Scielo RSS <![CDATA[Revista médica de Chile]]> https://scielo.conicyt.cl/rss.php?pid=0034-988720180011&lang=pt vol. 146 num. 11 lang. pt <![CDATA[SciELO Logo]]> https://scielo.conicyt.cl/img/en/fbpelogp.gif https://scielo.conicyt.cl <![CDATA[Seasonal variation in hospital admissions due to acute myocardial infarction according to sex and age in Chile]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101233&lng=pt&nrm=iso&tlng=pt Background: The incidence of acute myocardial infarction (AMI) varies according to seasonality, being higher in winter. The effect of sex on this phenomenon is not clear. Aim: To evaluate the effect of seasonality in men and women hospitalized for AMI at different ages. Material and Methods: We included all patients with a primary diagnosis of AMI admitted in public and private hospitals in Chile during 2002-2011 (codes I21-I22, of the tenth international classification of diseases). We obtained data from the National Discharge databases available at the Ministry of Health website. We estimated the number of discharges per month and per seasonality (cold /template), and the Standardized Incidence Ratio (SIR) with the formula: number of observed cases/expected cases (average annual hospitalizations), stratified by sex and age (&lt; 50 years, 50-64 years, 6574 years, ≥ 75 years). We evaluated the effect of sex with binomial regressions for the different age strata. Results: We assessed 59,557 AMI hospitalizations (69% men, with and without ST elevation segment). May, June and July (austral winter) had a SIR of 1.10; 1.12 and 1.10, respectively. Women had a 20% excess of hospitalizations during cold seasons at any age. In men, the excess of hospitalizations increased from 9% in those aged &lt; 50 years to 21% in those ≥ 75 years (p = 0.043). When comparing women and men, women aged &lt; 50 years showed the higher risk of being hospitalized during cold seasons (adjusted risk ratio = 1.06; 95% confidence intervals 1.01-1.13). Conclusions: Women have a stronger seasonal pattern in AMI hospitalizations than men. While this effect increases with age in men, in women it remains constant at all ages. <![CDATA[Usefulness of therapeutic monitoring of infliximab in the treatment of inflammatory bowel disease]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101241&lng=pt&nrm=iso&tlng=pt Background: Primary non-response and secondary loss of response (LOR) are significant problems of biological therapy for inflammatory bowel disease (IBD). Therapeutic drug monitoring (TDM) in IBD patients receiving these drugs can improve outcomes. Aim: To measure serum infliximab levels and anti-infliximab antibodies (ATI) in patients with IBD post-induction phase and during maintenance therapy assessing the clinical course of IBD. Patients and Methods: Prospective study of IBD patients receiving infliximab between July 2016-May 2017. Group-A included patients who received induction therapy while Group-B included patients who were in maintenance therapy. TDM was performed in serum samples collected at weeks-14 and 30 in Group-A and before the infliximab maintenance dose in Group-B. Clinical scores, fecal calprotectin and endoscopic score were also evaluated. Results: Of 14 patients in Group-A, 57% achieved endoscopic response. Median serum infliximab concentrations at week-14 and 30 were 2.65 AU/mL (0.23-32.58) and 2.3 AU/mL (0.3-16.8), respectively. Patients with mucosal healing had non-significantly higher median infliximab concentrations at week- 14, as compared to week 30 (median 3.2 vs 2.2 AU/ml, respectively, p 0.6). ATI &gt;10 ug/mL were found in one and seven patients at week-14 and 30, respectively. At 52 weeks of follow-up, four patients (31%) had LOR. Group-B included 36 patients, 33% had LOR. Median serum concentrations of infliximab were 1.4 AU/mL (0.27-7.03). No significant differences in serum infliximab concentration were observed between patients in remission and those with inflammatory activity. Seventeen patients had ATI &gt;10 ug/mL. Conclusions: Clinical algorithms using TDM might help to optimize the pharmacological therapy of IBD. <![CDATA[Association of the FTO (rs9939609) genotype with energy intake]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101252&lng=pt&nrm=iso&tlng=pt Background: Fat-mass-associated-gene (FTO) is associated with higher energy intake and specific food preferences. Aim: To investigate the association of the FTO genotype with energy intake, macronutrient and alcohol consumption. Material and Methods: Four hundred and nine participants of the GENADIO (Genes, Environment, Diabetes and Obesity) study were included. Energy intake, macronutrient and alcohol consumption were the outcomes of interest. The association of FTO (rs9939609) genotype with these outcomes was investigated using linear regression analyses, adjusting for confounding variables. Results: After adjusting for socio-demographic factors, being a carrier of the risk allele for the FTO gene was associated with a higher energy intake (173 kcal per each extra copy of the risk variant [95% confidence intervals (CI): 45; 301], (P = 0.008). After adjusting for lifestyle factors and body mass index, the association was slightly attenuated but remained significant (144 kcal [95% CI: 14; 274], p = 0.030). Conclusions: The FTO genotype is associated with a higher energy intake. <![CDATA[Features of excised pulmonary nodules in 100 patients]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101261&lng=pt&nrm=iso&tlng=pt Background: Pulmonary nodules are common, and surgery is the only alternative that allows a diagnostic and therapeutic management in a single procedure. Aim: To report the epidemiological, radiological, surgical and pathological features of excised pulmonary nodules. Material and Methods: Review of medical records of patients in whom a pulmonary nodule was excised between 2014 and 2018. Those with incomplete data or without a pathological study were excluded from analysis. Results: We retrieved 108 records and 8 had to be excluded, therefore 100 patients aged 34 to 82 years (57% females) were analyzed. Sixty percent had a history of smoking. Mean nodule size was 16 mm and the solid type was the most common (65%). Forty five percent of nodules had irregular margins and 55% were in the superior lobes. All patients operated by video-assisted thoracoscopic surgery and 40% underwent a lobectomy. Malignant lesions were observed in 87% of biopsies and a pulmonary adenocarcinoma was found in pathology in 40%. Conclusions: A multidisciplinary approach of pulmonary nodules, using adapted international guidelines, accomplishes an appropriate management, decreasing unnecessary surgical interventions. <![CDATA[Effectiveness of a case management intervention for high blood pressure and type II diabetes in primary health care]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101269&lng=pt&nrm=iso&tlng=pt Background: Adequate management of high blood pressure (HBP) and Type 2 Diabetes (DM2) is a challenge to the healthcare system in Chile. Aim: To evaluate the effectiveness of a case management (CM) approach to manage HBP and DMII at Primary Healthcare (PHC) level, headed by healthcare technicians with the supervision of registered nurses. Material and Methods: Two primary health care centers were selected. In one the case management approach was used and the other continued with the usual care model. Patients with HBP or DM2 were selected to participate in both centers. The main outcomes were changes blood pressure and glycosylated hemoglobin levels. Results: Three hundred twenty-eight patients were allocated to the intervention group and 316 to control group. At the baseline evaluation, participants at the control health center had better systolic and diastolic BP levels (SBP and DBP), but no difference in glycosylated hemoglobin. After twelve months the adjusted mean difference in HBP patients for SBP was −0.93 (95% conficence intervals (CI) −5.49,3.63) and for DBP was 1.78 (95%CI −2.89,6.43). Among HBP+DMII patients, the mean difference for SBP was −0.51 (95% −0.52,0.49) and for DBP was −3.39 (95%CI −6.07, −0.7). No differences in glycosylated hemoglobin were observed. In a secondary analysis, the intervention group showed a statistically significant higher SBP and DBP reduction than the control group. Conclusions: The case management approach tested in this study had promissory results among patients with high blood pressure. <![CDATA[Longitudinal association between chronic psychological stress and metabolic syndrome]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101278&lng=pt&nrm=iso&tlng=pt Background: Psychological stress and depressive symptoms are variables associated with metabolic syndrome (MetS). Aim: To determine the longitudinal association between psychological stress, depressive symptoms and MetS, and whether these variables predict MetS and its component trajectories. Material and Methods: Four hundred and twenty-three participants aged 44 ± 9 years (59% women), free of cardiovascular disease at baseline were enrolled into the Chilean study of psychological stress, obesity and