Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 141 num. 1 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[Transcatheter aortic valve implantation: Experience in 17 patients]]> Background: Transcatheter aortic valve implantation (TAVI) is taking a leading role in the management of patients with severe aortic stenosis. Valve replacement surgery prolongs survival and is the technique of choice considering its historical background and long experience worldwide. Recently however, TAVI has positioned itself as the only standard therapy for symptomatic patients who are not candidates for surgery. Aim: To report the experience with this new technique comparing our results with those reported in the literature. Material and Methods: Between May 2010 and December 2011,17patients aged 81 ± 7.3 years (58.8% men with an Euro SCORE 29 ± 22.4%) underwent a TAVI. Results: The median transvalvular gradient was 54 ± 15.7 mmHg. All patients received a CoreValveTM. Technical success was 100%, with a post implant gradient of 6.29 ± 3.3 mmHg. Residual aortic regurgita-tion was observed in 94%, none greater than grade II. There were no complications at the vascular access site. One patient developed cardiac tamponade during the procedure. Permanent pacemaker implantation was required in 35.2%. Hospital mortality rate was 5.8%, a figure that remained unchanged at 30 days offollow-up. Conclusions: In high-risk patients with aortic stenosis, TAVI has a high success rate and a low rate of complications. Besides an appropriate patient selection, a trained multidisciplinary team and technical conditions to solve possible complications of the procedure are required. <![CDATA[Relationship between self-directed learning and value profile in Chilean medical students]]> Background: Medical education should prepare students to face a dynamic environment, through competencies that allow them to learn independently. Aim: To evaluate the relationship between self-directed learning and value profile of undergraduate first year students in a medical school in Chile. Material and Methods: Self-Directed Learning Scale and Schwartz's Values Questionnaire were applied to 235 medical students from the University of Concepción, Chile. Results: Self-direction and Security are value types that correlate directly and significantly with the overall scale and with the five subscales of Self-Directed Learning. Conclusions: In first year medical students ofUniversity of Concepcion, Chile, Self-direction and Security are values that facilitate Self-directed Learning. <![CDATA[Effects of smoking on plasma antimüllerian hormone concentrations among infertile women]]> Background: Smoking may hamperfemale fertility, probably modifying ovarian reserve. Antimüllerian hormone (AMH) is an accurate marker for ovarian reserve. Aim: To look for an association between smoking status and plasma AMH concentration. Patients and Methods: A cohort of 141 infertile women in a university setting in Santiago, Chile was studied. Demographic and smoking data, including the number of cigarettes smoked during the last week, were collected. A blood sample was obtained and kept frozen until determination of AMH by ELISA and follicle stimulating hormone (FSH) and estradiol at day three of the menstrual cycle, by radioimmunoanalysis. Results: Thirty two participants smoked (23%). There were no significant differences in age, parity, body mass index, causes of infertility and day three FSH and estradiol between smokers and nonsmokers. According to a regression analysis, there was a significant decrease in AMH concentration with age and active cigarette smoking. A drop in AMH of -0.189 ng/mL with a unitary change in age and a decrease of -2.29 ng/mL when everything else remains constant, except the smoking status, were established (p < 0.001 and r2 = 0.134). However, no dose response was observed when the number of cigarettes smoked during the last week were introduced in the model. Furthermore, no significant association ofplasma AMH with day three plasma FSH and estradiol concentrations was observed. Conclusions: Cigarette smoking is associated with decreased AMHplasma concentrations among infertile women. However there was no dose response relationship. The mechanisms underlying this association are unknown and further investigation is required. <![CDATA[Factor analysis of abbreviated versions of the WHOQoL-Old in Chilean older people]]> Background: The increase in elderly population demands the needfor new health measures that are reliable and valid. Aim: To compare the factor structure of the Quality ofLife Scale WHOQoL-Old ofthe World Health Organization with the three proposed abbreviated versions ofthe