Revista medica de Chile最新文献

Liver transplantation is the only effective therapy to reduce the high mortality associated with acute liver failure and acute on chronic liver failure (ACLF). Single-pass albumin dialysis (SPAD) is an extracorporeal supportive therapy used as a bridge to liver transplantation or regeneration. We report a 44-year-old man with alcoholic cirrhosis admitted for critical COVID-19 pneumonia that evolves with ACLF. SPAD technique was performed completing six sessions, with a reduction of bilirubin and ammonia levels. He evolved with severe respiratory failure and refractory septic shock, dying. SPAD is a safe and efficient technique aimed to eliminate liver toxins, preventing multiorgan damage interrupting the process known as the "autointoxication hypothesis". It is easy to implement in any critical patient unit and has lower costs than other extracorporeal liver support therapies.

Background: Cancer is a public health priority in Chile.

Aim: To estimate the expected annual cost of cancer in Chile, due to direct costs of health services, working allowances and indirect costs for productivity losses.

Material and methods: We undertook an ascendent costing methodology to calculate direct costs. We built diagnostic, treatment and follow-up cost baskets for each cancer type. Further, we estimated the expenditure due to sick leave subsidies. Both estimates were performed either for the public or private sector. Costs related to productivity loss were estimated using the human capital approach, incorporating disease related absenteeism premature deaths. The time frame for all estimates was one year.

Results: The annual expected costs attributed to cancer was $1,557 billion of Chilean pesos. The health services expected annual costs were $1,436 billion, 67% of which are spent on five cancer groups (digestive, hematologic, respiratory, breast and urinary tract). The expected costs of sick leave subsidies and productivity loss were $48 and $71 billion, respectively.

Conclusions: Cancer generates costs to the health system, which obliges health planners to allocate a significant proportion of the health budget to this disease. The expected costs estimated in this study are equivalent to 8.9% of all health expenditures and 0.69% of the Gross Domestic Product. This study provides an updated reference for future research, such as those aimed at evaluating the current health policies in cancer.

Background: Clinical reasoning (CR) is a training mainstay in health care careers.

Aim: To describe the perception of students and teachers about the development of clinical CR in Kinesiology and Dentistry careers.

Material and methods: Exploratory descriptive qualitative study, with 12 informants (six teachers and six students), applying a script of questions through a semi-structured interview. A thematic inductive data analysis was carried out.

Results: Two hundred thirty-five meaning units, 38 codes, seven subcategories and three categories were collected. CR was reported as a basic analysis process in health care training. Its necessary elements are knowledge, a learning environment and a facilitator teacher, among others. Motivation, analysis models, variability and exposure are reported as facilitating factors for the development of CR. Teacher paternalism, resistance to change and few learning opportunities are presented as obstacles. Active strategies such as clinical cases, simulation and clinical practice are perceived as facilitators for the development of CR. Those situations where the student does not assume a leading role such as lectures and activities in large groups, are considered as obstacles.

Conclusions: Both students and teachers point to CR as an analysis process that is indispensable in both careers. Exposure to variable educational experiences through active educational strategies in small groups encourages CR.

Background: Cognitive dysfunction is a common complain in patients with fibromyalgia (FM).

Aim: To assess the perceived cognitive function and cognitive performance in women with FM.

Material and methods: Cross-sectional study including 100 women with FM (FMG) and 100 healthy controls (CG). Self-perceived cognitive functioning was evaluated using the Functional Assessment of Cancer Therapy Cognition scale (FACT-Cogv3). The neuropsychological performance was assessed with the Trail Making Test (TMT-A, TMT-B), Digit Span test (DS), Barcelona test (DS-F/B) and the Frontal Assessment Battery (FAB-E), Spanish version test.

Results: The mean scores of all cognitive self-perception factors and all neuropsychological tests were lower in the FMG (p < 0.001). Over 90% of the FMG took longer than the population mean (P50) to complete the TMT-A and TMT-B tests, while in the CG, 1/3 took longer than the P50 in both tests. The minimum expected scores for the DS-F and DS-B tests were not achieved by 40 and 9% of FMG participants, respectively. According to FAB-E, 54% and 24% of FMG were categorized as fronto-subcortical deficit and fronto-subcortical dementia, respectively.

Conclusions: Women with FM have a higher perception of cognitive dysfunction and lower cognitive performance in objective tests than healthy women. More research is needed to explore the clinical, psychosocial, and sociodemographic characteristics that predispose to cognitive deficits in this group of patients.

Background: Transcatheter aortic-valve implantation (TAVI) was introduced in 2002 and the first implants in our country were performed in 2010.

Aim: To review the TAVI experience in our hospital, considering the technology improvements and gained experience throughout this period.

Material and methods: All patients undergoing TAVI in our center were included. Results and complications were adjudicated according to the Valve Academic Research Consortium-2 (VARC-2) criteria. Patients were divided in 3 groups, according to procedural year: Period 1: 2010-2015 (n = 35); Period 2: 2016-2018 (n = 35); Period 3: 2019-2021 (n = 41). Mortality up to one year after the procedure was recorded.

Results: Between 2010 and 2021, 111 TAVI procedures were performed. The mean age of patients was 82 years and 47% were women. Risk scores for in-hospital mortality were STS 6.7%, EUROSCORE II 8.0% and ACC/STS TAVR Score 4.9%. The trans-femoral route was used in 88% and a balloon-expandable valve was chosen in 82% of patients. A successful implant was achieved in 96%, with an in-hospital mortality of 1.8%. Mortality at 30 days and 1-year were 2.7 and 9.0%, respectively. During period 3, 100% of implants were successful, with no in-hospital mortality, less vascular complications (p < 0.01), less stroke (p = 0.04), less severe paravalvular leak (p = 0.01) and significantly lower rate of acute complications (p < 0.01).

