Scielo RSS <![CDATA[Revista médica de Chile]]> https://scielo.conicyt.cl/rss.php?pid=0034-988720080008&lang=es vol. 136 num. 8 lang. es <![CDATA[SciELO Logo]]> https://scielo.conicyt.cl/img/en/fbpelogp.gif https://scielo.conicyt.cl <![CDATA[<b>Características de los pacientes que reciben ventilación mecánica en unidades de cuidados intensivos: primer estudio multicéntrico chileno</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800001&lng=es&nrm=iso&tlng=es Background: The outcome oí' mechanically ventilated patients can be inñuenced byfactors such as the indication of mechanical ventilation (MV) and ventilator parameters. Aim: To describe the characterístics of patients receiving MV in Chilean critical care uníts. Material and methods: Prospective cohort of consecutive adult patients admitted to 19 intensive care uníts ([CU) from 9 Chilean cities who received MV for more than 12 hours between September lst, 2003, and September 28th, 2003. Demographic data, severity of illness, reason for the initiation of MV, ventilation modes and settings as well as weaning strategies were registered at the initiation and then, daily throughout the course of MV for up to 28 days. ¡CU and hospital mortality were recorded. Resulte: Of 588 patients admitted, 156 (26.5%) received MV (57% males). Mean age and Simplified Acute Physiology Score-II (SAPSII) were 54.6±18years and 40.6±16.4 points respectively The most common indications for MV were acute respiratory failure (71.1%) and coma (22.4%). Assist-control mode (71.6%) and synchronized intermittent mandatory ventilation (SIMV) (14,2%) were the most frequently used. T-tube was the main weaning strategy. Mean duration of MV and length of stay in ICU were 7.8±8.7 and 11.1± 14 days respectively. OverallICUmortality was 33.9% (53patients). The main factors independently associated with increased mortality were (1) SAPS II ≥ 60 points (Odds Patio (OR), 10.5; 95% CI, 1.04-106.85) and (2) plateaupressure ≥ 30 cm Hfi atsecond day (OR, 3.9; 95% CI, 1.17-12.97). Conclusions: Conditionspresent at the onsetofMVand ventilator management were similar to those reported in the literature. Magnitude ofmultiorgan dysfunction and high plateau pressures are the most important factors associated with mortality). <![CDATA[<b>Efecto de la inhibición de la síntesis de angiotensina II en el consumo de alcohol</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800002&lng=es&nrm=iso&tlng=es Background: Central reninangiotensin system modulates alcohol intake and inhibition of angiotensin converting enzyme reduces ethanol consumption in rats, and may be potentially useful in the treatment of alcoholism. Aim: To study the effect of captopríl on alcohol intake, both in humans and animals . Material and methods: In a double-blind, placebo-controlled clinical study, 15 alcoholics who met DSM-IV criíteria were randomized to receive captopril 100 mg/day or placebo for 12 weeks. In the experimental study, daily consumption of ethanol (10% v/v), water and solid food was assessed in 12 male Wistar rats before and after the intraperítoneal administration of captopríl 50 mg/kg/day. Results: In alcoholics, mean weekly standard alcoholic drínk consumption was not different during captopríl treatment or placebo. However, both groups had a signiñcantly lower intake than duríng baseline. Days of abstinence increased and days of drunkeness decreased in the group receiving captopril, when compared with baseline but not with placebo. Craving was significantly reduced by captopríl when compared with placebo. In rats, captopríl reduced not only alcohol consumption but also water and food intake. Conclusions: Captopríl decreases alcohol intake in rats and this effect is not speciñc for ethanol. Captopril did not alter alcohol consumption in alcoholics when compared with placebo but reduced craving. <![CDATA[<b>Sobrecrecimiento bacteriano intestinal en pacientes con pancreatitis crónica</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800003&lng=es&nrm=iso&tlng=es Background: Previous reports describe 30-40% of small intestine bacterial overgrowth (SIBO) in patients with chronic pancreatitis (CP), SIBO is a cause of persistent symptoms in this group of patients even when they are treated with pancreatic enzymes. Aim: To asses the frequency of SIBO in patients with CP. Patients and methods: We studied 14 patients with CP using an hydrogen breath test with lactulose to detect SIBO, a nonabsorbable carbohydrate, whose results are not influenced by the presence of exocrine insufficiency. Main symptoms and signs were bloating in 9 (64%), recurrent abdominal pain in 8 (57%), intermittent diarrhea in 5 (36%) and steatorrhea in 5 (36%). At the same time we