Scielo RSS <![CDATA[Revista médica de Chile]]> https://scielo.conicyt.cl/rss.php?pid=0034-988720070005&lang=es vol. 135 num. 5 lang. es <![CDATA[SciELO Logo]]> https://scielo.conicyt.cl/img/en/fbpelogp.gif https://scielo.conicyt.cl <![CDATA[<b>Tumores gastrointestinales estromales (GIST)</b>: <b>Experiencia del Servicio de Cirugía del Hospital Clínico de la Universidad de Chile entre 1999 y 2005</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500001&lng=es&nrm=iso&tlng=es Background: Gastrointestinal stromal tumors (GIST) are the most common mesenchymatous tumors of the digestive tract. The pathological diagnosis is based on microscopy and immunohistochemistiy. Aim: To review the experience of our surgical unit in patients with GIST Material and methods: Review of medical records of 15 patients (aged 66+13 years, 11 women), with a pathological diagnosis of GIST, treated between 1999 and 2005. Results: The main presenting symptoms were melena in 40%, hematemesis in 20%, abdominal pain in 60% and anemia in 13%. In only one patient, the tumor appeared as an incidentaloma. All patients underwent upper gastrointestinal endoscopy A CAT scan was done in 87%, a barium swallow in 60% and a digestive endosonography in 20%. Thirteen tumors were located in the stomach and two in the small bowel. Mean tumor diameter was 5.3+1.7 cm. Surgical management was a tumor resection in 40%, a partial gastrectomy in 27%, a total gastrectomy in 20% and an intestinal excision in the rest. Mean hospital stay was 6.9+4.2 days. No postoperative complications were recorded. Conclusions: The main clinical presentation of GIST in this retrospective series was an upper gastrointestinal bleeding. Surgical treatment was devoid of complications <![CDATA[<b>Resultados clínicos inmediatos y alejados del implante de <i>stents </i>metálicos no recubiertos</b>: <b>¿Se justifica un reemplazo total por los <i>stents </i>liberadores de drogas?</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500002&lng=es&nrm=iso&tlng=es Background: Since the introduction of stents in 1994, improved clinical results have boosted the development of coronary angioplasty in Chile. Drug eluting stents, that have a reduced rate of restenosis, are being increasingly used. Aim: To assess the acute and long-term results of bare metal stent implantation. Patients and Methods: Acute and long-term clinical, procedural and angiographic results were assessed in non acute myocardial infarction patients undergoing coronary stent implantation between August 1996 and December 2003. Results: During the study period, 932 patients aged 30 to 87 years (194 women) had at ¡east one stent implanted. Twenty two percent were diabetic, 33% had recent myocardial infarction, 53% unstable angina and 22% stable angina. Angiographic and clinical success were 99.6% and 98.2%, respectively. In hospital death was 0.5%. During a mean follow-up of 19.1 months, all cause mortality was 3.9%, cardiac death 1.9% and survival free of major cardiac ischemic events was 85.3%. Only 6.4% of lesions underwent target vessel revascularization (TVR). Independent predictors of TVR were previous surgery, ¡eft anterior descending artery, small post stent minimum luminal diameter. Ostial location, in-stent restenosis, and younger age were non significant predictors. Conclusions: Acute and long-term results of bare metal stents in this population were excellent. An intriguingly low rate of TVR was seen. Selective bare metal stenting should continue in lesions and patients with a low risk of clinical restenosis <![CDATA[<b>Identificación molecular de enzimas modificantes de aminoglucósidos en cepas de <i>Enterococcus spp. </i>aisladas en hospitales de la Octava Región de Chile</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500003&lng=es&nrm=iso&tlng=es Background: Infectious diseases produced by Enterococcus spp, must be treated with a synergistic combination between a penicillin and an aminoglycoside. High level resistance to aminoglycosides is a serious therapeutic problem, since it predicts the loss of synergistic activity of this antimicrobial combination. Aim: To investigate the presence of genes encoding aminoglycoside-modifying enzymes (AMEs) among strains of Enterococcus spp with high level of resistance to aminoglycosides. Material and methods: The genes encoding some of the AMEs were investigated among 305 aminoglycoside-resistant strains of Enterococcus spp isolated in hospitals of the VIII region of Chile, by dot blot hybridization and Polymerase Chain Reaction (PCS). Results: High level resistance to some aminoglycosides was