Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 135 num. 7 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b><i>Revistas médicas</i></b>: <b><i>Antiguas, pero no senescentes. Homenaje a la Revista Médica de Chile en su aniversario 135</i></b>]]> Medical journals, like the Revista Médica de Chile, are the product of a long history of printing, literary styles, and scientific inquiry. They would not have developed without the craft of paper making, the invention of movable type, the need to communicate ideas and observations in a timely and digestible format, and the growth of "natural philosophy" during the European Renaissance and Enlightenment. The proliferation of scientific and medical periodical literature during Europe's industrialization in the nineteenth and twentieth centuries followed the emergence of medical science and care as a separate discipline and the creation of common and worldwide professional expectations and credentials. Medical journals continue to evolve with the advent of digital paperless publishing. Prognostication remains uncertain but it seems to me unlikely that printed paper, so called "hard copy, "journals will become extinct any time soon<hr/>Las revistas médicas, como Revista Médica de Chile, son el producto de una larga historia de impresores, estilos literarios e investigación científica. No se habrían desarrollado sin la pericia de fabricar papel, la invención de los tipos mecánicos en la imprenta, la necesidad de comunicar ideas y observaciones en un formato oportuno y digerible, y el desarrollo de una "filosofía de la naturaleza" durante el Renacimiento y la Ilustración en Europa. La proliferación de publicaciones periódicas científicas y médicas durante la industrialización de Europa en los siglos 19 y 20 siguió a la emergencia de la ciencia médica y la atención de salud como disciplina aparte, y a la creación de expectativas y credenciales profesionales comunes y universales. Las revistas médicas siguen evolucionando con el advenimiento de las publicaciones digitales electrónicas, sin papel. Pronosticar es incierto pero al autor de este artículo le parece improbable que las revistas impresas en papel vayan a desaparecer en un futuro próximo <![CDATA[<b>Angiografía coronaria</b>: <b>indicación, resultados y complicaciones en 5.000 pacientes consecutivos</b>]]> Background: There are guidelines about equipment, premises, personnel, indications and complications rates for coronary angiography, that every center performing this procedure should adhere. Aim: To report the experience with 5.000 coronary angiographies and to assess the compliance of the center with the current guidelines. Material and methods: Prospective registry of 5.000 patients aged 60±11 years (3.475 males) subjected to coronary angiography since 1992, assessing all aspects of the procedure with special emphasis on complications. Results: The indications for 80% of procedures was suspected coronary atherosclerosis. The main risk factors were hypertension and smoking. Coronary atherosclerosis was demonstrated in 62%, mainly one vessel disease. These were two deaths due to the procedure (0.04%), three patients (0.06%) had an acute myocardial infarction or a stroke. These figures are lower than referential values. Conclusions: In this center, coronary angiography is a safe procedure, with complications rates that are even lower than referential values <![CDATA[<b>Unidad de dolor torácico</b>: <b>primera experiencia en Chile</b>]]> Background: In large series, nearly 60% of admissions for suspected acute coronary syndrome (ACS) had a non-coronary etiology of the pain. However, short term mortality of non recognized ACS patients, mistakenly discharged from the emergency room is at least twice greater than the expected if they would had been admitted. The concept of a chest pain unit (CPU) is a methodological approach developed to address these issues. Aim: To evaluate the efficacy of a CPU in the emergency room of a general hospital for evaluation of acute chest pain. Material and Methods: Prospective study of patients with chest pain admitted in the CPU. After a clinical, electrocardiographic and laboratory evaluation with cardiac injury serum markers, patients were stratified in three risk groups, based on the likelihood of ACS of the American Heart Association. High probability patients were admitted to the Coronary Unit (CU) for treatment. Moderate probability patients remained in the CPU for further evaluation and low probability patients were discharged with telephonic follow-up. Results: Of 407 patients, 35, 30 and 35% were stratified as high, intermediate and low probability ACS, respectively. Among patients admitted with high probability, 73% had a confirmed ACS diagnosis. Among intermediate probability patients, 86% were discharged after an evaluation in the CPU without adverse