Scielo RSS <![CDATA[Revista médica de Chile]]> https://scielo.conicyt.cl/rss.php?pid=0034-988720090012&lang=es vol. 137 num. 12 lang. es <![CDATA[SciELO Logo]]> https://scielo.conicyt.cl/img/en/fbpelogp.gif https://scielo.conicyt.cl <![CDATA[<b>Factores pronósticos, evolución y mortalidad en el adulto inmunocompetente hospitalizado por neumonía neumocócica adquirida en la comunidad</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200001&lng=es&nrm=iso&tlng=es Background: Streptococcus pneumoniae is the main cause of community-acquired pneumonia in adults. Aim: To describe baseline characteristics, risk factors and clinical outcomes of adult patients hospitalized with pneumococcal pneumonia. Material and methods: Prospective study of adult patients admitted for a community acquired pneumonia in a clinical hospital. Immune deficient patients and those with a history of a recent hospitalization were excluded. Results: One hundred fifty one immuno-competent patients, aged 16 to 92 years, 58% males, were studied. Seventy-five percent had other diseases, 26% were admitted to the intensive care unit and 9% needed mechanical ventilation. There were no differences in clinical features, ICU admission or hospital length of stay among bacteremic and non-bacteremic patients. Thirty days lethality for bacteremic and non-bacteremic patients was 10.9% and 11.5%, respectively. The predictive values for lethality of Fine pneumonia severity index and CURB-65 (Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older) had an area under the ROC curve of 0.8 and 0.69, respectively. Multivariate analysis disclosed blood urea nitrogen over 30 mg/ dL (odds ratio (OR), 6.8), need for mechanical ventilation (OR, 7.4) and diastolic blood pressure below 50 mmHg (OR, 3.9), as significant independent predictors of death. Conclusions: Pneumococcal pneumonia was associated with a substantial rate of complications and mortality. Clinical presentation and outcome did not differ significantly among patients with and without bacteremia. <![CDATA[<b>Costo directo de la farmacoterapia de la leucemia aguda en el Hospital Clínico Regional de Valdivia, Chile</b>: <b>análisis del período 2003 a 2006</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200002&lng=es&nrm=iso&tlng=es Background: In Chile, leukemia is one of the diseases whose treatment is guaranteed by a special law called AUGE (universal access and explicit guaranties). Therefore, the knowledge of its treatment costs is of utmost importance. Aim: To determine and to characterize the direct costs of pharmacotherapy for leukemia at a regional hospital in Chile. Material and methods: Data were retrospectively obtained from electronic and manual records of the hospital for all patients treated for leukemia between 2003 and 2006. Patients were classified into four groups: pediatric and adult patients treated for acute lymphocytic leukemia (ALL children and ALL adults, respectively), and pediatric and adult patients treated for acute myelogenous leukemia (AML children and AML adults, respectively). Results: Total accumulated costs of pharmacotherapy for acute leukemia between 2003 and 2006 were 304,724,845 Chilean pesos (USD 574,952). The higher total or per patient costs, were generated by drugs for chemotherapy compared to other required medications. The exception were AML children, where support drugs, such as antimicrobials, ant emetic drugs and colony stimulating factors, generated the higher costs per patient. Among ALL adults, AML children and AML adults, the costs were concentrated in the first 6 months of treatment. NO children followed this tendency concentrating the costs between the seventh and twenty-fourth months. Conclusions: Annual costs of pharmacotherapy per patient for acute leukemia in this regional hospital were approximately USD 4,717. Chemotherapy was the item with the greatest impact on cost. <![CDATA[<b>Competencias médicas requeridas para el buen desempeño en Centros de Salud Familiares en Chile</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200003&lng=es&nrm=iso&tlng=es Background: Primary health care is considering the cornerstone of health care in Chile. Its efficiency is strongly influenced by the quality and competences of physicians that are responsible for health care at this level. Aim: To define the features and competences that should have primary care physicians. Material and methods: A group of experts that could be physicians or other professionals working in primary health care were invited to answer electronically a structured questionnaire containing a list of 71 competences, for a basic and an expert level of physician, using the Delphi method. Competences were classifying as "desirable" or "indispensable". If there was lack of consensus in the importance given to a specific competence, the researchers defined its importance. Results: Thirty-eight professionals (50% physicians) were inviting to participate and 16 answered the questionnaire. The competence profile defined for basic physicians has 13 knowledge items, 24 skills and 16 attitudes. The figures for