Scielo RSS <![CDATA[Revista médica de Chile]]> http://www.scielo.cl/rss.php?pid=0034-988720120002&lang=es vol. 140 num. 2 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.cl/img/en/fbpelogp.gif http://www.scielo.cl <![CDATA[<b>Taquicardia postural ortostática en 15 pacientes</b>: <b>disautonomía</b><b> compleja</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200001&lng=es&nrm=iso&tlng=es Background: Patients with postural orthostatic tachycardia syndrome (POTS) report dizziness, lightheadedness, weakness, blurred vision, and fatigue upon standing. The diagnosis of the syndrome is made when an orthostatic intolerance and tachycardia appear in the standing position. Aim: To report 15 patients with POTS. Material and Methods: Review of Tilt test reports in a period of 15 years. Those reports in which orthostatic postural tachycardia and symptoms compatible with POTS appeared, were selected for analysis. Results: We identified 15 patients (3.1% of all positive Tilt test reports) with compatible signs and symptoms. There was a lag of 8 -10 years between the onset of symptoms and the time of diagnosis. Most patients complained of orthostatic intolerance, dizziness and frequent fainting. Orthostatic tachycardia and symptoms occurred on average after 2.9 and 6.1 minutes, respectively,of staying in the standing position. These patients had a high frequency of family history of syncope orpresyncope (66% frequency) and hyper mobility syndrome (53% prevalence). Only 33% of the patients reported relief of their symptoms after being treated (most of them with fludrocortisone). Most patients that reported little or no relief, did not use medications or were treated for a short period. Conclusions: POTS syndrome is uncommon but disturbs quality of life of those who suffer it. Its association with hyper mobility syndromes must be investigated. <![CDATA[<b>Daño arterial asociado a la enfermedad renal crónica</b>: <b>evaluación mediante técnicas de laboratorio no invasivo en pacientes hemodializados</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200002&lng=es&nrm=iso&tlng=es Background: Hemodialysis patients (HD) display high rates of cardiac disease and mortality. The cardiovascular morbidity and mortality of HD patients is attributable in a significant proportion to endothelial dysfunction, arterial stiffness, and vascular calcifications. Aim: To measure vascular reactivity in HD subjects and compare them with healthy volunteers. Material and Methods: Forty eight non diabetic patients aged 58 ± 4.6 years (29 males) on hemodialysis for a mean lapse of 4.8 years were studied. Arterial stiffness was measured in the radial artery. Pulse wave velocity was measured by noninvasive peripheral arterial tonometry in carotid and femoral arteries. Endothelial function was assessed, measuring reactive hyperemia response after a 5 min period of ischemia. As a control, all values were also measured in age and gender-matched healthy volunteers. Results: Arterial stiffness was significantly higher in HD patients than controls (23.9 ± 3.3 and 18.4 ± 3.4% respectively, p < 0.05). HD subjects had an increased pulse wave velocity (10.0 ± 0.8 and 7.6 ± 0.9 m/s respectively, p < 0.05). A reduction in the change in pulse amplitude pressure, as a measure of arterial dysfunction, was only observed in male patients (1.7± 0.4 and2.7 ± 0.4 respectively p < 0.01). Conclusions: Noninvasive assessment of peripheral vascular function may be useful for the identification of patients at risk for late cardiac events. <![CDATA[<b>Identificación clínica y patológica de las diversas formas de la enfermedad de Creutzfeldt Jakob en Chile</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200003&lng=es&nrm=iso&tlng=es Background: The identification of clinical and pathological forms of Creutzfeldt Jakob Disease (CJD) started with the first cases of the disease. Genetic and biomolecular prion status assessment are allowing now a better classification. Aim: To identify the clinical forms of the disease that exist in Chile, based on clinical and neuropathological data. Patients and Methods: Review of records of 40 patients with CJD in whom a complete history, clinical details and neuropathological studies were available. Clinical aspects were grouped into five categories: behavioral and cognitive changes, sleep and alertness, visual impairment, motor disturbances, myoclonus and epilepsy. The neuropathological examination in each case allowed us to evaluate the damage of 13 areas of the central nervous system. Results: Five forms of CJD were identified. The classic form was present in 28 patients (70%), the Heidenhain form was present in five (12.5%), the ataxic form in four (10%), the form with Kuru plaques in two (5%) and the Vacuolar was present