Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 146 num. 10 lang. en <![CDATA[SciELO Logo]]> <![CDATA[Survival of patients with advanced HER2+ breast cancer. Analysis of a cancer center database]]> Background: HER2+ breast cancer (BC) subtype overexpresses the Human Epidermal growth factor Receptor type-2 (HER2) and is characterized by its aggressiveness and its high sensitivity to monoclonal antibody-based HER2-targeted therapies. Aim: To assess the prognosis and evaluate the impact of novel anti-HER2 therapies on advanced HER2+ BC patients treated at our institution over the last decades. Material and Methods: Analysis of the patient database at a cancer center of a university hospital. Information about the subtype of cancer was obtained in 2,149 of 2,724 patients in the database. Eighteen percent of the latter were HER2+. We analyzed data of 83 of these patients with advanced disease. Results: Median overall survival (OS) was 24 months. For patients treated between 1997-2006 median OS was 17 months and for those treated in the period 2007-2017 median OS was 32 months (p = 0.09). Conclusions: A non-significant trend towards better survival in the last decade was observed. HER2+ BC overall survival has improved in our center. This can be probably attributed to the use of novel more effective anti-HER2 therapies. <![CDATA[Lung cancer presenting as cystic lesions. Report of eight cases]]> Background:: Pulmonary cystic nodules are a relatively frequent finding in chest computed tomography (CT). There is a possible association between this finding and lung cancer. Aim: To report eight patients with malignant lung cystic lesions. Material and Methods: Retrospective analysis of images in a CT database from 2007 to 2015, looking for cystic lesions of the lung with wall thickening, whose pathological diagnosis was lung cancer. Results: We identified eight patients with cystic nodules aged 44 to 77 years, of which five were women. Six were active and two former smokers. The pathological diagnosis was adenocarcinoma in seven cases and squamous cell in one. The mean diameter of the cystic lesions was 11.5 mm. The mean diagnostic delay time was 871 days (range 0-1592). The main finding was a gradual thickening of the nodule walls. Conclusions: The presentation of lung cancer as cystic nodules is uncommon. In this series, the change in morphology due to a thickening of the walls with or without a diameter increase, was the clue for the diagnosis. <![CDATA[High prevalence of dyslipidemia and high atherogenic index of plasma in children and adolescents]]> Background: Dyslipidemias in childhood increase the risk of cardiovascular events in adult life. Aim: To evaluate the prevalence of dyslipidemia and risk of atherogenicity based in the atherogenic index of plasma (AIP) in a sample of school children and adolescents. Material and Methods: Cross-sectional study of 208 children aged 10.4 ± 1.0 years (107 women). Demographic data were obtained, and a clinical evaluation was conducted, including pubertal development according to Tanner and anthropometric parameters. A fasting blood sample was obtained to measure total cholesterol (CT), HDL cholesterol (cHDL) and triglycerides (TG), glucose and insulin. LDL cholesterol (cLDL), Non-HDL cholesterol and the indices CT/cHDL, cLDL/cHDL and AIP (log[TG/cHDL]) were calculated. Risk categories according to AIP for the pediatric population were also determined (low: AIP &lt; 0.11, intermediate: AIP 0.11-0.21, high: AIP &gt; 0.21). Results: Thirty eight percent of participants had dyslipidemia, without differences by gender and pubertal development. The frequency of dyslipidemia was significantly higher in children with obesity (54%, p &lt; 0.01) and a waist circumference over percentile 90 (61%; p &lt; 0.01). The later conditions had also higher CT/cHDL, cLDL/cHDL and AIP. According to AIP, 54% of children had a high atherogenicity risk along with alterations in anthropometric parameters and insulin resistance. All anthropometric and insulin resistance parameters were significantly correlated with the AIP. Conclusions: There is a high prevalence of dyslipidemia in the studied population, which is associated with an increased cardiometabolic risk. The indices of atherogenicity and particularly AIP are correlated with nutritional status, abdominal obesity and parameters of insulin resistance. <![CDATA[Accuracy of sleep questionnaires for obstructive sleep apnea syndrome screening]]> Background: Simple but accurate tools should be used to identify patients with obstructive sleep apnea syndrome (OSAS), aiming at an early detection and prevention of serious consequences. Aim: To assess the predictive value of four sleep questionnaires (Berlin, Epworth Sleepiness Scale [ESS], STOP, and STOP-Bang) in the screening of patients with OSAS. Material and Methods: The four sleep questionnaires were administered to 1,050 snorers aged 56 ± 15 years (68% males) assessed at a sleep clinic. An overnight unattended respiratory polygraphy was performed to all patients to confirm the diagnosis of OSAS. The sensitivity, specificity, positive and negative predictive values of the four questionnaires were calculated. Results: Eighty four percent of participants had OSAS. The clinical variables associated with OSAS risk were age, male gender, hypertension, overweight, cervical circumference, waist/hip ratio, history of snoring, witnessed apneas and nycturia. Eighty-three, 86, 92 and 46 % of cases were classified as having a high risk for OSAS, according to the Berlin, STOP and STOP-Bang questionnaires and ESS, respectively. STOP and STOP-Bang