Scielo RSS <![CDATA[Revista médica de Chile]]> https://scielo.conicyt.cl/rss.php?pid=0034-988720080009&lang= vol. 136 num. 9 lang. <![CDATA[SciELO Logo]]> https://scielo.conicyt.cl/img/en/fbpelogp.gif https://scielo.conicyt.cl <![CDATA[<b><i>Timing is crucial in acute myocardial infarction</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900001&lng=&nrm=iso&tlng= Thrombolytic agents and primary angioplasty (ACP) are two well defined methods for the treatment of patients with ST segment elevation myocardial infarction (STEMI). The use of both methods consecutively, called facilitated angioplasty, is a third alternative, that offers few advantages and is restricted to a small group of patients. The experience abroad demonstrated that ACP offers a higher reduction in mortality than thrombolysis. This is also the case in a national repon published in this issue, showing that hospital mortality of patients treated with thrombolysis and ACP was 10.5% and 5.6%, respectively (p <0.01). The figures for long term mortality were 20.4% and 9.7%, respectively (p <0.01). The crucial factor to improve the treatment results in myocardial infarction in to reduce the time of total ischemia, from the onset ofsymptoms to the start of reperfusion therapy Nowadays, the therapeutic challenges, besides improving percutaneous and pharmacological interventions, are to achieve an early consultation and to reduce institutional timing. <![CDATA[<b><i>Mortality of patients with ST-elevation acute myocardial infarction treated with primary angioplasty or thrombolysis</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900002&lng=&nrm=iso&tlng= Background: Primary angioplasty is the most effective treatment of ST-segment elevation acute myocardial infarction (STEMI). However, its worldwide implementation is difficult to obtain. Therefore thrombolysis continues to be the treatment most commonly used. Aim: To evaluate inhospital and long term mortality of patients with STEMI treated with thrombolysis or angioplasty, in three hospitals participating in the Chilean National Registry of Acute MI (GEMIgroup). Material and tnethods: Registry of 1,634 consecutive patients with STEMI admited between 2002 and 2006. Risk was stratified using the Thrombolysis in Myocardial Infarction (TIMI) Risk Score. Hospital and log term mortalities were adjusted using logistic and Cox regression models. Results: Fifty nine percent of patients (967 patients aged 60±12 years, 77% males) were subjected to reperfusion therapies, 28% with primary angioplasty and 72% with thrombolysis. Hospital mortality rates among patients treated with thrombolysis and angioplasty were 10.9% and 5.6% (p =0.01), respectively The figures for long term mortality were 20.4% and 9.7%, respectively (p <0.01). Multivariate analysis confirmed the lower mortality among subjects treated with angioplasty, with an odds ratio (OR) in favor of angioplasty of 8.5 (95% confidence intervals (CI) 3-35) for in hospital mortality and of 4.7 (95% CI 2.6-8.3) for long term mortality. The higher benefits of angioplasty were observed in males, in the elderly and in patients with a TIMI score over >3. Conclusions: Hospital and long term mortality of patients with STEMI was lower among those treated with primary angioplasty. This treatment is most beneficial among males, in the elderly and in patients with a TIMI score >3 . <![CDATA[<b><i>Thyroglobulin levels in needle lymph node cytology for the detection of papillary thyroid cancer recurrence</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900003&lng=&nrm=iso&tlng= Background: During the detection ofneck recurrence in patients with Papillary Thyroid Carcinoma (PTC), sometimes it is difficult to distinguish metastatic from inflammatory neck lymph nodes. The measurement of serum thyroglobulin (sTg) under thyroid hormone suppression therapy the presence of serum thyroglobulin antibodies (sAbTg), the diagnostic whole body sean and cytology can give false negative results. Measurement of thyroglobulin in the washout fluid from fine-needle aspiration biopsy (FNAB) of suspicious neck lymph nodes could improve the diagnostic aecuracy Aim: To evaluate the usefulness of detecting Tg in lymph nodes (LTg) suspicious by ultrasonography (US) and compare it to cytology. Patients and Methods: Between the years 2004 and 2007 we prospectively studied 30 patients with PTC and cervical US findings of suspicious recurrence. LTg was assayed in US guided FNAB used for cytology. Results: Sixteen out of 30 patients underwent surgery using as selective criteria an LTg higher than sTg or a positive cytology. Surgery confirmed the presence of metástasis in all 15 patients with positive LTg (8 with positive cytology) and in 1 patient with negative LTg and positive cytology (a case with undifferentiated thyroid cancer). The sensitivity was 93.7% for LTg and 56.2% for cytology. We identified byLTg 3 of 6 patients