Scielo RSS <![CDATA[Revista médica de Chile]]> http://www.scielo.cl/rss.php?pid=0034-988720190009&lang=es vol. 147 num. 9 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.cl/img/en/fbpelogp.gif http://www.scielo.cl <![CDATA[Experiencia de uso de inhibidores del cotransportador sodio-glucosa 2 en diabéticos tipo 2]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901093&lng=es&nrm=iso&tlng=es Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a new pharmacological alternative for the treatment of diabetes. Aim: To report our experience with the use of this type of drugs in type 2 diabetics treated in an outpatient clinic. Material and Methods: We selected 77 type 2 diabetic patients aged 59 ± 11 years (45 men) who started SGLT2i, based on the advice of their treating physician. We registered their demographic characteristics and changes in metabolic parameters, weight, blood pressure, albuminuria and adverse effects, during a follow-up of at least three months. Results: We observed a decrease of glycosylated hemoglobin A1c of 0.8 ± 1.14% (p &lt; 0.01) and a weight decrease of 2.5 ± 2.24 kg (p &lt; 0.01). The proportion of patients with a glycosylated hemoglobin A1c of less than 7% increased from 7.2% to 30.9% (p = 0.002). In addition, a relative decrease in albuminuria of 39.9% was observed (p = 0.07). The treatment was well tolerated with a rate of adverse effects of 21%, all of them being categorized as mild. Of these, most of them corresponded to genital mycotic infections. Conclusions: The effects observed in this study are comparable and of similar magnitude to randomized studies of SGLT2i reported in the international literature. <![CDATA[Cirugía en el paciente cirrótico: características clínicas y complicaciones en una cohorte de pacientes chilenos]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901099&lng=es&nrm=iso&tlng=es Background: Cirrhotic patients have an increased surgical risk due to potential intra and postoperative complications. Aim: To describe the clinical characteristics and surgical complications of cirrhotic patients undergoing surgery in a Chilean university hospital. Patients and Methods: Review of medical records of 102 cirrhotic patients aged 60 ± 11 years (52% males) who underwent elective or urgency surgery at an university hospital between 2010 and 2016. General, pre-surgical, and post-surgical complications were recorded. Results: The main etiologies of cirrhosis were non-alcoholic steatohepatitis (31%), and alcoholic cirrhosis (28%). Child-Pugh scores were A, B and C in 50, 28 and 22% of cases respectively. Median MELD (Model for End-stage Liver Disease) score was 11 (interquartile range: 10-15). The surgical procedure was elective in 71% of cases, with predominance of abdominal surgery (86%). The American Society of Anesthesiologists (ASA) score was three or more in 52% of patients. The frequency of any adverse outcome was 62%. The frequency increased along with the severity of cirrhosis and when surgery was urgent. The most common complications were acute renal failure (24%), increased ascites (23%) and encephalopathy (22%). Admission to intensive care unit occurred on 26% of patients, with six hospital deaths. Conclusions: In these patients, surgical complications were common, although with low mortality. <![CDATA[<em>Telestroke</em> en Chile: resultados de 1 año de experiencia de la Unidad de TeleACV del Servicio de Salud Metropolitano Sur en 7 hospitales ejecutores]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901107&lng=es&nrm=iso&tlng=es Background: Acute ischemic stroke (AIS) is one of the leading causes of death in Chile. Intravenous thrombolysis (IVT) is an effective treatment. Geographical barriers and lack of specialists limit its application. Telemedicine can overcome some of these pitfalls. Aim: To describe the implementation and results of AIS treatment by telemedicine at the TeleStroke Unit (TeleACV) of the Southern Metropolitan Health Service, connected with seven hospitals in Chile. Material and Methods: Descriptive analysis of a prospective tele-thrombolysis data-base that covers from 2016 to 2018, with an emphasis in the last year. Results: During the analyzed period, seven remote telemedicine centers were activated as far as 830 kilometers on a continental level from the reference center and up to 3,700 kilometers on an island level. There were 1,024 telemedicine consultations, 144 (14%) of them resulted in an IVT treatment. During 2018, 597 tele-consultations were made, thrombolysis was done in 115 (19%) patients aged 66+-13 years; 54 (46.6%) being female. The median admission National Institute of Health Stroke Scale was 8 (interquartile range (IQR) 5-14). The median door-to-needle time was 56.5 (IQR 