Revista medica de Chile最新文献

Background: The COVID-19 pandemic posed a great strain in health services.

Aim: To describe the epidemiological and clinical features of patients with SARS-CoV-2 admitted to a regional hospital in southern Chile between April and August 2020.

Material and methods: Clinical records of all hospitalized patients with RT-PCR (+) for SARS-CoV-2 were retrospectively analyzed.

Results: During the study period 226 patients aged 55 ± 18 years (55% men) were admitted. The main comorbidities were high blood pressure in 45%, diabetes in 31% and obesity in 21%. The main symptoms were dyspnea in 70%, cough in 69%, fever in 62% and myalgia in 47%. Pneumonia was the main cause of admission in 66%. Images on admission were compatible with pneumonia in 81%, and with a typical COVID-19 pattern in 84%. In 76% there was five-lobe involvement. Eighty-seven cases (39%) were admitted to critical care, with an APACHE score of 10.9 ± 7.1. Invasive mechanical ventilation was used in 16%, 30% required prone position and 13%, a high-flow nasal cannula. The mean stay in critical care was 13.3 days. The mean duration of invasive mechanical ventilation was 14.1 days. Antimicrobials were used in 55% and dexamethasone in 36%. Twenty-two (9.7%) patients aged 71.7 ± 14 died. A Charlson comorbidity index > 3, heart failure and connection to invasive mechanical ventilation were independent risk factors for death. An age > 65 years alone and other comorbidities were not risk factors.

Conclusions: Viral pneumonia is the main cause of hospitalization for COVID-19, usually extensive and bilateral. The greater severity and poor prognosis of these patients are mainly related to comorbidities.

Evidence-Based Medicine (EBM) is the methodological paradigm of Western medicine today. EBM is expected to reduce the use of intuition and to promote the use of scientific evidence, in the clinical decision-making process. Benefits of EBM in clinical practice are thoroughly documented, however, there are also critics. Among other issues, EBM is thought to contribute to an excessive reductionism, to neglect context variables and individual attributes involved in the physician-patient relationship. All the above could lead to several bioethical conflicts. This work consists in a literature review that examines the interaction between EBM and Bioethics in a reciprocity frame, in order to approach possible ethical conflicts that emerge with the use of EBM, and later analyze them from the perspective of the Narrative Ethics model, proposed by the philosopher Paul Ricoeur.

Background: EuroSCORE II is a mortality risk score for cardiac surgery in adults. This version is widely validated and compared with other scores in Europe, North America, and Asia.

Aim: To determine the performance of the EuroSCORE II for the prediction of mortality in cardiac surgeries in Latin America.

Material and methods: A systematic review was carried out of studies from Latin American countries evaluating the performance of EuroSCORE II in cardiac surgery. The inclusion criteria were patients older than 18 years, from Latin America, published in English, Spanish and/or Portuguese, between the years 2012 to 2020, with the term "EuroSCORE II" in the title. Observed mortality and estimated mortality data by EuroSCORE II were extracted. The calibration was determined by the observed/estimated mortality ratio and the discrimination was evaluated using receiver operating characteristic (ROC) curves.

Results: Four articles met the inclusion criteria, including 8372 patients. The average patients' age was 62 years and 34% were women. The observed and Euroscore II estimated mortality figures were 7.08 and 3.89%, respectively. The average area under the curve of ROC curves was 0.77 and the observed/ estimated mortality ratio was 2.04.

Conclusions: In these studies, EuroSCORE II underestimated mortality in cardiac surgery.

Background: Medical specialists are an essential resource for the functioning of the health system and in Chile there is a growing deficit of these specialists. To address this shortage, the government has strategies for training health professionals, such as a national public contest for medical scholarships, named CONISS, which stands out for its high capacity to produce medical specialists. The scoring system of this contest is used for the allocation of training resources to the best candidates.

Aim: To describe the results of the CONISS scoring system between 2016 and 2020.

Material and methods: Analysis of public registries of physicians participating in the CONISS contest between 2016 and 2020.

Results: During the study period 7,373 physicians participated in this contest (49% females). Annual participation increased progressively. The participants graduated from 21 Chilean universities and a variable number from foreign universities. The scores obtained by participants improved by 1.47 points between the first and last year of the study period.

Conclusions: Interpretation of these results is complicated by the characteristics and limitations of the measurements of the CONISS scoring system. This precludes establishing whether this system effectively filters out the best candidates for medical specialization programs.