studied a healthy control group paired by age and sex. Results: SIBO was present in 13 of 14 patients with CP (92%) and in 1 of 14 controls (p<0.001). The only patient with CP and without SIBO was recently diagnosed and had minimal morphologic alterations in computed tomography and endoscopic pancreatography Conclusions: SIBO is common in CP and may be responsible for persistent symptoms. Proper diagnosis and treatment could alleviate symptoms andimprove quality of Ufe. <![CDATA[<b>Efecto del probiótico <i>Saccharomyces boulardii </i>en la prevención de la diarrea asociada con antibióticos en adultos ambulatorios en tratamiento con amoxicilina</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800004&lng=es&nrm=iso&tlng=es Background: Antibiotic-associated diarrhea is one of the most common adverse effects of antimicrobials. Any antimicrobial can potentially produce diarrhea but beta-lactamics have a higher risk. Among these, amoxicillin is widely indicated in ambulatory practice. One ofthe alternatives suggested to prevent antibiotic-associated diarrhea, is the use of the probiotic Saccharomyces boulardii. Aim: To evalúate whether the concomitant use of Saccharomyces boulardii and amoxicillin can prevent antibiotic associated diarrhea in ambulatory adults with acute infections diseases, without provoking other adverse effects. Material and Methods: Eighty six adults (aged 15 to 81 years) with acute infectious diseases, excluding those arising in the gastrointestinal tract, that received a prescription of oral amoxicillin for 5 to 10 days, were included. In a controlled randomized, double blind trial, 41 patients were assigned to receive lyophilized Saccharomyces boulardii (500 mg/day) duríng 12 days, and 45 patients were assigned to placebo for the same period. Results: Ten percent of patients (9/86) reported acute diarrhea, 9,8% (4/41) in the experimental group and 11.196 (5/45) in the control group (p = 100). No adverse effects were associated to the use of the probiotic. Conclusions: Saccharomyces boulardii (500 mg/day) did not prevent diarrhea related to amoxicillin. <![CDATA[<b>Vigilancia nutricional en escolares chilenos</b>: <b>Validez de la información</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800005&lng=es&nrm=iso&tlng=es Background: Anthropometry is used to survey health and nutritional situation of the population. Therefore the quality of the information that is being used must be evaluated. Aim: To estímate the agreement in weight, height and nutritional status in schoolchildren, comparing measurements made by teachers in schools and a standardized and supervised team of professionals. Material and methods: Cross sectional study including 927 schoolchildren in 31 schools from 7 counties of Santiago. Schools were randomly chosen and the universe of children attending to first grade was measured. Weight, height and nutritional status collected by teachers and researches, were compared. Results: Total agreement for nutritional status reached 0.67, random-weighted Kappa was 0.40 and weighted Kappa, 0.42. Teachers tended to over diagnose under-nutrition and under diagnose overweight and obesíty measuríng 270 grams less than the qualified team (p <0.001) and 1.7 cm more in height (p <0.001), what is reflected in a difference of less than one point in body mass index (p <0.001). Discrepancies in height and body mass índex were higher in extreme valúes. Conclusions: There is a low agreement between the measurements taken by the research team and teachers. Even though there are discrepancies between measurements, high levéis of overweight and low prevalences of stunting and underweight are kept, reílecting problems with exactitude, but not bias. Corrective actions to improve the quality of information, which should include training programs for teachers, instrument maintenance, supervisión and verification system for data entry, are needed. <![CDATA[<b>Hipopituitarismo congénito</b>: <b>Experiencia en 23 casos</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800006&lng=es&nrm=iso&tlng=es Background: Congenital hypopituitarism is an uncommon cause of hypophyseal insufficiency It is less common than growth hormone deficiency which has an incidence of 1:4.000 to 1:8.000 Uve newborns. Early diagnosis ofthis condition is important to prevent impairment of cognitive function, poor growth and alterations in metabolic profile in these patients. Aim: To report 23 patients diagnosed with congenital hypopituitarism. Material and methods: Retrospective review of clinical records of 23 patients (12 males) with congenital hypopituitarism, diagnosed during a 21 years period. In a group of 16 patients a molecular study was performed searching