MetS. Participants were followed-up for three years (three waves). Each year, they completed psychological questionnaires, anthropometric variables were measured, and blood samples were obtained. Results: Hierarchical linear regression showed that chronic psychological stress at baseline predicted the total number of MetS components (MetS score) during the third assessment wave (β = 0.147; p &lt; 0.01). Growth curve modeling allowed to determine that participants who scored +1 standard deviation (SD) at baseline over the mean in psychological stress (βchronic stress = 0.903; 95% confidence intervals (CI) = 0.065; 1.741), and depressive symptoms (βdepressive symptoms = 2.482; 95% CI = 0.040; 4.923) had a higher waist circumference trajectory, as compared to those scoring −1 SD above the mean. Conclusions: Chronic psychological stress is longitudinally associated with the MetS score. Further, psychological stress and depressive symptoms at baseline predicted elevated MetS score trajectories, and a highest waist circumference. <![CDATA[Decisional conflict among people with diabetes mellitus or hypertension attending primary care]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101286&lng=pt&nrm=iso&tlng=pt Background: Decisional conflict refers to the personal uncertainty about which course of action to take when the choice involves risk, regret, or challenge to personal life values. Aim: To determine the level of decisional conflict (DC) of people with Diabetes Mellitus (DM) or High Blood Pressure (HBP) attending primary care centers (PCC) in Chile. Patients and Methods: A Spanish version of the Decisional Conflict Scale (DCS) was applied to patients who were recruited if they had DM or HBP, were 18 years old or older, and had an appointment at the PCC the day of the recruitment. The scale was self-administered. Analysis of covariance (ANCOVA) was used to determine association between DC and other variables of interest while controlling confounding variables. Results: The scale was answered by 1075 participants from 24 PCC aged 62 ± 14 years (74% female). Average score for the DCS scale was 16.8 ± 12.9 of a maximum of 100 points indicating a higher DC. The sub-scale “information” had the highest score (19.9 ± 20.0). Low educational level and older age were significantly associated with higher DCS scores (p &lt; 0.05). Having a bad health perception, deciding to initiate a medical treatment and being attended by a doctor were significantly associated with higher DC. These associations persisted when confounding variables such as sex, age and education were controlled. Conclusions: People with DM or HBP who have a poor health perception, who initiated their treatment and were attended by a doctor had higher levels of DC, independent of their age and educational level. <![CDATA[Quality of life scores among 411 medical students]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101294&lng=pt&nrm=iso&tlng=pt Background: The high academic burden may hamper the quality of life of medical students. Aim: To evaluate the quality of life (QOL) for medical students attending a Chilean university. Material and Methods: Four hundred eleven medical students aged 22 ± 2 years (51% women), studying in Santiago, Chile, answered online a validated Spanish version of the WHOQOL-BREF quality of life survey (scored from 0 to 100). Overall scores were assessed for the questionnaire domains Physical health, Psychological health, Interpersonal relationships, and Environment. Results: The global scores were 65.1 for Physical health, 63.1 for Psychological health, 61.3 for Interpersonal relationships and 67.2 for Environment. Students in clinical practice, females, those with sedentary behaviors and consuming modafinil had lower Physical health scores. Students coming from outside Santiago, with sedentary behaviors and who consumed modafinil had poorer Psychological health scores. Students coming from outside Santiago, males and those with sedentary behaviors had Lower Interpersonal relationship scores. Environment scores were also lower among students who were sedentary or from outside Santiago. Conclusions: The variables that had a greater negative impact in the quality of life of these students were the transition from theoretical courses to clinical practice, being from outside Santiago, being overweight or obese and consuming modafinil. Students that were physically active had better quality of life scores. <![CDATA[Low rates of participation and completion of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease in primary health