scale. Material and Methods: We performed confirmatory factor analysis on data collectedfrom 804 older people, aged 70 ± 6 years (66% females). Results: One of the unifactorial models that incorporate six questions had goodness offit values greater than 0.95 in the non-normed fit index and below .05 in the root-mean square error of approximation. Conclusions: The abbreviated version tested is a valid and reliable questionnaire to be used in Chilean older people. <![CDATA[Postoperative survival among nonagenarians: A retrospective study]]> Background: As the Chilean population ages, anesthesiologists are regularly faced with elderly and even nonagenarian people undergoing surgical procedures. Aim: To determine the postoperative survival time in nonagenarians and its risk factors at a private clinic. Material and Methods: Review of medical records of the clinic, searching for patients aged 90 years or older, which were subjected to a surgical procedure between 2001 and 2012. Certification ofsurvival or death was obtainedfrom the clinical records or death certification at the National Identification Service. Survival analysis was made using Kaplan-Meier and Gompertz regression. Results: The medical records of167 patients, aged 90 to 101 years (64% women), were reviewed. Sixty four percent had an underlying cardiovascular disease; in 37%, cognitive impairment. Hip fracture surgery was the most common procedure. One intraoperative death occurred. Five percent ofpatients died one month after surgery. The median survival time was two years and the longest, seven years. According to Gompertz probability regression, the predictors of death were the presence of cardiac disease (Hazard ratio (HR): 1.91, 95% confidence intervals (95% CI): 1.16; 3.16), cognitive impairment (HR: 2.10,95% CI: 1.32; 3,22), cancer (HR:2.10,95% CI: 1.32; 3.22), requirement of transfusion (HR: 1.79, 95% CI: 1.13; 2.83) and an American Society of Anesthesiologists (ASA) Class III classification (HR: 1.95, IC95%: 1.21; 3.15). Conclusions: In nonagenarian patients undergoing surgery; 50% mortality was observed 2 years after surgery. The presence of cardiac disease, cognitive impairment, cancer, transfusion and a Class IIIASA classification were predictors of death. <![CDATA[Prognostic value of PET/CT in lung cancer: Retrospective analysis of 47 patients]]> Background: PET/CT (Positron emission tomography/computed tomography) is a hybrid image modality widely used in oncology, for staging, therapy evaluation or follow up. Aim: To evaluate the prognostic value ofPET/CT in lung cancer. Material and Methods: Retrospective review of PET/CT records, selecting 51 patients with a lung malignancy, mass or nodule referred for PET/CT between December 2008 and December 2010. All had pathological confirmation of malignancy and had not been treated previously. Age, gender, body mass index, radiological features of lung tumor and metastases, and lung tumor 18F-fluoro-2-deoxy-d-glucose uptake using the SUV (Standardized uptake value) index were recorded. Survival was analyzed usingKaplan-Meier curves and a Cox proportional regression analysis. Results: Pathology confirmed the presence of lung cancer in 47 patients aged 30 to 88 years. Four patients (7.8%) had other type of tumors such as carcinoid or lymphoma. Fifty percent of lung cancer patients died during a mean observation lapse of 18 months (range: 2-34 months). Patients with metastases, local lymph node involvement, a lung tumor size > 3 cm and high tumor uptake (SUVmax > 6) had significantly lower survival. Occurrence of metastases was the only independent prognostic factor in the Cox regression. A lung lesion with a SUVmax ≥ 12 was always associated to hilar/mediastinal lymph node involvement. Conclusions: PET/CT imaging gives important prognostic information in lung cancer patients. <![CDATA[Diffusion and adoption of health care innovations in cardiology, in Argentina]]> Background: Medicine is changing rapidly and diagnostic and therapeutic innovations are common. Not all professionals adopt these innovations in the same way. Aim: To survey the physicians' opinions on adopting innovations in cardiovascular health care, to classify individuals from an innovative to a conservative behavior, and to individualize opinion leaders among them, in order to build a social network of influence. Material and Methods: Between November and December 2008, 765 Argentine cardiologists were surveyed via e-mail in Argentina, to assess the way they adopt and disseminate innovations in cardiovascular health care. Results: The survey was answered by 537professionals (70.2%). Fifty three percent of respondents were "Early adopters". However, 63 to 79.3% of