in one patient (2.5%). Conclusions: The variety and forms of CJD in Chile do not differ substantially from those found abroad. <![CDATA[<b>Evolución clínica de pacientes chilenos con tirosinemia tipo I tratados con 2-(2-nitro-4-trifluorometilbenzoil)-1,3-ciclohexanediona (NTBC)</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200004&lng=es&nrm=iso&tlng=es Background: Tyrosinemia type I is an inborn error of metabolism due to deficiency of fumarilacetoacetase. Acute presentation is with liver failure, hypophosphatemic rickets and peripheral neuropathy. Chronic presentation is with visceromegaly and subclinical rickets. The most severe complications are hepatic cancer and acute neurological crises. Without treatment, tyrosinemia type 1 is fatal. In 1992 treatment for tyrosinemia type 1 with 2-(2-nitro-4-trifluoromethybenzoyl)-1,3-ciclohexanedione (NTBC) was proposed. A clinical response was reported in 90% of patients. In cases that did not respond, a successful liver transplantation was performed, reducing mortality to 5%. Aim: To report the follow up of 12 patients treated with NTBC. Patients and Methods: Review of clinical records of 12 Chilean cases treated with NTBC at the Instituto de Nutrición y Tecnología de los Alimentos (INTA) from January 2004 until June 2010. Results: In all patients, a rapid metabolic control was achieved. Two patients developed hepatocarcinoma. One of these patients died and one was successfully treated with liver transplantation. One patient died after receiving a liver transplantation. Nine patients have at present good liver function, but 2 had peripheral neuropathy due to late diagnosis and discontinuing NTBC treatment. Conclusions: Treatment with NTBC allows metabolic normalization in tyrosinemia type 1, prevents liver cirrhosis and hepatic cancer, improving survival rates and quality of life in the patients. Neonatal screening is essential for the early diagnosis of this treatable disease, that otherwise may be lethal. <![CDATA[<b>Relación médico-paciente en la Pontificia Universidad Católica de Chile</b>: <b>evaluación de una escala de medición</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200005&lng=es&nrm=iso&tlng=es Background: Beneficence, respecting autonomy of patients to make their own decisions, is crucial for good physician-patient relations (PPR), a leading objective in health care. Aim: To validate a previously designed scale to assess PPR in Chile. Material and Methods: A scale with 55 questions grouped in six dimensions, was applied to a convenience sample of 146 individuals, composed by physicians, patients and medical students, at the school of medicine from the Pontificia Universidad Católica de Chile (PUC). Internal consistency (Alpha of Cronbach) of answers was analyzed. The existence of correlations between answers that may justify the application of a factorial analysis was assessed using Bartlett and Kaiser-Meyer-Olkin (KMO) tests. Factorial analysis was used to identify specific dimensions and reduce the number of questions. Results: Factorial analysis performed in 125 subjects with complete answers allowed to reduce the scale to 28 questions, grouped in six dimensions. Cronbach alpha value was 0.78. Bartlett test was highly significant (p < 0.0001), and KMO score was 0.784, considered as meritorious. Conclusions: The validated scale will allow the performance of new studies among physicians and patients, to assess and compare their respective scores. <![CDATA[<b>Consumo de sustancias y síntomas depresivos en escolares de liceos municipales de Santiago</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200006&lng=es&nrm=iso&tlng=es Background: The presence of emotional problems may trigger drug abuse. Aim: To determine the association between illicit drug use and severity of depression symptoms among students of public secondary schools in Santiago, Chile. Material and Methods: A probabilistic sample of2,597 adolescents aged between 12 and 18 years (45% women), attending first year in public high-schools in Santiago, answered self-report questionnaires about consumption, during the last 30 days ,of alcohol, tobacco and marihuana, and the Beck Depression Inventory - II. Logistic regression models were used to study the association between drug use and severity of depression symptoms, adjusting by sex. Results: Tobacco and marihuana use was reported by 38 and 13% of students, respectively. Frequency of consumption was significantly higher among women. Mild, moderate or severe depressive symptoms were found among 16%, 14% and 9% of students, respectively. Depressive symptoms were more common among women. There was a significant association between drug use and severity of depression among participants of both genders. Conclusions: The