with undetectable sTg and positive sAbTg. Conclusions: The presence of LTg showed a higher sensitivity than cytology for the detection of cervical lymph node metástasis. This method is useful even in the presence ofsAbTg. <![CDATA[<b><i>Fiberoptic bronchoscopy assisted percutaneous tracheostomy</i></b>: <b><i>Report of 100 patients</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900004&lng=&nrm=iso&tlng= Background: Development of percutaneous techniques for tracheostomy have facilitated its implementation in the intensive care unit (ICU). Aim: To evaluate the safety of performing percutaneous tracheostomy (PT) using the Ciaglia Blue Rhino thechnique with fiberoptic bronchoscopy assistance in patients with prolonged mechanical ventilation. Patients and methods: Prospective evaluation of 100 consecutive patients aged 62±16 years (38 women) subjected to percutaneous tracheostomy. AU the procedures were performed in the ICU. Demographic variables, APACHE II, days of mechanical ventilation before PT, operative and post operative complications were recorded. Results: Mean APACHE II score was 20±3. Patients required on average 16±7 days of mechanical ventilation before PT. Eight patients (8%) had operative complications. One had an episode of transitory desaturation, one had a transitory hypotension related to sedation and six had mild bleeding not requiríng transfusión. No patient required conversión to surgical tracheostomy. Four patients (4%) presentedpost operative complications. Two had a mild and transitory bleeding ofthe ostomy and two had a displacement ofthe cannula. No other complications were observed. Conclusions: PT using the Ciaglia Blue Rhino technique with fiberoptic bronchoscopy assistance is a safe procedure that can be performed in the ICU by trained intensivists. <![CDATA[<b><i>Ileorectal anastomosis in the surgical treatment of ulcerative colitis</i></b>: <b><i>Long-term results</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900005&lng=&nrm=iso&tlng= Background: Total colectomy with ileorectal anastomosis (IRA) is an alternative to the ileoanal pouch for the surgical treatment of ulcerative colitis in a selected group of patients. This technique leaves rectal mucosa Hable to develop persistent proctitis, dysplasia and cancer Aim: To describe short and long-term results of IRA and to assess the presence of dysplasia. Material and methods: Descriptive study of patients treated with IRA. The data were obtained from the clinical records, and the present status was evaluated with an interview. A proctoscopy and biopsy was offered free of cost to the contacted patients. Results: Between 1978 and 2005, 26 patients were operated. One patient presented an anastomotic leakage that was treated with a loop ileostomy There was no operative mortality. Twenty-three patients were followed for a períod of 1 to 23 years. Three patients evolved as Crohn 's disease and two of them needed a proctectomy. Three patients died of non-related diseases. In the remaining 17, the average evacuation rate was 3.7/24 h and all were continent. None developed a rectal cancer Only two patients had their planned annual endoscopic surveillance. In 2 of the 11 patients who accepted endoscopy and biopsy, a low-grade dysplasia was found. Conclusions: IRA has low morbidity and acceptable functional results in this selected group of patients. No patient present high-grade dysplasia or cancer; however, the adherence to the endoscopic follow-up ispoor. <![CDATA[<b><i>Intraoperative hemodynamic monitoring using transesophageal echocardiography in orthopedic su</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900006&lng=&nrm=iso&tlng= Background: Orthopedic surgery is commonly performed in elderly patients with higher cardiovascular surgical risk. Hemodynamic monitoring in these patients may prevent períoperative complications. Aim: To assess the usefulness of transesophageal echocargiography (TEE) for intraoperative cardiovascular monitoring duríng orthopedic surgery. Material and methods: Patients older than 65 years subjected to orthopedic surgery using general anesthesia and with a high cardiovascular risk were studied. Intraoperative TEE was performed to assess intravascular volume, myocardial contractility and the presence of myocardial ischemia. Results: Fifty three patients aged 72±5 years were studied. Hemodynamic stability was detected in 68% of patients, mainly reñected as episodes of hypovolemia. Myocardial ischemia was detected in two patients and embolic episodes in six (11%). Conclusions: Intraoperative TEE was useful for the hemodynamic evaluation of patients with high cardiovascular risk. <![CDATA[<b><i>Subclinical endothelial inflammation markers in a family with type I familial hyperaldosteronism caused by a de novo mutation</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900007&lng=&nrm=iso&tlng= Background: Type I familial hyperaldosteronism