Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 138 num. 3 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Chile</b><b>: Standing up again</b>]]> One of the biggest earthquakes recorded in human history has recently devastated a large part of the Chilean territory and, followed by a Tsunami, destroyed cities, seaports, fishermen’s coves, bridges, and countryside houses. This cataclysm affected a large proportion of our population, leaving homeless families, no working tools for work places, hospitals, schools, public buildings, museums. However, the loss of human Uves was small compared to similar disasters. It destroyed part of the national heritage as well as damaged people's living conditions. A national movement started immediately to help and recover, and international resources, both human and technological were also set in motion. As after previous earthquakes in Chile, young M.D.'s and medical students were organized in voluntary groups backed by institutions or by their own organizations and went from large cities as Santiago and others to provide medical and psychological care to those in most need. Young members and students of other health professions (nurses, physical therapists, etc.) were included in these groups or worked in their own ones. National and international experience indicates that the forthcoming months require special care of psychological reactions and sequel (posttraumatic stress symptoms) and health consequences after water pollution, restrictions in housing and deteriorated sanitary conditions. Nevertheless, our country will stand up once more. <![CDATA[<b>Reflections and feelings from a team of volunteers from the Ministry of Health and the Chilean Medical Association, after the recent earthquake</b>]]> The experience of a group of 9 doctors and 6 nurses, most of them younger than 30years of age, whom were part of the several volunteer groups directed towards the most damaged earthquake regions, is described. The team had to overcome a number of intense personal emotions related with the magnitude of the destruction, especially in the "adobe"-constructed houses and villages, in order to provide useful medical support. Moving out of the hospital setting, reaching out to the community in schools and emergency posts proved to be important in rural communities. An appropriate coordination of the volunteer groups, with the simultaneous action of municipal and state health authorities, together with well-guided leadership, was critical for an effective response in the larger city of Talcahuano /Hualpén. Within the second week of the aftermath, acute respiratory and intestinal infections were the most common medical complaints together with intense -in many cases severe- emotional distress associated mostly with fear to after shakes ("replicas"), tsunami, and social unrest. The severe earthquake that struck Chile has left many lessons for the future that will need to be analyzed seriously and with the conviction that effective and timely prevention of catastrophic aftermath consequences, although costly, must be a key element of the country's development plan. More importantly, the hundreds if not thousands of volunteers from a variety of health related professions that were moved by the scenes of suffering, and whom responded to individual or group initiatives, allow to foresee that the nation has the moral stamina required to overcome the tragedy and become a better society. <![CDATA[<b>Leukocyte count as a risk factor for coronary adverse events among patients admitted for an acute coronary syndrome</b>]]> Background: Leukocytosis occurs as a response to a variety of infammatory processes. Aim: To determine if white blood cell count (WBCC) at admission among patients who suffer an acute coronary syndrome (ACS) has an independent prog-nostic value for the occurrence of new cardiovascular adverse events (CAE). Patients and Methods: Prospective study of 558 patients aged 68 ± 13 years (122 women) admitted to the hospital for an acute coronary syndrome. WBCC was measured at admission. A logistic regression model was used to assess the association of WBCC with the occurrence of CAE during the next six months after admission (post infarction angina, re-infarction, cardiac failure and mortality). Results: An univariate analysis showed that patients with a WBCC > 15.000 cell/mm³ had a signifcantly higher mortality and occurrence of CAE. The multivariate analysis showed that subjects with WBCC < 10.000 cell/mm³ experienced fewer CAE than subjects with a WBCC > 15.000 cell/mm³, with an odds ratio of 0.46 (95% confdence intervals = 0.21-0.97, p = 0,042). Conclusions: An elevated WBCC at admission among patients with an ACS is associated with a higher incidence of CAE in the ensuing six months. <![CDATA[<b>Perceived difficulties among primary care physicians for the prescription of insulin for diabetic patients</b>]]> Background: Type 2 Diabetes Mellitus is not always treated successfully, in part due to the difficulties perceived by