for mutations in HESX1, PROP-1 or POUF-1. Results: Short stature was the most frequent sign at the first evaluation, followed by neonatal hypoglycemia and presence of nistagmus, strabismus, atrophic optic nerve or malformations in the middle Une showed in CNS imaging, suggesting septo-optic-dysplasia. All male patients diagnosed during neonatal period, exhibited micropenis. CNS images showed isolated hypophyseal hypoplasia or associated to an ectopic neurohypophysis in most patients. No patient in the subgroup subjected to molecular analysis had any of the mutations in the searched genes. Conclusions: The diagnosis of hypopituitarism must be based on clinical grounds, speciaUy when hypoglycemia, prolonged jaundice, micropenis or midline alterations are found in the neonatal period. <![CDATA[<b>Variables psicosociales asociadas a compensación metabólica de pacientes diabéticos de tipo 2</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800007&lng=es&nrm=iso&tlng=es Background: Patients' cultural oríentations play an important role in chronic diseases. However, medical education research still does not emphasize these variables. Aim: To measure the influence of psychosocial dimensions on blood glucose control in type 2 diabetic patients. Subjects and methods: Case-control design. Data were collected from institutional records and structured interviews. Blood glucose control was tested using glycosylated hemoglobin A1C. Patients with a good metabolic proñle defined as a glycosylated hemoglobin of less than 7% were considered cases while those with a glycosylated hemoglobin >7% were labeled as controls. Sixty seven cases and 61 controls were randomly selected at a public health center located in Los Angeles, Chile. Socio-demographic, illness-related, and psychosocial variables were measured and múltiple modeling using logistic regression was performed. Results: Seventy per cent of patients were female, mean age was 61 years, 57% were housewives and most had a low income and educational level. The cultural predictors of metabolic control of diabetes were the perception of obstacles for blood glucose control, attribution of health benefits to a good control, family support and bonding quality with the health team. Conclusions: Cultural variables play a significant role in metabolic control of diabetic patients and must be born in mind in educational campaigns. <![CDATA[<b>Validación y uso de la técnica del linfonodo centinela axilar con colorante exclusivo en pacientes con cáncer de mama</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800008&lng=es&nrm=iso&tlng=es Background: The use of a dye and radiocolloid to detect sentinel lymph nodes in breast cáncer increases the detection rates. However the use of either method alone does not modify the false negative rate. Therefore there is no formal contraindication for the exclusive use of dye to detect nodes. Aim: To repon a prospective analysis of the exclusive blue dye technique for sentinel node biopsy in patients with early breast cáncer Patients and methods: We analyzed the first 100 women with pathologically proven breast cáncer who met the inclusión criteria. Patent blue dye was used as colorant. In the first 25 cases sentinel node was identified using radiocolloid and blue dye an then an axillary dissection perfomed. In the next 25 women, blue dye was used exclusively for detection and an axillary dissection was perfomed. In the next 50 cases, blue dye was used and only isolated sentinel node biopsy was perfomed. Results: In 92 of the 100 women a sentinel node was successfully detected. In the first 50 women, the false negative rate of sentinel lymph node detection was 6.9%. No complications occurred. During follow-up, lasting three to 29 months, no axillary relapse was observed. Conclusions: Sentinel node biopsy in patients with early breast cáncer using exclusively blue dye is feasible and safe. <![CDATA[<b>Carga viral en pacientes pediátricos VIH positivos con terapia antirretroviral</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800009&lng=es&nrm=iso&tlng=es Background: Viral load in pediatric patients with HIV infections can help to make therapeutic decisions to modify the evolution of the disease. Aim: To evaluate viral load in positive HIV children with antiretroviral treatment. Material and methods: Viral load was measured every six months during three years in fifty pediatric patients chosen randomly in aged 1 to 12 years, using the Test Monitor HIV-1 AMPLICOR, versión 1.5. Results: During the three years follow up, there was an increase in CD4 and CD8 lymphocyte count and decrease in the viral load. However, there was no significant relationship between lymphocyte