Scielo RSS <![CDATA[Revista médica de Chile]]> https://scielo.conicyt.cl/rss.php?pid=0034-988720160001&lang=pt vol. 144 num. 1 lang. pt <![CDATA[SciELO Logo]]> https://scielo.conicyt.cl/img/en/fbpelogp.gif https://scielo.conicyt.cl <![CDATA[<strong>Shortening undergraduate medical training</strong>: <strong>now and for all medical schools in Chile?</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100001&lng=pt&nrm=iso&tlng=pt In Chile, undergraduate medical education starts after High School, it lasts seven years, with the final two dedicated to a rotary internship, taking to an M.D. degree that allows the graduate to enter working activities. The country needs more M.D.s in primary care, but there is also a shortage of specialists, mainly out of the main cities. In recent decades, post graduate programs leading to specialty titles have become competitively adopted by a large proportion of medical graduates. This is the case at the Pontificia Universidad Católica de Chile, stimulating its faculties and medical students to develop a collaborative review of their teaching programs, leading to a curricular reform with a new graduate profile and a new curriculum oriented to learning objectives, that will allow to obtain the M.D. degree in six instead of seven years of undergraduate education. This new program awakened expectations in other universities in Chile, that will have to face the attraction of this shortened program for future candidates to enter medical schools. However, any shortening of medical school careers should first consider the local conditions in quality of applicants, number of accepted students, the training of teachers in integrated teaching programs, the availability of adequate campuses. Furthermore, for students with different academic backgrounds and diverse personal and familial interests, the seven years programs may still be necessary to gain the expertise required to become medical doctors. <![CDATA[<strong>Sharing clinical trial data</strong>: <strong>a proposal from the International Committee of Medical Journal Editors</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100002&lng=pt&nrm=iso&tlng=pt El Comité Internacional de Editores de Revistas Médicas (ICMJE) considera que es una obligación ética compartir responsablemente los datos generados por ensayos clínicos, porque los participantes se han sometido a un riesgo particular. En un consenso creciente, muchos patrocinadores en el mundo -Fundaciones, Agencias Gubernamentales y la industria proveedora en salud- ya exigen compartir los datos. Por este motivo, en esta Editorial, que será publicada simultáneamente en enero de 2016 por las revistas que a la fecha integran el ICMJE, dicho Comité propone requerir a los autores de ensayos clínicos que compartan con otros los datos individuales, anónimos, que generaron los resultados que se presentan en el manuscrito enviado a publicación (incluyendo Tablas, Figuras y anexos o material suplementario) en un plazo menor a seis meses después de su publicación. Se define como “datos que generaron los resultados” a los datos individuales de cada paciente (anónimos) que se requieren para reproducir los hallazgos que muestra el manuscrito, incluyendo sus metadatos. Este requisito será aplicado a los ensayos clínicos que comiencen a reclutar pacientes desde un año después que el ICMJE adopte como requisito compartir los datos, lo que ocurrirá después de considerar el “feedback” que se reciba al difundir esta Editorial. El documento original, que se reproduce a continuación, reitera la definición de “ensayo clínico” y explicita la forma y condiciones que propone para cumplir con este requisito. <![CDATA[<strong>Ethical issues perceived by health care professionals working in chronic hemodialysis centers</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100003&lng=pt&nrm=iso&tlng=pt Background: Clinical teams working at chronic hemodialysis centers (CHC) frequently have to face ethical problems, but there is no systematic approach to deal with them. Aim: To study the ethical problems perceived by health professionals at CHC. Material and Methods: Eighty randomly selected physicians and 139 nurses from 23 CHC, answered a structured questionnaire, devised by the research team. Results: Twenty-six percent of respondents had postgraduate studies in clinical ethics. The ethical problems mentioned by respondents were therapeutic disproportion in 66.7%, lack of communication between patients, their families and the clinical team in 25.9%, personal conflicts of interests related with hemodialysis prescription in 14.6% and conflicts of interests of other members of the clinical team in 30.6%. The percentage of respondents that experienced not starting or discontinuing hemodialysis treatment due to decision of patients’ relatives was 86.8%. Only 45.2% of health professionals had the opportunity to take part in decision-making meetings. Eighty seven percent of respondents supported the use of advanced directives in the event of a cardio respiratory arrest during treatment. Conclusions: To improve the approach to ethical problems in CHC, it is necessary to improve training in clinical ethics, promote an effective dialogue between the patients, their families and health professionals, and follow their advance directives in case of