical Catholic University of Chile founded its School of Medicine in 1930, preceded by the Schools of Medicine of the University of Chile (founded in 1833) and the University of Concepción (founded in 1924). The founders of the new School were prominent members of the Catholic Church, advised by distinguished Chilean physicians and scientists, most of them already full Professors at the University of Chile. During the first decades, only a small number of full-time faculties could be recruited and the academic team included mostly part-time teachers, generally shared with the already established Medical Schools, as well as practising physicians with little or no previous teaching experience. Along 75 years of fruitful existence, this Medical School has evolved to become one of the leading organizations in graduate and post-graduate medical education in Latin America, with high standards in teaching methodology and a superb productivity in clinical and biomedical research. The history of this Medical School stands as an example to the currently nascent Medical Schools founded by private universities in Chile. The standards of high quality medical education should be maintained for the well-being of our population so that these new Medical Schools can become respected and accepted as peers by the entire community of Chilean Universities (Rev Méd Chile 2005; 133: 1135-8) <![CDATA[<b>Resultados alejados de la reparación versus reemplazo en insuficiencia mitral degenerativa</b>]]> Mitral valve repair is considered better than mitral valve replacement for degenerative mitral regurgitation. Aim: To evaluate late clinical results of mitral valve repair as compared to mitral valve replacement in patients with degenerative mitral regurgitation. Patients and methods: All patients subjected to open heart surgery for degenerative mitral regurgitation between 1990 and 2002 were assessed for surgical mortality, late cardiac and overall mortality, reoperation, readmission to hospital, functional capacity and anticoagulant therapy. Eighty eight patients (48 males) had mitral valve repair and 28 (19 males) had mitral valve replacement (23 with a mechanical prosthesis). Mean age was 59.9 ± 14.8 (SD) and 61.3 ± 14.6 years, respectively. Sixty three percent of patients with repair and 50% of those with valve replacement were in functional class III or IV before surgery. Results: Operative mortality was 2.3% for mitral valve repair and 3.6% for mitral valve replacement (NS). Also, there was no statistical difference in the need of reoperation during the follow-up period between both procedures (2.3% and 0%, respectively). Ninety four percent of the replacement patients but only 26% of the repair patients were in anticoagulant therapy at the end of the follow-up period (p <0.001). Ten years survival rates were 82 ± 6% for mitral valve repair and 54 ± 11% for replacement. The corresponding cardiac related survival rates were 89 ± 6% and 79 ± 10%. At the end of follow-up, all surviving patients were in functional class I or II. Ten years freedom from cardiac event rates (death, cardiac related rehospitalization and reoperation) were 90 ± 3% for mitral valve repair and 84 ± 6% for replacement. Conclusion: Repair of the mitral valve offers a better overall survival and a better chance of freedom from cardiac events as well as need for anticoagulation 10 years after surgery (Rev Méd Chile 2005; 133: 1139-46) <![CDATA[<b>Insuficiente control de factores de riesgo en prevención secundaria cardiovascular</b>]]> International studies show a low compliance with norms for the management of cardiovascular risk factors. Aim: To assess the prevalence of risk factors in patients admitted for a coronary or vascular event and to evaluate the proportion of patients that normalize these factors after one year of follow up. Material and Methods: Three hundred and fifty seven patients aged 64±13 years (264 males), admitted to a University Clinical Hospital for a coronary or vascular event were studied. They were educated about cardiovascular risk factors and followed by their treating physicians for a mean of 11.9±2 months. During this period, smoking habits, body mass index. blood pressure, serum lipid levels, blood glucose and the appearance of new cardiovascular events were registered. Results: One year survival was 96% (all 13 deaths were of cardiac origin). Eighty seven percent of patients were free of major cardiovascular events. At discharge from hospital and at the end of follow up 49% and 44% had a total cholesterol over 200 mg/dl respectively, 9,6% and 20,8% had systolic pressure over 140 mmHg. There was no diastolic hypertension in these patients, 27% and 31% had a body mass index over 25 kg/m² and 2% smoked (versus 32% before the event). Conclusions: After one year of follow up, the prevalence of risk factors in patients that had suffered a cardiovascular event, continues to be high (Rev Méd Chile 2005; 133: 1147-52) <![CDATA[<b>La mejoría electrocardiográfica