Central nervous system infections are a medical emergency, due to their high fatality and sequelae. Timely treatment is essential, and should be initially indicated empirically by clinical guidance, without microbiological certainty. Hence the importance of cerebrospinal fluid (CSF) analysis as an etiological and therapeutic guide in the crucial initial hours of management. We report a 57-year-old woman consulting for fever and altered mental status. A brain CAT scan was normal. A lumbar puncture disclosed a CSF with predominance of neutrophils. Suspecting a bacterial meningitis, antimicrobial treatment was started but 48 hours after, the patient did not improve. A new lumbar puncture disclosed a CSF with predominance of lymphocytes. The lymphocyte shift prompted a PCR that was positive for herpes virus. The patient was treated with acyclovir with a good evolution.

Background: Anticoagulation in continuous renal replacement therapy (CRRT) is essential to counteract the coagulation cascade activation, induced by the dialysis circuit. Heparin is the most widely used anticoagulant, followed by regional citrate anticoagulation (RCA).

Aim: To determine the effectiveness and safety of anticoagulant treatment with citrate in CRRT.

Material and methods: Retrospective study of adults in CRRT hospitalized between the years 2014 and 2020 in critical units, who required change to RCA according to established protocols.

Results: We studied 24 patients aged 63 ± 13 years (12 females). The reasons for admission were acute kidney injury (AKI) in 80% and stage 5 chronic kidney disease in 20%. The indication of RCA in 75% of patients was by coagulation of more than 3 circuits in 24 hours. The duration of the circuit in RCA was 18.5 ± 4.8 hours versus 11.9 ± 4.9 hours with heparin (p < 0.0001). There were 19 mild complications that did not affect the RCA.

Conclusions: RCA is feasible to perform, it is a safe and efficient procedure if it is protocolized, allowing a longer duration of the dialysis circuit.

Background: Neuropsychiatric symptoms can be part of the clinical spectrum of COVID-19 infections.

Aim: To devise an evidence based clinical algorithm as a guide for clinicians, to identify and treat underlying clinical syndromes of psychomotor agitation, such as delirium, catatonia or substance withdrawal in patients who are hospitalized and infected with SARS-CoV-2.

Material and methods: A review of the literature about the pharmacological management of neuropsychiatric manifestations of COVID-19 at the general hospital, to develop a clinical protocol based on a consensus from an interdisciplinary expert panel at a Clinical Hospital.

Results: A consensual clinical algorithm for the management of delirium, catatonia, and substance withdrawal, manifested as psychomotor agitation in patients hospitalized with COVID-19, was developed as a clinical proposal for physicians at different levels of complexity in health services.

Conclusions: Cooperation among different clinical units in the general hospital facilitated the implementation of a clinical algorithm for clinicians for the management of psychomotor agitation in COVID-19 patients.

BCR-ABL1 negative atypical chronic myeloid leukemia (aCML) is a rare type of myeloproliferative / myelodysplastic syndrome characterized by leukocytosis and proliferation of dysplastic neutrophilic precursors in the absence of positivity for the BCR-ABL1 fusion gene. We report a 66-year-old woman and a 57-year-old man with aCML, who initially presented with general malaise and weight loss, associated with anemia, thrombocytopenia, and leukocytosis with left shift and dysplasia in the neutrophil series. Both evolved unfavorably after admission and died a few days later due to multiple organ failure.

Percutaneous surgery is the treatment of choice of isolated aortic coarctation in adults However, when there are other heart problems related to aortic coarctation, its surgical management may vary. We report a 41-year-old male presenting with aortic coarctation associated with severe, symptomatic, bicuspid aortic valve lesions and significant left ventricular dysfunction. He underwent open heart surgery for the surgical resolution of these problems. One year after surgery the results are satisfactory with no evidence of postoperative complications and a significant improvement of patient symptoms and left ventricular function.

Background: The Learning Environment (LE) influences the performance of students, learning, social life, mental health, and the future of work.

Aim: To assess the learning environment (LE) among medical residents of 64 specialties.

Material and methods: Two validated instruments "Postgraduate Hospital Education Environment Measure" (PHEEM) and "Ambulatory Care Learning Educational Environment" (ACLEEM), and open questions were answered online by 1259 residents from 15 universities. A descriptive and analytical statistical analysis and semantic deductive-inductive analyses of open questions were performed.

Results: LE was positive rather than negative (PHEEM of 100.5 points (79-116) and ACLEEM of 138.5 points (120-157)). An age over 32 years, male sex, studying in a private university, being in first year of residence and being in a non-surgical specialty were associated with a better PHEEM score (p < 0.05). For ACLEEM, the first year of specialty, a non-surgical specialty and studying in a private university were associated with better scores (p < 0.05). Two programs had excellent LE (Pathological Anatomy and Ophthalmology) and no specialty had a very poor performance or many problems. Aspects of teaching, clinical activities, and teachers were strengths reported by students. Aspects to improve were teaching, protected times and clinical activities.

Conclusions: LE among medical specialties had more positive than negative features, but with areas that should be improved.