cardiac arrest during treatment. <![CDATA[<strong>Long-term outcomes with expanded criteria donors in kidney transplantation</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100004&lng=pt&nrm=iso&tlng=pt Background: Kidney transplantation of expanded criteria deceased donors (DCE) has become a common clinical practice. However, DCE outcomes are inferior compared to kidney transplants from standard criteria donors (DCS). Aim: To evaluate intermediate and long-term outcomes of DCE transplanted patients. Material and Methods: Cadaveric kidney transplants were evaluated using a retrospective cohort of eight consecutive years. Complications and long-term function of the transplant were assessed in DCE and DCS kidney recipients. Results: Of 213 patients analyzed, 34 (16%) underwent DCE transplantation. DCS recipients spent more time on the waiting list for transplantation (p = 0.04). DCE recipients showed higher frequency of surgical complications (p = 0.04), vascular complications (p = 0.02), acute transplant rejection (p = 0.05), and hospitalizations (p = 0.01). Creatinine (mg/dL) in DCE and DCS recipients was 2.3 and 1.5 respectively at year one (p < 0.01) and 2.6 and 1.6 respectively at year five (p < 0.01). Graft survival in the DCE group was significantly lower at 5 years (61 and 89% respectively, p < 0.01). Conclusions: DCE grafts are associated with lower survival, higher hospitalization rate and commonly develop surgical complications and rejections. <![CDATA[<strong>Subclinical atherosclerosis among Chilean subjects classified as having a low cardiovascular Framingham risk</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100005&lng=pt&nrm=iso&tlng=pt Background: Framingham risk score (FRS) has limitations and can underestimate risk. Carotid ultrasound to measure intima media thickness or plaques is recommended for cardiovascular risk assessment. Aim: To determine the prevalence of subclinical atherosclerosis in asymptomatic subjects classified as low and intermediate risk. Material and Methods: Cross-sectional study performed in subjects without cardiovascular disease. Cardiovascular risk was estimated using the Chilean FRS and the General Cardiovascular Disease FRS. Carotid ultrasound was performed in all subjects. We defined subclinical atherosclerosis as the presence of carotid plaque or intima media thickness greater than 75th percentile by gender and age. Results: We studied 203 subjects aged 47.2 ± 9.6 years (54% males). Mean intima media thickness was 0.62 ± 0.1 mm. An abnormal value was detected in 68 subjects (33%) and carotid plaques in 32 subjects (15.7%). Based on Chilean FRS, 96% were considered at low risk, 4% at intermediate, and none at high risk. In the low risk group the prevalence of abnormal intima media thickness and plaques was 40 and 14% respectively. Presence of plaques was more common in women than men (23 and 7% respectively, p < 0.01). According to the General Cardiovascular Disease FRS, 23% were at low, 39% at low intermediate and 28% at high intermediate risk. In the low risk group the prevalence of an abnormal intima media thickness was 34% and no subject had plaques. Conclusions: Carotid plaques were detected in Chilean subjects classified as having a low FRS risk. The underestimation of risk was higher in Chilean women. <![CDATA[<strong>Characteristics, management, and outcomes of illicit drug consumers with acute myocardial infarction</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100006&lng=pt&nrm=iso&tlng=pt Background: Consumption of illicit drugs (ID) has been associated with an increased risk of acute myocardial infarction (AMI). There is limited national evidence about the impact of substance use over the clinical presentation, management and outcomes of AMI patients. Aim: To describe the prevalence of ID consumption in patients within the Chilean Registry of Myocardial Infarction (GEMI), comparing clinical characteristics, management and outcome according to consumption status. Material and Methods: We reviewed data from the GEMI registry between 2001 and 2013, identifying 18,048 patients with AMI. The sample was stratified according to presence or absence of previous ID consumption, comparing different demographic and clinical variables between groups. Results: Two hundred eighty five patients (1.6%) had history of ID consumption (cocaine in 66%, cannabis in 35% and central nervous system stimulants in 24.0%). Compared with non-users, ID consumers were younger, predominantly male and had a lower prevalence of cardiovascular risk factors, except for tobacco smoking (86.3% and 42.5% respectively, p < 0.01). Among consumers, there was a higher percentage of ST segment elevation (85.2% and 67.8% respectively, p < 0.01) and anterior wall AMI (59.9 and 49.5% respectively, p = 0.01). Additionally, they had a higher rate of primary angioplasty (48.8% and 25.5% respectively, p < 0.01). There was no difference in hospital mortality between groups when stratified by age. Conclusions: A low percentage of patients with AMI had a previous history of ID consumption in our national setting. These patients were younger and had a greater frequency of ST segment elevation AMI, which probably determined a more invasive management. <![CDATA[<strong>Clinical skills of Chilean general practitioners for the