Scielo RSS <![CDATA[Revista médica de Chile]]> http://www.scielo.cl/rss.php?pid=0034-988720070002&lang=es vol. 135 num. 2 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.cl/img/en/fbpelogp.gif http://www.scielo.cl <![CDATA[<b>Valor predictivo de la historia clínica y examen físico en el diagnóstico de neumonía del adulto adquirida en la comunidad</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200001&lng=es&nrm=iso&tlng=es Background: Community-acquired pneumonia in adults is a serious health problem in the ambulatory care setting. Aim: To define clinical variables associated with the presence of pneumonia in adult patients presenting with fever or respiratory symptoms to the emergency department. Material and methods: Prospective study carried out in the emergency department from the Catholic University Hospital in Santiago, Chile. Three hundred twenty-five patients (53±22 years) presenting fever or acute respiratory symptoms were included. After obtaining a clinical history and physical examination, the physician established a tentative diagnosis. Subsequently, a definitive diagnosis was made with the chest X rays. Results: Thirty-four percent of the patients had pneumonia. The clinical diagnosis of pneumonia before X-ray examination was variable among emergency physicians (positive likelihood ratio: 1.5-4.8) and showed only moderate sensitivity (79%) and specificity (66%). The clinical variables significantly associated with the presence of pneumonia were: advanced age (over 75 years), cardiovascular disease, fever, chills, sputum production, orthopnea, altered mental status, cyanosis, dullness on percussion, bronchial breath sounds, crackles, any abnormal vital sign (heart rate ³100 beats/min, respiratory rate ³20 breaths/min or temperature ³38°C) and oxygen saturation below 90% breathing air. Conclusions: Clinical judgment prior to observation of chest X rays had moderate sensitivity and specificity for the diagnosis of pneumonia. There were no individual clinical findings, or combination of findings, that could confirm or exclude the diagnosis of pneumonia for a patient suspected of having this illnes <![CDATA[<b>Tratamiento "híbrido" del aneurisma tóraco-abdominal</b>: <b>revascularización visceral extraanatómica e inserción de endoprótesis</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200002&lng=es&nrm=iso&tlng=es Surgical treatment of thoracoabdominal aneurysms is a big technical challenge with a high rate of complications and mortality. It requires a large exposure and transient interruption of vital organ perfusion during its repair. Endovascular repair is a less invasive alternative available over the last decade. We report four male patients aged 44 to 76 years, with thoracic aortic aneurysms and involvement of visceral aorta, treated with a two stage procedure. During the first stage, a retrograde revascularization of the superior mesenteric and renal arteries from the infrarenal aorta was done, associated in two cases to a concomitant repair of an infrarenal aortic aneurysm. In the second stage, an endovascular graft was placed through the femoral artery, from the segment proximal to the aneurysm to the infrarenal aorta, above the origin of the visceral artery reconstructions, excluding the aneurysm from circulation. In one patient, both stages were concomitant and in three the second stage was delayed. One patient presented a postoperative bleeding that required reintervention without adverse consequences. No patient died, presented paraplegia or deterioration of renal function. After follow up of 6 to 20 months, there is no evidence of aneurysm growth or complications derived from the procedure <![CDATA[<b><i>Portación nasal de Streptococcus pneumoniae</i> en adulto mayor y su respuesta frente a la vacunación antineumocócica</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200003&lng=es&nrm=iso&tlng=es Background: S pneumoniae is the main cause of community-acquired pneumonia in the elderly, group that concentrates 95% of deaths. Aim: To assess the prevalence of nasal carriage of S pneumoniae in institutionalized elderly patients. Material and methods: One hundred eighteen institutionalized subjects aged over 60 years (65 males) were enrolled. Since they were also participating in a controlled protocol related to the immunogenicity of an anti-pneumococcal vaccine, our investigation was also blind and randomized. According to randomization, they received pneumococcal or tetanic vaccine. Nasal swab cultures were taken at the beginning of the trial and two months after vaccination. According to recommended methods, we identified S pneumoniae, the serotypes and their antimicrobial susceptibility. Results: In the first nasal sample, 16% of subjects were positive for S pneumoniae. The second sample was positive in 12%. Of the 33 isolated serotypes, 9.1% demonstrated intermediate resistance to penicillin and 3.3% were resistant to chloramphenicol. Conclusions: The study demonstrated a greater percentage of colonized patients than in the general population. The isolated serotypes are the same that cause invasive diseases in this age group, according to data of the Institute of Public Health of Chile. There were no differences in the percentage of colonization between subjects vaccinated against S pneumoniae and control groups, after two months of follow up. Isolated strains had a low resistance to penicillin. High