is caused by the presence of a chimaeñc gene CYPl 1B1/CYP11BZ which encodes an enzyme with aldosterone synthetase activityregulated by adrenocorticotrophic hormone (ACTH). Therefore, in patients with FH I is possible to normalize the aldosterone levels with glucocorticoid treatment. Recently it has been shown that aldosterone plays a role in the production of endothelial oxidative stress and subclinical inflammation. Aim: To evaluate subclinical endothelial inflammation markers, Me Metalloproteinase 9 (MMP-9) and ultrasensitive C reactive protein (usPCR), before and after glucocorticoid treatment in family members with FH-I caused by a de novo mutation. Patients and methods: We report three subjects with FH-I in a single family (proband, father and sister). We confirmed the presence of a chimaeric CYPl 1B1/CYP11B2 gene by ¡ong-PCR in all of them. Paternal grandparents were unaffected by the mutation. The proband was a 13year-old boy with hypertension stage 2 (in agree to The JointNational Committee VII, JNC-vIl), with an aldosterone/plasma rennin activity ratio equal to 161. A DNA paternity test confirmed the parental relationship between the grandparents and father with the index case. MMP-9 and usPCR levels were determined by gelatin zymography and nephelometry, respectively. Residís: All affected subjects had approximately a 50% increase in MMP-9 levels. Only the father had an elevated usPCR. The endothelial inflammation markers returned to normal range after glucocorticoid treatment. Conclusions: We report a family canying a FH-I caused by a de novo mutation. The elevation of endothelial inflammation markers in these patients and its normalization after glucocorticoid treatment provides new insight about the possible deleteríous effect of aldosterone on the endothelium. <![CDATA[<b><i>Ministernotomy for aortic valve surgery</i></b>: <b><i>Report of 20 patients</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900008&lng=&nrm=iso&tlng= Background: Aortic valve surgery can be performed through a reduced mid sternotomy with excellent long term results. Aim: To report the initial results obtained with this technique. Patients and methods: Descríptive study of 20 patients aged 48±11 years, subjected to valve replacement surgery for aortic valve disease between 2004 and 2007. Arterial and venous cannulation were performed with the usual method and extracorporeal circulation was performed with a mean perfusión of 4.5 L/min. Hypothermia and cardioplegia were performed infusing the hematíe cardioplegic solution at 4°C in the aortic root or coronary ostia. Results: Sixteen patients were in functional class (FC) III. Fourteen patients had aortic insufficieney and six had predominant stenosis. There was no operative mortality One patient had a left hemothorax and was reoperated. AU patients were discharged between 4 and 6 days after surgery. Mean follow up was 21 ± 4 months. AU patients are in FC I and free from cardiac events. Echocardiographic assessment was done in 16 patients, showing a good motility of valve disks. Actuarial survival probability was 100% and probability of freedom from cardiac events was 100% at 42 months of follow up. Conclusions: Ministernotomy is an excellent approach for aortic valve surgery providing good visualization ofthe ascending aorta, simplifying the surgical technique. <![CDATA[<b><i>Consumption of antidepressants in Chile from 1992 to 2004</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900009&lng=&nrm=iso&tlng= Background: Data from the Ministry ofHealth show that in Chile in 2004, 17% of the population had some form of depression and mood disorders are the tenth cause of disability-adjusted Ufe years (DALY) loss. Aim: To determine consumption of antidepressants (ADs) in Chile from 1992 to 2004. Material and methods: National sales data were obtained from the company IMS Health Chile and converted into defined daily doses (DDDs) per 1,000 inhabitants per day Available ADs were classified in four pharmacological groups (Le., serotonin-norepinephrine reuptake inhibitors, SNRLs; selective-serotonin reuptake inhibitors, SSRLs; tñcyclic antidepressants, TCAs; and others). Total economic burden of ADs utilization and cost per DDDs were also calculated. Trends over time were analyzed using Pearson-R2. Results: Total ADs consumption in Chile measured by DDDs per 1,000 inhabitants per day (DHD) increased linearly (y =0.901x+1.9129; R2 =0.9296; p <0.001) from 2.5 in 1992 to 11.7 in 2004 (total growth of 470.2%). SSRLs were the drug class with higher consumption, and ñuoxetine the most commonly consumed antidepressant. SSRLs were the drugs that dominated the market representing 79% of the total drug consumption throughout the years. Total economic burden of ADs in Chile (total cost ofDDDs consumed) increased from US$65.4 million in 2001 to US$74.6 million in 2004 (14% increase). Average cost per DDD of all AD increased