44.8-73.3) minutes; 60% of patients were treated within 60 minutes. Eight patients (7%) were referred for a subsequent mechanical thrombectomy to a center of greater complexity. Symptomatic intra-cranial hemorrhages occurred in four treated patients (4%). One patient had a systemic bleeding. Conclusions: The Telestroke Unit achieved a high rate of IVT and good door-to-needle times. This may help to overcome some of the geographic barriers and the specialist availability gap in our country. <![CDATA[Descripción de la progresión de la obesidad y enfermedades relacionadas en Chile]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901114&lng=es&nrm=iso&tlng=es Background: An explosive increase in overweight and obesity occurred in Chile since the 90's, without an integrative national policy. Aim: To describe the current obesity situation in Chile and its consequences. Material and Methods: Analysis of the available anthropometric data obtained by an annual census of anthropometry for students (Nutritional Map) collected by the Ministry of Education, and three National Health Surveys (2003, 2009-2010 y 2016-2017) performed by the Ministry of Health in adults. Results: According to the Nutritional Map the prevalence of obesity in 1987 was 7.5% among children of six years of age and increased to 24% in 2018 (8% with severe obesity). At 14 years of age, the frequency of obesity increased from 8 to 15% from 2011 to 2018. In children older than 15 years, overweight and obesity increased from 61 to 74% from 2003 to 2016. In the same period, total obesity increased from 23 to 34% and the frequency of diabetes duplicated from 6 to 12%. The frequency of hypertension did not change, but its prevalence is 45 and 73% after 45 and 65 years of age, respectively. Conclusions: The frequency of obesity will continue to increase, producing severe health risks for the population. Public policies addressing both structural and individual aspects are recommended. <![CDATA[Disección espontánea de arterias viscerales: reporte de una serie de casos]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901122&lng=es&nrm=iso&tlng=es Background: Spontaneous dissections of visceral arteries are rare and usually secondary to other disease. There is paucity of information about their natural course. Aim: To describe the imaging, clinical characteristics and follow-up of spontaneous visceral artery dissections diagnosed at our institution. Material and Methods: We report a series of 14 patients in whom a spontaneous dissection of a visceral artery was diagnosed on abdominal angio-CT between 2010 and 2018. Clinical features and evolution were recorded. Results: Isolated lesions of the celiac axis were the most common finding. Multiple territories were involved in 14% of cases. A dissection flap was observed in four cases, a hematoma-dissection complex in seven and an aneurysmal dilatation associated with the dissection in three. Of the 10 patients who were followed at our institution, 90% had stabilization or partial regression of the imaging findings. In the remaining case, new dissection events were observed. All cases were managed conservatively, and no death was reported. Conclusions: In this series of patients, spontaneous dissection of visceral arteries had a benign, favorable course, requiring only conservative management. <![CDATA[Riesgo de aparición de infarto agudo de miocardio en el largo plazo después de una intoxicación por monóxido de carbono (CO)]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901128&lng=es&nrm=iso&tlng=es ABSTRACT Background: After acute carbon monoxide intoxication, there may be a higher risk for late adverse cardiac events. However, these patients are usually not followed to monitor the appearance of these effects. Aim: To follow patients seen at an emergency department for carbon monoxide intoxication, monitoring the appearance of myocardial infarction. To assess the predictive value for such complication of serum troponin, carboxyhemoglobin, and procalcitonin levels at the moment of intoxication. Material and Methods: We followed 237 patients receiving emergency care for carbon monoxide intoxication, with a serum carboxyhemoglobin of 5% or more, between 2010 and 2012. Levels of procalcitonin and troponin I were measured. Patients were followed for five years after the intoxication. Results: During the follow up period, 35 patients had a myocardial infarction. These patients had significantly higher carboxyhemoglobin, procalcitonin and troponin I levels at the moment of the intoxication than their counterparts who did not had a myocardial infarction in the follow up. A logistic regression analysis showed that age, carboxyhemoglobin levels, procalcitonin, troponin 1 and length of CO exposure were associated with a higher risk of myocardial infarction. Procalcitonin, troponin and carboxyhemoglobin levels had a high sensitivity and specificity to predict the appearance of myocardial infarction, with high areas under the receiver operating characteristic (ROC) curves. Conclusions: In patients with CO intoxication, carboxyhemoglobin, troponin and procalcitonin levels at the moment of the intoxication are significant predictors of the late appearance of myocardial infarction.