events in the follow-up. Conclusion: Structured risk evaluation approach in a CPU improves the management of acute chest pain, identifying high probability patients for fast admission and start of treatment in a CU and allowing safe discharge of low probability ones <![CDATA[<b>Indicadores antropométricos, composición corporal y limitaciones funcionales en ancianos</b>]]> Background: Functional limitations limit the independence and jeopardize the quality of life of elderly subjects. Aim: To assess the association between anthropometric measures and body composition with functional ¡imitations in community-living older people. Material and Methods: Cross-sectional survey of 377 people >6 5 years old (238 women), randomly selected from the SABE/Chile project. Complete anthropometric measurements were done. Handgrip muscle strength was measured using dynamometers. Body composition was determined using Dual-Energy X-Ray Absorptiometry. Functional limitations were assessed using self reported and observed activities. Results: Body mass index was strongly associated with fat mass (men r =0.87; women r =0.91) and with lean mass (men r =0.55; women r =0.62). Males had significantly greater lean mass (48.9 kg vs 34.9 kg), and bone mass than females (2.6 kg vs 1.8 kg) and women had higher fat mass than men (26.3 kg vs 22.9 kg). The prevalence of functional ¡imitations was high, affecting more women than men (63.7% vs 37.5%, p <0.01). Functional ¡imitations were associated with lower handgrip strength in both sexes. In the multiple regression models, with functional ¡imitations as dependent variable and anthropometric measures as contributing variables, only hand grip strength had a significant association (negative) with functional ¡imitation in both genders. Age was also a significant risk factor for functional ¡imitations among women. Conclusions: Hand grip strength was strongly and inversely associated with functional ¡imitations. Handgrip dynamometry is an easy, cheap and low time-consuming indicator for the assessment of functional ¡imitations and the evaluation of geriatric interventions aimed to improve functional ability <![CDATA[<b>Uso de CPAP nasal en el largo plazo en síndrome de apnea-hipopnea del sueño</b>]]> Background: The use of CPAP is the conventional therapy for the Obstructive Sleep Apnea Syndrome (OSAS). Aim To establish the proportion of OSAS patients with CPAP indication who use it in the long-term and to determine predictive factors of adherence. Patients and Methods: Structured survey through personal interview or phone call, applied to all patients who had polisomnographically documented OSAS and CPAP titration at the Pontificia Universidad Católica de Chile Sleep Disorders Center between January 1998 and November 2001. Patients were divided in "Permanent Users" (Group I) and "Non Users" (Group II). Results: Of 440 patients that fulfilled inclusion criteria, 162 (32.8%) answered the survey. Seventy percent (114/162) of these patients had used CPAP and 86% (98/114) continued to use it at the time of the interview, with a mean follow-up of 12.3 months (Group I 60.5% of the interviewed population). Group II included 64 patients (39.5% of the interviewed patients). Among the latter, 25% (16/64) stopped using CPAP due to intolerance, 25% (16/64) could not use it because of economical restrictions, 20.5% (13/64) preferred other therapies and 29.5% (15/64) merely refused treatment. Predictors of long-term use of CPAP were number of respiratory events (p <0.01), hypersomnolence (p <0.01) and age (p =0.03). Conclusions: Approximately two thirds of patients with OSAS, with an indication for CPAP, continue to use this therapy in the long term in a Chilean population. This figure is similar to other reports from abroad. It is also possible to identify predictive factors for CPAP discontinuation in this population <![CDATA[<b>Análisis de la opinión de usuarios sobre calidad percibida y satisfacción con hospitales públicos</b>: <b>Estudio de caso desde la perspectiva de la aplicación del marketing</b>]]> Background: The level of satisfaction of patients with the services provided by public hospitals is becoming an important issue for health authorities. Aim: To analyze an enquiry applied to patients, about the level of satisfaction with the service provided by a public regional hospital in Chile. Material and methods: An enquiry was applied to 150 ambulatory (76% women) and 50 hospitalized patients (56% women). It included 28 questions about management aspects of health care and 20 questions about client satisfaction. Data was analyzed using factorial analysis and multiple regressions. Results: The manners of hospital personnel were the factor with the highest impact on the perception of patients about global quality of services. Attention timing was the most influential aspect on global