Scielo RSS <![CDATA[Revista médica de Chile]]> https://scielo.conicyt.cl/rss.php?pid=0034-988720180004&lang=es vol. 146 num. 4 lang. es <![CDATA[SciELO Logo]]> https://scielo.conicyt.cl/img/en/fbpelogp.gif https://scielo.conicyt.cl <![CDATA[Utilidad pronóstica del PET/CT en cáncer de páncreas]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400413&lng=es&nrm=iso&tlng=es Background: Pancreatic cancer is the tenth most prevalent cancer in world, and represents the fourth cause of cancer death. It has a five year-survival of 5%. Aim: To assess the prognostic value of PET/CT in pancreatic cancer. Material and Methods: Sixty-nine patients with pancreatic adenocarcinoma who underwent staging 18F-fluorodeoxyglucose (FDG) PET/CT between December 2008 and July 2016 were selected. Gender, age, body-mass index, laboratory tests (Ca 19-9, hemoglobin, erythrocyte sedimentation rate, liver enzymes, lactate dehydrogenase), histological differentiation of tumor, American Joint Committee on Cancer (AJCC) stage, size and 18F-FDG uptake (maximal stan-dardized uptake value [SUVmax]) of the primary tumor, nodal involvement and distant metastasis detected by PET/CT were registered. Survival was assessed using Kaplan-Meier curves, Log Rank test and Cox multivariable analysis. Results: Mortality was 66.7%, during a mean observation time of 18 months (range 20 days-66 months). Curative surgery, lack of metastases detected by PET/CT, histologically well differentiated tumors, and SUVmax ≤ 4.3 were significantly associated with a better specific survival, determined by the Log Rank test. Histological differentiation was the only variable that had a statistically significant prognostic value in the multivariable analysis. Conclusions: The detection of distant metastases and the intensity of primary tumor 18F-FDG uptake during PET/CT provide useful prognostic information in pancreatic cancer patients. <![CDATA[Variables clínicas y funcionales asociadas al riesgo de muerte en el seguimiento a largo plazo en pacientes con enfermedad pulmonar obstructiva crónica]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400422&lng=es&nrm=iso&tlng=es Background: Identifying risk factors for long-term mortality in patients with chronic obstructive pulmonary disease (COPD) could improve their clinical management. Aim: To examine the clinical variables associated to long-term mortality in a cohort of COPD patients. Patients and Methods: A clinical and respiratory functional assessment, chest computed tomography and clinical follow up for five years was carried out in 202 COPD patients aged 66 ± 9 years (59% males), active or former smokers of 10 or more pack-years. Results: Thirty four percent of patients were active smokers, consuming 46 ± 23 packs/year, 86% had comorbidities, especially chronic cardiovascular and metabolic diseases. Forty-six patients died in the five years follow-up (5-year mortality was therefore 22.8%). In the univariate analysis, the main risk factors associated to long-term mortality were an older age, male sex, dyspnea severity, severe exacerbation risk, chronic respiratory failure, magnitude of lung emphysema, airflow obstruction and lung hyperinflation, reduction of thigh muscle cross-sectional area and physical activity limitation. In the multivariate analysis, the three independent risk factors for long-term mortality were dyspnea severity, chronic hypoxemia and exercise limitation measured with the six minutes’ walk test. Conclusions: Systematic clinical assessment allowed to identify the main risk factors associated with long-term mortality in patients with COPD, which could be used in planning preventive and management programs aimed at the high-risk population. <![CDATA[Tiempo destinado a estar sentado y niveles de adiposidad ¿Cuál es su efecto sobre el desarrollo de diabetes mellitus tipo 2?]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400433&lng=es&nrm=iso&tlng=es Background: Obesity and sedentary behavior are risk factors acting independently in the development of type 2 diabetes. Aim: To investigate whether the association between diabetes and obesity is modified by the levels of sitting time (ST) in the Chilean population. Material and Methods: We included 4,611 participants from the cross-sectional 2009-2010 Chilean National Health Survey in this study. Diabetes was determined as fasting glucose levels ≥126 mg/dl. Body mass index (BMI) and waist circumference (WC) were measured using standardized protocols. Sitting time was assessed using the Global Physical Activity Questionnaire. The association among diabetes, obesity and ST was determined using logistic regression. Results: The odds for diabetes increased by 3.1-fold in people with high levels of ST and obesity in comparison to those with low levels of ST and normal BMI (Odds ratio (OR): 4.17 [95% confidence intervals (CI): 2.87 to 6.05], P &lt; 0.01). The odds for diabetes increased by 2.7- fold in highly sedentary