Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 146 num. 3 lang. es <![CDATA[SciELO Logo]]> <![CDATA[Comparación preoperatoria entre pruebas de coagulación y tromboelastografía en pacientes con cirrosis hepática sometidos a trasplante hepático]]> Background: Compared to standard coagulation essays (SCE), such as international normalized ratio (INR), prothrombin activated partial thromboplastin time (aPTT), or platelet count, thromboelastograhy (TEG) offers precise and real-time information about hemostasis. TEG tests both platelet function and coagulation by assaying several parameters of clot formation dynamically in whole blood. Aim: To evaluate hemostasis in cirrhotic patients undergoing liver transplantation and determine the positive and negative predictive values of SCE for alterations of TEG. Material and Methods: Preoperative SCE and TEG were prospectively analyzed in 25 patients. Results were categorized as normal, laboratory alteration or clinical alteration. SCE results were compared with TEG parameters to determine positive (PPV) and negative predictive values (NPV). Results: Hemostasis was abnormal and laboratory abnormalities were observed in all patients. One patient had clinical signs of excessive bleeding. SCE were abnormal in all patients and TEG was normal in nine patients. The most common alteration in TEG was hypocoagulability, in some cases associated with hypercoagulability and hyperfibrinolysis. Two patients had solely hypercoagulability. PPV of INR, aPTT, platelet count and fibrinogenemia were 0, 0, 0.5 and 0.17 respectively. NPV of the same tests were 1, 1, 0.34 and 1 respectively. Conclusions: Hypocoagulability was the most common laboratory alteration, however, clinical signs of coagulopathy were rarely present. SCE had a poor predictive value to diagnose o discard hemostatic abnormalities. <![CDATA[Riesgo de recurrencia en cáncer diferenciado de tiroides: escala MINSAL]]> Background: Differentiated thyroid cancer (DTC) is generally associated with a favorable prognosis. Its treatment requires surgery, selective use of radioiodine and levothyroxine, and its intensity must be adjusted to the initial risks of mortality and recurrence. Aim: To validate the risk of recurrence classification developed by the Chilean Ministry of Health in 2013 (MINSAL 2013), and compare it with the American Thyroid Association (ATA) 2009 and 2015 classifications. Material and Methods: Retrospective study of 362 patients with DTC aged 44.3 ± 13.4 years (84% women), treated with total thyroidectomy, selective radioiodine ablation and levothyroxine and followed for a median of 4.2 years (range 2.0-7.8). Risk of recurrence was estimated with MINSAL 2013, ATA 2009 and ATA 2015 classifications, and risk of mortality with 7th and 8th American Joint Committee on Cancer (AJCC)/TNM systems. Clinical data obtained during follow-up were used to detect structural and biochemical persistence/recurrence. Results: A mean dose of 104 ± 48 mCi radioiodine was received by 91% of patients. MINSAL 2013 classified 148 (41%), 144 (40%), 67 (19%) and 3 (1%) patients as very low, low, intermediate and high risk of recurrence, respectively. Forty-five (12.4%) patients had persistence or recurrence during follow-up: 33 structural and 12 biochemical. Rates of persistence/recurrence on each category of MINSAL 2013 were 4.1%, 7.6%, 37.3% and 100%, respectively (p &lt; 0.01). Areas under Receiver Operating Characteristic curves for persistence or recurrence of MINSAL 2013, ATA 2009 and ATA 2015 were 0.77 vs 0.73 vs 0.72, respectively. Conclusions: MINSAL 2013 classifies appropriately DTC patients and estimates correctly their risk of persistence or recurrence. <![CDATA[Evolución de mortalidad, abandono, traslado y retención a corto, mediano y largo plazo en pacientes con infección por VIH: Fundación Arriarán 1990-2015]]> Background: The HIV epidemic reached Chile in late 1980s and as an early response, AIDS care centers were organized. Fundación Arriarán (FA) was the first center. Free antiretroviral therapy (ART) was later provided with progressive coverage and complexity over the years. Aim: To quantify evolution of mortality, retention and loss to follow up (LTFU) over 25 years according to different periods of access to ART, from no availability to full coverage with current drugs at FA center. Material and Methods: Retrospective analysis of FA database of 5,080 adults admitted between 1990 and 2014. The sample was distributed in 7 groups: A: no ART (1990-92), B: monotherapy, C: dual therapy, D: dual/triple ART, E: early triple therapy with incomplete coverage, F same as E but with complete coverage and G: contemporary ART (2008-14). Mortality, retention and LTFU were evaluated at 1, 3, 5, 7 and 10 years and