satisfaction. Conclusions: There results confirm those from abroad and can orient an adequate management of public hospital <![CDATA[<b>Criocoagulación de venas pulmonares como tratamiento complementario de la fibrilación auricular en cirugía valvular</b>]]> Background: The Cox MAZE III operation for the treatment of atrial fibrillation (AF) is complex and consumes significant operative time. Cryoablation of the pulmonary veins (CPV) is a simpler alternative for patients that require concomitant valvular surgery. Aim: To evaluate CPV in patients with AF submitted to valvular surgery. Patients and Methods: Twenty one patients had simultaneous valvular surgery and CPV, 81 % of them had permanent AFfor an average of 5 years. Twenty patients had mitral valve disease. The etiology was rheumatic in 14. Average left atrial diameter was 60 mm. In 7patients the mitral valve was replaced, in 5 it was repaired, in 7 both mitral and aortic valve were replaced, in 1 the mitral valve was repaired and the aortic valve was replaced and in 1 only the aortic valve was replaced. A combined transeptal and superior approach was used for all patients. The CPV was performed after the valvular procedure with cryothermy at -60°C for 2 minutes with two 15 mm cryoprobes applied simultaneously. Results: CPV increased surgical time by 10 to 20 minutes. Operative mortality was 4.8% (1 patient). One patient developed a pericardial effusion and another a complete heart block that required a permanent pacemaker. All patients improved their functional class. At the end of an average 10.5 months of follow-up, 50% of patients were in normal sinus rhythm and 25% persisted in AF. The remaining patients were in some type of regular rhythm. Conclusions: CPV as a complementary procedure in patients with AF undergoing valvular surgery had good results to abate AF. It restored normal sinus rhythm in 50% of the cases, with low morbidity and mortality and little increment in surgical time <![CDATA[<b>Determinación de los índices glicémicos y de insulina en fórmulas para alimentación enteral en adultos sanos</b>]]> Background: In acute illnesses, plasma glucose levels are often increased and generally parallel the severity of stress. Hyperglycemia caused by reduced insulin sensitivity and reduced insulin secretion is associated with increased susceptibility to infections. Maintaining blood glucose levels at or below 110 mg/dl reduces morbidity and mortality in critically ill patients. Aim: To measure the glucose and insulin responses of four commercially available enteral formulas compared with a standard meal reference product. Material and Methods: The glycemic index (GI) and the insulin index (II) were determined in a randomized, cross over protocol in 38 healthy volunteers between 18 and 46 years of age. Each subject underwent five tests: three with the standard meal (bread) and two with the study products. The enteral formulas were Clinutren HPR (whole protein of high protein value), Crucial® (casein peptide based formula), Peptamen®, (whey peptide based formula), Glytrol® (formula for diabetics with whole protein with fiber). Each study product was evaluated 10 times. Results: The diabetic formula and the high protein energy dense formulas induced a significantly lower GI (p <0.02) compared with the standard meal. The GI response did not appear to be due to enhanced insulin secretion. The other tested formulas had lower GI than the standard meal, but in addition they exhibited increased II The whey based peptide formulation produced the highest insulin response (p <0.03). Conclusions: Both GI and II are related to the concentration, form and type of protein contained in the enteral formula. The whey peptide formulation produced a low GI with the highest insulin index. Based on the low GI of these enteral products, all can be useful to provide nutritional support during metabolic stress, without adding an additional challenge to blood glucose management <![CDATA[<b>Residuos hospitalarios peligrosos en un centro de alta complejidad</b>]]> Background: An inadequate management of hospital waste, that have toxic, infectious and chemical wastes, is a risk factor for humans and environment. Aim To identify, quantify and assess the risk associated to the management of hospital residues. Material and methods: A cross sectional assessment of the generation of hazardous waste from a hospital, between June and August 2005, was performed. The environmental risk associated to the management of non-radioactive hospital waste was assessed and the main problems related to solid waste were identified. Results: The rate of generation of hazardous non-radioactive waste was 1.35 tons per months or 0.7 kg/bed/day. Twenty five percent of hazardous liquid waste were drained directly to the sewage system. The drug preparation unit of the pharmacy had the higher environmental