linearly, however not significantly from US$ 0.94 in 2001 to US$ 1.04 in 2004 (y =0.0362x+0.8784; R2 =0.7382; p =0,262). Conclusions: DDDs per 1,000 inhabitants per day increased linearly over 470% from 1992-2004. SSRLs were the most commonly consumed drugs in Chile. Future research should evalúate the cost-effectiveness of antidepressants in Chile, comparing the results with drug utilization, and determining if unnecessary expenditures have been paid out. <![CDATA[<b><i>Value of a clinical test for assessing physical activity in children</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900010&lng=&nrm=iso&tlng= Background: An appropriate measurement of physical activity (PA) in children is useful, since inactivity is associated to obesity, cardiovascular and metabolic risk. Aim: To assess the reliability of the INTA questionnaire of PA, to compare the derived PA score with accelerometry and to assess its ability to identify excessively inactive children. Material and methods: One hundred eighty children aged 8 to 13 years answered an interviewer-administered questionnaire about their usual PA, consisting in 5 items (recumbent, seated, walking, playing outdoor, sports). The answers were converted to a PA score with a 0-10 points scale. Reliability was tested in 87 children by test/retest conducted 3-5 days apart. The PA score was compared with 3-day accelerometry in 77 of 93 children (35 obese and 42 non obese). Receiver operating characteristic (ROC) curves were used to determine the optimal cut-point for identify an excessively sedentary child. Results: The test/retest reliability of the questionnaire was 0.69 to 0.93 (Lin coefficient). Accelerometry was significantly associated with PA score (RHO: 0.60, p =0.008), outdoor plays (RHO: 0.37, p =0.0009) and practicing of sports (RHO: 0.33, p =0.003). Obese children were less active than non obese children, according both to PA score and to accelerometry. The optimal cut-point for classifying a child as too sedentary was a score of 5 (sensitivity =0.89). Conclusions: The INTA-test is a valuable instrument for measuring usual PA in clinicalpractice and is easy to administer. <![CDATA[<b><i>An opinión survey among readers of Revista Médica de Chile</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900011&lng=&nrm=iso&tlng= Background: A few objective indicators support the relevance of articles published in medical journals, such as the ISI Impact Factor and Citation Indices. However, a feedback from the readers can help to improve ajournal Aim: To report the results of an opinión survey addressed to readers of Revista Médica de Chile, in June-August 2007. Material and methods: A survey was devised and distributed electronically or by mail among all subscribers. It requested information about gender, age, site of work, proportion of time dedicated to clinical practice, teaching or research, plus their opinión about the contents and format of the journal, inviting them to propose improvements. Results: The survey was distributed to 1274 subscribers (98.7% physicians, most living in Chile) and was responded by 309 (24%). Those who responded were practicing medicine for a mean of 24 ± 13 (SD) years and did not differ in gender, age or years of medical practice from those that did not respond. Sixty three percent practiced as internists and dedicated 63 ± 26 (SD) % of their time to clinical practice, 21 ± 16% to teaching activities and 16 ± 17% to research. More than half of respondents qualified the sections of the journal asgood or excellent. Fifty one per cent requested to include more clinical topics updates, 35% more articles on evidence based medicine and 34% more articles focused on continuing medical education. The more frequent free suggestions referred to changes in the format of the journal. Conclusions: Most readers are satisfied with the journal's contents. Suggested changes were referred to review añides and the journals format . <![CDATA[<b><i>Papillary carcinoma in a thyroglossal duct cyst</i></b>: <b><i>Report of two cases</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900012&lng=&nrm=iso&tlng= Thyroglossal duct cyst is the most common congenital anomaly of thyroid gland development. However, papillary carcinoma is descríbed only in 1-2% of cases and the clinical appearance is indistinguishable from a benign thyroglossal duct cyst. We report two females aged 15 and 27years consulting for a cervical mass. In both, a solid cystic lesión was found and excised using the Sistrunk procedure. The biopsy disclosed a papillary carcinoma in both. The postoperative evolution of both patients was uneventful <![CDATA[<b><i>Evaluation of sublingual microcirculation in septic shock. Report of one patient treated with high volume hemofiltration</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900013&lng=&nrm=iso&tlng= Microcirculation is severely compromised in sepsis, with a