subjects with central obesity (OR: 3.73 [95% IC: 2.61 to 5.33], P &lt; 0.01) in comparison to those with low levels of ST and normal WC. Conclusions: Elevated levels of sitting time and obesity are associated with a higher odds of developing diabetes. <![CDATA[Comparación de los niveles de actividad física durante la vida universitaria]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400442&lng=es&nrm=iso&tlng=es Background: A high percentage of Chilean university students are inactive. Aim: To determine differences in physical activity (PA) levels and energy expenditure in a group of university students according to their length of stay in the university. Material and Methods: We studied 56 students aged 22 ± 2 years (29 women). They wore a triaxial accelerometer during seven days, determining steps/day, steps/min, sedentary time and PA levels. Participants also answered a PA questionnaire. Their weight and height were measured. They were divided in two groups according to the time spent at university (1-2 years and 3-5 years). Results: No significant differences in energy expenditure were observed between both groups of students. The number of steps/day and steps/ min was significantly higher in the group with 3 to 5 years in the university than their counterparts with 1-2 years. Conclusions: As the university years increase, there is a tendency to increase the time spent walking (18.3%) but without an increase in the moderate-vigorous PA. <![CDATA[Implicancias en la actividad física y la salud del Programa CicloRecreoVía en Chile]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400451&lng=es&nrm=iso&tlng=es Background: With approximately 66% of the population overweight and nearly 90% with sedentary lifestyles, obesity has become a major public health problem in Chile. Thus, in the last fifteen years health policies have promoted active lifestyles. An interesting initiative in this context is the CicloRecreoVia program, which closes a set of public streets on Sunday mornings, allowing people to carry out PA in streets free of vehicles. Aim: To characterize PA and mobility patterns of participants of the CicloRecreoVía program in Santiago. Material and Methods: 401 participants of five circuits of the CicloRecreoVia surveyed on the type, frequency and durantion of the PA carried out, their daily mobility habits, motivations for attending the CicloRecreoVia, self-perceived health condition, among other aspects. Results: Participants spent 113 minutes in the CicloRecreoVia, 77% declared walking or bicycling at least 10 minutes per day and 56.7% traveled actively (bicycling or walking) at least four times per week. Finally, 69.1% perceived their health condition “better” or “much better” than one year ago. In addition, it was noted that CicloRecreoVías attracted different type of participants depending on their location in the city. Conclusions: In line with previous studies, most users achieve about 75% of the weekly PA recommended by attending the CicloRecreoVía, and the main motivations to attend the program were to make PA, to be outdoor and to socialize. As a result, the CicloRecreoVía has the potential to become an effective public nationwide health policy to combat obesity. <![CDATA[Miastenia gravis: resultados inmediatos y alejados de la timectomía transesternal extendida]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400460&lng=es&nrm=iso&tlng=es Background: Thymectomy improves clinical outcomes and decreases the need for medical treatment in patients with myasthenia gravis (MG). Aim: To describe the immediate and long-term results of extended transsternal thymectomy (ETT) in patients with MG. Material and Methods: A review of databases, surgical protocols, clinical records and interviews of patients subjected to extended transsternal thymectomy for MG between 1990 and 2016. Perioperative clinical characteristics, anticholinesterase treatment, immediate and remote surgical results were analyzed and patients were followed from one to 10years. Results: We studied 58 patients aged 35 ± 14years (72%) women. In the preoperative period, according to Osserman classification, nine patients (15,5%) were in grade I, eight (13,8%) in grade IIA 8 and 40 (69%) in grade IIB. The pathological study of the surgical piece showed thymic hyperplasia in 39 cases (67,2%). Four patients had postoperative complications but none died. In the Follow-up at 1, 3, 5, 8 and 10years the Masaoka palliation rate was 71.7, 77.5, 67.7, 70.0 and 70,6% respectively. The figures for remission rate were 13.0, 15.0,19.4, 35.0 and 35,3% respectively. The figures for Zielinski positive results were 79.6, 87.5, 87.1, 90.0 and 82,4% respectively. The DeFilippi score improved by 80.4, 87.5, 87.1, 90.0 and 82.4% respectively. The Myasthenia Gravis Foundation of America Post-Intervention State improved by 67.4, 77.5, 77.5, 75.0 and 70,6% respectively. Mean Myasthenia Gravis Activities of daily living (MGADL) and