Conclusions: TAVI achieves excellent results. With greater experience and better available technologies, these results are even more favorable.

Background: The urea breath test (UBT-13C) is a non-invasive technique that allows the diagnosis and confirmation of eradication of Helicobacter pylori infection.

Aim: To evaluate H. pylori positivity and values of UBT-13C among infected Chilean children and adults, and to analyze its variation in relation to sex, nutritional status, and age of the patients.

Material and methods: Retrospective study of 1141 patients aged 6 to 94 years, with an indication for a UBT-13C either for diagnosis or for confirmation of eradication of H. pylori infection. 13C enrichment was measured using an infrared spectrometer calculating the delta 13C values before and after the ingestion of 13C marked urea. The clinical data of the patients were obtained at the time of the examination.

Results: We included 241 children and 900 adults. Infected children obtained lower UBT-13C delta values than infected adults (16.1 ± 8.7 and 37 ± 52.9, respectively). The rates of infection were higher in males who were recruited for diagnosis. Significant differences were obtained between positivity for H. pylori in overweight and obese children but not adults. UBT-13C titers were significantly associated with the body mass index (BMI) only in adults.

Conclusions: H. pylori infection rates are similar between sexes and are higher in children probably because of selection bias. In children, H. pylori positivity is associated with higher BMI and excess malnutrition although with similar UBT-13C values. In adults, H. pylori infection is not related with BMI, but a higher BMI impacts UBT-13C titers.

Electroconvulsive therapy (ECT) has multiple uses in psychiatry, but its mechanisms of action (MA) in patients with schizophrenia (PS) are poorly understood. We synthesize and discuss the available evidence in this regard. We conducted a search for primary human studies and systematic reviews searching MA of ECT in PS published in PubMed/Medline, SciELO, PsycInfo, and the Cochrane Library, including 24 articles. Genetic findings are scarce and inconsistent. At the molecular level, the dopaminergic and GABAergic role stands out. The increase in brain derived neurotrophic factor (BDNF) after ECT, is a predictor of positive clinical outcomes, while the change in N-acetyl aspartate levels would demonstrate a neuroprotective role for ECT. This intervention would improve inflammatory and oxidative parameters, thereby resulting in a symptomatic improvement. ECT is associated with an increase in functional connectivity in the thalamus, right putamen, prefrontal cortex and left precuneus, structures that play a role in the neural default mode network. A decrease in connectivity between the thalamus and the sensory cortex and an enhanced functional connectivity of the right thalamus to right putamen along with a clinical improvement have been reported after ECT. Moreover a volumetric increase in hippocampus and insula has been reported after ECT. These changes could be associated with the biochemical pathophysiology of schizophrenia. Most of the included studies are observational or quasi-experimental, with small sample sizes. However, they show simultaneous changes at different neurobiological levels, with a pathophysiological and clinical correlation. We propose that the research on ECT should be carried out from neurobiological dimensions, but with a clinical perspective.

Background: Simple surrogate indexes (SSI) to assess beta-cell function, insulin sensitivity (IS) and insulin resistance (IR) are an easy and economic tool used in clinical practice to identify glucose metabolism disturbances.

Aim: To evaluate the validity and reliability of SSI that estimate beta-cell function, IS and IR using as a reference the parameters obtained from the frequently sampled intravenous glucose tolerance test (FSIVGTT).

Material and methods: We included 62 subjects aged 20-45 years, with a normal body mass index and without diabetes or prediabetes. SSI were compared with the acute insulin response to glucose (AIRg), insulin sensitivity index (Si) and disposition index (DI) obtained from the FSIVGTT using the minimal model approach. Half of the participants (n = 31) were randomly selected for a second visit two weeks later to evaluate the reliability of all the variables.

Results: HOMA1-%B and HOMA2-%B had a significant correlation with AIRg (Spearman Rho (rs) = 0.33 and 0.37 respectively, p < 0.01). The SSI evaluating IS/IR that showed stronger correlation (rs > 0.50) with Si were fasting insulin, HOMA1-IR, HOMA2-IR, HOMA1-%S, HOMA2-%S, QUICKI, and the McAuley index. The parameters that showed good reliability with an intraclass correlation coefficient (ICC) > 0.75 were AIRg, HOMA1-%S, HOMA2-%S, and QUICKI.

Conclusions: Our results suggest that most of the SSI are useful and reliable.

Along with the increase in reported figures of depression in the world's population, organizations such as the WHO have begun to promote screening and pharmacological treatment of mild symptomatic cases. The problem in this context is that the manifestations of 'normal' and 'pathological' depressive mood do not differ much from each other, which creates difficulties at a diagnostic and scientific level. This article explores an approach that could facilitate the clinical and scientific task of differentiating between non-specific affective disturbances (depressive mood) and depression as an illness as such. It is proposed that various causal stressors interact with individual predispositions to trigger a transient change in mood as an adaptive response. In turn, the greater the intensity of the stressors (psychological, social, etc.), the greater the neuroinflammation, which would diminish neuronal plasticity and the possibilities of mood compensation and behavioral change of the subject. The existence of this neurobiological alteration (decreased neuronal plasticity), rather than depressive mood, would help us to categorize depression as a disease.