observed in 104 strains (34.1 %) and 93 of these harbored at ¡east one of the genes encoding the investigated AMEs. Three genes were detected: aac(6)Ie-aph(2")Ia (14.8%) encoding for the enzyme AAC(6)Ie-APH(2")Ia (resistance to all aminoglycosides, except streptomycin); aph(3)IIIa (26%), and ant(6)la (28.5%) encoding for the phosphorylating enzymes APH(3)Ilia (resistance to kanamycin, amikacin and neomycin), and ANT(6)-la (resistance only to streptomycin), respectively. None of the strains harbored the gene ant (4) which encode for the enzyme ANT (4). Conclusion: The low frequency of strains harbouring the bifunctional enzyme (<15%), conferring an extended resistance profile to aminoglycosides, allows us to propose the empirical use of aminoglycoside-aminocyclitols, associated to a penicillin, in the treatment of serious infections produced by species of enterococci <![CDATA[<b>Angioplastia con <i>stents </i>liberadores de rapamicina en diabéticos tipo 2</b>: <b>Experiencia del Hospital DIPRECA</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500004&lng=es&nrm=iso&tlng=es Background: Drug-eluting stents have been developed to reduce the rates of restenosis after coronary angioplasty. Several studies have demonstrated that rapamycin eluting stents are reliable and effective. Aim: To report the experience in our Health Centre with rapamycin-eluting stents. Patients and methods: Forty two stents with rapamicine were implanted to 32 diabetic patients, between June 2002 and December 2004. After the procedure, subjects were clinically followed-up for an average period of 19.9+9.9 months, evaluating functional capacity, angina pectoris, dyspnea, need for hospital admission, acute coronary events and cardiac death. In those subjects clinically suspected to have restenosis, a coronary angiography was performed. Results: Twenty-nine subjects (90.6%) remained asymptomatic, two subjects (6.3%) developed angina pectoris but restenosis was ruled out, and one subject (3.1%) died. Conclusions: The use of rapamycin-eluting stents in these patients was safe and successful with no evidence of clinic restenosis. These positive results are similar to those reported in the Diabetes Study <![CDATA[<b>Cambios en la prevalencia de asma en escolares chilenos entre 1994 y 2002</b>: <b><i>International Study of Asthma and Allergies in Childhood (ISAAC) - Chile phases I and III</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500005&lng=es&nrm=iso&tlng=es Background: In developed countries, the prevalence of asthma in children has significantly increased in the last decades. However, there is no information about the trends of asthma in Latin America. Aim: To determine changes in asthma prevalence between 1994 and 2002 in Chilean schoolchildren. Material and methods: The prevalence of asthma symptoms in schoolchildren aged 7 (n =18.697) and 13 years (n =18.939), from South Santiago, Valdivia and Punta Arenas, obtained during phases I and III of the ISAAC, carried out in 1994 and 2002, was compared. Results: From 1994 to 2002, the mean national prevalence of "wheezing in the last 12 months" in the group aged 6-7years, changed from 18.2% to 17.9% (p =NS); "asthma ever" from 12.5% to 10.7% (p =NS), and "severe episode" from 3.2% to 2.8% (p =NS). There was a significant increase of the prevalence of "wheezing in the last 12 months", in children aged 13-14years, from 9.8% to 15.5% (p =0.01); in "asthma ever" from 10.2% to 14.9% (p =0.01), and for "severe episode" from 2.8% to 3.8% (p =0.01). Conclusions: There was a significant increase in the prevalence of respiratory symptoms related to asthma in children aged 13-14 years that was consistent in all the 3 participating centres of the ISAAC. However, the prevalence of asthma symptoms in children aged 6-7 years remained without significant changes between 1994 and 2002 <![CDATA[<b>Un ensayo clínico aleatorizado de farmacoterapia con monitorización telefónica para mejorar el tratamiento de la depresión en la atención primaria en Santiago, Chile</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500006&lng=es&nrm=iso&tlng=es Background: Depression is a public health problem, due to its high prevalence and its associated disability. Aim: To compare a pharmacological intervention for depression controlled by phone from a central level (TM) and the usual treatment (TH) in a randomized clinical trial. Material and methods: Three hundred and forty five women, aged 22 to 59 years were studied. They were randomly assigned to receive the usual therapy or a pharmacological intervention with periodical telephone contacts with