advanced physicians are 29 knowledge items, 37 skills and 20 attitudes. Conclusions: This list of competences should been considered by medical schools to adapt undergraduate training of future physicians. <![CDATA[<b>Prevalencia de <i>Chlamydia trachomatis </i>y <i>Neisseria gonorrhoeae </i>en adolescentes chilenas</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200004&lng=es&nrm=iso&tlng=es Background: Chlamydia trachomatis and Neisseria gonorrhoeae are common sexually transmitted diseases among young women and little has been doing to study them in Chilean adolescents. Aim: Determine the rates of C trachomatis and N gonorrhoeae in Chilean young women. Material and methods: Urine samples were obtained from 203 sexually active females under 25 year-old, who attended hospitals from either high or low-income areas in Chile's capital, Santiago. C trachomatis and Ngonorrhoeae were detected by nucleic acid amplification testing. Results: Seven percent of samples were positive for C trachomatis. AU samples were negative for N gonorrhoeae. Among pregnant women, 19% of samples were positive for C trachomatis, while non-pregnant women were positive on 5.5% (p =0.04). Systematic use of barrier contraception was referring by 12% of women. AU of the latter was free of C trachomatis. No association was observing between age, number of sexual partners, age of first sexual intercourse, and presence of uro-gynecological symptoms, socioeconomic status and the rate of C trachomatis. Conclusions: Seven percent of this group of Chilean young women was infected with C trachomatis. The figure rises to 19% if pregnant. Surveillance and screening programs should been implemented to prevent sequels on this vulnerable population. <![CDATA[<b>Cumplimiento de la guía clínica de manejo ambulatorio de la neumonía adquirida en la comunidad en personas mayores en centros de atención primaria de salud de Santiago</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200005&lng=es&nrm=iso&tlng=es Background: Community acquired pneumonia (CAP) has a high mortality rate among older people. To increase its treatment efficiency, the Chilean Ministry of Health elaborated a clinical management guideline for CAP. Aim: To assess the degree of compliance with the clinical guidelines for CAP among professionals working at primary health care centers. Material and methods: A follow up of a cohort of 2,797 subjects aged 67 years or more, incorporated to a clinical study. All cases of bronchopneumonia or pneumonia diagnosed at primary health care centers between September 2005 and June 2008 were recorded. Results: During the follow up period, 192 cases of CAP were diagnosed. A chest X-ray was requested in 81% of cases and a confirmation consultation was done in 58%. Amoxicillin/ Clavulanic acid was the most common antimicrobial prescription in 61% of cases, followed by Clarithromycin in 17% and Amoxicillin in 12%. The antimicrobial used was not registered in 5% of cases. Conclusions: The clinical guidelines improve the efficiency of CAP treatment and decrease complications. However, these guidelines must been complemented with an adequate training and supervision of health care teams. <![CDATA[<b>Corrección mínimamente invasiva (Operación de Nuss) del <i>pectus excavatum </i>en pacientes adultos</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200006&lng=es&nrm=iso&tlng=es Background: A minimally invasive technique or Nuss procedure was devised for children with pectus excavatum (funnel chest), but it is also used in adult patients. Aim: To report the experience with the Nuss procedure in adults' patients with pectus excavatum. Material and methods: Prospective study of patients operated between January 2007 and January 2009. Clinical features, symptoms, operative time, postoperative complications, hospital stay and quality of life, using the Nuss questionnaire adapted for adults, was recorded. Results: Eighteen patients aged 18±2 years (14 males) were operated. Seven patients had scoliosis, two had depression, two had asthma and one had a Marfan syndrome. AU patients were concerned about aesthetic issues, nine had dyspnea, three had compression of cardiac cavities and three had pulmonary function disturbances. Haller index was 3.8. Mean operative time was 92 minutes. Postoperative complications were a pneumothorax without chest tube management in two patients, a peridural hematoma in one patient and a bar stabilizer infection that required a reoperation in one patient. No patient died and the mean hospital stay was six days. The Nuss questionnaire scores in the pre and postoperative periods were 33 and 48, respectively (p <0.05). Conclusions: Nuss operation is feasible and safe in adults with pectus excavatum. <![CDATA[<b>Utilidad de la PTH intraoperatoria como predictor de curación quirúrgica en hiperparatiroidismo primario</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200007&lng=es&nrm=iso&tlng=es Background: The aim of the surgical treatment of primary hyperparathyroidism (PHPT) is to achieve its complete cure, evidenced by normal serum calcium in the