<hr/> Antecedentes: Después de una intoxicación con monóxido de carbono, hay un mayor riesgo de desarrollar problemas cardiovasculares a largo plazo. Sin embargo, estos pacientes no son seguidos habitualmente para evaluar la aparición de estos eventos. Objetivo: Efectuar un seguimiento de pacientes que han sufrido una intoxicación con CO, evaluando la aparición de infarto del miocardio. Evaluar el valor de los niveles de troponina, carboxihemoglobina y procalcitonina para predecir la aparición de estos eventos. Material y Métodos: Seguimos 237 pacientes que fueron atendidos de urgencia por una intoxicación con CO, con niveles de carboxihemoglobina de 5% o más, entre 2010 y 2012. Se midieron los niveles de procalcitonina, troponina 1 y carboxihemoglobina y los pacientes fueron seguidos por cinco años después de la intoxicación. Resultados: Durante el seguimiento, 35 pacientes tuvieron un infarto al miocardio. Estos pacientes tenían niveles significativamente más altos de procalcitonina, troponina 1 y carboxihemoglobina al momento de la intoxicación, que los pacientes que no tuvieron un infarto durante el seguimiento. Una regresión logística mostró que la edad, carboxihemoglobina, procalcitonina, troponina y la duración de exposición a CO se asociaron a un mayor riesgo de infarto. Procalcitonina, troponina 1 y carboxihemoglobina tuvieron una alta sensibilidad y especificidad para predecir la aparición de infarto, con áreas bajo la curva ROC (receiver operating characteristic) elevadas. Conclusiones: En pacientes con intoxicación por CO, la carboxihemoglobina, procalcitonina y troponina son predictores significativos de la aparición de infarto agudo de miocardio en el largo plazo. <![CDATA[Efecto de un entrenamiento con ejercicios de autocarga a alta velocidad en el equilibrio dinámico y estático en mujeres adultas mayores]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901136&lng=es&nrm=iso&tlng=es Background: High-speed resistance training programs aiming to increase muscle power have beneficial effects on balance. Aim: To compare the effect of high-speed bodyweight resistance training and normal-speed bodyweight resistance training on the static and dynamic balance in community-dwelling older women. Material and Methods: Thirty-five non-disabled community-dwelling women aged 65 to 80 years were trained for 12 weeks using a high-speed bodyweight resistance training (HS-BT) or a normal-speed bodyweight resistance training (NS-BT). At baseline and after the intervention, One Leg Stance (OLS) and Timed Up and Go (TUG) tests were measured. Participants with an attendance to training sessions of less than 70% were excluded from the final analysis. Results: Data from 26 participants were analyzed, 14 women aged 71 ± 4 years who received HS-BT and 12 women aged 73 ± 4 years who received NS-BT. After 12 weeks of training, a significant improvement in TUG was observed in women receiving HS-BT (ΔTUG −1.07 sec, p &lt; 0.01), but without changes in the OLS test. No significant changes were observed in any of the tests in the NS-BT group. Conclusions: High-speed bodyweight resistance training for 12 weeks improved TUG in these women. <![CDATA[Caracterización de los estilos de vida en dueñas de casa chilenas. Análisis de la Encuesta Nacional de Salud 2009-2010]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901144&lng=es&nrm=iso&tlng=es Background: Housewives represent a important proportion of the Chilean population. However, there is limited evidence about their lifestyles. Aim: To characterize lifestyles and determine the level of compliance with healthy lifestyles guidelines of housewives in Chile. Material and Methods: Housewives from the 2009-2010 National Health Survey were included. The variables studied included levels of physical activity (PA), sedentary behavior, diet, hours of sleep and smoking. Compliance with healthy lifestyle behaviors was evaluated through logistic regression, granting a value of 1 for compliance and 0 for non-compliance. A healthy lifestyle was defined as meeting at least four healthy behaviors. Results: Housewives aged &gt; 55 years had a higher BMI and waist circumference compared to those aged &lt; 40 years. Housewives were also more likely to report