con el tratamiento de la enfermedad de Chagas crónica, es independiente de la persistencia de <i>Trypanosoma cruzi</i></b>]]> At the present time the assessment of results of treatment of Chagas disease is mainly parasitological. Anti Trypanosoma cruzi IgGs remain positive practically lifelong and electrocardiographic tracings are not usually used as criteria of improvement. Aim: To determine, in a long term follow up, if electrocardiographic evolution is associated with the persistence of the parasite in treated patients with chronic Chagas disease. Material and methods: Thirty patients with chronic Chagas disease that participated in a randomized trial of treatment with itraconazole or allopurinol, were studied. Seven years after treatment, patients were classified in group I if they had a positive xenodiagnosis test, polymerase chain reaction and hybridization in blood or in group II if they had negative tests. A 12 lead electrocardiogram (EKG) was performed each year to all patients. Results: Seventeen patients were classified in group I and 13 in group II. At baseline 10 patients in group I and 8 in group II had a normal EKG. Six years after treatment 13 patients in group I and 10 in group II had a normal tracing. Of those with a normal tracing at baseline, only one patient in each group presented alterations after six years. A regression of abnormal tracings was observed in four and three patients of groups I and II respectively. Conclusions: There is no association between the persistence of the parasite in treated patients with Chagas disease and the evolution of electrocardiographic tracings (Rev Méd Chile 2005; 133: 1153-60) <![CDATA[<b>Resultados del reemplazo valvular aórtico con prótesis mecánica en el Instituto Nacional del Tórax</b>]]> Mechanical aortic valve replacement (AVR) results have been published extensively in industrialized countries. Aim: To assess our immediate and late results in patients subjected to AVR. Patients and Methods: We retrospectively studied 194 patients subjected to isolated AVR between 1995 and 2003. Mean age was 57 ± 13 years and 119 (61%) were male. One hundred thirty nine (73%) were in functional class III-IV, 20 (10%) had a previous cardiac operation and 25 (13%) were operated as an emergency. Surgical indication was stenosis in 110 (58%), regurgitation in 49 (26%) and stenosis/regurgitation in 31 (16%). Etiology was bicuspid valve 56 (29%), degenerative lesions 55 (28%), rheumatic valve disease 38 (20%) and endocarditis 27 (14%). Medtronic Hall was the most common prosthesis used in 157 patients (81%). Mean cardiopulmonary bypass time 97 ± 29 min and mean cross clamp time was 69 ± 21 min. Results: Operative mortality was 4.6% (3% in elective surgery, 16% in emergency surgery and 0% in reoperations). Follow-up was complete in 100% of cases, totalizing 636 patients-year. Survival was 91 ± 2%, 80 ± 4% and 73 ± 6%, at 1, 5 and 7 years, respectively. Multivariate risk analysis identified renal failure and endocarditis as predictors of early and late mortality. During follow up, the linear incidence rate for hemorrhage was 3.29% /patients-year, thromboembolism 2.04% patients-year and endocarditis 1.1% patients-year. Conclusions: AVR has low overall and elective mortality. Midterm survival is good but linear event rates related to anticoagulant treatment are higher than those previously published in industrialized countries. Renal failure and endocarditis were risk factors for early and late death (Rev Méd Chile 2005; 133: 1161-72) <![CDATA[<b>TeenSTAR: una opción de madurez y libertad</b>: <b>Programa de educación integral de la sexualidad, orientado a adolescentes</b>]]> Urgent measures are required to stop the increase in the frequency of pregnancies and sexually transmitted diseases among teenagers. A means of facing this problem is promoting sexual abstinence among youngsters. There are studies that confirm the efficacy of this approach. Aim: To show the results of the application of a holistic sexuality program (TeenSTAR) among Chilean teenagers. Subjects and Methods: Students attending basic or high school were divided into a control or study group. The control group (342 students) received the usual education on sexuality given by their schools and the study group (398 students) participated in twelve TeenSTAR sessions lasting 1.5 hours each, given by a trained professor. Assessment of achievements was made using an anonymous questionnaire answered at the start and end of the program. Results: The rates of sexual initiation among control and study groups were 15 and 6.5%, respectively. Among sexually active students, 20% of those in the study group and 9% of those in the control group discontinued sexual activity. Conclusions: A higher proportion of students in the TeenSTAR program retarded their sexual initiation or discontinued sexual activity and found more reasons to maintain sexual abstinence than control students (Rev Méd Chile 2005; 133: 1173-82) <![CDATA[<b>Proteína