medical collaboration personnel, to reinforce compliance with treatment and educate about the disease. Women were blindly evaluated at 3 and 6 months with the Hamilton depression rating score (HDRS) and the SF-36 to assess depressive symptoms and quality of life, respectively. Results: In both evaluations, improvement was significantly greater in the TM group than the TH group. At 3 months, improvement was higher in the TM group in the subscales of physical function, pain, general health, energy, emotional role, mental health and standardized physical and psychic scales of SF-36. At 6 months, this significant difference in favour of TM was maintained for energy, mental health and the standardized psychic scale. Conclusions: A telephone reinforcement improves the outcomes of treatments for depression <![CDATA[<b>Genotipos de <i>Staphylococcus aureus </i>con fenotipo meticilino resistente, aislados de pacientes del Hospital Base de Valdivia</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500007&lng=es&nrm=iso&tlng=es Background: Methicillin resistant strains of Staphylococcus aureus (MRSA) are an important cause of nosocomial infections. Aim: To determine the genotypes of MRSA strains. Material and methods: Fifty five strains of MRSA, isolated from patients hospitalized in Hospital Base Valdivia, were studied. The phenotype was determined through MicroScan® in all strains and by minimum inhibitory concentration (MIC) in 41. The genotype of the strains was analyzed by a duplex polymerase chain reaction (PCR) of the mecA gene, amplifying eight hypervariable DNA regions associated to such gene. Results: According to MIC, 88% of strains had a pattern of resistance against multiple antimicrobial (penicillin, ampicillin, cephradine, gentamycin, ciprofloxacin, ¡incomycin and erythromycin). Vancomicin resistan strains were not detected. Only 53 strains (96%) had at least one of the eight hypervariable regions and were classified as MRSA. Genotypic patterns types 15 were the most commonly detected in 38% and 34% of strains, respectively. MicroScan® erroneously classified five strains in an incorrect phenotype, according to results obtained with duplex PCR. MIC results did not differ from those of duplex PCR. Conclusions: Duplex- PCR is a useful tool to detect hyper variable regions associated to mecA gene <![CDATA[<b>¿Cómo es la salud mental de los hijos de madres deprimidas consultantes a servicios de atención primaria?</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500008&lng=es&nrm=iso&tlng=es Background: Offspring of depressive parents have two times more risk of developing a depression, other psychiatric diseases or a poor social functioning. Aim: To assess psychopathology and social functioning among offspring of currently depressed mothers. Material and methods: We enrolled 290 depressed mother-child pairs in five primary-care clinics in Santiago. A two-stage screening process to identify female primary-care patients with current major depressive illness with children aged 6-16 years, was used. AH eligible and consenting patients were asked to complete the general health questionnaire (GHQ-12). Those scoring 5 or more were invited to participate in a baseline assessment. The final sample consisted of 290 mother-child pairs. Patients with a current DSM-IV diagnosis of major depression were eligible unless they had current psychotic symptoms, imminent suicide risk, history of mania, or current alcohol abuse. Child psychopathology was assessed with the Child Behavior Checklist (CBCL), a highly reliable and widely used parent-rated checklist to assess competencies and behavioural and emotional problems in children 4 to 18 years of age. Results: Fifty percent (95% confidence interval (CI): 43.9-55.7) of children had overall CBCL psychopathology scores in clinical range. Internalizing symptoms were more prevalent than externalizing symptoms (62.2% [9596CI: 56.3-67.8] and 35.7% [9596CI: 30.2-41.5]. Conclusions: A large proportion of children of depressed poor mothers attending primary care clinics in Chile, had psychopathological symptom scores in the clinical range, with a predominance of internalizing symptoms. These results are similar to those previously reported in the United States of America <![CDATA[<b>El cambio en la sensibilidad a la insulina no altera el perfil de lípidos en mujeres con posmenopausia temprana</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500009&lng=es&nrm=iso&tlng=es Background: It is not clear if changes in serum lipid profile during menopause are related to changes in the distribution of fat or to insulin