at 31/12/2015. Results: Mortality varied from 40% to 2%, and 62% to 7% at 1 and 5 years, for groups A and G respectively; from 71% to 16% at 10 years for groups A and E, respectively. Retention at 5 years were 28%, 23%, 39%, 62%, 75%, 75% and 77% for groups A to G, respectively. LTFU was 10%, 19%, 15%, 17%, 9% 12% and 10% at 5 years for same groups, respectively. At 12/31/2015 22% of patients had died, 11% were LTFU, 60% were retained in care and 6% had been transferred. Conclusions: There is a marked reduction in mortality and increase in retention of HIV patients’ concomitant to expanded access to modern therapy, although LTFU remains a problem. <![CDATA[Adaptación y validación de la Escala de Ansiedad y Depresión Hospitalaria en pacientes chilenos con cáncer]]> Background: Depression and anxiety are common in patients with cancer. Aim: To adapt and validate the Hospital Anxiety and Depression Scale (HADS) for adult Chilean cancer patients, and to provide information about their prevalence of anxiety and depression. Material and Methods: Two hundred fifteen patients with cancer answered an adapted version of HADS for Chilean population. The language adjustment of the scale was carried out with the opinions of 10 expert linguists and with a pilot study on 17 cancer patients. The Depression and Anxiety subscales of the DASS-21 were also applied to verify the convergent validity of HADS: Results: The confirmatory factor analysis indicated that the data fits the model of two correlated factors (anxiety and depression), χ2 = 98.608; df = 76;p &lt; 0.05; χ2/df= 1.23, RMSEA = 0.037; CFI = 0.99; TLI = .98. Reliability analysis showed an adequate internal consistency of both subscales (.76 for anxiety and .84 for depression) and the general scale (.87). Correlations between HADS and DASS-21 scores were significant for both anxiety (r =.514, p &lt; 0.001) and depression (r = 0.600, p &lt; 0.001). Prevalence rates were approximately 30% for depression (actual = 12%, possible = 22.8%) and approximately 20% for anxiety (actual = 7%, possible = 8.4%). Conclusions: We conclude that HADS is a reliable and valid instrument for screening clinically relevant anxiety and depression symptoms in Chilean cancer patients.<hr/> Objetivo: Adaptar y validar la Escala Hospitalaria de Ansiedad y Depresión (HAD) a población adulta oncológica chilena y aportar información sobre la prevalencia de ansiedad y depresión en la muestra. Método: Participantes: 215 pacientes oncológicos. Instrumentos: Protocolo de datos sociodemográficos y clínicos; HAD y el DASS-21, utilizada como Gold Standar para comprobar la validez de convergencia de la escala. Procedimiento: adaptación lingüística de la escala mediante juicio de expertos lingüistas (n = 10) y pilotaje con 17 pacientes oncológicos. Resultados: El análisis factorial confirmatorio indica que la escala se ajusta al modelo de dos factores correlacionados (ansiedad y depresión) (χ2 = 98,608; gl = 76; p &lt; 0,05; χ2/gl = 1.23; RMSEA = 0,037; CFI = 0,99; TLI = 0,98). Los análisis de confiabilidad ponen de manifiesto una adecuada consistencia interna tanto de las subescalas que la componen (0,76 para ansiedad y 0,84 para depresión) como de la escala general (0,87). Las correlaciones entre las puntuaciones del HAD y el DASS-21 fueron positivas y significativas tanto para ansiedad (r = 0,514, p &lt; 0,001) como para depresión (r = 0,600, p &lt; 0,001). Se señalan cifras de prevalencia en torno al 30% para depresión (caso = 12%; posible = 22,8%) y al 20% para ansiedad (caso = 7%; posible = 8,4%). Conclusiones: El HADS es un instrumento válido y confiable para el screnning de síntomas de ansiedad y depresión de relevancia clínica en pacientes oncológicos chilenos. <![CDATA[Identificación y medición de creencias culturales sobre los médicos: construcción y validación de un instrumento]]> Background: Beliefs about professionals' healthcare may influence healthcare behaviors. Such beliefs are in part the result of the interactions that professionals have with their patients. Recent studies highlight the importance of beliefs about physicians, their effect on health-care behaviors, and the requirement of culturally appropriate tools to measure such beliefs. Aim: To develop and validate a culturally appropriate instrument to measure beliefs about physicians. Material and Methods: Based on a “bottom-up” methodology, a culturally pertinent scale of beliefs about physicians was developed and then validated by expert judges. The resulting scale, with 26 items, was applied to 337 participants aged 31 ± 7 years (85% women). Results: Two factors, grouping 24 items, emerged from the exploratory factor analysis. The first was called negative beliefs about doctors (Cronbach's α = 0.96) and the second