Tax (HTLV-I), probable factor patogénico y marcador del síndrome sicca que se asocia a HAM/TSP</b>]]> Human T-cell lymphotropic virus type I (HTLV-I) is a retrovirus that influences cellular metabolism modifying biological responses. This results in oncogenic, degenerative or inflammatory changes. The myelopathy associated to HTLV-I or tropical spastic paraparesia (HAM/TSP) is a mainly degenerative response to the virus infection. On the other hand, Sjögren syndrome has an inflammatory appearance. The immunohistochemical study of CD-4, CD-8 and CD45 lymphocytes, metalloproteinase MMP-9 and viral Tax protein in pathological samples of salivary glands may help to differentiate primary from viral Sicca syndrome. Aim: To perform an immunohistochemical study of salivary glands of patients with HAM/TSP and Sicca syndrome and control subjects. Material and Methods: Pathological samples of salivary glands from 53 patients with HAM/TSP and Sicca syndrome and 10 control subjects, were studied. Immunohistochemistry was performed using antibodies against CD-4, CD-8 and CD-45 lymphocytes, metalloproteinase MMP-9 and viral Tax protein. Results: Only in patients with HAM/TSP and Sicca syndrome, the presence of Tax protein was observed in CD-4 and CD-8 lymphocytes and in glandular acini. Conclusions: Patients infected with HTLV-I express Tax protein in salivary glands. This finding has diagnostic and pathogenic implications (Rev Méd Chile 2005; 133: 1183-90) <![CDATA[<b>Influencia de la personalidad y el estilo de aprendizaje en la elección de especialidad médica</b>]]> Several studies indicate that doctors who work in the same area of the medical profession tend to behave somehow similarly. Thus, it has been suggested that personality relates to the medical specialty choice. However, it is not known whether people self-select into the medical specialties according to their personality or the professional practice in a particular field influences their behavior. Aim: To explore the possible association between the graduate's personality features and learning styles and their chosen specialty. Subjects and Methods: The psychological preferences and learning styles of 65 students of the 2001-graduating cohort of the Pontificia Universidad Católica de Chile School of Medicine were evaluated with the Myers Briggs Type Indicator and the Kolb Learning Style Inventory, respectively. These variables were correlated with the information of their specialty choice or occupation two years after graduation. Results: Graduates distributed unevenly in different areas of the medical profession. Surgical specialties concentrated a larger proportion of extraverted, intuitive and structured doctors, whereas in Pediatrics and Internal Medicine predominated intuitive and people-oriented MD's. Primary Care concentrated individuals with introverted, intuitive and flexible attitudes. Convergent learners (interested in problem-solving) preferred Surgery and Primary Care whereas Assimilator learners (abstract-reflexive) chose more frequently Internal Medicine, Pediatrics and Psychiatry. Conclusions: According to their personality and learning style, graduates tend to self-select into different medical specialties. This information may help medical graduates to guide their specialty choice process, and medical educators to develop learning experiences that take into account the individual differences of their residents (Rev Méd Chile 2005; 133: 1191-9) <![CDATA[<b>Prevalencia de Enterococos resistentes a antibióticos en aguas servidas en el norte de Chile</b>]]> There is little information available in Chile on the distribution of Enterococcus spp in waste water and its implications in transmission of antibiotic resistance through the water cycle. Enterococcus spp are common in nosocomial infections and may spread antibiotic resistance through the food chain. Aim: To determine the presence of antibiotic resistant Enterococcus spp in the sewage of Antofagasta, Chile. Material and Methods: Samples of sewage from two sewage treatment plants and from the Public Hospital of Antofagasta collector were obtained. Enterococcus spp were isolated on m-Enterococcus agar containing ampicillin, vancomycin and streptomycin. The isolates were identified and subjected to biochemical typing (PhPlate). Minimal inhibitory concentration determination was performed by agar dilution technique. Results: High counts of resistant Enterococcus spp were found on the streptomycin plates, lower on ampicillin and very low on vancomycin plates. A total of 63 Enterococcus spp strains were typed and the identification showed 5 different species; E faecalis (65%), E faecium (14%), E hirae (13%), E durans (6%) and E gallinarum (2%). The typing revealed a high diversity among the isolates. Two biochemical phenotypes were predominant, C1 (21 strains) and C6 (7 strains). Both were highly resistant to gentamycin and streptomycin; moderately resistant to ampicillin, cloramphenicol, tetracycline