the medical community about the use of insulin. Aim: To identify the constraints perceived by primary care physicians (PCPs) in the prescription and use of insulin. Material and Methods: Six PCPs were subjected to a semi-structured interview about self-perceived management difficulties, behaviors and beliefs on the use of insulin among diabetics. According to their responses a questionnaire about the subject was devised and PCPs were invited by e-mail to answer it. Results: There were 88 replies and 48% of respondents recognized to have management deficiencies in at least one aspect of insulin prescription. The most common deficiencies were determining the type of insulin and treatment of complications. The perceived difficulties were lack of training (58.0%), lack of medical hours (46.6%), lack of communication with specialists (46.6%), lack of reactive strips for capillary blood glucose determination (43.2%) and rotation of doctors (40.9%). The most common behaviors towards patients reluctant to use insulin were persuasion (83.0%), education and supervisión (63.6%) and signature ofan ad-hoc document (38.6%). Ninety percent considered that timely use of insulin is more beneficial  than its prescription as a last resort and 94.3% did not consider that insulin should be prescribed by a specialist. Conclusions: A significant percentage of physicians do not trust their own knowledge about insulin prescription. These professionals should receive training in not only technical aspects of prescribing insulin, but also in the psychological and persuasión strategies. There is willingness among PCPs to prescribe insulin. <![CDATA[<b>Cultural and trivial knowledge among Chilean university students</b>]]> Background: Culture is defined by the Webster's dictionary as acquaintance with and taste infine arts, humanities, and broad aspects ofscience as distinguished from vocational and technical skills. Aim: To assess the general cultural knowledge of university students. Material andMethods: A test containing 58 questions about art, national and universal literature, national and universal history, mythology science and trivial national issues was designed and applied to 251 medical students in Santiago (149 from first year and 86 from fifth year, Universidad de Chile) and 138 agronomy students in Valdivia (61 from first year and 77 from fifth year, Universidad Austral de Chile). Results: All students answered the test. Medical students from first and fifth year omitted 19 and 15% of questions respectively The figures for first and fifth year agronomy students were 23% each. The percentage of corred answers among first and fifth year medical students was 50 and 59% respectively. The figures for first and fifth year agronomy students were 39 and 44% respectively. The questions with higher rates of corred answers were those about trivial issues. Conclusions: There was a high rate of omissions and wrong answers about general cultural issues among university students particularly in national cultural subjects. <![CDATA[<b><i>Autoimmune pancreatitis</i></b>: <b><i>Report of 10 cases</i></b>]]> Background: Autoimmune pancreatitis is a special form of chronic pancreatitis, more common in men and usually presenting as obstructive jaundice or abdominal pain. It may be associated with other immunological disorders and sometimes it is possible to find positive serological markers. Typical images show pancreatic enlargement with focal or diffuse stenosis of the pancreatic duct but sometimes it presents as a focal pancreatic mass that is difficult to differentiate from pancreatic carcinoma. Aim: To report ten cases of autoimmune pancreatitis. Material and Methods: Retrospective review of clinical records of 10 patients aged 26 to 56 years (six males) with autoimmune pancreatitis. Results: The clinical presentation was obstructive jaundice in six cases, acute pancreatitis in two, persistent increase in serum amylase and Upase in one, and permanent abdominal pain and weight loss in one. On imaging studies, a circumscribed mass was founded in six patients. An endoscopic retrograde colangiopancreatography was performed in four patients showing an abnormal pancreatic duct in all. Six patients were operated and tissue for pathological study was obtained in five, showing inflammatory infiltration. Vive patients were treated with steroids with a good clinical response. Conclusions: Autoimmune pancreatitis must be borne in mind in the differential diagnosis of pancreatic lesions. <![CDATA[<b><i>Experience with capsule endoscopy diagnostic tool for the small intestine</i></b>]]> Background: Wireless capsule endoscopy (CE) is a relatively new method to evaluate the small intestine. Aim: To evaluate the indications of CE in our center and assess whether specific indications are associated with best results during CE studies. Material and Methods: Retrospective analysis of 69 patients aged 9 to 85 years (36 males) subjected to a CE at our institution between April 2004 and October 2007. Results: The