resistance. Aim: To look for an association between insulin resistance and changes in serum lipid levels in post menopausal women. Patients and methods: Cross-sectional study of 66 early postmenopausal women aged 45 to 55years. Body mass index (BMI), waist-to hip ratio (WHR), total body adiposity, systolic blood pressure (SBP), diastolic blood pressure (DBF), mean blood pressure (MBP) and pulse pressure (PP) were measured. Total cholesterol, low-density ¡ipoproteins, high-density ¡ipoproteins, triglycerides, glucose and insulin were determined in a fasting blood sample. Insulin sensitivity was calculated using the homeostasis model assessment method (HOMA) and patients were stratified in quartiles according to this parameter. Results: Patients stratified in the different quartiles of insulin sensitivity were comparable in age and postmenopausal period, but had no differences in serum lipid levels. Compared to women in the lower quartile of insulin resistance, women in the upper quartile had higher BMI (23 and 27 kg/m² respectively, p =0.02), SBP (110 and 125 mmHg respectively, p <0.01) and MBP (83 and 93 mmHg respectively, p <0.01). Differences in total body adiposity were observed between the lower, third, and the upper quartile (30%, 35% and 36% respectively, p <0.01). Conclusions: In this group of early postmenopausal women, no association was observed between the level of insulin sensitivity and serum lipid levels <![CDATA[<b>Prevalencia</b><b> de sepsis grave en las Unidades de Cuidado Intensivo</b>: <b>Primer estudio nacional multicéntrico</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500010&lng=es&nrm=iso&tlng=es Background: Severe sepsis (SS) is the leading cause of death in the Intensive Care Units (ICU). Aim: To study the prevalence of SS in Chilean ICUs. Material and methods: An observational, cross-sectional study using a predesigned written survey was done in all ICUs of Chile on April 21st, 2004. General hospital and ICU data and the number of hospitalized patients in the hospital and in the ICU at the survey day, were recorded. Patients were followed for 28 days. Results: Ninety four percent of ICUs participated in the survey. The ICU occupation index was 66%. Mean age of patients was 57.7+18 years and 59% were male, APACHE II score was 15+7.5 and SOFA score was 6+4. SS was the admission diagnosis of 94 of the 283 patients (33%) and 38 patients presented SS after admission. On the survey day, 112 patients fulfilled SS criteria (40%). APACHE II and SOFA scores were significantly higher in SS patients than in non SS patients. Global case-fatality ratio at 28 days was 15.9% (45/283). Case-fatality ratio in patients with or without SS at the moment of the survey was 26.7% (30/112) and 8.7% (17/171), respectively p <0.05. Thirteen percent of patients who developed SS after admission, died. Case-fatality ratios for patients with SS from Santiago and the other cities were similar, but APACHE II score was significantly higher in patients from Santiago. In SS patients, the independent predictors of mortality were SS as cause of hospital admission, APACHE II and SOFA scores. Ninety nine percent of SS patients had a known sepsis focus (48% respiratory and 30% abdominal). Eighty five patients that presented SS after admission, had a respiratory focus. Conclusions: SS is highly prevalent in Chilean ICUs and represents the leading diagnosis at admission. SS as cause of hospitalization, APA CHE II and SOFA scores were independent predictors of mortality <![CDATA[<b>Síndrome de deficiencia del transportador de glucosa tipo 1 (SDGLUT-1) tratado con dieta cetogénica</b>: <b>Caso clínico</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500011&lng=es&nrm=iso&tlng=es The glucose transporter type 1 deficiency syndrome (GLUT-1 SD) (OMIM 606777) is an inborn error of metabolism of brain glucose transport. The characteristic clinical manifestations are seizures, hypotonia, developmental delay, microcephaly and hypoglycorrhachia. We report a girl with normal weight and height at birth. At 6 weeks of age she started with convulsions reaching up to 20 myoclonic seizures a day. She was treated with valproate, phenobarbital and carbamazepine without response. Blood analysis including aminoacids and acylcarnitines were all normal. The brain MRI showed frontal atrophy with an increased subarachnoidal space and Electroencephalography was abnormal. Blood glucose was 84 mg/dl and spinal fluid glucose 26 mg/dl with a ratio of 0.31 (Normal Ratio >0.65+00.1). These results suggested the diagnosis of GLUT-1 SD, and was confirmed with erythrocyte glucose