and ciprofloxacin, and with intermediate susceptibility to vancomycin. Both phenotypes were found in the sewage of the hospital collector and in the treatment plants. Conclusions: In the sewage of Antofagasta we found dominating phenotypes of multiresistant Enterococcus spp. Sewage could be an important way of transmission of these microorganisms (Rev Méd Chile 2005; 133: 1201-10) <![CDATA[<b>Beneficios clínicos y funcionales de agregar teofilina a la terapia inhalatoria con broncodilatadores de acción corta en pacientes con enfermedad pulmonar obstructiva crónica</b>]]> Although theophylline is considered a third line bronchodilator drug for the treatment of chronic obstructive pulmonary disease (COPD), it is widely used in Chile, because it is administered orally and has a moderate cost. Aim: To evaluate if theophylline adds clinical and/or functional benefits when associated to standard recommended inhaled bronchodilator therapy. Subjects and methods: Thirty-eight stable COPD patients who accepted to participate in the study approved by the Ethics Committee of our institution were studied. Using a randomized double-blind placebo-controlled study, theophylline (250 mg) or placebo was administered twice a day for 15 days in addition to inhaled salbutamol and ipratropium bromide. Prior to and at the end of the study, patients underwent: a) a spirometry to evaluate changes in dynamic pulmonary hyperinflation using slow vital capacity (SVC) and inspiratory capacity (IC), b) the 6 min walking distance (6 MWD); and c) measurement of maximal inspiratory and expiratory pressures. Dyspnea and quality of life (QoL) were evaluated using appropriate questionnaires. Results: Compared to placebo, patients on theophylline showed significant increases in SVC (p=0.014), IC (p=0.002), and 6 MWD (p=0.005). They also experienced an improvement in dyspnea (p=0.042) and QoL (p=0.011). All patients improved at least one of these parameters with 53% of the patients showing an improvement in 3 or more. Conclusions: Our results indicate that adding theophylline to standard treatment with inhaled bronchodilators provides additional benefits in stable COPD patients by reducing dynamic pulmonary hyperinflation, improving exercise tolerance, dyspnea and QoL (Rev Méd Chile 2005; 133: 1211-9) <![CDATA[<b>Rescate con Sirolimus por rechazo agudo recurrente y diabetes mellitus en trasplante hepático</b>: <b>Caso clínico pediátrico</b>]]> Sirolimus (SRL) is a new immunosuppressive drug approved for renal transplantation, but is being used increasingly in orthotopic liver transplantation (OLT). Compared with the calcineurin inhibitors, SRL has different mechanisms of action and side effects profile. Thus, this drug offers significant potential advantages over other immunosuppressive agents. SRL does not cause glucose intolerance, hypertension or renal failure, but it may cause dyslipidemia, hepatic artery thrombosis, thrombocytopenia, anemia, leukopenia, oral mucosa ulcers, edema, arthralgias and wound complications. SRL inhibits the signal of interleukin 2 at a post-receptor level, inhibiting lymphocyte proliferation and fibroblast proliferation. It also has antineoplastic and antifungal effects. We report a 10 years old girl who underwent OLT, experiencing a biopsy-proven recurrent acute rejection (AR) in spite of using three immunosuppressive agents (tacrolimus, mofetil micofenolate and steroids). She developed diabetes mellitus as a consequence of the immunosuppressive therapy. She was rescued with SRL, not experiencing AR again. Mofetil micofenolate, steroids and insulin could be discontinued and tacrolimus doses were reduced, without experiencing severe complications. SRL is a new and safe immunosuppressive agent for rescue in patients with OLT and recurrent AR (Rev Méd Chile 2005; 133: 1221-4) <![CDATA[<b>Síndrome neuroléptico maligno y poliserositis en paciente usuaria de clozapina</b>: <b>una asociación infrecuente</b>]]> Malignant neuroleptic syndrome is a complication of antipsychotic medication use. Clozapine use is also associated with polyserositis and eosinophilia. We report a 17 years old female treated with clozapine, valproic acid, lithium carbonate and lorazepam that consulted in the emergency room for confusion, lethargy, catatonia, rigidity, myalgya and fever. Complete blood count showed eosinophilia. An abdominal CAT scan showed ascites and pleural effusion. Clozapine was discontinued and bromocriptine was started. One week after admission, the patient remained febrile and liver enzymes were elevated. Valproic acid was discontinued. Inflammatory parameters stated to subside and the patient was discharged afebrile days after admission (Rev Méd Chile 2005; 133: 1225-8) <![CDATA[<b>75 años de la Facultad de Medicina de la Pontificia Universidad Católica de Chile</b>]]> Aiming to join academic excellence and an ethical and Christian approach to medical profession, the Medical School of the Pontifical Catholic University of Chile initiated