management of depressive disorders</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100007&lng=pt&nrm=iso&tlng=pt Background: Diverse and sustained efforts have been developed to improve the management of depression by general practitioners (GPs), but they have not improved treatment coverage and quality of services. Aim: To explore the level of knowledge and clinical skills to diagnose and treat depression by GPs in Primary Health Care (PHC) in the Metropolitan Area of Santiago de Chile (RM). Material and Methods: Theoretical knowledge (TK), diagnostic skills (DS) and treatment skills (TS) were evaluated in 56 GPs of the RM with a battery of specially designed instruments. Results: In TK there were significant differences between GPs aged 31 years or less and their older counterparts and between Chilean and foreign doctors. Five percent of observed differences in TK were explained by age and nationality, respectively. Chilean GPs achieved higher scores in recognition of symptoms (RS), one of the dimensions of DS. No significant differences by age or nationality were observed for DS and TS. Conclusions: Achievement of GPs on tests measuring TK, DS, and TS was generally below 50%. This deficiency should be improved. <![CDATA[<strong>Evaluation of the Charing Cross Venous Ulcer Questionnaire in patients with chronic venous ulcers in Uruguay</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100008&lng=pt&nrm=iso&tlng=pt Background: Chronic venous ulcers (CVU) represent a frequent condition, with difficult therapeutic approaches, that impact on patients’ quality of life, and generate an economic burden to patients and health systems. Aim: To perform the cultural adaptation and initial evaluation of the Charing Cross Venous Ulcer Questionnaire (CCVUQ) for Uruguay, and to study the health-related quality of life (HRQL) of patients with CVU. Material and Methods: The translated and culturally adapted version of the CCVUQ was applied to a convenience sample of 50 patients. In addition, the PROMIS Global Health Survey was included in the assessment. Results: Both questionnaires showed good internal consistency (Cronbach alfa > 0.70). A statistically significant association was observed between the CCVUQ total scores, its subscales and both dimensions of the PROMIS: Global Physical (GPH) and Global Mental Health (GMH) (rho ≥ 0.40). The CCVUQ mean score was 54.9 ± 42 points while GPH and GMH mean scores were 37.9 ± 29 points, and 43.1 ± 35.1 points respectively. Simple linear regression showed that patients with higher income reported better emotional well-being, while in younger patients, ulcers had a higher impact on Emotional Status and Cosmetics. Conclusions: The translated and adapted version of the CCVUQ was easy to comprehend and apply, showing good psychometric properties. When used in association with the PROMIS Global Health Measure it provides complementary information. HRQL was severely affected in the study sample. <![CDATA[<strong>Pre and intraoperative scintigraphic detection of sentinel nodes in breast cancer</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100009&lng=pt&nrm=iso&tlng=pt Background: Sentinel node detection localizes the first node that drains a malignant lesion aiming to detect tumor dissemination. Aim: To assess the yield of sentinel node detection in breast cancer, using pre or intraoperative scintigraphy. Material and Methods: Review of medical records of patients with breast cancer who had a scintigraphic detection of sentinel nodes. Lymph node scintigraphy and surgery were performed in the same day. Results: We studied 174 women aged 53 ± 13 years, operated with a diagnosis of breast cancer, including six highly suspicious lesions in the contralateral breast (totaling 180 studied breasts). Preoperative scintigraphy showed a sentinel node in 174 of 180 breasts (97%). Intraoperative gamma probe confirmed the presence of the sentinel node in the same 174 breasts and detected an additional one reaching a detection yield of 97%. Four patients in whom a sentinel node was not detected in the preoperative scintigraphy, had macrometastases. Frozen section biopsies were available in 177 of 180 breasts. Metastases were informed in 45 patients who underwent axillary lymph node dissection, plus one additional patient with a suspicious lesion. Conclusions: A high rate of sentinel node detection in the preoperative scintigraphy was observed. Most sentinel nodes not detected with nuclear medicine had macrometastases. In 71% of patients, the detection of sentinel node avoided axillary lymph node dissection. <![CDATA[<strong>Changes associated with aging in angular kinematic parameters during a controlled speed walk</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100010&lng=pt&nrm=iso&tlng=pt Background: During normal aging, a reduction in walking speed and changes in stability are observed. Aim: To characterize and compare gait kinematic parameters of young (YA) and older adults (OA) at a controlled speed. Material and Methods: Gait angular kinematic parameters were analyzed in OA aged over 60 years and YA aged between 20 and 30 years. For data capture, six VICON Bonita cameras were used. Recording were made at a gait speed of 1.2 m/s. Kinematic data were normalized to 100% of the gait cycle using the Polygon 4.1 software. Time