level resistance was not observed <![CDATA[<b>Detección y tipificación de virus papiloma humano en lesiones preneoplásicas del cuello uterino mediante PCR-RFLP</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200004&lng=es&nrm=iso&tlng=es Background: The association of different genotypes of human papilloma virus (HPV) with cervical cancer is well known. However, there is little information about their association with pre-cancerous lesions. Aim: To assess the frequency of different HPV genotypes in pre cancerous cervical lesions. Material and methods: A cervical sample was obtained by cytobrush in 15 women with low grade lesions and 40 women with high grade lesions, subjected to conization by loop electrical excision procedure (LEEP). Detection and typification of HPV was done by polymerase chain reaction and restriction fragment length polymorphism. Results: All women were infected with HPV. Eighty five percent of samples were typified. A unique HPV subtype was found in 76% of women. Fourteen percent had an infection with multiple subtypes and in 10%, the viral genotype was not identified. The most common subtypes found were HPV 16, HPV 52 and HPV 53. Conclusions: There is a high rate of infection with HPV with a high oncogenic risk among these women <![CDATA[<b>Síndrome metabólico en niños y adolescentes</b>: <b>asociación con sensibilidad insulínica y con magnitud y distribución de la obesidad</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200005&lng=es&nrm=iso&tlng=es Background: In Chile between 1986 and 1998, the prevalence of obesity has increased from 4.6% to 24% in prepuberal and from 2.3% to 17% in puberal children. Aim: To assess the prevalence of metabolic syndrome (MS) in a sample of obese and overweight Chilean children. Patients and methods: Descriptive study in 489 children (273 females), aged from 6 to 16 years, consulting in an obesity program. Body mass index, Tanner puberal development, waist circumference, blood pressure, fasting blood glucose, insulin and lipid levels were measured. Insulin sensitivity was calculated using the mathematical models QUICKI and HOMA. MS was diagnosed when three or more of the following criteria were met: a waist circumference over percentile 90, a blood pressure over percentile 90, serum triglycerides over 110 mg/dl, HDL cholesterol of less than 40 mg/dl or a fasting blood glucose level over 100 mg/dl. Results: MS was present in 4% of children with overweight and 30% of obese children. No differences in prevalence were observed for sex or puberal development. The most prevalent cardiovascular risk factors were abdominal obesity, present in 76% of the sample and high triclycerides levels in 39%. The less prevalent risk factor was a fasting blood glucose over 100 mg/dl in 3.7%. The risk for MS increased ten fold in children with severe obesity, compared with those with overweight. Those with abdominal obesity had a 17 times higher risk of MS. Basal insulin sensitivity was significantly associated with the number of cardiovascular risk factors and the presence of MS. Conclusions: In this sample of children, fat distribution and the severity of obesity were strong determinants of MS. Waist circumference had a higher impact on MS than body mass index <![CDATA[<b>Diagnóstico de la infección poe <i>Helicobacter pylori</i> en niños mediante la detección de antígenos en deposiciones</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200006&lng=es&nrm=iso&tlng=es Background: During infancy, preventive, diagnostic and therapeutic efforts for Helicobacter pylori infection should be made. Aim: To evaluate non-invasive diagnostic methods such as stool antigen test (HpSA) and serum anti-H pylori antibody detection (IgG e IgA), compared to endoscopy-based invasive methods (histology and urease test) for the diagnosis of Helicobacter pylori infection. Patients and Methods: Thirty nine children (aged 3 to 14 years, 20 males) referred for upper gastrointestinal endoscopy, were studied. The gold standard to diagnose Helicobacter pylori infection was defined as a positive invasive diagnostic test (histology and/or urease test). Sensitivity (S), specificity (E) and positive (PPV) and negative (NPV) predictive values were obtained for HpSA and serum antibodies. Results: Ten children (26%) were infected with H pylori. S, E, PPV and NPV for HpSA were 90, 100, 100 and 97%, respectively. The figures for serum IgG were 81, 97, 89 and 93%, respectively and for IgA, 90, 76, 36 and 96%, respectively. Conclusions: HpSA was sensitive and specific as a clinical and epidemiological tool to evaluate H pylori infection in children. Serology was not as accurate, but IgG had a better performance than IgA <![CDATA[<b>Etiología de la ginecomastía</b>: <b>Importancia de no subdiagnosticar una ginecomastia patológica</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200007&lng=es&nrm=iso&tlng=es Background : Gynecomastia can be physiological or pathological. A limited study of gynecomastia is recommended during puberty and in the elderly, ages in which gynecomastia is usually considered physiological. Other authors suggest that this condition should be studied when it is painful, rapidly growing, of recent onset, when its diameter is more than 4 cm and when is associated to testicular masses. Aim: To investigate the causes of gynecomastia and to evaluate the above mentioned criteria to exclude pathological