postoperative period. Measurement of intraoperative serum parathormone (PTH) can be useful to predict complete cure of the disease. Aim: To assess the usefulness of intraoperative PTH measurement to predict complete cure of PHPT Material and methods: Serum PTH was measured to all patients operated for PHPT between 2003 and 2008, before and five and ten minutes after the excision of the parathyroid gland causing the disease. The criteria for complete cure were normal serum calcium at 24 hours and 6 months after surgery and the pathological confirmation of parathyroid gland excision. Results: Eighty-eight operated patients, aged 58±15 years (72 females) were studied. Sixty four percent were asymptomatic and their preoperative serum calcium was 11.6± 1.2 mg/dl. A normal serum calcium was achieved in 86 patients (98%) at 24 hours and 50 of 52 patients followed for six months (96%). The pathological study disclosed an adenoma in 69 (78%), and multiglandular disease in 16 (18%), a parathyroid cancer in one and a normal gland in one patient. Intraoperative PTH predicted early and definitive cure in 97% and 100% of patients with a single adenoma, respectively. Among patients with multiglandular disease, the predictive figures were 94% and 100%, respectively. Conclusions: Intraoperative PTH measurement efficiently predicts early and definitive surgical cure of PHPT. <![CDATA[<b>Linfangioma esplénico gigante</b>: <b>Caso clínico</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200008&lng=es&nrm=iso&tlng=es Splenic lymphangiomas are benign primary simple or multiple tumors. They are incidentally diagnosed in children and people younger than 20 year-old. We report a 26-year-old female presenting with a history of five months of abdominal pain localized over the left upper hemi abdomen. A computed tomographic abdominal scan demonstrated a cystic tumor of 16 cm diameter originating from the spleen. Hydatic serology was negative and all blood tests were normal. At surgery, a spienic cyst was found and almost all the cystic wall was excised, leaving only a small portion attached to the spleen. The pathological report described spienic parenchyma with endothelial lining over the internal side of the cyst. Immunohystochemical stains of the endothelial cells were positive for VIII Factor and D2-40 that are specific for lymphatic endothelium, yielding the final diagnosis of a cystic spienic lymphangioma. <![CDATA[<b>Romboencefalitis por <i>Listeria monocytogenes</i></b>: <b>Patología emergente en relación al brote epidémico. Presentación de tres casos clínicos</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200009&lng=es&nrm=iso&tlng=es An unusual number of cases of rhomb encephalitis have occurred in Chile because of the increased frequency of infections caused by Listeria monocytogenes. We report three females aged 36, 40 and 55 years, with the disease. All presented with a prodrome characterized by headache, nausea, vomiting and fever, followed by ataxia and unilateral palsies of the third, seventh and twelfth cranial nerves. One patient presented also a hemi-hypoesthesia. Magnetic resonance showed lesions in the posterior aspect of the brain stem, specifically in relation to the floor of the fourth ventricle. Blood cultures were positive for Listeria monocytogenes. <![CDATA[<b>Hiponatremia sintomática como forma de presentación clínica de un macroadenoma hipofisiario</b>: <b>Comunicación de tres casos</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200010&lng=es&nrm=iso&tlng=es Severe hyponatremia occurring as the presenting feature of hypopituitarism secondary to pituitary adenomas is rare. We report three patients with this condition: Two elderly males (74 and 78 year-old) presenting with impaired consciousness and low plasma sodium after an episode of diarrhea and a 56-year-old male presenting with impaired consciousness after an episode of vomiting. All had clinical features of hypopituitarism and pituitary adenomas were found on imaging studies. Two were subjected to a trans sphenoidal resection of the adenoma. <![CDATA[<b>Embolismo pulmonar tumoral</b>: <b>Reporte de dos casos</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200011&lng=es&nrm=iso&tlng=es Dyspnea and hypoxemia in a patient with cancer may have several causes, including infections, thromboembolism, metastases, and pulmonary injuries by drugs. We report a 47-year-old female with breast cancer and a 70-year-old male with urinary bladder cancer who were admitted for dyspnea, hypoxemia and pulmonary hypertension. Chest X rays and CT scans were normal. The ventilation-perfusion scintigram was highly suspicions of thromboembolism in the female. The male died 16 hours after admission and the post mortem examination revealed the presence of tumor cells in the pulmonary vasculature. <![CDATA[<b>Enfermedad celíaca y su patogenia</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200012&lng=es&nrm=iso&tlng=es Celiac disease (CD), with a 1% worldwide prevalence, is an enteropathy caused by an autoimmune reaction to gluten in genetically susceptible individuals, which