moderate alcohol consumption and were more likely to meet a healthier lifestyle score (Odds ratio = 1.52 [95% confidence intervals: 1.09 to 2.11], p = 0.013). No significant age trends were observed for other lifestyle behaviors. Conclusions: Housewives had high levels of central obesity, excess body weight and high levels of salt intake but low alcohol intake. Their healthy lifestyles behaviors increased along with increasing age. <![CDATA[Tiempos de llegada de pacientes con ataque cerebrovascular en un hospital regional de alta complejidad]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901154&lng=es&nrm=iso&tlng=es Background: Stroke is a time-dependent emergency. Most patients with acute ischemic stroke are excluded from reperfusion therapies due to late consultation. Aims: To estimate the arrival times of patients with stroke to the Emergency Room (ER) of a public hospital. To identify factors associated with early consultation. Material and Methods: A convenience sample, 583 patients aged 71 ± 13 years (55% males) consulting for stroke at an emergency room was analyzed in terms of delay between onset of symptoms and arrival to the ER, demographics and etiology of stroke. Results: The admission diagnoses were ischemic stroke in 76%, intracerebral hemorrhage in 12%, transient ischemic attack in 9% and subarachnoid hemorrhage in 3%. The median time of arrival was 8 hours and 11 minutes after the onset of symptoms. Nineteen percent of consultations for ischemic stroke occurred within 3 hours of symptom onset, and 38% within 6 hours. In the logistic regression analysis, having an address near the hospital and the severity of stroke were associated with early consultation with a combined odds ratio of 5.97 (95% confidence intervals 3.23-11.04). Conclusions: There were significant differences in the arrival times of patients with stroke. Only a low proportion of patients with ischemic stroke consulted within the window for reperfusion therapies. Severe strokes and living near the hospital were associated with early consultation. <![CDATA[Cambia el color y el riesgo… Nuevo escenario para el cáncer de próstata en Chile]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901159&lng=es&nrm=iso&tlng=es In 2017, migrants were 4.35% of the Chilean population, mainly from Peru and Colombia. From 2015, the amount of migrants from Central America, particularly from Haiti increased notably. This process changed the phenotype of the male population, increasing the proportion of black men, mainly between 20 and 50 years. Afro-descendant men have a higher risk for prostate cancer, and the tumor can appear as early as 40 years of age among them. This increase will have future repercussions on the public health system, since part of these men have low income and poor living conditions. Therefore, it is necessary to discuss early detection strategies focused on this population, including education for both patients and health professionals. This review includes data on the reality of migration in Chile and its impact on the health system. The higher incidence and mortality of prostate cancer in the migrant population is reviewed and risk-adjusted screening strategies are proposed. <![CDATA[Consumo de mono, di, oligo sacáridos y polioles fermentables (FODMAPs), una nueva fuente de sintomatología gastrointestinal]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901167&lng=es&nrm=iso&tlng=es An increasing number of children and adults are currently suffering symptoms due to FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) consumption. These carbohydrates are poorly digested in the human gastrointestinal tract, exerting an osmotic effect in the small intestine. In the colon, they become substrates to the microbiota. Microbial fermentation explains symptoms such as abdominal distention (postprandial fullness), bloating and flatulence, abdominal pain and loose feces or diarrhea. There are no standardized methods to measure them in daily clinical work. Daily tolerance and the no-effect doses are unclear. How to diagnose and treat FODMAP associated symptoms is also controversial. In this review, we aim to define FODMAP, their associated symptoms and the current techniques for assessing them. The low-FODMAP diet is described and how to implement it. <![CDATA[Enfermedad por priones, encefalopatía espongiforme humana y enfermedad de Creutzfeldt-Jakob]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901176&lng=es&nrm=iso&tlng=es The infectious protein or prion (PrPSC) is a transmissible and replicable polypeptide, which arises from an abnormal folding of the PrP protein, by unknown mechanisms and without changes in the primary sequence of its amino acids. Its new spatial disposition arises