conditions. Material and methods: Prospective study of 117 patients aged 10 to 83 years, consulting for gynecomastia. All were subjected to a standardized study including a clinical examination and measurement of plasma estradiol and testosterone levels. Results: Forty one percent of gynecomastias were considered pathological and the rest, physiological. Among pathological conditions, 18 patients had an endocrine etiology (hypogonadism in ten patients, estrogen secreting tumors in three, hyperestrogenism of unknown etiology in four and peripheral resistance to androgens in one), in 17 it was secondary to medications and in 13 it was secondary to other causes (idiopathic, pesticide exposure, alcoholism, diabetes or re feeding). In 79% of 86 patients of less than 20 years, the condition was physiological and in four of five elderly subjects, it was pathological. Thirty nine percent of pathological gynecomastias lacked the signs and symptoms that according to authors, should prompt a thorough study. Conclusions: All patients with gynecomastia should be studied with a complete medical history and the measurement of estradiol and testosterone levels. The criteria proposed to conduct minimal studies in gynecomastia, would miss a large volume of pathological conditions <![CDATA[<b>Efecto de la fortificación de la harina con ácido fólico sobre la evolución de las tasas de prevalencia al nacimiento de malformaciones congénitas en los hospitales chilenos del ECLAMC</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200008&lng=es&nrm=iso&tlng=es Background: The effects of folic acid fortification on neural tube defects is well known. Other reports show a beneficial effect of the fortification on orofacial clefts, urinary malformations and defects caused by limb reduction. Aim: To determine the changes in prevalence of congenital malformations after the start of flour folic acid fortification in Chile. Material and methods: The rates of 22 malformations occurring in the maternity of the University of Chile Clinical Hospital and other Chilean hospitals participating in the Latin American Collaborative Study of Congenital Malformations (ECLAMC) were compared before and after the start of flour folic acid fortification. Results: After the start of folic acid fortification a significant reduction in the rates of anencephalia, spina bifida and diaphragmatic hernia, was observed. The rates of all other malformations remained stable or increased. The rates of all malformations at the University of Chile Clinical Hospital had a steady increase until 2005 and were significantly higher than in the rest of hospitals participating in ECLAMC. Conclusions: Folic acid fortification was associated with an expected reduction in rates of spina bifida and anencephalia and an unexpected reduction in the rates of diaphragmatic hernia <![CDATA[<b>Distribución de las concentraciones de glucosa e indulina basal, HOMA IR Y MOMA ßcell en niños y adolescentes de la ciudad de Maracaibo, Venezuela</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200009&lng=es&nrm=iso&tlng=es Background: The raising prevalence of obesity among children increases the risk of insulin resistance and its adverse metabolic consequences. Aim: To determine the distributions of fasting serum glucose, insulin, HOMA IR and HOMA ß cell in a representative sample of children and adolescents from Maracaibo-Venezuela. Subjects and Methods: Fasting insulin and glucose were measured in 418 children and adolescents (191 boys and 227 girls) of 7, 9, 11, 13, 15 years of age. HOMA IR and HOMA ß cell were calculated. Results: Insulin levels were lower in 7 and 9 year-old girls and 7 year-old boys compared with 11, 13 and 15 year-old girls and boys. Fasting glucose concentrations were similar in boys and girls. HOMA IR was lower in 7 year-old girls compared to 11, 13 and 15 years-old girls, whereas boys in every age showed similar values. HOMA ß cell was higher in 11 and 13 year-old girls. Conclusions: Our findings provide useful values to assess insulin resistance and ß-cell functioning in children and adolescents <![CDATA[<b>Adenomiomatósis vesicular pseudotumoral</b>: <b>Diagnóstico ecográfico. Caso clínico</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200010&lng=es&nrm=iso&tlng=es Adenomyomatosis of the gallbladder wall is a frequent benign degenerative hyperplasia of unknown etiology. In some cases it looks like a malignant tumor. The diagnosis can be suspected during ultrasound examination. We report a 36 year-old male that presented with nonspecific dyspepsia. The ultrasound showed a gallbladder mass with small cyst and echogenic spot inside that suggested the presence of Rokitansky-Ashoff sinuses, seen in adenomyomatosis. The patient was operated and the tumor was excised. The pathological examination of the surgical specimen confirmed the presence of gallbladder adenomyomatosis <![CDATA[<b>Hipercolesterolemia familiar heterocigota</b>: <b>diagnóstico molecular y terapia combinada. </b><b>Caso</b><b> clínico</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200011&lng=es&nrm=iso&tlng=es Heterozygous familial hypercholesterolemia affects one every 400 individuals, is caused by mutations in the LDL receptor gene and is associated with premature coronary artery disease. Nowadays, LDL cholesterol can be efficiently reduced with the new therapies to reduce blood lipids. We report a female patient