subpopulation counts and viral loads. Conclusions: Viral load demonstrated to be an appropriate method to quantify plasma HIV-RNA. This tool can help to define the condition of a particular patient to predict clinical course of the disease and to assess the response to the treatment. <![CDATA[<b>Obstrucción intestinal causada por Tricobezoar</b>: <b>Síndrome de Rapunzel</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800010&lng=es&nrm=iso&tlng=es Rapunzel syndrome or gastrointestinal trichobezoar is caused by hair ingestión. The diagnosis may be suspected in young females with important weight loss, who deny hair eating. We report a 16 year-old female consulting in the emergency room for abdominal pain. She was subjected to an exploratory laparotomy and a big mass was palpated in the stomach. A gastrostomy and enterostomy were performed and a 17x6x5 cm tríchobezoar was extracted. The patient had an uneventful postoperative outcome and was derived to Psychiatry. <![CDATA[<b>Angiomiolipoma renal complicado como causa de dolor lumbar</b>: <b>Caso clínico</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800011&lng=es&nrm=iso&tlng=es Renal angiomyolipoma is a benign tumor formed by smooth muscle, adipose tissue and blood vessels. It is commonly found incidentally and its clinical manifestations are pain and abdominal mass or spontaneous tumor rupture with retroperitoneal bleeding. The clinical presentation of a hemorrhagic shock secondary to a retroperítoneal hematoma is uncommon. We report a 40 year-old male who presented to the emergency room with lumbar pain and deteríoration of hemodynamic parameters. The CT sean showed a left renal injury associated to an expansive retroperítoneal process. The abdominal exploration, vascular control of the renal pedicle and nephrectomy allowed a successful outeome. <![CDATA[<b>Rotura de válvula tricúspide con insuficiencia masiva secundaria a traumatismo torácico cerrado</b>: <b>Caso clínico</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800012&lng=es&nrm=iso&tlng=es Cardiac valve lesions after a blunt chest trauma are rare and less than 1% of cardiac lesions because of chest trauma affect the tricuspid valve. We report a 70 year-old female that suffered a severe chest trauma in a car accident. Duríng the repair of the múltiple skeletal lesions, the patient had a severe hemodynamic decompensation. A myocardial trauma with pericardial effusion and massive tricuspid insufficiency, due to anterior leaflet prolapse, was diagnosed on echocardiography. After discharge the patient remained in functional class II, with hepatomegaly, jugular ingurgitation and lower limb edema. A control echocardiogram, perfomed six months after the accident, showed dilatation of right heart chambers and massive tricuspid insufficiency. The patient was operated, and a tricuspid valve repair was performed suturing the ruptured papillary muscle to the ventricular wall and performing a triscuspid annuloplasty with a prosthetic ring. After 15 months of follow up, the patient remains asymptomatic. <![CDATA[<b>Nivel de níquel urinario en niños residentes en ciudades cercanas a megafuentes</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800013&lng=es&nrm=iso&tlng=es Background: Petcoke is a remmant of the oil refiningprocess that contains Ni and other heavy metáis. Undesired human exposure to these compounds may result from petcoke combustión in plants located in the vicinity ofthe cities. Aim: To compare levéis of urinary Ni in schoolchildren residing in cities exposed and not exposed to petcoke pollution. Material and methods: A cross sectional study was done in schoolchildren aged 7 to 8 years oíd in two cities in northern Chile: Mejillones (n = 59), near to a petcoke plant and Tocopilla (n = 56) as the reference city. First, morning urinary samples were collected and urinary Ni was determined by Atomic Absorption Spectrometry. Socioeconomic and environmental exposure information of families was obtained applying a questionnaire to parents. Múltiple linear regression was performed to identify other variables that may explain urinary Ni differences among the cities. Results: Median level of Ni was higher in Mejillones (4.9 fig/L) than in Tocopilla (3.9 fig/L). Residing in the exposed city was the most important explaining factor (B = 0.26; IC 0.107 - 0.428). Additionally years of residency was associated with urinary Ni (B = 0.03; IC 0.004 - 0.060). Conclusions: Urinary Ni in schoolchildren is higher in the city exposed to petcoke emissions. The difference does not imply that there are concrete hazards for the population s health. However, it warns about the existence of a higher exposure in places where petcoke is