codify for histocompatibility molecules HLA DQ-2/DQ-8. From the anatomical point of view, CD is characterized by intestinal villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis (IELs) and leukocyte infiltration of the lamina propriety. Patients achieve a complete clinical and endoscopic remission with a gluten free diet. However, symptoms and anatomical alterations recur when this protein is reintroduced in the diet. The pathogenic mechanisms in this disease are not yet well understood, but it is clear that genetic, environmental and immunological factors play a role. The latter are the focus of this review, since this is the only autoimmune disease whose precipitating factor for immunological tissue damage is known. <![CDATA[<b>Avances en la patogénesis de la embriopatía diabética</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200013&lng=es&nrm=iso&tlng=es The congenital malformations in the off spring of diabetic mothers are the result of a multifactorial process. Susceptibility to the effects of maternal diabetes in the pathogenesis of these anomalies is influenced by the genetic background, indicating that there are polymorphic genes that modify the cellular response to hyperglycemia. The modifier genes for the teratogenic effect of maternal diabetes are yet unknown. An excessive glucose supply to embryonic tissues leads to a state of oxidative stress, which affects the expression of genes encoding scavenging enzymes such as super oxide dismutase (SOD) and catastases and activates development genes such as PAX3, involved in neural tube defects. Cell proliferation and cell death are important mechanisms underlying malformations in infants born to diabetic mothers. There is an increase of apoptotic Bax and caspase-3 proteins and a low expression of Bcl-Z ant apoptotic protein in embryos exposed to a diabetic environment. Hyperglycemia decreases intracellular levels of reduced GSH, prostaglandin EZ (PGEZ) and DNA synthesis in embryo's tissues. Understanding the molecular pathogenesis of diabetic embryopathy will allow the use of effective therapies for the prevention of teratogenic effects in diabetic mothers. <![CDATA[<b>Algunos problemas del razonamiento médico en el proceso de diagnóstico</b>: <b>Papel de algunas heurísticas y posibles soluciones</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200014&lng=es&nrm=iso&tlng=es Making a diagnosis in medicine is a complex process in which many cognitive and psychological issues are involved. After the first encounter with the patient, an unconscious process ensues to suspect the presence of a particular disease. Usually, complementary tests are requested to confirm the clinical suspicion. The interpretation of requested tests can be biased by the clinical diagnosis that was considered in the first encounter with the patient. The awareness of these sources of error is essential in the interpretation of the findings that will eventually lead to a final diagnosis. This article discusses some aspects of the heuristics involved in the adjudication of priory probabilities and provides a brief review of current concepts of the reasoning process. <![CDATA[<b>Existe correlación entre depresión y función familiar en adultos mayores que asisten a una clínica de medicina familiar</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200015&lng=es&nrm=iso&tlng=es Making a diagnosis in medicine is a complex process in which many cognitive and psychological issues are involved. After the first encounter with the patient, an unconscious process ensues to suspect the presence of a particular disease. Usually, complementary tests are requested to confirm the clinical suspicion. The interpretation of requested tests can be biased by the clinical diagnosis that was considered in the first encounter with the patient. The awareness of these sources of error is essential in the interpretation of the findings that will eventually lead to a final diagnosis. This article discusses some aspects of the heuristics involved in the adjudication of priory probabilities and provides a brief review of current concepts of the reasoning process. <![CDATA[<b>Carcinoma esofágico e hipernefroma sincrónicos en un paciente trasplantado hepático</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872009001200016&lng=es&nrm=iso&tlng=es Making a diagnosis in medicine is a complex process in which many cognitive and psychological issues are involved. After the first encounter with the patient, an unconscious process ensues to suspect the presence of a particular disease. Usually, complementary tests are requested to confirm the clinical suspicion. The interpretation of requested tests can be biased by the clinical diagnosis that was considered in the first encounter with the patient. The awareness of these sources of error is essential in the interpretation of the findings that will eventually lead to a final diagnosis. This article discusses some aspects of the heuristics involved in the adjudication of priory probabilities and provides a brief review of current concepts of the reasoning process.