respondents preferred to wait for a full demonstration of the usefulness of innovation before adopting it. The opinion leaders' distribution adopted a scale-free network pattern, where few leaders had many connections and influence on the whole network. The giant component of the network included 41% ofphysicians; growth simulation of the network showed that the four most popular leaders influenced over 44% of the giant component. Conclusions: Among surveyed physicians there was an attitude towards rapid acceptance of innovations in health care. However, when analyzing the direct opinion ofphysicians, most cases preferred usefulness demonstrated before accepting innovations. The social network including respondents and opinion leaders showed a scale-free topology with a big influence of a few over the whole network. <![CDATA[Pulmonary hypertension associated with connective tissue diseases]]> Background: Pulmonary arterial hypertension is an important cause ofcomplica-tions amongpatients with connective tissue diseases. Aim: To describe the clinical and echocardiographic characteristics ofpatients with pulmonary hypertension associated with connective tissue diseases. Material and Methods: Retrospective, observational and descriptive study. We analyzed 35 patients with pulmonary hypertension associated with connective tissue diseases. All patients were evaluated and diagnosed by at least one medical specialist in rheumatology. Pulmonary arterial hypertension was defined as a pulmonary artery systolic pressure ≥ 40 mmHg by echocardiography. The group was divided as not severe when pressures ranged from 40 to 64 mmHg and severe, when pressures were ≥ 65 mmHg. Results: The most common connective tissue disease associated with pulmonary arterial hypertension was diffuse scleroderma in 46% of cases. Eighty nine percent of patients were female. Time of evolution of the pulmonary hypertension was 18.8 ± 21.8 months. The distance walked in the six minute walk test was < 400 m both in patients with and without severe pulmonary hypertension. Fifty one percent ofpatients had pulmonary restriction. No differences in gas exchange parameters were observed between groups. Comparing echocardio-graphic findings in patients with and without severe hypertension, the former had a higher frequency ofright ventricular dilatation (85.7 and 52.3% respectively, p = 0.04), right ventricular hypertrophy (42.8 and 0% respectively, p = 0.02) and right ventricular hypokinesia (71.4 and 9.5% respectively p = < 0.01). Conclusions: Patients with severe pulmonary arterial hypertension associated to connective tissue diseases have more commonly dilated, hypertrophic and hypokinetic right ventricles. <![CDATA[Protection against ionizing radiation by leaded glass googles during interventional cardiology]]> Background: It is not known whether leaded glass goggles with 0.25 mm Pb equivalency, used in interventional cardiology procedures, attenuate radiation below the levels established by the latest recommendation of the International Commission on Radiological Protection (ICRP). Aim: To assess ifthe degree of attenuation of the secondary ionizing radiation achieved by the use of 0.25 mm Pb leaded glass goggles, in occupationally exposed workers in interventional cardiology procedures, meets the latest ICRP recommendations. Material and Methods: A prospective investigation was carried out to compare the eye exposure to secondary ionizing radiation received by occupationally exposed personnel in a 9 months period. A set of two thermo luminescent dosimeters was arranged in the front and back of leaded glass goggles in a cohort ofseven members of an interventional cardiology service, exposed to 1057 consecutive procedures. Results: The monthly dose equivalent measurement performed in front ofthe goggles ranged between 1.1 and 6.5 mSv, for paramedics and interventional cardiologists. The radiation measured in the back of the glass varied between 0.66 and 2.75 mSv, respectively. The degree of attenuation of the dose at eye level ranged from 40% to 57.7%, respectively. The projected annual exposure would reach 33 mSvfor the interventional cardiologist. Conclusions: With a similar load ofwork and wearing 0.25 mm Pb equivalent glass goggles, interventional cardiologists will exceed the crystalline equivalent dose limit recommended by the ICRP (20 mSv/year averaged over the past 5 years). <![CDATA[Simulation in medical education: a synopsis]]> Clinical simulation is defined as a technique (not a technology) to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive fashion. Over the pastfew years, there has been a significant growth in its use, both as a learning tool and as an assessment