questionnaires had the highest sensitivity to predict OSAS (88 and 95%, respectively) while the Flemons Index had the highest specificity (82%). Conclusions: Sleep questionnaires were able to identify patients with a high risk for OSAS but without accurately excluding those at low risk. <![CDATA[Social support, self-rated health, treatment adherence and effectiveness in patients with type II diabetes and hypertension]]> Background: A high level of social support (SS) is associated with better health outcomes in many conditions, such as chronic diseases. Aim : To describe the level of SS in patients with Hypertension and type II Diabetes at Primary Health Care level in Chile and its association with self-rated health, adherence to treatment and better glycemic and blood pressure control. Material and Methods : SS was measured using a social support inventory previously validated in Chile. Self-Rated Health was assessed with a single non-comparative general question; adherence to medication was assessed using the four-item Morisky medication adherence scale. Blood glucose and blood pressure control were also assessed. A logistic regression was performed to estimate Prevalence Odds Ratio (POR) and Robust Poisson method to estimate the Prevalence Ratio (PR). Results : Eighty three percent of the 647 participants evaluated high for SS. There was a significant correlation between SS and Self-rated health (POR 2.32; 95% confidence intervals (CI) 1.19-11.23; PR 1.18; 95% CI 1.07-1.31). No statistically significant association was observed with medication adherence, glycemic or blood pressure control. Conclusions: High levels of SS were found. The association between self-rated health suggests that SS interventions targeting vulnerable subgroups would be worthwhile. <![CDATA[Reference values for the senior fitness test in Chilean older women]]> Background:: The Senior Fitness Test (SFT) is frequently used to assess physical fitness and functional independence in older people. Aim: To establish reference values for the SFT in Chilean physically active older women according to age ranges. Material and Methods: Cross-sectional study that included 1048 Chilean women aged between 60 and 85 years. Chair stand (CS), arm curl (AC), two-min walk (2 min), chair sit-and-reach (CSr), back scratch (BS), and timed up-and-go test (TUG) were evaluated. The reference values are presented in percentiles (p5, p10, p25, p50, p75, p90 and p95) and are distributed age intervals (60-64, 65-69, 70-74, 75-79 and ≥ 80 years). Results: There was a decrease in strength (CS and AC), aerobic resistance (2 min) and flexibility (CSr and BS) along with age, whereas the time required to perform the timed up and go increased along with age. Conclusions: Physically active older women show a deterioration in physical fitness along with age. These women have higher reference values in CS, AC, 2 min and CSr, and lower in BS and TUG, than those reported abroad for the SFT. <![CDATA[Psychological variables associated with adherence to treatment and complications in patients with type 2 diabetes mellitus]]> Background:: Lack of adherence to treatment may hamper the management of type 2 Diabetes Mellitus. Aim To identify if there is a profile of psychological variables associated with adherence to treatment and complications in patients with type 2 diabetes mellitus. Material and Methods: The psychometric instruments Multidimensional Scale of Locus of Control in Health, Locus of Control of Rotter and Inventory of Temporary Orientation of Zimbardo &amp; Boyd were applied to 192 patients aged 64 ± 10 years (78% women) with type 2 diabetes attending public primary health clinics. Adherence to treatment was assessed using glycosylated hemoglobin levels. Results: There was an inverse association between glycosylated hemoglobin and adherence to treatment (p &lt; 0.01). Adherence in patients with renal damage and diabetic foot was associated with the psychological variables Negative Time Perspective Profile (p &lt; 0.05) and External Locus of Control Powerful Other (p &lt; 0.05). Conclusions: A psychological profile associated with adherence was observed in the presence of kidney damage and diabetic foot. A fatalistic present and a negative past are the outstanding features of a negative temporal profile. <![CDATA[Epithelial tumors of salivary glands. Review of 286 pathology reports]]> Background:: Epithelial tumors of the salivary glands, including benign tumors and aggressive malignancies with different prognoses, are uncommon. Aim: To describe the frequency and distribution of salivary gland tumors according to age, gender and anatomical location. Material and Methods: Review of pathological reports of salivary gland tumors of a Pathology laboratory at a clinical hospital from 2006 to 2016. Results: Five hundred ninety salivary gland biopsies were reviewed. Of these, 286 (49%) were primary epithelial tumors of the salivary glands. Two hundred thirty (80%) were benign and 56 (20%) were malignant tumors. Regarding location, 274 (96%) were in the major salivary glands, and 12 (4%) in the minor salivary glands. The most common histological types were pleomorphic adenoma for benign tumors in 172 cases, followed by papillary cystadenoma lymphomatosum in 33 cases. Mucoepidermoid carcinoma was the most common malignant tumor in 14 cases. Conclusions: These results are similar to reports from abroad, however more studies are necessary to be able to establish a more representative and updated analysis. <![CDATA[Knowledge among physicians of the main cause of death in women]]> Background: There is a misconception that the main cause of death among women is breast cancer, even among physicians, who may neglect cardiovascular preventive measures in this gender Aim: To assess the knowledge among physicians about the main cause of death among women. Material and methods: A survey was answered by 231 physicians attending a Cardiology and a Gynecology Meeting. Results: Sixty eight percent of respondents indicated that cardiovascular diseases are the main cause of death among women. A higher proportion of specialists than trainees, answered correctly the question (72 and 56% respectively). No gender differences in the answers were recorded. Conclusions: The knowledge about cardiovascular risk in women should be reinforced among physicians. <![CDATA[Does menopause hormone therapy reduce the risk of chronic diseases?]]