association between depressive symptoms and drug use should be considered on the design of treatment guidelines for these health problems in Chile. <![CDATA[Percepción de dolor después de una inyección intramuscular en adultos]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200007&lng=es&nrm=iso&tlng=es Background: Vaccine use has been increasing worldwide, and adult populations are presented with more opportunities to experience pain from vaccine injection. The insertion of a needle through the skin is the most common source of iatrogenic pain, and needle phobia is a major concern in medical practice. However, it is unclear which factors play major roles in the perception of pain from vaccine injection in adults. Aim: To evaluate the influences of patient characteristics on pain perception due to intramuscular vaccine injection in healthy adult volunteers. Material and Methods: The injection of hepatitis B vaccine using a 24 mm, 24-G needle was performed as a uniform stimulus, and the intensity of injection pain was measured immediately after the injection using a 100-mm visual analogue scale (VAS). The influences of patient characteristics on pain intensity were investigated. Results: One hundred sixty volunteers (65 males, 95 females) were enrolled in this study. The average VAS score was 20.8 ± 17.1 (range 0 to 67) in males and 34.4 ± 19.7 (range 2 to 76) in females (P < 0.001). However, there were no correlations between VAS score and age, body mass index or maximal pain score from previous painful experiences. The VAS score was also not affected by the experience of previous vaccine injections, a history of childbirth in females, or religion. Conclusions: Gender appears to be the only major factor that influences the pain of intramuscular vaccine injection. Therefore, pain-reducing methods will be needed when performing injection procedures, particularly in women.<hr/>Antecedentes: La inserción de una aguja para inyecciones es la forma más común de inducción de dolor iatrogénico. No se sabe qué factores afectan la percepción del dolor. Objetivo: Evaluar la influencia de características propias de los pacientes en la percepción de dolor después de una inyección intramuscular. Material y Métodos: Se utilizó como estímulo, la inyección intramuscular de vacuna de hepatitis B, mediante una aguja de 24 mm (24 G). La intensidad del dolor fue evaluada inmediatamente después de la inyección utilizando una escala visual análoga de 100 mm (VAS). Se evaluó la influencia de las características de los pacientes en la intensidad del dolor. Resultados: Participaron 160 voluntarios (65 hombres). El puntaje VAS fue 20,8 ± 17,1 (rango 0 a 67) en hombres y 34,4 ± 19,7 (rango 2 a 76) en mujeres (p < 0,01). No hubo asociación entre el puntaje VAS y edad, índice de masa corporal, haber experimentado previamente dolor, haber dado a luz en mujeres o religión. Conclusiones: El género es la única variable que se asocia con la percepción de dolor después de una inyección intramuscular. <![CDATA[<b>Asociación entre tatuajes, perforaciones y conductas de riesgo en adolescentes</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200008&lng=es&nrm=iso&tlng=es Background: The use of tattoos and piercings has increased, especially among adolescents in the last decades. Aim: To evaluate the prevalence of these behaviors in adolescents and their association with risk behaviors such as alcohol, tobacco and illicit drug use and sexual promiscuity. Material and Methods: An anonymous and confidential survey about tattooing and piercings was applied to randomly selected high school teenagers, attending municipal, private-subsidized and private schools, in four sectors of Santiago (north-east, south-east, north-west, south-west). Results: The surveys were answered by 1329 participants with a mean age of 15 years (62% women) from 9 schools in Santiago. The prevalence of tattoos was 1.7% (confidence intervals (CI) 1.1% to 2.5%). The figure for piercings was 30.6% (CI 28.2 to 33.1%). A higher prevalence of tattooing and piercings was observed in groups with a history of psychiatric disorders, criminal records, alcohol, tobacco and illicit drug consumption and initiation of sexual activity (p < 0,001). Conclusions: This study confirms that tattoos and piercings are indicators of adolescent risk behaviors. <![CDATA[<b>Duración de las licencias médicas FONASA por trastornos mentales y del comportamiento</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200009&lng=es&nrm=iso&tlng=es Background: In Chile, the number of sick leaves due to mental health problems has systematically increased in recent years. Aim: To perform an analysis of sick leaves due to mental problems managed by the Fondo Nacional de Salud (FONASA) during 2008. Material and