windows representing the phases of gait were created for analysis. Results: At the hip-pelvis level, OA reduce their pelvic obliquity motion and increase hip abduction. At the knee level OA reduce movements in the frontal plane during the plantar support and half swing phases. At the ankle level OA reduce their maximum ranges of plantar flexion, during the toe-off and final swing phases. Conclusions: At a controlled speed, kinematic changes observed in OA allow an increase in body support base to maintain gait stability. <![CDATA[<strong>Management of pediatric status epilepticus</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100011&lng=pt&nrm=iso&tlng=pt Pediatric Status Epilepticus (SE) is an emergency situation with high morbidity and mortality that requires early and aggressive management. The minimum time criterion to define SE was reduced from 30 to 5 minutes, defined as continuous seizure activity or rapidly recurrent seizures without resumption of consciousness for more than 5 minutes. This definition considers that seizures that persist for > 5 minutes are likely to do so for more than 30 min. Those that persist for more than 30 minutes are more difficult to treat. Refractory SE is the condition that extends beyond 60-120 minutes and requires anesthetic management. Super-refractory SE is the state of no response to anesthetic management or relapse during withdrawal of these drugs. The aim of this review is to provide and update on convulsive SE concepts, pathophysiology, etiology, available antiepileptic treatment and propose a rational management scheme. A literature search of articles published between January 1993 and January 2013, focused on pediatric population was performed. The evidence about management in children is limited, mostly corresponds to case series of patients grouped by diagnosis, mainly adults. These publications show treatment alternatives such as immunotherapy, ketogenic diet, surgery and hypothermia. A 35% mortality, 26% of neurological sequelae and 35% of recovery to baseline condition is described on patient’s evolution. <![CDATA[<strong>Palliative care of patients with severe dementia</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100012&lng=pt&nrm=iso&tlng=pt Dementia is an important public health problem due to the complex challenges it poses during the progression of the disease and especially during its end-of-life stage. The aim of this article is to consider the issues that arise from the use of commonly administered therapies in patients with severe dementia. Scenarios where excessive or futile therapeutic interventions might occur are discussed. The article concludes that it is advisable to analyze the clinical criteria and ethical considerations related to the administration of those treatments in order to develop and disseminate better practice guidelines for health professionals. <![CDATA[<strong>Curriculum reform at the Pontificia Universidad Católica de Chile School of Medicine</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100013&lng=pt&nrm=iso&tlng=pt The career of Medicine at the Pontificia Universidad Católica de Chile was established from the beginning (1929), with a classical Flexner curriculum design. In seven years, the career is divided in three cycles: basic sciences, clinics and internship. It obtained Chilean accreditation and fulfilled American Association of Medical Colleges accreditation requirements. Changes in the Chilean epidemiological profile and health system, and new teaching methods in medicine, stimulated a process of deep curricular analysis, identifying strengths and weaknesses of the medical career. The curricular strengths were well-developed scientific and clinical components, fully committed students and faculties, well defined learning objectives and excellent clinical campuses. Curricular weaknesses included a poor vertical and horizontal integration, few student centered methodologies and a weak emphasis concerning doctor’s professionalism. Subsequently, the whole community of teachers, students and medical educators worked on the design of a new curriculum, establishing a new graduate profile and designed it oriented by learning objectives, of six years of duration, with an optimized course sequence that melds basic science and clinical concepts, with strong emphasis on humanities and professionalism. It prioritizes an early contact with patients from the first year and expands teaching methods. The main objective of this process was to achieve a new curriculum with an integrative structure. This was implemented in 2015 with an approved protocol to evaluate the outcomes. <![CDATA[<strong>Minimum legal drinking age in the Chilean context</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100014&lng=pt&nrm=iso&tlng=pt Alcohol consumption is harmful to minors. One of the most wide ly accepted measures for the prevention of harm associated with alcohol consumption for young people is to establish a minimum legal drinking age. This document presents the evidence available on this policy, offers a condensed analysis of its characterist ics in the United States of America, describes current consumption patterns of Chilean youth, and proposes concrete solutions to be implemented. <![CDATA[<strong>Hygiene and urban health as seen by physicians, architects