reduction of capillary density and flow impairment. These alterations have important prognostic implications, being more severe in non-survivors to septic shock. Today microcirculation may be assessed bedside, non-invasively usingpolarized light videomicroscopy a technique known as SDF (side dark field). We report a 54 year-old man with an extramembranous nephropathy that developed a necrotizing fascitis associated to septic shock, in whom microcirculation was periodically assessed during his management. The patient was treated with Buids, vasoactive drugs, antibiotics and was operated for exploration and debridement. As the patient persisted in refractory shock despite treatment, high-volume hemofiltration was started. Before hemofiltration the patient had severe microcirculatory alterations that improved during and after the procedure. Physiologic endpoints of high-volume hemofiltration in septic shock remain unknown, but it has the capacity to clear inñammatory mediators. Since microcirculatory alterations are in part secondary to these mediators, their removal is beneficia! Like other authors, we found no relation between microcirculation and other haemodynamic and perfusión variables. <![CDATA[<b><i>Celiac disease presenting as an intestinal intussusception.</i></b><b><i> Report of one case</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900014&lng=&nrm=iso&tlng= The usual form of presentation of celiac disease is chronic diarrhoea and deficiencies of vitamin D, vitamin K, iron and vitamin B12, due to malabsorption. Intestinal obstruction secondary to an intussusception is rare in adults and usuaUy is a compUcation of carcinoma of the colon or post operative adhesions. We report a 45 year-old female consulting for diarrhoea and vomiting lasting one week and progressive abdominal bloating. A plain abdominal Xray showed air fluid levels in the small bowel and a CT sean showed an intussusception. She was operated and discharged but continued with diarrhoea. She was admitted again and a new CT sean showed three intussusceptions that were resolved with the administration of oral contrast media. Antiendomisial antibodies were positive and a celiac disease was diagnosed. After one year with a gluten free diet, the patient remains asymptomatic. <![CDATA[<b><i>Spontaneous dissection of the renal artery ano kidney infarction</i></b>: <b><i>Report of two cases</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900015&lng=&nrm=iso&tlng= We report two previously healthy males aged 33 and 37 years, presenting with severe pain in the right and left part of the abdomen, respectively. An abdominal CT sean showed in both a kidney infarction. An angio-CAT sean showed changes compatible with a fibromuscular dysplasia in the renal arterial wall. An angiography showed an intimal tear or complex dissection flap in both cases. Both had a satisfactory evolution with conservative treatment. The relationship between fibromuscular dysplasia and spontaneous dissection of the renal artery is discussed. <![CDATA[<b><i>Cystic tumors of the pancreas</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900016&lng=&nrm=iso&tlng= Cystic tumors of the pancreas are diagnosed with increasing frequency. The main problems associated with their diagnosis are to determine ifthey are benign of malingnant and to decide their surgicai excisión or clinical follow up, since these tumors can be benign, potentiaiiy maiignant or malignant. Imaging techniques such as CT sean, magnetic resonance and endoscopic uitrasonography are the key procedures that must be performed before adopting a final therapeutic decisión. However, 10% of cystic lesions are unable to be categorized even after thorough imaging evaluation. We analyze the characteristics of the more common cystic pancreatic lesions and the means to recognize them. <![CDATA[<b><i>Scientific and ethical perspectives of perinatal and fetal medicine</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900017&lng=&nrm=iso&tlng= This review emphasizes the importance of recent developments and knowledge on cell biology and human genetics than have integrated, through a basic-clinical concept to an emerging branch of medicine, called Perinatal and Fetal Medicine. We discuss the possible role of fetal cells and DNA in the diagnosis and treatment of diseases in the intrauterine environment The associated bioethical issues associated to these medical actions are discussed, considering the imminent use ofthese agents in the human species . <![CDATA[<b><i>Studies about diagnostic tests</i></b>: <b><i>interpreting the results</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900018&lng=&nrm=iso&tlng= This review emphasizes the importance of recent developments and knowledge on cell biology and human genetics than have integrated, through a basic-clinical concept to an emerging branch of medicine, called Perinatal and Fetal Medicine. We discuss the possible role of fetal cells and DNA in the diagnosis and treatment of diseases in the intrauterine environment The associated bioethical issues associated to these medical actions are discussed, considering the imminent use ofthese agents in the human species . <![CDATA[<b>Critically appraised article</b>: <b>Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage?</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900019&lng=&nrm=iso&tlng= Study objective: Current clinical practice assumes a negative computed tomography (CT) head sean result and a negative lumbar puncture result together are adequate to rule out subarachnoid hemorrhage in patients with acute headache. Our objective is to determine the sensitivity of a negative CT result combined with a negative lumbar puncture result to exelude subarachnoid hemorrhage. Methods: This prospective cohort study was conducted at 2 tertiary care emergency departments (EDs) during 3 years. We enrolled all patients who were older than 15 years, had a nontraumatic acute headache and normal neurologic examination result, and who had a CT head sean and a lumbar puncture ifthe CT result was negative (ie, no blood in the subarachnoid space). Patients were followed up with a structured telephone questionnaire 6 to 36 months añer their ED visit and electronic hospital records review to ensure no missed subarachnoid hemorrhage. We calculated sensitivity, specifícity, and likelihood ratios of the strategy of CT and then lumbar puncture for subarachnoid hemorrhage. Results: Five hundred ninety-two patients were enrolled, including 61 with subarachnoid hemorrhage. The mean patient age was 43.6 years, with 59.1% female patients. Aneases of subarachnoid hemorrhage were identified on initial CT or lumbar puncture. One patient without subarachnoid hemorrhage was subsequently diagnosed with cerebral aneurysm, requiring surgery. The strategy classifíed patients with subarachnoid hemorrhage with sensitivity, specifícity, and positive and negative likelihood ratios (with 95% confidence intervals fCIsJ) of 100% (95% CI94% to 100%), 67% (95% CI 63% to 71%), 3.03 (95% CI 2.69 to 3.53), and 0. For diagnosis of subarachnoid hemorrhage or aneurysm, these were 98% (95% CI91% to 100%), 67% (95% CI63% to 71%), 2.98 (95% CI2.63 to 3.38), and 0.02 (95% CI0.00 to 0.17), respectively. Conclusión: To our knowledge, this is the largestprospective study evaluating the aecuracy of a strategy of CT and lumbar puncture to rule out subarachnoid hemorrhage in alert ED patients with an acute headache. This study validates clinical practice that a negative CT with a negative lumbar puncture is sufficient to rule out subarachnoid hemorrhage. <![CDATA[<b><i>On the death of Gabriel Cano de Aponte</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900020&lng=&nrm=iso&tlng= Gabriel Cano de Aponte was Governor of Chile since 1717 and util his death in 1733, being 68 years old. As a soldier, he was an experimented horse rider. The sequence ofevents that caused his death three months after an equestrian accident are unclear. A systematic clinical analysis of the later is the main objective of this review. Historians have documented Cano de Aponte's "inclination for unbridled fun and equestrian exercises". Duríng a holiday Cano de Aponte suffered a horse fall and subsequent crushing by the latter. It has been stated that a spinal lesion caused by the accident kept him bedrídden for a period of three months, clear in reason and with intense pain, before his death. However, there is no evidence on historie data that conveys any typical sign associated to spinal injury following the accident. Therefore we suggest that Cano de Aponte suffered a complex pelvic ring fracture. The fact that he was prostrated, lucid, but suffered and intense pain best sustains the hypothesis of a pelvic fracture. After the initial period, one ofthe most common causes of death resulting from a pelvic fracture is deep venous thrombosis with secondary pulmonary thromboembolism. This must have been the sequence ofevents that most probably caused Cano de Aponte's death). <![CDATA[<b><i>THE PROFILE AND NUMBER OF PRIMARY CARE PHYSICIANS REQUIRED IN CHILE</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900021&lng=&nrm=iso&tlng= Gabriel Cano de Aponte was Governor of Chile since 1717 and util his death in 1733, being 68 years old. As a soldier, he was an experimented horse rider. The sequence ofevents that caused his death three months after an equestrian accident are unclear. A systematic clinical analysis of the later is the main objective of this review. Historians have documented Cano de Aponte's "inclination for unbridled fun and equestrian exercises". Duríng a holiday Cano de Aponte suffered a horse fall and subsequent crushing by the latter. It has been stated that a spinal lesion caused by the accident kept him bedrídden for a period of three months, clear in