Revista chilena de neuro-psiquiatría

Conflicts of Interest

We have prompted a local discussion on the very timely issue of conflicts of interest in order to incorporate an official declaration into our publication. This editorial serves as a general introduction to the matter from the dynamics of communication. This issue of the journal also includes three articles on conflicts of interest based on the reflections of the Editorial Committee, the SONEPSYN Board, and the Ethical Council.

Conflicts of Interest: An Unpostponable Issue. Editorial Committee Panel

Our Editorial Committee presents a panel discussion on conflicts of interest in order to formulate a reflection on the issue. The panel defines "conflict of interest" both in general terms and specifically for publishing, and analyses other scenarios in medical practice in which conflicts of interest could potentially be a problem. The purpose of explicit declarations on conflicts of interest is evaluated as a means of bringing about greater preventive transparency, which is the key to community control over the problem. Finally, an analysis is made of cases and examples in which the interests were not made clear, as well as a study of how users of biomedical information are affected when they learn of conflicts of interest. From the information presented in the panel discussion, it can be concluded that conflicts of interest do indeed exist, that it is an issue that must inevitably be addressed, and that it is naïve to suppose that it is a problem that can easily be brought under control. We must create instruments to make the relationships and ties natural to our daily activities more transparent. Many of those who openly declare their conflicts of interest have healthy ties. In a scenario of explicit declarations, undeclared ties are potentially suspect by their very nature. A group consensus on an issue does not result in immediate behavior changes, but it is a first step that must be taken immediately. The possibility of a particular slant must be taken into consideration in a systematic analysis of any article, even in those articles backed by a group of professionals or by scientific associations. Finally, to distance oneself from the guidelines of the International Committee of Medical Journal Editors is an unwise and isolating course of action for a biomedical publication.

Con motivo de incorporar la declaración de conflicto de interés en nuestra revista, el comité editorial presenta un Panel sobre el tema. En éste, se define conflicto de interés en términos generales y editoriales, así como se analizan otros escenarios de la práctica médica con potenciales conflictos de intereses. Se evalúa el sentido de las declaraciones explícitas de conflicto de interés, como expresión de preventiva transparencia, clave del control comunitario del problema. Finalmente se evalúan casos y ejemplos de subnotificación de intereses y el impacto del conocimiento de los conflictos de intereses en los usuarios de la información biomédica. De la información presentada en el panel es posible concluir que: el conflicto de interés existe, el aludirlo es inevitable, el pensar controlarlo con facilidad es ingenuo. El generar instrumentos que sirvan para transparentar relaciones y vínculos que son naturales en nuestro quehacer, es necesario. Muchos de los que declaran sus conflictos de interés tienen vínculos sanos. En un escenario de declaraciones explícitas los vínculos no declarados por ese solo hecho resultan potencialmente sospechosos. El acuerdo y consenso conceptual en un tema tarda en cambiar conductas, pero el paso inicial es impostergable. La responsabilidad de pensar en el sesgo, como manera sistemática de análisis de un artículo, es una responsabilidad indelegable, incluso en aquellos artículos que cuentan con gran soporte corporativo profesional o de sociedades científicas. Finalmente el abstraerse de las pautas del International Committee of Medical Journal Editors, es editorialmente imprudente e insular.

Conflicts of Interest: A Concern of the Society of Neurology, Psychiatry and Neurosurgery (SONEPSYN)

Medical literature is paying increasing attention to conflicts of interest, mainly although not exclusively from the perspective of the physician-pharmaceutical industry relationship. When interests compete, the possibility of medical judgment being distorted is often not visible at first sight. The likelihood of an unconscious and unintentional self-serving bias, as well as the effects that professional judgment would appear to be influenced, regardless of whether it is or not, must be considered. The advent of Evidence-based Medicine and Administered Health poses tensions between the population focus of medicine and the duties that doctors have to individual patients. As in other countries, national scientific societies must prompt the study, knowledge, and diffusion of those factors that may contribute to bias in medical judgment, as well as institute local ethical codes to guide professionals.

La literatura médica está prestando creciente atención al conflicto de intereses, de modo principal aunque no exclusivo, desde la perspectiva de las relaciones entre los médicos y la industria farmacéutica. Cuando hay intereses en competencia muchas veces la posibilidad de la distorsión del juicio médico no es visible a primera vista. Deben considerarse el posible sesgo inconsciente y no intencionado de autoservicio, como los efectos de que el juicio profesional parezca influenciado, independiente de si lo está o no. El advenimiento de la Medicina basada en la Evidencia y de la Salud Administrada plantea tensiones entre el enfoque poblacional de la medicina y las obligaciones de los médicos hacia sus pacientes individuales. Al igual que en otros países, es necesario que las sociedades científicas nacionales impulsen el estudio, conocimiento y difusión de aquellos factores que pueden contribuir a sesgar el juicio médico, como asimismo instituir pautas éticas locales que guíen a los profesionales.