its activities in 1930. Since then, the associated Health Care Network has incorporated all the technological breakthroughs in medicine and developed all the specialties. Undergraduate teaching is oriented to promote creativity and innovation. There is also a special concern about humanity of Medicine, throught the Program of Humanistic Medical Studies and the Bioethics Center. Post graduate education is also an important activity of the School, through specialty training, Master and Doctorate programs. Researchers have also obtained important grants and generated a great number of publications in high impact journals. Our University is defined as «complex», meaning that we must take important challenges, be creative and lead knowledge generation. We must also improve ourselves to serve in the best possible way our students and the Country. Paraphrasing the words of our founder, Monsignor Carlos Casanueva, we must train physicians that will serve our community not only with science but also with humanity (Rev Méd Chile 2005; 133: 1229-32) <![CDATA[<b>Perforación esofágica</b>: <b>Experiencia clínica y actualización del tema</b>]]> Esophageal perforation is a complicated clinical entity that demands a high level of diagnostic and therapeutic skills. The management alternatives vary from conservative treatment to esophagectomy, including primary suture and esophageal exclusion. This paper is a review of the literature and personal experience with this condition, focusing on etiology, clinical presentation, diagnostic workout, treatment, complications and mortality. Finally, we propose a management algorithm (Rev Méd Chile 2005; 133: 1233-41) <![CDATA[<b>Síntomas psicológicos y conductuales asociados a demencias</b>: <b>actualización terapéutica</b>]]> Behavioral disturbances in dementias are relevant because they are very common, they worsen patients' medical and cognitive condition, increase the caregiver burden and accelerate the admission to nursing homes. The different behavioral disturbances in dementias can appear isolated, but in most cases, patients present a combination of disturbances producing one of two main syndromes: the psychotic or the affective syndrome. Proper handling of these behavioral disturbances requires a correct characterization of the syndrome, discarding medical or environmental causes and selecting the drug with the better effectiveness and safety profile for each patient. In spite of the important number of psychotropics available, there is not enough scientific evidence about their real effectiveness and security in patients with Alzheimer's disease. This article reviews recent advances in the treatment of most common and disruptive behavioral disturbances (Rev Méd Chile 2005; 133: 1242-51) <![CDATA[<b>Reflexiones sobre la evidencia en medicina</b>]]> This is a review of the basic concepts of evidence, medicine, evidence-based medicine and its effects. Evidence-based medicine is a contribution for statistical design and management, that allows the gathering of scientific information, but does not completely exclude bias. Its methodology proceeds with order and caution, generating a highly probable mass of knowledge. The quality of the information obtained from diverse sources such as meta-analysis to expert opinions is classified in different levels according to the «strength» of the evidence in which it is based. The best contribution of evidence-based medicine is probably for diseases of incidence and does not replace clinical experience and patients-physician relationship. Basically we treat ill people and not illnesses. Without clinical experience, medical practice can be tyrannized by evidence-based medicine that can become inapplicable or inappropriate. Without evidence-based medicine, medical practice will not be updated, limiting our professional skills (Rev Méd Chile 2005; 133: 1252-8) <![CDATA[<b>Cervantes, El Quijote y la medicina</b>]]> This is a review of the basic concepts of evidence, medicine, evidence-based medicine and its effects. Evidence-based medicine is a contribution for statistical design and management, that allows the gathering of scientific information, but does not completely exclude bias. Its methodology proceeds with order and caution, generating a highly probable mass of knowledge. The quality of the information obtained from diverse sources such as meta-analysis to expert opinions is classified in different levels according to the «strength» of the evidence in which it is based. The best contribution of evidence-based medicine is probably for diseases of incidence and does not replace clinical experience and patients-physician relationship. Basically we treat ill people and not illnesses. Without clinical experience, medical practice can be tyrannized by evidence-based medicine that can become inapplicable or inappropriate. Without evidence-based medicine, medical practice will not be updated, limiting our professional skills (Rev Méd Chile 2005; 133: 1252-8)