uptake of 44% (Normal range 80-100%). A molecular study found the mutation 969del, C971T in exon 6 of the gene Glut-1. Treatment with a ketogenic diet was started immediately and after 7 days with this diet seizures ceased. Anticonvulsants were progressively suspended. At present, the patient is 6 years old, she continues on a ketogenic diet and supplements with L-carnitine, lipoic acid, vitamins and minerals. Growth and development are normal with an intelligence quotient of 103. It is concluded that it is necessary to include GLUT-1 SD in the differential diagnosis of children with early seizures that are non responsive to pharmacological treatment <![CDATA[<b>Hiperplasia angiolinfoidea con eosinofilia</b>: <b>Presentación de un caso en cavidad oral y revisión de la literatura</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500012&lng=es&nrm=iso&tlng=es We report a 33 year-old female presenting with a 2 cm tumor of the upper lip lasting one year. The tumor was excised and the pathological examination showed multiple blood vessels with thickened walls, prominent endothelial cells, lymphoid follicles and an increased number of eosinophils. The final diagnosis was an angiolymphoid hyperplasia with eosinophilia. Six months after surgery, the patient was free of disease. This is a rare condition that must be distinguished from Kimura disease <![CDATA[<b>Dermopatía fibrosante nefrogénica</b>: <b>Reporte de dos casos</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500013&lng=es&nrm=iso&tlng=es Nephrogenic fibrosing dermopathy is a recent designation to describe cutaneous findings in patients with renal disease who developed scleromyxedema-like skin lesions with thickening and hardening of the skin. These skin lesions appear mainly after hemodialysis or renal transplantation but their origin is still unknown. We report a 63 years old male on hemodialysis and 56 years old male on peritoneal dialysis, who developed a nephrogenic fibrosing dermopathy that was confirmed by pathology and immunohistochemistry with monoclonal antibodies against CD34) <![CDATA[<b>Psicología de la salud</b>: <b>Una clave para comprender el fenómeno de la adherencia terapéutica</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500014&lng=es&nrm=iso&tlng=es The lack of compliance with treatment is a public health problem that affects the patient's quality of life, avoids an objective assessment of therapeutic effectiveness and may even cause death. Non compliance can be considered an one-dimensional problem that only depends of patients's responsibility. However, Health Psychology has generated theoretical models that allow the prediction and understanding of therapeutic compliance. It also expands the responsibility to other agents involved in the therapeutic process, specifically health care providers and health systems <![CDATA[<b>Evaluación de rasgos personales, <i>"self", </i>esquizofrenia y estructuras de la línea media cortical</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500015&lng=es&nrm=iso&tlng=es There is no consensus about the definition of self however it is traditionally associated to identity. Many researchers are searching the neural regions that process self related information. Some studies have observed an activation of midline structures during the processing of information related to self. Self perturbations are not a part of diagnostic criteria for schizophrenia, nevertheless they are implicitly considered as part of the clinical picture. Some studies have tried to determine its perturbation using psychometric tests, but there are no studies that assess the association between brain activity and the performance of schizophrenics in tasks that require self-referential evaluations. The attempt to find a neural substrate for self is polemical. However, this model could be evaluated studying if, in schizophrenic patients, the tasks related to self processing are different from normal subjects at the psychophysiological and behavioral levels. This line of research could provide new diagnostic tools for early diagnosis and prevention inpsychiatry <![CDATA[<b>El último año de lucidez de Friedrich Nietzsche</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500016&lng=es&nrm=iso&tlng=es As an outstanding philosopher Nietzsche poses the question whether his creativeness persisted in spite of his deteriorating disease or appeared, among other features, as a consequence of his illness. A thorough psychopathological understanding of his last lucid year is attempted. He had an exaggerated self-esteem and grandiose sense of confidence and