Methods: Analysis of all sick leaves awarded during 2008for mental or behavioral problems, that were managed at FONASA. A negative binomial regression, was performed to predict the effects of different variables on the total duration of sick leaves. Results: A total of546,477 sick leaves were awarded to 198,752 individuals (2.27per subject). The mean duration of each leave was 15.6 days. Summing all leaves, the lapse off work was 98 ± 96 days (median 65 days). Women had longer leaves than men. The type of medical leave, occupation, working for private or public institutions, economic activity and diagnosis were significantly associated with duration of time off work. Conclusions: Sick leaves for mental problems are prolonged and related to gender and socioeconomic variables. <![CDATA[<b>Trastornos neurológicos en niños con síndrome de Down</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200010&lng=es&nrm=iso&tlng=es Background: Neurological disturbances are common problems in children with Down Syndrome (DS). Aim: To determine the prevalence of neurological disorders affecting children with Down Syndrome. Patients and Methods: Review of medical records of253 children aged from 1 day to 23 years affected with DS, attended at a public hospital and a University clinic. Results: The overall prevalence of neurological disorders was 38.7%. The most common problems were ocular motor disorders in 26% of cases and epilepsy in 12%. Conclusions: Neurological disorders are more common in children with DS than in the general population. Motor ocular disorders and epilepsy are the predominant disturbances detected. <![CDATA[<b>Hipotermia intravascular prolongada en un paciente con hipertensión endocraneana refractaria</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200011&lng=es&nrm=iso&tlng=es The use of hypothermia after cardiac arrest caused by ventricular fibrillation is a standard clinical practice, however its use for neuroprotection has been extended to other conditions. We report a 23-year-old male with intracranial hypertension secondary to a parenchymal hematoma associated to acute hydrocephalus. An arterial malformation was found and embolized. Due to persistent intracranial hypertension, moderate hypothermia with a target temperature of 33°C was started. After 12 hours of hypothermia, intracranial pressure was controlled. After 13 days of hypothermia a definitive control of intracranial pressure was achieved. The patient was discharged 40 days after admission, remains with a mild hemiparesia and is reassuming his university studies. <![CDATA[<b>Linfoma intravascular de células B grandes</b>: <b>hallazgos clínicos y morfológicos en un caso con desenlace fatal</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200012&lng=es&nrm=iso&tlng=es Intravascular large B cell lymphoma is a rare subtype of large cell lymphoma that is characterized by the proliferation of lymphoid cells within the lumina of small blood vessels. We report a 61-year-old male presenting paresis of both lower limbs, confusion and a history of weight loss. Magnetic resonance and CAT imaging studies showed multiple images of brain and cerebellar infarctions. Twenty days after admission, the patient died and the postmortem study demonstrated a multisystem intravascular large B cell lymphoma. <![CDATA[<b>Taquicardiomiopatía, causa reversible de insuficiencia cardiaca</b>: <b>caso clínico</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200013&lng=es&nrm=iso&tlng=es Tachycardiomyopathy is a potentially reversible cause of heart failure. It can be induced by supraventricular or ventricular arrhythmias. When these are treated, systolic function improves or normalizes. We report a 20year-old male with deterioration of left ventricular function and dilated cardiomyopathy secondary to an incessant atrial tachycardia that was treated with radiofrequency catheter ablation. After the procedure, the patient experienced a significant improvement of his ventricular function. <![CDATA[<b>Linfoma marginal del bazo asociado a acidosis láctica tipo B</b>: <b>Caso clínico</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200014&lng=es&nrm=iso&tlng=es Lactic acidosis in the absence of hypoxia or tissue hypoperfusion (type B) is very rare and is associated with the use of some drugs or malignancy. We report a 79-year-old woman, with a marginal non-Hodgkin's lymphoma of the spleen that was subjected to a splenectomy one year ago. She presented with unexplained tachypnea associated with pancytopenia and elevation of IgM to 10 times over the higher normal limit. Laboratory tests showed the presence of metabolic acidosis and high lactic acid levels in the absence of infection, tissue hypoxia or hypoperfusion. She was treated with sodium bicarbonate and