from the substitution of its alpha helices by beta bands, which increase its structural stability, avoiding its complete proteolysis, resulting in a residual accumulation of prions. These prions induce the misfolding of normal PrP protein, generating their exponential increase, leading to a disturbance of neuronal homeostasis which results in the development of the fatal spongiform encephalopathy of the Creutzfeldt-Jakob disease (CJD). This is the most prevalent human prion disease, and 90% of cases are sporadic, suggesting the endogenous genesis of prions. There are different types of prions, identified based on the genetic variance of codon 129 amino acids of the prion protein. Meteonin (M) and Valine (V)), associated with the result of their enzymatic proteolysis, define prions type 1 (21 kDa) and type 2 (19 kDa). The Classical form of CJD produced by MM1 prion occurs in 70% of the cases. The Cerebellar form originated by the VV2 prion occurs in 15% of cases, the form with Kuru plates, associated with the prion MV2 occurs in 5%, and the Vacuolar, related to the MM2 prion occurs in 4%. CJD is always characterized by behavioral, motor, cognitive, and vision alterations and by findings in magnetic resonance imaging, electroencephalogram and cerebrospinal fluid that define each clinical and neuropathological form. <![CDATA[Las mujeres en la medicina chilena: Desde los tiempos de Eloísa Díaz a la actualidad]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901184&lng=es&nrm=iso&tlng=es Though the presence of many women in medicine goes unnoticed today, their incorporation to the field was slow and difficult. It took until the end of the nineteenth century for women to be finally allowed to study at the University in Chile, being Eloísa Díaz the first woman to become a medical doctor in 1887. In that century, only six women became medical doctors. However, throughout the twentieth century, this small proportion of women in medicine increased at a similar rate as tuition did in the schools of medicine, especially from the 1960's when limited quotas for women were abolished. At present, women doctors constitute 40% of the total pool of medical doctors in Chile, being present in all specialties, though preferably found as general practitioners, family doctors and pediatricians. While many women have stood out in academia and in politics, they have also successfully reached high positions in scientific societies (and other offices such in the Health Ministry, and even the country's presidency) their participation is still limited in these areas. It is only fair to conclude that the outstanding participation that women in Chilean medicine enjoy today is not solely due to their long-lasting efforts, but more importantly, to their tireless struggle to overcome prejudice, discrimination and misunderstanding; the latter being especially represented by pioneer women of medicine. <![CDATA[Julio Escámez Contreras y su original mural Historia de la Medicina y de la Farmacia en Chile]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901190&lng=es&nrm=iso&tlng=es Julio Escámez Contreras was a highly creative, skilled and versatile Chilean painter who painted in Chile from 1940 to 1974 when he went into exile to Costa Rica and died there in 2015. In 1953-54, Escámez painted a large mural in a private pharmacy in the city of Concepcion, Chile, The History of Medicine and Pharmacy in Chile. This mural describes the origins and development of medicine and pharmacy in Chile, placing that origin in the medicinal activities of the mapuche indigenous population. The mural consists of three sections, each painted on the upper segment of three adjacent walls in the pharmacy, with each section focused on one period in the evolution of medicine and pharmacy in Chile. The first section is devoted to indigenous medical practices including its pharmacopeia and religious practices, the second describes medical approaches during colonial times, still with strong indigenous components but also with indigenous and Catholic hybrid religious elements, while the third depicts modern medicine, including chemistry, anatomical, physical and pharmacological activities complemented with public health components such as nursing, vaccination and health education. Read from left to right, the mural provides a highly lively, accurate and valid depiction of the evolution of medicine and pharmacy in Chile. Escámez' artistry and skill in the use of perspective, color, landscape, architecture and Chilean subjects, including real life individuals, produces a typical Chilean mural. However, his originality and consummate use of a non-verbal visual language delivers a more universal message, one that helps to explain the repeated