reason and with intense pain, before his death. However, there is no evidence on historie data that conveys any typical sign associated to spinal injury following the accident. Therefore we suggest that Cano de Aponte suffered a complex pelvic ring fracture. The fact that he was prostrated, lucid, but suffered and intense pain best sustains the hypothesis of a pelvic fracture. After the initial period, one ofthe most common causes of death resulting from a pelvic fracture is deep venous thrombosis with secondary pulmonary thromboembolism. This must have been the sequence ofevents that most probably caused Cano de Aponte's death). <![CDATA[<b><i>HISTLOCYTLC NECROTIZING LYMPHADENITIS</i></b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900022&lng=&nrm=iso&tlng= Gabriel Cano de Aponte was Governor of Chile since 1717 and util his death in 1733, being 68 years old. As a soldier, he was an experimented horse rider. The sequence ofevents that caused his death three months after an equestrian accident are unclear. A systematic clinical analysis of the later is the main objective of this review. Historians have documented Cano de Aponte's "inclination for unbridled fun and equestrian exercises". Duríng a holiday Cano de Aponte suffered a horse fall and subsequent crushing by the latter. It has been stated that a spinal lesion caused by the accident kept him bedrídden for a period of three months, clear in reason and with intense pain, before his death. However, there is no evidence on historie data that conveys any typical sign associated to spinal injury following the accident. Therefore we suggest that Cano de Aponte suffered a complex pelvic ring fracture. The fact that he was prostrated, lucid, but suffered and intense pain best sustains the hypothesis of a pelvic fracture. After the initial period, one ofthe most common causes of death resulting from a pelvic fracture is deep venous thrombosis with secondary pulmonary thromboembolism. This must have been the sequence ofevents that most probably caused Cano de Aponte's death). <![CDATA[<b>CONSIDERATIONS TO USE ELECTRONIC REFERENCES FROM PRINTED JOURNALS</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900023&lng=&nrm=iso&tlng= Gabriel Cano de Aponte was Governor of Chile since 1717 and util his death in 1733, being 68 years old. As a soldier, he was an experimented horse rider. The sequence ofevents that caused his death three months after an equestrian accident are unclear. A systematic clinical analysis of the later is the main objective of this review. Historians have documented Cano de Aponte's "inclination for unbridled fun and equestrian exercises". Duríng a holiday Cano de Aponte suffered a horse fall and subsequent crushing by the latter. It has been stated that a spinal lesion caused by the accident kept him bedrídden for a period of three months, clear in reason and with intense pain, before his death. However, there is no evidence on historie data that conveys any typical sign associated to spinal injury following the accident. Therefore we suggest that Cano de Aponte suffered a complex pelvic ring fracture. The fact that he was prostrated, lucid, but suffered and intense pain best sustains the hypothesis of a pelvic fracture. After the initial period, one ofthe most common causes of death resulting from a pelvic fracture is deep venous thrombosis with secondary pulmonary thromboembolism. This must have been the sequence ofevents that most probably caused Cano de Aponte's death). <![CDATA[<b>EPIDEMIOLOGÍA BÁSICA, SEGUNDA EDICIÓN</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872008000900024&lng=&nrm=iso&tlng= Gabriel Cano de Aponte was Governor of Chile since 1717 and util his death in 1733, being 68 years old. As a soldier, he was an experimented horse rider. The sequence ofevents that caused his death three months after an equestrian accident are unclear. A systematic clinical analysis of the later is the main objective of this review. Historians have documented Cano de Aponte's "inclination for unbridled fun and equestrian exercises". Duríng a holiday Cano de Aponte suffered a horse fall and subsequent crushing by the latter. It has been stated that a spinal lesion caused by the accident kept him bedrídden for a period of three months, clear in reason and with intense pain, before his death. However, there is no evidence on historie data that conveys any typical sign associated to spinal injury following the accident. Therefore we suggest that Cano de Aponte suffered a complex pelvic ring fracture. The fact that he was prostrated, lucid, but suffered and intense pain best sustains the hypothesis of a pelvic fracture. After the initial period, one ofthe most common causes of death resulting from a pelvic fracture is deep venous thrombosis with secondary pulmonary thromboembolism. This must have been the sequence ofevents that most probably caused Cano de Aponte's death).