used. <![CDATA[<b>Utilidad de la biopsia de piel en el diagnóstico de enfermedades neurológicas</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800014&lng=es&nrm=iso&tlng=es Skin biopsy is a powerful diagnostic tool in Dermatology. Its use has been extended to other medical specialties, aüowing the diagnosis of several diseases that previously required complex and high risk diagnostic procedures. Skin contains numerous cell types, including blood vessels and peripheral nerves and represents a window to the systemic circulation and nervous system. In this review we discuss the use of skin biopsy to diagnose nervous system diseases in which patients do not exhibit any clinical cutaneous manifestations. We review the usefulness of skin biopsy in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopaty (CADASIL), some lysosomal storage diseases, Lafora disease and in peripheral neuropathies. <![CDATA[<b>La prueba de caminata en seis minutos en la evaluación de la capacidad de ejercicio en pacientes con enfermedad pulmonar obstructiva crónica</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800015&lng=es&nrm=iso&tlng=es Exercise capacity can be evaluated in patients with chronic obstructive pulmonary disease (COPD), measuring the distance that patients are able to walk in 6 minutes (six-minute walk distance test; 6WDT). This test is simple to perform, inexpensive, reproducible and safe. It has been frequently employed for the assessment of COPD patients due to its high prognostic valué of mortality and its usefulness to evalúate long-term of therapeutic interventions. In severe stages of the disease, the declining results of the best are useful to detect worsening. This review describes the method, standardization and reference valúes for the 6WDY and the results obtained with different therapeutic interventions, based on data from the literature and from the authors experíence. We also review its predictive valué for mortality and its valué in the assessment of patients with more severe COPD. <![CDATA[<b>Una mirada epistemométrica de la <i>Revista Médica de Chile </i>y su aporte al conocimiento en Medicina</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800016&lng=es&nrm=iso&tlng=es Background: During the last decade Revista Médica de Chile increased its visibility, measured on citations and impact factor. Aim: To perform a scientometric analysis to assess the performance of Revista Médica de Chile. Material and methods: Thomson's-ISI Web of Science and Journal Citation Reports QCR) were consulted for performance indicators of Revista Médica de Chile and Latin Amerícan journals whose subject is General and Internal Medicine. We also report the h-index of the journal, which infers quality ¡inked to the quantity of the output. Results: According to the h-index, Revista Médica de Chile ranks 4 among the 36 journals indexed and published by Argentina, Brazil, Chile and México. The top ten articles published by Revista Médica de Chile and the institutions with the higher contríbution to the journal, were identified using citations. In the Latin Amerícan región, Brazil relevantly increased its scientific output. However, Argentina, Chile and México maintain a plateau during the last decade. Conclusions: Revista Médica de Chile increased notoriously its performance. Its contríbution to the Chilean scientific community dedicated to Medicine appears to be of central value. <![CDATA[<b>Incorporación de médicos especialistas a la atención primaria ¿una paradoja nacional?</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800017&lng=es&nrm=iso&tlng=es In the last decade, the number of general practitioners has decreased in Chile and there is a lack ofinterest among new doctors to work in Primary Care. The low number ofpositions for primary care physicians in the national publie and community health services are one cause, among others, for this decrease. On top, there is a lack of incentives and continuous training in community health services. This situation lead to reinforce primary care with internists, gynecologist, surgeons and psychiatrists in training. During their residence, part of the working journey of these trainees will be carried out in general medical outpatients clinics. This solution has been criticized by university authorities. The other solution is to incorpórate certified basic specialists in teams of three to five, in outpatient clinics of communities with high number of beneficiarles. This initiative is supported by the great number of specialists available in Chile, but is hampered by the lack of working positions and financing. It would increase the problem solving capacity at the primary level, decreasing the number of