efforts, of the government responsible for his exile, to destroy some of the works produced by him. <![CDATA[Espiritualidad en medicina: análisis de la justificación ética en Puchalski]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901199&lng=es&nrm=iso&tlng=es The relationship between spirituality and medicine is present from the very origins of Medicine. Its relevance has been rediscovered during the past decades. Numerous publications report positive health results when spiritual needs of patients are addressed. Authors like Edmund Pellegrino and Christina Puchalski have gained an acknowledged leadership in this field. The purpose of the article is to study Christina Puchalkis' contributions to the field, specifically through the identification and analysis of the ethical reasons that - according to Puchalski – justify the medical duty to provide spiritual care. As a result of our investigations, we propose to systematize the ethical reasons identified in Puchalski's writings in seven categories, that presuppose a broad definition of spirituality and a conception of “whole patient care”. Our analysis shows that Puchalski's arguments are ultimately grounded on an ethics of virtue and a realist anthropology, more than in mere positive effects or in patient's wishes. Indeed, Puchaslki's anthropological conception recognized human dignity as an intrinsic value that must be always acknowledged, especially in the context of disease, where questions about the meaning of life, suffering, connection and transcendence inevitable arise. We conclude that Puchalski's ethical arguments are solid and suggest the challenge of including the spiritual dimension in the formation of health care professionals. <![CDATA[Enfermedad quística adventicial de la arteria poplítea. Presentación imagenológica de una causa rara de claudicación intermitente]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901206&lng=es&nrm=iso&tlng=es Adventitial cystic disease of the popliteal artery is a rare condition of uncertain etiology, which presents as intermittent claudication of the lower extremity in middle-age patients. We report a 44-year-old man presenting with intermittent claudication of his left leg. MR angiography showed cystic parietal lesions that caused compression with partial occlusion of the left popliteal artery. Surgical resection of the affected segment was performed, with venous graft interposition. The histopathological analysis of the surgical specimen was consistent with cystic adventitial disease. <![CDATA[Terapia continua intra-arterial selectiva con nimodipino para el tratamiento del vasoespasmo refractario en hemorragia subaracnoidea aneurismática. Caso clínico]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901210&lng=es&nrm=iso&tlng=es We report a 39-year-old male with an aneurysmal subarachnoid hemorrhage without hydrocephalus, in whom a right choroidal aneurysm was early excluded by endovascular coil insertion. Intracranial pressure (PIC) and cerebral oxygenation (PtiO2) sensors for neuromonitoring were installed due to a persistent comatose state. From the 3rd day, neuromonitoring became altered. CT angiography and cerebral angiography showed severe proximal and distal vasospasm (VE) of the middle (ACM) and anterior (ACA) right cerebral arteries. VE was treated with angioplasty and intravenous nimodipine. Forty eight hours later, despite hemodynamic maximization, neuromonitoring became altered again, mainly explained by a decrease in PtiO2 below 15 mmHg. A severe VE in ACM and right ACA was confirmed by angiography. Given the presence of an early and recurrent VE, which was associated with a decrease in cerebral oxygenation, internal carotid micro-catheters for continuous nimodipine infusion were installed. This therapy maintained a normal neuromonitoring for 15 days. During this period, attempts were done to decrease or discontinue the infusion, but the patient presented parallel falls of cerebral oxygenation or decreased cerebral perfusion observed with perfusion CT, interpreted as persistent VE. Finally, the infusion was stopped at day 15 without significant complication. We conclude that intra-arterial nimodipine continuous infusion in refractory VE can be useful and safe in selected patients. Multimodal neuromonitoring is essential. <![CDATA[Comentarios al artículo: “Actividad física y calidad de vida en personas con enfermedad renal crónica”]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901217&lng=es&nrm=iso&tlng=es We report a 39-year-old male with an aneurysmal subarachnoid hemorrhage without hydrocephalus, in whom a right choroidal aneurysm was early excluded by endovascular coil insertion. Intracranial pressure (PIC) and cerebral oxygenation (PtiO2) sensors