risk associated to the generation of hazardous waste. The internal transport of hazardous waste had a high risk due to the lack of trip planning. The lack of training of personnel dealing with these waste was another risk factor. Conclusions: Considering that an adequate management of hospital waste should minimize risks for patients, the hospital that was evaluated lacks an integral management system for its waste <![CDATA[<b>Metabolismo del glutatión y desarrollo posnatal del pulmón de la rata</b>]]> Background: Significant changes in lung antioxidants occur in preparation for birth. Little is known about physiological regulation of antioxidants in the postnatal period. Aim: To study the glutathione system in the lungs during postnatal development. Material and methods: In the lungs of 7, 15, 21, 50 and 70 days old Sprague-Dawley rats we measured total and oxidized glutathione content as well as the activity of the limiting enzyme in glutathione synthesis (y-GCS) and of the enzymes glutathione peroxidase (GPx) and glutathione reducíase (GRd). Results: Between 7 and 15 days the activities of GPx and GRd increase 32% and 26%, respectively (p <0.001). Whereas GPx activity remains high throughout the rest of the study period, GRd activity decreases progressively reaching adulthood values at 7 days. y-GCS activity shows a gradual increase that reaches significance at 50 days when it doubles values observed at 7 days (p <0.05). A significant correlation was found between GPx and GRd activities over the entire period (r =0.62, p <0.0001). Strength of the correlation is age dependent due to the differences in time course of the enzyme changes. Whereas total GSH does not change, oxidized glutathione decreases from 7% at 7 and 15 days to 4% later on (p <0.01). Conclusions: The activity of several enzymes involved in glutathione metabolism increases during postnatal development of the rat lung. Interpretation of lung responses to injurious agents needs to be done taking into consideration the physiological regulation of antioxidants during postnatal development <![CDATA[<b>Prevalencia de factores de riesgo cardiovascular clásicos en población adulta de Talca, Chile, 2005</b>]]> Background: Cardiovascular disease (CVD) has several traditional risk factors (RF), and some of them are potentially modifiable. Aim: To determine the prevalence of most common risk factors in adult population in Talca in Central Chile. Subjects and methods: We studied 1007 subjects aged 18 to 74 years (66% women), living in Talca, selected by a probability sampling. They answered a questionnaire and anthropometry, blood pressure, lipid profile and blood glucose were measured. Results: Thirty seven percent of subjects smoked, 70.1% had a body mass index over 25 kg/m² and 41% had an abnormally high circumference. High blood pressure was found in 37% (36% of these subjects were unaware of this condition), 44.5% had hypercholesterolemia, 21.5% had low HDL cholesterol, 40.1% had hypertriglyceridemia and 26.3% had high blood glucose levels. Conclusions: There is a high prevalence of risk factors for CVD in adult population from Talca. The prevalence of risk factors is higher than that reported by the 2003 National Health Survery <![CDATA[<b>Manifestaciones neurológicas de la granulomatosis de Wegener</b>: <b>Caso</b><b> clínico</b>]]> Wegener's granulomatosis is a systemic necrotizing vasculitis that affects medium size and small vessels. Neurological involvement occurs in 22% to 54% of patients, mainly in the form of mononeuritis multiplex. Central nervous system involvement is reported in only 2% to 8% of the cases. We report a 42-year-old male who presented with headache, diplopia, third and sixth cranial nerve palsies and ¡eft eye amaurosis associated to mass located in the ¡eft Meckel cavum and diffuse meningeal involvement. A biopsy of the mass disclosed a chronic granulomatous necrotizing inflammation with Langhans giant cells. A chest CAT scan showed three cavitated lung nodules and ANCA antibodies were positive in a titer of 1:80. Treatment with steroid and cyclophosphamide was started and cranial nerve palsies resolved and the number and size of lung nodules decreased. The patient was lost from follow up <![CDATA[<b>Trasplante alogénico de precursores hematopoyéticos en pacientes con síndrome de Wiskott-Aldrich</b>]]> Background: Wiskott-Aldrich syndrome (WAS) is an X linked congenital disease that presents as eczema, thrombocytopenia and immune deficiency. The only curative procedure for this illness is hematopoietic stem cell transplant (HSCT), preferably from a healthy HLA identical sibling donor. Cord blood is becoming an excellent alternative as stem cell source from unrelated donors. Aim: To report our experience with HSCT in children with WAS. Patients and methods: Six boys with WAS diagnosed at 1 to 6 months of age were