care]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101304&lng=pt&nrm=iso&tlng=pt ABSTRACT Background: Only 6% of patients with chronic obstructive pulmonary disease (COPD) participate in pulmonary rehabilitation programs (PR) and only 50% of those who participate, complete these programs. Aim: To determine rates of PR program participation and completion among patients with COPD in Chile. Material and Methods: Analysis of a database available at the Ministry of Health, which included data of 277491 patients with COPD (55% females) and their participation in PR programs, between 2014 and 2016. Results: Forty percent of patients were over 75 years of age. Participation rates in PR programs ranged from 2.4 to 2.9%. Rates of completion ranged from 26 to 36%. Conclusions: There is a low rate of participation in PR programs among patients with COPD. Approximately one third of participants complete these programs.<hr/> Antecedentes: solo el 6% de los pacientes con enfermedad pulmonar obstructiva crónica.(EPOC) participa en programas de rehabilitación pulmonar. (RP) y solo el 50% de los que participan, completan estos programas. Objetivo: Determinar los índices de participación y adherencia a programas de RP entre los pacientes con EPOC en Chile. Material y Métodos: Análisis de una base de datos disponible en el Ministerio de Salud, que incluía datos de 277,491 pacientes con EPOC (55% mujeres) y su participación en programas de RP, entre 2014 y 2016. Resultados: el cuarenta por ciento de los pacientes tenían más de 75 años de edad. Tasas de participación en programas de RP osciló entre 2,4 y 2,9%. Las tasas de finalización oscilaron entre el 26 y el 36%. Conclusiones: Existe una baja tasa de participación en programas de RP entre pacientes con EPOC. Aproximadamente un tercio de los participantes completan estos programas. <![CDATA[Physiopathology and management of acetylsalicylic acid intoxication]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101309&lng=pt&nrm=iso&tlng=pt Acetylsalicylic acid (ASA) intoxication is potentially lethal. After ingestion, AAS is rapidly transformed into salicylic acid that dissociates into an hydrogen ion plus salicylate. Salicylate is the main form of AAS in the body and produces multiple alterations. Initially, the stimulation of the ventilatory center promotes a respiratory alkalosis. Then, the mitochondrial dysfunction induced by salicylate, will generate a progressive metabolic acidosis due to the accumulation of ketoacids, lactic acid and dicarboxylic acids among others. Another alterations include hydro electrolytic disorders, gastrointestinal lesions, neurological involvement, ototoxicity and coagulopathy. The correct handling of acetylsalicylic acid intoxication requires an thorough knowledge of its pharmacokinetics and pharmacodynamics. Treatment consists in life support measures, gastric lavage, activated charcoal and urinary alkalization to promote the excretion of salicylates. In some occasions, it will be necessary to start renal replacement therapy as soon as possible. <![CDATA[A word of caution about the 2017 hypertension management guidelines]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101317&lng=pt&nrm=iso&tlng=pt The 2017 Guidelines on hypertension of the American College of Cardiology and American Heart Association, which proposed values of 130/80 mmHg as the cutoff points for the onset of hypertension, aroused great interest. This recommendation is based in the SPRINT study (The Systolic Pressure Intervention Trial), which included hypertensive patients over 50 years of age, non-diabetic, without a history of stroke and with a low representation of subjects with a history of coronary artery disease (16%). A group with intensive anti-hypertensive therapy (pressure achieved 121.5 mmHg) achieved a significantly lower cardiovascular risk as compared with a group with standard therapy (pressure achieved 134.6 mmHg). The Guide proposes immediate pharmacological therapy in diabetic hypertensive patients, in those with stage 3 chronic kidney disease or with persistent albuminuria, and in patients with atherosclerotic disease. The Guideline does not include the management of isolated systolic hypertension of the elderly and did not consider studies that show an increased risk when pressure is reduced below 130/80 mmHg in patients with coronary disease, peripheral vascular disease, diabetes mellitus or chronic renal failure. The new classification of hypertension would increase the number of hypertensive patients in our country by more than one million, would