specialist derivations, that collapse secondary levéis of health care. <![CDATA[<b>De los principios de la bioética clínica a una bioética social para Chile</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800018&lng=es&nrm=iso&tlng=es The scope of clinical bioethics must be broadened to a social bioethics that tackles institutional and public health ethical problems and those related to the health system reform. The superficial application of the four bioethical principies is not enough to face these problems and assure a complete respect of individual rights. Using a qualitative research in bioethics, we will be able to deal with those problems that rise from health care in Chile and propose solutions to avoid inequities, to promote a humane care of patients, develop an institutional ethics and provide an efficient protection to people 's rights. We propose to incorpórate these social issues to the academic bioethical discussion and to develop a bioethics with complementary principies that can be used to solve cases and in decisión making. We should use the means incorporated in our legislation such as Assistance Ethics Committees, Research Ethics Committees and the National Bioethics Commission, to pursue our objectives. <![CDATA[<b>Uso De Estatinas En El Síndrome Coronario Agudo</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800019&lng=es&nrm=iso&tlng=es The scope of clinical bioethics must be broadened to a social bioethics that tackles institutional and public health ethical problems and those related to the health system reform. The superficial application of the four bioethical principies is not enough to face these problems and assure a complete respect of individual rights. Using a qualitative research in bioethics, we will be able to deal with those problems that rise from health care in Chile and propose solutions to avoid inequities, to promote a humane care of patients, develop an institutional ethics and provide an efficient protection to people 's rights. We propose to incorpórate these social issues to the academic bioethical discussion and to develop a bioethics with complementary principies that can be used to solve cases and in decisión making. We should use the means incorporated in our legislation such as Assistance Ethics Committees, Research Ethics Committees and the National Bioethics Commission, to pursue our objectives. <![CDATA[<b>RECOMENDACIONES DE LA ASOCIACIÓN AMERICANA DE ESCUELAS DE MEDICINA AL APOYO DE LA INDUSTRIA A LA EDUCACIÓN MÉDICA</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800020&lng=es&nrm=iso&tlng=es The scope of clinical bioethics must be broadened to a social bioethics that tackles institutional and public health ethical problems and those related to the health system reform. The superficial application of the four bioethical principies is not enough to face these problems and assure a complete respect of individual rights. Using a qualitative research in bioethics, we will be able to deal with those problems that rise from health care in Chile and propose solutions to avoid inequities, to promote a humane care of patients, develop an institutional ethics and provide an efficient protection to people 's rights. We propose to incorpórate these social issues to the academic bioethical discussion and to develop a bioethics with complementary principies that can be used to solve cases and in decisión making. We should use the means incorporated in our legislation such as Assistance Ethics Committees, Research Ethics Committees and the National Bioethics Commission, to pursue our objectives. <![CDATA[<b>Las Emociones</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000800021&lng=es&nrm=iso&tlng=es The scope of clinical bioethics must be broadened to a social bioethics that tackles institutional and public health ethical problems and those related to the health system reform. The superficial application of the four bioethical principies is not enough to face these problems and assure a complete respect of individual rights. Using a qualitative research in bioethics, we will be able to deal with those problems that rise from health care in Chile and propose solutions to avoid inequities, to promote a humane care of patients, develop an institutional ethics and provide an efficient protection to people 's rights. We propose to incorpórate these social issues to the academic bioethical discussion and to develop a bioethics with complementary principies that can be used to solve cases and in decisión making. We should use the means incorporated in our legislation such as Assistance Ethics Committees, Research Ethics Committees and the National Bioethics Commission, to pursue our objectives.