transplanted at our institution. All of them developed eczema and thrombocytopenia. Two had episodes of severe bleeding and three had repetitive infections (two with recurrent pulmonary infections and one a recurrent otitis). Three patients had a positive family history. Two received HSCT from sibling donors and four from unrelated cord blood donors at 7 months to 4 years of age. Results: AH 6 patients had full hematopoietic engraftment after transplantation. Three had mild chronic graft-versus- host disease which responded to immune suppressive therapy. One patient died of cytomegalovirus related pneumonia 111 days after grafting. The other 5 patients are alive and healthy 11 to 104 months after transplantation. Conclusions: HSCT is an effective treatment for patients with WAS. The procedure should be done as soon as diagnosis is confirmed and before life threatening infections occur <![CDATA[<b>Quiste broncogénico retroperitoneal</b>: <b>Caso clínico</b>]]> Retroperitoneal cystic tumors are uncommon. More than two thirds are malignant. Benign lesions include lipomas and ¡eiomyomas, among others. Bronchogenic cysts are congenital anomalies that result from an abnormal budding of the primitive foregut, and are most commonly found in the mediastinum. Occasionally they can be seen in the skin, subcutaneous tissue, in the pre-sternal andpericardial areas, but those located under the diaphragm are extremely rare. We report a 24 year-old female who consulted for abdominal pain. An abdominal ultrasound disclosed a retroperitoneal cystic lesion, that was confirmed with a CAT scan. The patient was operated, finding a cyst that was adhered to the pancreas. A distal pancreatectomy and cyst excision were done. The pathological examination of the lesion showed a bronchogenic cyst. The patient was discharged ten days after surgery <![CDATA[<b>¿De qué mueren los chilenos hoy?</b>: <b>perspectivas para el largo plazo</b>]]> During the last decades, Chile experienced substantial socioeconomic, epidemiológica! and demographic changes. These resulted, among other consequences, in a deceleration of population growth, a notorious decrease in fertility rates, and one of the most rapid and deepest drop in general and infant mortality rates in the Latin American region. These changes resulted in a sustained increase of life expectancy and a substantial ageing of the Chilean population. This process is also changing the disease burden of the population. Infectious and perinatal diseases lost relevance as major causes of mortality, and have been replaced by chronic non transmissible diseases, specifically cardiovascular conditions and cancer, that are becoming the main causes of death. High blood pressure, cardiovascular risk, hypercholesterolemia, diabetes, overweight and obesity, smoking, sedentary lifestyle and depression will have a great impact on health conditions during the XXI century. These factors and a persistent social inequity will hinder the efforts to reduce the impact and consequences of chronic non transmissible, diseases in the Chilean population <![CDATA[<b>La referencia electrónica en artículos científicos</b>]]> Background: Publications in electronic format using Web sites facilitates and extends the access to information from any place in the world. Nevertheless, the use of electronic references still lacks the rigor with which the printed reference is handled. Aim: To analyze the citation of electronic references in Revista Médica de Chile. Material and methods: Twelve issues of volume 132 were analyzed, quantifying the number of electronic references. Their accuracy was assessed considering the elements available in the Web site and access date. Results: Seventy six electronic references were detected. Of these, 28 (37%) incorporated available in, 76 (100%) indicated the Web site and 38 (50%) indicated the access date. Conclusions: Electronic references are still scanty and incomplete in Revista Médica de Chile <![CDATA[<b>Revisión por pares en la <i>Revista Médica</i><i> de Chile, </i>año 2006</b>]]> Background: Publications in electronic format using Web sites facilitates and extends the access to information from any place in the world. Nevertheless, the use of electronic references still lacks the rigor with which the printed reference is handled. Aim: To analyze the citation of electronic references in Revista Médica de Chile. Material and methods: Twelve issues of volume 132 were analyzed, quantifying the number of electronic references. Their accuracy was assessed considering the elements available in the Web site and access date. Results: Seventy six electronic references were detected. Of these, 28 (37%) incorporated available in, 76 (100%) indicated the Web site and 38 (50%) indicated the access date. Conclusions: Electronic references are still scanty and incomplete in Revista Médica de Chile