Myasthenia Gravis Quality of life scale 15 (MGQOL 15) were 1.65 and 6.31 respectively. Conclusions: In selected patients with MG, extended transsternal thymectomy in MG has good immediate and long-term results. <![CDATA[Síntomas durante el sueño en pacientes con sospecha de Síndrome de Apnea e Hipopnea Obstruciva del sueño]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400470&lng=es&nrm=iso&tlng=es Background: Obstructive sleep apnea syndrome (OSAS) is a frequent sleep-related breathing disorder being associated with cardiovascular, metabolic and neurobehavioral consequences. Most patients with OSAS are untreated because they are not timely diagnosed. Aim: to determine the association of sleep symptoms and body mass index in patients with OSAS diagnosed by polysomnography. Material and Methods: We studied 144 patients aged 47 ± 14 years (75% males) in whom a polysomnography was done. These patients answered a sleep symptom questionnaire and the Epworth sleepiness scale. Their weight and body mass index was also recorded. Results: Snoring and the presence of pauses during breathing were the symptoms with the higher sensitivity to predict the presence of OSAS. Body mass index was significantly higher among patients with OSAS. No differences in the Epworth scale were observed between patients with and without OSAS. Conclusions: Snoring and apneas while sleeping are symptoms that should lead to the suspicion of the presence of OSAS. <![CDATA[Tamizaje de episodio depresivo en adolescentes. Validación del instrumento PHQ-9]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400479&lng=es&nrm=iso&tlng=es Background: There is a paucity of validated instruments for screening depression in adolescent populations in Chile. Aim: To determine the diagnostic accuracy of the adolescent version of Patient Health Questionnaire-9 (PHQ-9). Material and Methods: The PHQ-9 was transculturally adapted and administered to adolescents aged 15 to 19 years residing in Santiago de Chile, who were then evaluated with a semi structured interview (Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version or K-SADS-PL) and the Beck Depression Inventory. Internal validity, concurrent validity, and discriminatory power of the PHQ-9 were analyzed. Results: We evaluated 245 adolescents aged 16.2 ± 1 years (71% females). Two hundred and ten presented with a depressive episode and 35 were healthy. The sensitivity and specificity of the scale were 86.2 and 82.9% for 11 points, with a positive likelihood ratio of 5.02. Conclusions: The PHQ-9 is sensitive and specific enough to be used as a screening tool in adolescents with suspected depression. At a 11-point cut-off score as proposed, the likelihood to find a positive result in a subject with depression is five times higher. <![CDATA[Mortalidad por cáncer oral en Chile, 2002-2012]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400487&lng=es&nrm=iso&tlng=es Background: Oral cancer is the 15th most common cause of cancer death in the world. In Chile, 1% of all cancer deaths are related to oral and pharyngeal cancer. Aim: To determine mortality rates for oral cancer in Chile and its regions between 2002-2012. Material and Methods: Deaths and their causes between the years 2002-2012 were obtained from the Chilean National Statistics Institute. Crude and adjusted rates by age and sex were calculated for the country and its regions. The denominator was Chilean population on June 30, 2012 and the WHO standard population. Results: In the period studied, 1,611 individuals with a mean age of 67.6 years (63% men) died because of oral cancer. The most common location of the tumor was the tongue in 27% of cases and the parotid gland in 16%. The adjusted mortality rate in Chile was 0.85 / 100,000 inhabitants (1.13 and 0.58 in men and women, respectively). The regions with the highest rates were Antofagasta (1.51), Aysén (1.22) and Magallanes (1.17). Deaths among men occurred at younger ages than women. Conclusions: Mortality rates due to oral cancer in Chile are lower than abroad. The highest rates observed in some regions may be influenced by environmental factors such as arsenic contamination in Antofagasta and the lack of specialists and specialized care centers in Aysén and Magallanes. <![CDATA[Licencia médica psiquiátrica: revisión de los efectos positivos y negativos del reposo]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400494&lng=es&nrm=iso&tlng=es There is no consensus amongst physicians, social security representatives and researchers about optimum sick leaves. This is an indication that should maximize positive outcomes and minimize potential side effects, both for the patient and society. The use of sick leaves during the last decade rose steadily, particularly in the psychiatric field. The most important causes of this increase are: changes in public policies, overuse of psychiatric diagnosis to cover up unmet social needs, and modifications