increase the risk associated with diastolic pressure reductions in older adults and ignores the evidence indicating a risk associated with reductions below 130/80 mmHg in patients with diabetes, with chronic renal failure or with atherosclerotic disease. Therefore, it is advisable to maintain a threshold of 140/90 mmHg and perform a careful and gradual management of blood pressure in the latter group of hypertensive patients. <![CDATA[Gaps between country needs and intentions to obtain a subspecialty among general surgery trainees in Chile]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101325&lng=pt&nrm=iso&tlng=pt The fragmentation of a general specialty in subspecialties or derived specialties is a widely spread reality. Chilean health care system is becoming more complex, requiring more specialists. On the other hand, doctors in specialty training increasingly choose a subspecialty to continue their training and professional development. This contrasts with the growing need for well-trained general surgeons. We aimed to compare the evidence about the needs for general surgeons and the perspectives of Chilean physicians about their specialty training. A literature review about the intention of specialization in Chilean general surgery residents and the gaps in the Chilean health system, was performed. As of December 2016, there were 2,103 general surgeons in Chile, of whom 598 (28%) also have a subspecialty. Among the latter, 49% are plastic or vascular surgeons, which are also the specialties with the greatest demand in the public system. According to estimates of the Chilean Ministry of Health, on that year there was a deficit of 285 general surgeons and 142 subspecialists. These figures correspond to 18.5% and 23.8% of the existing resources. A survey published in 2009 reported that 78% of trainees in general surgery would prefer to continue studying a subspecialty, following the trend observed in the USA and Europe. Therefore, there is a disproportion between the intentions of general surgery trainees and the needs for these professionals in Chile. <![CDATA[Chilean guidelines for chronic urticaria]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101334&lng=pt&nrm=iso&tlng=pt Chronic urticaria (CU) is characterized by itchy wheals, angioedema or both lasting six weeks or more. It is classified as spontaneous (CSU) and inducible urticaria (CIndU), depending whether there is an identifiable trigger or not. CSU is the predominant form, affecting more than 75% of patients, although overlaps often occur. The prevalence of CSU throughout life is around 1.8% and predominates in women at a ratio of 2:1. The higher incidence of CSU is between 20 and 40 years of age and lasts between one to five years. However, in up to 20% of patients the disease may last longer. CSU not only hampers quality of life, but also affect performance at work and school. The diagnosis of CSU is mainly clinical, and laboratory tests are required depending on the clinical history of the patient. Extensive laboratory tests are usually unnecessary. Second generation anti-histamines are used as first line treatment for CSU treatment. In refractory patients, systemic treatments, such as cyclosporine or omalizumab are suggested. We herein report the first Chilean CSU guidelines. <![CDATA[Pulmonary expansion edema during the management of a spontaneous pneumothorax. Report of one case]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101343&lng=pt&nrm=iso&tlng=pt Pulmonary expansion edema is a rare complication of the management of primary spontaneous pneumothorax. We report a 20 year old male admitted with a right primary spontaneous pneumothorax. A chest tube connected to a water seal was placed, achieving lung expansion. Immediately, the patient presented hypotension and a reduction in arterial oxygen saturation to 78%. Non-invasive ventilation was started. A chest X ray showed extensive right lung edema. The patient was managed with noradrenaline and albumin infusion with good response. Pulmonary edema resolved on day 3 but air leak was persistant so, the patient required surgery to excise apical bullae in the right lung. He was discharged during the following days in good condition. <![CDATA[Delayed hemolytic reaction to transfusion in sickle cell anemia. Report of one case]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101347&lng=pt&nrm=iso&tlng=pt Sickle cell anemia was a rare disease in Chile, especially in adults, however the recent immigration wave from Haiti is changing this scenario. We report a 29 year old black