> The hormonal deficit of post menopause is not only linked to the classic hot flashes, but also to a higher risk of chronic diseases. Menopausal hormone therapy (MHT) adequately treats climacteric symptoms and can prevent some chronic diseases such as osteoporosis. The Women’s Health Initiative (WHI) study, which indicated risks of MHT in elderly postmenopausal women, caused a massive withdrawal of this therapy. But, in recent years the results of the WHI have been challenged by methodological problems and by several studies indicating that, if MHT is initiated early and the non-oral route is preferred, the risks could be minimized and it could improve not only the quality of life but also reduce the risk of chronic diseases. However, the US Preventive Services Task Force (USPSTF) recommends against the use of MHT for the prevention of chronic diseases, a position that has been challenged by publications of the North American Menopause Society and the International Menopause Society. This controversy persists so far. We report data that suggest a preventive role of MHT in perimenopausal women. <![CDATA[Consensus statement of the Chilean endocrinological society on the role of bariatric surgery in type 2 diabetes]]> Diabetes Mellitus (DM) and obesity are a public health problem in Chile. Bariatric surgery is the most effective treatment alternative to achieve a significant and sustained weight reduction in patients with morbid obesity. The results of controlled clinical trials indicate that, compared to medical treatment, surgery for obese patients with DM2 allows a better control of blood glucose and cardiovascular risk factors, reduces the need for medications and increases the likelihood for remission. Consensus conferences and clinical practice guidelines support bariatric surgery as an option to treat DM2 in Class III Obesity (Body Mass Index (BMI) &gt; 40) regardless of the glycemic control and the complexity of pharmacological treatment and in Class II Obesity (BMI 35-39,9) with inadequate glycemic control despite optimal pharmacological treatment and lifestyle. However, surgical indication for patients with DM2 and BMI between 30-34.9, the most prevalent sub-group, is only suggested. The Chilean Societies of Endocrinology and Diabetes and of Bariatric and Metabolic Surgery decided to generate a consensus regarding the importance of other factors related to DM2 that would allow a better selection of candidates for surgery, particularly when weight does not constitute an indication. Considering the national reality, we also need a statement regarding the selection and characteristics of the surgical procedure as well as the role of the diabetologist in the multidisciplinary team. <![CDATA[The uncertainties of statistical “significance”]]> Statistical inference was introduced by Fisher and Neyman-Pearson more than 90 years ago to define the probability that the difference in results between several groups is due to randomness or is a real, “significant” difference. The usual procedure is to test the probability (P) against the null hypothesis that there is no real difference except because of the inevitable sampling variability. If this probability is high we accept the null hypothesis and infer that there is no real difference, but if P is low (P &lt; 0.05) we reject the null hypothesis and infer that there is, a “significant” difference. However, a large amount of discoveries using this method are not reproducible. Statisticians have defined the deficiencies of the method and warned the researchers that P is a very unreliable measure. Two uncertainties of the “significance” concept are described in this review: a) The inefficacy of a P value to discard the null hypothesis; b) The low probability to reproduce a P value after an exact replication of the experiment. Due to the discredit of “significance” the American Statistical Association recently stated that P values do not provide a good measure of evidence for a hypothesis. Statisticians recommend to never use the word “significant” because it is misleading. Instead, the exact P value should be stated along with the effect size and confidence intervals. Nothing greater than P = 0.001 should be considered as a demonstration that something was discovered. Currently, several alternatives are being studied to replace the classical concepts. <![CDATA[Oscar Castro Zúñiga, the poet who succumbed to tuberculosis]]> The life of the renowned Chilean writer, Oscar Castro Zúñiga, was interrupted early, when he was 37 years old. He acquired tuberculosis during the epidemic in our country between the second half of the nineteenth century and the first half of the twentieth century. He developed the disease during a crucial stage in terms of diagnosis and treatment, coinciding with the end of the sanatorium stage and the