who consulted in 1975, when she was 46 years old, for severe hypercholesterolemia. In 2003, a sample of leukocyte DNA was obtained and the uncommon 1705 + 1G >A mutation of the LDL receptor gene was detected. No mutations in the apolipoprotein B gene were found. The patient was treated successfully with simvastatin 80 mg/day and ezetimibe 10 mg/day and LDL cholesterol levels were reduced below 200 mg/dl <![CDATA[<b>Exceso de morbilidad respiratoria en niños y adultos mayores en una comuna de Santiago con alta contaminación atmosférica por partículas</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200012&lng=es&nrm=iso&tlng=es Background: The relationship between air pollution and health damage has been sufficiently documented. In station "R" of the air quality monitoring system, located in a community of Metropolitan Santiago (Cerro Navia), the Chilean standard of 150 µg/m³, averaged in 24 hours, for particles with a diameter of 10 micrometers or less (PM10), has been exceeded more days than in the rest of the city stations. Aim: To investigate if the population living near that station has a higher proportion of lower respiratory infections than the Metropolitan Region (MR) as a whole. Material and methods: An outpatient clinic located near station "R" (Centro Albertz), was implemented as a sentinel center according to UNICEF methodology, used since 1992 by the Acute Respiratory Infections National Program. Daily information was collected between May and December 2004. Monitoring data included total number of consults by children less than 15 years old for lower respiratory tract infections, pneumonia, obstructive bronchitis syndrome in children and by adults over 64 years old for lower airway disease, chronic obstructive pulmonary disease (COPD), and pneumonia. Results were compared with those of the rest of MR. Results: Compared with the MR, children from the sentinel clinic had a significantly higher proportion of consults for obstructive bronchial syndrome (20.1% and 26.4% respectively, in p <0.01) and pneumonia (1.3 and 2.7% respectively, p <0.01). In the elderly, the average consults for lower airway disease were 17% in the sentinel clinic and 12.2% in MR (p <0.04). Conclusions: Children and elderly subjects at the sentinel clinic had a significantly higher proportion of respiratory infections (pneumonia and obstructive bronchial syndrome in children and lower airway disease in the elderly) as compared to the Metropolitan Region <![CDATA[<b>Cambios en la epidemiología de las hepatitis virales en Chile y consideraciones en estrategias de prevención</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200013&lng=es&nrm=iso&tlng=es The social and sanitary changes that Chile is experiencing will change the epidemiologic profile of viral hepatitis. Virus A hepatitis will displace to older ages, and immunization plans with specific vaccines should be considered. The real prevalence of hepatitis B may be higher, due to an underreporting of the disease. The education and vaccination of high risk groups should be reinforced. E virus hepatitis requires more research in risk groups and in certain animal species consumed by humans. C virus hepatitis is the greatest challenge as it causes chronic liver disease and is the main cause for liver transplantation <![CDATA[<b>Tendencias y características de la mortalidad chilena 1970-2003</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200014&lng=es&nrm=iso&tlng=es Background: Mortality data of a community allow to identify its severest diseases and health problems. Aim: To report epidemiologic data on Chilean mortality. Material and methods: Information about mortality was obtained from the World Health Organization, Pan American Health Organization, the Chilean Institute of Statistics and Ministry of Health. Results: A continuously declining trend in the risk of dying during the last 30 years was observed. Chile has the best situation among South American countries. Infant and general mortality rates fell in 89 and 39%, respectively, during the period 1970-2003. This reduction is observed in all Chilean geographical regions. At the county level, there are 11 counties that duplicate the figure of mortality of the 337 other counties. In the case of infant mortality, there are 91 counties that duplicate the national figure, indicating an important inequity. Mortality is significantly associated with population aging, availability and use of hospital beds. There is a lower level of association with the proportion of population living in urban areas and poverty levels. A projection until 2010 shows and increasing mortality caused by malignant tumors and diabetes and a declining trend for circulatory, respiratory and digestive diseases and accidental deaths. Conclusions: Mortality has been managed efficiently in Chile but future trends underscore the need for cancer and diabetes prevention and management programs <![CDATA[<b>La relación docente-asistencial en el nuevo contexto que establece la reforma de salud</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200015&lng=es&nrm=iso&tlng=es The new laws of the health reform in Chile, modified the pre-existent relationship between teaching and health care activities. This relationship allows the training of health care professionals by Universities, in the clinical services of the National System of Health Services that is dependent of the