most common indications for CE were overt gastrointestinal bleeding in 43.5% of patients, iron deficiency anemia in 39.1 %, suspicion of a small bowel tumor in 4.3%, chronic diarrhea in 4.3% and abdominalpain in 2.9%. CE was normal in 23.2% and was able to find lesions in 76.8% of the studies. Gastrointestinal bleeding, followed by iron deficiency anemia were the indications associated with the higher rates of positive findings during CE. Conclusions: Gastrointestinal bleeding and iron deficiency anemia were the indications that obtained the best diagnostic y ield for CE. <![CDATA[<b><i>Prevalence of suicidal ideations and suicidal attempts among adolescents living in Metropolitan Santiago</i></b>]]> Background: According to World Health Organization (WHO) estimates, suicide is one of the five leading causes of death among people aged l5-24 years. Suicide rates in Chile among young people have been increasing. In 1990 and 2005, the prevalence of suicide was 8.8% and 9.3% per 100,000 inhabitants, respectively. Aitns: To determine the prevalence of suicidal ideation and suicide attempt rates among teenagers aged 14 and 19 years, living in Metropolitan Santiago and analyze the factors related to suicide. Material and Methods: A self administered enquiry, containing a depression scale and five questions about suicide tendency, was applied to a representative sample of teenagers aged between 14 and 19 years, attending public and private schools in Metropolitan Santiago. Results: The enquiry was answered by 1567 teenagers aged between 14 and 20 years (54% males). Sixty two percent recognized suicidal ideation and 19%, suicidal attempts. These figures were significantly higher among women and those attending public schools. Sixteen years old adolescents had the highest rates of suicidal ideation and attempts. Conclusions: There is a high rate of suicidal ideation and attempts among teenagers living in Metropolitan Santiago. <![CDATA[<b>Gestational diabetes, comparison of women diagnosed in second and third trimester of pregnancy with non GDM women</b>: <b>Analysis of a cohort study</b>]]> Pregnant women are normally screenedfor Gestational diabetes (GDM) at week 24 of pregnancy. Howeversome women develop the disease later on their pregnancies. No study has analyzed women developing GDM later in pregnancy. Objective: To analyze data on a cohort study and compare women diagnosed with GDM in second and third trimester of pregnancy with women without GDM. Results: GDM women diagnosed during their first two trimesters of pregnancy were older (p = 0.0008) and had higher body mass Índex (BMI) (p = 0.0007) than non GDM women. However, the only risk factor in women diagnosed in their third trimester of pregnancy was having first degree relatives with type 2 DM and this was independent of age and BMI (OR of2.7, 95% CI 1.2 - 6.0). Conclusions: Women who develop GDM in their second trimester of pregnancy have known risk factors for diabetes mellitus such as age and higher BMI, however, the only recognised risk factor between non GDM women and women developing GDM late in pregnancy is family history of type 2 DM. Two populations ofGDM may exist andfuture studies should focus on analysing short and long term complications ofthese women to support the need to diagnosed and treat them all.<hr/>La pesquisa para diabetes gestacional (DG) se realiza normalmente en la semana 24 de embarazo. Sin embargo, muchas mujeres desarrollan la enfermedad más tardíamente durante el embarazo. No hay estudios analizando DG en tercer trimestre del embarazo. Objetivo: Analizar los datos de una cohorte para comparar mujeres con DG diagnosticada en segundo y tercer trimestre del embarazo con mujeres sin DG. Resultados: Las mujeres diagnosticadas en los primeros dos trimestres del embarazo eran mayores (p = 0,0008) y tenían mayor índice de masa corporal (IMC) (p = 0,0007) que las mujeres sin DG. El único factor de riesgo en mujeres diagnosticadas en el tercer trimestre del embarazo fue tener antecedentes familiares de DM, lo cual fue independiente de la edad e IMC (OR: 2,7, 95% CI 1,2 - 6,0). Conclusiones: Mujeres con DG diagnosticada en el segundo trimestre del embarazo tienen distintos factores de riesgo que mujeres diagnosticadas más tardíamente. Es posible que existan dos poblaciones de DG según el período de diagnóstico, por lo que debiera estudiarse si las complicaciones de estos dos subgrupos justifican el diagnóstico y tratamiento de ambos. <![CDATA[<b><i>Characterization of the variable region within class 1 integrons in Klebsiella pneumoniae nosocomials strains</i></b>]]> Background: Integrons are responsible for the capture and dissemination of resistance genes in Gram-negative bacteria. Aim: To characterize the variable region within class 1 integrons in nosocomial strains of Klebsiella pneumoniae. Material and Methods: Twenty-nine Klebsiella pneumoniae strains isolated from hospitalized patients were analyzed. The variable region of class 1 integrons was characterized by polymerase chain reaction