for accreditation. Example of this is the fact that simulation is an integral part of medical education curricula abroad. Some authors have cited it as an unavoidable necessity or as an ethical imperative. In Chile, its formal inclusion in Medical Schools' curricula has just begun. This review is an overview of this important educational tool, presenting the evidence about its usefulness in medical education and describing its current situation in Chile. <![CDATA[Recommendations for health care of people with Down syndrome from 0 to 18 years of age]]> People born with Down syndrome have an increased risk of birth defects and are more vulnerable to certain illnesses. Health care for them should emphasize prevention, early diagnosis and early treatment of their most common health conditions. A healthy lifestyle promotes future physical and intellectual development. The purpose of this review is to update health care recommendations for individuals with Down syndrome from 0 to 18 years ofage. The health professionals members involved in the care of these patients should be aware of these guidelines. <![CDATA[<strong>Ministry of Health Intensive Care Medicine Commission</strong>: <strong>Proposals for the development of the discipline</strong>]]> Intensive care medicine in Chile is still in its dawn. It has experienced a progressive growth in the last decade, but continues to be weak. Although investments in the discipline have increased fivefold, there is still a severe deficiency of intensive care specialists. This issue will represent a serious problem in the near future. The Ministry of Health gathered an expert committee to study the problem and propose solutions for the future development of the discipline. <![CDATA[Thyroid stimulating hormone reference values derived from the 2009-2010 Chilean National Health Survey]]> Background: The determination ofthyroid stimulating hormone (TSH) reference values is critical for the diagnosis ofthyroid diseases. Aim: To explore and discuss different definitions to establish TSH reference values using a Chilean national survey sample. Material and Methods: The 2009-2010 Chilean National Health Survey recruited 5,416participants between the ages of 15 and 96years, from all geographic regions of Chile, including urban and rural zones. TSH was measured in a random subsample of 2,785 adults. Median value, 2.5 and 97.5 percentiles were described in three different populations: total survey population, "disease-free population" and the "laboratory kit disease free population". Results: TSH values were higher among women, the elderly and the less educated population. The 97.5 percentile value in the disease-free population was 7.46 uUl/ml. Using this value as a cut-off, hypothyroidism prevalence would be 4.8% in Chile and estimated pharmacological treatment coverage would be 58%. When laboratory kit cut-offs are used, prevalence rises to 22% and treatment coverage drops to 12%. The 2.5 percentile value in the disease-free population was 0.83 uUl/ml, which yields an estimated hyperthyroidism prevalence of3.89%. Conclusions: Median TSH concentration values in the Chilean "disease-free population" are higher than those proposed by laboratory kits and those of developed countries. TSH values in the general population of Chile are also higher in women, the elderly and the less educated population. <![CDATA[Cerebral salt wasting syndrome associated with <i>Listeria monocytogenes</i> encephalitis. Report of one case]]> Hyponatremia is common in patients with severe neurological diseases and is often secondary to a syndrome of inappropriate antidiuretic hormone secretion (SIADH). However, in some patients, hyponatremia is due to cerebral salt wasting syndrome (CSWS). SIADH and CSWS treatments are opposite and misdiagnosis can lead to increased morbidity and mortality. We report a 52 years old female with a rhom-boencephalitis caused by Listeria Monocytogenes (LM), ventriculitis and abscesses in cerebellum and brainstem. It was associated with hyponatremia, hypotension, increased natriuresis, hypouricemia, and low creatinine and blood urea nitrogen levels. Large amounts ofsodium were needed and the condition persisted after hospital discharge. Hyponatremia is common in central nervous system involvement by LM, however we are not aware of CSWS reports of this condition. <![CDATA[Bifrontal cerebritis and brain abscess caused by <i>Sreptococcus anginosus</i> group: Report of one case]]> The etiology of brain abscesses is mostly polymicrobial. Streptococci and anaerobic bacteria are the most commonly isolated pathogens. We report a previously healthy female without predisposingfactors, presenting with a bifrontal cerebritis