was called positive beliefs about doctors (Cronbach's α = 0.95). Both factors explain 70 % of the scale variance. Conclusions: The devised instrument has adequate psychometric properties and is also culturally relevant. It allows the assessment of cultural beliefs about physicians. <![CDATA[Funcionamiento cognitivo en adultos mayores: rol de la reserva cognitiva, apoyo social y depresión]]> Background: Cognitive reserve (CR) is a protective factor in aging. Depression and perceived social support are associated with cognitive performance in older adults. However, their role in the relationship between CR and cognitive functioning is less clear. Aim: To determine the relationship between CR and cognitive functioning and whether this relationship is mediated by depression and moderated by social support. Material and Methods: CR, depression, perceived social support, and cognitive functioning scales were applied to a convenience sample of 206 older adults, aged 69 ± 1 years (77% women). Structural equation analysis and moderate mediation analysis were performed. Results: There was a direct effect of CR in cognitive functioning (β = 0.223, p = 0.005), which was not mediated by depression (β = 0.040, p = 0.096). High CR scores were associated with lower depression scores (β = −0.203, p = 0.002). Higher depression scores were associated with worse cognitive functioning (β = −0.168, p = 0.040). The effect of CR on depression was moderated by social support (β = −0.161, p = 0.032) controlling for income and age. Conclusions: The relationship between CR and cognition in older adults allows an early assessment of cognitive dysfunction risk. Depression is an independent risk factor for cognitive functioning. Social support protects individuals with high CR from developing depression. <![CDATA[Asma y salud mental en mujeres: estudio en centros de atención primaria]]> Background: Asthma is a chronic multifactorial disease with a fast-growing global prevalence. Its association with psychological factors is not completely elucidated. Aim: To analyze features associated with not well-controlled asthma and to test the association of psychological factors with asthma control criteria. Patients and Methods: Cross-sectional study that analyzed data from clinical records of asthmatic women under care in the Adult Respiratory Diseases Programs (ERA, in Spanish) and the Mental Health Program of Family Care Health Centers in the city of Arica. According to the asthma control score, patients were classified as having adequate control or not. Results: A total of 60 women were analyzed and 62% had a not well-controlled asthma. Factors associated with not well-controlled asthma were moderate depression (Odds ratio (OR) = 6.84;p &lt; 0.01), emotional lability (OR = 0.14; p = 0.02) and domestic violence (OR = 5.75; p = 0.05). The psychological factors associated with asthma control criteria were fear, emotional instability, domestic violence, sleep disorders, mixed anxiety-depressive disorders, and moderate depression. Conclusions: Psychological factors and violence exposure were consistently associated with asthma control. <![CDATA[Adaptación del instrumento WAST para la detección de violencia doméstica en Centros de Salud]]> Background: The Woman Abuse Screening Tool (WAST) is a screening tool for domestic violence used in Unites States. Aim: To carry out the cultural adaptation of the WAST instrument for early detection of domestic violence in primary health care. Material and Methods: Qualitative techniques for cultural adaptation were used in stages 1 and 2 and quantitative techniques were used in stage 3. The validity of content was assessed using judge tests carried out with experts in the field. Linguistic adaptation was carried out using a focal group technique to ensure semantic and language comprehension. Finally, the culturally adapted instrument was applied to 16 women who were victims of violence and to 28 women without a history of violence. Results: For cultural adaptation, the judges’ test added the item of economic violence to the instrument. According to the focus groups, some words were changed to facilitate understanding by the subjects. According to the scores obtained in women with and without a history of violence, a cut-off point of 15 points was defined to determine a history of domestic violence with a sensitivity of 100% and a specificity of 96%. The Cronbach Alpha of the questionnaire was 91%. Conclusions: WAST is an effective and easily applied instrument for the early detection of domestic violence. <![CDATA[Experiencia con el empleo del examen OSCE en el ciclo de evaluación de competencias clínicas de médicos que revalidan su título]]> Background: Our institution adopted the Objective