and direct sequencing. Genetic localization of class 1 integrons was determined by bacterial conjugation. Results: Ten strains contained class 1 integrons, with sizes ranging from 750 to 2000 base pairs. One integrant element was present in nine strains and two elements in one single strain. Integrons were associated to plasmids. Cassettes aadA, aac(6)-Iq, orfD, dfrA]7, aadA5 and aadB were found. Conclusions: The presence of class 1 integrons may play an important role in the dissemination of hospital resistance against amino glycosides. <![CDATA[<b><i>Prosthetic valve thrombosis in a patient with antiphospholipid syndrome</i></b>: <b><i>Report of one case</i></b>]]> Primary antiphospholipid syndrome (APS) is a thrombophilic disorder not associated with connective tissue diseases or with autoimmune diseases. We report a 39-year-old female with a mechanical prosthetic mitral valve and a primary antiphospholipid syndrome. Anticoagulation with warfarin was changedfor tinzaparine. Four days after the change, the patients was admitted in cardiogenic shock. A transesophageal echocardiogram showed a mass in the prosthetic valve suggestive of prosthetic thrombosis. The patient required two valve replacements due to thrombosis. Her anticardiolipin antibody titers were 84 UPL. She was discharged with a coagulation international normalized ratio of three. <![CDATA[<b><i>Pseudotumor cerebri </i>secondary to Behçet disease</b>: <b>Report of one case</b>]]> The classical manifestations of Behçet disease are mouth ana genital ulcers, cutaneous lesions ana ocular involvement. The central nervous system is affected in 5 to 59% of the cases, usually in the form of meningoencephalitis or sinus venous thrombosis. We report a 17-year-old femóle presenting with a two weeks history of progressive headache, nausea and blurred vision. An initial magnetic resonance was normal. Fifteen days later she was admitted to the hospital due to progression of visual impairment. Shegave a history of oral ulcers and arthralgias. A new magnetic resonance was normal. A lumbar puncture showed a cerebrospinal fluid with a protein concentration of 14 mg/dl, aglucose concentration of 64 mg/dl, 20fresh red blood cells and a pressure of 26 cm H(2)0. The diagnosis of a pseudotumor cerebri, secondary to Behçet disease was raised and the patient was treated with colchicine and acetazolamide. The evolution was torpid and an anterior uveitis was alsofound. After discharge, she continued with oral and genital ulcers and was treated with infliximab. Despite treatment, headache persists. <![CDATA[<b>Hantavirus infection associated to a staphylococcal sepsis</b>: <b>Report of one case</b>]]> We report a previously healthy 36-year-old mole who developed a pulmonary syndrome caused by Hantavirus infection. He was admitted to an intensive care unit in shock and respiratory failure and died four hours after admission. Blood cultures were positive for Staphylococcus aureus. This patient could be an index case that shows, for the first time, an association of Hantavirus Pulmonary Syndrome with Staphylococcus aureus infection similar to what happens with other viruses. <![CDATA[<b>Biopercular syndrome caused by unilateral ischemia. </b><b>Report of one case</b>]]> Biopercular syndrome is a labio-facio-pharyngeal-laryngeal-gloso-masticatory diplegia, with automatic dissociation of movements. Ischemia is the most common etiology when it occurs bilaterally in the opercular area, but it has been also described in patients with bilateral subcortical lesions. There arefew cases described with unilateral lesions. We report a 76-year-old woman who developed a biopercular syndrome caused by unilateral ischemic lesion ofthe right middle cerebral artery confirmed by magnetic resonance imaging and cerebral SPECT. <![CDATA[<b>Hypertension as a biological marker of systemic atherosclerotic disease</b>]]> There is a close link between hypertension and atherosderosis. Hypertension causes atherosclerotic damage of several organs, called target organs and the risk factors for hypertension and atherosderosis are very similar. The risk of mortality associated to hypertension increases with blood pressure values below the cutoff point of normality (140/90 mm Hg), even below 130/85 mm Hg, and includes a stage called pre hypertension. Moreover, the initial damage of the arterial walls and target organs are present before there is a significant elevation of blood pressure. Therefore, hypertension could become a biological marker of the evolution of an underlying atherosclerotic process. A new pathophysiological paradigm has been proposed in which the severity of hypertension is not classified according to blood pressure values, but rather on the initiation and progression of vascular damage among target organs. These alterations determine the prognosis and management of systemic vascular damage that can be called "hypertensive atherosclerotic disease" or simply systemic atherosclerotic disease. <![CDATA[<b>Anesthesia awareness</b>]]> Anesthesia