steroids without obtaining a reduction in lactate levels. Twelve days after admission, a single dose of Rituximab quickly normalized lactate concentrations and platelet count. After the fourth dose of Rituximab, pancytopenia disappeared and IgM fell to 25% of its baseline concentration. <![CDATA[<b>Linfoma relacionado a infección por virus de la inmunodeficiencia humana en un hospital público de Santiago, Chile</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200015&lng=es&nrm=iso&tlng=es Background: Cancer is the third cause of death in patients infected with human immunodeficiency virus (HIV) and lymphoma is the most common type. Aim: To describe the clinical characteristics, histology, risk factors and prognosis of these patients, in a Chilean public hospital in Chile. Material and Methods: Records of 55 patients (45 males) aged between 23 and 67years with lymphoma and HIV positive serology, diagnosed between 1992-2008, were reviewed. Results: Six patients (11%) had Hodgkin lymphoma (HL) and the rest, non-Hodgkin lymphoma (NHL). B-cell phenotype constituted 83.7% of NHL cases. The most common subtypes of all the lymphoma were diffuse large B cell lymphoma in 24 cases (43.6%), Burkitt lym-phoma in 12 cases (21.8%), andplasmablastic lymphoma in 5 cases (9.1%). Thirty five patients (64%) underwent curative intended chemotherapy (CT) concomitantly with highly active antiretroviral therapy (HAART). Three year survival of the whole cohort was 27%. By multivariate analysis, the most important prognostic factors for long term survival, were complete responses to CT, (p < 0.01) and a low international prognostic index (IPI) score for NHL, (p = 0.01). HAART, histologic subtype and CD4 lymphocyte count at diagnosis, did not influence survival. Conclusions: The most important prognostic factors for HIV patients with lymphoma, were achieving CR with CT and low IPI score. Prognosis remains poor, even with HAART therapy. <![CDATA[<b>Folatos y riesgo de cáncer de mama</b>: <b>revisión sistemática</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200016&lng=es&nrm=iso&tlng=es An increased folate intake may be beneficial in deficient populations. However, in women with adequate levels it may not deliver additional benefits while it may increase the risk for some forms of cancer. A systematic literature review of benefits or risks of folate in the development of breast cancer was performed using MEDLINE, systematic review of selected articles and references of the selected articles looking specifically at serum folate levels, dietary folate intake or total folate intake and the risk of developing breast cancer. Fourteen case-control studies, fourteen cohort studies, seven case-control nested studies, two randomized trials and two meta-analyses were selected for analysis based on pre-established criteria. The reviewed evidence does not support the hypothesis that higher intakes of dietary folate reduce the risk for breast cancer. Some studies showed a higher risk of breast cancer in populations exposed to high folate intake post fortification, especially when folic acid is used. The results support the need to be cautious and to limit the exposure of women to high intakes of folic acid, especially in countries with mandatory food fortification. <![CDATA[<b>Eutanasia, suicidio asistido y principio del doble efecto</b>: <b>Réplica al profesor Rodolfo Figueroa</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200017&lng=es&nrm=iso&tlng=es The purpose of this paper is to defend the traditional application of the principle of double effect as a criterion for assessing the permissibility of actions that have as their common aim to end the suffering of seriously ill patients. According to this principle, euthanasia and physician-assisted suicide are always illicit acts, while the same is not said for other actions that bring about patient's death as a foreseen effect, namely, palliative treatments that hasten death or failure or interruption of life support. The reason for this difference is that, in the first two cases, the patient's death is intended as a means of pain relief; whereas, in the latter two, death is only a side effect of a medical act, an act justifiable if it is necessary to achieve a proportionate good. In a recent issue of this Journal, Professor Rodolfo Figueroa denied the soundness of the principle of double effect and maintained that all actions described above should be considered equivalent in law enforcement. Here, the author presents a reply to that argument, and also offers a justification of the afore said principle's core, that is, the moral and legal relevance of the distinction between intended effects and foreseen side effects. <![CDATA[<b>El financiamiento de las revistas