female from Haiti with a non-disclosed history of sickle cell anemia. She was transfused with two units of red blood cells, found unconscious and with jaundice five days later and admitted to the hospital. On admission she had a hemoglobin of 3.3 g/dL, a total bilirubin of 5.08 mg/dL, a LDH of 1,306 Ui/L. She was transfused again, worsening her condition. An alloimmunization and delayed hemolytic reaction was suspected. A direct Coombs test was positive. She was treated with steroids and her serum hemoglobin rose progressively. <![CDATA[Multiple myeloma associated with a secondary amyloidosis. Report of one case]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101351&lng=pt&nrm=iso&tlng=pt Multiple Myeloma is a myeloproliferative disorder of plasma cells, which may be complicated with secondary amyloidosis. We report a 48 year old woman consulting to primary care for weight loss and malaise. An initial laboratory study revealed a hypogammaglobulinemia with a monoclonal component and lambda light chains. These results motivated her derivation to hematology: her serum calcium was 11.8 mg/dl, immunofluorescence showed a monoclonal component of lambda chains and urine Bence-Jones protein was positive. A bone marrow biopsy confirmed plasma cell infiltration. A Congo-red stain of a rectal biopsy was positive. The patient was treated with thalidomide, bortezomid and dexamethasone. <![CDATA[Giant cell arteritis of the vertebrobasilar system, posterior ischemia and palsy of the third nerve. Report of one case]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101356&lng=pt&nrm=iso&tlng=pt Giant cell arteritis is the most common vasculitis in patients aged over 50 years. We report an 89-year-old woman with significant weight loss and persistent frontal-occipital headaches lasting two months. The neurological examination at admission identified a decrease in visual acuity of the left eye, paralysis of the third cranial nerve of the right eye and alterations of body motility without objective signs of damage of the motor or sensitive pathways. Magnetic resonance imaging showed changes of the temporal artery wall and in both vertebral arteries, as well as bilateral cerebellar and occipital ischemic lesions. The Doppler ultrasound of the temporal arteries was compatible with Giant cell arteritis. Treatment with steroids was started. While receiving oral prednisone, the patient suffered new infarcts of the posterior territory, documented with a CAT scan. <![CDATA[Haitian immigration in Chile: a challenge for cardiovascular and renal health programs]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101361&lng=pt&nrm=iso&tlng=pt Giant cell arteritis is the most common vasculitis in patients aged over 50 years. We report an 89-year-old woman with significant weight loss and persistent frontal-occipital headaches lasting two months. The neurological examination at admission identified a decrease in visual acuity of the left eye, paralysis of the third cranial nerve of the right eye and alterations of body motility without objective signs of damage of the motor or sensitive pathways. Magnetic resonance imaging showed changes of the temporal artery wall and in both vertebral arteries, as well as bilateral cerebellar and occipital ischemic lesions. The Doppler ultrasound of the temporal arteries was compatible with Giant cell arteritis. Treatment with steroids was started. While receiving oral prednisone, the patient suffered new infarcts of the posterior territory, documented with a CAT scan. <![CDATA[Remission of Type 2 diabetes through weight loss is not an impossible mission]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018001101362&lng=pt&nrm=iso&tlng=pt Giant cell arteritis is the most common vasculitis in patients aged over 50 years. We report an 89-year-old woman with significant weight loss and persistent frontal-occipital headaches lasting two months. The neurological examination at admission identified a decrease in visual acuity of the left eye, paralysis of the third cranial nerve of the right eye and alterations of body motility without objective signs of damage of the motor or sensitive pathways. Magnetic resonance imaging showed changes of the temporal artery wall and in both vertebral arteries, as well as bilateral cerebellar and occipital ischemic lesions. The Doppler ultrasound of the temporal arteries was compatible with Giant cell arteritis. Treatment with steroids was started. While receiving oral prednisone, the patient suffered new infarcts of the posterior territory, documented with a CAT scan.