Structured Clinical Evaluation (OSCE) format to assess clinical skills of International Medical Graduates (IMGs) aiming to practice in Chile. The OSCE has clear advantages over oral exams due to its objective and structured nature. Aim: To report our experience with OSCE. Material and Methods: A team consisting of clinical specialists and medical educators with expertise in clinical simulation organized this OSCE cycle. IMGs were required to pass four clinical examinations (Internal Medicine, Surgery, Pediatrics and Obstetrics &amp; Gynecology) where their respective general medical competences were evaluated. The latter were carefully selected from those issued by the Chilean Medical Evaluation policy-making body (EUNACOM). Each OSCE consisted of ten stations. Initially conceived to last five minutes each, they were afterwards expanded to seven minutes, after it was realized that most candidates had never been exposed to an OSCE examination before. A post-hoc analysis according to qualitative and psychometric quality criteria followed each OSCE. Results: The proportion of candidates passing the first two examinations of the cycle, were 65 and 75% respectively and reached 100% in the last ones. Lack of IMG familiarity with the OSCE system initially hampered their full expression of competencies. Extending the stations’ duration to seven minutes subsequently rectified this situation, as well as potential adverse impacts on the validity of results. Conclusions: This evaluative process, which entails important consequences for the community and the IMGs, requires a meticulous and coordinated planning and post-hoc quality control. <![CDATA[Creatinina y su uso para la estimación de la velocidad de filtración glomerular]]> Glomerular filtration rate (GFR) is the best approximation to global renal function and its estimation is of great relevance for clinical practice. Since the measurement of GFR by reference methods is complex, costly and not widely available, its routine evaluation is performed using endogenous biomarkers. Within these, creatinine is the most commonly used. It allows the estimation of GFR by means of its clearance or by formulas based on its concentration on plasma. Creatinine measurement should be performed using enzimatic methods as they confer more accurate values than Jaffe methods, especially for normal and low creatinine levels. <![CDATA[Encefalitis autoinmunes: criterios diagnósticos y pautas terapéuticas]]> Autoimmune encephalitis are one of the emergent causes of subacute changes in the level of consciousness, behavior, cognitive impairment and seizures, mainly in young people. They are a consequence of inflammation or dysfunction of parts of the brain caused by antibodies against specific brain antigens, usually located in the limbic system, resulting in clinical presentation as a limbic encephalitis. The objectives of this article are to show the clinical presentation, complementary studies and treatment of this entity, considering that the patient's prognostic depends on a high level of clinical suspicion, and on an early initiation of immunosuppressive therapy. We did a nonsystematic review of the literature on autoimmune encephalitis between 2005 and 2017. We conclude that the prevalence of autoimmune encephalitis is increasing, even surpassing infectious causes of encephalitis in developed countries. Clinical presentation includes sub-acute cognitive and behavioral impairment, with or without alterations in consciousness and seizures. Fever and inflammation of the cerebrospinal fluid are less common than in the infectious causes but psychiatric symptoms are more frequent. There are specific clinical presentations according to the particular type of antigen/antibody present, which also determines the association with cancer, constituting a paraneoplastic syndrome only in some cases. Immunosuppressive therapy has been standardized in steps, and should be initiated early to improve prognosis. <![CDATA[Efecto del ejercicio físico sobre marcadores de estrés oxidativo en pacientes con diabetes mellitus tipo 2]]> Sedentarism, overweight and malnutrition generate an increase in the production of reactive oxygen species leading to a state of chronic oxidative stress. In patients with type 2 diabetes mellitus, oxidative stress alters pancreatic insulin secretion and the actions of the hormone on target cells, contributing to the development of micro and macrovascular complications. During physical exertion a state of transient oxidative stress occurs. As a consequence, the organism generates multiple physiological adaptations to these repetitive stimuli. Physical exercise is beneficial for type 2 diabetes mellitus but there is a paucity of information about the effects of physical