Ministry of Health. The new law established new requirements for specialization and quality of care accreditation. Up to the moment, the relationship between Health Care Services and the Universities was based on harmonic and consensual agreements between both counterparts. With the new law, such relationship becomes more relative and is based on new norms. Therefore, it is of utmost importance to establish a regulated and equilibrated relationship between both institutions, to assure the best possible training of health care professionals, in terms of skills and competences, to adequately satisfy the health needs of the population <![CDATA[<b>Perfiles de expresión génica en decisiones terapéuticas en cáncer de mama</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200016&lng=es&nrm=iso&tlng=es In the early stages of breast cancer, surgery and radiotherapy arrest the local and regional disease. However 30% of patients will die as a consequence of tumor dissemination. Parameters with a relative predictive value are used to assess candidates to adjuvant therapy. Genomic analysis methods (cDNA microarray) identified a gene expression profile of greater aggressiveness in breast cancer. This knowledge generated the project "Translating Molecular Knowledge Into Early Breast Cancer Management" of the Breast International Group (BIG). This is a consortium of 32 research groups in which Chile participates through the Chilean Cooperative Oncological Research Group (GOCCHI). The project consists in three protocols. In the first, denomimated MINDACT (Microarray for Node Negative Disease may Avoid Chemotherapy), 8000 women will be evaluated by gene expression profile and clinical pathological criteria to decide adjuvant therapy. Since a group of patients will not receive therapy, solely based on gene expression profile, GOCCHI is preparing a follow up protocol based on the expression of 22 genes. MINDACT is the first prospective effort to evaluate gene expression profiles in clinical practice. Our participation in this protocol, installs us in the first line of worlwide oncological investigation <![CDATA[<b>Arqueología del Hospital San Vicente de Paul</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200017&lng=es&nrm=iso&tlng=es The San Vicente de Paul Hospital was the first Clinical Hospital of the University of Chile and was located at the same place of present School of Medicine. The School area contains several old buildings, which are probably remains of the San Vicente de Paul Hospital. After a careful study of the current plans of the Faculty of Medicine of the University of Chile and those of the San Vicente de Paul Hospital, and after checking measurements on the actual site, we were able to demonstrate that two and a half clinical rooms of the original building and some parts of the old laundry still remain intact. At present, these constructions are being used as storerooms, student's union offices, and other activities. We expect that this article may contribute to improve the knowledge of our roots by our own as well as by future generations and that it may inspire our authorities to take care and preserve this important patrimonial remains of our national medicine <![CDATA[<b>Ley chilena sobre la investigación científica en el ser humano</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200018&lng=es&nrm=iso&tlng=es The San Vicente de Paul Hospital was the first Clinical Hospital of the University of Chile and was located at the same place of present School of Medicine. The School area contains several old buildings, which are probably remains of the San Vicente de Paul Hospital. After a careful study of the current plans of the Faculty of Medicine of the University of Chile and those of the San Vicente de Paul Hospital, and after checking measurements on the actual site, we were able to demonstrate that two and a half clinical rooms of the original building and some parts of the old laundry still remain intact. At present, these constructions are being used as storerooms, student's union offices, and other activities. We expect that this article may contribute to improve the knowledge of our roots by our own as well as by future generations and that it may inspire our authorities to take care and preserve this important patrimonial remains of our national medicine <![CDATA[<b>FE DE ERRATUM</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872007000200019&lng=es&nrm=iso&tlng=es The San Vicente de Paul Hospital was the first Clinical Hospital of the University of Chile and was located at the same place of present School of Medicine. The School area contains several old buildings, which are probably remains of the San Vicente de Paul Hospital. After a careful study of the current plans of the Faculty of Medicine of the University of Chile and those of the San Vicente de Paul Hospital, and after checking measurements on the actual site, we were able to demonstrate that two and a half clinical rooms of the original building and some parts of the old laundry still remain intact. At present, these constructions are being used as storerooms, student's union offices, and other activities. We expect that this article may contribute to improve the knowledge of our roots by our own as well as by future generations and that it may inspire our authorities to take care and preserve this important patrimonial remains of our national medicine