for neuromonitoring were installed due to a persistent comatose state. From the 3rd day, neuromonitoring became altered. CT angiography and cerebral angiography showed severe proximal and distal vasospasm (VE) of the middle (ACM) and anterior (ACA) right cerebral arteries. VE was treated with angioplasty and intravenous nimodipine. Forty eight hours later, despite hemodynamic maximization, neuromonitoring became altered again, mainly explained by a decrease in PtiO2 below 15 mmHg. A severe VE in ACM and right ACA was confirmed by angiography. Given the presence of an early and recurrent VE, which was associated with a decrease in cerebral oxygenation, internal carotid micro-catheters for continuous nimodipine infusion were installed. This therapy maintained a normal neuromonitoring for 15 days. During this period, attempts were done to decrease or discontinue the infusion, but the patient presented parallel falls of cerebral oxygenation or decreased cerebral perfusion observed with perfusion CT, interpreted as persistent VE. Finally, the infusion was stopped at day 15 without significant complication. We conclude that intra-arterial nimodipine continuous infusion in refractory VE can be useful and safe in selected patients. Multimodal neuromonitoring is essential. <![CDATA[Setenta años de existencia de la cepa Tulahuén de <em>Trypanosoma cruzi</em>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901218&lng=es&nrm=iso&tlng=es We report a 39-year-old male with an aneurysmal subarachnoid hemorrhage without hydrocephalus, in whom a right choroidal aneurysm was early excluded by endovascular coil insertion. Intracranial pressure (PIC) and cerebral oxygenation (PtiO2) sensors for neuromonitoring were installed due to a persistent comatose state. From the 3rd day, neuromonitoring became altered. CT angiography and cerebral angiography showed severe proximal and distal vasospasm (VE) of the middle (ACM) and anterior (ACA) right cerebral arteries. VE was treated with angioplasty and intravenous nimodipine. Forty eight hours later, despite hemodynamic maximization, neuromonitoring became altered again, mainly explained by a decrease in PtiO2 below 15 mmHg. A severe VE in ACM and right ACA was confirmed by angiography. Given the presence of an early and recurrent VE, which was associated with a decrease in cerebral oxygenation, internal carotid micro-catheters for continuous nimodipine infusion were installed. This therapy maintained a normal neuromonitoring for 15 days. During this period, attempts were done to decrease or discontinue the infusion, but the patient presented parallel falls of cerebral oxygenation or decreased cerebral perfusion observed with perfusion CT, interpreted as persistent VE. Finally, the infusion was stopped at day 15 without significant complication. We conclude that intra-arterial nimodipine continuous infusion in refractory VE can be useful and safe in selected patients. Multimodal neuromonitoring is essential. <![CDATA[Efectividad de intervenciones grupales versus individuales en el manejo de pacientes crónicos. Desafío para equipos de atención primaria]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872019000901219&lng=es&nrm=iso&tlng=es We report a 39-year-old male with an aneurysmal subarachnoid hemorrhage without hydrocephalus, in whom a right choroidal aneurysm was early excluded by endovascular coil insertion. Intracranial pressure (PIC) and cerebral oxygenation (PtiO2) sensors for neuromonitoring were installed due to a persistent comatose state. From the 3rd day, neuromonitoring became altered. CT angiography and cerebral angiography showed severe proximal and distal vasospasm (VE) of the middle (ACM) and anterior (ACA) right cerebral arteries. VE was treated with angioplasty and intravenous nimodipine. Forty eight hours later, despite hemodynamic maximization, neuromonitoring became altered again, mainly explained by a decrease in PtiO2 below 15 mmHg. A severe VE in ACM and right ACA was confirmed by angiography. Given the presence of an early and recurrent VE, which was associated with a decrease in cerebral oxygenation, internal carotid micro-catheters for continuous nimodipine infusion were installed. This therapy maintained a normal neuromonitoring for 15 days. During this period, attempts were done to decrease or discontinue the infusion, but the patient presented parallel falls of cerebral oxygenation or decreased cerebral perfusion observed with perfusion CT, interpreted as persistent VE. Finally, the infusion was stopped at day 15 without significant complication. We conclude that intra-arterial nimodipine continuous infusion in refractory VE can be useful and safe in selected patients. Multimodal neuromonitoring is essential.