Conflicts of interest in the clinical setting

The editor of this journal has invited the ethical committee to reflect and express its opinion about conflicts of interest in the clinical setting. We define "Conflict of Interest" and discuss the effect that mismanagement of a conflict of interest could have on the doctor-patient relationship. We conclude that the basic conflict in the clinical setting is the so-called "double-agent" doctor. This issue has been studied in relation to the development of the North-American system of clinical administration: "managed-care" The name managed care describes the two basic functions of the clinician: his role of "caring" for his patients, and therefore to search for the best for each individual; and his role to manage the resources available and to control costs. This new scenario may radically change the future of the medical profession. Doctors have an undeniable responsibility in the development of what may be a new paradigm in the way medicine is practiced, certainly changing the social contract of our profession.

En una interesante iniciativa, el Editor de esta Revista ha invitado al Comité de Ética de SONEPSYN a reflexionar y manifestar una opinión sobre el conflicto de intereses en la relación clínica. Exponemos una definición de lo que entendemos por conflicto de intereses y la influencia que puede tener esta situación mal manejada sobre la relación médico-paciente. Se proporcionan antecedentes que permiten concluir que el conflicto fundamental en la relación clínica es la llamada "doble agencia del médico". La bibliografía última en el tema se ha desatado como consecuencia del sistema conocido en Estados Unidos con el nombre de "Managed Care". Esa expresión se ha traducido de varios modos: en nuestro medio se conoce como Gestión Clínica. La expresión norteamericana es muy precisa, porque en sus dos palabras quiere significar las dos funciones fundamentales del clínico: de una parte, su obligación de "care" y, por tanto, de buscar lo mejor para su paciente, y de otra su condición de "manager", es decir, de gestor de recursos, y la necesidad de que mire por el control del gasto. Este es el tema de la llamada "doble agencia del médico". Con este nuevo escenario va a cambiar radicalmente el futuro de la profesión médica, en cuya construcción nos parece que los profesionales tienen una responsabilidad indelegable; planteamos que estamos a las puertas de un cambio de paradigma en la forma de ejercer la medicina. Lo que de todos modos significará un cambio en el contrato social de nuestra profesión.

Metabolic disorders in schizophrenic patients treated with Clozapine

Atypical antipsychotic drugs are considered to provide major advantages in treating schizophrenic patients. However, they can cause significant increases in weight, glucose, and lipid homeostasis. Obesity is an important factor in diabetes mellitus, dyslipidemia, and arterial hypertension. Clozapine has been described as acting as an antagonistic agent of several receptors at the hypothalamic level, accentuating hyperinsulinemia and plurimetabolic syndrome, of high vascular risk in obesity. Three patients (2 women, 1 man) treated with clozapine for 5 years or more at a dosage of 300-400 mg/day were clinically monitored for their body weight, glycemia, and lipid profiles, resulting in the diagnosis of significant metabolic disorders. It is suggested that patients undergoing treatment with atypical antipsychotics should also receive adequate metabolic and nutritional evaluations.

En pacientes esquizofrénicos los antipsicóticos atípicos están considerados como las drogas de mayor ventaja en el tratamiento de las psicosis. Sin embargo, pueden provocar un trastorno importante en el peso, en la homeostasis de la glucosa y de los lípidos. La obesidad es un factor importante en la patogenia de la Diabetes mellitus, dislipidemias secundarias y de hipertensión arterial. Se ha descrito que la clozapina actúa como antagonista de receptores a nivel hipotalámico, que puede generar hiperinsulinemia y el síndrome plurimetabólico (Síndrome X) de alto riesgo vascular en obesidades moderadas o severas (IMC > 30 kg/m²). Se describen tres casos (2 mujeres, 1 hombre) que fueron tratados por un período mayor de 5 años con clozapina, en dosis entre 300-400mg/día y monitorizados clínicamente (peso, glicemia y perfil lipídíco). Estas evaluaciones permitieron establecer trastornos metabólicos relevantes. Se sugiere la importancia de una adecuada evaluación metabólica y adoptar medidas nutricionales en pacientes tratados con antipsicóticos atípicos.