awareness, or "unintended intra-operative awareness" occurs during general anesthesia, on the operating table, when a patient has not had enough general anesthetic or analgesic to prevent consciousness or waking up during surgery. According to international studies its global incidence ranges from 0.1 to 0.2%. Its impact on people can be as severe as other traumatic experiences such as natural disasters, violent fights or sexual abuse. The prevalence of symptoms compatible with post traumatic stress disorder can be as high as 50%, after experiencing the awareness phenomenon. This paper reviews the main issues of the awareness phenomenon. <![CDATA[<b>Health related quality of life</b>: <b>Conceptual elements</b>]]> Health related Quality of Life is commonly used as a subjective assessment of health status. This article is a review of theoretical concepts about quality of life. Some models are proposed and general issues about it measurement are analyzed. Information about health related quality of life helps for decision making about health care both in clinical and public care settings. <![CDATA[<b>Contribution of epigenetics to understand human development</b>]]> Epigenetics refers to the study of how genes produce their effect on the phenotype of the organism. This article is a review on the scope and importance of recently discovered epigenetic mechanisms on human development and their relationship to perinatal epidemiological issues. It shows a general view and present concepts about epigenetics and its contribution to the comprehension of several physiologic and pathological conditions of human beings. Secondly, it analyzes the evidence coming from epidemiological and animal studies, about the influence of events that occur in the perinatal and early postnatal periods on adult life and the possible epigenetic mechanisms involved. Lastly, it underscores the implications ofthese results of future research and the design of public policies that take into account the importance of events in early life in thefuture development of individuals. <![CDATA[<b>Robert Walser</b>: <b>the loneliest writer. The influence of his disease on his literary work</b>]]> Robert Walser (1878-1956) is an important but unknown European writer of the twentieth century. He was also a mysterious and solitary man who lived at the margins of society. After the questionable diagnosis of schizophrenia, he nearly stopped writing and spent almost three decades in two Swiss psychiatric hospitals. The originality of his work, undoubtedly conditioned by his mental disorder, renders interesting a review of his life and a discussion of the possible differential diagnosis of his disease. <![CDATA[<b>Troponin in the diagnosis of myocardial infarction</b>: <b>An approach from the Clinical Laboratory</b>]]> Among the many biomarkers studied to evaluate myocardial damage, troponin is considered the most sensitive and specific. However, current methodologies present pre-analytical, analytical and post-analytical problems, of which the more significant are the lack of standardization and a high uncertainty in the level of decision or cut-off. It is hoped that a new generation of assays called "ultra sensitive" will improve analytical performance characteristics of the technique and achieve compliance with the internationally recommended quality specifications.<hr/>Entre los múltiples biomarcadores estudiados para evaluar daño miocárdico, la troponina se considera el más sensible y específico. Sin embargo, la mayoría de las metodologías actuales utilizadas para su determinación presentan problemas tanto pre-analíticos, analíticos como post-analíticos, de los cuales los más relevantes son la falta de estandarización y una imprecisión alta en el nivel de decisión o de corte. Se espera que una nueva generación de ensayos para la determinación de troponina, denominados ultrasensibles, mejoren las características de desempeño de la técnica y logren cumplir con las especificaciones de calidad recomendadas internacionalmente. <![CDATA[<b>Hutchinson</b><b> and his history</b>]]> The prolific life of Jonathan Hutchinson is reviewed. The importance of triads, a set of signs and symptoms that lead to the suspicion of the presence of one or more clinical entities, that are a demonstration of associative thinking, is also discussed. Nowadays, when technology plays a very important role in medicine, we would like to underscore the value of history taking and physical examination as useful clinical tools. <![CDATA[<b><i>Depression in medical students</i></b>: <b><i>A bibliometric approach</i></b>]]> The prolific life of Jonathan Hutchinson is reviewed. The importance of triads, a set of signs and symptoms that lead to the suspicion of the presence of one or more clinical entities, that are a demonstration of associative thinking, is also discussed. Nowadays, when technology plays a very important role in medicine, we would like to underscore the value of history taking and physical examination as useful clinical tools.