médicas</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200018&lng=es&nrm=iso&tlng=es Medical journals are published by scientific societies, universities, publishing agencies and other for-profit or non-profit organizations. The traditional way to cover the expenses in printed journals has been a "subscribers pay" model. The rise of electronic versions in the internet, either together with the printed version or replacing it entirely, plus a progressive adherence to an "open access" for electronic versions, has created financial difficulties. Therefore, the "authors pay" model has been added. Both models can be subsidized by commercial or institutional advertising, but still a main source for financing relies either in subscriptions or in authors' payments. A small source of income that helps to cover publishing costs is a "charge for manuscript reception", currently applied by several journals. Those authors whose work has institutional or external support can use their grants to cover any charges, but the situation is more difficult for those who do not have such support. Since 1872, Sociedad Médica de Santiago-Chilean Society of Internal Medicine, owner and publisher of Revista Médica de Chile, has employed the "subscribers pay" model, subsidized by commercial advertising and temporary sponsors (Chilean government and others). The printed journal is reproduced in an open access electronic version, in www.scielo.cl. The increasing cost of both publications systems demands a time for reflection. <![CDATA[<b>Camptocormia</b>: <b>de lo psicogénico a lo orgánico, como etiología de una sorprendente alteración postural y de la marcha</b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200019&lng=es&nrm=iso&tlng=es Medical journals are published by scientific societies, universities, publishing agencies and other for-profit or non-profit organizations. The traditional way to cover the expenses in printed journals has been a "subscribers pay" model. The rise of electronic versions in the internet, either together with the printed version or replacing it entirely, plus a progressive adherence to an "open access" for electronic versions, has created financial difficulties. Therefore, the "authors pay" model has been added. Both models can be subsidized by commercial or institutional advertising, but still a main source for financing relies either in subscriptions or in authors' payments. A small source of income that helps to cover publishing costs is a "charge for manuscript reception", currently applied by several journals. Those authors whose work has institutional or external support can use their grants to cover any charges, but the situation is more difficult for those who do not have such support. Since 1872, Sociedad Médica de Santiago-Chilean Society of Internal Medicine, owner and publisher of Revista Médica de Chile, has employed the "subscribers pay" model, subsidized by commercial advertising and temporary sponsors (Chilean government and others). The printed journal is reproduced in an open access electronic version, in www.scielo.cl. The increasing cost of both publications systems demands a time for reflection. <![CDATA[<b><i>Valor predictivo de la tinción de Gram en secreciones del tracto respiratorio bajo</i></b>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000200020&lng=es&nrm=iso&tlng=es Medical journals are published by scientific societies, universities, publishing agencies and other for-profit or non-profit organizations. The traditional way to cover the expenses in printed journals has been a "subscribers pay" model. The rise of electronic versions in the internet, either together with the printed version or replacing it entirely, plus a progressive adherence to an "open access" for electronic versions, has created financial difficulties. Therefore, the "authors pay" model has been added. Both models can be subsidized by commercial or institutional advertising, but still a main source for financing relies either in subscriptions or in authors' payments. A small source of income that helps to cover publishing costs is a "charge for manuscript reception", currently applied by several journals. Those authors whose work has institutional or external support can use their grants to cover any charges, but the situation is more difficult for those who do not have such support. Since 1872, Sociedad Médica de Santiago-Chilean Society of Internal Medicine, owner and publisher of Revista Médica de Chile, has employed the "subscribers pay" model, subsidized by commercial advertising and temporary sponsors (Chilean government and others). The printed journal is reproduced in an open access electronic version, in www.scielo.cl. The increasing cost of both publications systems demands a time for reflection.