A view of training neurologists in Chile: we should be doing our best

The training of clinical neurologists in Chile could be improved by introducing structural changes. It would be unacceptable not to try, although progress may be slow. The first of these changes would be to lengthen the present training period of three years in order to include, among other things, a more solid basis in Internal Medicine. It must always be borne in mind that our trainees are steeped in the passive attitude, intrinsic to the whole Chilean educational system, of expecting to be taught rather than actively seeking to learn by themselves. Creativity and energy are needed to foster periodic exchanges of trainees between centers whose different strong points offer desirable experience not available in all locations. Although classical neurology, usually seen in hospital wards, remains most important, equal time should be given over to ambulatory pathology. Certain aspects should be carefully pondered: pediatric neurology, psychiatry, neurosurgery, neuro-ophthalmology, neuropathology, and basic neuroscience. The need to devote separate time to some of these is questioned, e.g., imaging, neuropediatrics, psychiatry, neurosurgery, and neuropathology. Time should be devoted to defining how much of each a neurologist needs; it should be possible to regroup them in order to make the best use of available time. Neurological emergencies and basic neuroscience require reflection. Trainees should receive adequate remuneration and ample access to library facilities. Teaching postgraduates is an exacting task which should be undertaken by experienced clinicians aware of their duties in guiding and orienting future neurologists rather than simply securing instruction.

La formación de neurólogos en Chile, sin ser de mala calidad, puede ser mejorada si se introducen cambios estructurales. Lo primero es prolongar el actual período de tres años, para poder incluir entre otras cosas, una estadía en Medicina Interna. Un escollo importante, es la actitud pasiva de nuestros educandos, que tiende a estar a la espera de que se les entreguen conocimientos en vez de buscarlos ellos mismos en forma proactiva. Se requiere voluntad y creatividad para instaurar intercambios periódicos de becados entre diversos centros formadores de manera de aprovechar las ventajas comparativas de cada uno. Sin menoscabar la importancia de la neurología clásica se propone darle más tiempo a la formación en dolencias ambulatorias. Hay capítulos que deben ser abordados: neurología de urgencia, cuidados intensivos, imagenología, electrofisología, neurología pediátrica, psiquiatría, neurocirugía, neuro-oftalmología, neuropatología, anatomía patológica, y neurociencia básica. La necesidad de dedicarle tiempo aparte a algunos de ellos es cuestionada, por ejemplo, imagenología, neuropediatría, psiquiatría, neurocirugía y neuropatología. Se requiere definir qué se quiere lograr al proveer experiencia en cada una de estas disciplinas, siendo posible reagruparlas para optimizar el corto tiempo total disponible. Neurología de urgencia y neurociencia básica son temas especialmente complejos que requieren dedicación y reflexión. Los becados deben ser adecuadamente remunerados y dotados de facilidades amplias para su desarrollo. Finalmente, se enfatiza la seriedad con que debe emprenderse la tarea formativa por parte de los encargados de los programas, que va mucho más allá que el otorgar mera instrucción.

Neuroprotective therapy in Parkinson’s Disease

With the current limitations on treating Parkinsons disease, neuroprotection should be looked at as a possible way of slowing the varying processes involved in the onset of the disease. A review was made of the work of NINDS experts, who evaluated 59 drugs resulting from their Medline and Pub Med search. Twelve drugs, those considered the most promising, were included in the final analysis. We look at such substances as caffeine, coenzyme q10, estrogens, minocycline, nicotine, rasagiline-selegiline, and ropinirole-pramipexole. These agents acted dissimilarly, but favorably, on some of the diseases processes or on its underlying pathogenesis, although the mechanisms involved and the duration of the beneficial effects were not clear. The challenge is to overcome the difficulties that make the results of the few current studies uncertain, using new methods, such as transgenic models, to maintain hope for effective future treatments.

Neurological Consultations in Intensive Care

The paper "Neurological Consultations in the Medical Intensive Care Unit" by Rasvi SS, Bone I. published in J Neurol Neurosurg Psychiatry 2003; 74 (Suppl III): iii16-iii23 shows the epidemiological importance of neurological consultations in the Intensive Care Unit (ICU). It then analyses the clinical and technological difficulties of evaluating these patients, and defines such terms used in the ICU as sepsis, septic shock, adult respiratory distress syndrome (ARDS) and multiple organ failure. It describes the neurological testing that should be done in the ICU and, finally, reviews the various situations in which neurologists are needed in Intensive Care.