exercise on biomarkers of oxidative stress in patients with the disease. We herein try to elucidate if the effects of exercise on oxidative stress can help in the prevention and treatment of type 2 diabetes mellitus and which is the most effective modality of physical exercise to reduce oxidative stress markers. <![CDATA[Problemas éticos en las publicaciones científicas]]> Ethical problems have always been present in scientific publications. Since the founding of medical journals, in the XIX Century, until today they are a source of concern because one main purpose of medical scientific publications is to add new, reliable information that could guide or modify medical decisions and public health policies. Since 1997, Revista Médica de Chile has published several articles clarifying this situation and emphasizing the need to avoid ethical misbehavior. The present review reminds that the main sources of information dealing with publication ethics appear in the web sites of ICMJE, COPE and WAME. Misconduct have been detected in Revista Médica de Chile in a few cases of redundant publications, plagiarism, lack of recognition of conflicts of interest mainly with pharmaceutical companies, and one attempt of forging the publication of an article that had been previously rejected. In handling situations identified as ethical misbehavior, the editors of this journal have successfully followed rules established by COPE. This article reviews and reinforces recommendations to avoid ethical misbehavior in biomedical research and in manuscripts submitted for publication. <![CDATA[Identidad ocupacional en docentes de carreras de la salud y su relación con las prácticas pedagógicas]]> Background: Occupational identity is defined as the perception of occupational interests, abilities, goals, and values, and the structure of the meanings that link these self-perceptions to career role. We developed an occupational identity questionnaire suitable to be used with university teachers. Aim: To evaluate the psychometric properties of the Occupational Identity Questionnaire (OIQ) and relate its results with those of the Teaching Practices questionnaire. Material and Methods. The OIQ and Teaching Practices Questionnaire were answered by 311 university teachers along Chile, who were selected through a non-probabilistic volunteer sampling. An exploratory factor analysis was performed and the internal consistency of each factor was calculated with Cronbach's Alpha. Spearman correlations were used to explore the relationship between the two questionnaires. Results: Two factors were identified in OIQ: Teaching Vocation and Sense of Competence. Cronbach's Alpha was 0.75 for teaching vocation and 0.82 for the sense of competence. There was a moderate direct relationship between teaching vocation, sense of competence and the results of the Teaching Practices Questionnaire. Conclusions: OIS has an adequate internal consistency, its factorial structure showed two different types of identities and it is directly related to the results of the Teaching Practices Questionnaire. <![CDATA[Sobre el origen y desarrollo del libro Semiologia Médica]]> Semiotics and Semiology share a similar etymology and meaning: the study of signs. In Medicine, signs are objective manifestations of disease, as opposed to the subjective nature of symptoms. Medical semiology comprises the study of symptoms, somatic signs and laboratory signs, history taking and physical examination (in English-speaking countries is known as Bedside diagnostic examination or Physical diagnosis). The first edition of Medical Semiology dates from 1987, and new editions appeared in 1999, 2010, and 2017. The book is devoted to semiology proper with clinical orientation. Its origin, however, dates back to 1937, when the University of Chile appointed Dr. Hernán Alessandri (1900-1981), the eminent Chilean medical educator, Professor in Semiology at the Internal Medicine Section of the Hospital del Salvador in Santiago. The authors of the present book served as Dr. Alessandri's teaching assistants for decades. The two-semester course in semiology had a tutorial character: each teaching assistant was assigned five students whom engaged daily in practical activities in the hospital wards for a total of four hours, in addition to a 45- minute lecture on the theoretical aspects of the subject. The 720-page fourth edition of the book brings together teaching method and clinical experience of more than 50 years. The book consists of six Sections: “Cardinal manifestations of disease”, “Major clinical syndromes”, “History taking and Physical examination”, “Clinical diagnosis and the patient-physician relationship”, “Laboratory clinical tests and Instrumental exploration of the body,” and “Glossary of diseases.” In its forty Chapters, a total of 207 issues are described in detail. <![CDATA[Fracturas costales simétricas asociadas a tos]]> Cough may be associated with complications such as syncope, urinary incontinence, pneumothorax, and less frequently, pulmonary hernia and costal fractures. Chronic cough is a cause of rib fractures and when they occur it is likely to affect more than one rib. We report a 53 year-old obese male in treatment with enalapril 10 mg for hypertension with a dry cough lasting five months. He consulted for bilateral chest pain and a Chest X ray examination showed symmetrical fractures in the seventh left and right ribs. Enalapril was discontinued, cough and pain subsided in two weeks. <![CDATA[Desensibilización a levotiroxina. Caso clínico]]> We report a 39-year-old female who underwent a total thyroidectomy as treatment for a thyroid papillary cancer. She suffered several episodes of mild angioedema in lips and tongue, after using different commercial Levothyroxine formulations, with and without excipients. Given the need to use this drug, the patient was admitted in our hospital and we proceeded to desensitize her with oral Levothyroxine. The patient fasted throughout the whole procedure, was properly monitored and had an adequate peripheral venous access. On the first day of the procedure, a 15-step protocol was performed, first administering placebo and then, compounded formulations of Levothyroxine starting from 0.01 ug, followed by doubling doses every 15 minutes until the cumulative dose of 111.95 ug was completed, corresponding to the daily dose of Levothyroxine her endocrinologist prescribed (112 ug). The patient was monitored at baseline, between each dose and up to 3 hours after the procedure was completed. There were no incidents such as urticaria, angioedema, or others. On the second day, the patient received a single-full dose of 112 ug on an empty stomach. The medication was successfully tolerated and she was discharged. Thereafter, she tolerates daily Levothyroxine. <![CDATA[Aplasia medular adquirida y embarazo. Caso clínico]]> Aplastic anemia (AA) or acquired aplastic anemia is an uncommon and potentially fatal disease. It is defined as reduction of at least two peripheral blood series, associated with persistent bone marrow hypocellularity. It's association with pregnancy is even more uncommon, and it may result in high mortality for the mother and the child. We report an adolescent female with aplastic anemia, which worsened during pregnancy. Her hemoglobin was 5.2 g/dl, her leukocytes were 1,833/ul and her platelets were 19,000/ul. She was initially treated with cyclosporine and horse antithymocyte globulin without hematologic improvement. At 36 weeks of pregnancy methylprednisolone and platelet transfusions were used and a cesarean section was performed. Six month later she continues to require red blood cell and platelet transfusions. <![CDATA[Sobre la validación del cuestionario “Evaluación de la Atención de Enfermedades Crónicas para pacientes”]]> Aplastic anemia (AA) or acquired aplastic anemia is an uncommon and potentially fatal disease. It is defined as reduction of at least two peripheral blood series, associated with persistent bone marrow hypocellularity. It's association with pregnancy is even more uncommon, and it may result in high mortality for the mother and the child. We report an adolescent female with aplastic anemia, which worsened during pregnancy. Her hemoglobin was 5.2 g/dl, her leukocytes were 1,833/ul and her platelets were 19,000/ul. She was initially treated with cyclosporine and horse antithymocyte globulin without hematologic improvement. At 36 weeks of pregnancy methylprednisolone and platelet transfusions were used and a cesarean section was performed. Six month later she continues to require red blood cell and platelet transfusions. <![CDATA[Cuarenta años después: Volver a Alma-Ata]]> Aplastic anemia (AA) or acquired aplastic anemia is an uncommon and potentially fatal disease. It is defined as reduction of at least two peripheral blood series, associated with persistent bone marrow hypocellularity. It's association with pregnancy is even more uncommon, and it may result in high mortality for the mother and the child. We report an adolescent female with aplastic anemia, which worsened during pregnancy. Her hemoglobin was 5.2 g/dl, her leukocytes were 1,833/ul and her platelets were 19,000/ul. She was initially treated with cyclosporine and horse antithymocyte globulin without hematologic improvement. At 36 weeks of pregnancy methylprednisolone and platelet transfusions were used and a cesarean section was performed. Six month later she continues to require red blood cell and platelet transfusions.