and planners during the first half of the twentieth century</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100015&lng=pt&nrm=iso&tlng=pt Physicians took part in the promotion of public policies that regulated urban and architectural work, before engineers, architects, planners, and even before the State had a chance to take part in the formulation of such policies. Starting in the late nineteenth century, and especially during the first decade of the twentieth century, the State began to lead on the issue of hygiene and public health. This paper focuses on the role of these professionals, who generated debates within their respective disciplines, or provided -as ministries, public servants or consultants- technical knowledge to the central government. These debates are still relevant for two reasons. First, they serve as reminders of the way in which the voice of these professionals was crucial not only within their respective disciplines, but also in order to place the issue of hygiene and public health on the agenda and to promote public policies related to the urban environment and its population. Secondly, these debates represent a challenge to current planners, as this historic context provides insight on the complex relationship between public health and planning, which hitherto has received little attention. <![CDATA[<strong><i>Cerebriform variant type of T cell prolymphocytic leukemia</i></strong>: <strong><i>Report of one case</i></strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100016&lng=pt&nrm=iso&tlng=pt T cell Prolymphocytic Leukemia (T-PLL) is a rare and aggressive mature T cell Lymphocyte Leukemia. Twenty five percent of cases present as a small cell variant, and only 5% as a cerebriform variant. We report a 58 year-old man with rapidly progressive severe leukocytosis, skin lesions, lymphadenopathy, hepatosplenomegaly and pleural effusion. The lymphocytes had a cerebriform type. The diagnosis of T-PLL variant was made by morphology and immunophenotype study of peripheral blood. Karyotype was found to be complex. He was refractory to chemotherapy and died two months later. <![CDATA[<strong>Hypoglycemia induced by a solitary fibrous tumor of the lung or Doege-Potter syndrome</strong>: <strong>Report of one case</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100017&lng=pt&nrm=iso&tlng=pt We report the case of a 75-year-old man who was admitted to the hospital with symptoms of severe hypoglycemia. He had a history of solitary fibrous tumor diagnosed by Pathology after its complete surgical resection eight years before. The laboratory examination reported hypoglycemia with inhibited Insulin secretion. A computed tomography of the thorax revealed a large solid heterogeneous mass in the left hemithorax. Solitary fibrous tumor is a rare neoplasm. The association of solitary fibrous tumor and paraneoplastic hypoglycemia is known as Doege-Potter syndrome and occurs in less than 5% of all solitary fibrous tumors. <![CDATA[<strong>Outdoor fitness equipment in parks, in Santiago, Chile</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100018&lng=pt&nrm=iso&tlng=pt We report the case of a 75-year-old man who was admitted to the hospital with symptoms of severe hypoglycemia. He had a history of solitary fibrous tumor diagnosed by Pathology after its complete surgical resection eight years before. The laboratory examination reported hypoglycemia with inhibited Insulin secretion. A computed tomography of the thorax revealed a large solid heterogeneous mass in the left hemithorax. Solitary fibrous tumor is a rare neoplasm. The association of solitary fibrous tumor and paraneoplastic hypoglycemia is known as Doege-Potter syndrome and occurs in less than 5% of all solitary fibrous tumors. <![CDATA[<strong>Active squares</strong>: <strong>Who prescribes and dispenses the exercise?</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100019&lng=pt&nrm=iso&tlng=pt We report the case of a 75-year-old man who was admitted to the hospital with symptoms of severe hypoglycemia. He had a history of solitary fibrous tumor diagnosed by Pathology after its complete surgical resection eight years before. The laboratory examination reported hypoglycemia with inhibited Insulin secretion. A computed tomography of the thorax revealed a large solid heterogeneous mass in the left hemithorax. Solitary fibrous tumor is a rare neoplasm. The association of solitary fibrous tumor and paraneoplastic hypoglycemia is known as Doege-Potter syndrome and occurs in less than 5% of all solitary fibrous tumors. <![CDATA[<strong>CORRECTION</strong>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100020&lng=pt&nrm=iso&tlng=pt We report the case of a 75-year-old man who was admitted to the hospital with symptoms of severe hypoglycemia. He had a history of solitary fibrous tumor diagnosed by Pathology after its complete surgical resection eight years before. The laboratory examination reported hypoglycemia with inhibited Insulin secretion. A computed tomography of the thorax revealed a large solid heterogeneous mass in the left hemithorax. Solitary fibrous tumor is a rare neoplasm. The association of solitary fibrous tumor and paraneoplastic hypoglycemia is known as Doege-Potter syndrome and occurs in less than 5% of all solitary fibrous tumors.