first chemotherapeutic attempts. The symptoms and treatments of the disease in that age are described analyzing the letters, both written by himself and by people close to him and the biographies published during the historical and personal context of the artist. <![CDATA[A standardized objective structured clinical examination to assess clinical competencies in medical students]]> Background: Outcomes-based education is a trend in medical education and its assessment is one of the main challenges. The Objective Structured Clinical Examination (OSCE) is one of the tools used to assess clinical competencies. Although Chilean medical schools have used OSCEs for 18 years, there is a vast variability in the way these examinations are administered. Aim: To design and implement an integrated OSCE to assess clinical competencies at the end of the medical program in Chilean medical schools, aiming to reduce variability between these schools. Material and Methods: Seven medical schools, supported by experts from the National Board of Medical Examiners, designed a 12 station OSCE to measure clinical outcomes at the end of the seventh year of medical training. Unlike traditional OSCEs, this new examination incorporated the assessment of clinical reasoning and communication skills, evaluated from patients’ perspective. Results: One hundred twenty-five volunteers took the same exam at five different venues. The internal consistency was 0.62. Following a compensatory approach, 85% of students passed the exam. Communication assessment showed poorer results than those reported in the literature. Conclusions: Among Chilean medical students, the assessment of clinical outcomes in a collaborative way, through a valid and reliable exam, is feasible. A consensus on how to teach and assess clinical reasoning across the medical curriculum is required. The assessment of students’ communication skills requires further development. <![CDATA[Primary squamous cell carcinoma of the stomach. Report of three cases]]> Gastric squamous cell carcinoma (SCC) is a rare type of cancer. We report three patients with the tumor. A 65 years old male presenting with weight los and heartburn. An upper gastrointestinal endoscopy revealed an ulcerated tumor whose biopsy disclosed a gastric epidermoid carcinoma. The patient was operated and chemotherapy was attempted, but he died five months later. A 39 years old male with an antral tumor corresponding to an epidermoid carcinoma. He was operated and received chemotherapy and radiotherapy and died one year later. A 79 years old female with a distal antral tumor corresponding to a undifferentiated epidermoid carcinoma. She received palliative therapy and died two months later. <![CDATA[Paradoxical embolism due to a persistent patent foramen ovale. Report of one case]]> Abstract: Patent Foramen Ovale (PFO) is one of the most frequent congenital defects in adults. Its prevalence in middle-aged adults is close to 25-30% and may cause paradoxical embolic phenomena. We report a 45 years old male admitted for an ischemic stroke with an occlusion of the left terminal internal carotid artery. A thrombectomy was performed. Searching for possible sources of emboli, a patent foramen ovale was detected in an echocardiography, with an hypoechogenic examination image passing through it. Anticoagulant therapy was started and the patient had an uneventful evolution. <![CDATA[Liver transplantation in a patient with human immunodeficiency virus (HIV). Case report]]> Abstrac: Before the advent of highly active antiretroviral therapy (HAART), patients infected with human immunodeficiency virus (HIV) were considered as having an absolute contraindication for liver transplantation (LT). Considering the increased life expectancy in HIV positive patients under HAART and the improvements in the management of graft recipients, these patients are now suitable for carrying out transplants in selected cases. We report a 26 years old HIV positive male who developed acute liver failure possibly caused by drug induced liver injury who underwent a successful liver transplantation. <![CDATA[Intravenous radioiodine and recombinant human TSH in a patient with extensive thyroid cáncer. Report of one case]]> Abstract: We report a 72-years-old male patient with extensive differentiated thyroid cancer (DTC), who required a tracheostomy and gastrostomy. Considering his clinical condition, risk of aspiration and management of the ostomies, radioiodine (131I) was administered intravenously, using recombinant human thyrotropin (rhTSH) and levothyroxine. The procedure was successful, both clinically and in terms of radioprotection. <![CDATA[Aging inserted in health care curriculum: challenges and proposals]]> Abstract: We report a 72-years-old male patient with extensive differentiated thyroid cancer (DTC), who required a tracheostomy and gastrostomy. Considering his clinical condition, risk of aspiration and management of the ostomies, radioiodine (131I) was administered intravenously, using recombinant human thyrotropin (rhTSH) and levothyroxine. The procedure was successful, both clinically and in terms of radioprotection. <![CDATA[Stroke: Public Health when time is brain]]> Abstract: We report a 72-years-old male patient with extensive differentiated thyroid cancer (DTC), who required a tracheostomy and gastrostomy. Considering his clinical condition, risk of aspiration and management of the ostomies, radioiodine (131I) was administered intravenously, using recombinant human thyrotropin (rhTSH) and levothyroxine. The procedure was successful, both clinically and in terms of radioprotection.