caused by a Streptococcus anginosus group infection. The patient developed a brain abscess and a subdural collection with severe intracranial hypertension offatal evolution. The etiologic diagnosis was made culturing the material obtained from the subdural collection. It is presumed that, within the Streptococcus anginosus group, Streptococus intermedius could have been the causing bacteria, given its central nervous system tissue tropism and its predisposition to form brain abscesses. <![CDATA[<b>Neuro-Behçet</b>: <b>differential diagnosis of recurrent meningitis</b>]]> Behçet disease is a systemic inflammatory perivasculitis characterized by recurrent episodes oforal and genital ulcers associated with skin and ocular lesions. Neurological involvement occurs in 5 to 10% of the cases, and isolated meningeal involvement is very uncommon. We report a 21 years old man with a Behçet disease and a history of acute meningeal syndrome in two previous crises and meningoencephalitis in three others. He reported a history of conjunctivitis and oral and genital ulcers. On examination, he presented oral aphthoid lesions, macular edema, involvement of cranial nerves, pyramidal signs and meningeal irritation. The cell count in cerebrospinal fluid was 1800 cells/mm³, with polymorphonuclear predominance. Magnetic resonance imaging showed lesions in basal ganglia and the brainstem. The patient improved dramatically after intravenous steroid therapy.<hr/>La enfermedad de Behçet is una perivasculitis sistémica inflamatoria caracterizada por episodios recurrentes de úlceras orales y genitales asociadas a lesiones cutáneas y oculares. El 5 a 10% de los casos tiene compromiso neurológico y el compromiso meníngeo aislado es muy poco común. Presentamos un hombre de 21 años con enfermedad de Behçet y una historia de síndrome meníngeo en dos crisis previas y meningoencefalitis en tres otras. El paciente tenía una historia de conjuntivitis y úlceras orales y genitales. Al examen se encontraron lesiones aftosas, edema macular, compromiso de nervios craneanos, signos piramidales e irritación meníngea. El recuento celular del líquido cefalorraquídeo fue de 1.800 células/ml con predominancia polimorfonuclear. La resonancia magnética mostró lesiones en los ganglios basales y tronco encefálico. El paciente mejoró dramáticamente con el uso de corticoides endovenosos. <![CDATA[Parochial hospital of San Bernardo, Chile: Serving the community for over a century]]> The Parochial Hospital of San Bernardo is an intermediate complexity hospital that functions in its original 115- year- old building. It is one of the oldest hospitals in the country. Driven by the local Catholic Church and despite multiple difficulties, the hospital has uninterruptedly served a progressively growing community, with medical care and spiritual support. In the last two decades, it also has incorporated teaching activities with Universidad de los Andes Medical School. <![CDATA[<b><i>The new law on patient rights</i></b>: <b><i>changing the relationship between patient and physician</i></b>]]> The Parochial Hospital of San Bernardo is an intermediate complexity hospital that functions in its original 115- year- old building. It is one of the oldest hospitals in the country. Driven by the local Catholic Church and despite multiple difficulties, the hospital has uninterruptedly served a progressively growing community, with medical care and spiritual support. In the last two decades, it also has incorporated teaching activities with Universidad de los Andes Medical School. <![CDATA[<b><i>Medical students' scientific societies</i></b>: <b><i>A driving force for research</i></b>]]> The Parochial Hospital of San Bernardo is an intermediate complexity hospital that functions in its original 115- year- old building. It is one of the oldest hospitals in the country. Driven by the local Catholic Church and despite multiple difficulties, the hospital has uninterruptedly served a progressively growing community, with medical care and spiritual support. In the last two decades, it also has incorporated teaching activities with Universidad de los Andes Medical School. <![CDATA[<b><i>When was it born the term Internal Medicine?</i></b>]]> The Parochial Hospital of San Bernardo is an intermediate complexity hospital that functions in its original 115- year- old building. It is one of the oldest hospitals in the country. Driven by the local Catholic Church and despite multiple difficulties, the hospital has uninterruptedly served a progressively growing community, with medical care and spiritual support. In the last two decades, it also has incorporated teaching activities with Universidad de los Andes Medical School.