to labour structure. It is analysed the impact that this situation has implied for physician patient relationship as well as for health budget. Even though sick leave diminishes presentism associated to a psychiatric disorder, published evidence about the effect of prolonged sick leave shows that damage overruns potential benefits: augmented morbidity and mortality, workplace phobia, economic loss, among others. <![CDATA[Hiperglicemia por sepsis: del mecanismo a la clínica]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400502&lng=es&nrm=iso&tlng=es Stress hyperglycemia is frequently diagnosed in septic patients in critical care units (ICU) and it is associated with greater illness severity and higher morbimortality rates. In response to an acute injury, high levels of counterregulatory hormones such as glucocorticoids and catecholamines are released causing increased hepatic gluconeogenesis and insulin resistance. Furthermore, during sepsis, proinflammatory cytokines also participate in the pathogenesis of this phenomenon. Septic patients represent a subtype of the critical ill patients in the ICU: this metabolic disarrangement management strategies and insulin therapy recommendations had been inconsistent. In this article, we describe the pathophysiological mechanisms of stress hyperglycemia in critical patients including the action of hormones, inflammatory cytokines and tissue resistance to insulin. In addition, we analyzed the main published studies for the treatment of acute hyperglycemia in critical patients. <![CDATA[Internación psiquiátrica involuntaria. Antecedentes, reflexiones y desafíos]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400511&lng=es&nrm=iso&tlng=es The United Nations Convention on the Rights of Persons with Disabilities Article 12 General Commentary, explicitly states that persons with mental illnesses must always have full exercise of their legal rights in all their aspects. Assistants or support persons must not substitute or have undue influence on the decisions of persons with disabilities, including the expression of their consent. However, the number of involuntary psychiatric hospitalizations appears to be increasing globally and in our country. This article reviews the national and international context of involuntary hospitalizations, including the Chilean legislation and administrative rules, the published evidence about patients' outcomes and clinician attitudes. The authors conclude that the conflict in this issue is not limited to the respect for autonomy and the obligation to provide care. We are now experiencing a new way of caring patients. The complex local, social and cultural realities, require a renewed knowledge and documentation of experiences. <![CDATA[Análisis ético de la entrega parcial de información al paciente para prevenir efectos nocebo]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400518&lng=es&nrm=iso&tlng=es When prescribing a treatment, the physician should give truthful information about the likely benefits and the potential adverse effects, allowing the patient to make an autonomous decision about whether to take the treatment. However, the mere expectation of adverse effects may precipitate the corresponding symptoms. This is called “nocebo effect”, which in contrast to the placebo effect, can lead to harm to the patient due to psychological factors. Nocebo effects are common and clinically significant, although often unnoticed. This situation generates conflicts in medical ethics guiding principles, namely the moral obligation to disclose all possible effects of the prescribed drug as opposed to the duty of avoiding the harm of side effects that are likely to occur in a case. In other words, the physician faces a dilemma between the due respect for autonomy and the duty of non-maleficence. This article reflects about this conflict, by exploring the limits of the principle of autonomy and how to balance it with the principle of non-maleficence. We suggest an interpretation of the principle of autonomy from a patient-centered perspective, suggesting that it is ethically sound to give a prudential, partial disclosure of information to the patient, for the sake of avoiding potential nocebo effects. The article concludes with some cautionary considerations to be considered about this decision. <![CDATA[Necrolisis epidérmica tóxica en el curso de un síndrome hemofagocítico secundario a linfoma de Hodgkin. Caso clínico]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400523&lng=es&nrm=iso&tlng=es Toxic epidermal necrolysis (TEN) is a lethal entity, characterized by extensive epidermal necrosis and multiorgan failure. Hemophagocytic syndrome (HFS) is also a rare and lethal syndrome characterized by hyperinflammation that leads to the appearance of fever, pancytopenia, organomegaly and hemophagocytosis. The concomitance of these diseases is extremely uncommon. We report a 38 years old female, who during the