achievements. But his lack of insight did not lead him to engage in activities that could harm himself or his loved ones. Between January 1888 and until his ultimate deterioration in January 1889, Nietzsche was exceedingly productive. During this period, polar changes along with moderately overlapping periods appeared <![CDATA[<b>La reanimación cardiorrespiratoria y la orden de no reanimar</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500017&lng=es&nrm=iso&tlng=es In medical practice, the different scenarios in which cardio respiratory resuscitation (CPR) may be applied must be taken into account. CPR is crucial in subjects that arrive in emergency rooms or suffer a cardiac arrest in public places or at their homes. It is also critical in hospitalized patients with potentially reversible diseases, who suffer cardiac arrest as an unexpected event during their evolution. In intensive care units, the decision is particularly complex. The concepts of therapeutic proportionality, treatment futility and therapeutic tenacity can help physicians in their decision making about when CPR is technically and morally mandatory. The do not resuscitate (DNR) decision in taken when a patient is bearing an irreversible disease and his life is coming to an end. DNR decisions are clearly indicated in intensive care units to limit the therapeutic effort and in other hospital facilities, when death is foreseeable and therapeutic tenacity must be avoided. DNR orders must be renewed and reconsidered on a daily basis. It does not mean that other treatment should be discontinued and by no means should the patient be abandoned. DNR and previous directives, DNR and quality of life and DNR communication are also commented in the present article <![CDATA[<b>XXXI CONGRESO MUNDIAL DE MEDICINA INTERNA 2012</b>: <b>Santiago - Chile</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500018&lng=es&nrm=iso&tlng=es In medical practice, the different scenarios in which cardio respiratory resuscitation (CPR) may be applied must be taken into account. CPR is crucial in subjects that arrive in emergency rooms or suffer a cardiac arrest in public places or at their homes. It is also critical in hospitalized patients with potentially reversible diseases, who suffer cardiac arrest as an unexpected event during their evolution. In intensive care units, the decision is particularly complex. The concepts of therapeutic proportionality, treatment futility and therapeutic tenacity can help physicians in their decision making about when CPR is technically and morally mandatory. The do not resuscitate (DNR) decision in taken when a patient is bearing an irreversible disease and his life is coming to an end. DNR decisions are clearly indicated in intensive care units to limit the therapeutic effort and in other hospital facilities, when death is foreseeable and therapeutic tenacity must be avoided. DNR orders must be renewed and reconsidered on a daily basis. It does not mean that other treatment should be discontinued and by no means should the patient be abandoned. DNR and previous directives, DNR and quality of life and DNR communication are also commented in the present article <![CDATA[<b>ENCUESTA A LOS USUARIOS DE LA REVISTA MÉDICA DE CHILE</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000500019&lng=es&nrm=iso&tlng=es In medical practice, the different scenarios in which cardio respiratory resuscitation (CPR) may be applied must be taken into account. CPR is crucial in subjects that arrive in emergency rooms or suffer a cardiac arrest in public places or at their homes. It is also critical in hospitalized patients with potentially reversible diseases, who suffer cardiac arrest as an unexpected event during their evolution. In intensive care units, the decision is particularly complex. The concepts of therapeutic proportionality, treatment futility and therapeutic tenacity can help physicians in their decision making about when CPR is technically and morally mandatory. The do not resuscitate (DNR) decision in taken when a patient is bearing an irreversible disease and his life is coming to an end. DNR decisions are clearly indicated in intensive care units to limit the therapeutic effort and in other hospital facilities, when death is foreseeable and therapeutic tenacity must be avoided. DNR orders must be renewed and reconsidered on a daily basis. It does not mean that other treatment should be discontinued and by no means should the patient be abandoned. DNR and previous directives, DNR and quality of life and DNR communication are also commented in the present article