course of a HFS secondary to Hodgkin Lymphoma (HL), presented a TEN secondary to antibiotics. She was admitted due to a consumptive syndrome, lymphadenopathy, visceromegaly and severe pancytopenia. Laboratory and bone marrow tests confirmed HFS. Due to constant fever, imipenem was indicated. On the third day she started with pain and skin rash. She evolved with positive Nikolsky sign. Cutaneous biopsy was concordant with extensive TEN, which was managed with intravenous immunoglobulin and dexamethasone. A complete response and normalization of the blood count were achieved. Finally, the lymph node biopsy showed HL of mixed cellularity type, which was managed with 8 cycles of ABVD chemotherapy, achieving complete remission. <![CDATA[Hemoptisis como manifestación inicial de la enfermedad de Behçet. Casos clínicos]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400528&lng=es&nrm=iso&tlng=es Arterial involvement in Behçet's disease (BD) is less common than venous lesions. The most commonly affected arteries are: the aorta, lower extremity arteries, mesenteric, femoral, coronary, renal, subclavian and pulmonary arteries. The rupture of pulmonary arteries is the main cause of death of patients with EB and the presence of aneurysms is a bad prognostic factor. We report two patients with arterial involvement in BD. A 14 years old male presenting with hemoptysis lasting three days. A chest computed tomography showed an aneurismal dilatation of the right interlobar artery, bilateral intramural thrombi and alveolar hemorrhage. A right lobar pulmonary resection was performed but hemoptysis recurred. Suspecting a BD, prednisone was started and hemoptysis subsided. A 42 years old male presenting with chest pain and hemoptysis. A chest CT scan showed thrombi in pulmonary veins and anticoagulant therapy was started. Two months later he was admitted again due to a massive hemoptysis. The CT scan showed aneurisms in pulmonary arteries, mural thrombi and pulmonary infarction. With the diagnosis of BD, methylprednisolone, followed by prednisone and cyclophosphamide were used, with a good clinical response. <![CDATA[Oligoartritis, paniculitis y pioderma gangrenoso como manifestaciones de un Linfoma no Hodgkin]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400534&lng=es&nrm=iso&tlng=es An assortment of clinical and laboratory abnormalities may occur as paraneoplastic syndromes in lymphomas. Rheumatological and dermatological manifestations such as paraneoplastic arthritis and pyoderma gangrenosum must be underscored. We report a 28 years old woman who developed pyoderma gangrenosum and two years later presented with arthritis of knees and ankles associated with panniculitis interpreted as erythema induratum that was pathologically confirmed. She developed a reactivation of pyoderma gangrenosum, that was refractory to treatment. Complementary studies showed a pulmonary nodule and a right paravertebral mass with involvement of the psoas muscle. Biopsies of both masses and a new pathological skin study demonstrated a large B-cell non-Hodgkin's lymphoma. <![CDATA[Evaluación de la empatía en medicina]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400538&lng=es&nrm=iso&tlng=es An assortment of clinical and laboratory abnormalities may occur as paraneoplastic syndromes in lymphomas. Rheumatological and dermatological manifestations such as paraneoplastic arthritis and pyoderma gangrenosum must be underscored. We report a 28 years old woman who developed pyoderma gangrenosum and two years later presented with arthritis of knees and ankles associated with panniculitis interpreted as erythema induratum that was pathologically confirmed. She developed a reactivation of pyoderma gangrenosum, that was refractory to treatment. Complementary studies showed a pulmonary nodule and a right paravertebral mass with involvement of the psoas muscle. Biopsies of both masses and a new pathological skin study demonstrated a large B-cell non-Hodgkin's lymphoma. <![CDATA[Competencia comunicativa intercultural: un desafío para los profesionales de la salud en Chile]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000400539&lng=es&nrm=iso&tlng=es An assortment of clinical and laboratory abnormalities may occur as paraneoplastic syndromes in lymphomas. Rheumatological and dermatological manifestations such as paraneoplastic arthritis and pyoderma gangrenosum must be underscored. We report a 28 years old woman who developed pyoderma gangrenosum and two years later presented with arthritis of knees and ankles associated with panniculitis interpreted as erythema induratum that was pathologically confirmed. She developed a reactivation of pyoderma gangrenosum, that was refractory to treatment. Complementary studies showed a pulmonary nodule and a right paravertebral mass with involvement of the psoas muscle. Biopsies of both masses and a new pathological skin study demonstrated a large B-cell non-Hodgkin's lymphoma.